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17,820
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23886
|
Discharge summary
|
report
|
Admission Date: [**2193-6-10**] Discharge Date: [**2193-6-13**]
Date of Birth: [**2143-12-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Elective ethanol septal ablation
Major Surgical or Invasive Procedure:
Ethanol Septal Ablation
Temporary pacer wire insertion
History of Present Illness:
49 y/o male with htn, hyperlipidemia, resolved DM after L
kidney/pancreas transplant [**2183**], severe PVD s/p numerous
peripheral PCI's, "SVT" per chart and severe HOCM who presents
for elective ethanol septal ablation. [**3-23**] stress ECHO revealed
resting gradient 18, with valsalva 86 and post-exercise 191 (8
METS, lateral ST changes, stopped [**2-20**] claudication, mild-mod
AI). LVEDD 4.92, IV Septum 1.27. Pt has marked DOE, becoming
winded after 5 minutes of walking or going up 2 flights of
stairs. Also c/o numerous pre-syncopal events, last 3 nights
ago. Does have palpitations also. In addition to palliation of
HOCM symptoms, the patient is also to have PCI for his PVD
during this hospitalization. He notes severe L>R LE pain when
walking > 5minutes. Had coronary cath [**11/2183**] which revealed LCx
50% with no intervention. In [**Hospital1 18**] cath lab, peak gradient was
118 with Valsalva and post-PVC (Braunwald-Brockenbrough beat).
First septal artery was ablated. LHC revealed TO distal LCx.
Past Medical History:
1. HOCM
2. PVD: S/P stenting L common iliac x 2 in [**1-23**] c/b
retroperitoneal hemorrhage and RLE [**2192-9-27**] (6 x 29mm)
3. OSA: Not on CPAP
4. Moderate AI: By ECHO [**3-23**]
5. SVT: Had holter in past that showed lots of APB's, but no
SVT or VT.
6. Diabetes: S/P combined L kidney/pancreas transplant. On
tacrolimus, cellcept and prednisone. No longer diabetic.
7. HTN: On BB, clonidine, norvasc and minoxidil
8. Dyslipidemia
Social History:
Married, works as a home and building inspector.
Family History:
(?) FHx CAD: Brother died suddenly a few weeks ago at age 52 hx
of ETOH abuse. Mother has a pacemaker.
Physical Exam:
98.7 50 140/67 14 98%RA
Gen: NAD, A&O X 3
Heent: EOMI, PERRL, MMM
Neck: No JVD
Heart: RRR no mrg. PMI non-displaced.
Lungs: Clear
Abd: Benign
Ext: No c/c/e. Palpable DP's. [**Name (NI) **] PT's.
Pertinent Results:
[**2193-6-13**] 07:48AM BLOOD WBC-13.5* RBC-4.56* Hgb-12.9* Hct-38.4*
MCV-84 MCH-28.4 MCHC-33.7 RDW-14.9 Plt Ct-178
[**2193-6-10**] 05:41PM BLOOD Neuts-75.4* Lymphs-16.9* Monos-6.8
Eos-0.7 Baso-0.1
[**2193-6-13**] 07:48AM BLOOD Plt Ct-178
[**2193-6-13**] 05:58AM BLOOD PT-12.4 PTT-25.1 INR(PT)-1.0
[**2193-6-13**] 05:58AM BLOOD Glucose-102 UreaN-13 Creat-0.9 Na-139
K-4.1 Cl-105 HCO3-25 AnGap-13
[**2193-6-13**] 05:58AM BLOOD CK(CPK)-317*
[**2193-6-12**] 05:03AM BLOOD CK(CPK)-892*
[**2193-6-11**] 03:09PM BLOOD CK(CPK)-1821*
[**2193-6-11**] 05:45AM BLOOD CK(CPK)-1752*
[**2193-6-11**] 12:12AM BLOOD CK(CPK)-971*
[**2193-6-10**] 05:41PM BLOOD ALT-30 AST-44* LD(LDH)-219 CK(CPK)-338*
AlkPhos-53 TotBili-0.9
[**2193-6-13**] 05:58AM BLOOD CK-MB-6
[**2193-6-12**] 05:03AM BLOOD CK-MB-30* MB Indx-3.4
[**2193-6-11**] 03:09PM BLOOD CK-MB-153* MB Indx-8.4*
[**2193-6-11**] 05:45AM BLOOD CK-MB-180* MB Indx-10.3*
[**2193-6-11**] 12:12AM BLOOD CK-MB-93* MB Indx-9.6*
[**2193-6-10**] 05:41PM BLOOD CK-MB-22* MB Indx-6.5* cTropnT-0.18*
[**2193-6-13**] 05:58AM BLOOD Calcium-9.0 Phos-3.5# Mg-1.5*
Cath:
1. Selective coronary angiography revealed a right-dominant
system
with single-vessel coronary disease. The LMCA had no
angiographically
apparent disease. The LAD had no angiographically apparent
flow-limiting stenosis. The LCx was occluded in the distal
portion at
the take-off of the OM2 branch and filled via left-left
collaterals.
The RCA had mild luminal irregularities but no angiographically
apparent
flow-limiting disease.
2. Resting hemodynamics revealed mildly elevated left-sided
filling
pressures (LVEDP 16 mmHg). There was a resting gradient across
the LVOT
of 20-25 mmHg. With Valsalva maneuver, this gradient increased
to 100
mmHg. Post-PVC, the gradient increased to 115 mmHg with
associated
decrease in arterial pressure (Braunwald-Brockenbrough sign).
With
infusion of 20 mcg/kg/min dobutamine, the gradient across the
LVOT
increased to 65 mmHg.
3. Ethanol ablation of the first septal was performed.
ECHO ([**6-10**])ECHO: There is mild symmetric left ventricular
hypertrophy with normal cavity size andexcellent systolic
function (LVEF>75%). Valvular [**Male First Name (un) **] and a peak 64mmHg LVOT
gradient is identified. Right ventricular cavity size and free
wall motion are normal. There is mild aortic regurgitation. The
mitral valve leaflets are mildly thickened. There is systolic
anterior motion of the mitral valve leaflets. Mild mitral
regurgitation is seen.
Following injection of 1ml of diluted Optison (3ml with 7ml of
saline), there was prompt enhancement of the mid-septum
extending into the moderator band. The septal catheter was then
slightly withdrawn and angled towards a more basal septal
branch. 0.5ml of diluted Optison was again injected with
enhancement of the basal septum adjacent to the apposition of
the valvular [**Male First Name (un) **]. Following injection of alcohol 1ml into the
first septal, there was prominent enhancement of the basal
septum and a reduction in the LVOT gradient (on 10 mcg/kg/min)
to 36mmHg.
Alcohol 0.5ml and then 0.5ml (total 2ml) were then injected
during direct echo visualization. Dobutamine was then increased
to 30mcg/kg/min with resultant 36mmHg peak LVOT gradient.
Minimal mitral regurgitation was present. Valvular [**Male First Name (un) **] and mild
aortic regurgitation persist. Dobutamine was then stopped with
resting LVOT gradient of 30mmHg.
Brief Hospital Course:
49 y/o male with HOCM, severe PVD and kidney/pancreatic
transplant admitted for elective ethanol septal ablation.
1. Pump: Pt does not have a family history of HOCM based on
his brother's recent death and autopsy (severe coronary
disease). Pt underwent successful ethanol ablation of septum,
with reduction in LVOT gradient with valsalva and dobutamine
(see above). Pt has been ambulating since procedure and notices
a marked improvement in symptoms.
2. Rhythm: Pt went into polymorphic VT arrest ~2 hours post
ethanol ablation. This was attributed to myocardial necrosis.
He recieved 2 shocks and was amio was bolused and dripped for 24
hours. He was pulseless for ~2 minutes. Amio was dicontinued
and the patient had no more ventricular dyssrhythmias. EP was
consulted to evaluate patient for ICD to prevent sudden cardiac
death for HOCM. However, given his low septum thickness, lack
of family history or low age, it was decided to try holter
monitoring for 4-6 weeks before ICD implantation. Should he
have any NSVT or VT by holter, he should be referred for an ICD.
3. CAD: Found to have a TO distal LCx and OM1. Continued
asprin, BB, statin.
4. PVD: No limb-threatening vascular insufficiency while in
huose. He does suffer from severe L >R claudication and will
return to [**Hospital1 18**] in [**2-21**] weeks for staggerred iliac PCI's.
5. Kidney/Renal Transplan: Continued immunosuppressives.
Medications on Admission:
Cellcept 1gm [**Hospital1 **]
Prograf 2mg [**Hospital1 **]
Prednisone 5mg daily
Metoprolol 50mg [**Hospital1 **]
Clonidine 0.10mg [**Hospital1 **]
Norvasc 10mg daily
Zocor 40mg daily
Minoxidil 0.5mg daily
Aspirin 325mg daily
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal TID (3 times a day).
6. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p ETOH septal ablation
Hypertrophic Obstructive Cardiomyopathy
Myocardial Infarction
Polymorphic Ventricular Tachycardia
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as directed.
If you have chest pain lasting longer than 15 minutes, please go
to nearest emergency room for immediate evaluation.
If you have these symptoms, call your doctor:
- palpitations
- dizziness
- visual change
- chest pain
- shortness of breath
Followup Instructions:
Please follow up with your Dr. [**Last Name (STitle) 11250**], your cardiologist, on
discharge. She will need to arrange for you to have a Holter
monitor study in [**4-24**] weeks. The results of the Holter study
will need to be sent to Dr. [**Last Name (STitle) **] for a final decision RE:
ICD placment.
Completed by:[**2193-6-13**]
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1955, 2006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,697
| 117,793
|
35068
|
Discharge summary
|
report
|
Admission Date: [**2173-12-9**] Discharge Date: [**2173-12-10**]
Date of Birth: [**2111-12-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
s/p L Carotid Stent
Major Surgical or Invasive Procedure:
Stenting for Carotid Artery Stenosis
History of Present Illness:
This is a 61-year-old gentleman with a history of HTN, PVD, CVA
and CAD (s/p BMS-LCx and [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **] in [**12-16**]) now admitted to CCU
s/p stenting of the left carotid artery.
During workup for several months of anginal symptoms that
included cath showing 3 vessel disease, pt underwent carotid
doppler study on [**12-6**] that showed complete occlusion of the R
ICA and >70% occlusion of the L ICA, though the pt c/o no HA,
TIA, vision, dizziness or other neurologic sx.
Angiography on [**12-9**] showed 100% R ICA occlussion, 80% occlusion
(ulcerated plaque)of the L ICA with filling of ipsilateral and
contralateral ACA, MCA via L ICA. A Protege stent was placed in
the L ICA. The procedure was completed without complication and
without evidence of distal embolization. On arrival in CCU, pt
was maintained on .3mcg/kg/min of phenylephrine and pt was
without complaints.
Past Medical History:
CAD:
-BMS to LCx, DES to 1st diagonal in [**12-16**]
-3 vessel disease on cath on [**12-6**]--99% mid RCA, 85% prox LAD,
80% OM1
-scheduled for CABG on [**12-13**]
CVA '[**68**]
HTN
HPLD
BPH
B/l inguinal herniorraphies
Basal Cell Cancer s/p resection
Lumbar radiculopathy
Social History:
Married, 2 children. Works in construction. Denies smoking,
drugs. Drinks 1 glass of wine per day
Family History:
CAD-Father, MI 80yo
Physical Exam:
VS: T=97 BP=107/67 HR=66 RR=26 O2 sat=97 on RA
GENERAL: WDWN, NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. Dressing CDI. No femoral bruits,
hematomas.
SKIN: Decreased hair over distal LE. No livedo reticularis or
necrosis over toes.
PULSES:
2+ DPs, R>L
Neuro: A+Ox3, CNII-XII grossly intact. No pronator drift, [**6-14**]
b/l in proximal and distal UE muscles. [**6-14**] gastroc strength b/l.
(other leg muscles not tested following femoral puncture).
Sensation, reflexes, coordination equal b/l.
Pertinent Results:
139 106 17 AGap=12
-------------< 91
4.0 25 0.8
Ca: 8.8 Mg: 2.0
13.8
7.9 >----< 253
38.7
CARDIAC CATH REPORT
1. Access via left femoral artery (as right femoral had been
accessed two days prior for coronary angiography). 2. Limited
hemodynamics with BP 144/80 with HR 62 in sinus. 3. Angiography
of the aortic arch with a pigtail catheter in ascending aorta
showed a Type 1 arch without lesions. 4. Angiography of the
right carotid artery with Berenstein catheter in right common
carotid artery showed patent right external with occluded right
internal carotid artery. 5. Angiography of the left carotid
artery with Berenstein catheter in the left common carotid
artery showed the left common and external to be normal. The
left internal carotid had a ulcerated 80% lesion best seen in
LAO 45 view. This left internal carotid fills the ipsilateral
and contralateral ACA and MCA. The posterior circulation was
not fed by the left internal carotid. 6. Given severity of
lesion and upcoming surgery we elected to proceed with stenting.
We exchanged for a Shuttle sheath 6F into the left common
carotid and started heparin with therapeutic ACT. We crossed
easily with a SpartaCore wire and exchanged for a 5mm Spyder
filter. We predilated with a Quantum Maverick 2.75x20 at 14
atm. We then stented with a self expanding Protege 8-6 mm x40
mm tapered stent. We post dilated the stent at the lesion with a
Quantum Maverick 4.5x20mm balloon at 12atm Final angiography
with 10% residual and normal flow. The filter was recovered
without incident and presence of small amount of atheromatous
material. Final cerebral angiography without evidence of
embolization or vessel occlusion. 7. The LFA arteriotomy was
closed with a Mynx device.
FINAL DIAGNOSIS:
1. Occluded right internal carotid artery.
2. 80% stenosis of left internal carotid artery.
3. Stenting of left internal carotid artery with distal
protection.
Brief Hospital Course:
61 yo HTN, HPLD, CAD admitted to the CCU s/p L ICA stent. He was
doing well, and was admitted to CCU for BP management. He was
requiring fluids, phenylephrine on admission.
# CAROTID STENOSIS s/p STENTING and HYPOTENSION: Pt tolerated
stenting procedure well and was neurologically intact. After
admissin, he required phenylepherine up to 0.7 mcg/kg/min to
maintain SBPs>100 and he received 2.5 L of IV fluids. He was
weaned off by midnight and had stable blood pressures in the
100-120 SBP range throughout the morning. He continued to have
good neurological status.
Prior to discharge, an echo was done to evaluate pre-op EF.
Last recorded ef was 51%. The read of this was pending at
discharge.
He was discharged off blood pressure medications with
instructions to restart them on Sunday.
.
# CORONARIES: He is s/p BMS, DES in '[**71**], 3 vessel disease on
cath [**12-6**]. He was continued on ASA 81 and plavix
.
# PROPHYLAXIS:
-DVT ppx with sq heparin 5000u tid
-Bowel regimen-standing colace, senna prn
CODE: full
Medications on Admission:
ASA 81mg 3x daily
Plavix 75mg po daily
atenolol 50mg po daily
lisinopril 10mg po daily
lipitor 80mg po daily
isosorbide 60mg po daily
flomax .4mg po daily
finasteride 5mg po daily
loratadine 10mg po daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Will restart on Sunday:
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atenolol 50mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 10mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
CAROTID ARTERY STENOSIS
HYPOTENSION
Coronary Artery Disease
Discharge Condition:
Stable, Ambulating, Blood pressure 119/76 systolic, HR 62 off
pressors.
Discharge Instructions:
You were admitted with carotid stenosis. A stent was placed in
your carotid artery to improve blood flow to your brain. You
were admitted to the CCU while you were on a medication to keep
your blood pressure elevated. You were slowely taken off this
medication. You did well, and were discharged from the ICU.
You sould complete your pre-operative testing after you are
discharged from the CCU. This is to be completed on the [**Location (un) **] of the clinical center.
Your blood pressure and heart rate were improving but still
somewhat low at the time of discharge. You should wait to
resume your blood pressure medications, Lisinopril and Atenolol
until Sunday. You should also wait until Sunday to restart your
Flomax as this medication can also lower blood pressure. Please
call your PCP or go to the emergency room if you have symptoms
of low blood pressure such as feeling faint, lightheaded, weak
or dizzy.
Followup Instructions:
Please attend your pre-operative testing
Your surgery is scheduled for next week
Completed by:[**2173-12-10**]
|
[
"V12.54",
"724.4",
"414.01",
"433.10",
"V70.7",
"443.9",
"413.9",
"V45.82",
"401.9",
"272.4",
"V10.83",
"600.00",
"433.30",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.63",
"00.61",
"88.41",
"88.42",
"00.40",
"00.45"
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icd9pcs
|
[
[
[]
]
] |
6527, 6533
|
4751, 5781
|
337, 376
|
6637, 6711
|
2784, 4549
|
7683, 7796
|
1756, 1777
|
6037, 6504
|
6554, 6616
|
5807, 6014
|
4566, 4728
|
6735, 7660
|
1792, 2765
|
278, 299
|
404, 1329
|
1351, 1625
|
1641, 1740
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,010
| 194,375
|
27832
|
Discharge summary
|
report
|
Admission Date: [**2157-7-7**] Discharge Date: [**2157-7-16**]
Date of Birth: [**2102-5-30**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Lanolin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Necrotizing Pancreatitis
Increasing Epigastric Pain
Major Surgical or Invasive Procedure:
Laproscopic cholecystectomy
History of Present Illness:
55 yo M transfered from [**Hospital3 3765**] for progression of
necrotizing pancreatitis. He was admitted to the OSH on [**6-29**]
with 3-4 days of increasing epigastric pain amd chest pain. He
thought that he had some heartburn vs. his sternal osteomyelitis
He also had some nausea and nobloody/non-bilious emesis and
anorexia. He was taken to [**Hospital3 **] ICU with diagnosis
of necrotizing pancreatitis by CT. He also had an ultrasound tha
demonstrated gallstones. He had issues with his BP
control(admitted on nitro gtt), glucose and electrolyte control.
He was admitted to ICU and over the ensuing days he remained
febrile and his WBC increased to 17,000 (11,000 on admit). He
is transfered for management of pancreatitis.
Past Medical History:
1. BPH
2. History of osteomylitis of his sternum.
3. Acne
PSurgery: 1. Appendectomy
Social History:
Physicist
No tobacco use
2 glass of wine/day
married
2 childern
Family History:
NC
Physical Exam:
VS T 100.5 P115 BP 135/68 RR 22 O2Sat 95%RA
Gen: Awake, alert, oriented,
HEENT: No icterus, no jaundice, neck was supple
Chest: CTA bilaterally, no crackles
CV: RRR, no murmurs
Abdomen: soft, midly distended, obese, TTP in the upper
quadrant, no rebound, small umbilical hernia
Extremeties: 1+ Lower extremety edema.
Pertinent Results:
[**7-7**] Blood Cx was negative x 4, no fungal or AFB in his blood,
and urine Cx was negative, stool was negative for c. diff
[**7-8**]- Catheter tip was sent for culture and came back negative
[**7-11**] Blood Cx negative and stool was negative for c. diff
[**7-12**] Blood Cx negative x3 and urine Cx was negative
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 67842**],[**Known firstname **] C [**2102-5-30**] 55 Male [**-6/2726**]
[**Numeric Identifier 67843**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: GALLBLADDER AND OMENTUM NODULE (2).
Procedure date Tissue received Report Date Diagnosed
by
[**2157-7-14**] [**2157-7-14**] [**2157-7-18**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/kg
DIAGNOSIS:
1. Omental nodule (A):
Omental tissue with fat necrosis.
2. Gallbladder (B-C):
a. Chronic cholecystitis, mild.
b. No calculi.
Clinical: Acute pancreatitis.
Gross:
The specimen is received fresh in two parts, both labeled with
"[**Known lastname **], [**Known firstname 333**]" and the medical record number.
Part 1 is additionally labeled "omental nodule" and consists of
two pieces of tan soft tissue aggregating 0.3 x 0.2 x 0.2 cm.
The specimen is entirely frozen and frozen section diagnosis by
Dr. [**Last Name (STitle) 7108**] is "omentum: fat necrosis." The frozen section
remnant is entirely submitted in A.
Part 2 is additionally labeled "gallbladder" and consists of a
cholecystectomy specimen measuring 9 x 3.5 x 1.5 cm. The serosal
surface is focally erythematous with few punctate areas of
subserosal hemorrhage. Otherwise, there are no discrete lesions
or masses identified. The cholecystic duct remnant appears
dilated with a diameter of up to 0.9 cm, stapled. The specimen
is opened to reveal an aggregate of blood clot measuring up to
2.0 cm. The blood clot is easily removed from the mucosal
surface to reveal a mucosa that is pink and velvety without
lesions or masses identified. The specimen is represented as
follows: B = representative sections through cholecystic duct,
C = representative sections through gallbladder wall.
Brief Hospital Course:
CT from OSH revealed necrotizing pancreatitis and the interval
CT from the OSH showed no improvment of pancreatitis and showed
a larger fluid collection near the duodenal C loop.
The patient was transferred to [**Hospital1 18**] under the care of Dr.
[**Last Name (STitle) **] on [**2157-7-7**]. He was first admitted to the ICU at [**Hospital1 18**]
because he was on IV nitroglycerin drip and IV labetalol to
control BP and HR and an insulin drip for control of his blood
sugars. He was admitted IV imipenamen and fluconazole. When he
arrived the IV nitroglycerin drip was d/c'd and the he was given
lopressor 10mg q4 hour IV to keep SBP at between 100-140. Pain
was controlled with a dilaudid PCA. On HD #2 his NG tube was
d/c'd but he was kept NPO and started on TPN. His insulin drip
was turned off and he was started on Regular insulin sliding
scale. He was then transferred to the floor. After reviewing
the CT from Emerison it appeared that Mr. [**Known lastname **] suffered from
a "mild" attack of gallstone pancreatitis. He had some necrosis
at the neck of the pancreas and that he has some peripancreatic
edema as well. All of his cultures came back negative for
bacteria and his week old central line was d/c'd and sent for
culture which came back negative. Therefore his fevers are most
likely due to cytokine release. Therefore the antibiotics were
d/c'd. HD #3 was when his diet started to be slowly advanced as
tolerated which he tolerated well. Throughout the hospital
course, his pain decrease, his fever curve decrease and his WBCs
all were decreasing. Due to his fast improvement, he was then
taken to the OR on HD #8 for a laproscopic cholecystectomy which
he tolerated with no complications. At the end of his hospital
course, he was tolerating a regular diet therefore the TPN was
d/c'd, and his pain was controlled with PO pain medications. He
was also switched to PO lopressor when he was tolerating clear
liquid diet and his BP was controlled with the PO lopressor
during the rest of his hospital stay. He still had some problems
with high blood sugar therefore [**Last Name (un) **] was consulted. He was
educated on how to take his blood sugars and they gave him a
home regimen for which he can better control his blood sugars.
He was told that he should follow up in a couple weeks with his
primary care physician about his blood sugars and his blood
pressure medications. He was also told that his blood sugars
being high may be temporary and that as his pancreas recovers
that his blood sugars will most like also go down.
Medications on Admission:
Medications at time of Transfer:
Imipenem 1 gram q 6hour, Serax 30 qhs, ISS, labetolol prn, nrto
gtt, dilaudid PCA, protonix 40' IV, Tylenol, vitamin B12,
Maalox, heparin SC, Zofran 4 IV prn, ativan prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*40 Capsule(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: As needed for pain. Tablet(s)
5. Amaryl 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. INSULIN
Insulin SC Fixed Dose Orders
Bedtime
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-65 mg/dL [**1-3**] amp D50 [**1-3**] amp D50 [**1-3**] amp D50 [**1-3**] amp D50
66-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 0 Units 0 Units 0 Units 0 Units
161-200 mg/dL 2 Units 2 Units 2 Units 0 Units
201-240 mg/dL 3 Units 3 Units 3 Units 0 Units
241-280 mg/dL 4 Units 4 Units 4 Units 1 Units
281-320 mg/dL 5 Units 5 Units 5 Units 2 Units
321-360 mg/dL 6 Units 6 Units 6 Units 3 Units
7. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Breakfast, lunch, dinner,
bedtime.
Disp:*5 * Refills:*2*
8. Insulin Glargine 100 unit/mL Cartridge Sig: 8 units
Subcutaneous once a day: At bedtime.
Disp:*2 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Sever Pancreatitis
Cholelithasis
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
You may shower and wash your incision with soap and water. Pat
dry
Followup Instructions:
Please Follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call [**Telephone/Fax (1) 1231**]
for an appointment.
Please follow up with your primary care physician with regards
to your high blood pressure and blood pressumre medication
management.
Please follow up with the [**Hospital **] clinic in management of your
diabetes.
Completed by:[**2157-7-20**]
|
[
"577.0",
"575.11",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.23",
"99.15",
"54.23"
] |
icd9pcs
|
[
[
[]
]
] |
8369, 8375
|
4036, 6610
|
331, 361
|
8452, 8459
|
1690, 4013
|
8736, 9103
|
1333, 1337
|
6865, 8346
|
8396, 8431
|
6636, 6842
|
8483, 8713
|
1352, 1671
|
240, 293
|
389, 1126
|
1148, 1235
|
1251, 1317
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,711
| 114,911
|
3246
|
Discharge summary
|
report
|
Admission Date: [**2185-3-4**] Discharge Date: [**2185-3-11**]
Date of Birth: [**2104-5-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
s/p fall, sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 15138**] is an 80 year old Russian-speaking man with a h/o
colon cancer s/p hemicolectomy, bladder cancer s/p ureterostomy,
HTN, & CKD who presents to the [**Hospital1 18**] after falling out of his
chair at his nursing home. He was found on the floor by the
nursing home personell though he denied hip pain. He was also
noted to be increasingly agitated at rehab.
.
In the ED, his vitals were T 98.8, HR 72, BP 97/59, RR 16, 95%
on RA. He became hypotensive and was not responding to 5L of IV
fluids, so a Right IJ was placed. He got a hip film which
showed no fracture. His labs were notable leukocytosis and
obstructive LFTs. [**Name (NI) 5283**] sono showed no cholecystitis. Surgery
was consulted and recommended ERCP consult.
.
Upon arrival to the [**Hospital Unit Name 153**], patient has dementia and is russian
speaking only so no further history is obtained. Per his
daughter, his appetite decreased over the past few days.
.
Of note, patient was recently admitted to the [**Hospital Unit Name 153**] for
enteroccus sepsis. Given that the source of the sepsis was felt
to be the ampullary tumor which was untreatable and the
likelihood for recurrence, the decision was made to make the
patient DNR/DNI with no central lines. Therefor, EGD/ERCP was
not pursued.
Past Medical History:
#. Saddle pulmanary emboli [**2181-12-3**] s/p IVC filter.
- warfarin therapy eventually discontinued secondary to SDH
[**7-/2182**]
#. Left acoustic neuroma s/p XRT, left cerebello-pontine angle
mass still present on subsequent imaging, stable since [**2173**]
#. colon cancer (per chart, initially dx in [**2172**] with
resection), per daughter was dx in [**12-9**] (GIB while on coumadin),
underwent hemicolectomy [**1-9**] with primary reanastomosis. no
adjuvant chemo/xrt. note, path 13.X6cm mass, adenoca. Margins
clear BUT 2 of 18 LN examined were +cancer (T3N1).
#. Bladder cancer s/p bladder resection [**2166**] s/p ureterostomy
#. recurrent UTIs
#. lower back pain: L3-4 disc bulging, had admission in [**2178**] for
inability to walk
#. Severe DJD
#. HTN
#. OSA
#. Iron deficiency Anemia
#. Hyperlipidemia
# CKD, creat has been around 2.0 since [**11-8**], previously was
1.1, unclear etiology and was never worked up.
Social History:
Patient currently residing in a nursing home. Per his family,
he is alert & oriented x 1 at baseline. He has 2 daughters that
live nearby.
Tobacco: Quit >35 yrs ago after ~15 pack-yrs
EtOH: Rare
Illicits: None
Family History:
No family history of premature coronary artery disease, sudden
cardiac death, thyroid disease, colon cancer, diabetes, or
hypertension.
Physical Exam:
Vitals: T 97.6, HR 77, RR 11, 96% on RA, 97/55
HEENT: dry mucous membranes
CV: RRR, no m/r/g
Pulm: CTA b/l anteriorly
Abd: Soft, NT, ND, + BS, + ureterostomy tube with urine
Ext: 2+ pitting edema bilaterally, cool extremities
Pertinent Results:
[**2185-3-3**] 10:55PM BLOOD WBC-20.9*# RBC-2.96* Hgb-7.4* Hct-25.0*
MCV-85 MCH-25.1* MCHC-29.7* RDW-21.2* Plt Ct-343
[**2185-3-4**] 01:15AM BLOOD WBC-18.9* RBC-2.37* Hgb-6.0* Hct-20.4*
MCV-86 MCH-25.2* MCHC-29.3* RDW-21.2* Plt Ct-292
[**2185-3-10**] 05:07AM BLOOD WBC-20.0* RBC-3.63* Hgb-9.7* Hct-32.7*
MCV-90 MCH-26.7* MCHC-29.7* RDW-21.1* Plt Ct-140*
[**2185-3-3**] 11:42PM BLOOD PT-15.0* PTT-23.3 INR(PT)-1.3*
[**2185-3-10**] 05:07AM BLOOD PT-41.8* PTT-41.0* INR(PT)-4.4*
[**2185-3-3**] 10:55PM BLOOD Glucose-121* UreaN-40* Creat-1.7* Na-135
K-4.9 Cl-101 HCO3-19* AnGap-20
[**2185-3-10**] 05:07AM BLOOD Glucose-65* UreaN-73* Creat-4.0* Na-137
K-6.0* Cl-114* HCO3-12* AnGap-17
[**2185-3-3**] 10:55PM BLOOD ALT-71* AST-108* LD(LDH)-340*
AlkPhos-858* TotBili-4.7*
[**2185-3-8**] 03:31AM BLOOD ALT-80* AST-142* LD(LDH)-397*
AlkPhos-700* TotBili-6.5*
[**2185-3-4**] 12:32PM BLOOD Calcium-7.2* Phos-4.2 Mg-1.9
[**2185-3-10**] 05:07AM BLOOD Calcium-7.2* Phos-7.5*# Mg-2.2
[**2185-3-7**] 05:49AM BLOOD Vanco-27.5*
[**2185-3-9**] 03:45AM BLOOD Vanco-22.8*
[**2185-3-4**] 01:17AM BLOOD Glucose-118* Lactate-3.8* K-4.2
HIP film
IMPRESSION:
1. No fracture.
2. Chronic degenerative changes in the hips, right greater than
left.
[**Year/Month/Day 5283**] US:
1. Multiple isoechoic liver lesions most likely representing
metastatic colon
cancer in the setting.
2. Gallbladder dilation, sludge, and CBD dilation of 14 mm;
concerning for
acute cholecystitis, recommend HIDA.
3. Stent in CBD; not clear if same position or in lower CBD.
Brief Hospital Course:
Mr. [**Known lastname 15138**] is an 80 year old Russian-speaking man with h/o
multiple malignancies including recurrent colon cancer s/p
hemicolectomy and recent metastatic adenocarcinoma with unknown
primary and ampullary mass, HTN, & CKD who presents with septic
shock secondary to cholangitis. He had biliary stent placed in
[**Month (only) 404**]. [**Name (NI) 5283**] sono demonstrates CBD dilitation suggestive of
obstruction (likely from the ampullary mass). Also he was
recently treated for enteroccus endocarditis (finished
Ampicillin course [**3-2**]). He was placed on broad spectrum
antibiotics during this hospitalization; however, no bacteria
isolates were obtained from his blood culture. Patient has
history of several recent bleeds on top of baseline iron
deficiency anemia. He has a baseline Creatinine of 1.4-1.6.
Additionally, he has a history of multiple malignancies
including bladder, colon (with reucurrence), acoustic neuroma,
and new metastatic adenocarcinoma with unknown primary with mets
to the liver, large pericardial effusion, and necrotic ampullary
mass. Oncology was consulted on prior admission and felt that
he was not a candidate for therapy. At baseline, patient A&O x
1. Requires 24 hour assistance for all of his ADL's. Now living
at a rehab facility since prior admission.
Hospital course:
He became cutely agitated, hypertensive, clamp down (cyanosis
perioral and in toes), tachycardic to 120s. He was transiently
placed on nitro gtt and BPs reduced but then hypotensive, nitro
gtt was stopped. EKGs done were without signs cardiac ischemia.
Family consulted and decided only IVF, abx, O2 but no other
interventions. ERCP was deferred. He had worsening renal
function, worsening LFT. Sacral decub was noted - likely from
prior to hospitalization, wound care consulted. IVF boluses
were given for low BP and low UOP, but persistent low blood
pressure, so levophed was started. Patient became very agitated
at night with minimal response to haldol and zyprexa. He
developed arrythemias going in and out of AVNRT repeatly. He
was maintained on medical care geared towards comfort and
eventually became bradycardic and passed away from cardiac
arrest.
Code: DNR/DNI (confirmed with daughter)
Communication: Patient & patient's family (daughter, [**Name (NI) 15139**]
[**Name (NI) 15140**] [**Telephone/Fax (1) 15141**] cell [**Telephone/Fax (1) 15142**] home)
Medications on Admission:
Ferrous sulfate 325 mg daily
Colace prn
Remeron 15 mg qhs
Vicoden prn
Tylenol prn
MOM prn
[**Name2 (NI) 10687**] prn
Bisacodyl prn
Verapamil 80 mg q 8 hours
Metoprolol Tartrate 25 mg q 6 hours
Completed Ampicillin [**2185-3-2**]
.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock
Ampullary mass with path positive for adenocarcinoma (biliary
stent placed due to prior episode of cholangitis in [**12-22**])
Liver metastases (unknown primary)
Bladder cancer s/p bladder resection & ureterostomy, [**2166**]
Colon cancer s/p resection, [**2172**] with recurrence (T3N1) s/p
hemicolectomy, [**2181**]
L acoustic neuroma s/p XRT, [**2173**]
Saddle PE s/p IVC filter, [**2181**]
h/o SDH, [**2181**]
A-fib s/p cardioversion
Recurrent UTI's
L3-4 disc herniation, [**2178**]
DJD
HTN
OSA
Iron deficiency Anemia
Hyperlipidemia
CKD (baseline Cr 1.2-1.4) from bilateral hydronephrosis
Dementia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"038.9",
"585.9",
"V45.72",
"V10.51",
"V12.51",
"785.52",
"722.10",
"327.23",
"V87.41",
"V15.3",
"995.92",
"715.90",
"V13.02",
"V10.05",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7563, 7572
|
4831, 6155
|
337, 343
|
8230, 8239
|
3279, 4808
|
8295, 8441
|
2880, 3018
|
7534, 7540
|
7593, 8209
|
7278, 7511
|
6172, 7252
|
8263, 8272
|
3033, 3260
|
281, 299
|
372, 1678
|
1700, 2634
|
2650, 2863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,197
| 129,229
|
44941
|
Discharge summary
|
report
|
Admission Date: [**2154-1-13**] Discharge Date: [**2154-1-16**]
Date of Birth: [**2077-5-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Atenolol
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to proximal and
distal Rigth coronary artery
History of Present Illness:
The patient is a 76 y/o F with a PMH of CAD s/p NSTEMI [**8-31**], L
subclavian steal, Hypertension admitted with inferior STEMI. The
patient presented to the ED with complaints of diarrhea of
sudden onset X2 hours. Denied chest pain. She denies
nausea/vomiting, no fever/chills or shortness of breath.
.
In the ED, initial vitals were T 97.1 HR 45 BP 66/38 RR 12 O2
90%. Labs demonstrated a CK of 299 MB 15 and Trop 0.07. ABG
7.18/51/250/20. She was given Atropine 1mg, Dopamine gtt and
levophed gtts were started, ASA 600mg was given. ECG
demonstrated inferolateral ST elevations. Right sided leads
showed elevations in V4R. She was taken emergently to the
cardiac cath lab. On arrival to cath lab the patient's
respiratory status worsened and she required emergent
intbuation.
.
In the cath lab R and L femoral access was obtained for possible
IABP placement. Cardiac cath demonstrated a proximal RCA
occlusion. She had BMS stents placed to proximal and mid distal
RCA with good subsequent flow. She received 4-5L IVF during cath
and was weaned off of pressors. HR stable and no temp wire was
required.
.
On arrival to the CCU, the patient remains intubated and
sedated. Review of systems unable to be obtained.
Past Medical History:
-NSTEMI [**2153-8-25**] - medically managed
-Left subclavian steal -> therefore has discrepancy in BP in R
versus L arm. BP should be measured in R arm.
-Hypertension
-Tobacco habit, half pack per day times 40 years.
-Hyperlipidemia, primarily LDL elevation.
-Right carotid bruit.
-Peripheral vascular disease status post stenting to right iliac
artery.
-Thyroid cancer, papillary carcinoma, removed with total
thyroidectomy in [**2148-9-23**]. Of note, had two
hyperfunctioning nodules and one cold nodule. on synthroid
-Left rotator cuff tendonitis.
-Status post left hand crush injury in distant past
Social History:
-Tobacco history: Currently smokes [**11-24**] ppd for 54 years
-ETOH: None
-Illicit drugs: None
Patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], functional with ADLs and IADLs.
Drives. No help needed for ambulation.
Family History:
CVA in brother at 55 years of age, CHF in mother at [**Age over 90 **] years of
age.
Physical Exam:
VS: T97.6, HR 68, BP 127/74 AC 550x24 PEEP 10, FIO2 100%
GENERAL: intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. 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. R groin site with oozing and hematoma
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP dopplerable PT dopplerable
Left: Carotid 2+ Femoral 2+ DP dopplerable PT not dopplerable
Pertinent Results:
[**2154-1-13**] 04:16AM WBC-6.0# RBC-4.30 HGB-13.1 HCT-41.3 MCV-96
MCH-30.5 MCHC-31.7 RDW-14.5
[**2154-1-13**] 04:16AM NEUTS-54.0 LYMPHS-38.5 MONOS-3.9 EOS-3.4
BASOS-0.2
[**2154-1-13**] 04:16AM GLUCOSE-117* UREA N-11 CREAT-1.5* SODIUM-144
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-26 ANION GAP-14
[**2154-1-13**] 04:16AM CALCIUM-9.1 PHOSPHATE-4.2 MAGNESIUM-2.4
[**2154-1-13**] 04:16AM CK-MB-15* MB INDX-5.0
[**2154-1-13**] 04:16AM cTropnT-0.07*
[**2154-1-13**] 04:16AM CK(CPK)-299*
[**2154-1-13**] 04:23AM LACTATE-2.3*
[**2154-1-13**] COMMENTS: 1. Coronary angiography in this right dominant
system demonstrated single vessel disease. The LMCA had mild
luminal irregularities. The LAD had a 40% proximal lesion with
otherwise mild luminal irregularities. The LCx had minimal
luminal irregularities. The RCA was 100% occluded proximally
with faint left-to-right collaterals.
2. Resting hemodynamics limited to central aortic pressure
revealed
cardiogenic shock with SBP 70s and HR 30s at the beginning of
the case,
which markedly improved following RCA reperfusion with SBP 160s
and HR
80s at the end of the case. 3. Successful primary PCI of the
100% proximally occluded RCA in setting of cardiogenic shock and
maximal pressor support following intubation/mechanical
ventilation (performed in cath lab). 4. Sucecssful stenting of
the proximal RCA with two overlapping
MiniVision BMS (2.5x23 mm distally and 3.0x12 mm proximally
covering the
ostium) with excellent results (see PTCA comments) 5. Successful
stenting of the distal RCA subtotal occlusion with a 2.25x18 mm
MiniVision BMS with excellent result (see PTCA comments) 6.
Successful POBA of the distal RCA just adjacent to the edges of
the 2.25 mm stent with a 2.5 mm balloon with excellent results
(see PTCA comments). 7. Deployment of an entrapped 2.25x8 mm
MiniVision stent inside the proximal RCA stents at high pressure
followed by postdilatation with a 3.0 balloon to 22 ATM. Final
angiography showed excellent results. 8. Significantly improved
hemodynamics following RCA reperfusion as evidenced by the
weaning off of vasopressors.
FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2.
Cardiogenic shock secondary to inferoposterior and RV acute MI
requiring maximal pharmacologic hemodynamic support. 3. Severe
acidosis and hypercapnia requiring emergent endotracheal
intubation and mechanical ventilation.
4. Successful PTCA and stenting of the proximal RCA with two
overlapping
(2.5x23 and 3.0x12 mm) BMS, all postdilated to 3.0. 5.
Successful stenting of the distal RCA with 2.25x18 mm MiniVision
BMS. 6. Successful POBA of the distal RCA with 2.5 mm balloon.
7. Deployment of an entraped 2.25x8 mm MiniVision BMS inside the
stented proximal RCA (postdilated to 3.0 at 22 ATM). 8.
Successful closure of the LCFA with Perclose device. 9.
Unsuccessful closure of the RCFA with Perclose device requiring
application of manual pressure with successul hemostasis. 10.
ASA (325 mg daily for a month then 162 mg daily thereafter). 11.
Plavix once NG tube placed in CCU (600 mg load then 75 mg daily
for at least 1 year).
12. Continue Integrillin unless bleeding develops.
Brief Hospital Course:
Ms. [**Known lastname **] is a 76 y/o F with CAD s/p NSTEMI [**8-31**], Left
subclavian steal, Hypertension who was admitted with inferior
STEMI.
.
# Inferior STEMI:
Patient was admitted with Inferior STEMI with bradycardia and
hypotension in the ED, initially requiring norepinephrine and
dopamine. ECG showed ST elevations in leads III, II, and V4R,
suggesting RV involvement. Initial CK was 299 with Trop O.07.
She was not given any nitrates in setting of inferior MI.
Hypotension and bradycardia were consistent with acute MI with
RV involvement. She was sent for Cardiac Catheterization where
BMS was placed in proximal and distal RCA. She improved
hemodynamically following PCI without evidence of continued
bradycardia; pressors were also weaned off quickly after PCI.
She was started on integrilin initially. She was continued on
home dose aspirin 325mg and started on clopidogrel 150mg [**Hospital1 **] for
7 days then 75mg daily. CK peaked at 128, and Trop peaked at
5.57. She was given atorvastatin 80mg daily during
hospitalization, then switched back to home simvastatin 80mg
upon discharge. Home pindolol was held initially in the setting
of bradycardia but was restarted the day after admission when
bradycardia resolved. She was also restarted on her home dose of
lisinopril for cardioprotection and hypertension. TTE showed
moderate pulmonary artery systolic hypertension, symmetric left
ventricular hypertrophy, and mild dilation of right ventricular
cavity with focal basal free wall hypokinesis.
# Hypertension:
Patient was hypotensive on presentation in setting of inferior
STEMI, but hypotension quickly resolved post PCI. She was
hypertensive for the rest of hospitalization, so her home blood
pressure medications were restarted slowly and titrated upwards.
She was discharged on her home medications of hydralazine,
lisinopril and pindolol with the pindolol dose increased to 10mg
TID.
# Mechanical Ventilation:
Patient was intubated given hemodynamic instability on
presentation and need for catheterization. After PCI, she was
hemodynamically stable, and pressors were weaned off. Patient
was extubated without complications. She was somewhat agitated
for several hours after extubation.
.
# Diarrhea:
Patient reported diarrhea at home prior to hospitalization,
though she did not have any diarrhea during hospitalization.
Diarrhea was of unclear etiology, possibly viral
gastroenteritis. Stools were guaiac negative.
# Hyperlipidemia:
Patient was treated with atorvastatin 80mg during
hospitalization but switched back to home simvastatin 80mg daily
on discharge. Lipids were checked, and calculated LDL was
mildly elevated at 110.
Medications on Admission:
Aspirin 325 mg Tablet daily
Hydralazine 100 mg Tablet po TID
Levothyroxine 25mcg daily
Lisinopril 20mg tablet daily
Pindolol 5mg tablet [**Hospital1 **]
Simvastatin 80mg tablet daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. Pindolol 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
10. Pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO three
times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health
Discharge Diagnosis:
Inferior ST Elevation Myocardial Infarction
Hypertention
Tobacco Abuse
Paroxysmal Atrial fibrillation
Phlebitis right wrist s/p intravenous line
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You had a heart attack and needed to have a breathing tube to
help you through the acute event. You needed 2 bare metal stents
to be placed in your right coronary artery. Your right and left
groin have bruises after this procedure but there is no evidence
of new bleeding or infection. If you notice increasing and
painful lumps in your right or left groin, please call Dr.
[**First Name (STitle) 2031**]. It is very important that you take all of your medicines
every day. It is epsicially important that you take your Plavix
and aspirin every day and don't miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**], otherwise the
stents could clot off and you could have another heart attack.
Medication changes:
1. Take Plavix 150 mg twice daily for 4 days followed by Plavix
75 mg daily to prevent the stents from clotting off.
2. Take aspirin every day to prevent the stents from clotting
off.
3. Increase the Pindolol to 10 mg twice daily
4. Stop taking Capropril
5. Decrease Lisinopril 20 mg to once daily
.
Please keep your right arm elevated with warm packs every hour.
The phlebitis is improving today but please call Dr. [**First Name (STitle) 2031**] if
you notice increasing redness, pain or swelling.
Followup Instructions:
Primary Care and Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] P. Phone: [**Telephone/Fax (1) 77385**] 5114 Date/Time: Friday
[**1-18**] at 11:30 am
|
[
"401.9",
"285.9",
"414.2",
"305.1",
"412",
"272.4",
"414.01",
"427.31",
"785.51",
"V10.87",
"435.2",
"410.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.47",
"00.40",
"96.71",
"88.56",
"99.20",
"36.06",
"00.66",
"96.04",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
10520, 10586
|
6636, 9307
|
287, 380
|
10775, 10775
|
3455, 5566
|
12169, 12333
|
2544, 2632
|
9540, 10497
|
10607, 10754
|
9333, 9517
|
5583, 6613
|
10923, 11625
|
2647, 3436
|
11645, 12146
|
242, 249
|
408, 1625
|
10790, 10899
|
1647, 2254
|
2270, 2528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,543
| 199,091
|
22820
|
Discharge summary
|
report
|
Admission Date: [**2181-1-21**] Discharge Date: [**2181-1-30**]
Service: MEDICINE
Allergies:
Lidocaine
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
weakness and nausea/vomiting
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
83 year old male with htn, DM, hx CVA, PVD s/p bilateral BKA's,
was transferred from [**Hospital3 7569**] after presenting with 1
week weakness and 24 hours of n/v/d. W/U at OSH revealed new
ARF with Cr 2.4, CK 1720, Tn 6 with EKG revealing inferior Q's.
BP on admission 80's/40's. Given aspirin, plavix, heparin and
dopamine gtt. At [**Hospital1 18**] ED, noted to be febrile to 101.2 with
UTI. Pt then admitted to MICU.
Past Medical History:
HTN
NIDDM
Hx CVA '[**75**]
Bilateral BKA's
Social History:
30 pack year tob, now quit. No EtOH or IVDU. Lives alone.
Family History:
Non-contributory
Physical Exam:
98.1 141/65 80-95 20
Gen: NAD, A& O X 3, comfortable,
Heent: EOMI, PERRL, MMM, few excoriations on face
Neck: No JVD or LAD
Heart: Tachy. Irregular. [**3-18**] cresendo systolic murmur at base
radiating to carotids. Also [**2-18**] holosystolic murmur at apex
with no radiation.
Lungs: Few crackles left lower lung field.
Abd: Soft, nt/nd. +BS.
Ext: Bilateral BKA's. No sacral edema.
Pertinent Results:
[**2181-1-30**] 06:15AM BLOOD WBC-8.1 RBC-4.12* Hgb-12.2* Hct-35.4*
MCV-86 MCH-29.6 MCHC-34.4 RDW-14.4 Plt Ct-248
[**2181-1-24**] 08:26PM BLOOD WBC-16.0* RBC-2.98* Hgb-8.9* Hct-26.7*
MCV-89 MCH-30.0 MCHC-33.5 RDW-14.8 Plt Ct-56*
[**2181-1-21**] 09:30PM BLOOD WBC-12.9* RBC-3.84* Hgb-11.7* Hct-34.9*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.1 Plt Ct-90*
[**2181-1-30**] 06:15AM BLOOD Plt Ct-248
[**2181-1-28**] 05:24AM BLOOD PT-12.5 PTT-26.2 INR(PT)-1.0
[**2181-1-25**] 04:05AM BLOOD Plt Ct-52*
[**2181-1-21**] 09:30PM BLOOD Plt Smr-LOW Plt Ct-90*
[**2181-1-23**] 04:49AM BLOOD Fibrino-442*
[**2181-1-30**] 06:15AM BLOOD Glucose-191* UreaN-26* Creat-0.9 Na-138
K-4.0 Cl-100 HCO3-30* AnGap-12
[**2181-1-22**] 02:01AM BLOOD Glucose-163* UreaN-53* Creat-1.8* Na-143
K-4.1 Cl-117* HCO3-17* AnGap-13
[**2181-1-27**] 05:24AM BLOOD ALT-93* AST-46* AlkPhos-164* TotBili-0.8
[**2181-1-23**] 04:49AM BLOOD ALT-348* AST-295* LD(LDH)-392*
CK(CPK)-1679* AlkPhos-101 TotBili-0.9
[**2181-1-22**] 02:01AM BLOOD CK(CPK)-4156*
[**2181-1-26**] 10:47AM BLOOD GGT-96*
[**2181-1-26**] 06:07AM BLOOD Lipase-28
[**2181-1-23**] 05:30PM BLOOD CK-MB-79* MB Indx-6.7* cTropnT-1.44*
[**2181-1-30**] 06:15AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.1
[**2181-1-23**] 04:49AM BLOOD Albumin-2.8* Calcium-7.8* Phos-3.1 Mg-2.3
[**2181-1-26**] 10:47AM BLOOD TSH-2.4
[**2181-1-26**] 10:47AM BLOOD Free T4-1.3
[**2181-1-22**] 04:26AM BLOOD Cortsol-46.9*
[**2181-1-22**] 03:55AM BLOOD Cortsol-40.9*
[**2181-1-22**] 03:16AM BLOOD Cortsol-33.8*
[**2181-1-26**] 10:47AM BLOOD Digoxin-1.3
[**2181-1-21**] 09:57PM BLOOD Lactate-2.3*
TTE: The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with akinesis of
the basal 2/3rds of the inferolateral and basal inferior walls.
The distal septum is also hypokinetic. The remaining segments
contract well. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Minimal aortic valve stenosis. Mild mitral regurgitation.
Cath:
1. Three vessel coronary artery disease.
2. Moderate diastolic dysfunction.
3. Successful PCI of the LAD.
COMMENTS:
1. Selective coronary angiography revealed a right-dominant
system.
The LMCA had no angiographic disease. The LAD had 70% ostial and
sequential 80% proximal lesions with diffuse moderate disease.
The Lcx
had on occluded OM2 with diffuse severe proximal disease and an
80%
mid-vessel lesion. The RCA had an 80% proximal lesion with a
total
occlusion after a high-rising PDA which had proximal disease to
70%.
The rCA filled via LCA collaterals.
2. Left ventriculography was deferred.
3. Resting hemodynamics revealed moderately elevated left-sided
filling pressures (PCWP 21 mmHg mean). The right sided filling
pressures were mildly elevated (RA mean 6mmHg, PA mean 30mmHg).
The
calculated cardiac index was 2.1 l/min/m2.
4. Successful PCI of the LAD with rotational atherectomy with a
1.5 mm
burr and PTCA/Stenting using a 2.5 x 28 mm Cypher DES
(overlapping, covering both ostial and proximal LAD lesions). A
7 French IABP was placed in the RFA prophylactically during the
case and removed at the end of the case.
Brief Hospital Course:
83 year old male with PVD, hx CVA, htn, DM with PNA and early
sepsis, precipitating demand ischemia then unstable angina then
myocardial damage and cardiogenic hemodynamic embarassament.
1. CAD: Pt's peak CK 4156. Initially attributed to demand
event in setting of comorbidities (see below), but then
developed run of symptatic monomorphic VT, which was attributed
to coronary disease, so Mr.[**Known lastname **] was then taken to the cath lab.
Found to have 3VD with probable culprit lesion mid-LAD. After
extensive discussion with family, the decision to defer CABG was
made based on high risk of peri-operative mortality. After
overlap stenting of LAD, the pt remains pain free and stable.
Pt was started on aspirin and plavix, and will be on plavix for
at least 9 months. Beta-blocker was carefully started, given hx
of hypotension. Will be d/c'd on toprol XL 50 qD. Also on
lisinopril 10 mg po QD. High-dose statin for life. Mr.[**Known lastname **]
could very well continue to have angina that may be secondary to
his non-revascularized LCx, RCA, OM2 or PDA lesions.
2. Pump: Pt with EF 35-40% with regional wall motion
abnormalities. Cardiac output and index 3.5/2.1, PCWP 28, and
SVR 1600. IABP was used transiently during the pt's cath. He
transiently required dopamine, which was switched to
neosynephrine then vasopressin. This pressor requirement was
attributed to combination cardiogenic shock and early sepsis.
He currently has no pressor requirement. Digoxin was added to
Mr.[**Known lastname **] regimen to augment his inotropy. Pt diuresed while in
house but does not require any further diuresis as outpt. Now
that pt is partly revascularized, his EF may have improved
slightly and he may need an ECHO in the future to better
estimate his systolic function.
3. Rhythm: Mr.[**Known lastname **] was noted to have a variety of arrhythmias
while in house. His sinus rhythm has prolonged AV nodal delay
of 225 msec and inferior Q's on surface ECG. Prior to cath the
pt had occasional 6-8 beat runs of NSVT. He also had a 40 beat
run monomorphic VT 24 hours following recanulization, which was
self-terminated. He did not have any further episodes of VT or
NSVT. Mr.[**Known lastname **] was also noted to go in and out of A-fib/flutter.
His ventricular response is controlled in the 70's - 90's.
Digoxin was started to further control his rate. He will be
discharged with toprol XL 50 mg po qD for further rate control
(please watch the pt's PR if deciding to titrate up the
beta-blocker, or any other nodal blocker). The pt has been
started on coumadin given his very high CHADS risk score of [**6-18**].
4. ID: Pt noted to have a dirty UA on admission and a left
lower lobe infiltrate on CXR. His hypotension was initially
attributed to infection/sepsis, but his hemodynamics were more
consistent with cardiogenic shock (see above). He was started
on levaquin and ceftriaxone for UTI and PNA. All urine and
blood cultures have returned with no growth. Max WBC 24.9 (with
30% bandemia) and temperature 101.9. These trended down and
currently Mr.[**Known lastname **] has no fever and his WBC count is 8.1. His
ceftriaxone was d/c'd on day #5. The patient will continue on
levaquin for total of 14 days, will end on [**2181-2-5**].
5. Hypotension: Transferred to [**Hospital1 18**] on dopamine gtt and the
pt continued to require blood pressure augmentation with
neosynephrine, vasopressin and prn fluid boluses. Initially
attributed to sepsis, but hemodynamics during right heart cath
were more consistent with cardiogenic shock (CO/CI 3.42/2.08,
PCWP 28, SVR 1600). The pt's hypotension normalized after
revascularization of LAD.
6. ARF: Mr.[**Known lastname **] was transferred with Cr 0f 1.8 with FENA 1.2%.
This trended down with improved blood pressure augmentation.
Etiology likely non-oliguric ATN in setting of persistent renal
hypoperfusion. Currently Cr 0.8 and GFR estimate of 98
ml/min/meter^2 by MDRD equation (may be overestimate given lack
of lower extremity musculature).
7. Thrombocytopenia: Pt admitted with plt nadir of 90k.
Currently 248k. Most likely explanation is DIC given
coagulopathy at time of presentation also. However, although
low pre-test prob, all heparin and heparin containing compounds
were discontinued for worry of HIT. Mr.[**Known lastname **] has no evidence of
arterial/venous thrombosis seen in HIT. He had one HIT ab that
returned negative and his seretonin release assay is still
pending from [**State 3706**].
8. Transaminitis: AST 348 ALT 295 and LDH 392. All trending
down and thought to be secondary to hepatic congestion in
setting of cardiogenic shock. Current levels as above.
Medications on Admission:
atenolol 25 daily
liinopril 40 daily
actos 30 daily
hctz 12.5 daily
glipizide 10 [**Hospital1 **]
aspirin 325 daily
lipitor 40 daily
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
5. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO DAILY (Daily).
Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2*
11. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
6 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) **]
Discharge Diagnosis:
NSTEMI
Ventricular Tachycardia
Cardiogenic Shock
Left Lower Lobe Pneumonia
Thrombocytopenia
Retroperitoneal Hematoma
Discharge Condition:
Good
Discharge Instructions:
If you have these symptoms, [**Known lastname 138**] your doctor or go to the ED:
- chest pain
- shortness of breath
- dizziness
- visual changes
- blood in stool
- black stools
- sudden weakness
- fever, chills
Followup Instructions:
Please [**Known lastname 138**] your PCP and be seen within 10 days.
Please [**Known lastname 138**] the [**Hospital1 18**] General Cardiology Clinic, [**Telephone/Fax (1) 62**] to
arrange follow-up in 1 month.
Completed by:[**2181-1-30**]
|
[
"272.0",
"401.9",
"573.0",
"287.5",
"414.01",
"410.71",
"286.6",
"V49.75",
"998.12",
"250.00",
"584.5",
"486",
"599.0",
"427.89",
"428.0",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"36.01",
"36.07",
"97.44",
"99.04",
"37.61",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
11234, 11302
|
4958, 9669
|
254, 269
|
11463, 11469
|
1349, 4935
|
11730, 11973
|
883, 901
|
9852, 11211
|
11323, 11442
|
9695, 9829
|
11493, 11707
|
916, 1330
|
186, 216
|
297, 724
|
746, 790
|
806, 867
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,139
| 145,199
|
13481
|
Discharge summary
|
report
|
Admission Date: [**2106-10-29**] Discharge Date: [**2106-11-4**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Positive ETT
Major Surgical or Invasive Procedure:
[**2106-10-29**] CABGx3
[**Last Name (NamePattern4) 15255**] of Present Illness:
82 year old asymptomatic gentleman who while being worked-up for
back surgery was found to have a positive exercise tolerance
test. A cardiac catheterization was performed which revealed
left main and three vessel disease. He was subsequently referred
to Dr. [**Last Name (Prefixes) **] for surgical revascularization.
Past Medical History:
MI in [**2073**]
Spinal stenosis
Peripheral neuropathy
Left kidney cancer with metastatic disease to left lung
s/p Left nephrectomy
s/p left wedge lung resection
Bilateral cataract surgery
Social History:
Retired school teacher and principal. Lives with wife. very rare
alcohol use. Never smoked.
Family History:
Mother with 2 MI's and died of CVA at age 84
Physical Exam:
96.8 69 reg 185/67 99% RA
GEN: Pleasant elderly man in NAD
HEENT: PERRL, EOMI, OP benign
LUNGS: Clear
ABD: Benign
EXT: Warm, no edema, no varicosities. 2+ pulses.
Pertinent Results:
[**2106-11-4**] 06:55AM BLOOD WBC-11.3* RBC-3.51* Hgb-10.7* Hct-30.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-15.5 Plt Ct-246
[**2106-11-4**] 06:55AM BLOOD Plt Ct-246
[**2106-11-4**] 06:55AM BLOOD UreaN-35* Creat-1.2 K-4.6
[**2106-10-30**] CXR
The right IJ vascular line is present terminating in the lower
SVC. The heart is enlarged and there is an ill-defined opacity
present at the left base. The ETT, the NGT, and chest and
mediastinal tubes have been removed since [**2106-10-29**]. No definite
pneumothorax is noted.
[**2106-10-31**] EKG
Atrial fibrillation with a controlled ventricular response with
a single wide complex beat similar to the pattern seen earlier
on [**2106-10-31**]. The narrow omplexes appear similar to earlier on
[**2106-10-31**] as well, but are now much more frequent. Clinical
correlation is suggested.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Name13 (STitle) 4027**] was admitted to the [**Hospital1 18**] on [**2106-10-29**] for surgical
management of his coronary artery disease. He was evaluated and
taken to the operating room where he underwent coronary artery
bypass grafting to three vessels. Postoperatively he was taken
to the cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Name13 (STitle) 4027**] awoke neurologically intact,
although slightly confused and was extubated. He developed rapid
atrial fibrillation which converted to normal sinus rhythm with
amiodarone and beta blockade. He was transfused with packed red
blood cells for postoperative anemia. On postoperative day two,
he was transferred to then step down unit for further recovery.
Mr. [**Name13 (STitle) 4027**] was gently diuresed towards his preoperative weight.
A sitter was used to sit with him at night given his confusion
however was discontinued after two evenings as his confusion
cleared. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Mr.
[**Name13 (STitle) 4027**] continued to make steady progress and was discharged to
rehabilitation ([**Hospital **] Rehabilitation) on postoperative day
six. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist
and his primary care physician as an outpatient.
Medications on Admission:
Atenolol 25mg daily
Gabepentin 400mg three time daily
Aspirin 81mg daily
Saw [**Location (un) 6485**]
Metamucil
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 400mg twice a day through [**2106-11-7**]. Then 200mg twice
a day for 1 week and then 200mg once a day thereafter. .
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Gabapentin 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 3 days.
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 3 days.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): [**Month (only) 116**] discontinue on discharge from rehab.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
CAD s/p CABG x3
Prior MI
Spinal stenosis
Left renal cell cancer
HTN
Left lung wedge resection
Left nephrectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage and increased pain.
2) Reprot any fever greater then 100.5
3) Report any weight gain of greater then 2 pounds in 24 hours.
4) No lifting more then 10 pounds for 10 weeks from date of
surgery.
5) No driving for 1 month from date of surgery.
6) No lotions, creams or powders to wounds until they have
healed.
7) Take amiodarone 400mg twice a day for until [**2106-11-7**], then
200mg twice a day for 1 week, then 200mg once a day thereafter
until seen or instructed by Dr. [**Last Name (STitle) **].
8) Take lasix 20mg with potassium 20mEq twice daily for three
days then stop.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) **] in 2 weeks
Follow-up with Dr. [**First Name (STitle) **] in [**3-5**] weeks. [**Telephone/Fax (1) 250**]
Please call all providers for appointments.
|
[
"411.1",
"414.01",
"356.9",
"427.31",
"V10.52",
"285.1",
"197.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"99.04",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4760, 4790
|
282, 685
|
4945, 4952
|
1270, 2098
|
1022, 1068
|
3678, 4737
|
4811, 4924
|
3541, 3655
|
4976, 5627
|
5678, 5977
|
1083, 1251
|
2149, 3515
|
230, 244
|
707, 897
|
913, 1006
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,543
| 112,035
|
52397
|
Discharge summary
|
report
|
Admission Date: [**2196-10-17**] Discharge Date: [**2196-10-20**]
Date of Birth: [**2129-8-12**] Sex: M
Service: NEUROLOGY
Allergies:
Tegretol / Dilantin Kapseal / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Bactrim
Attending:[**First Name3 (LF) 13017**]
Chief Complaint:
Seizure/Possible GI Bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 67 year old man with history of diabetes,
dyslipidemia, hypertension, coronary artery disease (s/p
multilple stents and CABG in [**2189**]), seizure disorder (on
lamotrigine only), macrocytic anemia, who initially presented to
the ED after finding himself down on the ground.
He was brought int to the ED by EMS, and initially evaluted,
with trauma survey overall negative, but facial/nasal bone
fractures. During his initial presentation to the ED he was not
complaining of any problems other than facial pain. He stated
that his blood sugar might have been low, but EMS stick was FS
of 250s. While in the ED he had a seizure ( described as Jerking
Tonic/Clonic, generlized, with face deviating to the left,
looked like grand-mal, brief). At this time he was incontinent
of stool, but not urine.
He was not given anything, and seizure spontaneosly resolved. FS
of 85, given some glucose. ? Epistaxis running down back of his
throat. He had an episode of coffee-ground emesis. Guaiac
negative from below. Per report, he was diaphoretic, and "sick
looking".
.
At this time Patient was not given any medications other than
glucose to correct his episode of hypoglycemia. Prior to
transfer he was started on Protonix IV, Zofran. Nurse also noted
"compartment syndrome in left forearm" - could be IV
infiltrating, and patient is not complaining of painin that arm.
Doppler was done - radial pulse present.
.
.
His presentation, vs were: 96.1-76-132/68-18-98%RA
Timing of Events in ED:
- Emesis 15 minutes prior to transfer to ICU.
- Seizure - 40 minutes prior to transfer.
- Neuro came by but patient was vomiting, thus deferred
evaluation.
- Prior to transfer, the patient had another episode of seizure,
and was given ativan and sent for another CT scan of his head to
rule out bleed.
.
Vitals prior to transfer - 83 Pulse, 18 Resp 100% Room Air, BP
125/55 (but had as low as 105 SBP). Afebrile entire ED stay.
.
Initial CT spine was notable for:
1. No acute cervical spine fracture or malalignment.
2. Mild degenerative changes, worst at C4-C5.
.
Initial CT head was notable for:
1. No acute intracranial abnormality.
2. Bilateral nasal bone fractures and nasal septal fracture.
3. New mild bifrontal prominence of CSF spaces.
.
The patient then was reportedly worse, had another seizure, was
given a total of 4 ativan IV, noted to have worsening mental
status. ED was concerned for evolving intracranial process, and
repeated CT, which was unchanged.
.
On arrival to the floor, the patient was only responding to
painful stimuli. His vitals were stable and he did not grimace
on palpation of his extremities, his abdomen or back, and was
moving his extremities spontaneously.
Past Medical History:
- DM-1: for almost 50 years, he has neuropathy and retinopathy.
-- CAD: 4 stents [**2180**], RCA stent [**11/2189**], 3v-cabg [**9-/2190**], NSTEMI
[**2190**]
- Syncopal episode in [**Month (only) 205**], attributed to arrhythmia. Underwent
cath. without stent placement.
- GTC Seizures (wife describes that normal semiology = "lets out
a cry," shakes all limbs for ~30 sec, groggy afterwards): ?
related to hypoglycemia, stable on Lamictal, no seizures for
several years (previously on PHB, stopped in [**2190**])
- Onychodystrophy
- Seborrheic dermatitis
Social History:
Lives with wife. Retired H.S. English teacher
(retired early [**12-16**] encephalopathy). [**Month/Day (2) **] several times weekly.
-Tobacco history: 2 cigars per week (equivalent to a 25 py hx).
-ETOH: Has 1 EtOH drink with dinner.
-Illicit drugs: Denies.
Family History:
Father and sister with [**Name2 (NI) **] at young age (40-50).
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: Afebrile, HR 81 regular, BP 133/47 RR 14 SpO2 98% RA
fingerstick 213
General: Responds to painful stimuli by grimacing, not talking,
not responding to commands.
HEENT: Sclera anicteric, pupils 4mm, reactive to light,
Neck: supple, JVP not elevated, no LAD,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, with the exception of his left arm, but radial is
dopplerable.
Skin Exam: Small abrasion on top of scalp, several excoriative,
well healed lesions throughout. Overall dry skin. Some dried
blood around nares.
Neurological:
Mental status:
Groans to noxious stimuli, but not rousable.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements could not be assessed, but
gaze is conjugate.
V, VII: Face symmetric.
VIII: Hearing not evaluable.
IX, X: Not tested.
[**Doctor First Name 81**]: Not tested.
XII: Not tested.
Tone normal in legs, gegenhalten in arms.
Power: Strong withdrawal in legs and arms.
Reflexes: B T BR Pa Ac
Right 2 2 2 3 0
Left 2 2 2 3 0
Right toes up; left down.
Sensation intact to noxious stimuli.
At discharge:
Pertinent Results:
[**2196-10-17**] 12:00PM BLOOD WBC-8.5 RBC-3.92* Hgb-12.8* Hct-40.0
MCV-102* MCH-32.7* MCHC-32.1 RDW-15.2 Plt Ct-527*
[**2196-10-18**] 03:46AM BLOOD WBC-14.3* RBC-3.36* Hgb-11.2* Hct-34.6*
MCV-103* MCH-33.4* MCHC-32.4 RDW-15.2 Plt Ct-431
[**2196-10-17**] 12:00PM BLOOD Glucose-156* UreaN-15 Creat-0.7 Na-142
K-4.9 Cl-104 HCO3-29 AnGap-14
[**2196-10-18**] 03:46AM BLOOD Glucose-244* UreaN-17 Creat-0.8 Na-135
K-4.7 Cl-101 HCO3-24 AnGap-15
[**2196-10-17**] 12:00PM BLOOD ALT-20 AST-27 AlkPhos-61 TotBili-0.5
[**2196-10-17**] 12:00PM BLOOD cTropnT-<0.01
[**2196-10-17**] 12:00PM NEUTS-83.9* LYMPHS-10.5* MONOS-3.4 EOS-1.4
BASOS-0.8
[**2196-10-17**] 12:00PM LIPASE-9
[**2196-10-17**] 12:11PM GLUCOSE-145* LACTATE-1.8 K+-4.4
[**2196-10-17**] 03:50PM URINE MUCOUS-RARE
[**2196-10-17**] 03:50PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2196-10-17**] 12:00PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-1.3*#
MAGNESIUM-2.1
[**2196-10-17**] 03:50PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2196-10-17**] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2196-10-17**] 03:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2196-10-17**] 06:07PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2196-10-17**] 06:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-70 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
ECG:
Sinus rhythm. Prolonged Q-T interval. Early R wave transition.
Low
QRS voltage in the limb leads. T wave inversions in leads V1-V3
which are new compared to tracing of [**2196-6-1**]. Cannot exclude
myocardial ischemia. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 144 102 460/465 76 17 87
CT Head without contrast:
FINDINGS: There is no evidence of acute hemorrhage edema, shift
of midline
structures or major vascular territorial infarction. There is
new bifrontal prominence of the CSF spaces, likely representing
old subdural hematoma or CSF hygroma. The ventricles and sulci
are prominent consistent with age-related atrophy.
Atherosclerotic calcifications of the carotid and vertebral
arteries are noted. There are fractures of the bilateral nasal
bones and nasal septum.
There is mild mucosal thickening and a mucus-retention cyst in
the right
maxillary sinus. The remaining visualized paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Bilateral nasal bone fractures and nasal septal fracture.
3. New mild bifrontal prominence of CSF spaces.
CT C-spine without contrast:
FINDINGS: There is no acute fracture, dislocation, or
malalignment of the
cervical spine. There is no prevertebral soft tissue edema. The
craniocervical junction is intact. There is a posterior
disc-osteophyte
complex at C4-C5 causing mild spinal canal narrowing. There is
mild facet
spondylosis on the left at this level.
The visualized portions of the lung apices again demonstrate
chronic fibrotic changes in the medial aspect of the left lung.
There is no cervical lymphadenopathy. The thyroid gland is
unremarkable. There are bilateral atherosclerotic calcifications
of the carotid bifurcations.
IMPRESSION:
1. No acute cervical spine fracture or malalignment.
2. Mild degenerative changes, worst at C4-C5.
Head CT without contrast - repeat:
FINDINGS: There is no evidence of acute hemorrhage, edema, shift
of midline structures, or major vascular territorial infarction.
Again noted is bifrontal prominence of the CSF spaces, likely
representing old subdural hematomas or CSF hygromas. The
ventricles and sulci are prominent consistent with age-related
atrophy. Atherosclerotic calcifications of the carotid and
vertebral arteries are again noted.
There are fractures of the bilateral nasal bones and nasal
septum. There is mild mucosal thickening and a mucus retention
cyst in the right maxillary sinus. The remaining visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Bilateral nasal bone fractures and nasal septal fracture.
3. Bifrontal prominence of CSF spaces.
CXR - 1 view:
FINDINGS: In comparison with study of [**2195-8-10**], the cardiac
silhouette remains within overall normal limits. Minimal
indistinctness of pulmonary vessels raises the possibility of
increased pulmonary venous pressure. There is suggestion of some
increased opacification at the right base and in the
retrocardiac region on this side. This could merely reflect
crowded vessels or atelectasis and a lateral view would be ideal
if clinically possible to better assess for possible pneumonia.
ECG:
Sinus rhythm with atrial premature depolarization. Low QRS
voltage in limb
leads. Diffuse non-diagnostic repolarization abnormalities.
Rightward
precordial R wave transition point. Compared to the previous
tracing of [**2196-10-17**] there is no diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 142 102 448/472 59 49 110
Brief Hospital Course:
This is a 67 year old man with history of diabetes,
dyslipidemia, hypertension, coronary artery disease (s/p
multilple stents and CABG in [**2189**]), seizure disorder (on
lamotrigine only), macrocytic anemia, who initially presented to
the ED after finding himself down on the ground, became more
unresponsive and confused after witnessed seizures, now in the
MICU, responsive only to painful stimuly. Neurology was urgently
consulted and he was subsequently transferred to the general
neurology service when altered mental status improved.
.
# Altered Mental status - due to post-ictal state. Resolved over
the next few days. The patient returned to his baseline mental
status.
.
# Seizure disorder - The etiology of his fall was most likely
due to low blood sugars. The EMS team did not find this due to
the [**Last Name (un) 56493**] effect ([**Last Name (un) **] has repeatedly counseled the patient
and his family on this). We loaded the patient on Keppra and
started maintance dosing. He tolerated this well and was
discharged on his prior home dose Lamictal as well as Keppra
750mg po bid. Of note, Lamictal level has now come back and
shows a level of 2.3. The level was drawn likely after the
patient had missed 2 doses, but this level indicates that the
patient may have missed a few doses at home prior to the initial
seizure.
.
# Nasal fracture - The patient arrived to the ED with bloody
mouth and nose. CT shows that he fractured his bilateral nasal
bones and nasal septum. Plastic surgery consulted and
recommended follow up in clinic on Friday [**2196-10-21**] with possible
closed reduction the following week. Plastics is concerned for
difficulties with breathing in the future. Respiratory status
remained stable while in house. The patient was provided with
their clinic phone number on discharge.
.
# Coffee-ground emesis - had o/ne episode of what was described
as coffee- ground emesis, after the seizure. At the time he was
diaphoretic, and looked unwell. He was hemydynamically stable
however. His [**Doctor Last Name 80870**] score is 1 (Score predicting resolution
without intervention: <4) thus he is unlikely to benefit from
Upper GI endoscopy. He is Guaiac negative and his likely source
of bleeding is epistaxis given trauma of his face. He was Guaiac
Negative in ED.
- GI consulted
- HCT remained stable
- no further emesis
.
**** OF NOTE - In regard to future ED Visits:
[**Known firstname **] [**Known lastname **] has a strong history of having generalized
seizures early in the morning when his blood glucose is low.
Often by time EMS checks his blood glucose after the event, the
result is normal or high due to the [**Last Name (un) 56493**] effect. If he
arrives in the emergency room in such a context, he should be
either loaded on an anti-epileptic medicine or started on a
standing IV ativan bridge (e.g.: ativan 1mg IV q6 hours) in
order to prevent further generalized seizures within 24 hours.
This is important as when the patient has several seizures
within a 24 hour period, he becomes very somnolent for days due
to a post-ictal state. Thank you for taking this into
consideration.
Medications on Admission:
-One Touch Ultra - Strips Strips 5-6 times a day as directed
-Bd Ultra-fine Iii - Pen Needles 31g [**3-28**]" as directed injecting
5 times daily
-Levemir 100 Unit/ml 14 in am and 2 in pm
-Simvastatin 40 Mg take 1 tablet (40MG) by ORAL route every day
in the evening
-Humalog 100 Unit/ml pen approx 15 units a day as directed
-Glucagon Emergency Kit 1 Mg Use as directed
-Ketostix Reagent Check for ketones when BS > 250 and cannot
explain one time
-Insulin Syringe 31 Gauge X [**3-28**]" 2 per day
-Bd Ultra-fine - Syringes 30g 1/2cc 3 times a day
-Toprol Xl 25mg 1 per day
-One Touch Ultra Soft - Lancets Lancet as directed
-Bd Ultra-fine Iii - Syringes 30g 5/16l 1/2 cc. Use one daily.
-Ketostix - Strips Bottle Use as directed
-Pen Needle 29 Gauge X [**11-15**]" as directed
-Bd Ultra-fine - Syringes 29g [**11-15**] C as directed
-Aspirin Ec 81mg 1 per day
-Enalapril Maleate 10 Mg 1 per day
-Lamictal 100mg twice a day
-Plavix once a day
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
6. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
8. Levemir 100 unit/mL Solution Sig: 10 units in the morning and
2 units at night unit Subcutaneous twice a day: as directed by
[**Last Name (un) **].
9. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
once a day: as directed by [**Last Name (un) **].
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
nasal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: no deficits
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you during your stay. You were
admitted to the hospital after a fall, suspected to be due to a
seizure related to low blood glucose. During your stay you had 2
more seizures. You were started on a new anti-seizure medicine
by the name of Keppra. Please take Keppra 750mg by mouth twice
daily in addition to your home Lamictal. Please avoid swimming
for at least the next 6 months to ensure your safety as it would
be extremely dangerous and possibly deadly if you were to have a
seizure while swimming. Likewise, it is [**State 350**] state law
that anyone who has suffered a loss of consciousness such as a
seizure, may not drive until they have been seizure-free for at
least 6 months.
Unfortunately, your fall prior to admission resulted in a
fracture of your nose. The plastic surgeon team was consulted
and are concerned that you may need a closed reduction of your
nasal bone in order to prevent breathing problems in the future.
Please follow up with them in clinic to further discuss this.
Please call their clinic as listed below.
Followup Instructions:
The Plastic Surgery team asks that you please call their clinic
tomorrow, [**2196-10-21**], to arrange follow up with Dr. [**Last Name (STitle) 90769**]. Their
phone number is ([**Telephone/Fax (1) 2868**]. They ask that you call tomorrow
as the nasal fracture may need to be fixed sooner than later.
We have left a message for Dr.[**Name (NI) 10444**] assistant to call you
to schedule an appoinment within the next 2-4 weeks. If you do
not hear from her, please call ([**Telephone/Fax (1) 2528**] to schedule this
appointment.
Please attend your previously scheduled appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10490**], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**]
Date/Time:[**2196-10-26**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2196-11-1**] 3:00
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2197-1-19**] 11:20
|
[
"250.51",
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"250.81",
"784.7",
"690.18",
"345.10",
"250.61",
"357.2",
"362.01",
"414.00",
"E888.8",
"578.9",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15726, 15732
|
10790, 13924
|
377, 384
|
15798, 15798
|
5688, 10767
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|
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14918, 15703
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15968, 17071
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5669, 5669
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311, 339
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412, 3129
|
5094, 5653
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15813, 15944
|
3151, 3710
|
3726, 3987
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,081
| 125,180
|
25134
|
Discharge summary
|
report
|
Admission Date: [**2166-3-26**] Discharge Date: [**2166-4-3**]
Date of Birth: [**2127-3-7**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
L sided weakness and R sided sensory loss
Major Surgical or Invasive Procedure:
C5-C6 Corpectomy
History of Present Illness:
Mr. [**Known lastname **] is a 39 year-old right-handed man with a history
including HIV and ESRD s/p cadaveric transplant complicated by
graft failure who presents with a two-month history of
left-sided weakness and right truncal sensory change.
About two months ago, the patient first noticed an intermittent
"ache" that developed in a straight line across the upper part
of his back. At worst it rates [**9-15**]. There was no clear
trigger. Lying down exacerbates the discomfort (and he started
sleeping on the floor). The discomfort spontaneously resolves.
The discomfort has been associated with a constellation of other
sensorimotor symtoms.
He describes an intermittent "fire" "hot" discomfort that
involves the right hemi-trunk (front and back). It extends from
below the nipple level to about the hip. There are no clear
trigger, exacerbating factors, and alleviating factors; the
syndrome spontaneously resolves.
He has developed numbness in the dorsum of the left hand
including the thumb and index finger. He occasionally
experiences discomfort that seems to start in the left aspect of
the neck and extend down the left shoulder and up to the left
face. The discomfort has a throbbing quality and is associated
with pain behind the left eye. Again, there are no clear
triggers, exacerbating factors, or alleviating factors; the
syndrome spontaneously resolves.
.
In addition to the sensory changes, he developed left-sided
weakness. He noticed he was dragging his left foot at times and
had trouble going down stairs. He states his left knee feels
weak. He has also developed left arm weakness most apprecaible
distally.
.
For the syndrome, he presented to Dr. [**First Name (STitle) 3322**] [**Name (STitle) **] as an
outpatient. He was referred to the ED for further evaluation
and imaging.
Past Medical History:
HIV (CD 4 270, HIV VL undetectable [**3-/2166**] per notes)
HTN
neuropathy from HIV
s/p cadaveric renal transplant [**11-12**], c/b BK and allograft
nephropathy, failed transplant, now on HD
Social History:
Lives alone. Works as an accountant. He denies
tobacco use or alcohol; he has never used recreational agents.
He lived in [**Country **] until [**2143**]. He has lived in [**Location 7349**], [**Location (un) 86**] and
[**State **].
Family History:
N/C
Physical Exam:
Vitals: T: 97.8 P: 69 R: 16 BP: 200/90 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
Mucus
membranes moist, no lesions noted in oropharynx
Neck: Supple. No carotid bruits appreciated.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted. tattooes.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert. Able to relate history without
difficulty.
* Orientation: Oriented to person, place, day, month, year,
situation
* Attention: Attentive. Able to name the [**Doctor Last Name 1841**] backwards without
difficulty.
* Memory: Pt able to repeat 3 words immediately and recall [**2-6**]
unassisted at 30-seconds and 5-minutes.
* Language: Language is fluent without evidence of paraphasic
errors. Repetition is intact. Comprehension appears intact; pt
able to correctly follow midline and appendicular commands.
Prosody is normal. Pt able to name high (thumb) and low
frequency objects (knuckles) without difficulty. [**Location (un) **] and
writing abilities intact.
* Calculation: Pt able to calculate number of quarters in $1.50
* Neglect: No evidence of neglect.
* Praxis: No evidence of apraxia.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 3 to 2 mm and brisk. Visual fields full to
confrontation. Fundi not well-visualized.
* III, IV, VI: EOMI without nystagmus.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: No facial droop, facial musculature symmetric.
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.
Motor:
* Tone: possibly decreased in LLE
* Drift: No pronator drift.
Strength:
* Left Upper Extremity: 4+ infraspinatus, breakable Delt, 5
Biceps, trace weakness Triceps, 5 Wrist 5 Ext, Wrist 5 Flex,
Finger Ext, 4+ Finger Flex
* Right Upper Extremity: 5 infraspinatus 5 throughout Delt,
Biceps, Triceps, Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Left Lower Extremity: breakable Iliopsoas, 5 Quad, 4 Ham, 5
Adduc, breakable (can't heel walk either) Tib Ant, 5 Gastroc,
breakable Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
Reflexes:
* Left: 3 Biceps, 3 Triceps, 3 Bracheoradialis, 3+ Patellar
with
crossed adduction, 2 Achilles, about 5 beats clonus
* Right: 1+ thoughout Biceps, Triceps, Bracheoradialis, 2
Patellar, 1+ Achilles, no clonus
* Babinski: mute bilaterally (with no clear contraction of TFL)
Sensation:
* Light Touch: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Pinprick: decreased in right trunk (ant and post) from about
T2
to L2; otherwise intact bilaterally in lower extremities, upper
extremities, trunk, face
* Temperature: decreased in right trunk (ant and post) from
about
T2 to L2; otherwise intact to cold sensation
* Vibration: intact bilaterally at level of great toe bilat >12
sec, index finger bilat
* Proprioception: intact bilaterally at level of great toe,
index
finger
* Extinction: No extinction to double simultaneous stimulation
* Cortical: No evidence of agraphesthesia
Coordination
* Finger-to-nose: intact bilaterally
* Heel-to-shin: intact bilaterally
* finger tapping: quick, possible decrement/hesitation on left
Gait:
* Description: Good initiation. Narrow-based with normal-length
stride and symmetric arm-swing
* Tandem: Able to tandem walk
* Romberg: slight sway
* able to toe walk; has difficulty heel walking on left
Pertinent Results:
[**2166-3-25**] 07:55PM BLOOD WBC-2.5* RBC-3.48* Hgb-10.5* Hct-32.5*
MCV-93 MCH-30.3 MCHC-32.4 RDW-18.1* Plt Ct-121*
[**2166-3-26**] 05:19AM BLOOD PT-12.6 PTT-27.5 INR(PT)-1.1
[**2166-3-25**] 07:55PM BLOOD ESR-15
[**2166-3-25**] 07:55PM BLOOD Glucose-95 UreaN-73* Creat-9.5* Na-138
K-5.3* Cl-112* HCO3-17* AnGap-14
[**2166-3-26**] 05:19AM BLOOD Calcium-8.6 Phos-4.6* Mg-1.5*
[**2166-4-1**] 05:25AM BLOOD PTH-850*
Hepatitis B Surface Antigen NEGATIVE
Hepatitis B Surface Antibody POSITIVE
TITER IS BETWEEN 15 AND 100 MIU/ML
PROTECTIVE TITERS ARE >10 MIU/ML
Hepatitis B Core Antibody, IgM NEGATIVE
HEPATITIS C SEROLOGY
Hepatitis C Virus Antibody NEGATIVE
[**2166-3-26**] 05:19AM BLOOD tacroFK-4.1*
[**2166-3-25**] 07:55PM BLOOD CRP-0.6
[**2166-3-26**] 05:19AM BLOOD HCV Ab-NEGATIVE
[**2166-3-28**] 05:37PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-2* Polys-1
Lymphs-84 Monos-15
[**2166-3-28**] 05:37PM CEREBROSPINAL FLUID (CSF) TotProt-36 Glucose-61
LD(LDH)-10
CSF gram stain and cultures negative
MRI C/T/L SPINE
1. A large anterior epidural disc protrusion is present at C4-C5
with
extension superiorly to the superior endplate of C4 and
inferiorly to the
level of the C6 vertebral body likely representing disc material
and/or
thickened reactive posterior longitudinal ligament. The spinal
canal is
severely narrowed worst at C4-C5 with compression of the
cervical cord at
these levels, again most severely at C4-C5. T2 hyperintensity is
present
within the cervical cord at these levels. Whether this is acute
T2
hyperintensity edema or myelomalacia or a combination of the two
is
indeterminate without prior studies for comparison.
2. Moderate thoracic and lumbar spondylosis as described above
without
significant spinal canal or neural foraminal stenosis.
3. Diffuse homogeneous T1 hypointensity of the spinal marrow
signal possibly representing the sequella of anemia of chronic
disease.
CSpine AP/LAt post op
Patient is status post corpectomy at C4, C5 and C6. There has
been anterior plate fixation at C3 to C6. Anterior soft tissue
swelling is present.
Visualized lung apices are grossly clear. There is a vascular
stent
projecting over the mediastinum.
Brief Hospital Course:
39 yo RHM with h/o HIV, ESRD s/p cadaveric transplant presents
with 2 months of progressive symptoms of L sided weakness and R
trunk sensory loss.
# PARTIAL BROWN SEQUARD SYNDROME
Patient presents with a two-month history of left-sided weakness
and right truncal sensory change and was found to have evidence
of myelopathy (weakness of left limbs in an upper motor neuron
pattern, left-sided hyperreflexia with clonus, and absence
of pain and temperature sensation in the right hemibody from
about T2 to L2 with preserved dorsal column function
bilaterally).
MRI with gadolinium showed large disc protrusion at C4-C5, which
was consistent with the exam findings. There was initially
concern for neoplastic and infectious causes given his risk
factors. LP was performed which was negative for inflammation,
with normal cell count, normal protein and negative
cytology/flow. Neurosurgery was then consulted.
# ERSD
The patient is s/p cadaveric transplant complicated by allograft
and BK/polyoma nephropathy, leading to failure of the
transplant. The patient's creatinine was 9 on admission. Given
the need to perform MRI with gadolinium, renal team was
consulted. They recommened urgent HD immediately following MRI.
The patient had undergone AV fistula several weeks prior in
setting of imminent need for HD, however this AV fistula was
found to have clotted. Therefore, tunneled line was placed.
Patient underwent multiple HD sessions which he tolerated well.
Given that his transplant is no longer functioning, his
immunosuppresion regimen is being decreased gradually.
He will follow with renal as an outpatient.
# HTN
The patient had difficult to control hypertension on admission.
He was started on labetalol and amlodipine, and required prn
doses of hydralazine. However his blood pressure improved
significantly with HD sessions, and he was able to stop
amlodipine.
# HIV
Patient was continued on home HAART regimen. He was continued on
tenofivir qMON, but note that if he receives more than 12 hours
of dialysis in one week, this would need to be re-dosed.
On [**4-1**] he was transferred to the Neurosurgical service and
underwent C4 & C5 Corpectomies and anterior fusion. Surgery was
without complication, he was extubated and transferred to the
ICU.
On [**4-2**] he remained neurologically stable and has a dialysis
session. He was cleared for transfer to the floor.
On [**4-3**] he was again stable. He was tolerating a PO diet and
encouraged to ambulate. In the evening he was cleared for
discharge to home without services
Medications on Admission:
- Omeprazole 40 mg PO DAILY
- Oxycodone-Acetaminophen [**12-8**] TAB PO/NG Q4H:PRN pain
- Abacavir Sulfate 300 mg PO BID
- PredniSONE 5 mg PO/NG DAILY
- Furosemide 40 mg PO/NG DAILY
- Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
- Labetalol 600 mg PO/NG TID
- Tacrolimus 0.25 mg PO 1X/WEEK (MO)
- Lopinavir-Ritonavir 2 TAB PO BID
- Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (MO)
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
9. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO QMONDAY ().
10. tacrolimus 0.5 mg Capsule Sig: 0.5 Capsule PO 1X/WEEK (MO).
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical Compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**6-15**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**] to be seen in [**3-12**] weeks.
??????You will need x-rays prior to your appointment.
You also have the following appointments:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2166-7-14**] 11:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2166-7-14**] 1:30
Completed by:[**2166-4-3**]
|
[
"996.81",
"E878.0",
"287.5",
"996.73",
"V58.65",
"403.91",
"285.9",
"V45.11",
"722.71",
"585.6",
"344.89",
"042",
"288.50",
"584.9",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"81.63",
"03.31",
"88.49",
"80.51",
"81.02",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
12561, 12567
|
8714, 11256
|
348, 367
|
12632, 12632
|
6526, 8691
|
14660, 15634
|
2700, 2705
|
11690, 12538
|
12588, 12611
|
11282, 11667
|
12784, 14637
|
2720, 3240
|
267, 310
|
395, 2217
|
4129, 6507
|
12647, 12759
|
3265, 3265
|
2239, 2432
|
2448, 2684
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,051
| 151,511
|
47144
|
Discharge summary
|
report
|
Admission Date: [**2148-10-31**] Discharge Date: [**2148-11-1**]
Date of Birth: [**2079-4-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
food impaction
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
69 yo F with PMHx of COPD who presented to ED unable to swallow
food or water since lunch time yesterday. Had chicken and rice
at lunch and half way through felt lump in throat and stopped
eating. No aspiration or choking event. Patient denied dysphagia
but had not been vomiting anything she drank or eat. Endorsed
hiccups but has had a history of this.
.
In the ED, initial VS: 97.7 96 131/80 18 97%RA. 2PIV. GI
consulted. Given 1L IVF. Neck ST x-rays did not show foreign
body. Admitted to unit for endoscopy.
.
Currently, patient without complaints except hunger. Denied
chest pain, shortness of breath or cough. Denied nausea,
abdominal pain or diarrhea. Of note, patient has dentures but
has not been wearing them.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
Past Medical History:
COPD, fev-1 0.71 in [**2140**]
CCY
GERD
hyperchol
Social History:
+tobacco 130 pk/yrs
Lives w/ son and 2 grandsons
Family History:
Heart dz
Physical Exam:
Tmax: 37 ??????C (98.6 ??????F) Tcurrent: 36.7 ??????C (98 ??????F)
HR: 77 (77 - 98) bpm BP: 103/54(66) {101/54(66) - 138/92(103)}
mmHg
RR: 19 (19 - 23) insp/min SpO2: 93%
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL, Pupils dilated
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not
assessed
Pertinent Results:
[**2148-10-31**] 07:40PM BLOOD WBC-4.4 RBC-4.80 Hgb-13.4 Hct-41.6 MCV-87
MCH-28.0 MCHC-32.3 RDW-14.9 Plt Ct-267
[**2148-11-1**] 04:51AM BLOOD WBC-6.1 RBC-4.19* Hgb-11.6* Hct-36.3
MCV-87 MCH-27.6 MCHC-31.9 RDW-15.1 Plt Ct-250
[**2148-10-31**] 09:30PM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-137
K-4.2 Cl-99 HCO3-27 AnGap-15
[**2148-11-1**] 04:51AM BLOOD Glucose-96 UreaN-16 Creat-0.7 Na-138
K-4.3 Cl-106 HCO3-21* AnGap-15
[**2148-10-31**] 08:08PM BLOOD Glucose-94 Na-142 K-5.4* Cl-98*
calHCO3-28
Neck plain films:
SOFT TISSUE NECK, FRONTAL AND LATERAL VIEWS: The hypopharynx is
air
distended, although no definite foreign body is identified. Soft
tissue in
the hypopharynx likely reflects the larynx. The epiglottis is
normal. There
are degenerative changes of the cervical spine which is
incompletely
evaluated. There is no prevertebral swelling.
IMPRESSION: Distension of hypopharynx. However, no foreign body
is
identified. Correlation with direct visualization is
recommended.
The study and the report were reviewed by the staff radiologist.
Upper Endoscopy:
Impression: Esophageal ring Medium hiatal hernia
Food in the lower third of the esophagus
Friability and erythema in the gastroesophageal junction
Normal mucosa in the stomach
Erythema and a few petechiae in the duodenal bulb compatible
with duodenitis
Otherwise normal EGD to third part of the duodenum
Recommendations: follow-up with endoscopist within 1 week
EGD in 8 weeks.
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.
Protonix 40mg PO Bid
Brief Hospital Course:
The patient underwent upper endoscopy that revealed food
impaction at a ring at the GE junction. The food was
successfully extracted, and underlying duodenitis was seen. The
patient was started on [**Hospital1 **] PPI. She will follow up with GI in
one week and have repeat endoscopy at 8 weeks. She tolerated a
solid diet with small bites, and was discharged from the MICU to
home.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs inhaled up to four times a day as needed for
shortness of breath or wheezing
ALENDRONATE [FOSAMAX] - 70 mg Tablet - one Tablet(s) by mouth
weekly
AZELASTINE [OPTIVAR] - 0.05 % Drops - 1 (One) drop in each eye
twice a day as needed for allergy symptoms
CHLORPROMAZINE - 10 mg Tablet - 1 Tablet(s) by mouth daily as
needed for hiccups
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 (Two) puffs(s)
inhaled twice a day through a spacer
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
3
(Three) puffs(s) four times a day through a spacer
SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 (One)
inhalation(s) twice a day
ASPIRIN [ECOTRIN LOW STRENGTH] - 81 mg Tablet, Delayed Release
(E.C.) - one Tablet(s) by mouth daily
CALCIUM CITRATE - 250 mg Tablet - 1 Tablet(s) by mouth twice
daily
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. Azelastine 0.05 % Drops Sig: One (1) drop Ophthalmic twice a
day as needed for allergy symptoms.
5. Chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for hiccup.
6. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day: through spacer.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Three (3)
puffs Inhalation four times a day: through spacer.
8. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) inh
Inhalation twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Diagnosis:
1. Food impaction
Discharge Condition:
Stable. Tolerating po.
Discharge Instructions:
You were admitted because you had trouble swallowing. The
gastroenterologists saw you and performed an endoscopy that
found that you had food impacted in your esophagus. This food
was taken out. Your diet was advanced, and you started to
tolerate liquids.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2148-12-27**] 11:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2148-12-27**] 12:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2148-12-27**] 12:00
|
[
"530.81",
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"496",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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] |
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|
4101, 4485
|
331, 342
|
6384, 6408
|
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|
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1529, 2436
|
277, 293
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370, 1348
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1370, 1421
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1437, 1488
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,901
| 160,675
|
24112
|
Discharge summary
|
report
|
Admission Date: [**2185-7-1**] Discharge Date: [**2185-7-4**]
Date of Birth: [**2160-11-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Femoral line placement
History of Present Illness:
Mr [**Known lastname 61289**] is a 24M with poorly-controlled DM who presents with
DKA.
He was well until approx 4d ago when he developed a
nonproductive cough, along with chills and sweats and some nasal
congestion but no fevers. The evening prior to admission he
developed periumbilical abdominal discomfort accompanied by
nausea and non-bloody vomiting. Has chronic constipation with
BMs usually 1x week, had 4 BMs the day prior to presentation.
His PO intake was poor. He last took his insulin approximately
24h prior to presentation. Has been making urine, but no
dysuria, hematuria, no NSAID use. Reports low back pain similar
to prior. Denies metalic taste, pruritis, dyspnea.
.
In the emergency department, vitals were 98.3 104 154/82 16 100%
on RA. On exam, writhing in abdominal pain. He was given zofran,
ativan, insulin (10 units x2 sq) currently on 7units/hr drip.
CXR showed a LLL pna and he was given levofloxacin. Had a
femoral line placed for access, 22 wrist PIV. Given 4L of normal
saline. Renal was not contact[**Name (NI) **]. HR low 100's BP 160's RR 22.
Past Medical History:
- Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly
controlled with past DKA. Complicated with retinopathy,
nephropathy
- Hypertension, poorly controlled
- Chronic kidney disease
- Chronic constipation
Social History:
Lives with aunt in [**Location (un) 686**]. Smokes 2 packs per week since age
16. Denies recent alcohol use. Denies illicit drug use, now or
in the past.
Family History:
Father, grandmother with diabetes mellitus. No relatives
currently on dialysis.
Physical Exam:
Vitals 97.2 94 138/87 12 95% on RA
General Lying in bed appearing comfortable
HEENT Sclera anicteric, MMM
Neck Supple no JVD
Pulm Lungs clear bilaterally, no rales or wheezing
CV Regular S1 S2 no m/r/g
Abd Soft nontender +bowel sounds
Extrem Warm no edema palpable pulses
Neuro Sleepy but arousable, responds to commands, answering
appropriately, moving all extremities without focal deficits
Derm No rash
Lines/tubes/drains
Brief Hospital Course:
24 year old man with poorly controlled DM and HTN with ESRD not
yet on HD presents with DKA in setting of insulin noncompliance
and an underlying viral pneumonia versus viral URI. He was
admitted to the ICU and started on an insulin drip. The anion
gap closed and he was transitioned to glargine in the morning
(22 units) and maintained on a sliding scale. He was followed by
the [**Last Name (un) 387**] consult team while hospitalized and will see them as
an outpatient this week. He had abnormal chest film along with
cough and chills. He was started on empiric levofloxacin,
however, his flu swab came back positive for influenza A and the
antibiotics were discontinued. The influenza was not H1N1 by
state lab testing. He was afebrile for 24 hours prior to
discharge. We found normocytic anemia likely from CKD. Iron
studies were sent and were pending at the time of discharge.
They will be followed up by the [**Hospital **] clinic and he will likely
be started on epoetin as an outpatient. He was discharged on
empiric iron.
Medications on Admission:
metoprolol 50mg [**Hospital1 **]
amlodipine 10mg daily
simvastatin 20mg daily
hydralazine 50mg tid
aranesp 40mcg qweek
insulin galrgine 20 units qhs
insulin humalog sliding scale
miralax
senna
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous once a day.
7. Insulin Lispro 100 unit/mL Solution Sig: AS DIR Subcutaneous
four times a day: As needed per sliding scale.
8. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Keto-acidosis
Influenza A
Chronic Kidney Disease
Anemia of Chronic Disease
Discharge Condition:
Afebrile, hemodynamically stable.
Discharge Instructions:
You were admitted to the hospital with the flu. Because you were
sick your diabetes was not in good control and you needed
insulin through an IV for a couple of days. You have been able
to eat and take your insulin now and should continue doing this
when you are discharged.
Medication changes:
CHANGE: Glargine to 22units at breakfast time
START: Reglan 5mg by mouth with meals and at bedtime
START: Iron 325mg by mouth twice daily
Please come back to the hospital or call your doctor if you have
fevers, chills, abdominal pain, nausea, vomiting, inability to
take your insulin, inability to eat, chest pain, back pain,
rash, or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14166**]
([**Telephone/Fax (1) 14167**]) in the next 1-2 weeks.
Please follow up with Dr.[**Name (NI) 33126**] nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-[**Doctor Last Name **] ([**Telephone/Fax (1) 3637**]) on [**2185-7-7**] at 1:00pm.
Completed by:[**2185-7-4**]
|
[
"250.13",
"583.81",
"564.00",
"285.21",
"487.0",
"V15.81",
"585.4",
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"403.90",
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"250.53"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4449, 4455
|
2372, 3407
|
270, 294
|
4583, 4619
|
5330, 5771
|
1825, 1907
|
3650, 4426
|
4476, 4562
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|
4643, 4919
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1922, 2349
|
4939, 5307
|
227, 232
|
322, 1401
|
1423, 1636
|
1652, 1809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,513
| 163,557
|
31621
|
Discharge summary
|
report
|
Admission Date: [**2199-8-2**] Discharge Date: [**2199-8-22**]
Date of Birth: [**2151-4-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fever, chills
Major Surgical or Invasive Procedure:
cholangiogram left external biliary drain [**2199-8-3**]
PTC [**2199-8-13**]
[**2199-8-15**] right pleural tap
picc line placed
History of Present Illness:
48yoM with intrahepatic cholangiocarcinoma s/p right hepatic
lobectomy, common bile duct excision, cholecystectomy, portal
lymph node dissection, Roux-en-Y hepaticojejunostomy to left
hepatic duct on [**2199-6-21**], admitted with fever to 103 and chills
since yesterday. He has a PTC and JP drain in place Patient
states his appetite has been okay, had one episode of vomiting
yesterday, denies diarrhea, nausea. Denies chest pain, shortness
of breath, cough. Denies abdominal pain, but states he has had
bilateral flank pain. PTC drain output was almost to zero, JP
drain still had some output, but has increased to about 20cc
daily. Nature of drainage has not changed in color, is not
cloudy
and does not have a foul smell. Has been on Augmentin since
discharge on [**7-12**] when drains were repositioned.
Past Medical History:
Klatskins tumor, [**2189**] VATS for lung bulla, HTN,
hypercholesterolemia, allergies, T&A, L inguinal hernia repair
as child
Social History:
He is married and has two children, ages 21 and 18. He is the
vice president of a company.
He stopped drinking all alcohol on [**5-4**]
Family History:
mother:alive with breast cancer dx in [**2172**]
father alive with acute lymphocytic leukemia and had a valve
replacement
in [**2165**].
brother in good health.
Physical Exam:
Gen: NAD, A&Ox3
CV: RRR, no m/g/r
Lungs: CTAB, no increased work of breathing
Abd: soft, [**Name (NI) **], ND,
PTC (segment IV) in place - with bilious fluid in bag.
PTC (segment II/III) in place - capped
JP in place - with bilious/serous fluid in bulb. Insertion
points of all 3 drains clean and dry.
Ext: no C/C/E
Pertinent Results:
[**2199-8-2**] 06:40PM GLUCOSE-110* UREA N-21* CREAT-0.9 SODIUM-140
POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
[**2199-8-2**] 06:40PM ALT(SGPT)-65* AST(SGOT)-49* LD(LDH)-191 ALK
PHOS-313* TOT BILI-3.5* DIR BILI-2.8* INDIR BIL-0.7
[**2199-8-2**] 06:40PM ALBUMIN-2.8* CALCIUM-7.5* PHOSPHATE-1.9*#
MAGNESIUM-1.2*
[**2199-8-2**] 06:40PM WBC-14.8* RBC-3.74* HGB-11.5* HCT-34.2*
MCV-92 MCH-30.7 MCHC-33.5 RDW-14.1
[**2199-8-2**] 06:40PM NEUTS-82* BANDS-14* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2199-8-2**] 06:40PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2199-8-2**] 06:40PM PLT SMR-LOW PLT COUNT-107*#
[**2199-8-2**] 06:40PM PT-22.9* PTT-32.9 INR(PT)-2.3*
[**2199-8-22**] 04:32AM BLOOD WBC-9.6 RBC-2.98* Hgb-8.6* Hct-25.4*
MCV-85 MCH-28.7 MCHC-33.7 RDW-15.7* Plt Ct-238
[**2199-8-18**] 05:14AM BLOOD Neuts-76.2* Lymphs-13.3* Monos-8.0
Eos-2.3 Baso-0.3
[**2199-8-22**] 04:32AM BLOOD Plt Ct-238
[**2199-8-22**] 04:32AM BLOOD PT-16.0* PTT-27.6 INR(PT)-1.5*
[**2199-8-22**] 04:32AM BLOOD Glucose-117* UreaN-5* Creat-0.6 Na-135
K-3.8 Cl-99 HCO3-26 AnGap-14
[**2199-8-22**] 04:32AM BLOOD ALT-28 AST-21 AlkPhos-198* TotBili-1.7*
[**2199-8-21**] 04:42AM BLOOD ALT-27 AST-24 CK(CPK)-12* AlkPhos-189*
TotBili-1.9*
[**2199-8-19**] 03:33AM BLOOD Lipase-29
[**2199-8-22**] 04:32AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.3 Mg-2.0
Brief Hospital Course:
Pt was admitted on [**2199-8-2**], and was transferred to SICU that day
secondary to hypotension (100-120's/70's), tachycardia to 130's,
and fever to 103. Tbili 3.5, WBC 14.8, ALT/AST 65/49, AP 313,
INR 2.3. He was given 4L fluid, 2U FFP, 20IV Lasix, started on
Vanc & Zosyn, and was intubated for respiratory distress (80% on
5L O2). WBC was 40.2, pt febrile to 103.2. He had a CT scan
which showed intrahepatic dilation of biliary ducts, and he
underwent placement of L PTC external drain with IR (unable to
cross Roux-en-Y anastamosis. Bronchoscopy was also done on [**8-3**]
which showed patent airways, no lesions, BAL no growth, no
organisms. On [**8-5**], Cipro was added to Vanc and Zosyn for blood
culture that was positive for Klebsiella ([**Last Name (un) 36**] to Cipro).
Nutrition was consulted, and
He remained intubated and sedated in anticipation for PTC
manipulation (advance PTC across hepaticojej stricture) on [**8-7**]
with IR. Pt was extubated after the procedure without
difficulty. On [**8-8**] he was transferred back to the floor,
started on clear diet, and Zosyn was d/c'd. His diet was
advanced to reg, foley was d/c'd, and pt was ambulating by [**8-9**].
On [**8-10**], bile cx's positive for Enterococcus [**Last Name (un) 36**] to Vanc. On
[**8-14**], he underwent CT cholangio, and tube was exchanged. On
[**8-15**] peritoneal fluid cx positive for Stenotrophomonas
Maltophilia, [**Last Name (un) 36**] to Bactrim. Pt started on IV Bactrim in
addition to antibiotic regimen. CVL was d/c'd (tip cultured -
no growth), PICC line placed. Pt underwent U/S-guided tap of
pleural fluid (cultures - no growth). Infectious disease was
consulted, as total cultures from bile were growing Kleb,
Stenotroph, VRE, MRSA, non-candidal yeast, and other gram neg
rods. Per ID, he was started on Daptomycin, Caspofungin, and IV
Bactrim. He continued to have low-grade fevers, but temperature
curve decreased. PTC II/III was capped on [**8-20**]. On day of
discharge, the patient is afebrile (Tm 100.4), AVSS, TB 1.7, WBC
9.6, tolerating reg diet, ambulating, pain well-controlled with
no pain medications. He will follow-up with Dr. [**Last Name (STitle) **] in clinic
in 1 week, with f/u CT scan at that time. Per ID, he will be
discharged with Fluc (Caspo d/c'd), Bactrim, and Dapto. We will
continue to f/u his culture sensitivities, and he will have CK's
checked for Dapto, and weekly [**Last Name (STitle) **].
Medications on Admission:
Prilosec 20 daily, Paxil 20 daily, [**Doctor First Name **] 180 daily,
Augmentin 875/125 [**Hospital1 **]
Discharge Medications:
1. Daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 1230**]y (350)
mg Intravenous once a day for 2 weeks: give via picc line
stop date to be determined in follow up clinic.
Disp:*14 doses* Refills:*1*
2. Picc Line Care
per NEHT protocol
3. Outpatient Lab Work
Every Monday:
cbc with diff, chem 10, ast, alt, alk phos, t.bili, albumin, CK
Fax to [**Telephone/Fax (1) 697**] attn: [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 1005**], RN coordinator for
Hepatobiliary service and [**Telephone/Fax (1) 432**] attn: Dr. [**Last Name (STitle) 724**]
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO three
times a day for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
cholangiocarcinoma
s/p right hepatic lobectomy, roux en y hepaticojejunostomy to
left duct [**2199-6-21**]
cholangitis
biliary stricture
pneumonia
VRE/MRSA in bile
[**Female First Name (un) 564**], non-albicans & stenotrophomonas in bile
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, drainage at insertion site of drains,
increased drainage via open drains, abdominal distension or
shortness of breath.
Empty drain when half full, record output and bring record of
outputs to next appointment with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] twice a week -every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2199-9-6**] 11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2199-8-28**] 3:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"707.09",
"V10.09",
"038.9",
"995.91",
"576.1",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"51.98",
"33.24",
"96.71",
"38.93",
"87.51",
"87.54",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7431, 7497
|
3573, 6025
|
326, 456
|
7779, 7786
|
2132, 3550
|
8246, 8698
|
1617, 1780
|
6183, 7408
|
7518, 7758
|
6051, 6160
|
7810, 8223
|
1795, 2113
|
273, 288
|
484, 1297
|
1319, 1446
|
1462, 1601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,183
| 168,300
|
52072
|
Discharge summary
|
report
|
Admission Date: [**2102-6-18**] Discharge Date: [**2102-6-25**]
Date of Birth: [**2032-1-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
MRA of kidney
MRI and CT of chest.
MRI and CT of abdomen.
intubation.
History of Present Illness:
70 yoM w/ HTN, hyperlipidemia, CAD s/p CABG and redo transferred
from Cape Code Hospital for evaluation of possible distal
abdomen aortic dissection. She was brought to the OSH ED by her
husband c/o constant, severe left scapular pain, which she had
for the last 2-3 days, but which had progressively worsened over
the last day. Per husband, she did not have any associated chest
pain, SOB, N/V, abd pain, F/C, or chough. There, T 97.1, bp
204/77, HR 67, 98% RA. While there, she received 1 mg IV
dilaudid and 1 mg IV Ativan for pain and 20 mg Labetolol for bp
control after which she became nauseated and diaphoretic and
vomited. After having the CT (which showed possible distal
abdominal aortic dissection), she was intubated for agitation
and severe back pain, started on a Nipride gtt and transferred
to [**Hospital1 18**] for further management.
.
In [**Hospital1 18**] ED T 95.3, HR 58, bp 171/72, resp 18 100%. She was
continued on propofol gtt and nipride gtt. Vascular surgery
evaluated her and reviewed the CT scan, noting a 0.5 cm area of
heavily calcified/heterogeneous plaque that could represent
dissection. Vascular surgery did not recommend surgical
intervention and advised medical management with aggressive
blood pressure control. Currently, the patient is arousable to
voice/tactile stimulation and denies pain.
Past Medical History:
1) h/o GI bleed: [**2-11**] pill endoscopy showed multiple
phlebectasias and lymphangiectasias in SB mucosa
2) CABG [**2073**], redo [**2073**]
- [**6-/2092**] ETT MIBI: limited exercise capacity w/ SOB/LH. 0.5-[**Street Address(2) 11342**] dep and TWI inferolaterally. Moderate inferolat fixed defect
and moderate reversible apical defect
- [**10/2086**] TTE: enlarged LA and LV, decreased LV function (not
quantified), multiple wall motion abnl, mod MR
3) HTN
4) Hypercholesterolemia
5) CVA [**2091**] with residual right upper and lower extremity
weakness
6) Type II DM
7) Seizure disorder following CVA, last seizure [**2092**]
8) s/p open ccy
9) Hypothyroidism
Social History:
SHx: Quit tob [**2093**] (30 pk-yr history). No EtOH or other drug
use. At baseline, walks with a walker
Family History:
NC
Physical Exam:
Tc 97, HR 65, bpc 140/53, resp 18, 100%
AC TV 450, RR 18, FiO2 50%, PEEP 5
Gen: elderly female, intubated, sedated, opens eyes to
voice/tactile stimulation and intermittently follows commands.
HEENT: anicteric, pale conjunctiva, OMMM, intubated, OGT in
place, neck supple, JVP ~10 cm
Cardiac: RRR, nl S1 and S2, II/VI SM at apex. Well-healed
sternotomy scar
Pulm: Decreased BS at bases bilaterally, diffuse scatterred
ronchi
Abd: hypoactive BS, soft, NT/ND, no HSM
Ext: No C/C/E, warm with 1+ DP bilaterally, 2+ right radial,
non-palpable left radial.
Neuro: PERRL, tracks well, moves all 4 extremities in response
to noxious stimulis, 1+ DTR throughout, toes downgoing
bilaterally
Pertinent Results:
On admission:
[**2102-6-18**] 01:30AM BLOOD WBC-9.2 RBC-3.60* Hgb-10.3* Hct-29.7*
MCV-82 MCH-28.6 MCHC-34.8 RDW-13.8 Plt Ct-135*
[**2102-6-18**] 01:30AM BLOOD Neuts-84.9* Lymphs-10.6* Monos-3.6
Eos-0.6 Baso-0.3
[**2102-6-18**] 01:30AM BLOOD Glucose-186* UreaN-7 Creat-0.7 Na-133
K-4.0 Cl-100 HCO3-22 AnGap-15
[**2102-6-18**] 01:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2102-6-18**] 10:41AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2102-6-18**] 03:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2102-6-18**] 01:30AM BLOOD Albumin-3.6 Calcium-8.7 Phos-2.4* Mg-1.5*
Iron-88 Cholest-163
[**2102-6-18**] 04:15PM BLOOD Type-ART Temp-37.2 PEEP-5 FiO2-50
pO2-201* pCO2-38 pH-7.45 calHCO3-27 Base XS-3 Intubat-INTUBATED
[**2102-6-25**] 09:09AM BLOOD WBC-8.7 RBC-3.54* Hgb-10.3* Hct-28.8*
MCV-82 MCH-29.1 MCHC-35.8* RDW-13.5 Plt Ct-195
[**2102-6-23**] 06:11AM BLOOD Neuts-71.1* Lymphs-17.8* Monos-6.4
Eos-4.4* Baso-0.4
On discharge:
[**2102-6-25**] 09:09AM BLOOD Glucose-175* UreaN-11 Creat-0.8 Na-137
K-3.7 Cl-102 HCO3-25 AnGap-14
[**2102-6-25**] 09:09AM BLOOD ALT-49* AST-58* AlkPhos-63 TotBili-0.3
[**2102-6-25**] 07:25AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.6
Brief Hospital Course:
70 year old woman w/ HTN, hyperlipidemia, CAD s/p CABG and redo
transferred from Cape Code Hospital to [**Hospital1 18**] MICU for concern
for aortic dissection. Intubated at OSH for concern for airway
protection. On transfer, she ruled out for MI. Magnetic
resonance study negative for dissection. During MICU stay she
was maintained on labetalol and nipride drip for blood pressure
control. She self-extubated on [**6-18**] but never had any
respiratory distress after extubation, By end of stay she was
successfully weaned off those drips and maintained on a
antihypertensive regimen of isosorbide dinitrate, metoprolol,
verapamil, and lisinopril. SBP's ranging in low 130's. MRA to
assess for renal artery stenosis revealed normal renal
vasculature.
.
Other issues of note is that patient has been anemic with
hematocrit ranging around 25. She was also started on
ciprofloxacin for presumed UTI when sample from foley grew out
enterococus.
.
[**6-22**] Pt was transferred to floor on. Foley was dc'd. SBP's
ranged 130-140. No other events.
.
[**6-23**] Pt spiked temperature to 100.8, no signs of sepsis. SBPs
range 130-160. Only source was urine clean catch which grew
enterococcus which was sensitive to ciprofloxacin.
Ciprofloxacin restarted.
[**6-24**]
Since admission patient has denied any further chest pain. She
has denied shortness of breath, and palpitations. Tolerating
regular diet.
[**6-25**]
Patient was discharged. Husband declined transfer to
rehabiliation facilities.
In summary this is a 70 year old woman w/ HTN, hyperlipidemia,
CAD s/p CABG and redo transferred from Cape Code Hospital for
severe back pain symptoms consistent with aortic dissection.
MRI revealed no dissection in aorta, only a calcified plaque
which, per CT surgery, did not require intervention. Patients
chest/back pain resolved upon transfer. Patient's hypertension
proved difficult to control and required 4 anti-hypertensive
medications as noted. Cause never established, renal artery
stenosis ruled out by MRA, no symptoms or laboratory data c/w
hyperthyroid or pheochromocytoma. Blood pressure control was
adequate by time of discharge.
Medications on Admission:
1) Lisinopril 40 mg PO daily
2) Isosorbide dinitrate 20 mg PO four times a day
3) Atenolol 25 mg PO BID
4) Aggrenox twice a day
5) Glyburide 2.5 mg PO daily
5) Levothyroxine 200 mcg PO daily
6) Sanctura 20 mg PO BID
7) Verapamil 180 mg PO daily
8) ?Phentek 200 mg PO one day, then 300 mg PO the next
9) Trazodone 25 mg PO qhs
10) Lipitor 80 mg PO qhs
11) Senna 2 tab PO qhs
12) Phenobarbitol 32 mg PO TID
Discharge Medications:
1. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
4. Phenobarbital 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Isosorbide Dinitrate 20 mg Tablet Sig: 1.5 Tablets PO QID (4
times a day).
12. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days.
Disp:*6 Tablet(s)* Refills:*0*
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
anuerysmal ulcers
hypertension
urinary tract infection
Discharge Condition:
good, blood pressure controlled and afebrile
Discharge Instructions:
Please call or return if you have increase in shortness of
breath, chest pain or fevers, chills. Please take all
medications as prescribed.
Followup Instructions:
please follow up with your primary doctor in [**6-18**] days.
|
[
"244.9",
"401.9",
"438.89",
"272.4",
"599.0",
"440.0",
"V45.81",
"285.9",
"780.39",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8311, 8317
|
4480, 6645
|
329, 400
|
8416, 8462
|
3315, 3315
|
8651, 8716
|
2593, 2597
|
7101, 8288
|
8338, 8395
|
6671, 7078
|
8486, 8628
|
2612, 3296
|
4230, 4457
|
275, 291
|
428, 1763
|
3329, 4216
|
1785, 2453
|
2470, 2577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,770
| 114,277
|
5766
|
Discharge summary
|
report
|
Admission Date: [**2161-1-27**] Discharge Date: [**2161-2-12**]
Date of Birth: [**2093-10-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC:Spine Hardware protruding through skin. Left shoulder pain
Major Surgical or Invasive Procedure:
Thoracic wound debridement/hardware removal
Placement of VAC dressing
Flap rotation with thoracic wound closure
dobhoff placement
History of Present Illness:
HPI:67 yo male with metastatic thyroid CA to spine, who is well
known to this service presents from home with previously placed
spine hardware externalizing from his skin. There is associated
foul smelling drainage and erythema. He also has left shoulder
pain which began [**2161-1-26**] after feeling a "[**Doctor Last Name **]" in the shoulder
with no associated trauma.
Past Medical History:
Metastatic Thyroid Ca
HTN
Atrial Fibrillation
Pulmonary Embolus [**1-28**] - Anticoagulated with coumadin; has
two small lesions on MRI head c/w mets but not contraindications
to anticoag.
Hypothyroidism
Social History:
Lives with wife. Retired from full time work in [**2157-9-22**].
Smoked approximately 30 years ago (quit in [**2126**])
Family History:
Mother with h/o emphysema.
Physical Exam:
98% O2Sats 4L N/C
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs full
Neck: Supple. No carotid upstrokes
Lungs: CTA bilaterally. Diminished Lt base
Cardiac: RRR. S1/S2. No gallop, M/R
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T IP Q H AT [**Last Name (un) 938**] G
R 4 4 4 4 4 4 5 5 4
L 4 4 4- 4 4 4 5 5 4
Sensation: Intact to light touch, propioception
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Propioception intact
Toes downgoing bilaterally
Pertinent Results:
CT/MRI: Thoracic Spine with no obvious thoracic fluid
collection.
Air in the prior drain site.
[**2161-1-27**] 08:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2161-1-27**] 08:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2161-1-27**] 12:00PM GLUCOSE-193* UREA N-18 CREAT-0.6 SODIUM-135
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-31 ANION GAP-13
[**2161-1-27**] 12:00PM CRP-79.1*
[**2161-1-27**] 12:00PM WBC-12.8*# RBC-4.47* HGB-12.8* HCT-38.0*
MCV-85 MCH-28.7 MCHC-33.8 RDW-16.7*
[**2161-1-27**] 12:00PM NEUTS-96.0* LYMPHS-1.9* MONOS-1.7* EOS-0.3
BASOS-0.1
[**2161-1-27**] 12:00PM PLT COUNT-81*
[**2161-1-27**] 12:00PM SED RATE-40*
Brief Hospital Course:
Mr [**Known lastname 20598**] was admitted to the neurosurgery service after it
was noted that his spinal hardware was eroding through the skin.
He went to the OR and the wound was completely irrigated,
fibrous exudate was noted and a cross link was removed. In
conjunction with plastic surgery a VAC dressing was placed over
the wound. Post operatively he was back to his baseline
neurologic status, which was full motor strength with the
exception of his deltoids and slightly weaker left arm due to a
rotator cuff injury. Subsequent cultures showed STAPH AUREUS
COAG + he was placed on Vancomycin on admission that was
continued, a PICC line was also placed. The patient was started
on a calorie count due to his recent weight loss prior to
admission. On [**2-3**] he went to the OR in conjuction with plastic
to have a muscle flap placed for formal closure of the wound.
There were no perioperative complications to report.A dobhoff
feeding tube was also placed for good nutrition status while
wound healing. He has begun to work with PT again on [**2-4**]. He is
tolerating all p.o. food and fluids well with no nausea or
vomiting. Calorie counts have been maintained and nutrition made
recommendations on tube feeds for optimal support. He had JP
drains placed intra-op that are monitored for output and he will
go home with these. His dressings were dry with minimal
staining and monitored by plastic surgery. He was also followed
by hematology for a low platelet count and received platelet
transfusions peri-op.
Plans were made to discharge pt home with hospice but on [**2-6**] he
developed increasing oxygen needs. He recieved multiple doses
of lasix with good diuresis followed by chest xrays but
respiratory distress increased. He was transferred to ICU on
[**2-8**]. Conversations occurred between Dr. [**Last Name (STitle) 548**], the patient and
his wife with information provided by pts oncologist at [**Hospital1 2025**].
After discussions he was made DNR and DNI on [**2-10**]. Morphine IV
q1hr was begun, pt was transferred to the floor. Palliative
care service was consulted. After discussion, family wished
comfort measures. Feeding tube was removed at their request,
morphine drip with bolus doses and scopalamine patch were
initiated. On [**2161-2-12**] he expired.
Medications on Admission:
D
i
g
o
x
i
n
,
A
m
i
o
d
a
r
o
n
e
,
G
a
b
a
p
e
n
t
in,Dexamethasone,Omeprazole,Senna,Oxycodone,OxyconTin,Metoprolol
XL, Levothyroxine,
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic thyroid cancer
MRSA wound infection
pressure ulcer- stage 3, thoracic spine
respiratory distress
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2161-2-12**]
|
[
"427.31",
"V12.51",
"244.9",
"998.83",
"041.12",
"707.09",
"401.9",
"327.23",
"V43.64",
"198.5",
"197.0",
"726.10",
"V58.61",
"996.67",
"198.3",
"998.32",
"V10.87",
"707.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"78.69",
"96.6",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
5345, 5354
|
2828, 5127
|
352, 484
|
5506, 5516
|
2065, 2805
|
5572, 5611
|
1270, 1298
|
5316, 5322
|
5375, 5485
|
5153, 5293
|
5540, 5549
|
1319, 1573
|
251, 314
|
512, 886
|
1588, 2046
|
908, 1114
|
1130, 1254
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,822
| 171,036
|
26251
|
Discharge summary
|
report
|
Admission Date: [**2102-8-31**] Discharge Date: [**2102-9-7**]
Date of Birth: [**2021-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
bacitracin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times one (saphenous vein to
distal right coronary artery), ascending aorta, and hemiarch
replacement [**2102-9-1**]
History of Present Illness:
Mr [**Known lastname 43115**] has a known 7cm ascending aortic aneurysm who is in the
process undergoing his preoperative evaluation. He had
previously been unwilling to commit to the surgery so a date had
not been set. He underwent a cardiac
catheterization today which showed a 90% pRCA stenosis. He
elected to go home this pm to think about the surgery and left
the hospital not feeling very well. At home he was sitting at
the table feeling "woozy" and had just eaten a banana and some
chips. His daughter states that he started staring off in space
with deep breathing became pale and was unresponsive. He
slumped in the chair and was then lowered to the floor and the
daughter was unable to feel a carotid pulse. She began CPR,
called 911 and by the time that EMS arrived he was starting to
come around.
The patient recalls waking up on the floor and denies chest pain
or significant lightheadness prior to this episode. He is
currently free from chest pain, nausea, lightheadness. He
reports that his chest is sore from the CPR.
Past Medical History:
coronary artery disease
ascending aortic aneurysm
PMH:
- Hypertension
- Dyslipidemia
- Asbestosis on CT scan(bilateral pleural plaquing, interstitial
dz)
- Diverticular Disease
- Prostatism
- Bilateral Varicose Veins
- History of Skin cancer
- History of Gout
- Glaucoma with blindness in his left eye
- Macular Degeneration
- Iron deficiency Anemia(colonoscopy and upper GI [**2096**])
Past Surgical History
- Left ingunal hernia repair [**2096**]
- Right hand surgery for Dupytrens contracture
- Multiple left eye surgeries
- Left leg squamous cell Mohs procedure
- Basal Cell removal from ear
- Polypectomy
- Right Cataract
Social History:
He lives with his wife and is a retired telephone repairman. He
was on a naval ship for approximately four years with exposure
to asbestos. He denies ever smoking. He drinks two glasses of
wine daily and occasional beers. He denies illicit drug use. He
has three children, three grandchildren and close family.
Family History:
non-contributory
Physical Exam:
Triage: 98.3 62 134/80 16 98% 3L
BP 138/70 in R, 116/67 in L
Admit: 98.3 57 127/70 15 98RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-13**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, no pronator drift, steady
gait.
Pertinent Results:
[**8-31**] CXR: FINDINGS: The heart shows mild cardiomegaly. The
mediastinal contours demonstrate a prominent right mediastinal
contour, compatible with the known ascending aortic aneurysm.
There is also calcified atherosclerotic disease of the aortic
knob. The lungs demonstrate minimal linear atelectasis at the
right base as well as retrocardiac atelectasis. There is no
large pleural effusion or pneumothorax.
IMPRESSION: Mild cardiomegaly and large ascending aortic
aneurysm, but no acute cardiopulmonary process.
[**9-1**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with mild
inferior hypokinesis. The remaining segments contract normally
(LVEF = 50%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is severely dilated. The aortic arch is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Massively dilated ascending aorta and hemiarch.
Mild regional left ventricular systolic dysfunction, c/w CAD.
Mild aortic and mitral regurgitation. Mild pulmonary
hypertension.
[**9-1**] CTA Torso:
1. No evidence of aortic dissection.
2. Large fusiform ascending aortic aneurysm with ectasia of
the great vessels as discussed above.
3. Prominent pulmonary interstitium suggestive of interstitial
pulmonary
edema/ fibrosis with bibasilar atelectasis.
4. Pleural calcifications adjacent to the ribs as discussed.
This likely
represents sequela of prior trauma.
5. Cystic lesion in the pancreas. If clinically warranted this
can be
evaluated with MRCP.
6. Mass lesion in close association with the
descending/sigmoid colon. This likely represents a plug from
previous hernia repair. Correlate with previous surgical repair.
7. Post procedure changes involving the right groin.
8. Prostatomegaly.
[**2102-9-7**] 06:00AM BLOOD WBC-5.8 RBC-2.99* Hgb-9.8* Hct-27.9*
MCV-93 MCH-32.7* MCHC-35.1* RDW-15.9* Plt Ct-111*
[**2102-9-5**] 05:50AM BLOOD WBC-6.4 RBC-3.29* Hgb-10.6* Hct-29.5*
MCV-90 MCH-32.2* MCHC-35.8* RDW-16.4* Plt Ct-117*
[**2102-9-7**] 08:30AM BLOOD PT-15.7* INR(PT)-1.4*
[**2102-9-7**] 06:00AM BLOOD PT-15.1* INR(PT)-1.3*
[**2102-9-5**] 05:50AM BLOOD PT-13.8* PTT-27.5 INR(PT)-1.2*
[**2102-9-4**] 01:56AM BLOOD PT-15.1* PTT-34.3 INR(PT)-1.3*
[**2102-9-7**] 06:00AM BLOOD Glucose-89 UreaN-23* Creat-0.8 Na-142
K-4.3 Cl-103 HCO3-30 AnGap-13
[**2102-9-6**] 12:40PM BLOOD UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-102
[**2102-9-5**] 05:50AM BLOOD Glucose-113* UreaN-22* Creat-0.9 Na-139
K-3.4 Cl-100 HCO3-28 AnGap-14
[**2102-9-7**] 06:00AM BLOOD Mg-2.3
[**2102-9-5**] 05:50AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 43115**] is an 80 year old male with one vessel coronary artery
disease in the right coronary artery and a 7cm fusiform
ascending aortic aneurysm. He was discharged to home after his
catheterization to decide if he wanted to pursue surgery. That
evening while at home he presented to the emergency department
on [**2102-8-31**] after a syncopal episode. During this event he was
reportedly pulseless for 1-2 minutes, although it seemed
unlikely that he had a true cardiac arrest, given his clinical
picture and stable vital signs documented on arrival by
emergency services. He was readmitted on [**8-31**] and the
differential included vasovagal, transient arrhythmia, or
compression of the great vessels from his thoracic aortic
aneurysm. He ruled out for myocardial infarction with serial
enzymes.
On [**9-1**] he underwent a coronary artery bypass grafting times one
(saphenous vein to distal right coronary artery), ascending
aorta, and hemiarch replacement. Please see the operative note
for details. He tolerated the procedure well and was
transferred in critical but stable condition to the surgical
intensive care unit. He was weaned from pressors.
He required a left chest tube for a pneumothorax
post-operatively. He was seen in consultation post-operatively
by the electrophysiology service given his pre-operative
syncope. On [**9-5**] a permanent pacemaker was placed in the
electrophysiology lab. Epicardial wires were removed.
Pneumothorax resolved and chest tubes were removed without
incident. He experienced hematuria with foley trauma and was
irrigated continuously until clear. A urology consult was
obtained and recommended urology follow-up. The patient has
seen a urologist in [**Location (un) 620**], Dr. [**Last Name (STitle) 9125**], previously, and will
follow-up with him. He voided successfully prior to discharge
and he will be sent without a Foley. He is discharged on POD 6
to [**Hospital 49880**] Nursing and Rehab. All follow-up appointments are
advised.
Medications on Admission:
Simvastatin 10mg daily
Aspirin 81mg daily
Doxazosin 2mg daily
Trandolapril 4mg daily
Atenolol 100mg twice daily
Amlodipine 2.5 mg daily
Ativan 1 mg prn anxiety
MV
Glucosamine
Iron
Timolol eye gtts
Xalantan eye gtts
Cialis prn
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*0*
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
12. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: MD
to dose daily for goal INR 2-2.5, dx: afib.
18. Outpatient Lab Work
Labs: PT/INR
Coumadin for AFib
Goal INR 2-2.5
First draw [**2102-9-8**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
**Please arrange coumadin/INR follow-up prior to d/c from
rehab**
19. clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO three
times a day for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 49880**] Nursing & Rehabilitation Center - [**Location (un) 49880**]
Discharge Diagnosis:
coronary artery disease
ascending aortic aneurysm
PMH:
- Hypertension
- Dyslipidemia
- Asbestosis on CT scan(bilateral pleural plaquing, interstitial
dz)
- Diverticular Disease
- Prostatism
- Bilateral Varicose Veins
- History of Skin cancer
- History of Gout
- Glaucoma with blindness in his left eye
- Macular Degeneration
- Iron deficiency Anemia(colonoscopy and upper GI [**2096**])
Past Surgical History
- Left ingunal hernia repair [**2096**]
- Right hand surgery for Dupytrens contracture
- Multiple left eye surgeries
- Left leg squamous cell Mohs procedure
- Basal Cell removal from ear
- Polypectomy
- Right Cataract
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Right - healing well, no erythema or drainage.
No Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Device Clinic, [**Hospital Ward Name 23**] 7, [**9-14**], 9:30am
Wound check, [**Hospital Unit Name 4081**], [**9-14**] at 11:00am
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] on [**10-17**] at 2:15pm
Cardiologist: Dr.[**Name (NI) 29750**] office will call you with an appt.
Please call to schedule appointments with your
Urologist, Dr. [**Last Name (STitle) 9125**] [**Telephone/Fax (1) 18725**]
Primary Care, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 17753**] in [**3-14**] weeks
*Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for AFib
Goal INR 2-2.5
First draw [**2102-9-8**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
**Please arrange coumadin/INR follow-up prior to d/c from
rehab**
Completed by:[**2102-9-7**]
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68,629
| 128,041
|
37000
|
Discharge summary
|
report
|
Admission Date: [**2147-7-14**] Discharge Date: [**2147-8-12**]
Date of Birth: [**2081-10-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
headache, syncope, generalized seizure
Major Surgical or Invasive Procedure:
Bronchoscopy (twice) for BAL.
TEE
Evacuation of left-sided retroperitoneal hematoma
History of Present Illness:
The patient is a 65-year-old male with a mechanical mitral
valve, on coumadin, and hypertension. On [**2147-7-14**], he awoke
feeling generally unwell. His wife called EMS and - en route to
[**Name (NI) **] Hospital - the patient had a generalized convulsion.
The patient had a second generalized convulsion upon entry to
the [**Location (un) **] ER, he developed a massive tongue hematoma from a
tongue bite, and underwent a difficult and prolonged intubation
process. INR was 3.2, which was in the appropriate range given
the mechanical valve. NCHCT revealed ICH and SAH. He was
loaded with 1 gram of dilantin and transferred to [**Hospital1 18**].
At [**Hospital1 18**], CTA revealed left sylvian fissure subarachnoid
hemorrhage extending
to parietal sulci, 4-mm aneurysm at the left MCA bifurcation
pointing laterally, 2 to 2.5 mm aneurysm arising from the A2
segment of the left anterior cerebral artery at the level of
ventricular bodies. In the ED,
the patient received Factor 9 and 1 unit FFP. He subsequently
received 6 units of platelets and FFP to reverse his
coagulopathy. He was started on nimodipine and HOB was kept > 30
degrees.
A subsequent conventional angiogram further delineated the
aneurysms; the Neurosurgery team felt that these aneurysms were
unlikely to be the cause of the patient??????s bleeding. Since there
would be no further surgical intervention, the patient was
transferred to the Neurology team in the ICU.
Past Medical History:
Esophageal CA
CAD
Mechanical Mitral valve
s/p CABG x3
HTN
Asbestosis
Bilateral carotid endarterectomy
Social History:
Married, lives with wife. Occasional EtOH use.
Family History:
No history of known aneurysms.
Physical Exam:
VS 100.4 (t max 101.2) P 89 BP 92/46 RR 14 100% RA
Gen; obese middle-aged male, intubated, sedated
HEENT; markedly edematous tongue with midline laceration,
covered
with wet dressing
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, NT, ND
Extr; no edema
Neurologic Examination:
Propofol has been turned off for 6 minutes at the time of this
exam.
Eyes closed, does not follow commands.
PERRL 4mm to 3mm bilaterally. Face symmetrical. Makes
occasional chewing motions on the ETT. Reaches toward ETT in an
apparent attempt to remove it.
Spontaneously moves all 4 limbs symmetrically. Tone is
decreased
throughout.
Localizes and winces to painful stimuli in all 4 extremities.
Coordination and gait cannot be tested due to patient??????s state.
.
Neurologic Examination on discharge:
PERRL. Right lower facial droop. CN II-XII otherwise intact.
Sensation and coordination intact. No pronator drift but
orbiting shows more weakness on right upper extremity. RUE 5-/5,
LUE [**5-2**]. Lower extremities [**4-2**] bilaterally at proximal and
distal muscles. 2+ reflexes on right, 1+ on left, upgoing
Babinski on right.
Pertinent Results:
[**2147-7-14**]:
8.9
5.2 >---< 69
25.5
.
137 | 106 | 7 / 209
4.2 | 16 | 1.0 \
.
PT 32.1, PTT 36.7, INR 3.2
fibrinogen 356
.
CK 263, CKMB 10 Trop 0.03
lipase 50
urine tox screen negative
.
UA unremarkable
.
ABG:
[**2147-7-14**] 05:34PM TYPE-ART TIDAL VOL-550 O2-100 PO2-428*
PCO2-42 PH-7.38 TOTAL CO2-26 BASE XS-0 AADO2-243 REQ O2-48
INTUBATED-INTUBATED
.
IMAGING:
.
Admssion CTA CNS:
1. Left sylvian fissure subarachnoid hemorrhage extending to
parietal sulci.
2. 4-mm aneurysm at the left MCA bifurcation pointing laterally.
3. 2 to 2.5 mm aneurysm arising from the A2 segment of the left
anterior
cerebral artery at the level of ventricular bodies.
.
CT head [**2147-8-8**]: No evidence of acute new hemorrhage. Area of
prior hemorrhage in the left subinsular region is less apparent.
.
MRI/A: CNS:
1. Diffuse subarachnoid hemorrhage along the left Sylvian
fissure
and left occipital lobe with left temporal lobe hemorrhage,
magnetic
susceptibility change is also noted on the left frontal lobe,
raising the
possibility of chronic hemorrhage or microbleed (5:16), residual
intraventricular hemorrhage.
2. The previously noted aneurysms on the left ACA and left MCA
are not
clearly identified in this examination.
3. Sequela of a prior infarction is noted on the right
cerebellar hemisphere.
4. Restricted diffusion is noted on the left parietal lobe
likely consistent with subacute ischemic changes, measuring
approximately 6 x 7 mm.
Cerebral arteriography:
2-mm aneurysm of the left middle cerebral artery at the origin
of the anterior temporal branch.
This was thought not to be responsible for his left sylvian
fissure hemorrhage as there was no history of headache at onset
and the
hemorrhage itself was located remote from the aneurysm and there
was no blood in the basal cisterns at all.
A second aneurysm measuring 1.5-2 mm was also located in the
left pericallosal artery. The A1 was dominant on the left side
.
TTE: Mild symmetric left ventricular hypertrophy with mild
regional systolic dysfunction. Normal functioning aortic
bileaflet prosthesis. At least mild mitral regurgitation
.
Carotid dupplex showed: Right ICA stenosis <40%. Left ICA
stenosis <40%
.
CT chest/abd/pelvis;
1. Large 7 x 9 x 18 cm measuring retroperitoneal hematoma in the
iliopsoas
and iliacus muscle
2. Pleural calcifications consistent with asbestos exposure and
atelectasis in
bilateral lungs with round atelectasis in the right lower lobe
3. Gastric pull-up is visualized status post esophagectomy for
esophageal
cancer.
.
RUQ U/S: Slight increased echogenicity in the liver. More
advanced forms
of liver disease such as fibrosis / cirrhosis not excluded.
Otherwise normal right upper quadrant ultrasound without
evidence of biliary abnormality.
.
L knee X-ray [**2147-8-8**]:
Probable undisplaced tibial fracture, with a large joint
effusion
presumably representing hemarthrosis.
Brief Hospital Course:
#. mental status/neuro exam: The patient's baseline is oriented
to place, occasionally date (usually knows [**2146**], not month). He
has bizarre/tangential speech at times, and becomes temporarily
confused. He has 5/5 strength in upper extremities, 4-/5 in
lower extremities at both proximal and distal muscles, thought
to be secondary to deconditioning and ICU myopathy (not due to
stroke). He has 2+ reflexes on right, 1+ on left. Upgoing
Babinski on right.
.
#. seizures:
The patient presented after generalized seizures, complicated by
tongue biting and hematoma. Head CT showed left-sided
intraparenchymal and subarachnoid hemorrhage. It was unknown
whether bleeding was the precipitating event, followed by
seizure due to parenchymal irritation; or, if seizure occurred
initially and trauma sustained during the convulsion led to
bleeding. The patient was loaded with Dilantin and then
initiated on Keppra for seizure prophylaxis since this does not
interact with coumadin. He had no further seizure activity int
he ICU. After transfer to the medical floor, the patient had an
episode of lower extremity shaking while asleep in a chair,
witnessed only by wife. This was thought unlikely to represent
seizure activity, and more likely myoclonic jerks during sleep.
Neurology was called to see patient at this time. 20 minute EEG
was done, showing no epileptiform activity. The patient will
continue on Keppra for at least 6 months. He will follow-up with
Dr. [**Last Name (STitle) **] in neurology.
.
#. ICH:
The patient underwent a conventional angiogram which did show
2-mm aneurysm of the left middle cerebral artery at the origin
of the anterior temporal branch. However, this was thought not
to be responsible for his left sylvian fissure hemorrhage as
there was no history of headache at onset and the
hemorrhage itself was located remote from the aneurysm and there
was no blood in the basal cisterns at all. He did have an
intraparenchimal bleed with a SAH component that may have been
due to amyloid angiopathy and microbleeds in GRE. These added to
his age and PV white matter disease placed him at a higher risk
for a new bleed. However, he needed to remain anticoagulated
because of his mechanical valve. Thoracic surgery was consulted
about the possibility of pursuing a valve replacement for a
biological prosthesis to avoid anticoagulation. However, the
surgical risk was determined to outweigh the benefit of avoiding
anticoagulation. The patient remained off anticoagulation due to
this high risk. On [**7-18**], the patient developed new right-sided
weakness and MRI showed new left MCA infarct. This was thought
to have originated from AVR thromboembolization. Heparin was
resumed for goal PTT 40-60 and coumadin was resumed [**8-1**]. Several
repeat head CT have all been stable, most recent [**2147-8-8**].
Heparin infusion was stopped once a therapeutic INR was reached
on warfarin.
.
#. Retroperitoneal Bleed:
After the patient had a stroke off anticoagulation, heparin was
resumed. Shortly after, the patient developed worsening anemia
with HCT eventually falling to 19. He received a total of 15
units pRBCs during the hospital course. His systolic blood
pressure dropped to the 80s and he became tachycardic. A CT
abd/pelvis revealed a large retroperitoneal hematoma. He
required very aggressive transfusion of RBCs and underwent
evacuation of hematoma by vascular surgery on [**7-27**]. He
tolerated the procedure well and hematocrit has been stable
since the procedure. His heparin was resumed with goal PTT
40-60 on [**7-30**] and was restarted on coumadin [**8-1**].
.
The patient was transferred to the neuromedicine step-down
service on [**8-1**]. He was noted to have intermittant fevers. CT
of the torso and head did not reveal any new source. He became
hypotensive and Hct continued to decrease. EKG was concerning
for new T wave inversions and a stat ECHO showed possible
anterior wall motion abnormality, most likely intracranial T
waves. The patient responded to IV fluids and placement in
trendelenberg. This event was presumed to be due to continued
retroperitoneal bleeding. Anticoagulation was again held
temporarily.
The patient was eventually safely anticoagulated and INR was 3.0
on day of discharge. The patient's coumadin was being held for
supratherapeutic INR prior to discharge. PT and PTT are
elevated, likely due to poor nutritional status. INR will need
to be monitored daily and coumadin adjusted appropriately to
maintain goal range 2.5-3.5. He should have daily INR checks
and adjustment of dose to maintain INR 2.5-3.5. At the time of
discharge, he was restarted on coumadin 4.0 mg daily.
His hematocrit is currently 27.9 and stable.
#. Respiratory failure: The patient was intubated due to a large
tongue hematoma. On [**7-24**] (after extubation) he was found to
have increased respiration rate and work of breathing. He had a
clot removed from his trachea by ENT with moderate resolution of
symptoms. He is currently doing well on room air.
#. Ventilator-associated PNA: The [**Hospital 228**] hospital course was
also complicated by persistent fevers and leukocytosis secondary
to pneumonia while intubated. He underwent 2 bronchoscopies with
BAL and samples grew klebsiella, serratia, and staph aureus. He
completed a 12-day course of antibiotics, initially started on
vancomycin and cefepime. He is currently afebrile with no
leukocytosis.
#. Gout: The patient developed erythema, swelling and pain of
the left 1st MTP joint, consistent with gout. He has a prior
history of gout, so no joint aspiration was done. The patient
responded well to colchicine with reduced pain and inflammation.
#. Left knee trauma: The patient fell from bed in MICU. X-ray
showed possible small nondisplaced tibial fracture, but unable
to see joint line. The patient was weight bearing well with PT.
#. HTN: The patient was continued on metoprolol and Imdur.
#. Code status: DNR
*** Please perform daily INR checks to adjust warfarin dose to
maintain INR between 2.5-3.5***
Medications on Admission:
ASA 81mg
Betimol eye drops 1 gtt L eye daily
Isosorbide MN 30mg QHS
Meteorology Succinate 50mg Daily
Nexium 40mg Daily
Nitroglycerin PRN
Pravachol 80mg Daily
Pro Air HFA 2 puffs prn
Zetia 10mg Daily
Discharge Medications:
1. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
2. Levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime.
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
primary:
Left frontotemporal intraparenchymal hemorrhage and subarachnoid
hemorrhage.
Generalized seizure
Retroperitoneal hematoma
Left MCA infarct
.
Secondary:
Coronary Artery Disease
Mechanical Mitral Valve
Hypertension
Discharge Condition:
Awake, oriented to person, location, and year. Tangential
speech, dysarthric, but fluent language. Naming and repetition
intact, follows commands. EOMI, right lower facial droop,
tongue midline. No pronator drift, 5/5 strength in upper
extremities bilaterally, [**4-2**] in lower extremity bilaterally.
Upgoing toe on R.
Discharge Instructions:
You were admitted for seizures and intracranial hemorrhage. You
required intubation to assist your breathing. When your
bloodthinner was stopped, you had a stroke. You then had a large
hematoma requiring surgery. You will go to a rehab facility to
help build back your strength and skills.
.
Please continue your medications as prescribed and follow up
with Dr. [**Last Name (STitle) **] (neurology) as well as Dr. [**Last Name (STitle) **] (vascular)
as directed. Return to the Emergency Department immediately for
any new weakness or numbness, difficulty speaking, visual
changes, lightheadedness, or shortness of breath.
Followup Instructions:
[**2147-8-17**] 2:00
Vascular Surgery; [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD
Phone:[**Telephone/Fax (1) 1237**]
.
[**2147-9-6**] 03:30p
Neurology; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. ([**Telephone/Fax (1) 7394**]. [**Hospital1 18**] [**Hospital Ward Name **],
[**Hospital Ward Name 23**] Building
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"401.9",
"V58.61",
"V43.3",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.41",
"88.72",
"54.0",
"38.93",
"33.24",
"33.22",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13470, 13542
|
6237, 12287
|
355, 441
|
13808, 14135
|
3324, 6214
|
14808, 15188
|
2130, 2163
|
12539, 13447
|
13563, 13787
|
12313, 12514
|
14159, 14785
|
2178, 2442
|
2972, 3305
|
277, 317
|
469, 1922
|
2466, 2958
|
1944, 2048
|
2064, 2114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,599
| 139,560
|
11213
|
Discharge summary
|
report
|
Admission Date: [**2168-10-24**] Discharge Date: [**2168-11-9**]
Service: CCU
REASON FOR ADMISSION: Acute myocardial infarction.
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
woman with no known coronary artery disease who reported not
feeling well to her sister this morning. Her sister found
her to be weak but without chest pain or shortness of breath.
She was taken to the [**Hospital6 33**] where an
electrocardiogram showed inferior and right-sided myocardial
infarction. She was taken to the catheterization laboratory
there, where she was found to have three vessel disease with
total occlusion of left circumflex artery, total occlusion of
right coronary artery and diffusely diseased left anterior
descending. Her coronary artery was stented times three and
an intraaortic balloon pump was placed for hypotension.
Subsequently, she went into ventricular fibrillation arrest
and was intubated and converted to sinus rhythm with
defibrillation. She was then transferred to the [**Hospital6 1760**] for further management. At
the outside hospital she received heparin, Integrilin,
lidocaine, digoxin and transiently dopamine. No aspirin was
given due to allergy to aspirin. Echocardiogram done in
[**2168-4-10**] showed an ejection fraction of 65-70% and
normal wall motion.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia,
hypothyroidism, osteoarthritis, sprue and rheumatoid
arthritis.
OUTPATIENT MEDICATIONS: Viokase, Norvasc 5 mg q.d., Lipitor
20 mg q.d., Synthroid 15 mcg q.d., arthrotec 15 mg q.d.,
hydrochlorothiazide 50 mg q.d., Aleve 2 tablets q.a.m.,
prednisone taper 5 mg.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient's sister, [**Name (NI) 1743**] [**Name (NI) 1356**], is her
health care proxy. [**Name (NI) **] lives alone.
PHYSICAL EXAMINATION: Temperature 97. Pulse 50. Blood
pressure 70/40, saturating 100% on assist control
ventilation. In general, patient is intubated. Head, eyes,
ears, nose and throat: Pupils reactive to light but
sluggish. Cardiovascular: S1, S2. Lungs clear anteriorly.
Abdomen soft, nontender, positive bowel sounds. Extremities:
Right groin arterial and venous sheaths, intraaortic balloon
pump left groin. Extremities: Cool, peripheral pulses by
Doppler.
Electrocardiogram: Normal sinus rhythm at 63, left axis
deviation, Qs in III, aVF, T wave inversion in II, III, aVF,
ST depression in V2, V3, normal QRS.
LABORATORIES: White blood cell count 13.1, hematocrit 27.7,
platelets 606,000, PT 13.7, PTT 71, INR 1.3, sodium 137,
potassium 4.4, chloride 107, bicarbonate 14, BUN 12,
creatinine 0.9, glucose 196. CK 4401, AST 254, ALT 784, total
bilirubin 0.3.
Chest x-ray showed appropriate placement of balloon pump,
endotracheal tube. Pulmonary vasculature slightly engorged.
No effusions or infiltrates.
HOSPITAL COURSE: In the Coronary Care Unit, patient
initially had a poor urine output, low blood pressure
requiring pressors, occasional paroxysmal atrial fibrillation
requiring procainamide drip and one time DC cardioversion,
has a bradycardia requiring administration of atropine.
However, over the course of a few days, she was successfully
weaned off pressors, had satisfactory urine output and the
bradycardia resolved. Her cardiac enzymes also trended
downwards. Additionally, there were no more episodes of
atrial fibrillation. Cardiac echocardiogram done on [**10-26**] showed an ejection fraction less than 25%, severely
depressed left ventricular and right ventricular function, no
RA, mild to moderate mitral regurgitation, 2+ tricuspid
regurgitation, small to moderate pericardial effusion. She
was successfully extubated on [**10-28**]. She required some
supplemental oxygen post extubation, but was eventually
weaned off all supplemental oxygen. She continued to receive
Plavix and aspirin. Results from a repeat echocardiogram on
[**11-3**] were unchanged from the previous one. Lopressor
and captopril were slowly added to her regimen. She had a
hematocrit drop on initial presentation, requiring two units
of packed red blood cells. Her stool was trace guaiac
positive. It was thought to be due to blood that she had
swallowed during intubation. Over the course of her stay,
her hematocrit stabilized. Additionally, she had spiked a
fever of up to 101 and was empirically started on vancomycin.
Her initial blood cultures, as well as her surveillance
cultures were negative and the antibiotic was discontinued.
She did not spike a fever since that initial episode. Post
myocardial infarction, she was confused including not
oriented to place, but oriented to time and person. A head
CT was negative. Psychiatry and Neurology were consulted and
their opinion was that the mental status changes were due to
anoxic brain injury. Over the course of her stay in the
hospital, there was some improvement in her mental status,
however, she was not at her baseline.
DISCHARGE DIAGNOSES:
1. Acute right-sided myocardial infarction. status post
stents to right coronary artery.
2. Anoxic brain injury.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q.d.
2. Plavix 75 mg po q.d.
3. Lipitor 20 mg po q.d.
4. Synthroid 50 mcg q.d.
5. Captopril 12.5 mg t.i.d.
6. Lopressor 25 mg b.i.d.
7. Heparin subcutaneous.
8. Colace 100 mg po b.i.d.
9. Protonix 40 mg po q.d.
11. Nitroglycerin sublingual 0.4 mg prn.
12. Sarna cream.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to rehabilitation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2168-11-19**] 10:28
T: [**2168-11-19**] 10:28
JOB#: [**Job Number **]
|
[
"593.9",
"348.1",
"276.2",
"285.9",
"427.31",
"997.01",
"785.51",
"428.0",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"99.20",
"96.72",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
5415, 5762
|
4954, 5070
|
5093, 5393
|
2856, 4933
|
1458, 1669
|
1832, 2838
|
170, 1315
|
1338, 1433
|
1686, 1809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,109
| 142,713
|
1723
|
Discharge summary
|
report
|
Admission Date: [**2155-4-30**] Discharge Date: [**2155-5-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
fevers, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a [**Age over 90 **] y/o M with a h/o h/o urosepsis and cdiff colitis
who presents from Nursing home with fevers, diarrhea, and
sweating. Patient is non-verbal and has primary progressive
aphasia and is not very responsive at basline. Per family
report, patient had become less responsive to sternal rub and
there was concern that patient had infectious etiology to his
delirium. Patient was reported to have fever to 102 at Nursing
home today. Per patient's daughter (who is a physician) her
father was diaphoretic and tachypneic this morning.
[**Name (NI) **] wife reports 1 wk of explosive diarrhea. Patient has
multiple abx exposures over the past year and was treated most
recently for C Diff colitis one month ago with ten day course of
PO vancomycin.
In ER, patient was febrile to 101.8. VS HR 110, 112/67, 20, 100%
4LNC. Patient also has intermittant myclonic jerks at basline,
but has been worse over past several days. Patient had a CXR
that showed a possible LLL infiltrate and a UA that was floridly
positive. Patient received 2L NS, Vancomycin, Cefepime, Flagyl,
and Levofloxacin. Patient was weaned to 2L NC prior to transfer
to [**Hospital Unit Name 153**].
Past Medical History:
- Anemia
- BPH
- Atrial Fibrillation
- Benign Hypertension
- History of hemorrhagic prostatitis ([**4-/2154**])
- History of Stroke With Late Effects
- primary progressive aphasia and dysphagia s/p G tube
- Glaucoma
- History of MRSA bacteremia
- History of Enterococcal bacteremia
- History of Fungemia
- History of Recurrent UTIs
- History of C. diff
- History of Obturator Internis abscess
Social History:
The patient is currently a resident at [**Location (un) 169**] [**Hospital1 1501**]. He has
been hospitalized multiple times over the last few months, is
generally described as minimally communicative at baseline. The
patient is fully dependent for all ADL.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-Contributory
Physical Exam:
VS: TM=100.1, Tc=99.9, BP=92-142/53-80, BPc=98/50, RR=28, O2 sat
= 99% on 2L
GENERAL: Contracted in NAD
[**Hospital1 4459**]: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/[**Hospital1 3899**]. MMM. OP clear. Neck Supple.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops.
LUNGS: CTAB, good air movement biaterally but poor inspiratory
effort.
ABDOMEN: NABS. Soft, NT, ND. No HSM PEG site c/d/i.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Unable to assess orientation but responds to verbal
stimuli. Appropriate. No facial asymmetry. Contracted upper and
lower extremities.
PSYCH: Could not be assessed [**2-24**] minimally interactive state.
Pertinent Results:
[**2155-4-30**] 03:00PM GLUCOSE-114* UREA N-66* CREAT-1.5*
SODIUM-146* POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-28 ANION GAP-15
[**2155-4-30**] 03:00PM ALT(SGPT)-18 AST(SGOT)-33 CK(CPK)-325* ALK
PHOS-105 TOT BILI-0.5
[**2155-4-30**] 03:00PM LIPASE-34
[**2155-4-30**] 03:00PM CK-MB-3 cTropnT-0.07*
[**2155-4-30**] 03:00PM WBC-12.9* RBC-3.74*# HGB-11.5*# HCT-32.9*#
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.1
[**2155-4-30**] 03:00PM NEUTS-57.9 LYMPHS-34.1 MONOS-6.5 EOS-1.1
BASOS-0.4
[**2155-4-30**] 03:00PM PLT COUNT-295
[**2155-4-30**] 03:00PM PT-13.0 PTT-22.0 INR(PT)-1.1
[**2155-4-30**] 04:12PM URINE RBC-[**7-2**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2155-4-30**] 04:12PM URINE [**Year/Month/Day 3143**]-SM NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2155-4-30**] 04:12PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018
Brief Hospital Course:
[**Age over 90 **] year old male with multiple medical issues including
progressive aphasia, minimally interactive at baseline, h/o
cdiff in [**2154-11-23**] and [**2155-3-23**], MRSA parotiditis, who
presents with increasing lethargy, fevers, diarrhea.
#. Sepsis:
Patient febrile and tachycardic on admission with afib with RVR.
Very dehydrated on admission to the ICU requring 3L of IVF to
improve urine o/p. Also with h/o cdiff in [**3-31**] treated for 10
days PO vanc with new onset of diarrhea for the past 3/4 days.
Given prior Klebsiella UTI in [**9-30**] that was sensitive to
Cefepime and Meropenem and h/o Pseudomonas UTI in [**6-30**] that had
moderate sensitivities to Cefepime but strong for Meropenem,
started on Vancomycin and Cefepime for empiric UTI treatment.
He has a chronic foley due to severe BPH- last changed
[**2155-4-4**]. Now w/ + C. diff (?incompletely treated from [**3-31**]).
Initial UA was contaminated with skin flora, and repeat U/A was
negative but he had been on broad spectrum antibiotics for 2
days. Given that UA on admission showed fairly significant
pyuria, he will complete a 7-day course of cefepime. He will
continue PO vanc for C. diff for 2 weeks after the completion of
cefepime.
# Atrial Fibrillation with Rapid Ventricular Response: Patient
presented with rates in 110s-150s. Pt is rate controlled as
outpatient on diltiazem 90mg QID, and metoprolol 100mg TID. Home
medications resumed with good control of his heart rate.
# Acute on Chronic Renal Insufficiency: Cr b/l is 1.0 to 1.1.
Patient's Cr was 1.5 on presentation, improved to baseline with
IVF.
# Hypernatremia: Free water deficit on admission was 1.7L. Got
free water flushes 250 cc q 4 hours and hyponatremia resolved.
# Acute Delirium: Patient has a history of primary progressive
aphasia and has significantly deteriorated over past one year.
Patient is mostly non-verbal and only minimally responsive at
baseline. Per family, patient has not been very responsive to
stimuli over the past several days and has been off his
baseline. This is likely secondary to patient's infectious
process and improved with treatment of his UTI.
# Glaucoma: Continued Brimonidine, Dorzolamide, Latanoprost
# Anemia: recent labs c/w ACD
# BPH: Chronic Foley catheter in place
# Hypertension: continued lopressor and diltiazem
Medications on Admission:
heparin SC 5000 units tid
diltiazem 90mg qid
metoprolol 100mg tid
senna 8.6mg [**Hospital1 **]
Tylenol 325-650mg q4-6h prn
bisacodyl 10mg qhs prn
Maalox 150-30mL po qid prn
latanoprost 0.005% drops qhs
dorzolamide-timolol 2-0.5% [**Hospital1 **]
donepezil 5mg qhs
ferrous sulfate 400mg (60mg irn)/5 mL liquid po qd
polyethylene glycol 100% powder qd prn
brimonidine 0.15% q8h
Discharge Medications:
1. Pneumoboots
2. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
4. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Acetaminophen 160 mg/5 mL Solution Sig: [**11-11**] mL PO Q6H
(every 6 hours) as needed.
6. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
7. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 mL PO four
times a day as needed.
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
10. Donepezil 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five
(5) mL PO once a day.
12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
once a day.
13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
15. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 4 days.
16. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 18 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary: urinary tract infection, C. diff
Secondary: BPH, afib, hypertension, h/o hemorrhagic prostatitis,
h/o CVA, primary progressive aphasia and dysphagia s/p G-tube
Discharge Condition:
good, stable, improved mental status, afebrile
Discharge Instructions:
You were evaluated for fevers and diarrhea and were found to
have a C. diff infection as well as a urinary tract infection.
You will complete a seven-day course of IV antibiotics
(cefepime) and continue oral vancomycin for 2 weeks after the
cefipime is stopped.
If you have fevers, chills, worsening diarrhea, mental status
changes, shortness of breath, or any other concerning symptoms,
notify your doctor.
Followup Instructions:
You will be followed by the doctors at your nursing home.
|
[
"438.11",
"V44.1",
"600.01",
"427.31",
"438.82",
"403.10",
"293.0",
"285.9",
"365.9",
"599.0",
"584.9",
"276.0",
"585.9",
"008.45",
"787.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8078, 8168
|
4022, 6356
|
278, 285
|
8381, 8430
|
3091, 3999
|
8887, 8948
|
2249, 2267
|
6782, 8055
|
8189, 8360
|
6382, 6759
|
8454, 8864
|
2282, 3072
|
222, 240
|
313, 1501
|
1523, 1917
|
1933, 2233
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,558
| 194,247
|
28775
|
Discharge summary
|
report
|
Admission Date: [**2187-12-7**] Discharge Date: [**2187-12-11**]
Date of Birth: [**2128-11-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Renal cell carinoma with mets to brain
Major Surgical or Invasive Procedure:
Left frontal craniotomy
History of Present Illness:
59-year-old woman with a history of renal cell cancer and known
left frontal
metastasis and lung mets, who presented with new onset complex
partial seizure on [**2187-11-19**]. She had GTR of her L frontal met on
[**12-7**], with a good improvement of her transcortical motor
aphasia; Admitted for elective craniotomy
Past Medical History:
CHF with EF 40-55%
mitral valve regurgitation
HTN
anemia related to folate and iron defic
factor [**Month/Year (2) **] deficiency
renal cell cancer diagnosed in [**8-26**] with a left renal mass,
presented with LE swelling. Now s/p L nephrectomy and
adrenalectomy [**9-26**], pathology showing renal cell. On [**2187-11-14**]
had MRI with a hemorrhagic metastasis L frontal, following with
Dr. [**Last Name (STitle) 4253**].
CHF with EF 40-55%
mitral valve regurgitation
HTN
anemia related to folate and iron defic
factor [**Last Name (STitle) **] deficiency
Social History:
Lives with husband and son, HS education; formerly worked at
[**Male First Name (un) 28447**] club/sales, quit tob 30 yrs ago, formerly smoked <1pd x 10
yrs, former etoh, no drugs, no toxic exposures
Family History:
son with sz d/o, father d. lung ca with mets to brain; mother d.
stroke, sister with cervical ca, brother with cad
Physical Exam:
VITAL SIGNS: VSS
GENERAL: She is alert, pleasant, cachectic, middle-aged woman,
in no acute distress. She is lying in bed. She is alert and
attentive and is cooperative with the examination, which is
improved from before as her aphasia is better. She is mildly
inattentive.
NEUROLOGIC: The patient was alert and oriented x3. She took 2
attmepts to register. She was unable to coung backwards from 20
to 1 because of inattention. She had intact naming to
confrontation, but only able to generate a list of two animals.
She had intact repetition. She followed a [**3-23**] step command. She
had positive right-left disorientation. Recall was actually [**1-23**]
spont, [**2-23**] with hints, [**3-23**] with lists.
Pertinent Results:
[**2187-12-7**] 01:09PM PO2-166* PCO2-37 PH-7.46* TOTAL CO2-27 BASE
XS-3
[**2187-12-7**] 01:09PM GLUCOSE-90 NA+-134* K+-3.7
[**2187-12-7**] 01:09PM HGB-9.7* calcHCT-29
[**2187-12-7**] 01:09PM freeCa-1.14
Brief Hospital Course:
Ms [**Known lastname 69531**] [**Last Name (Titles) 1834**] a left frontal craniotomy on [**12-7**] with
out difficulty. As the foley was being placed blood was noted
in the vaginal canal. Post operatively she spent the overnight
in the PACU where her BP was kept below 140. Her exam was
orientated X2, following commands with word finding difficulty
and right sided weakness.
She was transferred to the floor on day 1 she continued
perservation/word finding difficulties had a right pronator
drift.
A pelvic ultrasound was completed to the vaginal bleeding that
was noted it showed: PELVIC ULTRASOUND: Transabdominal
evaluation of the pelvis was performed.
Transvaginal examination was not attempted as the patient was
unable to give
consent secondary to mental status change. The uterus is
heterogeneous and
enlarged measuring 8.9 x 7.0 x 8.5 cm. There are several large
hypoechoic
masses consistent with fibroids, the largest located in the mid
uterus
measuring 3.4 x 3.5 x 3.9 cm. The endometrium is poorly
visualized and
distorted by the underlying fibroids. The ovaries are not
visualized.
Superior to the uterine fundus, there is a mixed solid-cystic
lesion measuring
3.6 x 2.7 x 3.9 cm. Two sub-cm echogenic nodules are identified
along the
posterior aspect of the lesion. The origin and etiology of this
mass is
unclear. [**Name2 (NI) **] other lesions are identified. There is no free
pelvic fluid. A
1.5 cm thin- walled anechoic simple cyst is seen within the mid
right kidney.
There is no evidence of calculi or hydronephrosis. The patient
is status post
left nephrectomy. No tumor recurrence is seen within the
visualized surgical
bed.
The GYN service did not see the patient, they felt that the
bleeding was related to endometrial thickening and did not
warrent an inpatient consult and she should follow up as an
outpatient. An appointment was scheduled for early [**Month (only) 1096**].
She was seen by PT/OT which recommended home with PT.
A follow up MRI showed:
The present study shows high T1 signal, apparently blood
products, within the left frontal metastatic tumor resection
bed. There is also a surrounding ring of contrast enhancement.
Given the appearance of the mass on the prior studies, the
enhancement raises the possibility of residual tumor. There are
additional, somewhat gyral shaped areas of contrast enhancement
subjacent to the craniotomy flap and extending towards the left
frontal tumor resection bed. Some of these could be vessels, but
they do appear somewhat more prominent than was seen on the
prior study of [**2187-12-7**]. Thus, either altered vascular
status secondary to the recent resection, leptomeningeal tumor
and/or infection all have to be considered in the differential
diagnosis of this finding. There is pachymeningeal enhancement
subjacent to the craniotomy defect, a finding which can simply
be due to the surgery itself. The degree of mass effect upon the
adjacent left lateral ventricle appears unaltered. It is very
difficult to demonstrate the enhancement of the left cerebellar
lesion at this time, and this enhancement is only faintly
discernible on the coronal and possibly the sagittal
post-contrast images as well. The edema associated with both
lesions is re-demonstrated, as are the numerous punctate areas
of elevated FLAIR signal within the white matter of both
cerebral hemispheres, probably representing chronic small vessel
infarcts.
The present study shows susceptibility within the left
cerebellar metastasis, raising the question of interval
hemorrhage compared to the prior susceptibility scan of [**11-14**], [**2187**] (more recent intervening MR studies did not have a
susceptibility sequence). The size of this susceptibility area
conforms to the previously noted area of contrast enhancement at
this locale. Finally, there is re-demonstration of what is
likely a 1 cm right maxillary antral mucous retention cyst.
Neuro oncology, Dr [**Last Name (STitle) 4253**], also saw the patient who
recommended: to follow up in the brain tumor clinic. Where her
films, path, and history in our BTC
conference will be reviewed that morning and make the decision
on whether to give
her WBXRT vs SRS. L cerebellar met was already treated with SRS
about 10 days ago.
2. Cerebral edema. Can continue wean as planned, if pt worse,
would hold wean and have them call our office for further
instructions.
3. Seizures. Continue Keppra at 1000mg [**Hospital1 **].
4. Aphasia. This has improved and should continue to do so as
edema from surgery resolves.
Medications on Admission:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
8. 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*
9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*20 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Increase to 3 tab (1500mg/dose) [**Hospital1 **] in 2week. Then
increase to 4 tab (2000mg) [**Hospital1 **] in another 2 weeks.
Disp:*240 Tablet(s)* Refills:*2*
11. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 1 weeks: then follow taper. stop after last
dose 11/27.
Disp:*30 Tablet(s)* Refills:*0*
12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a
day: start on [**12-18**] and continue until seen in brain tumor
clinic.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Renal Cell Carcinoma with metastasis to brain
Discharge Condition:
Neurologically stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Watch incision for redness,drainage, bleeding, swelling or if
you develop fevers greater than 101.5, neurologic changes call
Dr[**Name (NI) 9034**] office
No driving while on narcotics
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-12-19**] 5:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2187-12-19**] 5:00
Have staples removed [**12-19**] at Dr [**Last Name (STitle) 17511**] office between
1200-4:00pm
Follow up at the brain tumor clinic on:[**2187-12-24**] at 3pm
F/U on [**2187-12-31**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] GYN at 08:30 AM [**Hospital Ward Name 23**] 8,
[**Telephone/Fax (1) 2664**]
Completed by:[**2187-12-12**]
|
[
"424.0",
"286.3",
"197.0",
"780.39",
"189.0",
"428.0",
"401.9",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
9743, 9806
|
2607, 7149
|
313, 339
|
9896, 9920
|
2371, 2584
|
10253, 10945
|
1502, 1619
|
8062, 9720
|
9827, 9875
|
7175, 8039
|
9944, 10230
|
1634, 2352
|
235, 275
|
367, 687
|
709, 1269
|
1285, 1486
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,867
| 103,017
|
54843
|
Discharge summary
|
report
|
Admission Date: [**2156-6-16**] Discharge Date: [**2156-6-22**]
Date of Birth: [**2092-9-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 year old male with h/o severe COPD who is being transferred
from [**Hospital1 2177**] after a prolonged admission for hypercapneic
respiratory failure from COPD complicated by pneumothorax and
bleb rupture. He is being transferred for consideration of
intrabronchial valve.
He was admitted to [**Hospital1 2177**] [**2156-5-19**] with hypercapneic respiratory
failure felt to be due to COPD. He has known COPD and was
reportedly not compliant with his medications and still smoking.
At baseline he reportedly has DOE and cannot climb a flight of
stairs and is dyspneic with shaving. He presented with
productive cough and dyspnea. His DNR/DNI status was reversed in
the ED at [**Hospital1 2177**] and he was intubated (initial ABG 7.13/96/234).
CXR showed left basilar PTX and urgent chest tube was placed by
CT surgery. CT chest showed large bulla in [**1-12**] of RLL of lung.
He was extubated on HD2. Course complicated by extensive SC
emphysema felt to be related to bleb rupture. A SC incision into
the left chest wall ("blow hole") was done by CT surgery which
resulted in slow improvement in his SC emphysema. He had
persistent air leak and small left sided PTX was seen on daily
films. Pleurodesis was performed [**2156-6-2**]. He continued to have
persistent air leaks and 2nd chest tube was placed on [**6-10**]. He
is on -40 wall suction on 1st chest tube, and -20 on 2nd chest
tube. He is now being transferred for placement of
intrabronchial valve by IP service.
During his course at [**Hospital1 2177**], he completed a course of steroids and
azithromycin for COPD exacerbation. On [**6-15**], he desatted to the
80's requiring non-rebreather with resolution of his symptoms.
CXR showed RLL infiltrate and he was started on vanco/cefepime
for HCAP, although f/u xray showed chronic changes and
antibiotics were stopped. He also developed diffuse abdominal
pain on [**5-10**] with emesis. CT showed SBO but he refused NG
tube per the discharge summary (per the patient, he agreed and
the team couldn't get it in and he refused to let them try
again). He was made NPO and started on IV fluids. He passed
flatus x 1 on [**6-14**] but has not yet had a bowel movement (last BM
[**6-9**]). Cause of SBO was felt unclear. Vitals on transfer 97.7 80
(100s-110s when moves) 106/57 [**12-24**] 95%4L.
Currently, he reports pain at the site of his chest tubes and
pain in his epigastrium. Denies any SOB, but has productive, wet
cough. States his breathing is okay as long as he has his "best
friend," referring to his nasal cannula. Denies CP. States he is
still passing flatus, but has not had BM. Cannot recall any of
the events leading up to the hospitalization and is not sure why
he was transferred here. He does know that he does not want
anyone to attempt to place another NG tube. Denies recent
fevers. Denies current nausea or vomiting.
Past Medical History:
Severe COPD, not on home O2 as still smoking
Malnutrition/FTT
Chronic hyponatremia
H/o PTX in setting of PNA many years ago
EtOH abuse, remote
Possible h/o cirrhosis per patient
Gastric ulcer
H/o cleft palate surgery in youth with subsequent difficulty
speaking
Social History:
Lived in [**Location 686**] in senior housing by himself prior to
hospitalization. Smokes 1ppd, history of alcohol abuse but quit
[**2137**], no IVDU. Worked in movie theaters and unloading trucks in
past.
Family History:
Brother had CABG, father died of MI, mother died of old age.
Physical Exam:
Admission Physical Exam
Vitals: 96.0 104/58 79 24 100%6L
GENERAL: Pleasant, but very cachectic male in NAD. Has
dysarthria that he reports is his baseline.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops.
LUNGS: Diminished breath sounds throughout L>R with coarse
expiratory wheezing. Right base also with rhonchi. Two chest
tubes in place.
ABDOMEN: Diminished bowel sounds but present, soft and only
mildly tender to palpation over epigastrium, not distended or
tympanic. No HSM palpable. Has diffuse subcutaneous emphysema
across abdomen
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
NEURO: A&Ox3. Appropriate.
PSYCH: Listens and responds to questions appropriately, pleasant
Discharge exam: Deceased
Pertinent Results:
Admission labs:
[**2156-6-17**] 02:12AM BLOOD WBC-5.1 RBC-3.13* Hgb-10.2* Hct-31.6*
MCV-101* MCH-32.6* MCHC-32.4 RDW-12.2 Plt Ct-212
[**2156-6-17**] 02:12AM BLOOD PT-12.6* PTT-27.4 INR(PT)-1.2*
[**2156-6-17**] 02:12AM BLOOD Glucose-86 UreaN-5* Creat-0.4* Na-139
K-3.8 Cl-99 HCO3-36* AnGap-8
[**2156-6-17**] 02:12AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.9
[**2156-6-17**] 02:12AM BLOOD ALT-9 AST-19 AlkPhos-55 TotBili-0.4
[**2156-6-17**] 08:03AM BLOOD Type-ART pO2-168* pCO2-72* pH-7.31*
calTCO2-38* Base XS-7 Intubat-NOT INTUBA
[**2156-6-17**] 08:03AM BLOOD Lactate-0.9
Discharge labs: Deceased
Imaging:
-CXR ([**2156-6-17**]): The lung volumes are increased. At the right
apex, there are severe emphysematous and bullous parenchymal
alterations. Identical lesions are seen in the lateral aspects
of the left lung and at the bases of the right lung. At the
bases of the right lung, a small pleural effusion is visible.
On the left, two chest tubes are seen. According to the lateral
radiograph, they appear to be correctly positioned. One of the
tubes, however, has its sidehole very close to the chest wall
and, as a consequence, could be advanced. The presence of a
small basal pneumothorax cannot be excluded with certainty.
There are extensive bilateral parenchymal opacities in the
middle and lower lung zones. The multiple air bronchograms with
irregular border suggest that these changes have a chronic
component. The size of the cardiac silhouette is normal. Also
normal are the hilar and mediastinal contours.
Given that this is the admission radiograph and that the
morphologic feature is complex, CT is recommended to obtain a
better assessment of the complex morphology and a valid baseline
for further followups.
-CT head ([**2156-6-19**]):
1. Thin 2.5 mm subdural hematoma at the right frontal lobe
without evidence of fracture or mass effect.
2. Left sphenoid bone lytic lesion. DDx includes hemangioma,
fibrous
dysplasia, but also metastasis or chondrosarcoma. Further workup
with MRI
might be considered.
3. Small amount of fluid in the left mastoid air cells.
-Right shoulder plain film ([**2156-6-19**]): There are no signs for
acute fractures or dislocations. There is normal osseous
mineralization. There are mild degenerative changes of the
glenohumeral joint. The visualized right lung apex is clear.
-Pelvis ([**2156-6-19**]): Single view of the pelvis demonstrates no
displaced fractures or dislocations. There are degenerative
changes of the right hip with spurring in the superolateral
acetabula. There are mild degenerative changes of the lower
lumbar spine. The sacroiliac joints are within normal limits.
There are vascular calcifications.
Brief Hospital Course:
MR. [**Known lastname 106556**] is a 63 yo M with endstage COPD who was admitted to
[**Hospital1 18**] from [**Hospital1 2177**] for evaluation for a bronchial valve to help
treat his bullous emphysema which had resulted in pneumothoraces
whose goals of care were shifted to comfort measures only during
this hospitalization, and he expired on [**2156-6-22**].
#Bullous Emphysema- The patient has long standing COPD, not on
home o2, as he continued to smoke and it has been complicated by
bleb rupture with pneumothoraces. On admission to the outside
hospital he was in hypercarbic respiratory distress and required
intubation (temporarily reversed his DNI status at that time).
He was ultimately extubated and required bipap while there. He
completed a course of antibiotics for COPD exacerbation at the
OSH. Patient was transferred to [**Hospital1 18**] for further evaluation by
interventional pulmonary. On admission here he was originally
on 6L of NC and was stable. He acutely became tachypneic,
dyspneic and complaining of not being able to breath and was
transferred to the ICU. In the ICU he was placed on a shovel
mask, received morphine and had an NG tube placed. His CXR
showed bullae in the left and right lung. IP evaluated the
patient and switched his Chest tubes to water seal on admission
to the ICU and then pulled them on HD#3. Ultimately, IP felt
there was no intervention that would be of benefit to the
patient.
He complained of multiple episodes of air hunger and was
treated with escalating doses of morphine. He was transferred to
the floor where his respiratory status continued to deteriorate.
After discussion with the patient and his family/HCP, he was
transitioned to [**Name (NI) 3225**] with inpatient hospice, as discussed below.
He expired on [**2156-6-22**] with his family at the bedside.
#Goals of care- the patient was originally DNR/DNI on admission
to the outside hospital however on admission to their ED he
changed this to DNR but okay to intubate. On admission to the
ICU here, he expressed his wishes to be DNR/DNI and that he did
not wish to have any further interventions and was looking for
hospice. Palliative care was consulted and helped to arrange
inpatient hospice. As his respiratory status continued to
decline, he was made full [**Date Range 3225**] and was transitioned to inpatient
hospice care.
#Small bowel obstruction- The patient had a known SBO at the OSH
and had refused NG tube placement there as well as on admission
here. When he was transferred to the ICU he agreed to a NG tube
placement and reported feeling better. There was audible air
that came out of the NG tube on placement. The plan was to get a
CT abd/pelvis to further evaluate however given that he was
unable to lie flat this was not performed and was not pursued
given his change in GOC. The patient pulled the NGT on HD3
while he was delirious and it was not replaced.
#Fall abd subdural hemorrhage- Early on HD4, the patient tried
to leave his room while he was delirious and had a fall with
head strike. Her reported right shoulder and arm pain after the
fall, no fracture on right shoulder plain film and no fracture
on pelvic fx. Head CT showed a 2.5mm frontal subdural hematoma.
He did not have any major apparent neurological sequelae of
this subdural (pupils remained reactive and equal, moving all
extremities) and no repeat imaging was obtained after his GOC
were changed to [**Date Range 3225**].
Medications on Admission:
1000 mL NS Continuous at 75 ml/hr
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/wheeze
Acetaminophen 650 mg PO/NG Q6H:PRN pain, fever
Famotidine 20 mg IV Q12H
Heparin 5000 UNIT SC TID
Ipratropium Bromide Neb 1 NEB IH Q6H
Lidocaine 5% Patch 1 PTCH TD DAILY
MethylPREDNISolone Sodium Succ 125 mg IV Q8H
Morphine Sulfate 2-4 mg IV Q4H:PRN air hunger Hold for sedation
Morphine Sulfate 4 mg IV ONCE Duration: 1 Doses
Ondansetron 4-8 mg IV Q8H:PRN nausea
Discharge Medications:
Expired
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"300.00",
"V15.81",
"493.22",
"492.0",
"518.83",
"E888.9",
"285.29",
"276.1",
"V85.0",
"V66.7",
"719.41",
"560.9",
"305.1",
"512.83",
"293.0",
"V13.64",
"263.9",
"852.21",
"799.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11458, 11516
|
7423, 10884
|
324, 331
|
11567, 11576
|
4708, 4708
|
11632, 11642
|
3746, 3808
|
11426, 11435
|
11537, 11546
|
10910, 11403
|
11600, 11609
|
5290, 7400
|
3823, 4663
|
4679, 4689
|
265, 286
|
359, 3218
|
4724, 5274
|
3240, 3504
|
3520, 3730
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,569
| 115,191
|
12893
|
Discharge summary
|
report
|
Admission Date: [**2185-4-20**] Discharge Date: [**2185-4-23**]
Date of Birth: [**2131-3-30**] Sex: M
Service: MEDICINE
Allergies:
Benadryl Allergy / Ambisome / Flomax
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 year old man with h/o AML s/p allo cord transplant (now day
+516) complicated by chronic GVHD with arthritis, BOOP, who
presented to the BMT floor from clinic with worsening renal
function(2.3) and hyperkalemia, and worsening odynophagia on
[**2185-4-20**].
On arrival to the BMT floor, as he was transitioning into the
bed, he became mom[**Name (NI) 11711**] unresponsive to verbal stimuli and
physical stimuli. No jerking movements or incontience were
noted. A code blue was called. On arrival of the code team, BP
124/80, Hr 70s, satting 100% on 5L NC. He was responsive to
verbal stimuli and answering questions appropriately. He does
not recall only seconds of the entire episode; wife notes that
his eyes were closed. 1 amp of D50, 10units regular insulin, and
abuterol nebs were given for known hyperkalemia. An EKG was
obtained which showed isolated peaked T waves. CXR showed no
interval change when accounted for technique from prior in the
day. During this time, he did experience a headache that was
located in the forhead, temples and described as a pressure /
squeeze that he has experienced with prior tension headaches.
He was then transferred to the [**Hospital Unit Name 153**] for further cardiac
monitoring. During this time, he was also noted to have some
tremors in hands and legs, but this was not associated with any
loss of consciousness or loss of consciousness. These episodes
will occur for only seconds at a time and tend to occur when he
is holding objects in his hands / intention tremor. He has not
had formal workup for this, but there was no clear etiology to
this tremor (which has been present intermittently over the past
2 years) to date.
His wife also relays the presence of intermittent episodes of
unresponsiveness over the past x2 years ago at a frequency of
1-2x per week lasting only seconds at a time. This has not been
formally evaluated to date.
Past Medical History:
Past Medical History (taken from previous notes)
1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+334. Day 100 bone marrow biopsy showed no
siagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Hx of post chemo-induced cardiomyopathy; TTE [**6-19**] with
preserved EF.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses/candidiasis ([**8-/2182**])
14) BOOP requiring extended ICU/hospital course in [**3-/2184**] and
home oxygen
15) Peripheral neuropathy
Social History:
Formerly worked as auto mechanic, now disabled econdary to AML
and GVHD. Lives with wife, teenage son. Past tobacco use, but
non currently.
Family History:
Father- CAD s/p CABG. Type II Diabetes
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.
Physical Exam:
GENERAL: Middle-aged, Cushingoid, overweight man in NAD
HEENT: EOMI, PERRLA, mucous membranes moist, no cervical LAD, no
JVD, neck supple w/out tenderness
CARDIAC: RRR no m/g/r, S1, S2 nl
CHEST: kyphotic
LUNG: few bilateral crackles at bases, no wheezes, rhonchi
ABDOMEN: obese, soft, NT, ND, unable to appreciate HSM [**2-14**] body
habitus, no rebound or guarding
EXT: warm, + bilateral 2+ pitting edema to knees, DP+
bilaterally, no cyanosis - L elbow medial epicondyle tenderness
w/ effusion, no joint erythema or effusion
NEURO: CNII-XII intact, motor symmetric strength, hyperesthetic
sensation bilateral LE/feet, no evidence of toe nail erythema
DERM: ecchymoses on abdomen [**2-14**] insulin, no other lesions.
Psych: Mood liabile, affect appropriate, intermittently tearing
up to labs draws, movement to ICU
Pertinent Results:
CBC:
[**2185-4-20**] 11:11AM BLOOD WBC-5.3 RBC-2.84* Hgb-9.3* Hct-29.3*
MCV-103* MCH-32.7* MCHC-31.7 RDW-15.2 Plt Ct-101*
[**2185-4-23**] 06:10AM BLOOD WBC-2.5* RBC-2.79* Hgb-9.2* Hct-29.1*
MCV-104* MCH-33.1* MCHC-31.7 RDW-15.3 Plt Ct-88*
[**2185-4-20**] 11:11AM BLOOD Neuts-84.9* Lymphs-4.7* Monos-7.5 Eos-2.9
Baso-0
[**2185-4-23**] 06:10AM BLOOD Neuts-70.4* Lymphs-11.9* Monos-13.8*
Eos-3.7 Baso-0.2
Chemistries:
[**2185-4-20**] 11:11AM BLOOD Glucose-156* UreaN-91* Creat-2.3* Na-137
K-5.5* Cl-103 HCO3-22 AnGap-18
[**2185-4-20**] 07:49PM BLOOD Glucose-108* UreaN-74* Creat-2.1* Na-136
K-4.8 Cl-126* HCO3-18* AnGap--3*
[**2185-4-21**] 04:18AM BLOOD Glucose-112* UreaN-83* Creat-2.2* Na-137
K-5.7* Cl-108 HCO3-23 AnGap-12
[**2185-4-21**] 08:18AM BLOOD Na-139 K-6.8* Cl-109*
[**2185-4-21**] 08:18AM BLOOD Na-142 K-5.6* Cl-110*
[**2185-4-21**] 02:12PM BLOOD Na-140 K-5.7* Cl-108
[**2185-4-22**] 05:14AM BLOOD Glucose-88 UreaN-72* Creat-2.0* Na-142
K-4.8 Cl-108 HCO3-24 AnGap-15
[**2185-4-23**] 06:10AM BLOOD Glucose-88 UreaN-61* Creat-1.9* Na-142
K-4.0 Cl-108 HCO3-26 AnGap-12
LFTs:
[**2185-4-20**] 11:11AM BLOOD ALT-35 AST-28 LD(LDH)-246 AlkPhos-189*
TotBili-0.2
[**2185-4-21**] 04:18AM BLOOD ALT-33 AST-27 CK(CPK)-17* AlkPhos-168*
TotBili-0.1
Cardiac Enzymes:
[**2185-4-20**] 06:29PM BLOOD CK-MB-3 cTropnT-<0.01
[**2185-4-21**] 04:18AM BLOOD CK-MB-3 cTropnT-<0.01
[**2185-4-20**] 11:11AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.6
[**2185-4-23**] 06:10AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.2
Antibody Titers:
[**2185-4-20**] 11:11AM BLOOD IgG-412* IgA-54* IgM-17*
ABG:
[**2185-4-20**] 06:30PM BLOOD Type-ART pO2-134* pCO2-39 pH-7.38
calTCO2-24 Base XS--1 Intubat-NOT INTUBA
[**2185-4-20**] 06:30PM BLOOD Glucose-442* Lactate-1.7 Na-132* K-6.5*
Cl-100
[**2185-4-20**] 06:30PM BLOOD freeCa-1.13
Blood and urine cultures from [**4-20**] negative.
Head CT ([**4-21**]):
IMPRESSION: No acute intracranial hemorrhage. Paranasal sinus
disease in the left maxillary and sphenoid sinus, as described
above.
CXR: ([**4-21**]) :
FINDINGS: Allowing for differences in technique there has been
no interval
change in appearance of the chest since the recent study with no
acute
cardiopulmonary abnormality identified.
Brief Hospital Course:
Summary of Hospital Course: 53 year old man with h/o AML s/p
allo cord transplant (day +516 on admission) complicated by
chronic GVHD with arthritis, BOOP, who now presents to clinic
with acute on chronic renal failure. Hospital course complicated
by syncopal episode the day of admission resulting in Code Blue
and hyperkalemia, requiring brief ICU admission.
#Syncope: Patient had syncopal episode the day of admission,
where he was unresponsive for ~1 minute while lying flat.
Unclear etiology, possible due to orthostatic hypotension (noted
to have orthostatic physiology in the ICU and on the floor) vs
arrythmia vs seizure activity. Of note, (per wife), patient has
had many of these episodes recently (~2 years, ~1-2 episodes per
week). Patient denied any heralding symptoms and was not
post-ictal afterwards, but was noted to have a resting tremor in
the MICU. His history of tremor is not consistent wtih seizure
activity. It appears to be an intention tremor that gets worse
when holding on to objects and is low in amplitude while high in
frequency, bilateral and not associated with change in
consciousness or incontinence.
Noted to be hyperkalemic during the code, given amp D50 and 10 U
insulin peri-code and kayexalate in the ICU, with drop in
potassium down to 4.0 on discharge. Neurology consulted on
patient who recommended EEG and possible midodrine or fluorinef
support. Held patient's lisinopril, but continued him on his
carvedilol 12.5 mg PO BID as this was recently decreased in the
setting of light headedness/dizziness by his cardiologist on
[**3-21**], although informed him not to take the medication if he had
any pre-syncopal symptoms. Medication can be decreased at the
discretion of his cardiologist. Patient had no further syncopal
episodes or events on telemetry in the ICU or on the floor.
Neurology was consulted who recommended an EEG, possible blood
pressure support with midodrine or fluorinef, at the discretion
of the patient's outpatient oncologist and nephrologist. Was
noted to not have any telemetry events or syncopal events while
ambulating, with appropriate increase in pulse and blood
pressure. and requested to be discharged with outpatient syncope
work-up. Outpatient TTE, EEG, carotid U/S, and holter monitering
were arranged prior to discharge.
#Acute on chronic renal failure: Noted to have mildly elevated
Cre to 2.3 in clinic the day of admission. Creatine has
fluctuated over the past two years, with several episodes of
acute renal failure while hospitalized. Followed by nephrology
as an outpatient. Per outpatient notes, etiology of CKD thought
to be [**2-14**] ATN that has not resolved, medication effect in the
setting of bactrim, voriconazole, lisinopril, or AIN. Less
likely due to AML infiltration of kidneys (very rare) or
chemotherapy. Unlikely progressive glomerular disease given
patient only has scant proteinuria. Patient has refused renal
biopsy in the past. Baseline Cre has been 1.4-2.0 over the past
few months. Lisinopril was held. Cellcept was decreased to
[**Telephone/Fax (3) 39636**] as GFR was ~30. Oral fluid intake encouraged. Renal
failure resolved to baseline creatinine (1.9) on discharge.
Renal did not have chance to formally consult on patient since
he requested discharge, but stated informally that they had no
further recommendations as an inpatient since he was refusing
renal biopsy, and he could be accommodated very soon in renal
clinic with his current outpatient nephrologist.
#Congestive Heart Failure: Euvolemic to mildly hypervolemic on
exam. Requested TTE as outpatient. Continued home meds including
aspirin, beta-blocker. Held ACEI due to hyperkalemia.
#AML: allo SCT +519 days. counts stable. continued prophylactic
medications. Arranged to follow up with outpatient oncologist.
#Epigastric discomfort: Gastritis, likely in setting of
prednisone. Patient has tried and failed Nexium, reporting it
has not helped his gastritis for 3 months. Relieved with
protonix, which was added to med list on discharge. Can obtain
prior authorization from PCP [**Name Initial (PRE) 5564**].
Medications on Admission:
-Acyclovir 400 [**Hospital1 **]
-Carvedilol 12.5 [**Hospital1 **]
-Cyanocobalamin 1000mcg IM 1xmonth
-Nexium 20mg PO BID
-Furosemide 40mg PO BID
-Gabapentin 300 cap 3caps tid
-Insulin Novolog 4xday, sliding scale
-Glargine 10u qhs
-Lisinopril 5mg daily
-Montelukast 10mg PO daily
-Morphine 15mg PO q6-8 hrs prn pain
-MMF 500mg TID
-Nitro 0.3mg tab SL
-zofran 4-8mg q8 hrs prn nausea
-Oxycodone SR 10mg PO BID
-Prednisone 20mg daily
-Bactrim 800-160 MWF
-Voriconazole 200mg tab, 1.5 tab q12h
-AA Magnesium Sulfate OTC 1tab daily
-Vit C 500mg tab daily
-Aspirin 81 mg tab Enteric coated
-Cal Carb 1000mg tab [**Hospital1 **]
-Vit D3 400u daily
-Hexavitamin 1 tab daily
-Miconazole 2% powder to affected areas [**Hospital1 **]
-Thiamine 50mg PO daily
-Docusate 100mg PO BID
-Senna 1 tab [**Hospital1 **] prn
Discharge Medications:
1. Acyclovir 200 mg Capsule [**Hospital1 **]: Two (2) Capsule PO Q12H (every
12 hours).
2. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times
a day.
3. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Oxycodone 10 mg Tablet Sustained Release 12 hr [**Hospital1 **]: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Morphine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO every 6-8 hours
as needed for pain.
11. Voriconazole 200 mg Tablet [**Hospital1 **]: 1.5 Tablets PO Q12H (every
12 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: Two (2)
Tablet, Chewable PO BID (2 times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Thiamine HCl 100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
16. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
17. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
18. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day: HOLD if patient loses consciousness or has systolic blood
pressure less than 100.
19. Hexavitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
20. Vitamin D-3 400 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
21. Vitamin C 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
22. Insulin Aspart 100 unit/mL Solution [**Hospital1 **]: One (1) as directed
Subcutaneous four times a day: per sliding scale.
23. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: One (1) syringe
Subcutaneous at bedtime: 10 Units at bedtime.
24. Zofran 4 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
25. Mycophenolate Mofetil 250 mg Capsule [**Hospital1 **]: Two (2) Capsule PO
BID (2 times a day).
26. Mycophenolate Mofetil 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily): please administer at noon .
Discharge Disposition:
Home
Discharge Diagnosis:
1' Diagnosis
Acute on Chronic Renal Failure
Hyperkalemia
Syncope
2' Diagnosis
Congestive Heart Failure
Hypertension
Acute Myelogenous Leukemia
Discharge Condition:
afebrile, hemodynamically stable, without syncopal episode x48
hours
Discharge Instructions:
You were admitted with a diagnosis of acute on chronic renal
failure, high potassium levels, and syncope. Your kidney
function resolved back to it's baseline, and your potassium
levels normalized with some kayexalate. We wanted to run some
lab tests to evaluate the reason for your syncope, but you felt
well and wanted to go home and have the testing done as an
outpatient.
Please take your medications as directed
- Please hold your lisinopril as this medication can cause
elevated potassium levels. Please restart at the discretion of
your PCP or cardiologist.
- Your Cellcept was decreased as noted on the medication list.
- We started you on protonix for your heart burn in place of the
Nexium. You may need prior authorization from your primary care
physician or oncologist for this medications.
Please return to the hospital if you have fever > 100.4, any
further fainting episodes, chest pain, palpitations, or any
other symptoms not listed here concerning enough to warrant
physician [**Name Initial (PRE) 2742**].
Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F [**Name Initial (NameIs) **]/ONCOLOGY-7F
Date/Time:[**2185-4-25**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2185-4-25**] 2:00
Provider: [**Name10 (NameIs) 3310**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-7F
Date/Time:[**2185-4-25**] 2:00
with your cardiologist as an outpatient. The phone number is
[**Telephone/Fax (1) 62**].
with renal as an outpatient. Please call ([**Telephone/Fax (1) 773**] to make
an appointment.
to get your trans-thoracic echocardiogram, your carotid
ultrasound, your holter monitoring, and your EEG. They have all
been ordered and your outpatient oncologist should follow up on
the results.
- Please call [**Telephone/Fax (1) 327**] to schedule your carotid ultrasound.
- Please call [**Telephone/Fax (1) 62**] to schedule your trans-thoracic
ultrasound.
- Please call [**Telephone/Fax (1) 3104**] to schedule your holter monitoring.
- Please call [**Telephone/Fax (1) 5285**] to schedule your EEG.
Completed by:[**2185-4-25**]
|
[
"255.0",
"V15.82",
"307.81",
"403.90",
"564.00",
"781.0",
"V02.54",
"205.00",
"780.2",
"V18.0",
"E933.1",
"272.0",
"356.9",
"279.52",
"585.9",
"275.0",
"V17.3",
"516.8",
"999.89",
"584.9",
"535.40",
"530.81",
"276.7",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15016, 15022
|
7343, 7343
|
319, 326
|
15210, 15280
|
5115, 6362
|
16356, 17533
|
4110, 4262
|
12292, 14993
|
15043, 15189
|
11462, 12269
|
15306, 16333
|
4277, 5096
|
7371, 11436
|
6379, 7320
|
266, 281
|
354, 2253
|
2275, 3937
|
3953, 4094
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,146
| 125,668
|
51654
|
Discharge summary
|
report
|
Admission Date: [**2125-4-1**] Discharge Date: [**2125-4-3**]
Date of Birth: [**2059-8-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Tylenol / Penicillins
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD with injection and endoclip of gastric antrum
History of Present Illness:
Mrs. [**Known lastname **] is a 65 year old female with a history of an
ascending aortic dissection s/p repair [**10-11**], who presented with
hematemesis x 1. She had one loose dark bowel movement the
morning of admission but has otherwise been well. On the day of
admisison after lunch (noon) she had an episode of emesis of
dark blood with clots ~300cc. She felt lightheaded during this
time but no syncope. She takes chronic NSAIDS for spinal
stenosis, in past on 2400mg/day, now weaned down to 800mg/day.
On baby ASA daily.
On arrival in the ED, vitals signs were: 98.8, 73, 10, 148/71,
97% RA. The patient was noted to be beta blocked, with a
nontender abdomen and on rectal exam stool with gross melena. IV
Protonix and 2 L NS given. The patient refused NG lavage despite
reassurance from CT surgery that it would be safe to perform
this procedure. Access: 2 18g. Crossed for 2 units pRBCs. ED
vitals: 61 133/70 17 99RA. CTA prelim negative.
On arrival in the MICU, the patient was comfortable. GI was at
the bedside for EGD. Vitals: 98.8, 73, 10, 148/71, 97% RA.
ROS: As per HPI. Negative for CP, SOB, abdominal pain, fevers,
diarrhea or constipation.
Past Medical History:
- raynaud's disease
- ADHD
- brachial plexus injury-left
- Type A dissection
- s/p Asc Ao replacement
- s/p laminectomy for spinal stenosis
- s/p TAH
Social History:
1.5 oz Vodka/D
lactose intolerance
nonsmoker
retired psychiatrist
Family History:
Mother had [**Name (NI) 2481**]
Father had [**Name2 (NI) 499**] cancer
Physical Exam:
VS: 98.8, 73, 10, 148/71, 97% RA
Gen: NAD, well-appearing
HEENT: PERRL
Heart: s1s2 RRR
Pulm: CTAB
Abd: soft, +BS, nontender, nondistended
Ext: no c/c/e
Rectal: per ED, melena
Neuro: A&O x3, nonfocal; has old contracture of the L 4th and
5th digits
Pertinent Results:
Admission Labs:
[**2125-4-1**] 03:15PM WBC-15.0* RBC-4.20# HGB-12.3# HCT-36.5#
MCV-87 MCH-29.4 MCHC-33.8 RDW-15.0
[**2125-4-1**] 03:15PM NEUTS-84.0* LYMPHS-11.1* MONOS-2.4 EOS-2.1
BASOS-0.3
[**2125-4-1**] 03:15PM PLT COUNT-319#
[**2125-4-1**] 03:15PM PT-14.0* PTT-23.2 INR(PT)-1.2*
[**2125-4-1**] 03:15PM CK-MB-NotDone cTropnT-<0.01
[**2125-4-1**] 03:15PM CK(CPK)-48
[**2125-4-1**] 03:15PM GLUCOSE-101 UREA N-42* CREAT-0.8 SODIUM-138
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2125-4-1**] 09:26PM HCT-30.2*
[**2125-4-1**] 09:26PM HCT-30.2*
.
CTA Chest [**2125-4-1**] - 1. Post-operative changes along the
ascending aorta with no evidence of aortic dissection, leak, or
aortoenteric fistula.
2. Stable-appearing up to 7-mm pulmonary nodules within the
right lung since [**2124-10-1**]. Given size, follow up in 6
months would be warranted per current Fleichner guidelines.
.
CXR [**2125-4-1**] - Postoperative changes without evidence of acute
intrathoracic process.
.
EGD [**2125-4-1**] - Findings: Esophagus: Normal esophagus.
Stomach: Excavated Lesions Multiple acute cratered ulcers
ranging in size from 3mm to 8mm were found in the distal body,
proximal antrum. There were stigmata of recent bleeding with
visible vessel in the largest of the ulcers (approximately [**7-11**]
mm in diameter and 3-4 mm in depth). 4 1 cc. Epinephrine 1/[**Numeric Identifier 961**]
injections were applied for hemostasis with success. One triclip
was successfully applied to the stomach antrum for the purpose
of hemostasis.
Duodenum: Excavated Lesions Multiple patchy erosions were seen
in the bulb.
Impression: Ulcers in the distal body, proximal antrum
(injection, endoclip). Erosions in the bulb
Recommendations: follow-up with endoscopist 8-12 weeks for
repeat endoscopy
Monitor Hct closely
IV PPI today switch to po PPI when tolerating po's
Brief Hospital Course:
Mrs. [**Known lastname **] is a 65 year old female with a history of
ascending aortic dissection s/p repair [**10-11**]. The patient was
admitted to the ICU for endoscopy following deveral episodes of
hematemesis. She was found to multiple acute cratered ulcers
ranging in size from 3mm to 8mm in the distal body, proximal
antrum. There were stigmata of recent bleeding with visible
vessel in the largest of the ulcers (approximately 7-8 mm in
diameter and 3-4 mm in depth). 4 1 cc.Epinephrine 1/[**Numeric Identifier 961**]
injections were applied for hemostasis with success. One triclip
was successfully applied to the stomach antrum for the purpose
of hemostasis. Multiple patchy erosions were seen in the bulb
of the duodenum. The patient was started on a PPI and remained
NPO overnight. She remained hemodynamically stable but was
transfused one of packed red blood cells to maintain a
hematocrit greater than 30. The patient's diet was successfully
advanced and the patient was transferred out to the floor. She
remained there until discharge the following day. On the
medicine floor her hematocrit remained stable and was 32 on the
day of discharge. Her metoprolol was restarted on the morning
of discharge and vital signs were monitored and remained stable.
The patient was instructed to follow-up with gastroenterology
for repeat endoscopy 8-12 weeks following discharge and was
given an appointment. Per GI, they plan to take biopsies at
that time to examine cytology and test for H. pylori. The
patient was discharged on omeprazole 40 mg [**Hospital1 **] with instructions
to continue this medication and stop aspirin and all NSAIDs
until she receives further instructions from GI when she sees
them in follow-up.
Incidental finding of 7mm nodule in Lungs was also noted on
CTA and pt needs repeat CT in 6 months to ensure stability.
Medications on Admission:
- metoprolol 100 [**Hospital1 **]
- simvastatin 20 qhs
- estratest
- citalopram 20 qhs
- oxazepam 10 [**Hospital1 **] prn
- asa 81
- vitamin A
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day) as needed.
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Omeprazole 40 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:*2*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Gastric ulcers
2. Hemetemesis
Secondary Diagnosis:
1. History of aortic dissection
Discharge Condition:
Vital signs stable. Hematocrit 32.
Discharge Instructions:
You were admitted to the hospital for evaluation of vomiting
blood and blood in your stool. You had an upper endoscopy that
showed ulcers and erosions in your stomach. The largest of
these was clipped and your blood counts have remained stable
since. It is recommended that you do not take any ibuprofen,
naproxen, or other NSAIDs as these can irritate the lining of
the stomach. Also, please stop taking aspirin until you see the
gastroenterologist in follow-up. You have been given a
prescription for omeprazole to help reduce stomach acid and heal
the lining of your stomach. Please take this as prescribed
until told otherwise by the gastroenterologist you see in
follow-up. You will need to have a repeat endoscopy in [**8-15**]
weeks, and a follow-up appointment has been made for you as
shown below. Please call to reschedule if this appointment does
not work with your schedule.
You also had a CT scan of your chest. There was no evidence of
dissection of your aortic graft. There were some nodules noted
in your lungs, but these were unchanged from your scan in
[**2124-9-4**]. The radiologist recommends that you have a
repeat CT scan in 6 months to ensure that there are no further
changes.
Please call your physician or return to the hospital if you have
further vomiting of blood, bright red blood in your stool, or
any other concerning symptoms. It was a pleasure to care for
you in the hospital.
Followup Instructions:
Please follow-up with your primary care provider within [**Name Initial (PRE) **] week
and have your hematocrit checked.
Endoscopy appointment: Please arrive at 8 am on [**2125-5-29**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2125-5-29**] 9:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2125-5-29**] 9:00
|
[
"314.01",
"285.1",
"300.00",
"531.40",
"E935.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6709, 6715
|
4069, 5935
|
302, 353
|
6865, 6903
|
2178, 2178
|
8376, 8819
|
1822, 1894
|
6129, 6686
|
6736, 6789
|
5961, 6106
|
6927, 8353
|
1909, 2159
|
251, 264
|
381, 1548
|
6810, 6844
|
2194, 4046
|
1570, 1722
|
1738, 1806
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,244
| 189,653
|
45427+58857+58817
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2144-3-21**] Discharge Date: [**2144-4-13**]
Service: SURGERY
Allergies:
Penicillins / Sulfonamides / Erythromycin Base / Cortisone /
Metronidazole / Ciprofloxacin / Ivp Dye, Iodine Containing /
Protamine
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal pain / weight loss
Major Surgical or Invasive Procedure:
Abdominal aortogram via left brachial approach with failed
attempt to identify celiac orifice, open repair of left brachial
artery with thrombectomy.
Exploratory laparotomy with retrograde celiac stent placement.
History of Present Illness:
86F p/w acute-on-chronic mesenteric ischemia
Past Medical History:
1. Chronic obstructive pulmonary disease.
2. Type 2 diabetes.
3. Hypertension.
4. Hypercholesterolemia.
5. Hypothyroidism.
6. Diverticulitis.
7. Gastroesophageal reflux disease.
8. Negative stress MIBI in [**2140-2-27**] with an ejection
fraction of 65%.
9. Status post cholecystectomy.
10. History of hyponatremia.
11. Hx Colonic polyp: carcinoma in situ
Social History:
Lives alone in [**Location (un) **]. Two children, several grandchilderen.
No tobacco/alcohol/ or drugs. Completes ADLs.
Family History:
non-contributory
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2144-4-8**] 04:01AM BLOOD
WBC-11.2* RBC-3.26* Hgb-9.9* Hct-29.3* MCV-90 MCH-30.5 MCHC-34.0
RDW-14.9 Plt Ct-327
[**2144-4-3**] 04:59AM BLOOD
PT-10.4 PTT-25.3 INR(PT)-0.9
[**2144-4-8**] 04:01AM BLOOD Plt Ct-327
[**2144-4-8**] 04:01AM BLOOD
Glucose-77 UreaN-12 Creat-0.8 Na-138 K-3.2* Cl-98 HCO3-31
AnGap-12
[**2144-4-8**] 04:01AM BLOOD
Calcium-8.0* Phos-5.7*# Mg-2.1
[**2144-3-30**] 12:06AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2144-3-30**] 12:06AM
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2144-3-21**] 09:30PM URINE RBC-[**3-2**]* WBC-0 Bacteri-RARE Yeast-NONE
Epi-0-2
Brief Hospital Course:
[**3-23**]: Abdominal aortogram via left brachial approach with failed
attempt to identify celiac orifice, open repair of left brachial
artery with thrombectomy.
sheath pulled without difficulties / no adverse sequele
Pt pre-op'd for below surgery:
[**3-30**]: Exploratory laparotomy with retrograde celiac stent
placement.
Pre-operatively, s/he was consented, prepped, and brought down
to the operating room for surgery. Intra-operatively, she was
closely monitored and remained hemodynamically stable. She
tolerated the procedure well without any difficulty or
complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She was then transferred to the VICU for further recovery. Pt
delined post operative day number 2. Kept NPO untill pos BS and
passing gas. Her diet was advanced as tolerated.
On the floor, he remained hemodynamically stable with her pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. She was discharged to a rehabilitation
facility in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]: Darvocet, Glipizide 2', Diovan 40', Synthroid 25'
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every
2 hours) as needed.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
MESENTERIC ISCHEMIA
COPD, DMII, HTN, ^Chol, Hypothyroid, GERD
Discharge Condition:
STABLE
Discharge Instructions:
CALL IMMEDIATLY IF YOU HAVE THE FOLLOWING SYMPTOMS:
Signs and symptoms of acute intestinal ischemia typically
include:
Sudden abdominal pain that may range from mild to severe
An urgent need to move your bowels
Frequent, forceful bowel movements
Abdominal tenderness or distention
Blood in your stool
Nausea, vomiting
Fever
Chronic intestinal ischemia, in which blood flow to the
intestines is reduced over time, is characterized by:
Abdominal cramps or fullness, beginning within 30 minutes after
eating and lasting for one to three hours
Abdominal pain that gets progressively worse over weeks or
months
Fear of eating because of subsequent pain
Unintended weight loss
Diarrhea
Nausea, vomiting
Bloating
Chronic intestinal ischemia may progress to an acute episode. If
this happens, you might experience severe abdominal pain after
weeks or months of bouts of pain after eating.
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.
OTHER INFORMATION:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re wound / incision site and this should
be left in place for three (3) days. Remove it after this time
and wash your incision(s) gently with soap and water. You will
have sutures, which are usually removed in 4 weeks. This will be
done by the Surgeon on your follow-up appointment.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for
removal.).
When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re wound / incision site and this should
be left in place for three (3) days. Remove it after this time
and wash your incision(s) gently with soap and water. You may
have staples and or sutures, which are usually removed in 4
weeks. This will be done by the Surgeon on your follow-up
appointment.
Limit strenuous activity and or heavy lifting until the wound
is well healed. Activity may prevent the wound from healing.
Do not drive a car unless cleared by your Surgeon.
Try to keep your affected limb elevated when not in use, This
decreases swelling to the affected wound and helps in the
healing process.
You may have an ace wrap around the affected limb with the
wound. This helps prevent swelling to the area. You may take
this off at night. But when you are doing activity the ace wrap
should be worn.
ANTIBIOTICS:
You may have a prescription for antibiotics. Take as directed.
Be sure you take the full course even if the wound looks well
healed. Failure to do so may lead to infection.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2144-4-20**] 1:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2144-7-27**] 1:10
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2144-7-27**] 1:30
YOU HAVE AN APPOINTMENT SCHEDULED FOR THURSDAY [**5-14**] AT 0845.
THIS IS WITH DR [**Last Name (STitle) **]. IT IS IN THE [**Last Name (un) **] BUILDING, [**Hospital Unit Name 96961**]. YOU WILL GET AN US AF YOUR ABDOMEN AT
THIS TIME
Provider: [**Name10 (NameIs) 6811**] STONE, RVT Date/Time:[**2144-5-14**] 8:45
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY
(NHB)Date/Time:[**2144-5-14**] 9:30
Completed by:[**2144-4-8**] Name: [**Known lastname 10766**],[**Known firstname 888**] Unit No: [**Numeric Identifier 15441**]
Admission Date: [**2144-3-21**] Discharge Date: [**2144-4-13**]
Date of Birth: [**2057-9-12**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfonamides / Erythromycin Base / Cortisone /
Metronidazole / Ciprofloxacin / Ivp Dye, Iodine Containing /
Protamine
Attending:[**First Name3 (LF) 726**]
Addendum:
pt with increase phosphorous and decrease calcium
given phoslo x 6 doses with meals
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]
Completed by:[**2144-4-8**] Name: [**Known lastname 10766**],[**Known firstname 888**] Unit No: [**Numeric Identifier 15441**]
Admission Date: [**2144-3-21**] Discharge Date: [**2144-4-13**]
Date of Birth: [**2057-9-12**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfonamides / Erythromycin Base / Cortisone /
Metronidazole / Ciprofloxacin / Ivp Dye, Iodine Containing /
Protamine
Attending:[**First Name3 (LF) 726**]
Addendum:
Patient had serosanguinous drainage from upper pole of abdominal
wound. Wound culture positive for coag neg. staph. Patient
started on levofloxacin on [**4-12**] for a 10 day course. Patient
remained afebrile and continued with daily lasix for LE edema.
Patient may be discharged to rehab facility on [**4-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]
Completed by:[**2144-4-13**]
|
[
"997.2",
"557.1",
"496",
"285.9",
"250.00",
"272.0",
"244.9",
"530.81",
"444.21",
"401.9",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"88.42",
"38.03",
"00.40",
"39.31",
"00.45",
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
10765, 11009
|
2408, 3555
|
367, 583
|
4758, 4767
|
1707, 2385
|
8176, 9694
|
1193, 1211
|
3682, 4543
|
4672, 4737
|
3581, 3659
|
4791, 5689
|
1226, 1688
|
299, 329
|
5702, 8153
|
611, 657
|
679, 1037
|
1053, 1177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,416
| 159,389
|
8719+55967
|
Discharge summary
|
report+addendum
|
Admission Date: [**2188-6-27**] Discharge Date: [**2188-7-21**]
Service: MEDICINE
Allergies:
Tetracyclines / Penicillins / Neomycin
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Thoracentesis x 3
Angiography of lower extremeties
History of Present Illness:
The patient is a [**Age over 90 **] year old woman with PMHx of CAD s/p stent x
4, HTN, and afib on coumadin who presented from [**Hospital 100**] Rehab
with 2 episodes of dark BRBR starting the night prior to
presentation and then 4 episodes on the day of admission since
8am soaking through 4 chucks/pads. At [**Hospital 100**] Rehab, her
hematocrit went from 28 -> 25 overnight.
BP at [**Hospital1 18**] ED at presentation was 70/40, HR 110 -> 150/p, HR 92
with 600 NS. Upper Lavage of 500 cc was clear with out any
coffee grounds or bright red blood.
In the ED, the patient was noted to have a large dark clot at
anus - about one cup; she received 3-4 units of ffp, 2 units of
prbcs and 40 of IV lasix, 10 sub q vitamin k.
Hematocrit was 23.1 (baseline 29.6) at presentation, PT: 18.8
PTT: 40.5 INR: 2.4, PLT CT 369. She takes Aspirin, Coumadin and
Lovenox (60 [**Hospital1 **])- and by one report (but not in [**Hospital **] Rehab notes)
Plavix as well.
Pt denies abdominal pain, nausea, vomitting, chest pain. She
does report overall "not feeling well," "weak," "dizzy" and
overall fatigue.
Past Medical History:
CAD s/p NSTEMI PCI [**2186**], 3 VD PCI to LCx, RCA, LAD, OM1
HTN
Hypothyroid s/p thyroidectomy
BL pleural effusions on CT "small" [**1-3**]
Anemia
Afib
Hyponatremia
IHSS?
Moderate Diastolic Dysfunction by Cath
Social History:
The patient lives at [**Hospital 100**] Rehab. She has two daughters,
[**Name (NI) 30512**], and [**Name (NI) 30513**] who lives in [**Location 30514**], RI. She has no tobacco
history or alcohol history. She is a retired bookkeeper.
Family History:
Mother Deceased at 56 with DM
Father Deceased at 65 unknown causes
2 daughters healthy and living
Widowed for 4 years
Physical Exam:
On admit:
Tc= 94.1 oral, axillary P=90-110 SBP=96/43 RR=16 100% on RA
Gen - Weak, thin, pale elderly woman, fatigued but AOX3
HEENT - Pale conjuctiva, dry MMM
Heart - Irregular, Grade II/VI SEM at LSB not radiating to the
carotids
Lungs - Decreased breath sounds mid-bases bilaterally
Abdomen - Soft, NT, ND + BS
Ext - No C/C/E, bilateral calf tenderness with no edema, +1 d.
pedis
Pertinent Results:
Pertinent labs:
[**2188-7-21**] 05:20AM BLOOD WBC-11.3* RBC-3.47* Hgb-9.9* Hct-30.1*
MCV-87 MCH-28.5 MCHC-32.8 RDW-15.4 Plt Ct-535*
[**2188-7-9**] 05:15AM BLOOD WBC-6.7 RBC-3.86* Hgb-11.5* Hct-34.7*
MCV-90 MCH-29.7 MCHC-33.1 RDW-16.2* Plt Ct-297
[**2188-6-27**] 09:41PM BLOOD WBC-10.4 RBC-2.49* Hgb-7.1* Hct-20.5*
MCV-82 MCH-28.6 MCHC-34.7 RDW-15.6* Plt Ct-305
[**2188-6-27**] 02:00PM BLOOD WBC-8.0 RBC-2.72* Hgb-7.4* Hct-23.1*
MCV-85 MCH-27.2 MCHC-32.0 RDW-16.3* Plt Ct-369
[**2188-6-27**] 02:00PM BLOOD Neuts-74.3* Lymphs-20.7 Monos-4.9 Eos-0
Baso-0.2
[**2188-7-8**] 06:20AM BLOOD Neuts-68.1 Lymphs-23.9 Monos-7.4 Eos-0.1
Baso-0.5
[**2188-7-21**] 05:20AM BLOOD PT-16.4* PTT-102.4* INR(PT)-1.8
[**2188-6-27**] 02:00PM BLOOD PT-18.8* PTT-40.5* INR(PT)-2.4
[**2188-7-14**] 05:45AM BLOOD Ret Aut-2.3
[**2188-7-21**] 05:20AM BLOOD Glucose-101 UreaN-23* Creat-1.0 Na-133
K-4.2 Cl-101 HCO3-23 AnGap-13
[**2188-6-27**] 02:00PM BLOOD Glucose-175* UreaN-26* Creat-1.0 Na-134
K-4.5 Cl-102 HCO3-23 AnGap-14
[**2188-7-17**] 11:06AM BLOOD ALT-28 AST-20 LD(LDH)-169 AlkPhos-100
TotBili-0.2
[**2188-6-28**] 03:20AM BLOOD CK(CPK)-58
[**2188-6-27**] 09:41PM BLOOD CK(CPK)-73
[**2188-6-27**] 02:00PM BLOOD CK(CPK)-24*
[**2188-7-12**] 08:35PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2188-7-12**] 04:15PM BLOOD CK-MB-2 cTropnT-0.02*
[**2188-7-10**] 05:10AM BLOOD proBNP-2190*
[**2188-6-28**] 03:20AM BLOOD CK-MB-4 cTropnT-0.01
[**2188-6-27**] 09:41PM BLOOD CK-MB-4 cTropnT-<0.01
[**2188-6-27**] 02:00PM BLOOD cTropnT-0.02*
[**2188-7-21**] 05:20AM BLOOD Calcium-7.8* Phos-4.0 Mg-2.0
[**2188-7-17**] 11:06AM BLOOD TotProt-4.8* Albumin-2.3* Globuln-2.5
Calcium-7.9* Phos-3.1 Mg-1.9
[**2188-6-27**] 02:00PM BLOOD Iron-28*
[**2188-6-27**] 02:00PM BLOOD Calcium-8.0* Phos-3.0 Mg-1.7
[**2188-7-14**] 05:45AM BLOOD VitB12-482 Folate-9.9
[**2188-6-27**] 02:00PM BLOOD calTIBC-176* Ferritn-370* TRF-135*
[**2188-7-11**] 05:25AM BLOOD TSH-29*
[**2188-6-27**] 02:00PM BLOOD TSH-14*
[**2188-7-16**] 05:15AM BLOOD PTH-53
[**2188-7-11**] 05:25AM BLOOD Free T4-1.1
[**2188-7-1**] 06:37AM BLOOD Free T4-1.5
[**2188-7-11**] 05:25AM BLOOD Cortsol-21.9*
[**2188-7-16**] 05:35AM BLOOD freeCa-1.10*
[**2188-7-20**] 11:37AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.007
[**2188-7-20**] 11:37AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2188-7-20**] 11:37AM URINE RBC-[**4-5**]* WBC-[**12-21**]* Bacteri-MOD
Yeast-NONE Epi-[**12-21**]
[**2188-7-13**] 07:58PM URINE RBC-9* WBC-14* Bacteri-NONE Yeast-NONE
Epi-0
[**2188-6-27**] 02:50PM URINE RBC-[**7-11**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
[**2188-7-17**] 04:28PM PLEURAL WBC-57* RBC-556* Polys-33* Lymphs-11*
Monos-42* Meso-1* Macro-13*
[**2188-7-17**] 04:28PM PLEURAL TotProt-3.2 Glucose-121 Creat-1.0
LD(LDH)-82 Amylase-27 Albumin-1.6 Triglyc-29
[**2188-7-15**] 12:00PM PLEURAL WBC-115* RBC-1083* Polys-36* Lymphs-3*
Monos-0 Meso-2* Macro-59*
[**2188-7-15**] 12:00PM PLEURAL TotProt-3.1 Glucose-162 LD(LDH)-88
Albumin-1.7
[**2188-7-10**] 03:51PM PLEURAL WBC-50* RBC-6475* Polys-27* Lymphs-17*
Monos-6* Macro-50*
[**2188-7-10**] 03:51PM PLEURAL TotProt-3.1 Glucose-123 LD(LDH)-79
Albumin-1.9
[**2188-7-15**] 12:00PM OTHER BODY FLUID ADENOSINE DEAMINASE, FLUID-PND
Micro:
[**2188-7-20**] URINE INPATIENT Pending
[**2188-7-17**] PLEURAL FLUID INPATIENT
GRAM STAIN (Final [**2188-7-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2188-7-20**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2188-7-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2188-7-16**] URINE INPATIENT contamination
[**2188-7-15**] PLEURAL FLUID INPATIENT GRAM STAIN (Final [**2188-7-15**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2188-7-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2188-7-21**]): NO GROWTH.
ACID FAST SMEAR (Final [**2188-7-16**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2188-7-14**] BLOOD CULTURE INPATIENT NO GROWTH
[**2188-7-13**] URINE INPATIENT NO GROWTH
[**2188-7-13**] BLOOD CULTURE INPATIENT NO GROWTH
[**2188-7-12**] BLOOD CULTURE INPATIENT NO GROWTH
[**2188-7-12**] BLOOD CULTURE INPATIENT NO GROWTH
[**2188-7-12**] URINE INPATIENT contamination
[**2188-7-11**] BLOOD CULTURE INPATIENT NO GROWTH
[**2188-7-11**] BLOOD CULTURE INPATIENT NO GROWTH
[**2188-7-11**] URINE INPATIENT contamination
[**2188-7-10**] PLEURAL FLUID INPATIENT
GRAM STAIN (Final [**2188-7-10**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2188-7-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2188-7-16**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2188-7-11**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2188-7-1**] URINE INPATIENT NO GROWTH
[**2188-6-27**] URINE EMERGENCY [**Hospital1 **] NO GROWTH
Pertinent reports:
[**2188-7-20**] Radiology CHEST (PA & LAT)
FINDINGS: Pleural effusions have increased in size since prior,
right greater than left. This is not accompanied by increased
distention of the pulmonary vasculature. The frontal perspective
is in a more lordotic position. Due to the sizable pleural
effusions, it is not possible to determine evolution of
underlying air space disease. No new sites of air space disease
in the upper lungs. IMPRESSION: Worsening pleural effusions.
[**2188-7-19**] Radiology CHEST (PA & LAT)
IMPRESSION:Bilateral pleural effusions which are difficult to
compare to prior given technical and positioning differences.
Increasing air space consolidation in the left retrocardiac
region which could be atelectasis or pneumonia.
[**2188-7-17**] Cardiology ECG [**2188-7-18**]
Sinus rhythm
Premature atrial contractions
Long QTc interval
Nonspecific ST-T abnormalities
Since previous tracing of [**2188-7-15**], not suggestive of left
ventricular
hypertrophy
[**2188-7-17**] Cytology PLEURAL FLUID [**2188-7-18**] [**Last Name (LF) **],[**First Name3 (LF) **] A. Logged
Only
[**2188-7-16**] Radiology CT CHEST W/CONTRAST
IMPRESSION:
1) Large amount of bilateral pleural effusion, partially
loculated and greater on the left, associated with bibasilar
atelectasis. The pleural effusion measures [**11-16**] Hounsfield
units and no enhancement or nodularity of the pleura is noted.
2) Increased size of pretracheal lymph node measuring 18 mm in
short axis, as well as perivascular and subcarinal lymph nodes.
3) Coronary artery calcification and small pericardial effusion.
4) Incidental note is made of calcifications in right breast.
Please correlate with physical examination and finding on
mammography
[**2188-7-15**] Cytology PLEURAL FLUID
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, macrophages, lymphocytes and
neutrophils.
[**2188-7-10**] Cytology PLEURAL FLUID
NEGATIVE FOR MALIGNANT CELLS.
Rare mesothelial cells, macrophages and blood
[**2188-7-2**] Radiology ART EXT (REST ONLY)
FINDINGS: Doppler evaluation shows triphasic waveforms at the
femoral levels bilaterally. All other waveforms are monophasic
and that at the DP and PT level on the right, absent. Thus no
ABI measurement on the right, that on the left measures .56 cm.
The volume recordings suggest a waveform widening diffusely and
bilaterally with essentially absent waveform at the right ankle
and metatarsal levels.
IMPRESSION:
Findings as stated above which indicate:
1. Significant SFA and likely tibial disease on the left.
2. Significant right SFA and significant right-sided tibial
disease.
[**2188-7-1**] Cardiology ECHO
Conclusions:
1. The left atrium is normal in size. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function appears
normal (LVEF>55%) though the views are limited. [Intrinsic left
ventricular systolic function may be more depressed given the
severity of valvular regurgitation.]
3.The aortic valve leaflets are mildly thickened. There is mild
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
4.The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. Moderate (2+) mitral
regurgitation is seen.
5.Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe
pulmonary artery systolic hypertension. 6.There is a small
pericardial
effusion. There are no echocardiographic signs of tamponade.
7. There is a large bilateral pleural effusion present.
[**2188-6-27**] Cardiology ECG [**2188-7-1**] Atrial fibrillation with
moderate rapid ventricular response Extensive ST-T changes may
be due to myocardial ischemia Repolarization changes may be
partly due to rhythm
Since previous tracing of [**2187-1-26**], atrial fibrillation is new
and ST-T wave abnormalities seen
[**2188-6-27**] Radiology GI BLEEDING STUDY IMPRESSION: Large amount
of tracer collection in the groin, which is due to fecal and/or
urinary incontinence. Findings suggest rectosigmoid source of
blood.
[**2188-6-27**] Radiology CHEST (PORTABLE AP) CHEST, UPRIGHT AP
PORTABLE: Comparison is made to [**2187-1-21**]. The heart is markedly
enlarged. There is upper zone redistribution of the pulmonary
vascularity, Kerley B lines, and perihilar alveolar opacity,
consistent with CHF, as well as a large left-sided pleural
effusion. A small left effusion is also present. There is no
pneumothorax. The surrounding osseous structures and soft
tissues are unremarkable.IMPRESSION: Congestive heart failure,
with large left-sided pleural effusion.
Brief Hospital Course:
The patient is a [**Age over 90 **] year old female with a history of Afib on
coumadin, hypothyroidism, HTN, and 3 vessel CAD who presented on
[**2188-6-27**] with bright red blood per rectum, hypotension and a 10
point Hct drop from baseline consistent with LGIB s/p
sigmoidoscopy on [**6-28**].
# Lower GI Bleed/BRBPR with positive tag red cell showing
bleeding in the rectosigmoid region:resolved, no further
bleeding with stable hemodynamics
- The patient had an NG lavage that was negative in the ED
- The patient received 6 units PRBCS, 4 units ffp, and vitamin k
10 mg SQ in the ED.
- Lovenox was held, aspirin was decreased to 81 mg can coumadin
was continued with a goal INR [**3-6**]
- sigmoidoscopy did not reveal any source of bleeding but did
show Grade II internal hemorrhoids
- colonoscopy revealed A single angioectasia that was not
bleeding was seen in the distal sigmoid colon.
Protruding Lesions A few benign appearing polyps were found in
the right colon. They were not removed given the patient's age
and her need to be on anticoagulation. Grade 2 internal
hemorrhoids were noted.
Excavated Lesions A single deep linear non-bleeding 1.5 cm
ulcer was found in the sigmoid colon.
# Ischemic right toe:
- underwent angiography per vascular surgery which revealed
diffuse stenosis of right popliteal with significant extension.
given patient's overall health status she was considered too
hight risk to undergo bypass. The plan was to continue to
monitor with no plans for reperfusion. She is to follow up as an
outpatient with DR [**Last Name (STitle) **] from vascular surgery
# Pleural effusions:
- Pt had large left pleural effusion and mod right pleural
effusion on admit, which was initially thought [**3-5**] CHF despite 3
taps in [**6-5**] at [**Hospital1 **] that were exudate by Light's criteria.
Underwent a TTE which revealed EF 55%, 3+ TR, 2+ MR, with no
evidence of HOCM. She had diffuse TW changes on admission, which
were attributed to demand ischemia in the setting of anemia. On
admit, she was started on standing Lasix and Lisinopril for
afterload reduction, and had no symptoms of CHF for most of her
admission. She underwent three separate thoracenteses of her
recurrent pleural effusions which were also exudative in nature
but still thought possibly secondary to CHF with diuresis
causing exudative picture. She underwent evaluation by pulmonary
and interventional pulmonary, who recommended re-tap and if
these effusions are to recur, possible VATS/pleurodesis.
Cytology and laboratory studies and culture were all negative.
Most CXRs were negative for pulm edema or vasc resistribution,
and these effusions may indeed be from an alternative etiology.
However, given that effusions seem to have recurred and the
patient is tolerating them well with no SOB and only mild
hypoxia, may not need to pursue VATS and pleurodesis. Of note,
patient did have CHF at one point during this admission in the
setting of Afib with RVR, urosepsis and IVF, and did have SOB at
that point. However, after this resolved, she had no SOB for the
rest of her stay.
# CAD
- The patient had diffuse new TWI on admit likely secondary to
demand ischemia. She ruled out for acute MI by cardiac enzymes.
- Her cardiologist is Dr. [**Last Name (STitle) 30515**] and her last cath was by Dr.
[**Last Name (STitle) **] in [**2186**].
- She has stents in her LAD, OM1, LCX, and RCA with a history of
NSTEMI in the past.
- Currently stable, no ASA, On B-blocker and statin. Patient to
f/u with Dr. [**Last Name (STitle) **] one week after discharge
# AFIB
- Hospitalization complicated by Afib with RVR with rates to
160s exacerbating CHF. She responded to lopressor and was
started on amiodarone with good effect.
- Will need to monitor INR closely given coumadin interaction
with amiodarone.
# HTN
- Titrated during hospital course to lisinopril 5 qd, metoprolol
25 [**Hospital1 **].
# UTI
- Completed a course of levoquin for UTI/urosepsis. UA from day
PTA still with WBCs, bacteria; patient remains afebrile though
with mildly elevated WBC. Culture pending. Will treat with Cipro
x 7d, Day #1 [**2188-7-21**].
#Hypothyroidism
- Currently on synthroid 112 mcg qd. Had an elevated TSH on
admission will need repeat TFT's in 4 weeks.
# Communication - [**Doctor First Name 30512**] [**Telephone/Fax (1) 30516**]
# Code - Patient is full code, confirmed with patient and
daughter/HCP
Medications on Admission:
Lopressor 25 mg [**Hospital1 **]
Lasix 40 po qam
Prozac 10 mg PO QD
Lipitor 10 mg PO QD
Ecotrin 81 mg PO QD
Coumadin
Lovenox 60 mg PO QD
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO twice
a day.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
8. Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
9. Lasix 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
AFib with RVR
CAD
HTN
lower GI tract hemorrhage
anemia, from blood loss
hypovolemic shock
PVD/ischemic right toe
multiple RLE arterial occlusions
orthostasis
bilateral pleural effusions, L>R
hypoxia
CHF
hypothyroidism
urosepsis; also had borderline UTI on clean catch on day prior
to d/c, sent straight cath specimen on day of discharge, will
call [**Hospital **] Rehab with results
Discharge Condition:
Hemodynamically stable, with no further orthostasis and stable
pleural effusions, stable mild hypoxia (94-95% on RA while lying
down with HOB at 30%).
Discharge Instructions:
Please continue to take all medications as prescribed, cooperate
with your rehab team, and follow up with your doctors. You will
need to have repeat thyroid function tests in [**3-6**] weeks as your
thyroid medication dose has been changed. Also, you will need to
have serial EKGs while at the rehab facility to watch the QT
length as you are on Amiodarone for your atrial fibrillation.
You may also have a urinary tract infection (UTI) based on a
urinalysis (clean catch) that was done on the day prior to your
discharge. We repeated the UA by straight cath on the day of
your discharge, and will let the healthcare team at your rehab
facility know if it returns positive for a UTI.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 575**] (Pulmonary):
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital1 18**] [**Hospital Ward Name **] CENTER
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2188-9-12**] 8:00
You will also have the following appointments that day:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2188-9-12**]
7:45
Also, you have an appointment with Dr. [**Last Name (STitle) **] (Cardiology) on
Wednesday [**2188-7-30**], at 1230pm. Please call Dr. [**Last Name (STitle) **] to confirm
[**Telephone/Fax (1) 2394**].
Please call Dr [**First Name8 (NamePattern2) 17563**] [**Last Name (NamePattern1) **] (Vascular Surgery) to set up a
follow up appointment [**Telephone/Fax (1) 1784**].
You will also need to schedule an appointment with your PCP to
follow up on the many issues raised during this admission. If
you would like to have a PCP at the [**Hospital1 18**], please call
[**Telephone/Fax (1) 250**] to set up an appointment with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or
another doctor.
Name: [**Known lastname **],[**Known firstname 5320**] Unit No: [**Numeric Identifier 5321**]
Admission Date: [**2188-6-27**] Discharge Date: [**2188-7-21**]
Date of Birth: [**2096-7-2**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Penicillins / Neomycin
Attending:[**First Name3 (LF) 1852**]
Addendum:
Patient will be sent on heparin drip as INR not yet therapeutic
(1.8 this AM). "Treatments" section updated to reflect required
PTT, INR, QTc checks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - Acute Rehab
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**]
Completed by:[**2188-7-21**]
|
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"578.1",
"286.9",
"569.82",
"244.9",
"440.24",
"285.1",
"455.8",
"599.0",
"V45.82",
"707.15",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.07",
"96.34",
"88.48",
"45.24",
"88.42",
"34.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
20984, 21214
|
12497, 16910
|
274, 327
|
18276, 18428
|
2502, 2502
|
19160, 20961
|
1960, 2080
|
17097, 17753
|
17870, 18255
|
16936, 17074
|
18452, 19137
|
2095, 2483
|
7478, 7596
|
7626, 12474
|
207, 236
|
355, 1458
|
6053, 6068
|
2518, 6017
|
1480, 1693
|
1709, 1944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,870
| 113,467
|
1838
|
Discharge summary
|
report
|
Admission Date: [**2158-10-22**] Discharge Date: [**2158-10-28**]
Date of Birth: [**2089-11-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Central line placement and removal
History of Present Illness:
The patient is a 68 year-old female with history of bilateral
breast cancer and metastatic kidney cancer, with extensive
osseous and pulmonary metastases, who was discharged to NH from
[**Hospital1 18**] on [**2158-10-19**] after an admission during which she was
diagnosed with extensive bony metastasis, and was treated with
T9-L1 posterior fusion for unstable T11 metastasis. Reportedly,
she developed fever and was found to have decreased oxygen
saturation to 80s at room air at the NH and some confusion and
was transferred to the ED at [**Hospital1 18**]. She had denied chest pain,
and reported mild sob. Denied abdominal pain, diarrhea, or
dysuria. Denied calf pain. She had been minimally mobile at NH
and was taking heparin SQ TID for DVT prophylaxis.
Her VS in the ED were: 99.6 (Tm:101),124/91, 20, 96% 4L Nasal
Cannula. A UA was abnormal. And she had an elevated WBC to 15.
She had a head CT that did not show evidence of acute CVA.
Unfortunately due to IV access issues (it could not be
determined whether she had a power port), she could not obtain a
CT chest with contrast to evaluate for PE. But was empirically
treated with therapeutic dose of lovenox after a D-dimer was
found to be mildly elevated. A chest CXR showed worsening pul
edema, but given extensive lung mets, a consolidative process
could not be ruled out. She was empirically started on
vancomycin and cefepime for UTI as well as possible pneumonia,
and admitted to the floor.
Review of Systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies blurry vision, diplopia, loss of vision, photophobia.
Denies sinus tenderness, rhinorrhea or congestion. Denies chest
pain or tightness, palpitations, lower extremity edema. Denies
cough, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
[**2142-6-26**]: left nephrectomy for 11 cm clear cell renal cell
carcinoma
[**2155-3-15**]: diagnosted with bilateral breast cancer
(node-positive on left, ER/PR positive, HER-2 negative). Treated
with neoadjuvant dose-dense AC and weekly taxol ending [**2155-10-3**],
bilateral mastectomy [**2155-12-25**] (after lumpectomy with positive
margins), radiation ending [**3-22**]. On arimidex since completion of
chemotherapy.
[**2156-7-14**]: CT torso (done because of elevated alk phos) showed
1.5 and 0.6 cm left upper lobe nodules.
[**2156-8-26**]: Left upper lobectomy showed two foci of clear cell
renal cell carcinoma.
[**2157-5-4**]: MRI of T/L spine with disease at T10, T11 vertebral
bodies, soft tissues T10-T12, and L3 body. CT-guided biopsy
consistent with renal cell carcinoma. Bone scan [**2157-4-18**] also
showed involvement of several left ribs. Subsequently received
XRT to thoracic spine.
[**5-/2157**]: Began sunitinib; dose reduced over time to 25 mg because
of toxicities. Sutent ended in [**2158-1-14**] because of disease
progression.
[**2158-2-7**]: MRI L-spine with T11 disease with persistent mass
effect
on thecal sac but no significant cord compression, and T9 and
T10
disease, all likely unchanged. New T12 compression fracture.
Significant progression of L3 vertebral body lesion with
pathologic fracture and retropulsion of posterior cortex.
[**2158-2-13**]: CT torso with interval marked progression of
innumerable
pulmonary mets since [**2157-8-2**]. Destructive lytic lesion within
left femoral head.
[**2158-2-14**]: XRT to lumbar spine
[**2158-4-12**]: signed consent for 08-184 trial of avastin and
temsirolimus. CT torso showed osseous mets in spine and left
ibs, with interva lincrease in size in soft tissue component at
T11 encasing thecal sac, invading cord, and invading more than
50% of the spinal canal. At L3, compression fracture with soft
tissue component extending into spinal canal. Increase in number
and size of numerous pulmonary mets bilaterally. Destructive
lytic lesion within left femoral head.
[**2158-4-19**]: C1D1 08-184 (avastin/temsirolimus)
[**2158-6-7**]: CT torso with significant decrease in size of bilateral
pulmonary lesions and stable osseous disease with decrease in
soft tissue mass at T11
- [**Date range (3) 10263**]: admitted for PNA, mental status changes, found
to have frontal CVA, taken off study
- [**2158-8-9**] CT TORSO: stable disease
Other Past Med Hx:
- Hypertension
- Breast Cancer s/p resection
- gout
Social History:
She lives with her 3 sons who assist with her medical care. She
used to work at [**Hospital3 2568**] in the GI division. She is a
non-smoker, no alcohol or other drugs.
Family History:
Father had esophageal cancer. Her maternal grandmother had
breast cancer in her
70s.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 100.4 BP: 132/81 P: 111 R: 28 O2: 100% on 4L NC
General: Drowsy, confused but orientable, mild respiratory
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, exam limited by body
habitus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, mildly decreased air entry.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, +Obesity, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place, draining yellow urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Vitals: 96.0 100-140/70-90 90-100 18-22 93-96%RA, requiring some
O2 at night
General: Awake and oriented but anxious appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to interpret, no LAD, exam limited
by body habitus
Lungs: Clear to auscultation bilaterally except for mild
anterior wheezes (unable to get full posterior lung exam due to
pain) and some bibasilar crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: Foley in place, draining yellow urine
Ext: Warm, well perfused with 2+ nonpitting edema on all four
extremities, LUE>RUE
Pertinent Results:
ADMISSION LABS
[**2158-10-22**] 05:05PM WBC-15.7*# RBC-3.09* HGB-9.2* HCT-28.1*
MCV-91 MCH-29.8 MCHC-32.9 RDW-16.6*
[**2158-10-22**] 05:05PM NEUTS-96.5* LYMPHS-1.6* MONOS-1.5* EOS-0.3
BASOS-0.1
[**2158-10-22**] 05:05PM PLT COUNT-263
[**2158-10-22**] 05:05PM PT-15.0* PTT-50.1* INR(PT)-1.3*
[**2158-10-22**] 05:05PM GLUCOSE-100 UREA N-12 CREAT-0.9 SODIUM-136
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
[**2158-10-22**] 05:38PM LACTATE-2.0
[**2158-10-22**] 08:43PM D-DIMER-2523*
[**2158-10-22**] 06:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.5 LEUK-LG
[**2158-10-22**] 06:15PM URINE RBC-14* WBC-173* BACTERIA-MOD YEAST-NONE
EPI-2 TRANS EPI-1
[**2158-10-22**] 06:15PM URINE COLOR-AMBER APPEAR-Hazy SP [**Last Name (un) 155**]-1.030
DISCHARGE AND OTHER PERTINENT LABS:
[**2158-10-25**] 04:34AM BLOOD WBC-8.6 RBC-2.94* Hgb-8.7* Hct-27.1*
MCV-92 MCH-29.6 MCHC-32.1 RDW-16.5* Plt Ct-281
[**2158-10-25**] 04:34AM BLOOD PT-14.7* PTT-38.7* INR(PT)-1.3*
[**2158-10-24**] 12:29PM BLOOD ESR-81*
[**2158-10-24**] 04:09AM BLOOD Ret Aut-2.3
[**2158-10-25**] 04:34AM BLOOD Glucose-94 UreaN-14 Creat-0.7 Na-136
K-4.0 Cl-105 HCO3-21* AnGap-14
[**2158-10-24**] 04:09AM BLOOD LD(LDH)-226 TotBili-0.5
[**2158-10-25**] 04:34AM BLOOD TotProt-PND Calcium-7.0* Phos-2.0* Mg-2.0
[**2158-10-24**] 04:09AM BLOOD Hapto-348*
[**2158-10-25**] 04:34AM BLOOD TSH-PND
[**2158-10-24**] 04:09AM BLOOD Cortsol-19.5
[**2158-10-24**] 04:09AM BLOOD CRP-GREATER TH
[**2158-10-23**] 08:41AM BLOOD Lactate-1.4
[**2158-10-22**] CXR: UPRIGHT FRONTAL CHEST RADIOGRAPH: A right-sided
catheter terminates within the right atrium. Spinal fusion
hardware in the mid thoracic region is unchanged in position.
Multiple left upper quadrant surgical clips are present. Again
seen are innumerable pulmonary nodules, compatible with known
history of metastatic disease. Since the [**2158-10-13**]
examination, there has been interval increase in pulmonary
vascular congestion and mild underlying pulmonary edema is
present. Small bilateral pleural effusions are present. There is
no pneumothorax.
[**2158-10-22**] CT Head w/o contrast: No acute intracranial process or
evidence. No evidence of metastatic disease, though please note
MRI is more sensitive.
[**2158-10-23**] CTA Chest: 1. No pulmonary embolism or acute aortic
pathology. 2. Ground-glass opacification in the right middle
lobe likely reflects infectious process with new right greater
than left small-to-moderate pleural effusions. 3. Innumerable
pulmonary metastases, many of which are increased in size.
Unchanged left sixth rib, left pectoral and T11 vertebral body
metastases with interval vertebral fusion, which is incompletely
characterized.
[**2158-10-23**] LLE US: 1. No left lower extremity DVT above the knee.
2. Diffuse subcutaneous edema.
[**2158-10-23**] LUE US: 1. No left upper extremity DVT. 2. Diffuse
subcutaneous edema.
[**2158-10-24**] TTE: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. An eccentric,
laterally directed jet of at least mild to moderate ([**1-15**]+)
mitral regurgitation is seen (likely moderate 2+). The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2158-10-24**]: MRI T/L spine: Metastatic disease to L3 vertebral body
is again identified and unchanged. Indentation on the thecal sac
and moderate spinal stenosis is also seen at this level. Fluid
collection is identified in the upper lumbar posterior soft
tissues at L1 level measuring 3 x 2.5 cm which likely is
postoperative in nature, but MRI appearances alone cannot help
in excluding infection in this postoperative collection and
clinical correlation is recommended.
[**2158-10-26**]: CT T/L spine:
1. No evidence of retroperitoneal fluid collection, however, a
large fluid
collection in the subcutaneous fat posterior to the paraspinal
region
extending from L2-T10, larger than on MR from 2 days prior. In
order to
visualize if this is a CSF leak, a CT myelogram would be a more
appropriate study. 2. L3 compression fracture secondary to
metastatic disease. Lytic lesion within the posterior rib at the
T8 vertebral level.
3. Multiple pulmonary metastatic nodules. Bilateral pleural
fluid, right
greater left. 4. Cholelithiasis. 5. Possible kink in the
centralv enous catheter on the scout, unchanged from prior CTA
Chest - d/w RN taking care of pt by Dr.[**Last Name (STitle) **] on [**2158-10-27**].
PENDING STUDIES:
- Pleural fluid cytology
- TSH
- Pleural fluid beta2-transferrin and protein electropheresis
- [**10-22**] Blood cultures pending, no growth to date
- [**10-26**] Pleural fluid culture, no growth to date
Brief Hospital Course:
68 year-old female with history of bilateral breast cancer and
metastatic kidney cancer with extensive osseous and pulmonary
metastases who was discharged to NH from [**Hospital1 18**] on [**2158-10-19**] after
an admission during which she was diagnosed with extensive bony
metastasis, and was treated with T9-L1 posterior fusion for
unstable T11 metastasis. On this admission, she presented with
fevers, confusion, hypoxia and felt to have sepsis due to UTI.
#. Hypotension: She was admitted with hypotension that was fluid
responsive. It was ultimately felt to be sepsis due to UTI.
She did not require pressors. She was ruled out for PE. AM
cortisol was 19.5. TTE was unremarkable. She was initially
treated with vancomycin and cefepime which was narrowed to cipro
and then changed to bactrim.
#. Hypoxia: She has extensive pulmonary disease as evidenced by
her CXR and CTA. No evidence of PE as above. She had the new
development of pleural effusions felt to be either related to
her spinal wound drainage or the fluid resuscitation in the ICU.
She responded well to one dose of lasix but further doses were
deferred as she was on room air most of the time and refused
further labs draws. She also responded to nebulizers at times.
# Urinary tract infection: Admission UA was consistent with
infection. Urine culture grew E Coli and Klebsiella both
sensitive to cipro and Bactrim. She was initially on broad
spectrum antibiotics and then narrowed to cipro. There was some
concern for delirium induced by cipro and her antibiotics were
changed to bactrim. She is being discharged with a chronic
foley.
#. Wound drainage s/p Spinal Fusion: She recently had spinal
fusion on [**2158-10-11**] and her wound drained a large amount of serous
fluid during her admission. Her orthopedics team followed her
wound and consulted neurosurgery. She had multiple imaging
studies that showed a fluid collection around the wound. There
was concern that her new pleural effusions may be related to
leakage of CSF. Therefore, she underwent thoracentesis to
sample the fluid. Beta2 transferrin and PEP are pending at the
time of discharge, which will help determine if the pleural
fluid is CSF. The neurosurgery team will follow-up these
studies as an outpatient and decide if a lumbar drain is needed.
She has follow-up scheduled with neurosurgery.
#. Metastatic renal cancer with mets: Patient was recently
found to have extensive bony mets and has reportedly had
difficulties controlling pain. Palliative care follwed during
this admission for titration of pain control meds.
#. Anemia: Likely anemia of chronic disease secondary to
underlying cancer. Received 1 unit pRBC on [**2158-10-24**] with good
response. Hemolysis labs were unremarkable.
# HTN: Valsartan was held given episode of hypotension that
responded well to fluid boluses. It can be restarted after
discharge.
#. Port-a-cath blockage: She had difficulty with blood return
from her port. She refused a chest film to confirm patency of
indwelling chest port. There was also some concern that the
line was kinked on her CT chest. Her line was given TPA in an
attempt to clog it. Blood return was achieved and line was
patent on DC.
#. Delirium/Anxiety: She was mildly delirious during her
admission with difficulty with attention. This is likely
related to her ongoing medical issues, as well as pain. She
responded well to olanzapine 2.5mg po at night, and also was
written for Ativan as needed. She continued to be anxious,
requiring frequent reminders of her medical plan.
#. Goals of care: The patient was refusing multiple procedures
and studies during this admission. She was following by primary
care and her primary oncologist. She expressed a desire to
focus on comfort, but a full discussion of hospice was deferred
until her delirium improves. She refused all labs and xrays
over the last 1-2 days of her admission.
TRANSITIONAL ISSUES:
- Pending studies: TSH, blood culture, pleural fluid culture,
cytology, beta2 transferrin and PEP
- Needs neurosurgical/ortho-spine followup for her wound in 2
weeks. It has continued to drain serous fluid requiring
multiple changes per day.
Medications on Admission:
- anastrozole 1 mg Tablet 1 Tablet(s) by mouth once a day (Not
Taking as Prescribed: no prescription now so not taking)
- levothyroxine 50 mcg Tablet 1 Tablet(s) by mouth once a day
- lorazepam [Ativan] 0.5 mg Tablet [**1-15**] Tablet(s) by mouth three
times a day as needed for anxiety
- ondansetron 4 mg Tablet, Rapid Dissolve 1 Tablet(s) by mouth
every 8 hours as needed for nausea
- oxycodone 5 mg Tablet 1 Tablet(s) by mouth every 4 hours as
needed for pain
- oxycodone [OxyContin] 10 mg Tablet Extended Release 12 hr 2
Tablet(s) by mouth twice a day
- prochlorperazine maleate 10 mg Tablet 1 Tablet(s) by mouth
every six (6) hours as needed for nausea/vomiting
- simvastatin 10 mg Tablet 1 Tablet(s) by mouth once a day
- valsartan [Diovan] 160 mg Tablet 1 Tablet(s) by mouth once a
day hold for bp < 110
- acetaminophen 325 mg Tablet 1 Tablet(s) by mouth every 6 hours
(OTC) prn
- aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth daily
- docusate sodium 100 mg Capsule 1 Capsule(s) by mouth
Discharge Medications:
1. anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for anxiety.
4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
5. oxycodone 60 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
6. hydromorphone 2 mg Tablet Sig: 3-5 Tablets PO Q3H (every 3
hours) as needed for pain.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day): Hold for loose stool.
14. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Patient may refuse.
15. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours): For prophylaxis.
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
17. ipratropium bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours) as needed for
wheeze.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 10264**] Rehab
Discharge Diagnosis:
Primary Diagnosis:
Urinary tract infection
Pleural effusions
Wound fluid collections
Metastatic renal cell carcinoma
Secondary Diagnosis:
Hypertension
Gout
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital due to fevers, confusion and
low blood pressures felt to be related to an urinary tract
infection (UTI). You were admitted to the ICU and were given
antibiotics for your UTI and your symptoms improved.
Your oxygen level was also low on admission, but improved prior
to discharge. It was felt to be due to some fluid around your
lungs, as well as the cancer in your lungs. You had a procedure
where fluid was removed around your lungs.
You were also evaluated by the orthopedic surgeons and
neurosurgeons due to concern about leakage from your wound. It
is still leaking significantly and you have labs that are
pending to determine the source of leakage. Your neurosurgery
team will follow-up on these studies.
CHANGES TO YOUR MEDICATIONS:
ADD Bactrim 1 DS tab by mouth twice daily for 5 more days
INCREASED oxyCONTIN to 60mg by mouth every 8 hours
ADD olazapine 2.5mg by mouth at bedtime as needed
ADD enoxaparin 30 mg SC every 12 hours for prophylaxis
Followup Instructions:
You have the following appointments scheduled:
Department: SPINE CENTER
When: FRIDAY [**2158-11-10**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*You should discuss with him if you need a separate appointment
with Dr. [**Last Name (STitle) **]*
|
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71,645
| 197,370
|
32422
|
Discharge summary
|
report
|
Admission Date: [**2168-4-6**] Discharge Date: [**2168-5-11**]
Date of Birth: [**2109-12-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known lastname 943**]
Chief Complaint:
Ascites fluid leakage / umbilical hernia repair
Major Surgical or Invasive Procedure:
Umbilical hernia repair
Multiple paracenteses
Central line placement
Post-pyloric tube placement
History of Present Illness:
Mr [**Known lastname **] is a 58M w ESLD [**2-15**] HepC (dx'd in [**2139**]) c/b HCC
(dx'd in [**2167**], s/p RFA), SBP, encephalopathy, esophageal
varices, ascites refractory to paracentesis (weekly sessions),
and FTT (on tube feeds at home), who originally presented to
[**Hospital3 **] Hospital on [**2168-4-6**] with ascites leaking through
umbilical hernia, transferred to [**Hospital1 18**] from [**Hospital3 **] Hospital
for surgical repair, s/p primary hernia repair and drainage of
ascites [**2168-4-7**]. Pt is transferred to the medicine service for
further management. Pt denies F/C, CP/SOB, N/V/abd pain. Reports
poor appetite.
Past Medical History:
- Hepatitis C x 30 years (presumed to have been contracted
through intranasal cocaine use); c/b portal hypertension,
varices, refractory ascites, SBP
- DM (diet and exercise-controlled before, though requiring
insulin in setting of infection and therafter)
- HCC s/p RFA in [**3-20**].
Social History:
Patient denies a history of IVDU, but has a remote history of
intranasal cocaine use. He denies tobacco or alcohol use. Lives
in [**Hospital3 **] w/ wife and 2 daughters. Reports to be independent
in ADLs.
Family History:
NC
Physical Exam:
VS: 98.0, 96/64, 82, 20, 100% RA
GEN: cachectic, sitting in the chair quietly
HEENT: NC/AT; PERRLA, EOMI, mild conjunctival icterus; OP clear
NECK: supple, no LAD, normal JVP
CV: RRR, normal S1S2, no M/R/G
CHEST: CTAB, no W/R/R
ABD: distended, tense, nontender, NABS
EXTR: WWP, 2+ pitting edema b/l, 2+ DP/rad pulses b/l
NEURO: AOx3, CNII-XII intact, [**5-17**] Motor strength in UE/LE b/l,
2+ DTR in [**Name2 (NI) **]/LE, normal stance and gait, no asterixis
Pertinent Results:
LABS ON ADMISSION:
[**2168-4-6**] 05:05PM BLOOD WBC-7.6# RBC-2.65* Hgb-9.4* Hct-27.0*
MCV-102*# MCH-35.4*# MCHC-34.7 RDW-16.8* Plt Ct-66*
[**2168-4-6**] 05:05PM BLOOD PT-23.9* PTT-48.2* INR(PT)-2.3*
[**2168-4-6**] 05:05PM BLOOD Glucose-179* UreaN-65* Creat-2.0* Na-126*
K-5.4* Cl-101 HCO3-18* AnGap-12
[**2168-4-6**] 05:05PM BLOOD ALT-29 AST-33 AlkPhos-97 TotBili-5.1*
[**2168-4-6**] 05:05PM BLOOD Albumin-2.6* Calcium-8.0* Phos-4.1#
Mg-2.5
.
LABS ON DISCHARGE:
Ca: 9.1 Mg: 2.4 P: 2.6
Na 137; Cl 101; BUN 29; Glucose 54; K 4.1; HCO3 27; Creatinine
1.1
ALT: 27 AP: 90 Tbili: 14.7 AST: 54 LDH: 197
PT: 27.0 PTT: 46.3 INR: 2.7
WBC: 4.4 Hgb: 8.6 Plt: 84 Hct: 24.6
.
LIVER:
[**2168-4-18**] 02:56AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
[**2168-4-13**] 06:05AM BLOOD AFP-1.5
.
URINE:
[**2168-4-12**] 06:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2168-4-12**] 06:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2168-4-26**] 01:03PM URINE Color-[**Location (un) **] Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2168-4-26**] 01:03PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2168-4-26**] 01:03PM URINE RBC-144* WBC-66* Bacteri-FEW Yeast-MOD
Epi-<1
[**2168-5-1**] 09:23AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2168-5-1**] 09:23AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2168-5-1**] 09:23AM URINE RBC-0-2 WBC-<1 Bacteri-MOD Yeast-FEW
Epi-0-2
.
ASCITES FLUID:
[**2168-4-11**] 04:48PM ASCITES WBC-220* RBC-5750* Polys-31* Lymphs-11*
Monos-50* Mesothe-2* Macroph-6*
[**2168-4-13**] 04:47PM ASCITES WBC-150* RBC-5750* Polys-22* Lymphs-23*
Monos-0 Eos-1* Mesothe-4* Macroph-50*
[**2168-4-15**] 10:13AM ASCITES WBC-6250* RBC-2450* Polys-91* Lymphs-0
Monos-0 Macroph-9*
[**2168-4-17**] 03:29PM ASCITES WBC-1000* RBC-3850* Polys-88* Lymphs-0
Monos-0 Macroph-12*
[**2168-4-20**] 05:15PM ASCITES WBC-300* RBC-[**Numeric Identifier 24587**]* Polys-73*
Lymphs-13* Monos-7* Eos-2* Macroph-5*
[**2168-4-26**] 09:11AM ASCITES WBC-500* RBC-[**Numeric Identifier 75688**]* Polys-40*
Lymphs-39* Monos-0 Atyps-1* Macroph-20*
[**2168-5-4**] 10:17AM PLEURAL WBC-155* RBC-[**Numeric Identifier 75689**]* Polys-30*
Lymphs-45* Monos-13* Eos-3* Meso-2* Macro-7*
[**2168-5-10**] WBC: 61 RBC: [**Numeric Identifier 57548**] Poly: 13 Lymph 46 Mono 0 EOS 4;
CYTOLOGY PENDING ON DISCHARGE
.
MICROBIOLOGY:
Blood cx ([**4-15**]) - MRSA
Blood cx ([**Date range (1) 75690**]) - NEGATIVE
Peritoneal fluid ([**4-11**], [**4-15**], [**4-17**]) - MRSA
Peritoneal fluid ([**4-20**], [**4-26**], [**5-4**]) - NEGATIVE
STOOL - negative
Urine cx ([**4-26**]) - yeast
Urine cx ([**4-15**], [**5-1**]) - NEGATIVE
.
CARDIOLOGY:
TTE ([**4-19**]):
Conclusions
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 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. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen (good-quality study). Normal global and
regional biventricular systolic function. Ascites.
In presence of high clinical suspicion, absence of vegetations
on transthoracic echocardiogram does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2167-3-19**],
ascites is more prominent. The cardiac findings are similar.
.
RADIOLOGY:
CXR ([**4-6**]) - preop: IMPRESSION: No acute cardiopulmonary
process.
CXR ([**4-15**]): IMPRESSION: New right IJ line tip projects at the
cavoatrial junction. Low volumes with right basilar atelectasis.
No other significant change.
CXR ([**4-22**]):
Since [**2168-4-15**], right internal jugular catheter was removed
and
left-sided dual-lumen subclavian catheter was installed, ending
in the low
SVC. The Dobhoff tube tip is in the third duodenum in expected
position.
Lung volumes are persistently low. Left lower lobe opacity
increased, could be due to atelectasis. Note that the left
costophrenic angle was excluded. Right basilar opacity is
unchanged, likely atelectasis. There is no other change.
.
CXR ([**4-26**]):
FINDINGS: In comparison with the study of [**4-24**], allowing for
differences in technique, there is little interval change. Low
lung volumes persist.
Retrocardiac opacification is again seen as well as a probable
small right
pleural effusion. No evidence of acute focal pneumonia.
Monitoring and
support devices remain in place.
.
CXR ([**5-4**]):
REASON FOR EXAM: End-stage liver disease, fever. Quantified
pleural
effusions. Small bilateral pleural effusions are greater on the
left side. There is mild fluid overload. There are low lung
volumes. Cardiac size is top normal. Bibasilar atelectasis
greater on the left side have worsened. Nasogastric tube tip is
out of view below the diaphragm.
.
LENI ([**2168-5-11**]): No left lower extremity DVT.
Brief Hospital Course:
57 year-old male with hepatitis C cirrhosis awaiting liver
transplant, HCC status-post RFA, originally admitted on [**2168-4-6**]
for umbilical hernia repair in the setting of ascites leakage,
transferred to the hepatorenal medicine service for management
post-surgery, with prolonged hospital course c/b MRSA
peritonitis leading to sepsis, s/p MICU stay, ATN s/p temporary
hemodialysis, as well as ? hospital-acquired PNA. Hospital
course was as follows.
1. ESLD: Patient has HepC/HCC cirrhosis with multiple
complications in the past. Currently awaiting OLT. Admitted for
umbilical hernia repair because of ascites leakage through
hernia ([**2168-4-7**]), subsequently transferred to medicine.
Following hernia repair, he had two therapeutic paracentesis
with 5.5 L on the [**2168-4-11**] and [**2168-4-13**]. Ascites culture from
[**2168-4-11**] grew MRSA, for which vancomycin was started on
[**2168-4-15**]. Had endoscopic Dobhoff replacement on [**2168-4-14**] due to
clogging. Pt then developed fulminant MRSA peritonitis (ascites
fluid PMN > 6000 on diagnostic paracentesis, fluid cx growing
MRSA) with leukocytosis to 19.4, worsening renal failure and
hypotension and was transferred to the MICU. Treated w
vanc/zosyn until cultures grew MRSA, then a 4-week course of
vancomycin ([**Date range (1) 75691**]) was given. Zosyn switched to ciprofloxacin
at first, then restarted for a 7-day course ([**Date range (1) 75692**]) for a
possible HAP, given low-grade fevers and ? finding on CXR.
Otherwise, pt continued on prophylactic medications -
lactulose/rifaximin for encephalopathy, nadolol for esophageal
varices, furosemide/spironolactone for ascites. Pt also required
therapeutic paracentesis every 3-4 days for refractory ascites.
Received nutritional supplements through tube feeds. Last
therapeutic paracentesis was on [**2168-5-10**] with 4.5L removed; no
evidence of SBP. Post-pyloric tube was replaced on [**2168-5-11**], day
of discharge, due to clogging. Patient remains active on
transplant list, and is transferred to rehabilitation facility
awaiting transplant.
2. Acute renal failure: Baseline creatinine 1.4, currently at
1.1. He developed oliguric ARF in the setting of hypotension
from large-volume paracentesis and sepsis. Likely ATN [**2-15**]
hypotension and poor flow, +/- HRS. Patient treated with volume
expansion, as well as albumin/midodrine/octreotide. Required
temporary hemodialysis for total volume overload (though
intravascular volume low). Kidney function improved to baseline,
and patient was taken off dialysis. Octreotide/midodrine
stopped, albumin only given with paracentesis. Due to risk of
hypotension, the amount of fluid taken off during paracenteses
was reduced to 3-4L/session. On day prior to discharge, 4.5L
removed and FFP given; creatinine remained stable overnight
3. Hyponatremia: Possibly a component of pseudohyponatremia
from high blood sugars. Resolved on discharge
4. Diabetes mellitus type II: Prior to admission he was
diet-controlled, however, with infection he became difficult to
control and started on insulin drip in the setting of infection.
Once infection treated, pt transitioned to SC insulin with
better sugar control - 100s-low 200s. [**Last Name (un) **] has been following
him daily. Most recent insulin regimen included with discharge
paperwork.
Medications on Admission:
Aldactone 50 mg [**Hospital1 **]
Insulin Sliding Scale
Lactulose 30 mL
Protonix 40 mg QD
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X/DAY (5 Times a Day): thrush prophylaxis.
2. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4
times a day): titrate to 4 BM/day.
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (FR).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
9. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): SBP prophylaxis.
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
12. Insulin regimen
Please see attached insulin regimen and scale. Patient receives
Lantus 40 units at night. He also receives standing and sliding
scale Humalog.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
MRSA peritonitis
Decompensated hepatitis C cirrhosis
End-stage liver disease, awaiting liver transplant
Refractory ascites
Diabetes mellitus, type II
Discharge Condition:
Hemodynamically stable. Ambulating well. Mentating well; no
evidence of encephalopathy.
Discharge Instructions:
You were admitted to the hospital with ascites fluid leakage
from your umbilical hernia. The hernia was repaired
successfully; however, you developed a serious abdominal
infection (MRSA peritonitis), for which you had to be treated in
the intensive care unit. You were on a prolonged course of
antibiotics to treat your infection. You were also on
hemodialysis temporarily, until your kidney improved. On
discharge, your kidney function has improved to baseline. You
received a paracentesis the day prior to discharge with
improvement in the distention of your abdomen. Your feeding tube
was also replaced on the day of discharge.
Your medication regimen has changed. Please review the
medication list closely.
While at [**Hospital1 **], your transplant coordinators will be in
contact with the [**Name (NI) **] staff. They will coordinate times for
laboratory work and appointments.
If you have fevers, chills, headache, nausea/vomiting, diarrhea,
chest pain, shortness of breath, abdominal pain or any other
concerning symptoms, please call your physician [**Name Initial (PRE) 2227**].
Followup Instructions:
While at [**Hospital1 **], your transplant coordinators will be in
contact with the [**Name (NI) **] staff. They will coordinate times for
laboratory work and appointments.
Call the liver center for follow-up visit upon discharge from
rehab or if any questions before then: ([**Telephone/Fax (1) 7144**] (Dr.
[**Known lastname **] [**Last Name (NamePattern1) 497**])
Completed by:[**2168-5-12**]
|
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1151, 1438
|
1454, 1661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,330
| 107,593
|
26912
|
Discharge summary
|
report
|
Admission Date: [**2177-4-25**] Discharge Date: [**2177-5-12**]
Date of Birth: [**2103-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
73 year old male with hypertension who presented on [**4-25**] with
increased abdominal girth, cough. He had developed a cough
productive of copious sputum about 1 week prior to presentation.
His PCP had given him antibiotics, however it did not clear up.
ROS is positive for about 60 pound weight loss over the last 4
months which he had attributed to being on the South Beach Diet.
His wife remarks that his weight loss was interesting, however
in that his pant size actually increased. He had also been
complaining of some "indigestion."
.
He was admitted on [**4-25**] and treated for LLL pneumonia, however
his course has been complicated by development of renal failure,
bilateral deep venous thromboses in his legs, and hypercarbic
respiratory failure requiring intubation. He additionally had
increasing ascites, and a CT of the abdomen demonstrated a large
exophytic right liver mass as well as diffuse peritoneal
thickening/omental caking suggestive of neoplastic involvement.
He subsequently had a paracentesis on [**4-28**], the pathology of
which returned with malignant cells consistent with poorly
differentiated non-small cell carcinoma. The tumor cells are
positive for keratin AE1/AE3, CAM 5.2, CEA, Leu M1 and B72.3 and
negative for calretinin.
Past Medical History:
HTN
H/o polio (involving half his body)
BPH
Physical Exam:
97.9, 131/79, 95, 18, 99% on AC
Gen: Intubated caucasian male appearing ill.
Abd: Tensely distended abdomen, appears to be tender to
palpation.
Extr: 2+ pitting edema of LE b/l.
Pertinent Results:
[**2177-5-12**] 04:46AM BLOOD WBC-9.7 RBC-3.13* Hgb-9.3* Hct-27.9*
MCV-89 MCH-29.8 MCHC-33.4 RDW-15.4 Plt Ct-368
[**2177-5-2**] 04:07AM BLOOD Neuts-76.9* Lymphs-13.0* Monos-5.6
Eos-4.1* Baso-0.4
[**2177-5-12**] 04:46AM BLOOD Plt Ct-368
[**2177-5-12**] 04:46AM BLOOD Glucose-86 UreaN-56* Creat-5.0* Na-135
K-4.8 Cl-102 HCO3-18* AnGap-20
[**2177-5-7**] 05:38AM BLOOD ALT-17 AST-26 LD(LDH)-205 AlkPhos-125*
TotBili-0.2
[**2177-5-12**] 04:46AM BLOOD Calcium-9.2 Phos-6.4* Mg-2.0
[**2177-5-7**] 11:44AM BLOOD CA125-202*
[**2177-4-28**] 06:20AM BLOOD CEA-41* PSA-0.3 AFP-<1.0
Brief Hospital Course:
Patiet was in resp failure. After extensive family discussion,
it was decided to extubate him and he was made CMO. Patient
eventually died.
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2177-7-28**]
|
[
"995.92",
"572.3",
"138",
"785.52",
"584.5",
"038.9",
"481",
"591",
"788.20",
"197.7",
"453.8",
"199.1",
"507.0",
"600.00",
"197.6",
"342.90",
"401.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.95",
"39.95",
"33.24",
"38.93",
"00.17",
"96.72",
"96.6",
"96.04",
"38.91",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
2669, 2678
|
2505, 2646
|
323, 335
|
2729, 2738
|
1911, 2482
|
2794, 2832
|
2699, 2708
|
2762, 2771
|
1712, 1892
|
276, 285
|
363, 1629
|
1651, 1696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,900
| 180,986
|
29229+57628
|
Discharge summary
|
report+addendum
|
Admission Date: [**2172-8-24**] Discharge Date: [**2172-10-2**]
Date of Birth: [**2122-6-10**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Bacitracin / Morphine / Percocet / Oxycodone
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
Left foot gangrene of second and third toes.
Major Surgical or Invasive Procedure:
[**8-27**] - Contralateral third order arteriography, abdominal
aortogram with unilateral extremity runoff, angioplasty of
posterior tibial artery corresponding with CPT codes [**Numeric Identifier 4237**],
[**Numeric Identifier 4238**], [**Numeric Identifier 8881**], [**Numeric Identifier 8882**]
[**9-2**] - Contralateral third order arteriography with unilateral
extremity runoff, first order subclavian arteriography with
unilateral extremity runoff and aortic arch for great vessels
corresponding with CPT codes [**Numeric Identifier 4237**],
[**Numeric Identifier 8881**], [**Numeric Identifier 70295**], [**Numeric Identifier 8881**], [**Numeric Identifier 70296**].
[**9-3**] - Left below-knee amputation, right 1st toe amputation.
History of Present Illness:
[**Known firstname 487**] [**Known lastname 70290**] is a 50-year old patient of Dr. [**First Name (STitle) **], Dr.
[**Last Name (STitle) 4026**] and Dr. [**First Name (STitle) **]. He has seen By Dr. [**Last Name (STitle) **] in clinic
[**2172-8-18**] for gangrene of the left finger. At that time he was
noted to have gangrene to bilateral feet and toes. At the
present time he reports intermittent pain to bilateral feet
Left > Right which increases with activity. The patient is able
to ambulate but has decreased mobility. Neuropathy has increased
to bilateral feet over the past several months.
Mr. [**Known lastname 70290**] has a long history of renal failure with a post
failed kidney transplant. He presently has HD three times a
week. In [**Month (only) 1096**] he was admitted for pneumonia and spent
several months in the ICU.
It is noted that Mr. [**Known lastname 70290**] has been followed by Dr. [**Last Name (STitle) **] in
the arrhythmia service for palpitations and presented today with
a CardioNet monitor on. The
patient also being followed by dermatology for a rash to his
knees and back. He had a biopsy of a lesion of the right knee
last week
Past Medical History:
1. L cadavaric kidney transplant ([**2152**]) for renal failure [**1-31**]
presumed chronic glomerulonephritis
2. ESRD, baseline Cr 1.5 in [**5-3**]
3. DM
4. Restrictive lung disease
5. HTN
6. Interstitial pulmonary fibrosis
7. s/p L AV fistula
8. hypercholesterolemia
9. Gout
Social History:
lives by himself, divorced; no EtOH or tobacco
Family History:
diabetes mellitus
Physical Exam:
HEENT: Normocephalic, atraumatic.
SKIN: No scleral icterus. PEERLA
NECK: Supple, no LAD.
CV: RRR, +S1, S2. Palpable 2+ femoral pulses bilaterally.
No ulnar pulses bilaterally. No post-tibial and dorsal pedis
pulses bilaterally.
LUNGS: CTA bilaterally
ABDOMEN: Normoactive bowel sounds, soft, nontender,
nondistended.
SKIN:Right chest quinton in place, dressing clean, dry and
intact. Erythematous plaque rash to bilateral knees and back.
EXTREMITIES:Left Leg clean Surgical site, Right foot clean toe
amputation site
Pertinent Results:
[**2172-9-8**] 05:20AM BLOOD
WBC-17.4* RBC-3.16* Hgb-9.4* Hct-31.6* MCV-100* MCH-29.8
MCHC-29.8* RDW-18.9* Plt Ct-454*
[**2172-9-8**] 05:20AM BLOOD
Plt Ct-454*
[**2172-9-8**] 05:20AM BLOOD
PT-18.1* INR(PT)-1.7*
[**2172-9-8**] 05:20AM BLOOD
Glucose-76 UreaN-50* Creat-6.6* Na-136 K-5.7* Cl-100 HCO3-19*
AnGap-23*
[**2172-9-8**] 05:20AM BLOOD
Calcium-7.7* Phos-6.9* Mg-2.1
[**2172-9-7**] 09:16PM
URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.013
URINE Blood-LG Nitrite-NEG Protein-500 Glucose-TR Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD
URINE RBC-[**3-2**]* WBC->1000 Bacteri-MANY Yeast-NONE Epi-0
[**2172-9-5**] 2:20 pm STOOL CONSISTENCY: NOT APPLICABLE
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2172-9-6**]):
FEcES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2172-9-4**] 8:32 PM
CHEST (PA & LAT)
HISTORY: Fever spike, question pneumonia.
FINDINGS: Single frontal view of the chest is compared to prior
study [**2172-8-28**]. Right hemodialysis catheter remains in place
terminating in the right atrium. Cardiac silhouette remains
enlarged. There is no pleural effusion or pneumothorax. Lungs
are clear. Bony structures are unchanged.
IMPRESSION: No focal airspace disease.
[**2172-8-26**]-spirometry-Mechanics: The FVC and FEV1 are mildly
reduced, while the FEV1/FVC ratio is
elevated.
Flow-Volume Loop: Reduced volume excursion.
Volumes: The TLC and RV are mildly reduced, while the FRC is
moderately
reduced, and the RV/TLC ratio is within normal limits.
DLCO: Moderately reduced.
Impression:
Mild restrictive ventilatory defect. The reduced diffusing
capacity
suggests an interstitial process. There are no prior tests for
comparison.
Pathology tissue BKA [**2172-9-3**]-Concentric capillary calcification
involving panniculitis as well as large vessel calcification
with thrombosis is noted. This picture is most consistent with
an advanced stage of calciphylaxis, however a combination of
calciphylaxis and "metastatic calcification" cannot be excluded.
ECG Holter [**2172-9-8**]-Long-term ECG monitoring was performed using
a Continuous-Loop
Recorder ("[**Doctor Last Name **] of Hearts") to evaluate this patient with
palpitations
to rule out significant arrhythmia. Reported medications include
Atenolol 50 mg daily, Diltiazem, Fluoxetine, Coumadin and
insulin.
The baseline recording was sinus tachycardia at rates 102 to 104
BPM with 8 isolated APBs and 1 atrial couplet. On [**2172-9-8**] the
baseline intervals were as follows: rate 102 BPM; QT
.34 (slightly prolonged), QRS .08, PR .16. There were no
recordings transmitted during this monitoring
session.
[**9-11**] chest/abdomen/pelvis CT
1. Nonspecific predominantly bilateral upper lobe ground-glass
opacities may be infectious or inflammatory in etiology,
including atypical or viral
infections, especially if patient is still immunosuppressed.
Also the
differential given upper lobe predominance, is hypersensitivity
pneumonitis/drug reaction.
2. Minimal bilateral pleural effusions with adjacent
compression atelectasis. Stable atherosclerotic disease
involving the aorta and coronary circulation.
3. Likely stable atypical enhancement of the splenic periphery
compared to a non-contrast [**2171-12-30**] exam, but not definitely
present on non- contrast [**2171-12-4**] exam. The etiology is unclear
but may represent sequelae of prior infection or infarction.
4. Increased hydronephrosis involving the transplant kidney.
Slightly
prominent enhancement to distal collecting system and ureter
suggests
infection/inflammation in this patient with known
UTI/colonization. No
radiographic findings to suggest pyelonephritis.
5. Anasarca.
[**9-11**] abdominal u/s-Mildly distended gallbladder containing a
prominent stone within, however, no definite son[**Name (NI) 493**]
evidence of cholecystitis.
[**9-13**] CT head w/o contrast-No evidence of acute intracranial
hemorrhage.
Small apparently new hypodensity of the left corona radiata
which may
represent a lacunar infarct.
[**9-13**]-EEG-This is an abnormal portable EEG due to the frequent
triphasic waves and slow and disorganized background rhythm.
These
abnormalities are suggestive of a moderate encephalopathy, which
may be
due to toxic metabolic abnormalities, medication effect or
infections.
No epileptiform discharges or electrographic seizures were
noted.
[**9-16**]-CT abdomen and pelvis-
1. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**].
Severe
atherosclerotic disease and arterial calcifications as described
above. Of note, the patencies of these vascular structures,
especially penile arteries could not be assessed on this study.
2. Bilateral hydroceles and edematous testicles. Soft tissue
stranding
surrounding the penis with calcification, likely due to necrotic
penis on the physical examination as noted in the history. The
study does not directly assess the presence or abscence of
penile ischemia. If indicated, please consider further
evaluation by ultrasound.
3. Transplanted kidney in the left lower pelvis, with
persistent fat
stranding surrounding collecting system with slight decrease of
the
hydronephrosis, consistent with known UTI.
4. Diffuse anasarca.
5. Slight increase of pleural effusion with atelectasis.
[**9-21**]-scrotal u/s-No focal fluid collection.
[**9-23**]-left lower extremity CT-Status post below the knee
amputation. Surgical skin staples present.
Multiple foci of subcutaneous gas identified separate from the
skin wound.
Infection cannot entirely be excluded; however, no defined
abscess or fluid collection is seen. Please correlate with any
recent instrumentation or prior location of drainage catheter.
2. Intact underlying cortex of the tibia. No evidence of
osteomyelitis on CT.
3. Diffuse atherosclerosis of the vessels.
[**2172-9-24**]-bilateral lower extremity U/S-No evidence of deep venous
thrombosis.
[**10-1**]-triple phase bone scan-pending
[**2172-8-24**] 04:00PM PT-15.7* PTT-30.8 INR(PT)-1.4*
[**2172-8-24**] 04:00PM PLT COUNT-273
[**2172-8-24**] 04:00PM NEUTS-94.3* LYMPHS-3.7* MONOS-1.4* EOS-0.4
BASOS-0.2
[**2172-8-24**] 04:00PM WBC-13.0* RBC-3.74* HGB-11.7* HCT-38.9*
MCV-104* MCH-31.2 MCHC-30.0* RDW-19.8*
[**2172-8-24**] 04:00PM CALCIUM-8.3* PHOSPHATE-6.7* MAGNESIUM-2.1
[**2172-8-24**] 04:00PM CALCIUM-8.3* PHOSPHATE-6.7* MAGNESIUM-2.1
[**2172-8-24**] 04:00PM ALT(SGPT)-7 AST(SGOT)-9 ALK PHOS-145* TOT
BILI-0.2
[**2172-8-24**] 04:00PM ALT(SGPT)-7 AST(SGOT)-9 ALK PHOS-145* TOT
BILI-0.2
Brief Hospital Course:
The patient is a 50 yo M with a history of DM II, CAD, severe
PVD, ESRD on HD after failed transplant admitted on [**2172-8-24**] for
gangrenous wounds. He was referred to the ED by his PCP. [**Name10 (NameIs) **]
wounds were on his fingers and discovered on his toes by his
PCP. [**Name10 (NameIs) 20282**] were not painful.
The patient was initially admitted on [**2172-8-24**] to the vascular
service for management of gangrenous wounds involving the
left>right toes and fingers. He had lesions that were dry,
indurated and black on his left fingertips, and left and right
toes, his penis and scrotum, as well as small lesions on his
ear. He underwent left BKA with right first toe amputation on
[**2172-9-3**]. The patient was empirically covered for infection of
the gangrenous areas with Vanc/Cipro/Flagyl from
08.27.07-09.13.07. The necrotic areas were thought most likely
to be due to metastatic calification/calciphylaxis. He had an
elevated calcium phosphate product on admission, ESRD, DM and
coumadin use, all of which are risk factors for this. Of note
he had been on coumadin for several months and it was
discontinued on admission to the hospital. His imaging studies
showed calcification of the medium and small sized vessels.
Pathology of the tissue from his BKA and toe amputation
confirmed this. His course in the vascular ICU was complicated
by mental status changes, EEG and head CT were negative and the
cause was attributed to his pain medications. He was
transferred from the vascular ICU to the medical floor.
On the medical floow he was febrile with a low blood pressure
and was then transferred to the MICU. The patient had a
persistent left-shifted leukocytosis. He also had fevers and
altered mental status (of unclear etiology though thought
perhaps related to pregabalin toxicity). On [**2172-9-16**] in
accordance with ID consult recs, the patient was started on
Vanc/[**Last Name (un) **]/Caspo. The caspofungin was for treatment of his
candiduria, and the vanc/[**Last Name (un) 2830**] was for empiric coverage of
pathogens entering through his necrotic skin lesions. His only
microbiology growth was [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**] in the urine on
[**2172-9-10**]. All imaging studies (including scrotal u/s,TEE RUQ
u/s, chest, abdomen, pelvis CT) were negative for infectious
source. After 2 days, he was clinically improving and was then
transferred to the medical floor again. He started receving
pamidronate IV 30mg q day for the calciphylaxis.
After transfer he remained afebrile and his blood pressure was
stable. He continued his HD three times per week. His
caspofungin course was completed on [**9-29**] and urine
culture afterward was negative. He continued to receive
pamidronate for a total of five doses. He was also receiving
cinacalcet and renagel. His calcium phosphate product was
stable in the low 20's. He continued to have pain and chronic
pain service was consulted. He was put on a regimen of MS
contin 20mg [**Hospital1 **], with po dilaudid q3 hours and IV dilaudid if
needed q 3 hours. He was seen by physical therapy but was too
fatigued to work with them. Urology continued to follow him, a
bladder scan showed 900cc urine and a coudet catheter was
placed. As per urology, it should be changed every month. A
new area of mottled purple skin was noted on his left medial
thigh. He reported that it had been there for several weeks and
been rather painful, now less so. Over the course of his
hospitalization the pain in this area became subdued. He also
had a new plaque on his right medial thigh that was similar.
Clinically he was stable and was discharged to [**Hospital1 100**]
Rehabilatation Facility.
Medications on Admission:
Fosrenol 1000mg'", Gemfibrizol 600mg", Vitamin C 250mg",
Glipizide 10mg", Prednisone 5mg', Diltiazem 420mg', Atenolol
100mg', Vitamin B-12 50mg' , Protonix 40mg', Zinc Sulfate
220mg', Coumadin 2.5mg'(last dose Saturday [**8-22**]), Allopurinol
100mg 1 tab post dialysis, Renal Caps 1 tab'
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Allopurinol 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO POST HD ().
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap
PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Lidocaine HCl 2 % Gel [**Month/Year (2) **]: One (1) Appl Mucous membrane PRN
(as needed).
7. Diphenhydramine HCl 25 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO Q6H
(every 6 hours) as needed.
8. Simvastatin 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
9. Cinacalcet 30 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO every other
day
10. Sevelamer 800 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
11. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID
(2 times a day).
12. Digoxin 125 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q MONDAY AND
FRIDAY ().
13. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
14. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID
(2 times a day).
15. Gabapentin 300 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO Q24H
(every 24 hours).
16. Hydromorphone 4 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed.
17. Morphine 30 mg Tablet Sustained Release [**Month/Year (2) **]: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
18. Meropenem 500 mg IV Q24H
Please first dose after HD -- OK to start on [**9-16**].
end date [**2172-10-15**]
19. Vancomycin 1000 mg IV HD PROTOCOL
PATIENT GETS VANCO DOSES IN DIALYSIS
end date [**10-15**]
20. Hydromorphone 2 mg/mL Syringe [**Month/Year (2) **]: One (1) Injection Q3H
(every 3 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Ischemic b/l feeet
PAD
HTN, CAD, DM2, gout, wound healing issues, Hypertriglyceridemia,
Myopathy, depression, HD for ESRD. afib
Discharge Condition:
Good
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL / ABOVE KNEE OR
BELOW KNEE / TOE AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of amputation
(leg) you are non weight bearing for 4-6 weeks. You should keep
this amputation site elevated when ever possible.
You may use the heel of your amputation site (Right) for
transfer and pivots. But try not to exert to much pressure on
the site when transferring and or pivoting. If possible avoid
using the heel of your amputation site when transferring and
pivoting.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
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.
Exercise:
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 14 days.
Try to keep legs elevated when able.
BATHING/SHOWERING:
You may shower immediately. No bathing. A dressing may cover
you??????re amputation site and this should be left in place for
three (3) days. Remove it after this time and wash your
incision(s) gently with soap and water. You will have sutures,
which are usually removed in 4 weeks. This will be done by the
Surgeon on your follow-up appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
1. Please follow up with your primary care doctor in [**12-31**] weeks.
The appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is at Date/Time:[**2172-11-17**]
2:30 PM. Phone:[**Telephone/Fax (1) 250**]
2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2934**] Follow-up
appointment should be in 2 weeks
3. Please follow up with your renal doctor. Dr. [**Last Name (STitle) 4883**],
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]- Tue [**11-3**] at 11am
4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] please call
next week and make an appointment for next week
5. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] please
call and make an appointment in two weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]
Completed by:[**2172-10-2**] Name: [**Known lastname 11912**],[**Known firstname 448**] A Unit No: [**Numeric Identifier 11913**]
Admission Date: [**2172-8-24**] Discharge Date: [**2172-10-2**]
Date of Birth: [**2122-6-10**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Bacitracin / Morphine / Percocet / Oxycodone
Attending:[**First Name3 (LF) 11914**]
Addendum:
discharge medication update
ASA 325
Etidronate 500mg q daily for three months
Cinacalcet every other day
Renagel when phos is >4
Discharge Disposition:
Expired
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 11915**]
Completed by:[**2173-1-16**]
|
[
"440.24",
"585.6",
"112.2",
"357.2",
"403.91",
"275.49",
"788.20",
"607.2",
"293.9",
"427.31",
"730.07",
"996.81",
"250.60",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.95",
"99.10",
"39.50",
"00.40",
"88.48",
"84.11",
"84.15",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
23346, 23578
|
9802, 13542
|
364, 1109
|
16224, 16231
|
3264, 9779
|
21712, 23323
|
2692, 2712
|
13887, 15942
|
16071, 16203
|
13568, 13864
|
16255, 18108
|
2727, 3245
|
279, 326
|
18121, 21015
|
21039, 21689
|
1137, 2310
|
2332, 2611
|
2627, 2676
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,327
| 114,950
|
33350
|
Discharge summary
|
report
|
Admission Date: [**2148-1-9**] Discharge Date: [**2148-2-2**]
Date of Birth: [**2106-1-28**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Adhesive Bandage / Dicloxacillin
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
Diagnostic Paracentesis
Therapeutic Paracentesis
[**Last Name (un) 1372**]-jejunal tube placement
History of Present Illness:
This is 41 year old male with history of cirrhosis secondary to
EtOH and hepatitis C virus, obstructive sleep apnea and
hypothyroidism, with recurrent episodes of severe
enceophalopathy and ascites.
Mr. [**Known lastname 19420**] was re-admitted to [**Hospital1 18**] [**1-9**] for worsening
encephalopathy. The patient has multiple admits for
encephalopathy (5 since [**8-27**]). He has had 10 MICU
admissions/floor transfers and at least 6 intubations since
[**2147-10-21**] as a result of his encephalopathy. He was
hospitalized from [**Date range (2) 77415**], during which time he had
recurrent episodes of encephalopathy requiring MICU admissions,
w/ one of them to be secondary to possible aspiration with
poorly-fitting CPAP mask. He was most recently hospitalized
again this month with discharge [**1-8**]. During this most recent
admission, he likewise required MICU level care for
encephalopathy and respiratory compromise when even a single
Lactulose dose was delayed. He has demonstrated that he is
exquisitely sensitive to any decrease in frequency of lactulose
administration, and the results of delayed or missed doses lead
to severe obtundation.
Past Medical History:
- HCV and EtOH Cirrhosis with ascites and edema, biopsy
diagnosed in [**2139**], last vl 32,600 copies; last MELD 24.
- h/o SBP early [**7-27**] on cipro prophylaxis
- Grade II esophageal varices
- Recurrent hepatic encephalopathy of unclear precipitant
- Pulmonary HTN
- Hypothyroidism
- Anxiety disorder
- h/o EtOH abuse, IVDU
- osteoperosis of hip and spine per pt
- Anemia w/ hx of guaiac positive stool.
- pulmonary HTN - echo [**2146-12-28**] unable to assess; EF > 55%, MR
slightly increased
Social History:
Pt lives with his Mother. Pt quit smoking [**5-27**], was smoking
1/3ppd. Quit drinking etoh 11 years ago. Prior remote hx of IVDU
as teen. No current drug use.
Family History:
Mother with DM and HTN. Father with rheumatic heart disease.
Physical Exam:
EXAM PRIOR TO MICU TRANSFER ON [**2148-1-10**]
Gen: Nonresponsive, eyes open,
HEENT: dry MM, + scleral icterus
Pulm: rhonchi BL, no wheezes or crackles
CV: S1 & S2 regular without murmur
Abd: Distended, tympanitic, + shifting dullness, firm. Unable to
determine tenderness.
Ext: 2+ edema bilteraly.
Neuro: Non-responsive
Pertinent Results:
ADMISSION LABS:
CBC:
[**2148-1-8**] 06:00AM BLOOD WBC-4.8 RBC-2.45* Hgb-8.2* Hct-24.6*
MCV-101* MCH-33.6* MCHC-33.4 RDW-19.1* Plt Ct-78*
[**2148-1-8**] 06:00AM BLOOD Neuts-71.0* Lymphs-19.1 Monos-7.6 Eos-2.0
Baso-0.4
COAGS:
[**2148-1-8**] 06:00AM BLOOD PT-23.5* PTT-46.5* INR(PT)-2.3*
CHEMISTRIES:
[**2148-1-8**] 06:00AM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-141
K-3.6 Cl-109* HCO3-25 AnGap-11
LIVER ENZYMES:
[**2148-1-8**] 06:00AM BLOOD ALT-27 AST-66* LD(LDH)-276* AlkPhos-100
TotBili-3.7*
[**2148-1-9**] 01:15PM BLOOD Lipase-46
[**2148-1-8**] 06:00AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.3 Mg-1.8
[**2148-1-9**] 01:15PM BLOOD Ammonia-87*
-------
-------
DISCHARGE LABS:
[**2148-2-2**] 05:37AM BLOOD WBC-7.3 RBC-2.72* Hgb-8.5* Hct-26.8*
MCV-98 MCH-31.2 MCHC-31.7 RDW-18.9* Plt Ct-67*
[**2148-2-2**] 05:37AM BLOOD Glucose-104 UreaN-10 Creat-0.8 Na-142
K-3.9 Cl-116* HCO3-21* AnGap-9
[**2148-2-1**] 05:50AM BLOOD ALT-28 AST-71* LD(LDH)-282* AlkPhos-149*
TotBili-5.2*
MICROBIOLOGY:
[**2148-1-9**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2148-1-15**]**
Blood Culture, Routine (Final [**2148-1-15**]): NO GROWTH
------
[**2148-1-11**] 3:29 pm PERITONEAL FLUID
**FINAL REPORT [**2148-1-17**]**
GRAM STAIN (Final [**2148-1-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2148-1-14**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2148-1-17**]): NO GROWTH
------
[**2148-1-22**] 11:17 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2148-1-24**]**
GRAM STAIN (Final [**2148-1-22**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2148-1-24**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
------
[**2148-1-22**] 11:19 am STOOL CONSISTENCY: WATERY Source:
Stool.
CANCELLED TESTS TO BE PERFORMED PER REQUEST OF PHYSICIAN.
**FINAL REPORT [**2148-1-24**]**
FECAL CULTURE (Final [**2148-1-24**]):
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final [**2148-1-24**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2148-1-23**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
This is a 42 year old gentleman with a history of cirrhosis
secondary to EtOH + HCV, history of spontaneous bacterial
peritonitis, who has had multiple hospitalizations for
encephalopathy who presented with mental status changes again
consistent with encephalopathy.
# Encephalopathy: The patient was admitted for mental status
change secondary to encephalopathy. Within 24 hours of admission
patient was transferred to the medical ICU for worsening
encephalopathy and witnessed vomiting/aspiration while on CPAP.
He was intubated & sedated for airway protection with an NG tube
placed for gastric decompression and medicine administration.
His chest x-ray and vital signs did not indicated any lung
damage. He was extubated approximately 24 hours later. The
patient's mental status cleared, he tolerated food and was
returned to the Liver-Kidney service.
The patient was transferred to the MICU again approximately 24
hours later for repeat altered mental status and
unresponsiveness without witnessed aspiration or known cause.
He was given lactulose, rifaximin and acidophilus and his mental
status cleared within 12 hours. He was kept for 60 hours for
monitoring wherein he developed an additional episode of
somnolence that resolved with continued lactulose
administration. He was again returned to the floor.
Patient's encephalopathy remained stable on the floor for nearly
1 week until he became acutely obtunded. He was witnessed
vomiting a small amount with subsequent aspiration. He was
transferred to the MICU for treatment and intubated again for
airway protection. Again lactulose and rifaximin were continued.
Patient was again extubated and called out to the liver service.
Close attention paid to patient receiving all scheduled
lactulose doses while on the floor. In addition patient started
on Zinc. He was also switched to a vegetarian diet so as to
reduce his intake of animal proteins. This combination of
treatments resulted in the patient's encephalopathy remaining
stable until discharge.
# Aspiration: Two of patient's transfers to the MICU were
related to concern for aspitation. Patient felt to develop an
aspiration pneumonitis versus pneumonia. Sputum gram stain
showed gram positive cocci in clusters, chains and pairs. Cx
growing only oropharyngeal flora. Patient was treated with a 7
day course of vancomycin and cefepime. Patient was maintained on
aspiration precautions and was evaluated by speech and swallow
who recommended thin liquids and
ground consistency solids, Pills whole with thin liquids.
# Attempt at Spleno-renal Embolization: Patient underwent IR
guided spleno-renal embolization in an attempt to embolize
shunts in his liver which could be contributing to his
encephalopathy. Unfortunately, these shunts could not be
embolized during the procedure given team unable to pass into
the shunt from
the renal vein.
# End Stage Liver Disease: Secondary to alcohol and hepatitis C.
Patient required two therapeutic paracentesis which yielded
4liters and 3.5 liters respectively. Patient received albumin
following each tap. In addition, patient continued on nadolol,
though at a decreased dose, and spironolactone. Lasix was held
given episodes of hypotension while in the MICU and was not
restarted given patient achieved a degree of stability on his
medication regimen while lasix held. His liver function tests
remained stable. Patient continued on daily cipro for SBP
prophylaxis. Patient is currently awaiting a liver [**Year/Month/Day **].
He is scheduled to follow up in [**Year/Month/Day **] clinic with Dr.
[**Name (NI) **].
# Anemia: Likely a combination of anemia of chronic disease and
mild blood loss anemia given chronically guiac positive stools.
It has been unclear what the source of bleed. Hematocrit
remained stable during this admission. Would recommend an
outpatient colonoscopy to assess for source of GI bleeding.
# Thrombocytopenia: Likely secondary to liver disease. Platelets
remained stable.
# Hypothyroidism: Patient was continued on levothyroxine 88mcg
PO daily.
# Pulmonary HTN: Patient continued on his outpatient regimen of
iloprost. Patient should follow up in pulmonary clinic for
further management of this issue.
# OSA: He was started on a brief trial of modafinil but this was
not continued after he was discharged from the ICU. Patient was
continued on CPAP throughout his hospital course.
Patient was a FULL code during this admission.
Medications on Admission:
1. Ciprofloxacin 250 mg PO Q24H
2. Lactulose Sixty (60) ML PO Q2H as needed for confusion.
3. Rifaximin 400 mg PO TID
4. Levothyroxine 88 mcg PO DAILY
5. Omeprazole 20 mg PO once a day.
6. CALCIUM 500+D 500 PO once a day.
7. Magnesium 400 mg PO once a day
8. Lactulose Forty Five (45) ML PO QID
9. Nadolol 20 mg PO DAILY
10. Home oxygen 2L continuous
11. CPAP 5 - 15 CM H2O
12. Iloprost 10 mcg/mL One (1) nebulizer treatment Inhalation 6x
daily.
13. Lasix 20mg PO daily
14. Spironolactone 50mg PO BID
15. Clotrimazole Troche 10mg 5x/day
Discharge Medications:
1. Levothyroxine 88 mcg 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. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
5. Acidophilus Oral
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. [**Hospital **] Hospital Bed: Diagnosis: End stage liver
disease complicated by encephalopathy::Patient requires daily
tube feeds and aspiration precautions at all times
8. 3 in 1 commode
9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
[**Hospital **]:*60 Tablet(s)* Refills:*2*
10. Tube Feeding
Formula: Fibersource HN Full strength;
Rate: At goal rate of 40 ml/hr
Flush w/ 100 ml water q6h
11. FiberSource HN
Liquid
Sig: Forty (40) cc per hour: continuous via post pyloric feeding
tube.
[**Hospital **]#: **120** One hundred and 20 cans
Refills: **1**
12. Tube feeding supplies
Tube fedding supplies
supply pump, tubing syringes, pole
supply 1 month
refill: 1
13. Iloprost 10 mcg/mL Solution for Nebulization Sig: 60mL MLs
Inhalation 9 times daily ().
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital **]:*30 Tablet(s)* Refills:*2*
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Hospital **]:*60 Capsule(s)* Refills:*2*
16. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Hospital **]:*15 Tablet(s)* Refills:*2*
17. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
[**Hospital **]:*120 Capsule(s)* Refills:*2*
18. Lactobacillus Acidophilus Capsule Sig: 500 million cell
Capsules PO TID (3 times a day).
19. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO Q3H
(every 3 hours).
[**Hospital **]:*[**Numeric Identifier 16501**] qs* Refills:*2*
20. Calcium cholecalciferol 600-40 mg unit TID
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary: Hepatic Encephalopathy, Ascites secondary to end stage
liver disease
Secondary: Pulmonary Hypertension, Obstructive Sleep Apnea,
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with encephalopathy. Your encephalopathy
improved with aggressive and timely administration of Lactulose.
During your hospital stay we also performed two therapeutic
paracentesis to remove ascites. You have had a tube placed that
goes from your nose to your intestines so that you can have tube
feeds.
The following medications STOPPED:
**Lasix: please call Dr. [**Name (STitle) 23173**] if you notice increased leg
swelling since this medication may need to be restarted.
The following medications are NEW:
**Zinc: this is for your encephalopathy
The following CHANGES were made to your meds:
** Lactulose is now 45mL q3 hr: in the hospital we had a goal of
700 cc of stool daily
** Spironolactone is now 50 mg twice a day
** Magnesium oxide is now 280 mg twice a day
** Nadolol is now 10 mg daily
If you experience changes in your mental status please come to
the ED immediately. If you experience shortness of breath, chest
pain, fevers or abdominal pain please contact your primary care
physician or come to the ED for evaluation.
Please let Dr. [**Name (STitle) 23173**] know if your legs are getting more
swollen since you may need to have your lasix restarted.
Followup Instructions:
You have been scheduled to see Dr. [**Last Name (STitle) 1383**] ([**Last Name (STitle) 1326**]
Center) on [**2148-2-23**] at 8:30 am. The office phone number is ([**Telephone/Fax (1) 10248**].
You should make an appointment to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] [**Location (un) 6330**] within the next 7-10 days. The office phone number
is [**Telephone/Fax (1) 46571**].
Completed by:[**2148-2-7**]
|
[
"287.5",
"285.9",
"572.2",
"571.2",
"276.0",
"733.00",
"300.00",
"416.8",
"327.23",
"263.9",
"244.9",
"456.1",
"789.59",
"518.81",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"45.13",
"54.91",
"96.04",
"96.08"
] |
icd9pcs
|
[
[
[]
]
] |
12172, 12228
|
5150, 9589
|
328, 439
|
12425, 12434
|
2767, 2767
|
13673, 14127
|
2349, 2411
|
10177, 12149
|
12249, 12404
|
9615, 10154
|
12458, 13650
|
3450, 5127
|
2426, 2748
|
267, 290
|
467, 1632
|
2784, 3433
|
1654, 2154
|
2170, 2333
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,714
| 155,420
|
11776+11777
|
Discharge summary
|
report+report
|
Admission Date: [**2102-11-9**] Discharge Date: [**2103-1-16**]
INTERIM SUMMARY
Date of Birth: [**2102-11-9**] Sex: M
Service: NEONATOLOGY
THIS IS AN INTERIM SUMMARY TO [**2102-1-16**].
HISTORY: [**Known lastname 5621**] [**Known lastname 37227**] was a 730 gram product of a
28-2/7 weeks gestation [**Known lastname **] to a 29 year old, Gravida 3, Para
[**12-24**] mother. The patient's mother was transferred from [**Hospital6 11241**] the night prior to admission due to the fact
that the [**Hospital1 2177**] Neonatal Intensive Care Unit was full.
The pregnancy was notable decreased growth two weeks prior to
the delivery. The patient was admitted to [**Hospital6 14430**] on [**11-7**] with a BPP of [**2-26**]. No formal
evaluation of the etiology of the growth restriction was
done. Mother had two previous normal grown infants by her
report. The placenta was normal on gross examination. There
was no history of maternal hypertension and the patient's
mother did receive one dose of betamethasone prior to
delivery.
The maternal screens were blood type of O negative, antibody
negative, Hepatitis B surface antigen was negative. GBS was
unknown. RPR was nonreactive.
In the Delivery Room, the patient emerged with decreased
tone, respirations and heart rate. Responded to bag mask
ventilation. Was intubated in the Delivery Room for poor
effort. Apgars initially were 4 and 6 and was brought to the
Neonatal Intensive Care Unit after briefly showing the
patient to the mother.
PHYSICAL EXAMINATION: On admission, the patient weighed 730
grams, that was approximately the 5th percentile, was pink,
active and non-dysmorphic. The skin was without any lesions.
There was bilateral red reflex noted. Nares were patent.
The palate was intact. The head circumference was 23 cm
which was also the 5th percentile. The lungs had coarse
crackly breath sounds bilaterally. Cardiac examination had a
regular rate and rhythm without murmur. The abdomen was
soft, nontender, with no hepatosplenomegaly. The genitalia
was normal for gestational age male. Both testes were
undescended. The hips were stable and the back and skeletal
structures were normal. The neurologic examination was
nonfocal and appropriate for age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The patient was initially intubated in the
Delivery Room and over the course of the first day to 24
hours, received Surfactant times three and progressed rapidly
from conventional ventilator to high-frequency ventilation.
The patient remained on the high-frequency ventilator from
[**11-10**] until [**12-15**], at which time he was taken off
to conventional ventilation. The patient did have
conventional ventilation settings that have remained high
even to date. The ventilator settings have ranged from
positive inspiratory pressures of 22 to 30 over peak
end-expiratory pressures of 5 to 7 with rates from 23 to 28.
As of [**1-16**], the current ventilator settings were 28/7
with a rate of 28.
The patient developed bilateral pleural effusions that seemed
to be related to leakage of parenteral nutrition. This was
noted on [**2102-11-23**], however, it was unclear as to how
this fluid got into the chest cavity. The PICC line came
from below and had no access to the chest cavity itself and
the IVC was below the diaphragm, however, the fluid that was
tapped from the right and drained from the left with a chest
tube on [**11-23**], was consistent with parenteral nutrition.
The left chest tube was placed on [**11-23**]; the right chest
tube was placed on [**11-25**], and continued to drain until
the chest tubes were placed to Water-Seal on [**11-28**], with
subsequent removal. The patient has not had any further
reaccumulation of pleural effusions.
The patient was initially loaded on caffeine for the first
time on [**12-14**] for apnea of prematurity. Caffeine was
discontinued on [**2103-1-2**].
The patient was tried on Combivent [**12-4**]. Combivent was
continued, either scheduled or p.r.n. until [**12-16**], when
it was discontinued because of little perceived benefit.
However, the patient did have an episode where he his chest
was tight with poor aeration that appeared to respond to
Combivent. As a result, Combivent was restarted on [**1-13**], with what seemed to be a positive result. The Combivent
was discontinued [**1-16**] after Inhaled steroids were
begun.
The patient, for chronic lung disease management, was
started on a trial of Lasix on [**12-7**], and was changed
over to Diuril on [**12-9**] and to this day remains on
Diuril 40 mg per kilo per day in an effort to help improve
the chronic lung disease. The patient was fluid restricted
further from initially total fluids of 140 in [**Month (only) 404**] down to
today's 130 cc per kilo per day and in addition to the
Diuril, Lasix was given on an every-other-day basis on
[**12-28**] for a total of six days with slight improvement
in ventilation, at which time the Lasix was discontinued and
Aldactone was started in an effort to get the potassium
sparing effect.
In an effort to improve the need for extremely high
ventilator settings and chronic lung disease management,
inhaled Beclomethasone was started on [**2103-1-11**], with
eight puffs q. four hours. Over the course of the next four
days, the O2 requirements did improve from near 80% down to
about 40 to 50% but there was no movement on the ventilator
settings and the patient still had pCO2s into the 60s on cap
gases. It was then determined in conjunction with
suggestions from the Pulmonary consultants, to begin systemic
dexamethasone therapy. He was started on [**1-15**], at
which point inhaled Beclomethasone was discontinued. The
starting dose for the dexamethasone was 0.25 mg per kilo per
day divided and twice a day.
The wean for the dexamethasone currently is being determined
based on effect, but will likely be weaned over the course of
ten to 14 days. Currently, [**Known lastname 5621**] [**Known lastname 37227**] is on
ventilator settings of 28/7 with a rate of 28, remains on
Diuril, Aldactone, and dexamethasone for his chronic lung
disease management as well as fluid restrictions.
2. CARDIOLOGY: [**Known lastname 5621**] had his first cardiac
echocardiogram on [**2102-11-10**]. This echocardiogram
report showed a large PDA with a dilated left and right
atrium with good left and right ventricular function and also
a patent foraminal valve. The patient, at that point, was
already NPO and did get a course of Indomethacin at which
point the follow-up echocardiogram on [**11-12**] showed that
the PDA had closed. The patient has never had any other
evidence of a PDA and currently does not have a murmur. Line
access initially did include a UAC, UVC and has had a
peripheral arterial line as well as PICC as mentioned above.
The patient was hypotensive at least initially and was
started on Dopamine shortly after birth with a peak Dopamine
requirement of 20 micrograms per kilo per minute which was
weaned fairly rapidly after the PDA was closed and the
Dopamine was discontinued on [**2102-11-17**]. The patient
has not needed any other cardiovascular support to this date.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
initially NPO, was started on D10 and then advanced to
parenteral nutrition due to concerns of sepsis in addition to
PDA and courses of Indomethacin. The patient was not fed and
was completely on PN until [**2102-12-3**], when trophic
feeds were begun of breast milk, however, those feeds were
not initially tolerated and was made NPO briefly again.
Feeds were restarted on [**12-5**], at 10 cc per kilo per
day, and reached full feeds on a slow advancement by [**2102-12-16**]. In addition, the patient was started on sodium and
potassium supplements on [**12-16**]; this was about the same
time that the Diuril was started. The patient was worked up
on calories and is currently on breast milk or parenteral
nutrition 32 with ProMod. The patient was started on
potassium and phosphorus on [**12-27**], due to a low
phosphate of 3.4.
Current medications for Fluids, Electrolytes and Nutrition:
Include sodium and potassium supplementations; the potassium
supplementations are in the form of chloride as well as
phosphate.
4. GASTROINTESTINAL: The patient had the initial problems
with sepsis which I will detail in the next subsection as
well as being PN dependent for the first three to four weeks
of life and has subsequently had a rise in his both total and
direct bilirubin as well as his liver function tests. On
[**1-1**], the ALT reached 238; the AST was 323 and
alkaline phosphatase was 830 with a total bilirubin of 12 and
a direct bilirubin of 9. The patient was started on
phenobarbital for elevated bilirubin on [**1-4**], and
seemed to have a good response. Repeat liver function tests
and bilirubin on [**1-8**], showed an ALT of 167, an AST of
185, a total bilirubin of 8.5 and a direct of 6.5. However,
over the course of the next week, these values tended to
trend back up and on [**1-15**], the total bilirubin reached
9.8 with a direct of 7.6 and a phosphorus of 4.4, at which
time the GI Service was consulted.
They made several recommendations, all of which are currently
underway. The first is that a HIDA Scan be performed. The
HIDA scan will be performed on [**2103-1-17**]. Testing
for alpha 1 antitrypsin and P typing, which will be sent with
the next blood draw, this Friday, [**1-19**]. They also asked
for urine for CMV which was sent today, [**1-16**], and
depending upon the results of the HIDA Scan they would
consider starting Ursodiol. In addition, due to concerns
about the potential for silent reflux, Zantac and Reglan were
started empirically on [**1-12**]. The patient has not had
any overt signs of reflux and has been fed over two to three
hours, not necessarily for concerns of reflux, but rather due
to problems with sugars. Currently the patient is receiving
his feeds over a two hour period of time. There has not been
a pH probe or an upper GI done to this point.
5. INFECTIOUS DISEASE: Initially, when the baby was [**Name2 (NI) **] on
[**2102-11-9**], Ampicillin and Gentamicin were started for
a rule out sepsis. Due to dilated loops and a distended
abdomen and concerns about NEC, Clindamycin was added and
the patient remained on Ampicillin, Gentamicin and
Clindamycin for the first 14 days of life. The antibiotics
were changed on [**11-23**], to Vancomycin, Gentamicin and
Clindamycin and finished a total of 21 days of total
antibiotic course. The change to Vancomycin was done about
the time the bilateral pleural effusions arose with the
substance that appeared to be PN. A subsequent rule out
sepsis was performed in the end of [**Month (only) 404**], on [**12-19**] to
[**12-22**]; the patient was on Vancomycin and Gentamicin and
the rule out sepsis turned out to be negative.
On [**2102-12-28**], after several days of increasing
amounts of trachea aspirate and a color change from white to
tan, a trachea aspirate culture was sent which showed
moderate beta Strep as well as [**Known lastname 37228**] and antibiotics at
that time were started. A 14 day course of Cefotaxime and
Gentamicin was begun. A lumbar puncture obtained at that
time was benign and was felt to be an isolated respiratory
infection.
The repeat culture from the tracheal aspirate was sent on
antibiotic day nine with continued presence of [**Known lastname 37228**].
It was determined at that time to finish a 14 day course and
then begin treatment for the chronic lung disease with the
inhaled steroids.
6. NEUROLOGY: The patient has had currently six head
ultrasounds. Head ultrasound number one was done on [**11-13**], which showed a left Grade III intraventricular
hemorrhage. Head ultrasound number two on [**11-16**],
showed mild retraction of the clot with no further
dilatation. Head ultrasound number three on [**11-20**],
showed no change. Head ultrasound number four on [**11-28**],
showed a stable resolving clot consistent with the previous
scan. Head ultrasound number five on [**12-16**], showed a
resolving clot with a recommendation for follow-up in one
month. Head ultrasound number six on [**1-12**], was
essentially normal with a small choroid plexus cyst and
lateral ventricles that were within the normal range but more
prominent that the slit appearance that was present on the
[**12-12**] scan.
This patient is to be followed up in the [**Hospital 878**] Clinic
with [**First Name5 (NamePattern1) 3608**] [**Last Name (NamePattern1) **] upon discharge from the Neonatal
Intensive Care Unit.
7. SENSORY: The patient's audiology screens have had one
prior pass to this point.
8. OPHTHALMOLOGY FINDING: The first eye examination on
[**12-20**] showed a Stage I, Zone I, with two clock hours
bilaterally. On [**12-26**], the follow-up eye examination
again showed Stage I, Zone 2 this time, with four clock hours
bilaterally. [**1-3**], again the examination was stable;
it showed Stage I, Zone 2, four clock hours and the patient
is due for a repeat eye examination on [**1-17**].
9. PSYCHOSOCIAL: Social Work has been involved with the
family in addition to weekly family meetings with an
interpreter. She has been providing the family support for
this prolonged hospitalization.
DIAGNOSES:
1. Respiratory distress syndrome, now Chronic lung disease.
2. Hyperalimentation hydrothorax, resolved.
3. [**Known lastname 37228**] tracheitis (treated) vs colonization.
4. Hypotension, resolved.
5. Patent ductus arteriosus, s/p Indocin.
6. Presumed sepsis, resolved.
7. [**Hospital **] medical NEC, resolved.
8. Direct Hyperbilirubunemia, possibly PN cholestasis.
9. r/o gastrointestinal reflux.
10. Resolved left Grade III intraventricular hemorrhage.
11. Retinopathy of Prematurity.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 37229**]
MEDQUIST36
D: [**2103-1-16**] 15:31
T: [**2103-1-16**] 15:41
JOB#: [**Job Number 37230**]
Admission Date: [**2102-11-9**] Discharge Date: [**2103-1-28**]
Date of Birth: [**2102-11-9**] Sex: M
Service: NEONATAL
THIS IS AN INTERIM/TRANSFER SUMMARY; PLEASE REFER TO PREVIOUS
INTERIM SUMMARY DICTATED BY DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**] ON [**2103-1-16**].
This summary is intended to provide the details of the
hospital course from [**2103-1-16**] through [**2103-1-28**], detailing the current health issues for [**Known lastname 5621**]
[**Known lastname 37227**]. The purpose of this summary is to provide these
details for communication to [**Hospital3 1810**] Newborn
Intensive Care Unit where the infant will have an elective
tracheostomy with post op recovery prior to transfer back to
[**Hospital1 69**] for ongoing care.
HISTORY: Briefly, [**Known lastname 5621**] [**Known lastname 37227**] is 80 days of age
at the time of transfer to [**Hospital3 1810**] for
tracheostomy placement. He is at the corrected gestational
age of 39 6/7 weeks. He was [**Hospital3 **] at 28-2/7 weeks gestation to
a 29 year old Gravida 3, Para 2 to 3 mother. Pregnancy was
notable for a falling off in fetal growth two weeks prior to
delivery. Two days before birth, the infant showed evidence
of fetal compromise with a Biophysical Profile of 4 out of 8.
The mother did receive one dose of betamethasone prior to
delivery of the infant due to fetal distress.
Maternal screens were blood type of O negative, antibody
negative, hepatitis B surface antigen negative, GBS unknown,
RPR nonreactive.
Delivery Room course was remarkable for some bag mask
ventilation and intubation with Apgars of 4 and 7 at one and
five minutes respectively.
Physical examination on admission is outlined in the previous
interim summaries included with this packet.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The patient had Surfactant deficiency in
the first days of life. He received three doses of
Surfactant. He was minimally responsive to this and had
progressive respiratory distress necessitating high
frequency ventilation for the first 35 days of life. During
this time, the patient also developed bilateral pleural
effusions thought to be related to leakage of parenteral
nutrition, however, this was unclear since the PICC line was
present only in the subdiaphragmatic IVC. Pleurocentesis,
however, was productive of fluid that was suggestive of
parenteral nutrition leak. The infant had a chest tube for
drainage bilaterally from the [**1-21**] until the [**1-26**].
The patient was also briefly on caffeine for apnea of
prematurity, although this is no longer an issue.
His respiratory distress progressed to severe chronic lung
disease which has been managed with fluid restriction at 130
cc. per kilo per day as well as diuretic therapy. At two
months of age, attempts were made to wean him from the
ventilator using inhaled Beclomethasone therapy. While this
did result in some improvement in oxygen requirement, the
infant still required moderate to high ventilatory settings
due to inability to ventilate. Pulmonary consultation at that
time recommended initiation of systemic dexamethasone therapy
due to severe unremitting bronchopulmonary dysplasia. This
was initiated on [**1-15**], and the infant still is
receiving a prolonged taper of dexamethasone. He will be on
his last wean of dexamethasone prior to transfer to [**Hospital3 18242**] for tracheostomy placement. He will need stress
doses of steroids for his surgery.
Our efforts to improve his pulmonary status using high doses
of corticosteroids have been unproductive. We are left with
no option except to recommended tracheostomy to the family.
This will maximize his ability to develop, feed and get to
the point where he is a candidate for discharge home or to
[**Hospital1 37231**] Medical Center as a transitional place for him
prior to transfer home. He is currently on ventilatory
settings of 27/6 times 28 with an oxygen requirement of
around 60%. He has been on these settings for the past
several days. His most recent arterial blood gas shows a pH
of 7.27 with a pCO2 of 68. He tends to have a pCO2 in the
mid to high 60s.
2. Cardiology: He had his first echocardiogram on [**11-10**], which is at birth. This showed a large patent ductus
arteriosus with dilated left and right atrium, good left
ventricular and right ventricular function and a patent
foramen ovale. The patient received a course of
Indomethacin to close the ductus. The patient does not
currently have a murmur. The patient received Dopamine for
low blood pressures for the first week of life, after which
this was discontinued. He has had no other problems with
cardiac function.
3. Fluids, Electrolytes and Nutrition: Due to abdominal
concerns and concerns for sepsis, the infant was not fed for
the first 20 days of life and was dependent solely on
parenteral nutrition. Feedings were slowly advanced
between day of life 25 and day of life 35, until he attained
full feeds. The patient has recently been tolerating full
feeds. He is currently on PE 32 with promod at 130 cc/kg/day
pg. His weight on transfer is 2375 grams.
His electrolytes are also affected by chronic
diuretic therapy. He is currently on Diuril and Aldactone.
He is also receiving supplementation with sodium and
potassium. His most recent electrolytes showed a sodium of
135, potassium 5.2, chloride 96, bicarbonate 25.
[**Known lastname 5621**] has also had some transient difficulties with
maintaining a blood glucose above 60. We have had to give
his feeds over two and a half hours to insure that he has
good blood glucose levels. Occasionally, his blood glucose
still dips into the mid-50s to low-60s. Of note, he did not
have hyperglycemia in response to large doses of systemic
corticosteroids. The fact that he responds to feeding over a
two and a half hour stretch of time suggests that he may have
some difficulty mobilizing glycogen. We are in the process
of evaluating this by getting urine organic acids and serum
amino acids. His blood gases and electrolytes are altered
due to chronic diuretic management, however, he has not shown
any evidence of a wide anion gap metabolic acidosis during
this time.
We have also initiated a GI work-up which will be outlined
below, including liver function tests. Although he
occasionally had low blood sugars, usually his blood glucose
is well within normal limits, and he responds well to feeding
over two and a half hours. It is recommended, hence, that
when he is advanced onto full feedings, that these be given
over time to insure euglycemia.
4. Gastrointestinal: The patient had initial problems with
sepsis as well as total parenteral nutrition dependence for
the first 20 to 25 days of life. It was also noted that he
had elevated transaminases with an elevated alkaline
phosphatase and direct bilirubin. He has been on
phenobarbital due to elevated conjugated bilirubin. Most
recently, he has had a drop in his conjugated bilirubin from
6.4 one week ago to 4.5 more recently. His most recent liver
function tests show a normal albumin, GGT of 880, ALT 161, AST
127 with a alkaline phosphatase of 144. Hepatitis serologies
have been negative. Alpha I antitrypsin levels have been
sent; the results are still pending. He has had testing for
the Alpha I anti-trypsin mutation. His genotype is MM which
is usually normal. Gastroenterology is involved and is
consulting in his case. A HIDA scan was recommended. Our
reports from this showed that there was a decrease in
clearance of bile. We are waiting for a follow-up from
Gastroenterology to get further recommendations in terms of
work-up and management. A metabolic work up is being pursued
with organic and amino acids. He will need a lactate and
pyruvate. If these are not fruitful, we will consider
endocrine evaluation, especially in light of the relative
hypoglycemia.
The infant is on Zantac and Reglan due to concerns for
potential silent reflux. These were started empirically on
[**1-12**]. He has not had a pH probe or upper
gastrointestinal study.
5. Infectious Disease: The infant had a sepsis evaluation
after birth. Early abdominal films showed a distended
abdomen with some concerns for possible medical necrotizing
enterocolitis. There is no clear mention of pneumatosis in
his early abdominal films. He received 14 days of
Ampicillin, Clindamycin and Gentamycin. On [**11-23**], due
to further emerging of sepsis concerns, his Ampicillin was
switched to Vancomycin for an additional seven days. He
ended up receiving a total course of 21 days of triple
antibiotics.
At one and a half months of life, Cefotaxime and Gentamycin
were initiated due to concern for possible [**Known lastname 37228**]
tracheitis. A lumbar puncture was obtained at that time
which was benign. He was treated with antibiotics for 14
days.
He is currently not on any antibiotics and has not been on
any since [**1-11**]. A tracheal aspirate was sent a few
days ago due to a change in the color of his secretions which
has grown [**Known lastname 37228**] pneumonia resistant to Gentamycin. He
has not had any other signs of pneumonia or worsening
respiratory status, so we have elected not to treat what we
consider to be colonization with Gentamycin resistant
[**Known lastname 37228**]. We do make a note of this, however, since
contact precautions have been initiated due to the presence
of this organism.
6. Neurology: The infant has had several ultrasounds. His
initial ultrasound on day of life three showed left Grade III
intraventricular hemorrhage. Progressive ultrasounds have
shown resolution of this hemorrhage with relatively normal
appearance of the lateral ventricles and the presence of a
small choroid plexus cyst. Neonatal [**Hospital 878**] Clinic follow
up is needed.
7. Sensory: The patient has not had a hearing screening.
8. Ophthalmology: The infant is being followed for
retinopathy of prematurity. Examination on [**12-20**] showed
Stage 1, Zone 1, with two clock hours bilaterally. Most
recent examination showed a mature right eye, but a left eye
which which was poorly dilated. He will need a repeat eye
examination the week of [**1-29**].
9. Psycho-Social: The Social Worker has been involved with
the family. They are French-Creole speaking. They have been
involved in and are participating in his care. They have
another child at home. We had a family meeting with the
patient's mother four days ago where we discussed the risks
and benefits of tracheostomy. It was the feeling of our Team
that tracheostomy offers the best option for this patient at
this time given the fact that he has not responded to
aggressive attempts at medical management. The parents have
understood the reasons for this procedure and have been
informed; questions have been answered and they are amenable
to this option for care. We have notified Otolaryngology as
well, they have scheduled the surgery but they have yet to
obtain consent but the plan is for them to do so with the aid
of a translator. He is being transferred to [**Hospital3 18242**] for the placement of a tracheostomy on [**1-29**].
10. OTHER: He has not received hepatitis B vaccination or
his 2 month immunizations yet.
CONDITION ON DISCHARGE: Guarded.
DISCHARGE DISPOSITION: To [**Hospital3 1810**] for
tracheostomy placement.
PRIMARY PHYSICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 37232**], M.D. Dr. [**First Name (STitle) **] has
been kept informed of [**Known lastname 26524**] condition while at [**Hospital1 1444**].
CARE RECOMMENDATIONS AT DISCHARGE:
A. Nutrition: The infant is receiving 130 cc. per kilo per
day of PE32 fortified with ProMod.
B. Medications:
1. Ranitidine 4 mg pg q. eight hours.
2. Metoclopramide 0.2 mg pg q. eight hours.
3. Phenobarbital 10 mg pg q. day.
4. Ferinsol 0.2 cc. pg q. day.
5. Aldactone 4.2 mg pg daily.
6. Diuril 45 mg pg q. 12 hours.
7. Potassium phosphate 2 millimoles pg q. 12 hours.
8. Potassium chloride, 2 mEq pg q. 12 hours.
9. Sodium chloride 2 mEq pg q. 12 hours.
10. Vitamin E 5 International Units pg daily.
DISCHARGE DIAGNOSES:
1. History of Surfactant deficiency, progressed to severe
chronic lung disease.
2. History of hydrothorax, resolved.
3. History of medical necrotizing enterocolitis, resolved.
4. History of [**Known lastname 37228**] tracheitis/pneumonia, treated for
14 days.
5. Patent ductus arteriosus status post medical closure with
Indomethacin.
6. Presumed sepsis, resolved.
7. Persistent direct hyperbilirubinemia of unknown etiology.
8. Gastroesophageal reflux disease.
9. Resolved left Grade III intraventricular hemorrhage.
10. Retinopathy of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Name8 (MD) 37234**]
MEDQUIST36
D: [**2103-1-26**] 16:11
T: [**2103-1-26**] 16:34
JOB#: [**Job Number 37235**]
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29,601
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34682
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Discharge summary
|
report
|
Admission Date: [**2135-9-9**] Discharge Date: [**2135-9-23**]
Date of Birth: [**2062-2-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
VT storm, transfer from OSH
Major Surgical or Invasive Procedure:
VT ablation x 2
[**Company 1543**] Virtuoso dual chamber pacemaker implantation
Intubation/extubation
Central venous line placement
External defibrillation
History of Present Illness:
Mr. [**Known lastname 66402**] is a 73 yo male with a h/o CAD, CHF, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], AICD, CKD and atrial fibrillation who presented to [**Hospital1 **]
with a complaint of feeling lightheaded. He was shocked at home
x1 on the day prior to presentation and was evaluated by his
Cardiologist Dr. [**First Name (STitle) 1075**] who found him to have multiple episodes of
monomorpic VT which were stopped with ATP and defibrillation x
1. His Toprol was increased.
.
The following evening , patient experienced multiple episodes of
lightheadedness each lasting for seveal seconds. He reports
three syncopal episodes. The first episode occurred while
standing in the kitchen, and he fell and struck his head as a
result. A second episode occurred while in the seated position.
And the third episode occurred while in bed.
.
On arrival to [**Hospital1 **], he was started on an amiodarone drip
for management of recurrent episodes of VT. He had a
self-limited episode of VT, HR 160, in the [**Hospital1 **] ED. A CT
scan of his head was performed, which was negative for acute
bleed. He was then transferred to [**Hospital1 18**] for further management.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, or palpitations. He endorses intermittent
lightheadedness for approximately the past two weeks.
Past Medical History:
Atrial fibrillation, anticoagulated on coumadin
s/p AICD in abdomen
Renal insufficiency
Severe TR & MR
Cardiomyopathy
CAD
NIDDM
s/p MV reconstruction
CAD s/p CABG
s/p AAA repair
Hypertension
Dyslipidemia
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse but he endorses
occasional consumption..
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 98.4, BP 134/80, HR 74, RR 24 , O2 100% on 3L NC
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
irregularly, irregular. Normal S1, S2. No S4, no S3. [**3-31**]
holosystolic murmur.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. Abdominal ICD intact.
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; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
[**2135-9-9**] 04:02PM PT-30.4* PTT-37.5* INR(PT)-3.1*
[**2135-9-9**] 04:02PM PLT COUNT-199
[**2135-9-9**] 04:02PM NEUTS-77.7* LYMPHS-13.8* MONOS-7.5 EOS-0.5
BASOS-0.5
[**2135-9-9**] 04:02PM WBC-8.8 RBC-4.36* HGB-14.6 HCT-42.3 MCV-97
MCH-33.6* MCHC-34.6 RDW-15.4
[**2135-9-9**] 04:02PM TSH-1.0
[**2135-9-9**] 04:02PM CALCIUM-9.4 PHOSPHATE-4.2 MAGNESIUM-1.9
[**2135-9-9**] 04:02PM estGFR-Using this
[**2135-9-9**] 04:02PM GLUCOSE-94 UREA N-59* CREAT-2.2* SODIUM-136
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-21* ANION GAP-19
Echo ([**2135-9-10**]): The atria are markedly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is severe global left ventricular hypokinesis (LVEF =
10-15%). The estimated cardiac index is depressed
(<2.0L/min/m2). The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. A mitral valve
annuloplasty ring is present. The transmitral gradient is normal
for this prosthesis (though may be underestimated given severe
LV dysfunction). Moderate (2+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is at least moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
ASSESSMENT/PLAN: 73 yo male with h/o CAD, CHF, ICD who p/w VT
storm on [**9-9**], s/p bedside pacer placement and requiring
intubation-- had guidant pacer in place; extubated, permanent
pacer with atrial sensing placed.
.
# Rhythm: the patient was admitted initially for VT storm at an
outside hospital, was stable on a lidocaine drip with
intermittent VT in CCU. Patient had a VT ablation, was deemed
there were too many foci to ablate all areas of automaticity,
though some foci were ablated. On [**2135-9-9**], patient presented
with refractory VT storm, implanted ICD at the time was not
firing adequately, patient was internally shocked via pacer
interrogation over 6 times, VT was refractive. Patient
restarted on lidocaine and amiodarone drips, femoral line was
placed, patient needed to have bedside pacer placement (atrial
sensor). The patient was intubated and given fluids, required
external defibrillation that night. The next day, the patient
was taken for a repeat VT ablation, femoral artery was lacerated
and required vascular surgery repair. Decreased Hct required
frequent blood transfusions. Patient was taken back to CCU, had
no episodes of VT, Hct was stable, was extubated, and a
permanent atrial sensing pacemaker was placed. The patient was
placed on mexilitene and quinidine sulfate.
.
# Pump: EF previously documented as 20% with LV dysfunction,
possibly with shocked heart after procedures, the patient was
continued a beta blocker and switched to Toprol XL.
.
# Valves: Recent ECHO ([**2135-9-10**]) shows moderate MR, severe TR,
no interventions were done.
.
# CAD/Ischemia: No evidence of active ischemia, the patient had
continued his beta-blocker as tolerated, as well as his Zetia.
.
# Groin bleed s/p catheterization: The patient had a decrease
in Hct which required blood transfusions, a subsequent CT pelvis
showed no RP bleed, Hct was stable before discharge, was given a
unit of blood prior to discharge solely because existing stable
Hct was lower than admission Hct.
.
# Renal insufficiency: Pt. presented with cr at 2.2, now at
1.5, diuretics were held for most of stay, but half dose of home
lasix was restarted prior to discharge due to stable and
decreasing Cr.
.
# HTN: had been on metoprolol tartrate and then toprol XL prior
to discharge.
.
# DM: Pt complaining of fingersticks. Regularly on glyburide,
placed on glyburide prior to discharge.
Medications on Admission:
Furosemide 20 mg [**Hospital1 **]
Glyburide 2.5 mg daily
Toprol XL 150 mg daily (50 mg in morning and 100 mg in evening)
Zetia 10 mg daily
Coumadin 4 mg 6 days/week, 2 mg 1 day/week
Lisinopril 2.5 mg daily
Discharge Medications:
1. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable [**Hospital1 **]:
One (1) ML Injection ASDIR8 (ASDIR).
2. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed.
3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ezetimibe 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Mexiletine 150 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q12H (every
12 hours).
9. Quinidine Gluconate 324 mg Tablet Sustained Release [**Last Name (STitle) **]: One
(1) Tablet Sustained Release PO Q8H (every 8 hours).
10. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
12. Cephalexin 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Glyburide 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
15. Warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM.
16. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
18. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3549**]
Discharge Diagnosis:
Ventricular tachycardia
Congestive heart failure
Groin bleed
Acute renal failure
Discharge Condition:
stable, eating, drinking, voiding, and eating well.
Discharge Instructions:
You were admitted from an outside hospital for having an
abnormal heart rhythm (called ventricular tachycardia, or VT).
You had some bouts of the VT in CCU, were placed on
antiarrhythmic medication, and had a surgery which involved
ablating areas of your heart which were causing the rhythm. You
subsequently went into more VT in the unit, at which point you
were shocked through your internal pacemaker with the doctor's
help, but the arrhythmia did not resolve. As a result, we had
to place a temporary bedside pacemaker, and you underwent
another surgery to remove areas of your heart which might be
causing the arrhythmia but could not be seen the first time.
During this time you were placed on a ventilator to breath.
After these procedures, you were removed from the ventilator,
and had another procedure to give you a permanent new pacemaker.
You currently have appointments scheuled at the device clinic
at [**Hospital3 **] in one week and the device clinic at Dr.[**Name (NI) 16071**]
office after that. Please attend both. Additionally, please
weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Please
adhere to 2 gm low-sodium, diabetic diet.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC
Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2135-9-28**] 2:30 p.m.
Provider: [**Name10 (NameIs) 676**] CLINIC AT DR.[**Last Name (STitle) **] OFFICE
Phone: [**Telephone/Fax (1) **]
[**2135-9-30**] at 2:30 PM
Completed by:[**2135-10-2**]
|
[
"428.22",
"998.12",
"427.1",
"250.00",
"428.0",
"412",
"585.9",
"425.4",
"424.0",
"414.00",
"272.4",
"V45.81",
"403.90",
"427.31",
"E879.8",
"V58.61",
"276.2",
"584.9",
"424.2",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"37.34",
"37.27",
"99.04",
"96.04",
"37.78",
"96.71",
"37.94",
"37.26",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
9758, 9854
|
5126, 7532
|
343, 501
|
9979, 10033
|
3738, 5103
|
11263, 11549
|
2725, 2807
|
7790, 9735
|
9875, 9958
|
7558, 7767
|
10057, 11240
|
2822, 3719
|
276, 305
|
529, 2316
|
2338, 2544
|
2560, 2709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,705
| 116,885
|
51451
|
Discharge summary
|
report
|
Admission Date: [**2114-1-25**] Discharge Date: [**2114-2-3**]
Date of Birth: [**2036-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
77M with hx of COPD, recent admit for COPD flare, ARF (d/c
[**1-20**]), afib, CHF sent to ED from [**Hospital1 1501**] with severe shortness of
breath and desaturation to 86%. Pt states that this am, he woke
up and was feeling well. He got up to go the bathroom but needed
to take his oxygen off because it would not reach. When he got
back from the bathroom, he was severely short of breath. He put
his oxygen back on but it did not help. He states that he could
hear himself wheezing. Later, he again got up to go to the
bathroom and had to take off his O2. Once again, he became
severely short of breath. This time, he sat in his chair because
that makes his breathing better but his O2 does not reach to the
chair. He felt very short of breath and [**Doctor Last Name **] for his nurse. His
O2 sat was checked and found to be 86% on RA. Nursing home notes
state that pt has been coughing up blood tinged sputum. pt
states he has a chronic cough productive of dark brown sputum.
Her cannot walk more than 3 feet without stopping to rest. He
denies chest pain, palpitations.
.
In ED, CXR showed RUL pneumonia and pt was given levaquin and
nebs.
Past Medical History:
* COPD: no PFTs on record, on home O2 3L/m for past 2 weeks
* Interstitial lung disease
* atrial fibrillation (formerly on coumadin; stopped during last
admission)
* CHF: last echo [**12-31**] with LVEF >55%, 2+ MR, 3+ TR, mild AV
stenosis, severe pulm art HTN
* severe pulm art HTN by echo
* DM type II
* CRI: baseline creat 1.6
* BPH
* known bladder mass since [**2108**]
* ? lung mass
* anemia
Social History:
lives with his wife in a 2 story house but is now at a [**Hospital1 1501**] since
recent hospitalization; smoked 150 pack-years, quit 7 years ago;
formerly worked in a battery factory and may have been exposed
to hazardous chemicals during this time; has a h/o asbestos
exposure; no alcohol or illicit drug use. One daughter lives
down the street.
Family History:
Father with CAD.
Physical Exam:
temp 98.2, BP 130/60, HR 102, R 20, O2 94% 4L; wt 187lbs
Gen: NAD, pleasant; moderate resp distress after moving about in
bed; AO x 2
HEENT: EOMI, MMM; +accessory muscle use with resp distress
Neck: no JVD, no bruit
CV: tachy, irreg irreg; difficult to ascultate heart sounds due
to breath sounds; no murmurs detected
Chest: diffuse exp wheezes with prolonged exp phase; crackles at
bilateral bases
Abd: +BS, soft, mildly distended, nontendner; multiple bruises
Ext: venous stasis skin changes; 2+ DP
Skin: multiple abrasions on arms, abdomen, lower ext; on LLE,
4cm area of raw skin; on RLE, 3cm area of raw skin; on top of
right foot, large area of raw skin, tender
Pertinent Results:
[**2114-1-25**] 02:28PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-FEW
EPI-0
[**2114-1-25**] 02:28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-1-25**] 02:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2114-1-25**] 04:05PM PLT COUNT-278
[**2114-1-25**] 04:05PM NEUTS-83* BANDS-2 LYMPHS-3* MONOS-9 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2*
[**2114-1-25**] 04:05PM WBC-16.5*# RBC-3.14* HGB-9.3* HCT-27.5*
MCV-88 MCH-29.8 MCHC-33.9 RDW-18.6*
[**2114-1-25**] 04:05PM CK-MB-4 cTropnT-0.05* proBNP-969*
[**2114-1-25**] 04:05PM CK(CPK)-144
[**2114-1-25**] 04:05PM GLUCOSE-165* UREA N-45* CREAT-1.5* SODIUM-138
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2114-1-25**] 05:05PM LACTATE-1.2
.
Micro:
- BCX ([**2114-1-25**]) 4/4 bottles No Growth (final)
- Sputum cx ([**2114-1-27**]) contaminated with resp secretions
- Urine legionella Ag negative (final)
.
CXR ([**2114-1-30**]): There is no significant interval change in
multifocal patchy opacities bilaterally since multiple prior
exams, including chest CT dated [**2114-1-26**]. The pulmonary
vasculature is normal. There is no pneumothorax. Tiny
bilateral pleural effusions are slightly smaller than one day
earlier. The cardiac silhouette, mediastinal and hilar contours
are stable. The surrounding soft tissue and osseous structures
are unremarkable.
.
[**2114-1-26**] CT-chest w/o contrast.
IMPRESSION:
1. Poorly defined patchy and nodular airspace opacities seen
bilaterally suggesting multifocal pneumonia. Followup imaging
following treatment to document resolution is recommended.
2. Small bilateral pleural effusions, right greater than left.
3. Pleural calcifications bilaterally, suggesting prior asbestos
exposure.
4. Diffuse coronary artery calcifications and atherosclerotic
calcifications noted within the aorta.
.
ECHO [**2114-1-16**]:
The left and right atria are moderately dilated. The estimated
right atrial pressure is 16-20 mmHg. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal. The
right ventricular cavity is dilated. Right ventricular systolic
function is normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
mitral regurgitation jet is eccentric. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension.
.
EKG ([**2114-1-29**]): afib at 87 bpm, LAD, flattened T waves in I,
borderline IVCD with left bundyloid pattern; flipped T waves in
avL; no ST changes; overall unchanged from prior tracing [**2114-1-28**].
Brief Hospital Course:
77-yo-man w/ COPD, afib, diastolic CHF, anemia, CKD, admitted
with PNA. He had recently been discharged [**2114-1-19**] after a COPD
exacerbation treated with steroids. He is status post MICU stay
for hypoxia/respiratory distress.
.
# Hypoxia/Resp distress: This was though to be multifactorial,
due to PNA, COPD, and diastolic CHF. His acute dyspnea that
resulted in ICU transfer was felt due to volume overload, and
improved after diuresis with IV lasix. He was diuresed with IV
lasix, treated with IV antibiotics (see below), and round the
clock nebulizers.
.
# PNA: This was multilobar, noted both on chest x-ray and
non-contrast CT scan of the chest. Blood cultures had no growth
(final). Initial sputum culture was contaminated and repeat
grew oropharyngeal flora (not speciated). Initially he was
placed on levofloxacin, with vancomycin added 24 hours later.
The pneumonia was complicated by CHF and COPD exacerbations, so
his progress was slow. After 6 days of levofloxacin and 5 days
of vancomycin, his coverage was broadened to Zosyn instead of
Levofloxacin for presumed nosocomial pneumonia, acquired at the
nursing home. Vanco was continued. He remains afebrile and
his WBC normalized. He should receive an additional 7 days of
Vancomycin and Zosyn. He should follow up with Dr. [**Last Name (STitle) **] (his
primary care physician) in [**12-26**] weeks.
.
# COPD: The patient has no PFTs on record, but he has had a
constant O2 requirement since his last discharge on [**1-19**] of 3L
nasal cannula. His COPD was likely exacerbated by his PNA.
He was continued on Advair and placed on a more extended
prednisone taper (he should begin 20mg x 7 days on [**2114-2-4**],
tapered to 10mg daily for 7 days, then to 5mg daily x 7 days,
then off). He should continue nebulizers, atrovent q6H and
albuterol q4H). Once his acute flair has improved, he should be
referred for outpatient PFTs.
.
# Atrial fibrillation: The patient was rate controlled on
diltiazem which was continued. Coumadin was stopped during his
last admission due to hematuria. He was continued on aspirin.
B-blocker was not given as not to exacerbate his COPD.
.
# DM type 2: The patient was diet controlled until his prior
hospitalization in [**Month (only) 404**]. Since he has been on steroids, he
has required insulin. His fingersticks should be checked four
times a day. He should receive 20 units of NPH insulin each
morning and at bedtime, along with a sliding scale. His doses
of insulin may need to be decreased as his steroids are tapered.
.
# CRI: This is likely from HTN and DM nephropathy. The patient
was at baseline (creat ~ 1.6). His medications were renally
dosed. He has an appointment with his nephrologist in [**Month (only) 958**] as
noted on the discharge paperwork.
.
# Anemia - This is a combination of blood loss and chronic
inflammation. His baseline HCT 26-28. He had hematuria (see
below) and received 4 units total of packed RBCs. His Hct was
stable post transfusion, and he is currently at baseline Hct.
He was noted to have guiac positive stools, and will need
outpatient colonoscopy once his acute respiratory issues have
improved sufficiently. He was started on iron supplements.
.
# Hematuria: Pt has known bladder mass and BPH. Urology was
consulted during last admission, and recommended stopping his
coumadin and outpt Urology followup. Urology was re-consulted
for hematuria after foley insertion. They again recommended
outpatient workup and cystoscopy. Proscar was started as per
Urology and urine cytology sent (can be followed up by Urology
at the outpatient appointment.) The patient had continuous
bladder irrigation and his urine cleared. Bladder irrigation
was stopped 36 hours prior to discharge and the patient's urine
remained clear. On the day of discharge the foley was changed
from a 3-way to an 18-french 2 way catheter. Some hematuria was
again noted but this was felt due to the trauma of foley
replacement. He should follow up with Urology on [**2114-2-27**]
as previously scheduled. He can have a voiding trial in [**12-26**]
days as the catheter is no longer required for medical
management.
.
# LE Wounds: The patient had skin ulcers on his lower
extremities likely secondary to blisters and excoriation by
patient. There was good perfusion on exam and no evidence of
ulcer progression or superinfection. He was followed by the
wound nurse [**First Name (Titles) **] [**Last Name (Titles) 106675**] were changed daily (wound gel and
adaptic, covered with kerlix). The wound care should continue
at rehab and his wounds monitored closely for sign of infection.
.
# FEN: Diabetic/cardiac diet. Electrolytes were stable.
.
# Prophylaxis: SC heparin, bowel regimen, diet
.
# Full code
.
# Communication: [**Name (NI) **] [**Name (NI) 4427**] (Wife) [**Telephone/Fax (1) 106676**]
Medications on Admission:
* Ipraptropium
* Senna/colace
* Levalbuterol prn
* Prednisone 20mg until [**1-27**]
* Furosemide 40 mg qMWF
* Aspirin 325 mg qd
* Lisinopril 2.5 mg qd
* Diltiazem HCl 240 qd
* Tamsulosin 0.4 mg qhs
* Insulin SS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulized
treatment Inhalation Q4H (every 4 hours).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Diltiazem HCl 240 mg Tablet Sustained Release 24HR Sig: One
(1) Tablet Sustained Release 24HR PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. 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.
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) units Subcutaneous qAM.
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) units Subcutaneous at bedtime.
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
15. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
17. Piperacillin-Tazobactam Na 2.25 gm IV Q6H
18. Vancomycin HCl 1000 mg IV Q 24H
19. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: Then decrease dose to 10mg x 7 days, then 5mg x 7
days, then off.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for For pain with dressing changes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Pneumonia, nosocomial
2. COPD (Chronic Obstructive Pulmonary disease)
3. CHF (congestive heart failure)
.
Secondary:
1. Bladder Mass
2. Diabetes
3. Atrial Fibrillation
Discharge Condition:
Afebrile, breathing improved. Stable.
Discharge Instructions:
Please take all your medications as prescribed. You were
admitted with pneumonia and need another week of IV antibiotics.
You should continue to use oxygen (3L nasal cannula) at all
times).
.
Call your doctor or return to the hospital if you have fever,
shortness of breath, chest pain, or any other concerning
symptom.
Followup Instructions:
Please call your primary doctor, Dr. [**Last Name (STitle) **], for an appointment
within 1-2 weeks.
.
You should follow up with your kidney doctor, Dr. [**Last Name (STitle) **] as noted
below. You have an appointment with a urologist, Dr. [**First Name (STitle) **], on
[**2114-2-27**] as noted below for work up of your bladder mass.
.
Provider: [**Known firstname **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 6317**]
Date/Time:[**2114-2-27**] 10:15
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2114-3-8**] 9:00
Completed by:[**2114-2-3**]
|
[
"511.9",
"403.91",
"250.40",
"427.31",
"496",
"596.8",
"285.9",
"599.7",
"600.01",
"515",
"428.0",
"486",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13283, 13362
|
5980, 10839
|
334, 356
|
13586, 13626
|
3057, 5957
|
13996, 14660
|
2335, 2353
|
11100, 13260
|
13383, 13565
|
10865, 11077
|
13650, 13973
|
2368, 3038
|
275, 296
|
384, 1533
|
1555, 1953
|
1969, 2319
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,306
| 194,086
|
11635+11636
|
Discharge summary
|
report+report
|
Admission Date: [**2111-11-27**] Discharge Date: [**2112-1-19**]
Date of Birth: [**2061-12-9**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Shortness of breath and chest discomfort.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old
Hispanic woman who reports developing intermittent chest
discomfort described as substernal tightness with radiation
to the left arm sometimes related to activity and sometimes
not, also associated with shortness of breath. This chest
discomfort has been occurring more frequently in the recent
past week. She also reports near syncope when she climbs a
flight of stairs. All symptoms resolve with rest and
sublingual nitroglycerin. The patient was transferred to [**Hospital **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] from [**Hospital6 22197**] Center in
[**Location (un) 5583**] [**State 350**] where she underwent
echocardiographic evaluation and was found to have tight
aortic stenosis. She subsequently underwent a cardiac
catheterization also at Bay State, which demonstrated normal
coronary arteries, tight aortic stenosis and a possible
ascending aortic aneurysm. She is referred to [**Hospital **] [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **] for aortic valve replacement.
PAST MEDICAL HISTORY: 1. Rheumatic fever. 2. Noninsulin
dependent diabetes mellitus. 3. Hypertension. 4.
Hypercholesterolemia. 5. Asthma. 6. Status post
hysterectomy.
MEDICATIONS ON TRANSFER: Cardizem, nitropaste, insulin and
Paxil.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She smokes one pack per day. She lives with
her daughter [**Name (NI) **] whose phone number is [**Telephone/Fax (1) 36909**]. She
is Spanish speaking only.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs heart rate 60
and regular. Blood pressure 120/70. Respiratory rate 20.
General, Hispanic woman in no acute distress. HEENT is
unremarkable. Neck is supple. Bilateral carotid bruits with
no lymphadenopathy. Lungs are clear to auscultation. Heart
sounds 3/6 systolic ejection murmur. Abdomen is soft,
nontender, nondistended. No masses. Well healed vertical
midline incision. Extremities no clubbing, cyanosis or
edema. Good pulses throughout. No varicose veins.
Neurological cranial nerves II through XII grossly intact.
Alert, responsive and communicative.
LABORATORY DATA: Sodium 143, potassium 3.7, BUN 6,
creatinine 0.8, white count 4.9, hemoglobin 12.9, hematocrit
37.1, platelet count 222. Cardiac catheterization at Bay
State normal coronary arteries. Valve gradient per
echocardiogram also done at Bay State 65 mmHg with a mean and
115 mmHg for the peak. Normal ejection fraction of 70%.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] where she underwent preoperative
workup, which included a dental examination as the patient
states that she had not had a dental examination in quite
some time. The dental examination recommended teeth
extractions and on [**12-3**], the patient underwent dental
extractions times four. The patient also had a preoperative
cardiology consult as well as repeat cardiac catheterization.
Repeat catheterization showed clean coronaries with severe
AS, bicuspid aortic valve, hypertrophic cardiomyopathy, a
peak gradient of 115 and a mean gradient of 68, aortic valve
area 0.8 cm square. Post catheterization discussion centered
around degree of AS versus left ventricular outflow
obstruction and whether or not the patient could be treated
medically or she was best served undergoing an aortic valve
replacement. The decision was made by the cardiothoracic
team as well as cardiology that the patient did indeed need
to have her aortic valve replaced and on the [**12-5**]
the patient was brought to the Operating Room at which time
she underwent an aortic valve replacement. Please see the
operating report for full details.
In summary, the patient underwent an aortic root and valve
replacement with a #19 Carbomedics. It was a prolonged
procedure with a bypass time of two and a half hours and a
cross clamp time of two hours. Postoperatively, TEE showed
bileaflet prosthesis in aortic position well situated with an
aortic valve area of 1.5 cm squared and a gradient of 20
mmHg, severe tricuspid regurgitation, trace mitral
regurgitation with no dynamic outflow tract obstruction. The
patient was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. She did well in the
immediate postoperative period. She remained hemodynamically
stable, however, there was high chest tube output over the
course of the first 24 hours. She received 5 units of packed
red blood cells, 6 units of fresh frozen platelets,
cryoprecipitate and several liters of crystalloid. For these
reasons the patient was kept sedated and intubated throughout
postoperative day one. On postoperative day two the
patient's sedation was discontinued. She was weaned from the
ventilator and successfully extubated. She did, however,
fail a post extubation swallow test. On postoperative day
three the patient spiked a temperature to 102.8. She was pan
cultured at that time. She also became tachypneic and
required reintubation. A chest x-ray done with reintubation
showed a presumed aspiration pneumonia.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2112-1-19**] 08:51
T: [**2112-1-19**] 09:04
JOB#: [**Job Number 36910**]
Admission Date: [**2111-11-27**] Discharge Date: [**2112-1-19**]
Date of Birth: [**2061-12-9**] Sex: A
Service: CARDIOTHORACIC SERVICE
CHIEF COMPLAINT: Shortness of breath and chest discomfort.
HISTORY OF THE PRESENT ILLNESS: The patient is a 49-year-old
Hispanic woman transferred from [**Hospital6 22197**] Center in
[**Location (un) 5583**] to [**Hospital1 69**]. Prior
to had admission at [**Hospital6 22197**] Center she reports
having intermittent chest discomfort. She described a
substernal tightness with radiation to the left arm,
sometimes related to activity, sometimes not. It was also
associated with shortness of breath. Over the past week, she
has been experiencing the episodes of discomfort more often
with activity. She also reported near syncope after climbing
a flight of stairs. All symptoms reportedly resolved with
rest and/or nitroglycerin. While at [**Hospital6 22197**] Center
she underwent an echocardiographic evaluation. She was found
to have tight aortic stenosis. She subsequently underwent
cardiac catheterization, which demonstrated normal coronary
arteries a tight aortic stenosis with possible ascending
aortic aneurysm. She was referred to [**Hospital1 190**] for aortic valve replacement.
PAST MEDICAL HISTORY:
1. Rheumatic fever.
2. Noninsulin dependent diabetes mellitus.
3. Asthma.
4. Hypertension.
PAST SURGICAL HISTORY: History is significant for a
hysterectomy.
MEDICATIONS ON TRANSFER:
1. Cardizem.
2. Nitropaste.
3. Insulin.
4. Paxil.
ALLERGIES: The patient denied known allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient smokes one pack per day. She
lives with her daughter, [**Name (NI) **], whose phone # is
[**Telephone/Fax (1) 36909**]. The patient is Spanish-speaking only.
PHYSICAL EXAMINATION: Examination at the time of admission
revealed the following: Vital signs: Heart rate 70 and
regular, blood pressure 120/70, respiratory rate 20.
GENERAL: Hispanic woman communicating with the translator in
no acute distress. HEENT: Unremarkable. NECK: Supple with
bilateral carotid bruits. There was no lymphadenopathy.
LUNGS: Lungs were clear. HEART: Heart sounds with 3/6
systolic ejection murmur. ABDOMEN: Soft, nontender,
nondistended, no masses. There was a well healed vertical
midline incision. EXTREMITIES: No clubbing, cyanosis or
edema. Strong pulses, femoral, dorsalis pedis and posterior
tibial, no varicose veins. NEUROLOGICAL: The patient was
alert and conversant, moves all extremities. Cranial nerves
II to XII grossly intact.
LABORATORY DATA: Laboratory data revealed the following:
Sodium 143, potassium 3.7, BUN 6, creatinine 0.8, white count
5, hematocrit 37, platelet count 220,000. Cardiac
catheterization from [**Hospital6 22197**] Center demonstrated no
coronary artery disease. Echocardiogram at [**Hospital6 22197**]
Center showed the mean valve gradient to be 65 -mm of Mercury
and a peak gradient of 115 mmHg with a normal ejection
fraction of 70%. The patient was transferred to [**Hospital1 346**] for evaluation of aortic valve
replacement. Upon arrival at [**Hospital1 188**] the patient underwent preoperative workup, which
included a dental consultation. The dental consultation
recommended extraction of four teeth and on the [**12-3**] the patient had those four teeth extracted.
Preoperative workup also included a cardiology consultation.
The Department of Cardiology reviewed the cardiac
catheterization and echocardiogram data provided from [**Hospital6 22198**] Center. Following this review, the patient
underwent an additional cardiac catheterization. Repeat
cardiac catheterization showed severe aortic stenosis with a
bicuspid aortic valve, hypertrophic cardiomyopathy, peak
valve gradient of 115, mean of 68, and aortic valve area of
0.8-cm squared. Following the repeat cardiac
catheterization, the discussion between CT Surgery and
Cardiology centered around the degree of aortic stenosis
versus a left ventricular outflow tract obstruction.
Decision was then reached that the patient indeed need to
undergo aortic valve replacement. On [**12-5**], .she was
brought to the operating room at which time she underwent an
aortic valve replacement. Please see OR report for full
details.
In summary, the patient underwent an aortic root and valve
replacement with a #19 Carbomedics valve. This was a
prolonged procedure with a bypass times 2.5 hours and cross
clamp time of 2 hours. Postoperatively, the TEE showed
normal biventricular function, prosthetic valve in the aortic
position was well seated with normal leaflet function, mild
aortic insufficiency, aortic valve area of 1.5 -cm squared
with a gradient of 20-mm of Mercury with severe tricuspid
regurgitation and trace mitral regurgitation with no dynamic
outflow tract obstruction. For the operation, the patient
was transferred to the cardiothoracic Intensive Care Unit,
where in the initial postoperative care, she remained
hemodynamically stable on Levophed, Milrinone, and
Nitroglycerin. She did, however, have significant amount of
drainage from her mediastinal and pleural chest tubes. Over
the course of the first twenty-four hours she was treated
with five units of packed red blood cells, six units of FFP
cryoprecipitate and several liters of crystalloid. Given her
high-volume requirements, the patient was kept sedated and
intubated throughout the postoperative day #1. On
postoperative day #2, the patient's sedation was
discontinued. She was successfully weaned from the
ventilator and ultimately extubated. The cardioactive drugs
were weaned to off. She was, however, at that point, started
on a Labetalol drip for blood pressure control. Following
extubation, the patient failed the swallow study.
On postoperative day #3, the patient spiked a temperature to
102.8. She was pancultured at that time. She also had
periods of tachypnea requiring re-intubation. Chest x-ray,at
that time, revealed a presumed aspiration pneumonia. The
patient remained intubated on pressor-support ventilation
over the next several days. On postoperative #6, the patient
self extubated. She did well for the first twenty-four
hours, but on postoperative day #7, she required
re-intubation. The patient again did well with pressor
support wean. Over the next several days, attempt was made
at extubation again on postoperative day #10. The patient,
initially did well. However, after several hours of being
extubated, she again became tachypneic with worsening blood
gases. Attempt was made to use BiPAP to avoid reintubation,
however, this was unsuccessful and the patient was
reintubated five hours after extubation. The patient
required minimal ventilatory support following reintubation.
On postoperative day #14, she underwent a diaphragmatic
ultrasound to assess phrenic nerve injury. The ultrasound
was positive for phrenic nerve injury of questionable
etiology. At that time pulmonary medicine was consulted.
Their recommendation was to maintain the patient on
ventilatory support to give her diaphragms a chance to
recover. Given this scenario, the patient was then scheduled
to undergo a percutaneous tracheostomy and PEG placement. At
this point, the patient was also noted to have a small amount
of drainage from the lower pole of her sternum. At that time
the distal portion of the incision was opened. Tissue was
healthy, viable, and beefy red. Dressings were normal saline
wet-to-dry t.i.d. Cultures at that time revealed no growth.
The patient remained stable over the next several days. On
[**12-29**], the patient underwent a percutaneous
tracheostomy with a #8 [**Doctor Last Name 4726**] Tex and a percutaneous PEG
placement. Two days following PEG placement, the patient was
noted to have increasing abdominal tenderness around the PEG
site. She was also noted to have a slight elevation of her
white blood cell to 10.9 and the temperature to 101.0. She
was pancultured at that time. General Surgery was consulted
regarding the PEG-site placement. The patient was also
started on an antibiotic regimen of Vancomycin, Levofloxacin,
and Flagyl. The following day, [**1-1**], the patient
continued to complain of abdominal pain. At that time she
underwent an abdominal CAT scan. CAT scan showed
subcutaneous extravasation of contrast; etiology unclear.
Plans were made to remove the tube at that time. She was
returned to the operating room with General Surgery, where at
that time the patient underwent exploratory laparotomy,
removal of her G-tube, closure of her gastrostomy site,
insertion of jejunostomy tube and insertion of Penrose drain
to drain an abdominal wall abscess. Since that time,
patient's white count has returned to [**Location 213**]. Fever has
resolved and the abdominal pain has diminished. The
patient's pulmonary status over the past two weeks has
improved. At this point, she is maintained on trach collar
during the day, with short periods of pressor-support
ventilation during the overnight hours. The patient's
transfer will be postoperative day #43. The patient remained
hemodynamically stable. Respiratory status continued to show
gradual improvement. Infectious Disease status: The patient
remains on Vancomycin, Levaquin, and Flagyl for a one-month
course. She is tolerating tube feeds at goal rate. She is
ambulating with minimal assistance around the Intensive Care
Unit. At this time, it has been decided that she is stable
and ready for transfer to [**Hospital3 **] for
continuing postoperative care and cardiac respiratory
rehabilitation. At the time of transfer, the patient's
physical examination was as follows: Temperature 99, heart
rate 110 to 115 sinus tachycardia, blood pressure 117/60,
respiratory rate 24, oxygen saturation 99% on 40% trach
collar.
In the overnight hours, the patient has periods where she is
maintained on CPAP 40% with PEEP and pressure support. Tidal
volumes of that ventilatory support ranged between
300 and 400 cc.
LABORATORY DATA: Laboratory data revealed the following:
White count 13.3, hematocrit 32, platelet count 165, sodium
136, potassium 3.8, chloride 97, CO2 30, BUN 11, creatinine
0.6, glucose 132, INR 2.7.
PHYSICAL EXAMINATION: The patient was alert and oriented.
HEENT: Pupils equal, round, and reactive to light. Neck was
supple. Trach in place. Breath sounds revealed fine
rhonchi. HEART: Heart sounds tachycardiac, S1 and S2, no
murmurs. ABDOMEN: Abdomen was soft, with staples. The
wound was clean and dry. Left PEG site is granulating.
EXTREMITIES: Warm with no edema and good pedal pulses.
Sternum is stable with a small distal incision. There was
some fibrinous material at the base of the incision,
otherwise, beefy red.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg b.i.d.
2. Zinc sulfate 220 mg q.d.
3. Vitamin C 500 mg b.i.d.
4. Lopressor 75 mg b.i.d.
5. Flagyl 500 mg t.i.d.
6. Vancomycin 1 gram q.12h.
7. Levaquin 500 mg q.d.
8. Prevacid 30 mg q.d.
9. Nystatin powder at the PEG site t.i.d..
10. Paxil 50 mg q.d.
11. NPH insulin 25 units q.a.m. and 20 units q.p.m.; regular
insulin sliding scale q.a.c. and q.h.s.
12. Coumadin 2.5 to 5 mg q.d. for a goal INR of 3.0.
P.R.N. MEDICATIONS:
1. Tylenol 650 q.6h.p.r.n.
2. Motrin 600 q.6h.p.r.n.
3. Ativan 0.5 mg b.i.d.p.r.n.
Abdominal dressing is normal saline wet-to-dry t.i.d.. Chest
dressing is Santyl ointment covered with dry sterile dressing
b.i.d.
Tube feeds are Promote with fiber at 50 cc per hour.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis status post aortic valve replacement with
a #19 Carbomedics mechanical valve.
2. Rheumatic fever.
3. Noninsulin dependent diabetes mellitus.
4. Asthma.
5. Hypertension.
6. Idiopathic hypertrophic subaortic stenosis.
7. Status post percutaneous tracheostomy and PEG placement.
8. Status post exploratory laparotomy with closure of PEG
site and jejunostomy tube placement.
9. Status post hysterectomy.
Th[**Last Name (STitle) 1050**] was discharged to [**Hospital3 **]. She
is to have followup with Dr. [**Last Name (Prefixes) **] in one month. She
is to followup with her cardiologist on discharge from
[**Hospital3 **] and followup with her primary care
physician upon discharge from [**Hospital3 **].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2112-1-19**] 09:43
T: [**2112-1-19**] 10:00
JOB#: [**Job Number 12312**]
|
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24,118
| 180,453
|
21780
|
Discharge summary
|
report
|
Admission Date: [**2119-9-25**] Discharge Date: [**2119-10-11**]
Date of Birth: [**2052-4-26**] Sex: F
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
transferred from ECHO lab after finding pericardial effusion.
Major Surgical or Invasive Procedure:
Pericardiocentesis with temporary drain
History of Present Illness:
HPI: 67-year-old w/ newly diagnosed metastatic non-small cell
lung cancer, originally called in to ED after finding of
pericardial effusion on ECHO. SHe was admitted to the [**Hospital Unit Name **]
service on [**2119-9-25**] for pericardial effusion and went to cath for
drainage of 240 cc of serous fluid with relief of tamponade. A
drain was placed in the pericardial sac, with 9 cc of outpu per
discussion with the CCU resident. F/u echocardiograms showed no
pericardial effusion. The drain was removed [**2119-9-29**] and she was
transferred to the OMED for further oncologic mangement. MICU
course c/b [**Month/Day/Year **] and rising WBC count, now being treated for
PNA.
Further background history prior to admission is as follows.
The pt was in her usual good state of health until mid-[**Month (only) 205**] when
she noted a dry [**Month (only) **], increased fatigue, and decreased
appetite. In early [**Month (only) 216**], she had a chest x-ray, which showed
multiple pulmonary nodules, followed by CT scan of her chest at
[**Location (un) 620**], which confirmed multiple pulmonary nodules, bilateral
pleural effusions, and a possible pericardial effusion. A
subsequent lymph node biopsy from the right lateral neck on
[**2119-9-14**] and showed poorly differentiated non-small cell
carcinoma consistent with lung primary.
Per the admission note ROS: the patient has continued to [**Date Range **]
sometimes at night, often during the day. The only thing that
she has been taking is an over-the-counter regimen. She may have
tried Tessalon but not clear on the dose. She had a mammogram a
year ago that was fine. She notes no breast problems or past
history of breast issues. Denies cp/palpitaitions. No pleuritic
CP. Mild inc in SOB w/ exertion on one flight of stairs. No
orthopnea/PND. Denies f/chills/n/v.
Current ROS on transfer to OMED:
Past Medical History:
BSO-TAH for carcinoma in situ of the cervix in [**2109**]
osteoporosis
anxiety +/- depression
Social History:
She has been a long-term smoker at least 45 years of often over
a
pack a day. She quit several years ago but admitted that she
still continues to smoke from time to time. She lives by
herself in [**Location (un) 701**]. She is divorced and her ex-husband is
deceased. She has two grown children,
both live in [**State 1727**]. Two pregnancies, two deliveries, first
pregnancy at age 22 or 23. She was a former heavy drinker. It is
not clear whether she was an alcoholic but she quit drinking in
[**2114**]. She had worked prior to her marriage as a stenographer.
Physical Exam:
V- 97.2, 98/65, 92, 22, 96% on 3L, pulsus - 8
gen - NAD
HEENT - MM dry, PERRLA, EOMI
neck - supple, no JVD
lungs - diffuse expiratory wheezes, decreased BS with dullness
to percussion b/l, L>R.
c/v - RRR, no m
abd - s/nt/nd, NABS
extr - no c/c/e
neuro - A+Ox3, no focal signs
EKG: NSR at 90 bpm, nl axis, meets low volatage criteria, no ST
or TW changes. No change from prior.
Pertinent Results:
[**2119-9-25**] 08:18PM K+-4.4
[**2119-9-25**] 08:10PM GLUCOSE-103 UREA N-16 CREAT-0.8 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-23 ANION GAP-20
[**2119-9-25**] 08:10PM CK(CPK)-61
[**2119-9-25**] 08:10PM CK-MB-NotDone cTropnT-<0.01
[**2119-9-25**] 08:10PM WBC-8.7 RBC-3.90* HGB-12.0 HCT-35.2* MCV-90
MCH-30.7 MCHC-34.0 RDW-12.3
[**2119-9-25**] 08:10PM NEUTS-73.5* LYMPHS-13.1* MONOS-6.7 EOS-5.9*
BASOS-0.8
[**2119-9-25**] 08:10PM PLT COUNT-448*
[**2119-9-25**] 08:10PM PT-13.3 PTT-24.4 INR(PT)-1.1
Echo [**9-25**]:
Impression: Large pericardial effusion with right atrial
collapse detected. The right ventricle appears compressed, but
no clear diastolic collapse is seen. Cannot fully exclude
tamponade physiology. Clinical correlation is required.
Echo [**9-26**], [**9-28**]:
Overall left ventricular systolic function is normal
(LVEF>55%). Right
ventricular systolic function is normal. No aortic
regurgitation is seen. No
mitral regurgitation is seen. There is a trivial pericardial
effusion. There
is echo dense material within the pericardial space consistent
with blood,
inflammation or other cellular elements.
Compared with the findings of the prior study (tape reviewed)
of [**2119-9-26**],
there has been no significant change.
Brief Hospital Course:
67F newly-diagnosed NSCLCa presented originally for
echocardiogram to evaluate shortness of breath, found to have
significant tamponade.
1) Pericardial effusion: Catheterization revealed a significant
pericardial effusion with tamponade. Pericardiocentesis was
successfully performed in the catheterization lab and a drain
was placed. The patient did well and was taken to the CCU for
continued monitoring. Following the procedure the drain
continued to put out 9cc over 18 hours. Repeat echocardiogram
two days following pericardiocentesis revealed no reaccumulation
of fluid. The drain was removed on the second day following
percardiocentesis and the patient was transferred from the CCU
to the OMED service. Patient continued to do well following
removal of the drain with pulsus paradoxicus ranging between
5-7mmHg.
On therapeutic cath, found to have sig tamponade -> s/p
pericardiocentesis with post-procedure drain. Patient monitored
in CCU given post-procedure drain with limited (9 cc) output in
18 hrs. Pt transferred to OMED for further oncologic mangement.
MICU course c/b [**Date Range **] and rising WBC count, treated for PNA,
completed course of antibiotics.
2) Shortness of breath: Despite successful pericardiocentesis,
patient continued to have shortness of breath and supplement
oxygen requirement. Chest xray revealed a number of
nodularities likely due to the patient's NSCLC disease, however,
a pneumonia could not be excluded. Therefore, the patient was
started on antibiotic therapy for a presumed pneumonia. She
completed a 11 day course of antibiotics.
On CXR she was noted to have an enlarging left sided pleural
effusion. On [**2119-10-3**] she had an ultrasound guided
thoracentesis, at which time 1200mls of fluid were removed. Her
SOB improved after the thoracentesis. Over the next several
days she continued to have gradually increasing SOB. A repeat
CXR on [**2119-10-9**] showed re-accumulation of her left sided pleural
effusion and worsening of her right sided pleural effusion. She
had a repeat ultrasound guided thoracentesis on [**2119-10-10**] at which
time 1050ml of fluid was removed prior to the proceedure being
terminated for [**Date Range **].
3) NSCLCa: She was started on Chemotherapy while in house for
her NSCLCA. Her first course of Taxol/Carboplatinum was on
[**2119-9-29**], she tolerated the treatment well. She had neutropenia
requiring her to be placed on precautions and treated with GCSF.
Her WBC count resolved with GCSF treatment. She had a dosage
of Taxol chemotherapy on [**2119-10-9**]. Social work has been envolved
with her discussing coping and her diagnosis. On discharge she
was started on Megace to encourage increased PO intake.
4) [**Date Range **]: While in the hospital she had lots of problems with
[**Name2 (NI) **] productive of white sputum. She was treated with tesillon
perles, robitussin w/ codeine, hydrocodone syrup, and cepacol
losenges.
5) Depression/Anxiety: While in the hospital she was continued
on her outpatient regimen of Buspar, Paxil CR, and Ativan/Xanax
as needed.
6) Oral thrush: While in the hospital she was found to have some
oral thrush and was started on Nystatin swish and swallow.
7) Hypotension/decreased Urine output/dehydration: After coming
out of the CCU she was found to be hypotensive. She responded
well to fluids. Several days later she was orthostatic while
ambulating with PT. She responded again to IV fluids. It was
determined that she had very poor PO intake of fluids and food.
She was started on IV fluid and developed worsening edema. The
fluids were held as her albumin was low and the fluid was not
remaining intravascular. She has been encouraged to take
adequate fluid and food PO. She responds well to bolus fluids
as needed. Nutrition evaluated her and advised her on adequate
PO intake.
8) Code status: On this admission the patient had a
conversation with Dr. [**Last Name (STitle) 3274**] at which time her code status was
changed to DNR/DNI.
Medications on Admission:
MEDICATIONS: Evista, Cipro which she is finishing for a UTI,
Ambien for sleep, Wellbutrin, Paxil, Xanax, niacin for
cholesterol, and iron for some anemia in the past.
Discharge Medications:
1. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime).
2. Raloxifene HCl 60 mg Tablet Sig: One (1) Tablet PO qd ().
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
4. Paxil CR 37.5 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO qd ().
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
7. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
11. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
15. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed for
constipation.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. Chlorpheniramine-Hydrocodone 8-10 mg/5 mL Suspension, Sust.
Release 12HR Sig: Five (5) ML PO QID (4 times a day) as needed.
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day) as needed for oral thrush.
23. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
24. Morphine Sulfate 10 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed for dyspnea.
25. Ondansetron HCl 2 mg/mL Solution Sig: One (1) Intravenous
Q6H (every 6 hours) as needed for nausea.
26. Megace Oral 40 mg/mL Suspension Sig: Four Hundred (400) mg
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] Center - [**Location (un) 701**]
Discharge Diagnosis:
1. Non-small cell lung cancer
2. Depression
3. Pleural effusion
Discharge Condition:
Stable, needs some help with ADLs secondary to shortness of
breath.
Discharge Instructions:
See Dr. [**Last Name (STitle) 3274**] in Clinic [**Hospital Ward Name 23**] 9 on [**Hospital Ward Name 766**] [**10-16**] at
10:00 AM
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3274**] [**Name (STitle) 766**] [**10-16**] at 10:00 AM
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"458.0",
"196.0",
"276.5",
"288.0",
"253.6",
"162.8",
"486",
"112.0",
"423.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"34.91",
"37.0",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
11461, 11542
|
4725, 8743
|
374, 415
|
11653, 11722
|
3429, 4702
|
11904, 12115
|
8961, 11438
|
11563, 11632
|
8769, 8938
|
11746, 11881
|
3030, 3410
|
273, 336
|
443, 2314
|
2336, 2432
|
2448, 3015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,544
| 148,900
|
53516
|
Discharge summary
|
report
|
Admission Date: [**2138-5-19**] Discharge Date: [**2138-5-27**]
Date of Birth: [**2059-7-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
asymptomatic -referred for echocardiogram to evaluate murmer
during evaluation for right knee arthroscopy.
Major Surgical or Invasive Procedure:
[**2138-5-19**]:
1. Coronary artery bypass graft x3: Left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to obtuse marginal and posterior descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
3. Aortic valve replacement with a size 27-mm St. [**Male First Name (un) 923**] Epic
tissue valve.
4. Ascending aorta and hemiarch replacement with a 32-mm
Gelweave graft under deep hypothermic circulatory arrest.
History of Present Illness:
78 year old male who was referred for echocardiogram to evaluate
murmur during evaluation for right knee arthroscopy.
Echocardiogram on [**2138-4-7**] revealed EF 60%, moderate aortic
stenosis with [**Location (un) 109**] 1.0cm2, peak gradient 41/26 mmHg and dilated
aorta measuring 4.4 cm at the sinuses of valsalva, 5.6 cm at the
ascending aorta and 4.6 cm at the transverse aorta. He was
referred for cardiac cath and was found to have three vessel
disease. Recently underwent Chest CT which confirmed dilated
aorta. He is now referred to cardiac surgery for
CABG/AVR/Aortic Aneurysm repair.
Past Medical History:
Past Medical History:
Diabetes
Hypertension
Hyperlipidemia
Glaucoma
Patellofemoral arthritis (R)
Carpal tunnel syndrome
Bells Palsy 50 years ago
Past Surgical History:
Left shoulder surgery
Tonsillectomy
Bells palsy surgery x2
Social History:
Lives with: Wife
Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 110010**]
Occupation: Retired bricklayer
Cigarettes: Smoked no [] yes [X] Hx:quit 35 years ago, smoked
2ppd X 40 years
Other Tobacco use: Denies
ETOH: < 1 drink/week [x] [**2-11**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Last Dental Exam: Edentulous
Family History:
Family History: non contributory
Race: Caucaisan
Physical Exam:
Pulse: 89 Resp: 16 O2 sat: 99/RA
B/P 147/87
Height: 6'1" Weight: 222 lbs
Admission Exam:
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [] see below for neuro findings
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**3-11**] syst
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema-none
Varicosities:
mild->mod L>R
Neuro: Left facial droop/facial paralysis from Bell's palsy.
Otherwise 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: - Left: -
Pertinent Results:
[**2138-5-19**] Intra-op TEE:
Conclusions
PRE-BYPASS:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. 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. Overall left ventricular
systolic function is normal (LVEF>55%).
The aortic root is midly dilated at the sinus level. The
ascending aorta is severely dilated. The aortic arch is mildly
dilated. The descending thoracic aorta is mildly dilated. There
are simple atheroma in the descending thoracic aorta.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
mild aortic valve stenosis (valve area 1.2cm2). Mild (1+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
There is a very small pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
POST-BYPASS:
The patient is AV paced on epinephrine, norepinephrine &
phenylephrine infusions. The patient was subsequently weaned to
low dose epi & norepi while still paced. There is a well seated
bioprosthetic valve in the aortic position. There is a very
small jet noted near the suture line in the area of the left or
non cusp seen in the deep transgastric position only. There is
no AR. Peak & Mean gradients are 13mmHg & 6mmHg, respectively.
The remaining valves are unchanged. Biventricular function is
maintained. There is acoustic shadowing consistent with a graft
in the ascending aortic position. The remaining aorta is intact.
[**2138-5-26**] 04:42AM BLOOD WBC-10.1 RBC-3.02* Hgb-9.1* Hct-28.3*
MCV-94 MCH-30.3 MCHC-32.3 RDW-13.8 Plt Ct-367#
[**2138-5-19**] 12:59PM BLOOD WBC-12.7* RBC-2.96*# Hgb-8.9*# Hct-27.1*#
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.3 Plt Ct-189
[**2138-5-27**] 04:46AM BLOOD PT-13.5* INR(PT)-1.3*
[**2138-5-19**] 12:59PM BLOOD PT-16.2* PTT-31.2 INR(PT)-1.5*
[**2138-5-26**] 04:42AM BLOOD Glucose-160* UreaN-33* Creat-1.1 Na-133
K-4.9 Cl-96 HCO3-26 AnGap-16
[**2138-5-19**] 02:51PM BLOOD UreaN-13 Creat-0.9 Na-139 K-5.0 Cl-109*
HCO3-22 AnGap-13
Brief Hospital Course:
The patient was brought to the Operating Room on [**2138-5-19**] where
the patient underwent AVR (27mm tissue), CABG x 3 Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to obtuse marginal and posterior descending
arteries/ Ascending Aorta replacement and hemiarch replacement
with a size 32-mm Gelweave graft under deep hypothermic
circulatory arrest with Dr. [**First Name (STitle) **] (see operative note for
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. He was
bradycardic and intermittantly in a junctional rhythm
post-operatively.POD#3 he went into rate controlled atrial
fibrillation. He was treated with Amiodarone and beta-blocker.
He became bradycardic and required Vpacing. Of note preop his
rhythm was first degree AV block. Episodes of 2 sec pauses were
noted. AV nodal agents were discontinued. EP was consulted. As
recommended, Anticoagulation for paroxysmal afib was initiated
and no nodal agents used. He was gently diuresed towards preop
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued per protocol, without complication. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD #8
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged to [**Hospital **] health Center rehab in good condition
with appropriate follow up instructions.
Medications on Admission:
Medications at home:
Lisinopril 10 mg daily
Tamsulosin 0.4 mg daily
Metformin 500 mg twice daily
Pravastatin 80 mg daily
Aspirin 81 mg daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. potassium chloride 10 mEq [**Hospital 8426**] Extended Release Sig: Two
(2) [**Hospital 8426**] Extended Release PO Q12H (every 12 hours).
3. pravastatin 20 mg [**Hospital 8426**] Sig: Four (4) [**Hospital 8426**] PO DAILY
(Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. ranitidine HCl 150 mg [**Hospital 8426**] Sig: One (1) [**Hospital 8426**] PO BID (2
times a day).
8. aspirin 81 mg [**Hospital 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital 8426**], Delayed Release (E.C.) PO DAILY (Daily).
9. acetaminophen 325 mg [**Hospital 8426**] Sig: Two (2) [**Hospital 8426**] PO Q4H (every
4 hours) as needed for pain, fever.
10. oxycodone-acetaminophen 5-325 mg [**Hospital 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. metformin 500 mg [**Hospital 8426**] Sig: One (1) [**Hospital 8426**] PO BID (2 times
a day).
14. warfarin 1 mg [**Hospital 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM.
15. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing.
16. warfarin 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for
1 doses.
17. Lasix 40 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Healthcare
Discharge Diagnosis:
s/p Aortic Valve Replacement with #27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic
tissue/Coronary Artery Bypass Grafting x3 with Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to obtuse marginal and posterior descending
arteries/Ascending Aorta replacement wirh #32 Gelweave graft
Past Medical History:
Diabetes
Hypertension
Hyperlipidemia
Glaucoma
Patellofemoral arthritis (R)
Carpal tunnel syndrome
Bells Palsy 50 years ago
Past Surgical History:
Left shoulder surgery
Tonsillectomy
Bells palsy surgery x2
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
Leg Right/Left - healing well, no erythema or drainage.
Edema no edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr [**Last Name (STitle) 7772**] [**2138-6-24**], 1:15, [**Telephone/Fax (1) 170**] in the
[**Hospital **] Medical office Building, [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 88768**] [**Name (STitle) 10102**] [**2138-6-23**] at 1:40
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1955**] W. [**Telephone/Fax (1) 24047**] in [**4-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication:postop Atrial
fibrillation
Goal INR:[**2-7**]
First draw:[**2138-5-28**]
**Will require outpt. Coumadin follow up arranged upon rehab
discharge
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2138-5-27**]
|
[
"250.00",
"427.89",
"997.1",
"424.1",
"427.31",
"365.9",
"272.4",
"458.29",
"441.2",
"401.9",
"285.1",
"414.01",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"36.12",
"38.45",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9406, 9463
|
5448, 7295
|
417, 885
|
10084, 10320
|
3006, 5425
|
11878, 12866
|
2157, 2192
|
7487, 9383
|
9484, 9834
|
7321, 7321
|
10344, 11855
|
7342, 7464
|
10002, 10063
|
2207, 2987
|
270, 379
|
913, 1510
|
9856, 9979
|
1777, 2125
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,291
| 109,058
|
1960
|
Discharge summary
|
report
|
Admission Date: [**2112-3-11**] Discharge Date: [**2112-3-18**]
Date of Birth: [**2029-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain radiating to midback and jaw
Major Surgical or Invasive Procedure:
[**2112-3-14**] Coronary artery bypass graft x 4 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
right coronary artery, saphenous vein graft to diagonal,
saphenous vein graft to obtuse marginal)
History of Present Illness:
This 83 year old female developed substernal pressure radiating
to her back, neck and jaw. She called EMS and the chest pressure
subsided on its own in 15 minutes prior to EMS arrival. She
relates several years of dyspnea on exertion. She was brought to
[**Hospital6 33**] were she was admitted and a cardiac
catheterization was done. She was found to have multivessel
disease and is was transferred to [**Hospital1 18**] for revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Non insulin dependent diabetes
Osteoarthritis
Shingles [**2111**]
Cholecystectomy
bilateral hip replacement
resection of thyroid nodule and a right parotid excision
Social History:
Race:Caucasian
Last Dental Exam:partial on lower and full upper dentures
Lives with:Son, very active does her own ADLs and walks her dog
3
times/day. Does not use any assisted devices.
Contact:[**Name (NI) **] (son) [**Telephone/Fax (1) 10811**], [**Doctor First Name **] (daughter) [**Telephone/Fax (1) 10812**]
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago, history
of
40 ppy
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-23**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Father died of MI at age 51,
Two brothers died in their 50's of uncertain causes
Physical Exam:
Pulse:83 Resp:18 O2 sat:95/RA
B/P 117/78
Height:5' Weight:89.3 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x-occas irreg] Irregular [] Murmur [] grade ______
Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema [x] none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit None Right: Left:
Pertinent Results:
[**2112-3-12**] Echo: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a prominent fat pad.
.
[**2112-3-16**] 04:35AM BLOOD WBC-17.9* RBC-3.14* Hgb-9.8* Hct-28.0*
MCV-89 MCH-31.1 MCHC-34.8 RDW-14.1 Plt Ct-235
[**2112-3-11**] 07:15PM BLOOD WBC-14.0* RBC-4.17* Hgb-13.5 Hct-37.9
MCV-91 MCH-32.3* MCHC-35.5*# RDW-13.8 Plt Ct-363
[**2112-3-11**] 07:15PM BLOOD Glucose-111* UreaN-30* Creat-0.9 Na-141
K-4.2 Cl-105 HCO3-26 AnGap-14
[**2112-3-11**] 07:15PM BLOOD %HbA1c-6.1* eAG-128*
[**2112-3-18**] 12:37AM BLOOD WBC-14.9* RBC-3.04* Hgb-9.3* Hct-27.8*
MCV-92 MCH-30.7 MCHC-33.6 RDW-13.5 Plt Ct-347
[**2112-3-18**] 12:37AM BLOOD PT-11.6 INR(PT)-1.1
[**2112-3-18**] 12:37AM BLOOD Glucose-135* UreaN-35* Na-136 K-4.9
Cl-101 HCO3-27 AnGap-13
Brief Hospital Course:
Mrs. [**Known lastname **] was transferred from outside hospital after
cardiac cath revealed severe three vessel coronary disease
requiring surgery. Upon admission she was medically managed and
underwent surgical work-up. On [**3-14**] she underwent coronary
artery bypass graft x 4. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition.
Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. Post-op day one she was
started on beta-blockers and diuretics and gently diuresed
towards her pre-op weight. Later on this day she was transferred
to the step-down floor for further care. Chest tubes and
epicardial pacing wires were removed per protocol.
Physical Therapy worked with her for mobility and strength. She
was able to return to her home where she lives with her son who
will be with her for the first week.
On [**2-/2029**] she developed rapid atrial fibrillation with a
ventricular response of 140 and transient BP to 80s. She
received a total of 10mg of IV Lopressor with restoration of
sinus rhythm. The following day she had multiple short bursts
of SVT and Amiodarone and Coumadin were instituted. She was in
sinus with occassional VPCs/ junctional beats at discharge. Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], her primary care physician agreed to monitor her
anticoagulation. She will take 2.5 mg of Coumadin on [**3-18**]-4 and
have an INR drawn on [**3-21**].
All follow up appointments were given.
Medications on Admission:
Zocor 40mg HS
Zestril 30mg [**Hospital1 **]
Metformin 1000mg [**Hospital1 **]
Janusian 10mg Daily
Hydrochlorothiazide 25mg Daily
Aspirin 81mg Daily
Lopressor 12.5mg [**Hospital1 **] (started at [**Hospital3 **])
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets 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 DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg (2 tablets) twice daily for two weeks, then
200mg (one tablet) twice daily for two weeks, then 200mg (one
tablet) daily until directed to discontinue.
Disp:*100 Tablet(s)* Refills:*2*
11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
12. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: one tablet at 4pm on [**3-18**]. Then as directed by Dr.
[**Last Name (STitle) **] on [**3-21**].
Disp:*100 Tablet(s)* Refills:*2*
14. Outpatient [**Name (NI) **] Work
PT/INR on [**2112-3-21**], then prn.
Please call result to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at
[**Telephone/Fax (1) 10813**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass graft x 4
Hypertension
Hyperlipidemia
Non insulin dependent diabetes
Osteoarthritis
Shingles [**2111**]
s/p Cholecystectomy
s/p bilateral hip replacement
s/p resection of thyroid nodule and right parotid excision
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg left - 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) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**2112-4-13**] at 1:30pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] ([**Hospital Ward Name 23**] 7) on [**2112-3-30**] at 10am
Please call to schedule appointments with:
Primary Care Dr. [**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 10813**]in [**4-21**] 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 paroxysmal atrial
fibrillation
Goal INR 2-2.5
First draw [**2112-3-21**]
Results to phone: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10813**]
Completed by:[**2112-3-18**]
|
[
"278.00",
"411.1",
"458.29",
"427.31",
"272.4",
"250.00",
"V43.64",
"285.9",
"414.01",
"427.89",
"401.9",
"V85.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7892, 7943
|
4144, 5721
|
350, 581
|
8252, 8470
|
2622, 4121
|
9393, 10296
|
1828, 1945
|
5983, 7869
|
7965, 8231
|
5747, 5960
|
8494, 9370
|
1960, 2603
|
271, 312
|
609, 1055
|
1077, 1271
|
1287, 1812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,265
| 104,723
|
23152+57338
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-3-9**] Discharge Date: [**2106-3-25**]
Date of Birth: [**2046-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tree Nut
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2106-3-18**]
Coronary artery bypass grafting x3 with a left internal mammary
artery to the left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery and the
diagonal artery
History of Present Illness:
59 year-old male with a history of cardiomyopathy EF 45-50% with
PCM/ICD who presented due to SOB. He awoke in respiratory
distress and called EMS. He was found to have a SBP in 200s, RR
30-40s, rales in bilateral lung fields. He
was given nitropaste and started on CPAP with presumed flash
pulmonary edema. His symptoms improved enroute to the ER. He had
taken his home lasix of 80mg and urinated before EMS arrived. At
baseline he gets short of breath with a flight of stairs. In
the ED he was given lasix 80mg IV x 1 and started on a nitro
gtt. He was continued on CPAP with fiO2 of 50%. He was
diaphoretic on
arrival. He was given vanco and levo for possible PNA. He was
admitted for futher evaluation.
Cardiac Catheterization: Date:[**2106-3-15**] Place:[**Hospital1 18**]
LMCA: non-obstructed
LAD: diffuse mid to distal up to 80% stenosis, proximal 60%
lesion
LCX: RI has a 30% proixmal lesion
RCA: hazy, 85% ostial PDA
RA=17
PCW=30
PA= 46/28
Past Medical History:
-Ischemic and Hypertensive cardiomyopathy,
-chronic systolic CHF s/p BiV pacer-ICD placement [**1-/2100**],
echo-EF 45-50% [**5-15**]
with LVH ([**Company 1543**] [**Hospital1 **]-V/ICD with epicardial LV lead placement
[**2103**])
-Hypertension
-Hyperlipidemia
-Type 2 diabetes mellitus
-Obstructive sleep apnea - on 15 CPAP
-Spinal stenosis, herniated disc (Lumbar spinal stenosis.
Radiculopathy, Neurogenic claudication.,Right L5), s/p fusion
[**7-16**] far-lateral nerve compression)
-s/p tonsillectomy
-nephrolithiasis s/p lithotripsy
-BPH
-Gout
-Sigmoid diverticulosis by CT scan in [**2100**]
-CAD s/p DES D1, [**6-/2104**]
Social History:
Race:Caucasian
Last Dental Exam:1 year ago
Lives with:wife and 2 children
Occupation:retired manager of auto parts wear house.
Tobacco:quit in [**2093**], history of 25 pack-year
ETOH:1-2 beers/wk
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse:90 Resp:16 O2 sat: 95/RA
B/P Right:139/88 Left:146/86
Height:5'4" Weight:192 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]; +IACD with several well
healed scars over left anterior chest
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft, obese [x] non-distended [x] non-tender [x] bowel
sounds +;
Extremities: Warm [x], well-perfused [x] no Edema
Varicosities: None;
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ access site is w/o hematoma Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:no Left:no
Pertinent Results:
[**2106-3-24**] 04:50AM BLOOD WBC-7.5 RBC-3.41* Hgb-9.8* Hct-29.4*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.0 Plt Ct-277
[**2106-3-24**] 04:50AM BLOOD Glucose-122* UreaN-28* Creat-1.1 Na-136
K-4.2 Cl-100 HCO3-28 AnGap-12
[**2106-3-23**] 04:35AM BLOOD Glucose-118* UreaN-30* Creat-1.0 Na-138
K-4.2 Cl-100 HCO3-28 AnGap-14
[**2106-3-23**] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-9.5* Hct-28.3*
MCV-82 MCH-27.7 MCHC-33.8 RDW-15.3 Plt Ct-246
[**2106-3-18**] Intraop TEE
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thicknesses are normal. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is severe global left
ventricular hypokinesis (LVEF = 20 %). Overall left ventricular
systolic function is severely depressed (LVEF= 20 %). The
estimated cardiac index is depressed (<2.0L/min/m2).
Right ventricular chamber size and free wall motion are normal.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion.
Post_Bypass:
Patient is on epinephrine infusion. Cardiac output 3.4L/min by
swan ganz method.
There is moderate improvement of LVEF global systolic function.
LVEF 35%
Intact thoracic aorta.
Aortic valve area calculations by continuity is 1.2 cm2 with
peak aortic velocity at 2.1m/sec.
Surgeon informed of the findings.
Other valves similar to prebypass.
Brief Hospital Course:
This is a 59-year-old male with history of cardiomyopathy who
had an ejection fraction of 45-50% and had a biventricular
pacemaker placed about a year or 2 ago. He
presented in respiratory distress and responded to diuresis. He
had an echocardiogram which demonstrated that his left
ventricular function was depressed with moderate to severe
regional systolic dysfunction and ejection fraction about 25%.
His aortic valve showed minimal aortic stenosis. There was also
a mass that was in the left ventricle and it appeared to be
attached to the papillary
muscle suggestive of a fibroblastoma or torn chord. He had a
dobutamine stress echo which showed that the majority of his
heart had viable myocardium except for the inferior wall. He
had a small mitral palpable muscle mass which was suggestive
of a torn chord. Cardiac surgery was asked to evaulate for
surgery. He was brought to the operating room on [**2106-3-18**] where
the patient underwent coronary artery bypass grafting x3 with a
left internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery and the diagonal artery. See operative note
for full 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 on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. A fib was noted to be his rhythm under his
pacemaker and he was loaded with Amiodarone. The patient was
transferred to the telemetry floor for further recovery. He did
have some dizziness and orthostatic hypotension which improved
with albumin. He had scant sternal drainage which had improved
at the time of discharge with no drainage noted for 48 hours.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 7 the patient was ambulating freely,
tolerating a full oral diet and the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home with VNA in good condition with appropriate follow up
instructions.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
CARVEDILOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth twice a day
COLCHICINE - (Prescribed by Other Provider) - 0.6 mg Tablet - 1
Tablet(s) by mouth q hs
CYCLOBENZAPRINE - (Prescribed by Other Provider) - 10 mg Tablet
- 1 Tablet(s) by mouth q hs
DILTIAZEM HCL [TAZTIA XT] - (Prescribed by Other Provider) -
300
mg Capsule, Sustained Release - 1 Capsule(s) by mouth once a day
FENOFIBRATE MICRONIZED - (Prescribed by Other Provider) - 200
mg
Capsule - 1 Capsule(s) by mouth q hs
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 2
Tablet(s) by mouth in am and 1.5 tabs at hs
GABAPENTIN [NEURONTIN] - (Prescribed by Other Provider) - 300
mg
Capsule - 1 Capsule(s) by mouth three times daily
GLYBURIDE - (Prescribed by Other Provider) - 2.5 mg Tablet - 2
Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
NAPROXEN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth q 8 hr as needed for prn
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually q 5 minutes as needed for
as needed for chest pain
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a
day
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq
Capsule, Sustained Release - 1 Capsule(s) by mouth once a day
SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 Tablet(s) by mouth once a day
TERAZOSIN - (Prescribed by Other Provider) - 1 mg Capsule - 1
Capsule(s) by mouth at hs
TERAZOSIN - (Prescribed by Other Provider) - 2 mg Capsule - 1
Capsule(s) by mouth at hs together for 3 mg at hs
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 320 mg
Tablet - 1 Tablet(s) by mouth once a day
Metformin 1000mg [**Hospital1 **]
Isosorbide 90mg Daily
Medications - OTC
EC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
MAGNESIUM - (Prescribed by Other Provider) - 250 mg Tablet - 1
Tablet(s) by mouth q hs
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg daily x 1 week, then 200mg daily until further
instructed.
Disp:*60 Tablet(s)* Refills:*2*
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
Disp:*qs * Refills:*0*
8. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for muscle pain.
Disp:*30 Tablet(s)* Refills:*0*
13. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
Disp:*90 Capsule(s)* Refills:*2*
14. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 40mg [**Hospital1 **] x 10 days, then resume previous home dose 40mg
am, 30mg pm.
Disp:*60 Tablet(s)* Refills:*2*
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours).
Disp:*60 Tablet, ER Particles/Crystals(s)* Refills:*2*
17. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
18. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule
PO daily ().
Disp:*30 Capsule(s)* Refills:*2*
19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
20. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
21. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
22. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-7**] Sprays Nasal
QID (4 times a day) as needed for dry nares .
Disp:*qs * Refills:*0*
23. magnesium oxide 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease
s/p CABG x 3
PMH:
-Ischemic and Hypertensive cardiomyopathy,
-CHF s/p BiV pacer-ICD placement [**1-/2100**], echo-EF 45-50% [**5-15**]
with LVH ([**Company 1543**] [**Hospital1 **]-V/ICD with epicardial LV lead placement
[**2103**])
-Hypertension
-Hyperlipidemia
-Type 2 diabetes mellitus
-Obstructive sleep apnea - on 15 CPAP
-Spinal stenosis, herniated disc (Lumbar spinal stenosis.
Radiculopathy, Neurogenic claudication.,Right L5), s/p fusion
[**7-16**] far-lateral nerve compression)
-s/p tonsillectomy
-nephrolithiasis s/p lithotripsy
-BPH
-Gout
-Sigmoid diverticulosis by CT scan in [**2100**]
-CAD s/p DES D1, [**6-/2104**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
1+ 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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2106-3-25**] Name: [**Known lastname 158**],[**Known firstname **] C Unit No: [**Numeric Identifier 10921**]
Admission Date: [**2106-3-9**] Discharge Date: [**2106-3-25**]
Date of Birth: [**2046-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tree Nut
Attending:[**First Name3 (LF) 135**]
Addendum:
Med Clarification for Pharmacy:
Colchicine 0.6mg tab daily, may substitute generic
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2106-3-26**]
|
[
"425.8",
"402.91",
"327.23",
"250.00",
"428.0",
"V45.02",
"272.4",
"584.9",
"428.23",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
14928, 15143
|
5088, 7529
|
293, 512
|
13410, 13628
|
3218, 5065
|
2384, 2467
|
9802, 12628
|
12730, 13389
|
7555, 9779
|
13652, 14905
|
2482, 3199
|
234, 255
|
540, 1497
|
1519, 2153
|
2169, 2368
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,435
| 112,449
|
39990+58340
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-11-9**] Discharge Date: [**2167-11-18**]
Date of Birth: [**2114-5-14**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
HCV cirrhosis
Major Surgical or Invasive Procedure:
Liver transplant [**2167-11-9**]
History of Present Illness:
53-y.o. female with HCV cirrhosis s/p TIPS is called in for
potential liver transplantation. Patient was recently
hospitalized [**Date range (1) 87949**] for hepatic encephalopathy and treated
with PO and PR lactulose. Per daughter, Pt has been at baseline
since being discharged two days ago: able to converse and
perform
daily activities of living. Although her mental status was
normal yesterday, pt complained of weakness and "not feeling
well." This morning, she woke up confused and unoriented.
Denies fever, chills, nausea, vomiting, cough, dysuria, SOB or
CP. Most of history is obtained through her daughter and HCP as
pt is minimally conversant.
Past Medical History:
- HCV: Dx [**2166**]; she is infected with G3A genotype. She has no
history of UGIB or varicies. She has no history of IDU or
transfusions.
- DM-2
- Asthma: never required hospitalization or intubation
- Migraine headaches
- history of Gallstones
- ? peripheral vascular disease
- Cirrhosis
- Diuretic refractory ascites s/p TIPS [**2167-3-25**]
- HCC s/p RFA ablation
Social History:
She has 2 children and 2 grandchildren ages 15 and 18. They have
no pets, she does not garden or keep indoor plants. She has
worked in a local store as a stockperson. Not working. From
[**Male First Name (un) **] and moved here 40 yrs ago.
.
She was born in [**Male First Name (un) 1056**]. While there, she worked in assembly
lines, stores, and other manual labor jobs; She left [**Male First Name (un) 1056**]
over 40 years ago, and lived first in [**Location (un) 7349**] then NJ with her
present husband. They moved to [**State 87856**] over 1 year
ago.
Family History:
There is no known family history of liver disease or liver
cancer. She has 6 brothers and 5 sisters; her father died when
she was 17 (ETOH abuse) and her mother is alive and living in
[**Name (NI) 108**] now.
Physical Exam:
T: 97.3 P: 82 BP: 127/43 RR: 18 O2sat: 96% on RA
General: awake, alert, follows commands, NAD, oriented to
person,
oriented to place after much encouragement
HEENT: NCAT, EOMI, icteric sclera
Heart: RRR
Lungs: normal excursion, no respiratory distress
Abdomen: obese, soft, NT, ND, no fluid wave
Extremities: WWP, 2+ pedal edema
Skin: multiple ecchymotic areas on both arms
Neuro: moves all extremities
Studies:
Serum electrolytes:
pending
CBC:
pending
CT head [**2167-11-2**] showed:
No acute intracranial process.
Brief Hospital Course:
53-y.o. female HCV cirrhosis admitted for liver transplantation.
Upon admission, she was lethargic and was given
lactulose/rifaximin. Ammonia level was 128. She underwent liver
transplant and ventral hernia repair on [**2167-11-9**]. Surgeon was
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details. 3
JPs were placed (posterior to liver, under hilum and
subcutaneous at hernia repair). Drains were non-bilious. She was
sent to the SICU postop and was extubated the next day.
LFTs increased postop day 1. Liver duplex was wnl. Mental status
was improved from preop. LFTs continued to trend down. She was
sent out of SICU on postop day 2. Diet was slowly advanced and
tolerated. Insulin was given for hyperglycemia due to steroids.
[**Last Name (un) **] was consulted and ordered 75/25 pen. Vital signs remained
stable.
Lasix was given for low urine output and edema. Creatinine
increased on postop day 2, up to 1.5 from 2 then improved daily.
Immunosuppression consisted of Cellcept which was well
tolerated, steroid taper and Prograf that was started on postop
day 1. Doses were adjusted per trough. She did well with
medication teaching and self administration of insulin with
assist of family members.
VNA Greater RI 1-[**Telephone/Fax (1) 87950**] was arranged to assist with JP
drain care (in hernia bed). Nsg anf PT services were requested.
Medications on Admission:
Ciprofloxacin 250 mg daily, clotrimazole 10 mg troche 5x daily,
metformin 500 mg [**Hospital1 **], glimepiride 1 mg daily, rifaximin 550 mg
[**Hospital1 **], esomeprazole 40 mg daily, furosemide 20 mg daily,
spironolactone 50 mg daily, lactulose 10 g/15 mL x 30 mL TID,
tramadol 50 mg Q6H PRN pain, ropinirole 0.5 mg daily, ferrous
sulfate 300 mg daily, docusate sodium 100 mg [**Hospital1 **], polyethylene
glycol 17 g PO BID PRN constipation, fleet enema PRN
constipation, vitamin D-2 50,000 unit Qweek.
Allergies:
NKDA.
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow taper schedule.
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
8. Humalog Mix 75-25 KwikPen 100 unit/mL (75-25) Insulin Pen
Sig: Forty (40) units Subcutaneous once a day.
Disp:*30 pens* Refills:*4*
9. Humalog Mix 75-25 KwikPen 100 unit/mL (75-25) Insulin Pen
Sig: Twenty Five (25) units Subcutaneous at bedtime: take at
dinner.
10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Breeze 2 Test Strips Strip Sig: One (1) Miscellaneous
four times a day.
Disp:*1 box* Refills:*2*
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
16. Kayexalate Powder Sig: Fifteen (15) grams PO 15 gm(s) by
mouth As directed Only take if directed by transplant team .
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
visiting nurse services of greater RI
Discharge Diagnosis:
HCV cirrhosis
Asthma
DM II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Visiting Nurses services of Greater [**Doctor Last Name 792**]have been
arranged
-Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following: fever (101 or greater), shaking chills,
nausea, vomiting, inability to take any of your medications,
jaundice, increased abdominal/incision pain, incision
redness/bleeding/drainage or diarrhea/constipation.
-You will need to have blood drawn every Monday and Thursday for
lab monitoring at Quest lab or Lab provider recommended by [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 23170**], RN
-Please empty and record abdominal drain output. Bring record of
drain output to next Transplant appointment
-Do not lift anything heavier than 10 pounds. No straining
-You may shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-11-26**] 3:40
Completed by:[**2167-11-19**] Name: [**Known lastname 9292**],[**Known firstname 3351**] Unit No: [**Numeric Identifier 13944**]
Admission Date: [**2167-11-9**] Discharge Date: [**2167-11-18**]
Date of Birth: [**2114-5-14**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2800**]
Addendum:
Patient experienced ARF postop that resolved by time of
discharge. She also had thrombocytopenia postop liver
transplant.
Discharge Disposition:
Home With Service
Facility:
visiting nurse services of greater RI
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**2167-11-24**]
|
[
"155.0",
"789.59",
"571.5",
"286.7",
"572.8",
"553.21",
"250.00",
"V58.65",
"070.44",
"287.5",
"584.9",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"53.61",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
8145, 8373
|
2800, 4214
|
317, 352
|
6492, 6492
|
7436, 8122
|
2027, 2237
|
4789, 6330
|
6442, 6471
|
4240, 4766
|
6643, 7413
|
2252, 2777
|
264, 279
|
380, 1043
|
6507, 6619
|
1065, 1435
|
1451, 2011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,852
| 124,379
|
7950
|
Discharge summary
|
report
|
Admission Date: [**2180-5-4**] Discharge Date: [**2180-5-12**]
Date of Birth: [**2113-1-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old
gentleman with metastatic renal cell carcinoma to the lung
and bone transferred from [**Hospital3 3765**] where he presented
with increased left sided weakness starting at 9:00 a.m. on
the day of admission. Head CT showing a right frontal lesion
surrounding edema and mass effect and intraventricular
extension of hemorrhage with 3 mm of midline shift to the
left consistent with a hemorrhagic renal cell carcinoma
metastasis.
PAST MEDICAL HISTORY: Renal cell carcinoma status post IL2
treatment, insulin dependent diabetes mellitus.
MEDICATIONS: NPH insulin 20 units subQ q.a.m., 6 units subQ
q.p.m., Humalog 2 to 3 units subQ q.a.m., 1 to 2 units subQ
q.p.m.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Blood pressure 126/70. Heart rate 91.
Respiratory rate 20. Sats 93% on room air. The patient is a
pleasant gentleman in no acute distress. HEENT pupils are
equal, round and reactive to light. Extraocular movements
intact. Tongue midline. Cardiac regular rate and rhythm.
No S3 or S4. Lungs clear to auscultation. Abdomen positive
bowel sounds, nontender, nondistended. No masses.
Extremities warm, well profuse and no edema. Neurologically,
awake, alert and oriented times three, speech fluent.
Cranial nerves II through XII intact. Subtle left sided
weakness 4/5 in the lower and upper extremity. Positive
Babinski on the left. Toes down going on the right.
LABORATORIES ON ADMISSION: White blood cell count 3.4,
hematocrit 27.6, platelet count 132, sodium 129, K 4.6,
chloride 96, CO2 24, 23 is his BUN and creatinine 1.2,
glucose 321.
HOSPITAL COURSE: The patient was admitted to the Oncological
Service and seen by the Radiation/Oncology Service and also
the Neurosurgical Service. On [**2179-5-9**] the patient had a
repeat head CT, which showed increase in the left anterior
[**Doctor Last Name 534**] of the ventricular size and a nonhemorrhagic thalamic
lesion. On [**2180-5-9**] the patient underwent an MRI-guided
frameless stereotactically guided right frontal craniotomy for
excision of tumor with no intraoperative complications.
Postoperatively, he was monitored in the Surgical Intensive Care
Unit. He was awake, alert and oriented with no drift. He was
able to follow simple commands moving all four extremities with
good strength. He was transferred to the regular floor. On
[**2180-5-10**] he was seen by physical therapy and occupational
therapy and found to require a short rehab stay prior to
discharge to home. His incision is clean, dry and intact.
MEDICATIONS ON DISCHARGE: Decadron 2 mg po q 8 hours to wean
down to 2 mg po b.i.d., insulin sliding scale, Dilantin 100
mg po t.i.d., Zantac 150 mg po b.i.d., Tylenol 650 po q 4
hours prn, NPH insulin 33 units at breakfast, regular insulin
10 units at breakfast, NPH 11 units at bedtime.
CONDITION ON DISCHARGE: Stable. The patient will follow up
in the Brain [**Hospital 341**] Clinic a week from Monday for staple
removal and follow up. The patient was stable at the time of
discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2180-5-12**] 09:50
T: [**2180-5-12**] 10:02
JOB#: [**Job Number 28519**]
|
[
"198.5",
"V10.52",
"198.3",
"197.0",
"250.01",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
2739, 3003
|
1787, 2712
|
914, 1601
|
158, 616
|
1616, 1769
|
639, 891
|
3028, 3466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,144
| 172,584
|
51461
|
Discharge summary
|
report
|
Admission Date: [**2138-1-24**] Discharge Date: [**2138-2-2**]
Date of Birth: [**2071-3-7**] Sex: M
Service: SURGERY
Allergies:
Percocet / Prozac
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
Sigmoid Cancer
Major Surgical or Invasive Procedure:
1. Sigmoid colectomy with low anterior resection and stapled
colorectal anastomosis.
2. Rigid sigmoidoscopy.
History of Present Illness:
Mr. [**Known lastname 9907**] is a 66-year-old gentleman presenting with a sigmoid
mass worrisome formalignancy. As you know, he underwent a
routine colonoscopy first in [**2132**]. Some polyps were seen and
repeat colonoscopy was recommended by Dr. [**First Name (STitle) 679**]. He underwent a
colonoscopy in 12/[**2136**]. At which point, two small polyps were
seen, one in the ascending colon and one in the descending colon
at 60 cm. Both of these were 5 mm, were resected, and found to
be benign adenomas. However in the sigmoid colon at 30 cm, there
was a worrisome friable lesion seen, which was infiltrative and
malignant appearing with multiple diverticula are rounded with
narrowing. That was biopsied and the 30-cm mass revealed cells
suspicious
for malignancy with markedly dysplastic glands and difficult to
evaluate for invasion given lack of submucosal tissue.
.
His review of system only reveals some tarry black stools, which
may be related to gastritis.
Past Medical History:
His past medical history is significant for coronary artery
disease status post quadruple bypass and multiple stents placed
here at [**Hospital1 18**]. His bypass was eight years ago and was
uncomplicated. He also has severe asthma and COPD under the
care of Dr. [**Last Name (STitle) 575**]. He also has a history of hypertension.
He has no history of cancer or radiation or kidney disease.
Social History:
He continues to smoke. He has a "heavy smoking history the
past" for a short period but is now smoking one and a half packs
per day again.
Physical Exam:
On exam, he is a well-appearing gentleman in no acute distress.
He is obese with a protuberant abdomen. There is no
hepatomegaly and no splenomegaly and no hernias. His rectal
exam reveals a normal prostate with brown stool.
Pertinent Results:
[**2138-1-25**] 03:21AM BLOOD WBC-9.5 RBC-3.03* Hgb-10.6* Hct-28.3*
MCV-93 MCH-35.0* MCHC-37.6* RDW-13.6 Plt Ct-125*
[**2138-1-26**] 04:06AM BLOOD WBC-8.0 RBC-2.66* Hgb-9.3* Hct-24.7*
MCV-93 MCH-35.0* MCHC-37.7* RDW-13.4 Plt Ct-100*
[**2138-2-2**] 01:46AM BLOOD WBC-9.0 RBC-3.42* Hgb-11.4* Hct-31.4*
MCV-92 MCH-33.3* MCHC-36.2* RDW-13.6 Plt Ct-283
[**2138-1-26**] 04:06AM BLOOD PT-12.4 PTT-29.9 INR(PT)-1.1
[**2138-2-2**] 01:46AM BLOOD Plt Ct-283
[**2138-1-25**] 03:21AM BLOOD Glucose-130* UreaN-8 Creat-1.0 Na-138
K-4.0 Cl-106 HCO3-26 AnGap-10
[**2138-1-26**] 04:06AM BLOOD Glucose-101 UreaN-7 Creat-0.9 Na-139
K-3.5 Cl-103 HCO3-28 AnGap-12
[**2138-2-2**] 09:06AM BLOOD Glucose-109* UreaN-21* Creat-1.2 Na-135
K-4.2 Cl-107 HCO3-19* AnGap-13
[**2138-1-27**] 02:00AM BLOOD ALT-20 AST-41* AlkPhos-73 TotBili-4.6*
DirBili-3.7* IndBili-0.9
[**2138-1-28**] 02:15AM BLOOD ALT-40 AST-77* AlkPhos-166* TotBili-5.0*
DirBili-4.3* IndBili-0.7
[**2138-1-29**] 11:30AM BLOOD CK-MB-3 cTropnT-0.10*
[**2138-1-29**] 06:20PM BLOOD CK-MB-3 cTropnT-0.13*
[**2138-1-30**] 04:34AM BLOOD CK-MB-3 cTropnT-0.12*
[**2138-1-30**] 09:45PM BLOOD CK-MB-2 cTropnT-0.15*
[**2138-1-31**] 05:02AM BLOOD CK-MB-2 cTropnT-0.12*
[**2138-1-24**] 08:28AM BLOOD Glucose-114* Lactate-1.3 Na-139 K-3.7
Cl-107
[**2138-1-24**] 10:01AM BLOOD Glucose-135* Lactate-1.0 Na-139 K-3.7
Cl-105
[**2138-2-2**] 09:16AM BLOOD Lactate-0.9
Brief Hospital Course:
This patient with history of CAD, CABG, angioplasty, asthma,
GERD, PVD, HTN, L iliac-femoral bypass was admitted s/p low
anterior resection for malignancy of the sigmoid colon on
[**2138-1-24**]. Please see operative note for full details.
.
Post-operatively, the patient was admitted to the SICU given his
multiple medical morbidities. The patient was followed by the
Pulmonary and Cardiology service. On post-operative day #2, the
patient noted erythema around the superior aspect of the
incision. The incision was opened and packed and the patient was
started on Kefzol. This wound infection improved. On
post-operative day #4, the patient experienced chest pain
without any EKG changes and a rise in troponin that was thought
to be secondary to a troponin leak. As a result, the patient was
started on ASA and beta blocker was increased, but given the
patient's recent surgery, heparin was not instituted. On
post-operative day #9, the patient was noted to have erythema
and induration on the inferior aspect of the incision. The
incision was opened and packed and the patient was sent home
with a 7 day course of Kefzol to complete (per Dr. [**Last Name (STitle) 6633**]. The
wound will be assessed daily by [**Last Name (STitle) 269**] and changed at least twice
daily until his follow-up with Dr. [**Last Name (STitle) **]. Otherwise, on
discharge the patient was ambulating and voiding without
difficulty, tolerating fluids and afebrile.
.
Medications on Admission:
His medication list includes prednisone, metoprolol, Lipitor,
Zestril, aspirin, Imdur, Plavix, Celexa, Klonopin, Norvasc, and
Protonix.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*2*
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*QS Cap(s)* Refills:*2*
5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
Disp:*QS Disk with Device(s)* Refills:*2*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*QS * Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*2*
10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
Disp:*30 Capsule(s)* Refills:*2*
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Atorvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
17. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
partners [**Name (NI) **]
Discharge Diagnosis:
Malignant neoplasm of sigmoid.
Discharge Condition:
Stable, tolerating po
Discharge Instructions:
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting,
inability to eat, wound redness/warmth/swelling/foul smelling
drainage, abdominal pain not controlled by pain medications or
any other concerns.
Please resume taking all medications as taken prior to this
surgery and pain medications as prescribed.
Please call Dr.[**Name (NI) 22019**] office to arrange an appointment in a
week.
No heavy lifting for 4-6 weeks or until directed otherwise.
Wound Care: [**Month (only) 116**] shower (no bath or swimming) if no drainage from
wound, if clear drainage cover with dry dressing. The drain and
staples will remain in place until your follow-up with Dr.
[**Last Name (STitle) **].
Followup Instructions:
Please call Dr.[**Name (NI) 22019**] office to arrange an appointment in
one week's time ([**Telephone/Fax (1) 33502**].
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2138-2-2**]
|
[
"411.1",
"276.7",
"E849.7",
"998.59",
"V45.81",
"E878.6",
"250.00",
"153.3",
"401.9",
"493.20",
"041.11",
"305.1",
"440.20",
"562.10",
"414.00",
"V09.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"48.23",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
7379, 7435
|
3661, 5110
|
291, 408
|
7510, 7534
|
2253, 3638
|
8318, 8566
|
5297, 7356
|
7456, 7489
|
5136, 5274
|
7558, 8059
|
2005, 2234
|
237, 253
|
8071, 8295
|
436, 1415
|
1437, 1833
|
1849, 1990
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,108
| 191,889
|
41979
|
Discharge summary
|
report
|
Admission Date: [**2178-10-24**] Discharge Date: [**2178-10-26**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Sepsis, jaundice, fever
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
[**Age over 90 **] F with history of CAD s/p MI, HTN presents initially to OSH
with weakness, anorexia, jaundice, fevers and ill defined
abdominal pain x 2 weeks. Her sons report that she has been
feeling weak and has had a decreased level of activity over the
last 48 hours. The morning prior to admission, she began to
develop fevers to 102 and new onset jaundice was noted.
Patient was brought to [**First Name8 (NamePattern2) 189**] [**Hospital1 **] [**10-23**] where she was found to be
febrile, WBC count to 22 and elevated cholestatic liver enzymes
+ lipase had RUQ ultrasound performed which showed gallstones in
gallbladder and dilated CBD of 9 mm, with no evidence of acute
cholecystitis. Patient received levofloxacin and flagyl prior
to transfer for concern for cholangitis. OSH Bcx grew [**3-9**] GNR.
.
Of note patient previous hospitalization was 2 months ago at LGH
for UTI which was treated with IV Abx.
.
In the ED
- inital vitals were, 101.2 95 108/43 18 96% 2L NC.
- jaundice, distended abdomen, hepatomegaly
- Labs were notoable for leukocytosis to 15.3 with 93%
neutrophils and elevated liver enzymes with cholestatic pattern
+ elevated lipase.
- also had some ST-T changes and minimal troponin peak which
cards consult attributed to demnad ischemia
- ERCP fellow aware and recommended emergent ERCP.
- in the ED patient recieved Aspirin 325mg once + Flagyl 500mg
(got first dose of levoflox + flagyl at OSH)+ 1L NS then started
on NS at 125cc/h.
.
.
In the MICU, patient is alert and cooperative though poor
historians. She denies any pain, nausea, vomtiing, chest pain,
SOB or other discomfort.
Past Medical History:
CAD s/p MI
HTN
s/p hip replacement
s/p hysterectomy
h/o breast cancer
Social History:
lives on her own next door to her daughter, in all has 2
daughters + 2 sons all [**Name2 (NI) 91158**] in [**Name (NI) 189**] area and supportive. She
is ADL independent: washing, cooking. Mobilizes with walker.
Daughter helps with chores around the house.
- Tobacco: Denies
- Alcohol: rarely
Family History:
NC
Physical Exam:
General: thin, oriented X [**1-8**]: knows month, knows
[**Holiday **]'s coming up, knows she's in hospital but not which,
doesn't know day of week. No acute distress, appears mildly SOB
and tachypnic lying at 15%.
HEENT: Jaundiced, MMM, oropharynx clear
Neck: supple, prominent right carotid pulse (aneurism?) JVP not
elevated, no carotid bruitsm, no LAD
Chest: pectus corinatum, Clear to anterior auscultation
bilaterally
CV: distant Regular rate and rhythm, no obvious murmurs, rubs,
gallops
Abdomen: mildly distended but soft, RUQ fullness w/o clear mass
felt, liver edge felt under rib cage, spleen not felt, no
distinct masses, mild LUQ tenderness on deep palpation, muroph's
negative, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2178-10-24**] 01:10AM BLOOD WBC-15.3* RBC-3.68* Hgb-11.7* Hct-34.3*
MCV-93 MCH-31.9 MCHC-34.1 RDW-13.2 Plt Ct-146*
[**2178-10-24**] 01:10AM BLOOD Plt Ct-146*
[**2178-10-24**] 01:10AM BLOOD Glucose-81 UreaN-26* Creat-1.0 Na-139
K-3.2* Cl-104 HCO3-22 AnGap-16
[**2178-10-24**] 01:10AM BLOOD ALT-170* AST-138* AlkPhos-554*
TotBili-7.5*
[**2178-10-24**] 01:28AM BLOOD Lactate-2.2*
Studies:
CXR - FINDINGS: Interval appearance of massive amounts of free
intraperitoneal air. The referring physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14150**] was
paged at the time of dictation, 11:24 a.m., on [**2178-10-24**], and the findings were discussed over the telephone.
Nasogastric tube in situ. Small lung volumes, borderline size of
the cardiac silhouette. Atelectasis at the lung bases, but no
evidence of pneumonia or pulmonary edema. No pleural effusions.
Brief Hospital Course:
Ms. [**Known lastname 18769**] was a [**Age over 90 **] F with history of CAD s/p MI, HTN,
breast Ca who was transfered from OSH d/t acute cholangitis +
gall stone pancreatitis.
At [**Hospital1 18**], the patient underwent ERCP. During the procedure, the
bulb of the duodenum was perforated. The procedure was stopped
and the patient returned to the ICU intubated. Surgery consulted
and were willing to repair the bowel perforation. The patient's
sedation was removed and she was allowed to wake up. Upon
awaking the patient was alert and oriented. She reported that
did she not want surgery. At that time the patient was made
comfort measures only. Placed on a morphine drip. Family
brought to bedside. The patient passed away on the morning of
[**2178-10-26**] with family at bedside.
Medications on Admission:
loratadine 10 mg Tab Oral 1 Tablet(s) Once Daily, as need
calcium carbonate -- Unknown Strength 1 Capsule(s) Once Daily
ascorbic acid -- Unknown Strength 1 Capsule, Extended Release(s)
Once Daily
One Daily Multivitamin Tab Oral 1 Tablet(s) Once Daily
aspirin 81 mg Tab Oral 1 Tablet(s) Once Daily
ferrous sulfate 325 mg (65 mg iron) Tab Oral 1 Tablet(s) Twice
Daily
triamterene-hydrochlorothiazide 37.5 mg-25 mg Cap Oral 1
Capsule(s) once every other day
amlodipine 10 mg Tab Oral 1 Tablet(s) Once Daily
pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet, Delayed
Release (E.C.)(s) Once Daily
metoprolol tartrate 25 mg Tab Oral 1 Tablet(s) Twice Daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2178-10-27**]
|
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,904
| 145,729
|
6744
|
Discharge summary
|
report
|
Admission Date: [**2140-10-5**] Discharge Date: [**2140-10-18**]
Date of Birth: [**2061-6-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Horse Blood Extract
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
central line
History of Present Illness:
Mr. [**Known lastname **] is a 79 y/o male with a history of DM1 on an insulin
pump (last A1c 8.1), hypertension and glaucoma who presented
with elevated blood sugars and altered mental status from
nursing home ([**Hospital1 **]). Patient also described abd pain as
well. Patient was found to be "glazed over" and blood sugar was
found to be critically high. Per nursing home, patient is very
independent and takes care of many of his own ADLs, including
taking his own medications. Of note, patient had insulin pump
malfunction on [**8-19**] where he filled up reservoir w/ 100 units
Novolog and when restarting pump it accidentally discharged all
100 units insulin into the pt. Patient was taken to ED and
treated, BGs stabilized in 90's by evening over 2 hrs. Not clear
what happened w/ pump and pump may be malfunctioning, [**Last Name (un) **]
c/s, advised pt to contact pump company asap to get replacement.
In the meantime, pt was to take 6 units Lantus (given in ED eve
of [**8-19**]) and cover meals as usual w/ Novolog sq until he has a
properly functioning pump. Nursing home unaware of pump/lantus
situation given that patient is so independent.
.
In the ED initial vitals were 96.1 101 138/121 25 100%RA. An
hour later, patient became hypotensive to 95/46. Patient's BS
was 743 and started on Insulin gtt, given KCl, Normal Saline
(6L). Patient's SBP remained in the 90s and a R IJ was placed,
patient started on levofed at 0.03 to maintain map >60. DKA was
thought to be perhaps due to infection and patient was pan
cultured. Vanc, Levo, & Flagyl were started, as patient has PCN
allergy. CXR was obtained which showed bilat opacities c/w pna.
An abd CT was performed as well as patient was complaining of
abd pain, but was essentially negative, did show inguinal
hernia. Patient's cardiac enzymes were checked as well and were
found to be elevated at 0.83. EKG revealed sinus tachy @100 with
normal axis, normal intervals, new ST depressions in lat leads.
cardiology consulted, patient started on heparin gtt but thought
due to demand. A bedside echo was performed, found to have good
systolic function. Patient was also given calcium gluconate,
ativan & morphine x1, at some point as well. Prior to transfer,
vitals were 96.6 82 116/53 40 93%3L NC.
.
Upon arrival to the ICU, patient was arousable but somnolent.
Unclear if sedation due to medications given in ED or if this
was how nursing home found patient. Rpt EKG showed resolution of
lateral ST depression but new TWI in V3 but rpt enzymes show
trop elevation to 2.97 with MB 80s and MBI 6.6. Cardiology was
called, will come to eval patient & perform stat ECHO. Patient
satting at 90% on 2L but found to be mouth breather, placed on
face mask FiO2 40% --> sats 97%. He brought up frequent
secretions and a sample was collected, appeared brown and
bloody. Review of systems as above, otherwise negative.
.
Past Medical History:
1. Hypertension.
2. Type I diabetes on an insulin pump
3. Glaucoma.
4. History of a colon adenocarcinoma, resected.
Social History:
patient lives in nursing home ([**Hospital1 **]), very independent. He
quit tobacco 38 years ago. He is a retired computer scientist.
Family History:
Father had a question of coronary artery disease and had a
pacemaker and died at the age of 81. His mother died of CA,
unknown.
Physical Exam:
ADMISSION:
Vitals: T: 97.9 ??????F BP: 102/56 P:79 R:22 O2:97% on 2L NC and FM
@40%
General: somnelent, arousable, unable to really answer questions
HEENT: Sclera anicteric, dry MM
Neck: supple, no LAD, JVD
Lungs: rhonchi/crackles diffusely
CV: RRR, +S1, S2, no murmurs, rubs, gallops
Abdomen: soft, NT/ND, BS present, no r/r/g
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
[**2140-10-8**] 03:46AM BLOOD WBC-13.6* RBC-3.56* Hgb-11.9* Hct-33.6*
MCV-95 MCH-33.5* MCHC-35.4* RDW-13.9 Plt Ct-168
[**2140-10-5**] 11:55AM BLOOD WBC-16.7*# RBC-2.98*# Hgb-10.1*#
Hct-32.0* MCV-107*# MCH-33.9* MCHC-31.6 RDW-14.5 Plt Ct-186
[**2140-10-5**] 11:55AM BLOOD Neuts-86.4* Lymphs-9.5* Monos-3.1 Eos-0.7
Baso-0.2
[**2140-10-7**] 03:46AM BLOOD Neuts-89.7* Lymphs-7.2* Monos-2.8 Eos-0.3
Baso-0
[**2140-10-8**] 03:46AM BLOOD Plt Ct-168
[**2140-10-5**] 11:55AM BLOOD PT-14.1* PTT-30.1 INR(PT)-1.2*
[**2140-10-8**] 05:25PM BLOOD Na-140 K-3.4 Cl-105
[**2140-10-8**] 03:51PM BLOOD Glucose-276* UreaN-27* Creat-1.2 Na-136
K-6.5* Cl-102 HCO3-22 AnGap-19
[**2140-10-8**] 03:46AM BLOOD Glucose-72 UreaN-24* Creat-1.1 Na-140
K-2.9* Cl-104 HCO3-23 AnGap-16
[**2140-10-5**] 11:55AM BLOOD Glucose-743* UreaN-52* Creat-2.1* Na-136
K-5.3* Cl-104 HCO3-7* AnGap-30*
[**2140-10-5**] 08:30PM BLOOD CK(CPK)-1318*
[**2140-10-8**] 03:46AM BLOOD CK(CPK)-950*
[**2140-10-8**] 03:46AM BLOOD CK-MB-13* MB Indx-1.4 cTropnT-1.82*
[**2140-10-8**] 03:46AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.9
[**2140-10-8**] 03:46AM BLOOD VitB12-1250* Folate-5.8
[**2140-10-6**] 03:49AM BLOOD %HbA1c-7.7* eAG-174*
ECHO:
[**10-7**]:
[**Known lastname **], [**Known firstname **] S [**Hospital1 18**] [**Numeric Identifier 25651**]Portable TTE
(Focused views) Done [**2140-10-7**] at 11:06:13 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) 2437**], [**First Name3 (LF) **]
Pulmonary, Critical Care & [**Last Name (un) 9368**]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 830**], E/KS-B23
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2061-6-27**]
Age (years): 79 M Hgt (in):
BP (mm Hg): 129/58 Wgt (lb):
HR (bpm): 90 BSA (m2):
Indication: Assess LV Function
ICD-9 Codes: 410.91, 402.90, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2140-10-7**] at 11:06 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**Name2 (NI) 1151**]
Dreiding, RDCS
Doppler: Limited Doppler and color Doppler Test Location: East
MICU
Contrast: None Tech Quality: Adequate
Tape #: 2011E000-0:00 Machine: Vivid i-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aorta - Ascending: *3.8 cm <= 3.4 cm
TR Gradient (+ RA = PASP): *26 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2140-10-6**].
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.
LEFT VENTRICLE: Mild regional LV systolic dysfunction. No
resting LVOT gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTA: Mildly dilated ascending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus.
Conclusions
The left atrium is dilated. The right atrium is dilated. There
is mild regional left ventricular systolic dysfunction with mild
septal hypokinesis. The remaining segments contract normally
(LVEF = 45-50%). The right ventricular cavity is moderately
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. 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. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Dilated right ventricle with mild systolic dysfunction.
Compared with the prior study (images reviewed) of [**2140-10-6**],
the findings are similar.
.
BILAT LOWER EXT VEINS Study Date of [**2140-10-6**] 10:49 AM
IMPRESSION: No evidence of DVT in the bilateral lower
extremities.
The study and the report were reviewed by the staff radiologist.
.
Head CT [**10-5**]-IMPRESSION: Chronic microvascular ischemic disease.
Otherwise unremarkable.
.
[**10-5**]:CT abd/pelvis
IMPRESSION:
1. No evidence for mesenteric ischemia.
2. Bilateral lower lobe consolidations, left more than right,
consistent with multifocal pneumonia.
3. Small amount of ascites and gallbladder wall edema,
consistent with third spacing, possibly related to vigorous
fluid resuscitation.
4. Multiple calcified granulomas in the liver and spleen.
5. Left inguinal hernia containing ascites.
6. Air overlying the left groin, likely related to attempted
line placement. Please correlate clinically.
.
[**10-7**] CXR-INDINGS: There is worsening right pulmonary edema.
Consolidations in thelower lobes bilaterally, left greater than
right, and in the hila bilaterally,also left greater than right,
have increased.
Pleural effusions are more conspicuous than before. The cardiac
size is top
normal. There are low lung volumes. Right IJ catheter tip is in
the mid to
lower SVC. There is no evidence of pneumothorax.
.
[**2140-10-17**] 06:45AM BLOOD WBC-11.4* RBC-3.44* Hgb-11.2* Hct-33.9*
MCV-99* MCH-32.7* MCHC-33.1 RDW-14.0 Plt Ct-555*
[**2140-10-18**] 06:40AM BLOOD WBC-8.9 RBC-3.40* Hgb-11.1* Hct-33.6*
MCV-99* MCH-32.8* MCHC-33.1 RDW-13.9 Plt Ct-620*
[**2140-10-18**] 06:40AM BLOOD Glucose-276* UreaN-21* Creat-0.7 Na-131*
K-4.8 Cl-100 HCO3-24 AnGap-12
[**2140-10-6**] 03:49AM BLOOD CK-MB-114* cTropnT-5.21*
[**2140-10-6**] 10:18AM BLOOD CK-MB-112* cTropnT-3.97*
[**2140-10-6**] 11:05PM BLOOD CK-MB-55* MB Indx-4.4 cTropnT-2.72*
[**2140-10-7**] 03:46AM BLOOD CK-MB-43* cTropnT-2.47*
[**2140-10-8**] 03:46AM BLOOD CK-MB-13* MB Indx-1.4 cTropnT-1.82*
[**2140-10-6**] 03:49AM BLOOD %HbA1c-7.7* eAG-174*
[**2140-10-14**] 06:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2140-10-14**] 06:20PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2140-10-14**] 06:20PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
[**2140-10-14**] 06:20PM URINE CastHy-5*
C. diff ([**2140-10-17**]): negative
Blood Culture x 2 sets ([**2140-10-14**]): no growth to date, final
pending.
Brief Hospital Course:
Mr. [**Known lastname **] is a 79 y/o male with a history of DM1 on an insulin
pump last A1c 8.1, hypertension and glaucoma who presented with
diabetic ketoacidosis, NSTEMI, and pneumonia.
.
.
#Diabetetic Ketoacidosis: The potential causes include
pneumonia, NSTEMI, or potentially malfunctioning insulin pump.
He was continued on an insulin drip with D5 in normal or [**1-24**]
normal saline until the anion gap closed and he was tolerating a
PO diet. [**Last Name (un) **] diabetes service provided recommendations. He
was changed to lantus and sliding scale insulin initially.
However, as the Diabetes service felt that the patient would not
be able to resume his insulin pump, and wanted to simplify his
insulin regimen as much as possible, with the goal of having the
patient being able to manage his own insulin regimen at home, he
was then transitioned to a [**Hospital1 **] regimen with Humalog 75/25 mix.
His blood sugars have been stable on this current regimen, and
he will follow-up with is outpatient endocrinologist after
discharge.
.
NSTEMI: The patient was found to have new EKG changes with
elevation in troponin, peaking at 5.21. TTE showed mild
regional left ventricular systolic dysfunction consistent with
CAD. He was evaluated by the cardiology service. The etiology
of his MI was either secondary to hypoperfusion in setting of
pneumonia/sepsis OR he had a primary cardiac event. Management
options including cardiac catheterization were discussed with
the patient and healthcare proxy. The decision was made to not
pursue cardiac catheterization given high probability he would
have multivessel disease and the patient was not interested in
bypass surgery. He was put on a heparin drip for 48 hours,
started on aspirin, plavix, atorvastatin and metoprolol. He has
also received PRN doses of Lasix for volume overload, but
appears to have been euvolemic for several days now off of
Lasix. Can consider additional doses of PRN lasix as needed.
Pt has responded well to low-dose IV lasix of 20mg. The patient
wishes to follow-up with Cardiology closer to home, and will ask
his PCP for [**Name Initial (PRE) **] referral to a local cardiologist. He is also on
his prior home dose of ACE-inhibitor. His [**Last Name (un) **] (losartan) has
been discontinued to simplify his medical regimen, and his ACE-i
can still be uptitrated in follow-up as his blood pressure
allows.
.
#Pneumonia: He was found to have bilateral lower lobe
consolidation concerning for pneumonia. Urine legionella was
negative. He was started on broad spectrum antibiotics for
health care acquired pneumonia given that he is a nursing home
resident. He received a course of vancomycin, aztreonam, and
levofloxacin x8 days. His respiratory status has improved
significantly, he has been afebrile, and his leukocytosis has
resolved as well.
.
#Altered mental status/encephalopathy- This was likely due to
toxic-metabolic encephalopathy, which was likely multifactorial
in the setting of infection, NSTEMI, DKA. His mental status
improved in the ICU to where his son felt he was close to
baseline. AAOx3 on the medical floor. Pt was treated for
infection.
.
#Acute kidney injury: His elevated creatinine on admission was
thought to be due to pre-renal etiology, likely volume depletion
in the setting of infection. He was volume resuscitated with
normalization in the creatinine.
.
#Thrombocytosis-likely reactive thrombocytosis due to recent
infection and DKA. Patient should have repeat CBC checked in
follow-up with his PCP.
.
# Code: Confirmed DNR/DNI with HCP, [**Name (NI) **] [**First Name4 (NamePattern1) **] [**Name (NI) **]:
[**Telephone/Fax (1) 25652**], or [**Telephone/Fax (1) 25653**].
Medications on Admission:
LISINOPRIL 10 mg Tablet daily
LOSARTAN [COZAAR] 25 mg daily
ASPIRIN 325 mg daily
FUROSEMIDE - 20 mg Daily
INSULIN LISPRO [HUMALOG] - 100unit/mL Solution - via pump
BRIMONIDINE - gtt
LATANOPROST [XALATAN] eye gtt
Discharge Medications:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/Wheezing.
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig:
Eighteen (18) units Subcutaneous twice daily (with breakfast and
dinner): if FS < 70, [**Name8 (MD) 138**] MD.
11. sliding scale insulin regimen
please check fingersticks QAC and QHS.
For breakfast and dinner
FS 0-70, [**Name8 (MD) 138**] MD
FS 71 - 200, no units
FS 201 - 250, Humalog 3 units SQ
FS 251 - 300, Humalog 5 units SQ
FS 301 - 350, Humalog 7 units SQ
FS 350 - 400, Humalog 9 units SQ
FS >400, [**Name8 (MD) 138**] MD
For lunch and bedtime
FS 0 - 70, [**Name8 (MD) 138**] MD
FS 71 - 400, no units
FS >400, [**Name8 (MD) 138**] MD
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) **]
Discharge Diagnosis:
[**Hospital 7792**]
health care associated pneumonia
diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were sent from your assisted-living facility for elevated
blood sugars. Initially, you admitted to the ICU and found to
have diabetic ketoacidosis, pneumonia and a heart attack. For
your diabetic ketoacidosis you were followed by the [**Last Name (un) **]
service, given insulin, and your symptoms improved. You will no
longer use your insulin pump. For your pneumonia, you were
started on and completed a course of antibiotics with
improvement in your symptoms. For your heart attack, you were
evaluated by the cardiology service and started on new
medications. You and your family declined a cardiac
catherization during this admission.
.
New Medications:
1.plavix
2.metoprolol
3.atorvastatin
3. Humalog 75/25
.
Please STOP the folowing medications:
1. Losartan
Please take all of your medications as prescribed and follow up
with the appointments below.
.Please follow-up with your doctors as listed below.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
When: [**Last Name (LF) 2974**], [**10-21**], 2PM
.
When you are ready to be discharged from Rehab, please call your
PCP's office, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25654**] at [**Telephone/Fax (1) 4775**]. You have
asked to follow-up closer to home for Cardiology, so please ask
him for a Cardiology referral.
.
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|
3389, 3525
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,298
| 157,677
|
51050+59306
|
Discharge summary
|
report+addendum
|
Admission Date: [**2164-6-14**] Discharge Date: [**2164-6-18**]
Date of Birth: [**2089-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
L temporal metastatic brain tumor
Major Surgical or Invasive Procedure:
L craniotomy for resection of L temporal mass [**2164-6-14**]
History of Present Illness:
Mr. [**Known lastname **] is a 75 yr old right handed gentleman who in
[**Month (only) 116**] was noted to have difficulty word finding. He initially was
seeing PCP for UTI and his wife called PCP when the patient did
not mention symptoms at time of visit.
Work up consisted of chest x-ray which revealed RUL mass and a
brain MRI which revealed left temporal and a right frontal
lesion.
Patient's main symptom is word finding. In the beginning of may,
he was noted to have slurred speech which improved on oral
steroids
The patient was then referred to medical ocology and later to
neurooncology, who in return referred the patient to us for
evaluation.
The patient denies HA,N V, Dz, Sz. He has mild word finding
difficulties but does not metion any significant systemic
complaints.
Past Medical History:
Hypertension
Diverticulitis, surgery approximately [**2152**]
BPH
Social History:
Lives with wife of 51 years in [**Location (un) 4628**]. Has 4
children, 8 grandchildren. Works as a [**Doctor Last Name **] driver for Airport
Sheraton. Hx of 40 pack years tobacco; current [**1-2**] ppd. Drinks
2-3 drinks a week. No illicits
Family History:
Mother - CAD, Father - CVA, diabetes in the family; no
cancer
Physical Exam:
AF VSS
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-2**] bilateral EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Trouble with certain words. When asked what type of place he
was
in, he stated postipal instead of hospital.\
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-5**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception
Reflexes: B T Br Pa Ac
Right 2+2+2+2+2+
Left 2+2+2+2+2+
Coordination: normal on finger-nose-finger
Handedness Right
Exam on Discharge:
Patient is alert and oriented x2, but globaly disphasic.
Motor exam full
Cranial incision on the left with healing wound and disolveable
sutures.
Pertinent Results:
[**5-12**] MRI and fMRI is available for review
This revelas a left side cystic tumor with a mural nodule. It is
located in the superior and middle temporal gyrus between the
frontal oeprculum and the Wernicke area; As it reaches the
surface, it apprears suitable for surgical decompression.
Surgery scheduled for [**6-14**]
Cardiovascular Report ECG Study Date of [**2164-6-14**] 7:43:00 PM
Sinus rhythm. Occasional ventricular premature beats. Compared
to the
previous tracing of [**2164-6-7**] there is no significant diagnostic
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 136 82 362/407 39 28 48
Radiology Report MR HEAD W/ CONTRAST Study Date of [**2164-6-14**] 4:30
AM
IMPRESSION:
1. Unchanged left temporal mass lesion with cystic area and
internal nodular heterogeneous enhancement.
2. Stable right frontal mass lesion with ring enhancement,
likely consistent with metastatic disease. No new lesions are
identified since the most recent exam.
3. Fiducial markers are in place.
CT HEAD W/O CONTRAST Study Date of [**2164-6-14**] 12:11 PM
IMPRESSION:
Expected postoperative changes after a left temporo-parietal
crainotomy and left temporal tumor resection with a small amount
of edema, pneumocephalus, and blood products in the surgical
bed. No evidence of large hemorrhage.
MR HEAD W & W/O CONTRAST Study Date of [**2164-6-15**] 7:29 AM
IMPRESSION: Resection of the left temporal lobe multiloculated
cystic lesion since the MRI of [**2164-6-14**]. Blood products are
seen in the surgical cavity with some marginal or restricted
diffusion. Some residual enhancement is seen at the inner
margin of the surgical cavity. Right frontal lesion is again.
No hydrocephalus or midline shift.
[**6-18**] CXR:
Lung volumes are lower today than on [**6-7**], but there is no
evidence of
pneumonia or pulmonary edema. Suprahilar right upper lobe mass
appears larger, attributable to differences in radiographic
technique although some interval growth is possible. There is
no pneumothorax or pleural effusion. Heart size is top normal.
Brief Hospital Course:
This is a 75 year old Male with left temporal mass presents for
elective resection. The patient was taken to the OR on [**6-14**] by
Dr [**Last Name (STitle) **]. Intraoperatively, there were no complications and
patient was transported to the ICU for close monitoring.
On [**6-15**], Dilantin was discontinued. In the afternoon, the
patient had Right mouth focal motor seizure (? generalization)
that self-resolved within 1-2 minutes. The patient was loaded
with Keppra. Keprra was intiatated at a dose of 1 mg [**Hospital1 **].
On [**6-16**], The patient was very aggitated overnight. Due to
extreme aggitation decadron was weaned to 2 mg [**Hospital1 **]. Ativan
.25mg iv for aggitation given in the afternnon. Due to
constipation a triple bowel regimen was initiated. The
patient's serum BUN was elevated to 33 and poor po intake was
noted with possible difficulty swallowing noted and IVF were
initiated NS at 50 cc/hr. A Urine Analysis was sent in teh
setting of confusion which was negative. Physical Therapy,
Occupational Therapy, and speech therapy consult were placed. On
exam, the patient was intermittently agitated. He followed
simple commands. The patient continued to have difficulties
with little inteligible output. The patient was alert and
oriented to self. Strength was full. There was no pronator
drift.
On [**6-17**], The patient's exam ws consistent with improved
receptive/expressive aphasia. He was able to follow simple
commands and was not aggitated all day. Physical Therapy
determined may go home with 24 hour supervision with PT OT home
safety eval. After discussion with the patient's wife she was
hesitant to take the patient home given his recent periods of
aggitation over the past 24 hours. The patient was given
magnesium citrate forconstipation and had a Bowel Movement.
IVF was infusing at 60cc/hr given low systolic blood pressure of
85 and elevated BUN as well as poor po intake over the past few
days. Physical therapy attempted to work with the patient and
he was orthostatic sbp 70 when sitting. The patient was given a
500 cc bolus. In the late afternoon the patient continued to
have persistent orthostatic hypotension which was slightly
improved. The lung spounds were clear and the patient was given
an additional normal saline bolus of 250cc. The serum sodium was
improved to 136. The serum BUN improved to 27.
Medications on Admission:
Atenolol 25 mg daily
Hydrochlorothiazide 12. 5 mg daily
Lisinopril 20 mg daily
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg once a day Disp #*30 Capsule Refills:*0
3. Dexamethasone 2 mg PO BID
RX *dexamethasone 2 mg twice a day Disp #*60 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg twice a day Disp #*60 Capsule Refills:*0
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. LeVETiracetam 1000 mg PO BID
RX *Keppra 1,000 mg twice a day Disp #*60 Capsule Refills:*1
7. Lisinopril 10 mg PO DAILY
8. Nicotine Patch 14 mg TD DAILY
while not smoking and/or in hospital.
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg every four (4) hours Disp #*60 Capsule
Refills:*0
10. Quetiapine Fumarate 25 mg PO BID
You will need to have an EKG periodically to monitor your QTC by
your pcp.
[**Last Name (NamePattern4) 9641**] *quetiapine 25 mg twice a day Disp #*30 Capsule Refills:*0
11. Pantoprazole 40 mg PO Q24H
Continue medication while taking steroids (dexamethasone)
RX *pantoprazole 40 mg daily Disp #*60 Capsule Refills:*1
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left temporal mass
Right upper lobe mass
Orthostatic hypotension
Expressive Aphasia
Discharge Condition:
Mental Status: Clear and coherent. Globaly dysphasic.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending
?????? **You have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? **You have been 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.
?????? you are being sent home on steroid medication( decadron 2mg po
BID), make sure you are taking a medication to protect your
stomach (Prilosec, Protonix, or Pepcid), as these medications
can cause stomach irritation. Make sure to take your steroid
medication with meals, or a glass of milk.
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
** No wound check needed if being seen in BTC within 14 days.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**6-25**]
at 2:30 pm with Dr. [**Last Name (STitle) **] The Brain [**Hospital 341**] Clinic is located on
the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **].
Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to
change your appointment, or require additional directions.
You also have the following appointment in our system:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2164-6-25**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD Phone:[**Telephone/Fax (1) 2205**]
Date/Time:[**2164-6-26**] 9:10
Completed by:[**2164-6-18**] Name: [**Known lastname 1385**],[**Known firstname **] Unit No: [**Numeric Identifier 17268**]
Admission Date: [**2164-6-14**] Discharge Date: [**2164-6-18**]
Date of Birth: [**2089-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 599**]
Addendum:
added nicotine patch to discharge meds
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2164-6-18**]
|
[
"600.00",
"564.00",
"355.8",
"V49.87",
"784.3",
"458.0",
"V12.72",
"198.3",
"305.1",
"780.39",
"V15.3",
"293.9",
"162.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"00.32"
] |
icd9pcs
|
[
[
[]
]
] |
12461, 12655
|
5256, 7643
|
342, 406
|
8997, 8997
|
3168, 5233
|
11066, 12438
|
1591, 1655
|
7773, 8789
|
8890, 8976
|
7669, 7750
|
9199, 11043
|
1670, 1890
|
268, 304
|
434, 1223
|
2204, 2982
|
3001, 3149
|
9012, 9175
|
1245, 1313
|
1329, 1575
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
878
| 102,365
|
3250
|
Discharge summary
|
report
|
Admission Date: [**2137-10-7**] Discharge Date: [**2137-10-31**]
Date of Birth: [**2061-8-17**] Sex: F
Service: MEDICINE
Allergies:
Lasix / Diuril / Keflex / Iodine
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Dyspnea, Renal Failure, anemia, fluid overload
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
76 year old female with h/o IPF on chronic prednisone, COPD with
trach, CHF, mechanical mitral valve, pacemaker, and anemia who
presents with several days of worsening dysypnea, peripheral
edema, and fatigue. She reports difficulty walking very short
distances due to SOB and lightheadness frequently. She reports
[**2-28**] pillow orthopnea that remains unchanged from baseline. She
reports frequent productive cough that occasionally is bloody,
last bloody sputum was this morning. She reports frequency of
cough and sputum production is same as baseline. She believes
she has had an unknown amount of weight gain. Peripheral edema
fluctuates in severity. She denies changes in bowel habits and
denies changes in urination. She denies changes in appetite,
denies fever, chills, chest pain, nausea, vomiting, abdominal
pain, melena, and BRBPR.She denies sick contacts and recent
travel.
In the ED, labs were significant for Hct 14, INR 10, creatinine
2.1. Had peripheral edema on exam. She was ordered for 2 units
PRBCs (not given due to difficult crossmatch), crossmatched 4
units. Also given 5mg po vitamin K. She was not given lasix or
FFP. Most recent vitals 85 113/49 23 100% 5L.
.
In the MICU, she was noted to be short of breath and had brown,
guaiac positive stool.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats,denies headache, sinus
tenderness, rhinorrhea or congestion.Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.
Past Medical History:
- s/p mechanical mitral valve repair [**2125**]
-sinus node dysfunction s/p DDD pacemaker placement [**2125**]
- atrial flutter s/p ablation [**2-/2132**] and cardioversion [**11-3**]
- congestive heart failure, Last echo [**2137-9-12**] LVEF= 40-45%
Moderate to severe [3+] tricuspid regurgitation
- chronic obstructive pulmonary disease: 4LO2 trach at home at
rest
- idiopathic pulmonary fibrosis on chronic prednisone
- chronic kidney disease; baseline creatinine 1.3-1.6 on [**2137-9-18**]
UreaN-40* Creat-1.1
- anemia due to mechanical valve and chronic kidney disease
- hypertension
- hypercholesterolemia
- hypothyroidism
- meniere??????s disease (HOH)
- spinal arthritis
- breast cancer radical mastectomy right breast [**2095**]. Partial
left [**2097**].
- s/p hysterectomy [**2101**]
- s/p nasal embolization for refractory epistaxis [**6-30**]
Social History:
-smoked 36 years, quit in [**2111**].
-denies alcohol use.
-no IVDU.
-requires assistance with all ADLs and IADLs
-uses walker at baseline.
-housekeeper 2x /week in past.
-peapod for groceries.
-HHA twice a week and for assitance with showers.
-husband does [**Name2 (NI) 14994**].
-Husband [**Name (NI) 9102**] [**Name (NI) **] [**Telephone/Fax (1) 15153**]
Family History:
Father had polymyositis and coronary artery disease; mother had
metastatic bone cancer. She has several cousins with breast
cancer.
Physical Exam:
Vitals: T:98.3 BP:119/51 P:86 R:13 SpO2:100%
General: Alert, oriented, short of breath, difficulty finishing
sentences
HEENT: Sclera anicteric,pale conjuctiva, no tenderness,
increased pigmentation bilateral cheeks, dry oral mucosa,
oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardia, normal S1 loud mechanical S2, no rubs,no
gallops
Lungs: slight use of accessory muscles,decreased breath sounds
bilaterally L>R, crackles in R Lung, large healed scar on R
chest in mammary region from radical mastectomy
Abdomen:refused
GU: foley
Rectal: refused
Ext: cap refill <2 sec, +2 pitting edema upper and lower
extremities
Pertinent Results:
[**2137-10-7**] 02:24PM WBC-13.6*# RBC-1.49*# HGB-4.6*# HCT-14.2*#
MCV-95 MCH-30.6 MCHC-32.1 RDW-17.5*
[**2137-10-7**] 02:24PM PLT COUNT-240#
[**2137-10-7**] 02:24PM NEUTS-92.1* LYMPHS-4.3* MONOS-2.0 EOS-1.4
BASOS-0.1
[**2137-10-7**] 02:24PM PT-86.1* PTT-53.0* INR(PT)-10.0*
[**2137-10-7**] 02:24PM GLUCOSE-254* UREA N-72* CREAT-2.1* SODIUM-138
POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-29 ANION GAP-17
[**2137-10-7**] 02:24PM cTropnT-0.13*
[**2137-10-7**] 03:20PM IRON-13*
[**2137-10-7**] 03:20PM calTIBC-329 HAPTOGLOB-122 FERRITIN-64 TRF-253
[**2137-10-7**] 03:20PM CK-MB-3 proBNP-1495*
[**2137-10-7**] 03:20PM ALT(SGPT)-20 AST(SGOT)-23 LD(LDH)-405*
CK(CPK)-48 ALK PHOS-48 TOT BILI-0.3
[**2137-10-7**] 08:36PM RET MAN-15.1*
[**2137-10-7**] 10:03PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2137-10-7**] 10:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2137-10-7**] 10:03PM URINE OSMOLAL-335
[**2137-10-7**] 10:03PM URINE HOURS-RANDOM UREA N-451 CREAT-71
SODIUM-39 POTASSIUM-44 CHLORIDE-29
.
Day of Discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
11.4* 3.32* 9.7* 30.1* 91 29.3 32.3 16.7* 169
.
PT PTT INR(PT)
20.4* 47.3* 1.9
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
87 76* 1.7* 152 3.1* 109* 28 18
.
Anemia work-up
retic: 6.6
calTIBC Hapto Ferritn TRF
329 122 64 253
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
30 28 72 492* 0.4
.
TFTs
TSH: 12
FT4: 1.1
Images:
[**10-7**] Chest AP: Low lung volumes with known idiopathic pulmonary
fibrosis. While a subtle superimposed acute consolidation in the
lung bases is difficult to exclude, it would be highly
coincidental and is felt less likely with the increased opacity
likely due to crowding.
CXR ([**10-8**]):
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Status post sternotomy, status post valvular
replacement. The
external and internal pacemaker with leads are visible.
Unchanged evidence of a right basal opacity with a predominantly
reticular pattern, that might, in part be, fibrotic. These are
likely to be related to the known history of idiopathic
pulmonary fibrosis. There is no evidence of fluid overload on
the current image. No pleural effusions. No parenchymal
opacities have newly occurred.
.
CT Torso: [**10-27**]
IMPRESSION:
1. Emphysema and pulmonary fibrosis with mild bibasilar
consolidations, worse on the right than the left, likely
reflecting atelectasis, although
superimposed pneumonia cannot be excluded.
2. Status post right mastectomy.
3. Cholelithiasis in a nondistended gallbladder with mild wall
edema/pericholecystic fluid likely reflects either CHF or
hypoproteinemia.
4. Diverticulosis without diverticulitis.
5. No evidence of intra-abdominal free air or organized fluid
collection.
6. Indistinct pancreatic head; correlate with pancreatic enzymes
if clinical concern for pancreatitis.
.
RUQ US [**10-25**]
1. Sludge and stones in the gallbladder neck without other
findings to
suggest acute cholecystitis. If there is continued clinical
concern, a HIDA scan may be more definitive in the exclusion of
acute cholecystitis.
2. Dilated hepatic veins consistent with diastolic dysfunction
.
CT Head [**10-20**]
1. No acute intracranial abnormality.
2. Small vessel ischemic disease and diffuse cerebral atrophy.
.
Pathology:
Bronchial lavage:
ATYPICAL.
Atypical squamous cells.
Bronchial cells and inflammatory cells.
.
Colonic polyp, distal ascending/proximal transverse (biopsy):
1. Fragments of adenoma with focal high grade dysplasia.
.
Micro:
[**2137-10-28**] 2:47 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2137-10-29**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-10-29**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15154**] @ 0550 ON
[**2137-10-29**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2137-10-27**] 2:27 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2137-10-29**]**
GRAM STAIN (Final [**2137-10-27**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2137-10-29**]):
MODERATE GROWTH Commensal Respiratory Flora.
[**2137-10-27**] 1:09 am URINE Source: Catheter.
**FINAL REPORT [**2137-10-28**]**
URINE CULTURE (Final [**2137-10-28**]):
YEAST. ~7000/ML.
Brief Hospital Course:
76 y.o woman with PMH of IPF,COPD,anemia, mechanical mitral
valve,and pacemaker presents with worsening dyspnea, acute renal
failure, and fluid overload.
#. Anemia: On admission hemoglobin of 4.6 and hematocrit of 14.2
from a
hgb 10 and hct 33.1 within the last several weeks. Hemolysis
labs negative, and rectal exam showed guiac positive brown
stool. Her anemia was believed to be secondary to a GI bleed.
She was transfused 4 units total with appropriate hct response,
and her hct/hgb ramined stable. She underwent EGD/colonoscopy
which showed esophageal and fundal varices and a large polyp in
the colon, concerning for malignancy which was believed to be
the source of bleeding. On biopsy, this lesion was found to be
an adenoma with high grade dysplasia. Gastroenterology believed
that it would be possible to perform a transluminal resection
but that the procedure would have high risk of perforation and
death. After a goals of care discussion with the [**Hospital 228**]
health care proxy, [**Name (NI) **] [**Name (NI) 15155**], and the gastroenterology team
it was decided that though the adenoma is high risk for
malignancy, she will likely succumb to her severe pulmonary
disease in the next 1-5 years and removal of the mass is not in
line with her goals of care. She was started on nadolol for
esophageal varaces.
OUTPATIENT ISSUES:
-- Obtain 2x weekly HCTs and transfuse for HCT <21
-- Continue Fe supplementation and epo administration
.
#. Hypoxemic respiratory failure: The patient presented on 5L
trans-trach from a baseline of 4L at home in the setting of
known IPF, COPD, and chronic heart failure. Her dyspnea was
attributed to anemia vs fluid overload from CHF, and remained
stable in-house and gradually improved upon discharge from the
ICU. There was low suspicion for a COPD or IPF exacerbation.
She was given IV Torsemide for diuresis with her packed red cell
transfusions, and her home Bumex was held in-house. Her home
prednisone and nebulizers were continued in-house. Related to
her shortness of breath, she occassionally coughed up "blood
balls", which she attributed to bloodly mucous originating at
her catheter site. These were inconsistent, and associated with
epistaxis, and we believed that there was a component of bloody
post-nasal drip contributing, exacerbated by the fact that she
was on a heparin gtt for her heart valve. The total blood loss
from these episodes was essentially non-contributory. On the
floor, she continued to be dyspneic at times. She was found to
have evidence of a RUL HAP, so she was started empirically on
vancomycin and cefepime. She developed progressive respiratory
distress and returned the MICU where she was intubated. She
underwent broncheoalveolar lavage which was culture negative and
her antibiotics were discontinued on [**10-23**]. She continued to be
intermittently diuresed but it was stopped when her creatinine
bumped from 1.8 to 2.7. She was extubated and returned to the
medical floor with o2 sats 95% on 2LNC The thought is that her
respiratory distress was likely due to a mucus plug and
pulmonary edema. After two days on the medical floor, she pulled
out a nasogastric tube which had been used for tubefeeds,
aspirated and developed respiratory distress with hypoxia and
acidemia. She was transferred to the MICU for a third time where
she was again intubated. Out of concern for HCAP the pt was
started on vanc/[**Last Name (un) 2830**]. Due to increasing wbc and decreased stool
output there was also concern for c.diff, which ultimately was
positive, and the pt was started on flagyl/PO vanc. The pt's
respiratory status improved and she was successfully extubated.
Vancomycin was discontinued on [**10-30**] with plan to complete a
total of 8d of meropenem.
OUTPATIENT ISSUES:
-- Continue meropenem thru [**11-3**].
-- Ongoing discussion regarding replacement of transtracheal
catheter.
.
#Clostridium Difficile: The pt was found to have a rising WBC,
episodes of hypotension and decreased stool output. She was
empirically started on IV flagyl and PO vanco which were
continued when stool culture was positive for c.diff. Pt had
subsequent decreased in WBC to normal with improvement in loose
stools.
OUTPATIENT ISSUES:
-- Plan to complete PO vancomycin 125mg PO Q6hrs as well as
Flagyl 500mg Q8hrs; end date [**11-9**].
.
#Anticoagulation: Patient anticoagulated due to presence of
mechanical valve. Patient presented with an INR of 10 for
unclear reasons. She received 5mg PO Vit K, and her INR
down-trended to the sub-therapeutic range and she was started on
a Heparin gtt for her mechanical mitral valve. She experienced
epistaxis and coughed up bloody mucus in the setting of a
slightly supratherapeutic PTT which resolved with decreasing her
Heparin gtt. She was kept on a heparin drip for bridging on the
medicine floor. When the decision was made to pursue
endomucosal resection of her adenoma, her warfarin was
discontinued, however given this was put on hold, the pt was
restarted on coumadin [**10-29**]. At time of discharge patient
remained on hep gtt as well as coumadin 3mg daily; INR on day of
discharge 1.9
OUTPATIENT ISSUES:
-- COntinue hep gtt and coumadin until INR therapeutic (2.5 -
3.5).
.
#Volume Status/Acute Renal Failure. Patient with oscillating
renal function in house. Peak Cr 2.8 from a baseline of ~1.4,
likely secondary to hypovolemia as well as renal hypoperfusion
[**2-27**] anemia. Urine lytes showed were consistent with
hypovolemia. Initially Bumex was held and she was given IV
hydration. Creatinine increased from 1.8-2.7 in the setting of
diuresis (as above) and bumex was held. During hospital stay
patient was intermittently diuresised and prior to discharge
restarted on PO Bumex 5mg daily with creatinine of 1.7. Weight
at time of discharge: 62.4kg ; sating >95% on 5L NC.
OUTPATIENT ISSUES:
-- Pleae continue Bumex 5mg PO daily; monitor weights daily as
well as renal function; may consider increasing bumex to [**Hospital1 **] or
transitioning to IV if weight increases >3lb
.
# Esophageal Varices. Newly diagnosed. Patient placed on nadolol
10mg daily.
.
# Hypertension. Patient largely hypotensive to normotensive in
house. Decision made to hold home amlodipine 5mg daily as well
as spironolactone 50mg [**Hospital1 **] at time of discharge.
OUTPATIENT ISSUES:
-- Close hemodynamic monitoring; plan to re-initiate
anti-hypertensives if needed.
.
# Pulmonary fibrosis. Patient with transtracheal O2 catheter as
well as use of chronic steriods as an outpatient. During 1st
intubation transtracheal cath was removed. In house patient
received stress dose steriods which were weanted to home
prednisone 10mg daily at time of discharge.
OUTPATIENT ISSUES:
-- Continue chronic prednisone; consider need for PCP [**Name9 (PRE) **]
[**Name9 (PRE) **] Continue discussion re replacement of transtracheal cath
.
# Hypernatremia. Patient noted to be intermittently
hypernatremic when NPO/intubated. Received free water boluses
thru NGT as well as IV D5 with improvement. Na at time of
discharge 152
OUTPATIENT
-- Continue monitoring of electrolytes; encourage PO intake and
adminster D5W if needed (however by cautious in setting of known
diastolic CHF).
# Goals of Care: On [**2137-10-25**] a goals of care discussion was held
with the patient's HCP [**Name (NI) **] [**Name (NI) 15155**]. The decision was made to
forgo aggressive management of the colonic adenoma as her life
expectancy with idiopathic pulmonary fibrosis (which she has
suffered with for ~8 years) is now less than 5 years and likely
less than one. The family wanted the patient to remain full code
and to have aggressive management of her pulmonary disease.
# Code: Full
# HCP [**Name (NI) **] [**Name (NI) 15155**] [**Telephone/Fax (1) 15156**]
.
.
TRANSITIONAL ISSUES
===================
Health Care Associated Pneumonia treatment
-- Continue on meropenem for planned 8d course, end date [**11-3**]
.
C. Difficile infection
-- Continue on flagyl and PO vanc for planned 10d course; end
date: [**11-9**]
.
Congestive Heart Failure
-- Continue PO Bumex 5mg daily; monitor weights as well as renal
function with weekly chem 10 panel
.
Mitral Valve Replacement; goal INR 2.5 - 3.5
-- Continue hep gtt until bridged with coumadin, 3mg daily, to a
therapeutic INR
.
Colonic Polyp; GI bleed
-- Please check twice weekly hematocrit check with plan to
transfuse if <24
.
Arrythmia
-- Restarting home dofetilide on discharge; primary cardiologist
aware.
.
Hypernatremia
-- Patient with improved PO intake in days leading up to
discharge however sodiums borderine in 140s-150s. Please monitor
closely to ensure patient does not need additional free water to
correction of electrolyte abnormality.
.
PCP [**Name Initial (PRE) **]:
[**Month (only) 116**] consider starting PCP prophylaxis given chronic steroid use.
Discussed with the patient's pulmonologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient
has been on it in the past, but when she was on higher doses of
PO steroids (~20 mg) chronically.
Left kidney mass was seen on CT abdomen which is new since [**2134**]
and will need follow up ultrasound and monitoring.
Medications on Admission:
1.amlodipine 5 mg PO DAILY
2.fexofenadine 60 mg Tablet PO BID
3.levothyroxine 112 mcg Tablet PO DAILY
4.omeprazole 20 mg Capsule, Delayed Release PO BID
5.multivitamin One Tablet PO DAILY
6.tiotropium bromide 18 mcg Capsule, w/Inhalation Device One Cap
Inhalation DAILY
7.atorvastatin 20 mg Tablet One Tablet PO DAILY
8.docusate sodium 100 mg Capsule One Capsule PO BID
9.dofetilide 125 mcg Capsule One Capsule PO Q12H
10.albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Two
Puff Inhalation Q4H (every 4 hours)PRN dyspnea.
11.cholecalciferol (vitamin D3) 1,000 unit Tablet Two Tablet PO
DAILY 12.fluticasone 110 mcg/Actuation Aerosol Two Puff
Inhalation [**Hospital1 **] 13.morphine 15 mg Tablet Extended Release One
Tablet
14.morphine 10 mg/5 mL Solution [**1-28**] PO Q4H PRN dyspnea.
15.calcium carbonate 200 mg calcium (500 mg) Tablet [**Hospital1 **]
16.warfarin 5 mg One Tablet PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR).
17.warfarin 2 mg One Tablet PO 3X/WEEK (TU,TH,SA).
18.Epogen 20,000 unit/mL One Injection once a week.
19.guaifenesin 600 mg Tablet Extended Release One
Tablet Extended Release PO twice a day.
20.bumetanide 5 mg Tablet [**Hospital1 **]
21.prednisone 10 mg Tablet Sig: Please follow attached taper
instructions. Tablet PO once a day: On [**8-9**], take 40mg (4
tablets once daily). On [**8-11**], take 30mg (3 tablets once
daily). On [**8-14**], take 20mg (two tablets once daily). On
[**9-26**] and onwards, take 10mg per day (one tablet once daily).
22.ferrous sulfate 325 mg (65 mg iron) One Tablet PO once a day.
23.spironolactone 50mg [**Hospital1 **] added [**2137-10-5**]
Discharge Medications:
1. Outpatient Lab Work
Please obtain twice weekly hematocrits, INR (INR goal 2.5 - 3.5)
2. Outpatient Lab Work
Please obtain twice weekly chemistry panels (sodium, potassium,
chloride, bicarb, BUN, creatinine, mag, calcium, phosp) to
monitor for hypernatremia and chronic kidney insufficiency
3. bumetanide 1 mg Tablet Sig: Five (5) Tablet PO once a day.
4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
5. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: goal inr 2.5 - 3.5.
6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): TO END [**2137-11-9**].
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day.
9. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
13. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO twice a
day.
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
16. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
17. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day as needed for pain: hold for
sedation, RR< 12.
19. morphine 10 mg/5 mL Solution Sig: [**1-28**] PO every four (4)
hours as needed for shortness of breath or wheezing.
20. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
21. Epogen 20,000 unit/mL Solution Sig: One (1) Injection once
a week: Please administer on Monday.
22. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
23. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): TO END [**2137-11-9**].
24. heparin (porcine) in D5W Intravenous
25. nadolol 20 mg Tablet Sig: 0.5 Tablet PO once a day.
26. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every eight (8) hours for 3 days: TO END [**2137-11-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
GI bleed secondary to colonic lesion
Health care associated pneumonia
Acute on chronic kidney insufficiency
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms [**Known lastname **] it was a pleasure taking care of you.
You were admitted to [**Hospital1 18**] for evaluation of GI bleed and while
in house you developed respiratory compromise requiring
intubation.
.
Regarding the GI bleed, you were seen by our team of GI doctors
who performed a colonscopy. During the procedure a colonic
lesion was seen and a plan was devised to proceed for excisional
biopsy. You were transfused RBCs as needed and your blood counts
were monitored closely. After discussion with your family the
decision to undergo biopsy was deferred to the outpatient
setting.
.
While in house your breathing became labored on several
occassions which required intubation twice. The cause of the
distress included aspiration and possible pneumonia. You were
started on antibiotics with a plan to complete an 8d course.
Your transtracheal catheter was removed with plan to discuss
replacement as an outpatient. At time of discharge you were
oxygenating well using supplemental oxygen delivered by nasal
cannula.
Also you were noted to have an infection in your GI tract and
were started on antiobiotics to eradicate this bacteria.
Prior to discharge you were feeling much improved and the
decision was made to transition to a nursing facility/rehab
where you can work to optimize strength, mobility and nutrition.
.
CHANGES TO YOUR MEDICATIONS:
START 10mg Nadolol daily for gastric varices
CONTINUE MEROPENEM until [**2137-11-3**]
CONTINUE VANCOMYCIN AND FLAGYL until [**2137-11-9**]
STOP SPIRONOLACTONE and AMLODIPINE until told otherwise
CHANGE COUMADIN to 3mg daily (goal INR 2.5 to 3.5)
CHANGE BUMEX to 5mg daily (previously 5mg twice a day)
Again it was a pleasure taking care of you. Please contact with
any questions or concerns.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2137-11-26**] at 8:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
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66,079
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Discharge summary
|
report
|
Admission Date: [**2177-6-20**] Discharge Date: [**2177-6-26**]
Date of Birth: [**2146-7-21**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid / Iodine-Iodine Containing
Attending:[**First Name3 (LF) 5806**]
Chief Complaint:
Chief Complaint: Headache
Reason for ICU Admission: Monitoring after contrast allergic
reaction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
Ms. [**Known lastname **] is a 30 year old lady on HD (previously PD until
[**4-/2177**]) for ESRD secondary to type 1 DM for the past 3 years.
Per her mother with whom she lives, she developed a headache,
hypoglycemia, nausea and vomiting and abdominal pain with chills
over the past day. She was also more combative and somnolent at
home. She did have HD on Thursday as scheduled and per a
nephrology census note, has a history of catheter infections.
She was brought in by ambulance to the [**Hospital1 18**] for further
evaluation.
.
In the ED, initial vs were: 100.4 90 [**Telephone/Fax (2) 5809**]. Patient
underwent LP after receiving Vanc, CTX and acyclovir and blood
cultures. CSF unrevealing. The patient also underwent Head CT
and CXR. She was slated for CT Ab/Pelvis with IV contrast to
evaluate her abdominal pain given her recent hernia repair
(despite her mother's protestations) and during the contrast
exposure, developed rapid facial swelling, oropharyngeal rash
without wheezing or hives. She was given Solumedrol,
Famotidine, Benadryl and 1L NS for allergic reaction and
transferred to the ICU for further monitoring. CT Ab with PO
contrast was obtained prior to transfer. Renal was consulted. VS
ib transfer: 87 199/93 14 100% RA- no headache or chest pain.
.
On the floor, the patient is somonolent but arousable. She is
tacitly refusing to answer questions but does respond to
commands and express her displeasure at my attempt to interview
her. A brief meeting with her mother confirmed the story above.
.
Review of systems: Unable to obtain
Past Medical History:
Past Medical History:
- ESRD since [**2174-8-29**] HD through L IJ Tunnelled line
- Peritonitis [**8-7**]
- Type I DM complicated by neuropathy and nephropathy
- Bilateral cataract surgeries
- Ventral Hernia, repaired [**4-/2177**]
Social History:
- Lives with her mother, + tobacco history, social ETOH,
marijuana use noted in history
Family History:
DM type II, otherwise NC
Physical Exam:
Initial Exam:
Vitals: T: 98.7 BP: 188/89 P: 88 R: 14 O2: 100% RA
General: Sleeping, arousable, no acute distress
HEENT: Swollen facies, tongue, eyelids. No upper airway wheezes
Neck: supple, JVP not elevated, no LAD
Lungs: Limited exam, anteriorly, laterally and apically clear.
CV: S1 & S2 regular without murmur appreciated. Tunnelled L IJ
present on chest, not erythematous
Abdomen: Soft, tender, patient swatted away my hand on attempted
examination, bowel sounds present.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
Labs on Admission:
[**2177-6-20**] 07:29PM CEREBROSPINAL FLUID (CSF) PROTEIN-51*
GLUCOSE-109
[**2177-6-20**] 07:29PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-1*
POLYS-78 LYMPHS-10 MONOS-12
[**2177-6-20**] 09:32AM GLUCOSE-166* LACTATE-1.8 K+-4.0
[**2177-6-20**] 09:20AM GLUCOSE-176* UREA N-40* CREAT-7.6* SODIUM-140
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-27 ANION GAP-23*
[**2177-6-20**] 09:20AM estGFR-Using this
[**2177-6-20**] 09:20AM LIPASE-39
[**2177-6-20**] 09:20AM LIPASE-39
[**2177-6-20**] 09:20AM ALBUMIN-5.0 CALCIUM-9.4 PHOSPHATE-5.0*
MAGNESIUM-2.5
[**2177-6-20**] 09:20AM WBC-13.5*# RBC-4.50 HGB-13.4 HCT-40.8 MCV-91
MCH-29.9 MCHC-32.9 RDW-16.5*
[**2177-6-20**] 09:20AM NEUTS-90.3* LYMPHS-6.5* MONOS-2.0 EOS-0.8
BASOS-0.4
Labs on Discharge:
[**2177-6-26**] 07:10AM BLOOD WBC-4.5 RBC-4.69 Hgb-13.8 Hct-43.9 MCV-93
MCH-29.4 MCHC-31.5 RDW-16.4* Plt Ct-206
[**2177-6-26**] 07:10AM BLOOD Glucose-600* UreaN-29* Creat-6.5*#
Na-132* K-4.7 Cl-91* HCO3-29 AnGap-17
[**2177-6-26**] 07:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.7*
Imaging:
CXR ([**6-20**]): IMPRESSION: No acute pulmonary process. Dialysis
access recently replaced,
but otherwise no interval change noted.
CT Head w/o contrast ([**6-20**]): IMPRESSION: Normal head CT, without
acute intracranial process.
CT Abdomen/Pelvis w/o contrast ([**6-20**]):
IMPRESSION:
1.Small soft tissue density noted within the subcutaneous fat
overlying the previous site of ventral hernia, likely
post-surgical changes. No evidence of abscess or colitis.
2. Focal ground glass opacity in right lower lobe could be due
to edema, infectious or inflammatory change. Small left pleural
effusion.
3. Small amount of intermediate density free fluid in the
pelvis, a nonspecific finding. If there are symptoms referable
to the pelvis then pelvic ultrasound would further evaluate.
Abdominal u/s ([**6-25**]):IMPRESSION: Findings compatible with
surgical mesh material in the anterior abdominal wall at the
site of hernia repair with adjacent hypoechoic vascularized
tissue that may represent scarring or keloid. No evidence of
bowel containing hernia. Continued clinical followup with
palpation is recommended. If the mass continues to grow, then
further assessment could be obtained with MRI.
Brief Hospital Course:
30F on HD for ESRD [**12-31**] type 1 DM who p/w headache,
nausea/vomiting and abdominal pain, whose hospital course was
complicated by an anaphylactic rxn to IV contrast. The patient
was started on vancomycin/cefepime/cipro for fevers and
leukocytosis, but no source of infection was found.
.
1) Abdominal pain and fevers: The patient presented with a
diffusely tender abdomen, fevers, and leukocytosis. There was
concern for intraabdominal process given recent PD catheter
removal and hernia repair. CT abdomen with contrast was
complicated by allergic reaction (described below). CT
abd/pelvis without contrast showed no evidence of abscess or
colitis. There were no clear localizing findings on physical
exam. The patient received a course of vancomycin, cefepime, and
ciprofloxacin; all were discontinued when the patient remained
afebrile for >48 hours. The patient's pain, fevers, and white
count resolved by the time of discharge.
.
2) Contrast reaction: The patient developed rapid facial
swelling, oropharyngeal rash without wheezing or hives upon
administration of IV contrast. She was given Solumedrol,
Famotidine, Benadryl and 1L NS for allergic reaction and
transferred to the ICU for further monitoring. There was no
evidence of respiratory compromise, and did not require
intubation during her hospital course. The patient's facial
swelling resolved during the course of her hospital stay.
.
3) Type 1 DM: The patient developed hyperglygemia in the setting
of steroid administration during her allergic reaction. The
patient had consistent BS readings in the 400s while in the ICU.
There was no evidence of anion gap acidosis. Once the patient
arrived on the floor, [**Last Name (un) **] was consulted to help manage her
diabetes. The patient's dose of lantus was adjusted, but
ultimately she remained well-controlled on her home dose of
lantus and ISS.
.
4) Headache: The patient presented with severe headache, that
resolved by day 3 of hospital course. A LP performed in the ED
was negative for infection.
.
5) ESRD on HD: The patient underwent HD as an inpatient as per
her schedule. The patient's lisinopril dose was reduced from
40mg to 10mg as per Renal recommendation.
.
6) HTN: The patient's SBP ranged from 140-200 during the course
of her hospital stay. The higher numbers were attributed to pain
that the patient was experiencing.
.
Medications on Admission:
Aspirin 81mg PO daily
B Complex Vitamins 1 Cap Daily
Carvedilol 12.5mg PO BID
Cinacalcet 30mg PO Daily
Docusate Sodium 100mg PO BID
Epoetin Alfa [Epogen] 10,000 unit INJ weekly
Folic Acid 1mg PO daily
Furosemide 60mg PO daily
Insulin Aspart [Novolog] sliding scale
Insulin Glargine 10 units SQ Daily
Latanoprost 0.005 % Drops One (1) Drop Ophthalmic HS
Lisinopril 20mg PO daily
Oxycodone PRN
Sennosides [Senna] PRN
Sevelamer HCl 800mg PO TIDAC
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) INJ
Injection once a week.
6. Insulin Aspart Subcutaneous
7. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units
Subcutaneous once a day.
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Type I Diabetes
Allergic Reaction to contrast dye
ESRD on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital for evaluation and treatment
of your severe headache, fevers, nausea, and vomiting. In the
process of evaluation, you developed a serious allergic reaction
to the contrast solution used for imaging. Once stabilized after
the reaction, your blood sugars were managed through adjustments
in your insulin regimen. You were dialyzed according to your
home schedule. Your fevers did not appear to be caused by an
underlying infection.
Please CHANGE the following medications:
From LISINOPRIL 40mg daily to LISINOPRIL 10mg daily.
Please STOP the following medications:
Folic Acid
Lasix (Furosemide)
Followup Instructions:
Please follow-up at the following times/places:
Please schedule a follow up visit with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] by
calling
[**Telephone/Fax (1) 250**]. Please schedule this visit within 1-2 weeks.
.
Department: [**Hospital **] HEALTH CENTER
When: FRIDAY [**2177-7-4**] at 10:40 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5808**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PODIATRY
When: TUESDAY [**2177-7-8**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], 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
.
Department: TRANSPLANT CENTER
When: THURSDAY [**2177-10-9**] at 9:20 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
|
[
"789.00",
"693.0",
"366.9",
"585.6",
"357.2",
"V45.11",
"E947.8",
"403.91",
"250.61",
"250.41",
"780.60",
"784.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9008, 9014
|
5280, 7644
|
393, 400
|
9186, 9186
|
3010, 3015
|
10024, 11250
|
2410, 2437
|
8138, 8985
|
9035, 9035
|
7670, 8115
|
9337, 10001
|
2452, 2991
|
2015, 2034
|
275, 355
|
3773, 5257
|
456, 1995
|
9054, 9165
|
3029, 3754
|
9201, 9313
|
2078, 2289
|
2305, 2394
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,806
| 110,603
|
2146+55354+55359
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2122-1-10**] Discharge Date: [**2122-1-25**]
Date of Birth: [**2052-4-9**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Erythromycin Base / Oxycodone
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Fever, [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line and Swan Ganz catheter placement
Chest tube placement
History of Present Illness:
69 year-old female with CAD s/p RCA stent x 2 (last one [**2121-12-26**]
post IMI), CHF with EF 60%, PVD s/p aorto-bifem bypass, and s/p
left brachial pseudoaneurysmal repair, transferred from
[**Hospital3 3834**] with fever and hypotension, as well as
troponin leak. Of note, she was recently admitted to [**Hospital1 18**] on
[**2121-12-26**] with sudden onset right-sided CP and SOB, and was found
to have NSTEMI (ST depressions in lateral leads, peak troponin
of 5.0), with mild CHF. A cardiac catheterization revealed 95%
RCA stenosis (in-stent re-stenosis). A RCA Cypher stent was
placed with 10% residual stenosis. She was discharged home on
[**2121-12-27**].
On [**2122-1-8**], she presented to [**Hospital3 3834**] [**Hospital3 **] with
non-exertional right-sided CP, along with SOB, which is her
anginal equivalent. Symptoms lasted approximately 1/2 hour, and
were improved but not resolved with SLNTG. In the ER her vital
signs were stable with T 97.0, BP 147/64, RR 18, Sat 98%RA. JVP
was elevated at 6cm, lungs with end expiratory wheezes. An EKG
revealed NSR with RBBB, no acute changes. Her initial CK was 25,
trop 0.04, WBC 4.8, and Cr 0.9. She was treated with aspirin,
nebs for possible COPD flare, and started on heparin IV for
possible unstable angina. While in the hospital, she had a
Myoview, showing an inferior filling defect.
On the night prior to admission to the [**Hospital1 18**], she became
hypotensive with SBP to low 80's, temperature to 104, CK of 300
and CKMB 15.7, trop I 13.5. Her BP did not improve with fluid
resuscitation, and she was transferred to the [**Hospital1 18**] CCU on
neosynephrine and heparin IV for possible re-cath. Of note, she
was on 50% FM, with decreased UO.
Further history revealed a sister with recent influenza and
hospitalization. ROS otherwise negative for worsening orthopnea,
PND, DOE, diarrhea, dysuria.
Past Medical History:
1. CAD. Cardiac cath in [**2117**] with 80% proximal RCA lesion,
50-60% distal RCA lesion, 50% OM and a 40% distal LM/PLAD
lesion. S/p PTCA and stent placement to the proximal RCA.
Cardiac cath [**2118**]: RCA had an ostial 30-40% stenosis and mild
30-40% diffuse in-stent restenosis. EF of 60%. Cardiac cath
[**2121-12-26**], with 30% instent restenosis in the previously placed
RCA stent, and 95% mid vessel stenosis. PTCA with Cypher stent
placement performed, with 10% residual stenosis.
2. CHF, last EF 60% in [**2118**].
3. Hypothyroidism
4. Diabetes mellitus type 2
Past Surgical History:
1. Aorto-bifem bypass [**2111**]
2. Pseudoaneurysm repair '[**17**]
3. Bilateral cataract surgery
Social History:
She lives with her sister, no etOH. Ex-smoker, stopped smoking 9
years ago (smoked [**12-21**] ppd X 35 yrs).
Family History:
N/A
Physical Exam:
Physical examination on admission per resident note:
VITALS: T 99.9, HR 125, BP 101/42, RR 18, Sat 100% on 4L
HEENT: WNL
NECK: JVP 6 cm ASA.
RESP: Bibasilar crackles.
CVS: Tachycardic, regular. Normal S1, S2. No S3, S4. No murmur
or rub.
GI: BS normoactive. Abmone soft, non-tender.
Ext: No bruit at cath site. No hematoma. No clubbing, cyanosis.
No pedal edema.
Pertinent Results:
Relevant laboratory data on admission:
WBC-5.2 RBC-3.49* HGB-10.3* HCT-31.2* MCV-89 MCH-29.6 MCHC-33.2
RDW-14.9
PLT COUNT-267
GLUCOSE-177* UREA N-25* CREAT-1.2* SODIUM-136 POTASSIUM-4.7
CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-1.1*
Cardiac enzymes:
[**2122-1-10**] 11:30AM CK(CPK)-234*
[**2122-1-10**] 11:30AM CK-MB-14* MB INDX-6.0 cTropnT-1.22*
[**2122-1-10**] 07:48PM CK-MB-10 MB INDX-5.1 cTropnT-1.11*
[**2122-1-10**] 07:48PM CK(CPK)-198*
EKG: NRS, rate 125 bpm. [**Street Address(2) 4793**] depressions in V3-6, ST
depressions in II (old). TW flattening in III+aVF.
Relevant studies in hospital:
[**2122-1-10**] ECHO:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed. Resting regional wall
motion abnormalities include inferior, inferoseptal, and
inferolateral akinesis with relative preservation of the lateral
and anterior walls..
3.Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets are mildly thickened. Insufficent
doppler studies performed of the aortic valve to determine the
presence of stenosis or regurgitation.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen but studies limited..
6.There is no pericardial effusion.
****************
[**2122-1-13**] ECHO:
The left atrium is normal in size. The left ventricular cavity
is dilated.
There is severe global left ventricular hypokinesis (LVEF
25-30%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a fat pad, though
a loculated anterior pericardial effusion cannot be excluded.
****************
[**2122-1-19**] ECHO:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated with severe global
hypokinesis. No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size is normal with mild
global right ventricular free wall hypokinesis. The aortic valve
leaflets appear structurally normal. Mild (1+) aortic
regurgitation is seen. The mitral leaflets and supporting
structures are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2122-1-13**], the
findings are similar (Overall LVEF was somewhat overestimated on
the prior study).
Brief Hospital Course:
69 year-old female with CAD s/p RCA stent on [**2121-12-27**] for
in-stent restenosis, CHF, PVD, who returned to [**Location **] on [**1-8**]
with chest pain, initially ruled out, and who then developed
fever to 104, hypotension and rise in troponin I, transiently on
Neo drip, transferred to [**Hospital1 18**] for further management. Her
hospital course will be reviewed by problems.
1) CAD: On arrival, an echo revealed an EF of 25%, and resting
regional wall motion abnormalities with inferior, inferoseptal,
and inferolateral akinesis with relative preservation of the
lateral and anterior walls. CK was 250, Troponin 1.22 (peak),
EKG without ST elevations. Her picture was felt most consistent
with sepsis with demand-related ischemia rather than stent
thrombosis, and the decision was taken not to proceed to cardiac
catheterization. Her most recent cath in [**Month (only) 404**] revealed
single-vessel CAD which was stented. A PA line was placed on
admission, with initial numbers CVP 11, PA 43/16, SVR 620, CO/CI
7.1/3.76 felt most consistent with sepsis physiology, and MUST
protocol was initiated, with fluid resuscitation. She required
pressors intermittently, intially Neosynephrine, then Levophed,
which were eventually weaned off. She was continued on Heparin
IV for 48 hours, then D/C'd.
While in hospital, she was continued on ASA, Plavix and Lipitor.
BB and ACE were temporarily held in the setting of hypotension.
BB therapy was eventually resumed when BP stable. ACE inhibitor
held pending recovery of renal function, resumed on [**2122-1-21**]
with improving renal function and titrated up.
Follow-up arranged with Dr. [**Last Name (STitle) 11493**] 1 week following discharge.
She will need repeat LFT's as an out-patient given dose
titration of Lipitor.
2) CHF: On admission, an echo revealed a depressed EF with
inferior, inferoseptal, and inferolateral akinesis. She
eventually developed pulmonary edema secondary to aggressive
fluid resuscitation in the setting of likely sepsis. Diuresis
was initiated when the patient was hemodynamically stable, and
she was intermittently placed on a Lasix drip prior to
extubation, with good diuresis. Subsequent echocardiograms
revealed poor EF approximately 20% (overestimated on [**2122-1-13**])
with global LV hypokinesis. It is unclear whether her current
cardiomyopathy can all be accounted for by ischemic
cardiomyopathy. Mycoplasma titers were sent (given her
respiratory illness, possible contribution to cardiomyopathy)
and still pending at discharge. Please repeat an out-patient
echo in 2 weeks to reassess LVEF.
Post-extubation, she was given Lasix intermittently, with a goal
negative daily fluid balance. Her CXR picture slowly improved.
ACE inhibitor therapy was held pending recovery of her renal
function, and was resumed on [**2122-1-21**]. She was discharged on
Lasix 20 mg PO QD. She will need daily weights, with titration
of Lasix to 40 mg PO QD if weight increases >3 lbs. Weight at
discharge 68.7 (likely still [**1-22**] kg from goal weight). Again,
please consider a repeat echo in 2 weeks as an out-patient to
reassess LVEF.
3) Pulmonary: On admission, a PA line was placed via the left
subclavian vein, complicated by a tension pneumothorax requiring
intubation and emergent chest tube placement. Her course was
complicated by reaccumulation of the pneumothorax on water seal,
replaced on suction. She was difficult to extubate. Serial ABGs
and labs revealed a non-anion gap metabolic acidosis, with
compensatory hyperventilation. Bicarbonate was repleted. She was
also aggressively diuresed pre-extubation, and was finally
extubated on [**2122-1-17**]. The chest tube was pulled on [**2122-1-18**],
without subsequent reaccumulation. Her oxygen requirements
slowly declined with continued diuresis. She was also started on
a Prednisone taper for possible COPD exacerbation, to be
continued as an out-patient. She was given bronchodilator
therapy via nebulizers, changed to inhalers at discharge. She is
on room air to 1L/min at discharge.
4) ID: As mentionned above, her initial presentation was felt
consistent with sepsis, and the MUST protocol was instituted.
The initial CXR revealed atelectasis but no definite
consolidation. She was ruled out for influenza. All cultures
were unremarkable, including sputum, urine and blood cultures.
She was empirically started on Levofloxacin on admission.
Vancomycin and Flagyl were added on [**2122-1-11**] in the setting of
ongoing fever and hypotension and she completed an empiric 7-day
course of antibiotics, D/C'd on [**2122-1-16**]. Serial CXRs failed to
reveal a definite consolidation, and it was felt that she may
have had a viral pneumonia. She defervesced around hospital day
#6, and has been afebrile since.
5) Renal failure: Patient with baseline creatinine of 0.5-0.7,
up to 1.2 on admission. Her creatinine rose to a peak of 1.7 in
hospital. Renal was consulted to address her renal failure and
non-anion gap metabolic acidosis. The latter was felt to be
likely secondary to her renal failure and also dilutional in the
setting of large volume resuscitation. Her renal failure was
felt most likely secondary to ATN (although FeNA<1%), and renal
function gradually recovered. Creatinine 1.1 on [**2122-1-22**].
6) Heme: While in hospital, her WBC count was noted to be
trending down (nadir 2.7), which was felt most likely secondary
to myelosuppression in the setting of acute illness. She was
also anemic, and was transfused 2 units of PRBCs on [**2122-1-12**] to
maintain her hematocrit above 30. Hematocrit at discharge 33.2.
Please consider out-patient work-up of anemia (? GI work-up).
Medications on Admission:
Medications prior to admission to outside hospital:
Aspirin 325 mg PO QD
Plavix 75 mg PO QD
Losartan 50 mg PO QD
Lipitor 40 mg PO QD
Imdur 60 mg PO QD
Glyburide 5 mg PO QAM, 10 mg PO QHS
Levothyroxine 100 mcg PO QD
Toprol XL 100 mg PO QD
Albuterol, Atroven inhalers
Metformin
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
7. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: [**12-21**]
inhalations Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
8. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
Disp:*1 diskus* Refills:*2*
12. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) Inhalation
four times a day.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: Please take first dose on [**2122-1-23**].
Disp:*3 Tablet(s)* Refills:*0*
15. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: Please start after 20 mg tapered dose. .
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease
Congestive heart failure
Pneumothorax
Acute renal failure resolving
Probable viral pneumonia
Diabetes mellitus type 2
Hypothyroidism
Discharge Condition:
Patient discharged to rehabilitation facility in stable
condition.
Discharge Instructions:
increases > 3lbs.
We have scheduled an appointment for you with Dr. [**Last Name (STitle) 11493**] on
Wednesday [**1-28**] at 10:45. It is important that you go to
this appointment.
We have made some changes to your medications. Please take only
the medications that we have prescribed.
Followup Instructions:
We have scheduled an appointment for you with Dr. [**Last Name (STitle) 11493**] on
Wednesday [**1-28**] at 10:45. It is important that you go to
this appointment.
Completed by:[**2122-1-22**] Name: [**Known lastname 400**],[**Known firstname 1617**] E Unit No: [**Numeric Identifier 1618**]
Admission Date: [**2122-1-10**] Discharge Date: [**2122-1-25**]
Date of Birth: [**2052-4-9**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Erythromycin Base / Oxycodone
Attending:[**First Name3 (LF) 1619**]
Addendum:
Feces came back positive for C. difficile on [**2122-1-24**] (results
back on [**2122-1-25**]). Rehabilitation facility contact[**Name (NI) **] and Flagyl
prescribed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1620**] - [**Location (un) 1621**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1622**] MD [**MD Number(2) 1623**]
Completed by:[**2122-1-26**] Name: [**Known lastname 400**],[**Known firstname 1617**] E Unit No: [**Numeric Identifier 1618**]
Admission Date: [**2122-1-10**] Discharge Date: [**2122-1-25**]
Date of Birth: [**2052-4-9**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Erythromycin Base / Oxycodone
Attending:[**First Name3 (LF) 1619**]
Addendum:
Ms. [**Known lastname **] developed watery diarrhea on the anticipated day of
discharge, along with a leukocytosis and thrombocytosis. She was
kept in hospital for close monitoring. Stool was sent for C.
difficile, still pending at discharge but low suspicion.
Metformin was also stopped in the setting of hypoglycemia
(likely secondary to poor PO intake) and known possible GI side
effects. Her diarrhea resolved, as well as her leukocytosis (WBC
11-->6.6) and thrombocytosis (platelet 610s -->477). The latter
was felt to be most likely reactive. She had no diarrheal stools
X 24 hours prior to discharge. Possible viral gastroenteritis.
Of note, as mentionned above, she had hypoglycemia in the days
preceding discharge (mostly fasting hypoglycemia with fasting BS
50s). Glyburide 10 mg PO QPM D/C'd, as well as Metformin 1000 mg
PO BID. She was kept only on Glyburide 5 mg PO QAM. Please
reintroduce her oral hypoglycemics gradually as an out-patient
(at rehab) with close monitoring of her blood sugars.
She has a scheduled follow-up appointment with Dr. [**Last Name (STitle) 1653**] on
Wednesday [**1-28**]. Please consider a repeat echo in
approximately 2 weeks as an out-patient to reassess LV function.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1620**] - [**Location (un) 1621**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1622**] MD [**MD Number(2) 1623**]
Completed by:[**2122-1-25**]
|
[
"512.0",
"410.72",
"285.9",
"428.0",
"038.9",
"250.00",
"584.9",
"414.00",
"480.9",
"244.9",
"995.92",
"496",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.04",
"96.6",
"96.72",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
17412, 17643
|
6488, 12140
|
334, 427
|
14398, 14466
|
3594, 3619
|
14803, 15542
|
3191, 3196
|
12466, 14103
|
14218, 14377
|
12166, 12443
|
14490, 14780
|
2949, 3048
|
3211, 3575
|
3880, 6465
|
264, 296
|
455, 2330
|
3634, 3863
|
2352, 2926
|
3064, 3175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,485
| 106,527
|
3656
|
Discharge summary
|
report
|
Admission Date: [**2174-2-9**] Discharge Date: [**2174-2-14**]
Date of Birth: [**2136-10-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Left calf pain
Major Surgical or Invasive Procedure:
1. Ultrasound-guided puncture of left soleal vein.
2. Introduction of catheter into inferior vena cava.
3. Left iliofemoral popliteal venogram and inferior
venacavogram
4. AngioJet thrombolysis of left iliofemoral popliteal deep
venous thrombosis.
5. Placement of lysis catheter in the left iliofemoral
venous system.
History of Present Illness:
37yF with crohns, well known to our service, recently
discharged after undergoing an Exlap, takedown of ileocolonic
anastamosis, ileosigmoid fistula and LAR. She was then taken
back for peritonitis and found to have ischemic right colon and
underwent resection of this. In the post-op period she
continued
to have multiple intraabdominal abscesses which were drained
multiple times by IR. She was discharged home [**2174-1-28**].
She recently was seen by Dr. [**Last Name (STitle) **] in the clinic and her
last drain was removed. Over the past few days she has noticed
increased swelling and pain in her left lower extremity.
She denies SOB, chest pain, did have one episode of vomiting
this
morning. Admits to poor nutrition since discharge. Normal BMs
and passing flatus. No abdominal pain.
Past Medical History:
Crohn's disease, status post-ileocecectomy [**1-24**]
s/p ccy [**2165**]
vitamin B12 and vitamin D deficiency
Social History:
She is a tax assistant. She currently is off of work. She is
single. She moved in with her mother. She quit tobacco smoking
three months ago. She drinks wine socially. She denies drug
use.
Family History:
She is of Haitian descent. There is no IBD or GI cancers in the
family.
Physical Exam:
at discharge:
Gen: a and o x3, NAD
V.S: 98.9, 93, 131/86, 20, 98%RA
CV: RRR, no m/r/g
Resp: lscta bl
Abd: soft, non-tender
Ext: good pulses
Pertinent Results:
[**2174-2-13**] 03:54AM BLOOD WBC-7.4 RBC-3.61* Hgb-9.8* Hct-29.3*
MCV-81* MCH-27.2 MCHC-33.5 RDW-16.5* Plt Ct-279
[**2174-2-9**] 11:52AM BLOOD Neuts-86* Bands-0 Lymphs-8* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2174-2-14**] 05:47AM BLOOD PT-26.0* INR(PT)-2.6*
[**2174-2-10**] 03:28PM BLOOD Fibrino-415*
[**2174-2-14**] 05:47AM BLOOD K-3.5
[**2174-2-14**] 05:47AM BLOOD Mg-2.1
[**2174-2-13**] 11:47PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2174-2-13**] 11:47PM URINE RBC-10* WBC-167* Bacteri-NONE Yeast-NONE
Epi-66
[**2174-2-13**] 11:47PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
.
[**2-9**]: CTA chest-large right main pulmonary artery emboli
.
[**2-12**] CXR: A right PICC has been placed and terminates in the
cavoatrial junction. There are patchy airspace opacities in the
right perihilar region and left lower leg. These have not
changed substantially since the prior study. Heart and
mediastinum are unremarkable.
Brief Hospital Course:
The patient was admitted to the SICU for close assessment. A
foley was placed, telemetry monitor was placed and
IVF/medications were started. A CTA was done and indicated a
large left lower extremity venous thrombus and PE. Vascular was
consulted and the patient was started on a heparin drip and
taken to the OR for emergent IVC filter placement, thrombolysis
of left iliofemoral popliteal deep
venous thrombosis and placement of lysis catheter in the left
iliofemoral venous system.. The patient returned to the SICU and
was administered two units of packed red cells for a hematocrit
of 22 with good response. A PICC line was place on [**2-10**]. The
patient's diet was advanced to regular and her IVF were d/c'd,
medications were changed to oral.
.
The patient was bridged from heparin to coumadin and was also
started on plavix. She was transfered to [**Hospital Ward Name **] 5 on [**2-11**].
[**2-13**] PTT/INR were theraputic and the heparin drip was d/c'd. The
patient was provided oral/written education regarding coumadin
and plavix. Her potassium was also low during this admission.
However the patient was unable to tolerate the oral supplements
provided inpatient (tablets). She was repleated with IV
potassium and encouraged to eat high potassium foods. Nutrition
was consulted to provide more education regarding this. Her
pharmacy was [**Month/Year (2) 653**] and they carry potassium capsules, she
will try to take these. She was advised to call her PCP if she
can not tolerated these pills.
The patient's PCP was [**Name (NI) 653**] and she will follow up on [**2-18**]
to check lab's.
Social work has arranged follow-up for the patient. She will be
[**Month/Year (2) 653**] by the social work team in regard to this follow-up.
At the time discharge, she was afebrile, tolerating a regular
diet and was feeling safe about going home.
Medications on Admission:
Vit B12, colace, cipro 500'', flagyl 500''', FeSO4', Famotidine
20'', fluconazole 400'
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months: Take with pain medication.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 1 weeks: do not take more than
4000mg in 24 hrs. .
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 1600 (): Please
take daily at 4pm. .
Disp:*30 Tablet(s)* Refills:*2*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 1 months.
Disp:*60 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Primary:
Left lower extremity deep vein thrombosis with pulmonary
embolus.
.
Secondary:
Crohn's disease, status post-ileocecectomy [**1-24**]
s/p ccy [**2165**]
vitamin B12 and vitamin D deficiency
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral 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 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.
.
Medications:
1. Coumadin:
-You were started on this medication secondary to a blood clot.
-Please take this medication every day at 4:00.
-You need to see your PCP [**Name9 (PRE) 16579**] to have lab's drawn to check
your INR/PTT.
-Your PCP will adjust the dose according to the INR/PTT level.
2. Clopidogrel/Plavix
-You were started on this medication to prevent future clots.
-You should take this every day.
.
Potassium:
-Your potassium level has been low while you were in the
hospital.
-Please eat foods that are high in potassium (refer to foods on
handout provided).
-Please take potassium capsules daily. If you can not take these
please call your PCP.
[**Name10 (NameIs) **] will need to have lab work drawn to check you potassium
level. This will be done at your PCP's office.
Followup Instructions:
1. Please call Dr.[**Name (NI) 10946**], [**Telephone/Fax (1) 9**], office to make a
follow up appointment in [**12-28**] weeks.
.
2. Please follow up with your PCP, [**First Name8 (NamePattern2) 15**] [**Name11 (NameIs) **],[**Name12 (NameIs) 16577**] F. B.
[**Telephone/Fax (1) 16578**], on [**2-18**] at 1200. If you can not make this
appointment please call his office. You need to have labs drawn
to check you INR/PTT and potassium level's. Your PCP may adjust
your coumadin dose.
.
3. Please call DR. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] from vascular, [**Telephone/Fax (1) 16580**], to make a follow up appointment in [**11-26**] weeks.
.
Scheduled Appointments:
Provider: [**Name10 (NameIs) 1248**],BED THREE [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2174-3-10**]
5:00
You will be [**Month/Day/Year 653**] by [**Name (NI) 16581**] [**Name (NI) 16582**] in social work. She will
coordinate with your visiting social worker to obtain a
therapist consultation as an outpatient.
Completed by:[**2174-2-15**]
|
[
"266.2",
"555.9",
"415.19",
"268.9",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.90",
"39.79",
"88.51",
"38.93",
"00.41",
"38.7",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
5849, 5922
|
3102, 4960
|
326, 658
|
6165, 6243
|
2101, 3079
|
8140, 9221
|
1852, 1926
|
5097, 5826
|
5943, 6144
|
4986, 5074
|
6267, 8117
|
1941, 1941
|
1955, 2082
|
272, 288
|
686, 1490
|
1512, 1624
|
1640, 1836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,411
| 172,206
|
49276
|
Discharge summary
|
report
|
Admission Date: [**2156-11-24**] Discharge Date: [**2156-11-28**]
Date of Birth: [**2086-2-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 70-year-old female with stage IIIC ovarian
cancer. She is status post one cycle of carboplatin and Taxol
chemotherapy alone. She is status post 5 doses of IV
chemotherapy with intraperitoneal cisplatin given on
day #2 and status post 4 doses of intraperitoneal Taxol given on
day #8. She has just received her last dose of chemotherapy last
Thursday. Today is cycle #6, day #13 of chemotherapy. She was
seen in clinic today for an acute complaint of RUQ pain. [**Known firstname 2429**]
states that she
has a deep right upper quadrant pain on palpation, movement, and
inspiration. She rated this pain a [**9-5**]. No actual chest pain,
no nausea, vomiting, diarrhea, constipation. She is moving her
bowels and going to the bathroom without problems. She is eating
well as well.
Patient was tachycardic in clinic. given pleuritic pain and
hyprecoagulable state, she was sent to ED for evaluation. IN ED
patient had CT Torso which revealed a saddle embolus and right
sided saddle embolus with near complete occlusion of RLL pulm.
artery, with wedge shaped consolidation in RLL likely
representing infarction as well as a Left common femoral vein
acute DVT, as well as left gonadal vein thrombus. Patient wAs
started on IV heparin and remained hemodynamically statble
throught her 9 hour emergency room visit.
Given fever, patient also cultured and given dose of cefepime in
ED.
Upon arrival to the floor: Patient VS: 100.1 150/100 110 20 100%
RA. [**Known firstname 2429**] continues to experience RUQ pain, R sided pleuritic
chest pain and mild shortness of breath with exertion. She
denies any chest pain at rest, denies any lightheadness,
dizziness or palpitations. ROS is otherwise negative.
Past Medical History:
-HTN
-Hypercholesterolemia
Past Surgical History:
-Removal rectal polyp
-Biopsy of left breast mass
-Bilateral tubal ligation
Past Gynecologic History:
-LMP age 47. h/o uterine fibroids. No h/o abnormal paps.
Past Obstetric History:
-G6P4
Social History:
Pt used to work at [**Hospital1 18**]. Pt is married. Denies tob/etoh/drug
use.
Family History:
No family h/o cancer
Physical Exam:
GEN: chronically ill appearing female in mild resp distress
VS:100.1 150/100 110 20 100%RA
HEENT:PERRL, OP-clear, no erythema, no exudates
NECK:
CVS:? split S1 S2 tachy
Chest: rales 1/2way up on Right side; +splinting
Abd:obese; soft; Non-tender
ext:+2 edemia b/l
Pertinent Results:
[**2156-11-24**] 02:40PM WBC-3.7* RBC-3.95* HGB-11.0* HCT-31.7*
MCV-80* MCH-27.7 MCHC-34.5 RDW-19.4*
[**2156-11-24**] 02:40PM NEUTS-43.6* LYMPHS-51.1* MONOS-4.2 EOS-0.8
BASOS-0.3
[**2156-11-24**] 02:40PM ANISOCYT-2+ MICROCYT-2+
[**2156-11-24**] 02:40PM PLT COUNT-138*
[**2156-11-24**] 11:54AM UREA N-19 CREAT-1.0 SODIUM-135 POTASSIUM-3.3
CHLORIDE-94* TOTAL CO2-31 ANION GAP-13
[**2156-11-24**] 11:54AM ALT(SGPT)-73* AST(SGOT)-53* LD(LDH)-315* ALK
PHOS-100 AMYLASE-79 TOT BILI-0.5
[**2156-11-24**] 11:54AM LIPASE-23
[**2156-11-24**] 11:54AM ALBUMIN-4.0 MAGNESIUM-1.7
[**2156-11-24**] 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2156-11-24**] 03:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2156-11-24**] 03:57PM LACTATE-1.3
CXR: IMPRESSION: Low lung volumes. Opacities in both bases are
likely secondary to atelectasis. Followup PA and lateral
examinations may be helpful when the patient is clinically able.
CTA CHEST: The heart, pericardium, and great vessels are
unremarkable. There is no evidence of pleural or pericardial
effusion. No significant axillary, hilar, or mediastinal
lymphadenopathy is identified. The central airways are patent
bilaterally.
There is a large saddle embolus in the right main pulmonary
artery, which nearly completely occludes the right lower lobe
pulmonary artery, and there is evidence of wedge shaped,
parenchymal opacity localized to the right lower lobe, which may
represent pulmonary infarction. Some contrast passes the
embolism to the right middle and right upper lobe pulmonary
arteries, and the lung parenchyma in these areas is
unremarkable. There is no evidence of pulmonary embolism on the
left side. The left lung fields are clear.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver enhances
homogeneously, without evidence of focal intrahepatic lesion.
There is no evidence of ascites. There is no evidence of intra-
or extra-hepatic biliary ductal dilatation. The gallbladder,
pancreas, spleen, and adrenal glands are unremarkable. There is
evidence of a subcutaneous Chemo-Port in the left abdominal
wall, with a peritoneal catheter extending into the left lower
quadrant. The kidneys enhance symmetrically and excrete contrast
normally bilaterally. The ureters are normal in appearance,
without evidence of hydronephrosis. Within the midpole of the
right kidney, there is a low attenuation focus measuring 1.4 x
1.8 cm, which contains low-density fluid, consistent with a
simple cyst. Smaller hypodensities are seen throughout both
kidneys, but are too small to definitively characterize. The
stomach and opacified loops of intraabdominal bowel are
unremarkable. There is no free air, free fluid, or pathologic
mesenteric or retroperitoneal lymphadenopathy.
Expansile, centrally located thrombus is seen within the left
gonadal vein, beginning inferiorly at the level of the mid psoas
muscle and extending proximally up to and involving the
confluence at the superior mesenteric vein. No thrombus is seen
more proximally than the SMV. Expansile, acute thrombus is also
seen within the left common femoral vein, extending proximally
to the level of the pubic symphysis.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon,
pelvic loops of bowel, urinary bladder, and distal ureters are
unremarkable. The patient is status post hysterectomy. No free
fluid is seen within the pelvis, and no abnormal pelvic or
inguinal lymphadenopathy is identified.
CT head:
1. No evidence of intracranial hemorrhage or mass effect.
2. No enhancing lesions identified.
3. Mottled appearance of the calvarium, suggesting possible
renal osteodystrophy.
EKG: nl sinus; Left axis deviation; t wave inversion III; .5mm
st depression V5-6
Brief Hospital Course:
.
A/P: 70 y.o. woman with a history of metastatic ovarian CA
presenting with chest pain, found to have large pulmonary
embolus with significant DVT clot burden, hemodynamically
stable, saturating well on RA, now on lovenox.
.
# PE with large DVT clot burden. The patient presented with
chest pain and was found on CT scan to have a large saddle
embolus with near complete occlusion of the RLL pulmonary artery
and a likely infarct of the RLL. CT scan also revealed left
common femoral vein DVT and Left gonadal vein thrombus. It is
likely that these clots occurred secondary to hypercoaguability
of malignancy. The patient was hemodynamically stable. EKG
showed sinus tachycardia without clear signs of Right heart
strain. The patient was initiated on IV heparin and briefly sent
to the ICU out of concern for her considerable clot burden and
potential hemodynamic complications. The patient had a fever,
likely secondary to her clot burden. The patient was changed to
lovenox for long-term anticoagulation. She remained
hemodynamically stable throughout her admission, saturating well
(>95%) on RA and with improved chest pain. Lower extremity
ultrasound was ordered to further assess clot burden. However,
the ultrasound tech was not available to complete the study and
after discussion with radiology it was felt that the CT scan
provided adequate imaging of the deep veins. There was no change
of management to be made based upon the Lower extremity
ultrasound study. The patient will likely require life-long
lovenox vs. coumadin therapy.
.
# Anemia. On admission, the patient's Hct dropped from 34.4 to a
nadir of 26.4 in the setting of new anticoagulation. The patient
had no obvious source of bleeding. The patient's Hct stabilized
and trended upward prior to discharge.
.
# Ovarian CA. Intravenous and intraperitoneal chemotherapy per
primary oncologist.
.
# HTN. Well controlled on CCB and diuretic.
.
# Leukopenia. Likely secondary to chemotherapy. Not neutropenic
by numbers.
.
# Fever. Resolved. Likely secondary to clot burden. Cultures
without growth to date.
.
# Hyperlipidemia. The patient's statin therapy was held while
LFT's were elevated, likely secondary to recent chemotherapy.
This therapy was re-instated prior to discharge as her LFT's
normalized.
Medications on Admission:
MEDICATIONS: Norvasc 5 mg po QD, this is dose reduced from her
primary care doctor from 10 mg po QD. Lipitor 10 mg p.o. once
daily, Compazine, hydrochlorothiazide 12.5 mg p.o. once daily,
milk of magnesia.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 60* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pulmonary embolism with large deep vein thrombosis clot burden
.
Metastatic ovarian cancer
Hypertension
Hypercholesterolemia
Discharge Condition:
Good, saturating well on room air with decreased chest pain.
Discharge Instructions:
You were admitted with chest pain. This was likely due to blood
clots in your lungs. These clots came from the blood vessels in
your legs and abdomen. This is likely a complication from your
ovarian cancer. You were started on a medication, called lovenox
(also called enoxaparin), to thin your blood and prevent further
clotting. Please inject this medication as you have been taught
twice a day.
.
Follow-up with Dr. [**Last Name (STitle) 2244**] in the oncology clinic on [**2156-12-2**] for further management of your ovarian cancer and blood
clot complications.
.
Take all medications as prescribed. The only change in your
medications is the addition of Lovenox (also called enoxaparin).
.
Call your doctor or return to the hospital for any new or
worsening chest pain, shortness of breath or other concerning
symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2156-12-2**] 9:30
Provider: [**Name11 (NameIs) 5558**],[**Name12 (NameIs) 5557**] HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2156-12-2**] 9:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
[
"V10.43",
"415.19",
"272.0",
"E933.1",
"284.8",
"453.41",
"453.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9603, 9661
|
6631, 8907
|
326, 333
|
9830, 9893
|
2806, 6339
|
10767, 11188
|
2485, 2507
|
9166, 9580
|
9682, 9809
|
8933, 9143
|
9917, 10744
|
2175, 2369
|
2522, 2787
|
278, 288
|
361, 2102
|
6348, 6608
|
2124, 2152
|
2385, 2469
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,588
| 144,952
|
9120
|
Discharge summary
|
report
|
Admission Date: [**2205-12-23**] Discharge Date: [**2205-12-27**]
Date of Birth: [**2143-12-3**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Roxicet / Sirolimus
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
R femoral central venous line placement ([**2205-12-23**])
Esophagogastroduodonoscopy ([**2205-12-23**]) with 3 clip placement to
stop duodenal ulcer
History of Present Illness:
62 yo male with history of HBV/HCV/EtOH cirrhosis s/p liver
[**Month/Day/Year **] on immunosuppression, ESRD on HD, polymyositis on
prednisone, recent STEMI ([**2205-12-5**]) on ASA/plavix, recent
diagnosis of duodenal ulcer s/p clipping and injection
([**2205-12-2**]) presents with hypotension, melena. Patient went to
his usual HD session today and was noted to have BRBPR and
hypotensive in the 70's. He only received 20 minutes of his HD
session today. Sent to the ED for further management.
In the ED, his initial VS were: 94, 77/55. He had a large amount
of guaiac positive stool, described by the ED resident as a
mixture of cherry red, maroon, and melanotic stool. His
hematocrit is down from 33 on his last discharge to 23 today.
Blood pressure has been averaging in the high 90s - 100s.
Patient was given a bolus of pantoprazole 80 mg IV and started
on pantoprazole drip. Hepatology was consulted who recommended
that the ED transfuse blood. Patient has limited access, has a
PICC line in his left arm and a 20 gauge in his right. They
wanted to give him zosyn, given his WBC of 17.9 and
immunosuppressed status, however did not have the IV access to
give it while he is on the PPI drip and getting blood. MICU
resident requested that more IV access be obtained. Vital signs
on transfer were: 97.5, 86, 95/59, 18, 100% on 2L. Hepatology
plans to perform EGD today and requested his ASA/Plavix be
stopped. This was discussed with the interventional cardiology
fellow who stated that it would be preferable to continue his
anticoagulation given he is only 1 month out from his BMS
placement ([**2205-12-5**]) but decision to stop anticoagulation would
be up to the primary team.
Once in the MICU, patient was alert and oriented. Stated he felt
'fatigued' but admitted to some epigastric abdominal pain.
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:
s/p liver [**Month/Day/Year **] [**1-8**] HBV, HCV, and EtOH abuse ([**2194**])
s/p hepatic artery replacement ([**2195**])
ESRD on HD
Asymptomatic strokes ([**2195**]: left corona radiata and posterior
putaminal infarct, periventricular white matter disease; [**8-12**]
MRI with evidence of chronic cerebellar infarcts)
Frontal gait disorder of unclear etiology
Central and obstructive sleep apnea (sleep study [**2203**])- not on
CPAP
Polymyositis of unclear etiology though possibly from tacrolimus
Seizure disorder
Paraproteinemia
Cataract removal
Retinal detachment
Inguinal hernia repair
Duodonal ulcer [**2205-12-2**]
STEMI with BMS to proximal LAD ([**2205-12-5**])
Social History:
Patient lives with wife and pets (3 cats, 2 dogs). They have no
children. He denies current use of tobacco or EtOH. Says he has
smoked 2ppd for 40 years and quit 7 years ago. Also endorses
heavy drinking history (~30 years) and says he drank 6pack/day
at his worst. He quit EtOH use several years prior to
[**Year (4 digits) **]. H/o IVDU as per previous records. Walks w/ walker at
baseline.
Family History:
The patient is adopted. No known family history of stroke or
neurological disease.
Physical Exam:
On DISCHARGE:
Vitals - T:98.6/98.6 BP:108/74 (102-172/57-100) HR:84(76-92)
RR:18 02 sat: 99% RA
GENERAL: Middle aged male comfortable in no acute distress
CHEST: CTABL no wheezes, no rales, no ronchi
CV: Systolic II/VI murmur at the LUSB with radiation to the
apex. RRR.
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT:Stable right groin hematoma. wwp, no edema. DPs, PTs 2+.
SKIN: Stable well circumscribed erythemia at the insertion point
of the right dialysis tunneled catheter. nontender, no increased
warmth.
NEURO: CNs II-XII intact. 5/5 strength in Left U/L extremities.
4+/5 strength in Right U/L extremities. DTRs 3+ BL patellar,
DTRs 2+ BL (biceps, bracheo rad).
Pertinent Results:
[**2205-12-23**] 09:40AM BLOOD WBC-17.9*# RBC-2.63*# Hgb-8.1*#
Hct-23.1*# MCV-88 MCH-30.7 MCHC-35.1* RDW-17.0* Plt Ct-145*
[**2205-12-23**] 01:00PM BLOOD Hct-20.1*
[**2205-12-23**] 06:55PM BLOOD Hct-37.7*#
[**2205-12-23**] 09:42PM BLOOD WBC-15.1* RBC-2.71* Hgb-8.1* Hct-23.3*#
MCV-86 MCH-30.0 MCHC-34.9 RDW-16.5* Plt Ct-140*
[**2205-12-23**] 10:40PM BLOOD Hct-23.4*
[**2205-12-24**] 03:02AM BLOOD WBC-13.4* RBC-3.84*# Hgb-11.5*#
Hct-31.1*# MCV-81* MCH-30.0 MCHC-36.9* RDW-15.8* Plt Ct-102*
[**2205-12-24**] 08:39AM BLOOD Hct-30.3*
[**2205-12-24**] 02:14PM BLOOD Hct-29.2*
[**2205-12-24**] 03:02AM BLOOD ALT-25 AST-35 CK(CPK)-102 AlkPhos-33*
TotBili-0.9
.
HCT TREND:
[**12-27**] at 11am 26.4
[**12-27**] at 6am 25.8
[**12-26**] 28.6
[**12-25**] 30.6
.
Discharge:
[**2205-12-27**] 12:02PM BLOOD Hgb-9.7* Hct-26.4*
[**2205-12-27**] 05:41AM BLOOD Glucose-76 UreaN-29* Creat-3.3* Na-141
K-3.5 Cl-107 HCO3-27 AnGap-11
[**2205-12-26**] 05:58AM BLOOD ALT-38 AST-54*
EGD ([**2205-12-23**]): Duodenal bulb ulcer s/p clipping x 3
.
Brief Hospital Course:
62 yo male with history of HBV/HCV/EtOH cirrhosis s/p liver
[**Year (4 digits) **] on immunosuppression, ESRD on HD, polymyositis on
prednisone, recent STEMI ([**2205-12-5**]) on ASA/plavix, recent
diagnosis of duodenal ulcer s/p clipping and injection
([**2205-12-2**]) admitted with with hypotension, melena and found to
have recurrent upper GI bleed. Admitted to MICU, underwent
repeat EGD and clipping.
.
# Acute Blood Loss Anemia: From upper GI bleed requiring ICU
admission, intubation, EGD and clipping of vessel overlaying
duodenal ulcer. Hematocrit on admission was 20.3 down from 33 on
his last discharge. Aspirin and plavix were held after
discussion with cardiology initially and restarted after HD
stability maintainted. He was transfused a totaly of 7 units
PRBC and he was hemodynamically stable and hematocrit was stable
x 96 hours at the time of discharge.
.
# R Groin Hematoma: Occurred in setting of femoral line
placement for transfusion in setting of upper GI bleed. No signs
of vacsular compromise or compartment syndrome, hematoma
remained stable. Pain controlled with prn tylenol.
.
# CAD: S/P ST Elevation Myocardial Infarction: STEMI on [**2205-12-5**]
for which he got BMS to proximal LAD. Had been on ASA and
plavix since, needs to be on it for at least 1 month to prevent
instent restenosis. Held aspirin and plavix on admission due to
active GI bleed. Restarted after transfer to floor and HD
stability maintained. Plan is to discontinue plavix 30 days
after stent was placed, final day of plavix will be [**2206-1-5**].
Continue aspirin 81 indefinitely.
.
# HBV/HCV/EtOH cirrhosis s/p orthotopic liver [**Year (4 digits) **]: On
mycophenolate mofetil and tacrolimus, for immunosuppression.
Tacrolimus recently restarted once HD was initiated, with
thought that cellcept can be weaned off. Has f/u in hepatology
who will adjust these medications.
.
# ESRD: Initiated on HD during his last admission on T/TH/SA
schedule. Renal failure thought possibly due to tacrolimus
toxicity. Tacro restarted on last admission as protecting renal
function was no longer a priority following starting HD. Last
hemodialysed on [**2205-12-26**].
.
# Polymyositis: of unclear etiology though possibly from
tacrolimus. Patient has been on prednisone with some
improvement of his symptoms. Continued on prednisone 20 mg/30
mg every other day and propylactic bactrim while on prednisone.
.
# HTN: Labetolol held in the setting of GI bleed and restarted
once HD stable.
.
# Seizure disorder: Continued on oxcarbazepine
.
# Depression: Continued on venlafaxine
Medications on Admission:
-alendronate 35 mg qweek
-aspirin 81 mg daily
-atorvastatin 80 mg daily
-B-complex with vitamin C 1 tablet daily
-bisacodyl 10 mg qhs
-calcium carbonate 500 mg (1,250 mg) TID
-clopidogrel 75 mg daily
-folic acid 1 mg daily
-insulin lispro SQ: FOR BREAKFAST, LUNCH and DINNER: 150-200: 2
units, 201-250: 4 units, 251-300: 6 units, 301-350: 8 units,
351-400: 10 units.
-labetalol 200 mg [**Hospital1 **]
-methylphenidate 5 mg QAM AND QNOON
-multivitamin 1 tablet daily
-mycophenolate mofetil 500 mg [**Hospital1 **]
-nystatin 5 mL QID prn candidiasis
-oxcarbazepine 150 mg [**Hospital1 **]
-oxybutynin chloride 5 mg qhs
-pantoprazole 40 mg q12h
-prednisone 20 mg and 30 mg alternating days
-sucralfate 1 gram TID (wait 4 hours after tacrolimus to give)
-sulfamethoxazole-trimethoprim 800-160 mg qTuesThursSat
-tacrolimus 0.5 mg q12h
-thiamine HCl 100 mg daily
-venlafaxine SR 150 mg daily
Discharge Medications:
1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for candidiasis.
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. prednisone 10 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (TU,TH,SA) as needed for
Tuesday/Thursday/Saturday.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. tacrolimus 0.5 mg Capsule, twice daily Sig: One (1) Capsule,
twice daily PO Q12H (every 12 hours).
8. B-complex with vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
10. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
12. venlafaxine 150 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
13. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 9 days: Last dose [**2206-1-5**].
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
17. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
19. insulin lispro 100 unit/mL Solution Sig: per scale below
Subcutaneous qachs: 150-200: 2 units, 201-250: 4 units, 251-300:
6 units, 301-350: 8 units, 351-400: 10 units.
.
20. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Upper GI Bleed [**1-8**] Duodenal Ulcer
Secondary:
ESRD on HD on T/TH/SA schedule
CAD s/p MI and BMS on [**2205-12-5**]
S/p liver [**Date Range **] [**1-8**] HBV, HCV, and EtOH abuse ([**2194**])
S/p hepatic artery replacement ([**2195**])
Asymptomatic strokes ([**2195**]: left corona radiata and posterior
putaminal infarct, periventricular white matter disease; [**8-12**]
MRI with evidence of chronic cerebellar infarcts)
Frontal gait disorder of unclear etiology
Central and obstructive sleep apnea not on CPAP
Polymyositis of unclear etiology though possibly from tacrolimus
Seizure disorder
Paraproteinemia
Cataract removal
Retinal detachment
Inguinal hernia repair
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 with a GI bleed and low blood pressure. You
went to the ICU and had an endoscopy which showed bleeding from
your known duodenal ulcer. It was clipped and the bleeding
stopped. You received 4 units of blood and your hematocrit
stabilize.
This bleeding was likely worsened by the Plavix and Aspirin
you're on for your heart and the prednisone you are on. These
were held for several days and then restarted once the bleeding
stopped.
You will be treated with medication to minimze irritation of the
GI tract to prevent further bleeding.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
[**2205-12-31**] 02:40p FISH-CC7
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
CC7 CARDIOLOGY (SB)
[**2206-1-2**] 01:30p [**Last Name (LF) 540**],[**First Name3 (LF) 539**] E.
[**Hospital6 29**], [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
[**2206-1-8**] 02:40p [**Year/Month/Day **] [**Hospital **] CLINIC
LM [**Hospital Unit Name **], [**Location (un) **]
[**Location (un) **] MEDICINE (NHB)
[**2206-2-10**] 03:00p [**Last Name (LF) 163**],[**First Name3 (LF) 161**] K.
[**Hospital6 29**], [**Location (un) **]
UROLOGY CC3 (NHB)
[**2206-2-18**] 10:30a [**Doctor Last Name **] [**Doctor Last Name **],EAST PROCEDURES
[**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
ENDOSCOPY SUITES
|
[
"E933.1",
"E879.8",
"V12.09",
"710.4",
"273.2",
"585.6",
"V42.7",
"781.2",
"345.90",
"285.21",
"532.00",
"998.12",
"410.91",
"403.91",
"V12.54",
"788.20",
"327.21",
"327.23",
"311",
"285.1",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"96.04",
"44.43",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11263, 11329
|
5761, 8345
|
308, 459
|
12057, 12057
|
4715, 5738
|
12877, 13729
|
3891, 3975
|
9283, 11240
|
11350, 12036
|
8371, 9260
|
12233, 12854
|
3990, 3990
|
4004, 4696
|
2320, 2767
|
254, 270
|
487, 2301
|
12072, 12209
|
2789, 3464
|
3480, 3875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,562
| 110,457
|
1417
|
Discharge summary
|
report
|
Admission Date: [**2157-1-14**] Discharge Date: [**2157-1-18**]
Service: MEDICINE
Allergies:
Lidocaine (Anest)
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89-yo M w/extensive hx including HTN, MI, CABG X 2, carotid
stenosis s/p bilat CEA, afib, CRI, and non-Hodgkins lymphoma in
remission. Presents w/hx of SOB since shortly before noon today
until arrival in ED in evening. Hx limited due to patient being
taken for VQ study. Basically, pt. notes that he began to feel
SOB around lunch time with no precipitant that he can recall. It
persisted until he came to ED at which point it began to
resolve. Only recent problems pt. can note are difficulty eating
since his L CEA as well as recent diarrhea and very little
urination. Per pt., nursing home told him diarrhea had a little
bit of blood in it. Pt. reports some recent nausea w/o vomiting.
No fevers, weight change, sweats, chills. Found to have INR of
10 on arrival at ED. Was given 5 mg SC vit K and 1 unit FFP.
Past Medical History:
-hypertension
-carotid stenosis s/p Rt. CEA'[**52**] and now s/p L CEA with patch
angioplasty on [**2156-12-21**]
-hypercholestremia
-CAD with chronic angina-stable, s/p MI, s/p CABG's x2
-chronic Atrial fibrillation
-CHF, EF 50%, O2 dependant --> more recent ECHO [**12-17**] showed EF
of 20-30% and 3+ MR [**First Name (Titles) **] [**Last Name (Titles) **]
-chronic renal insuffiency ( 1.2-1.6)
-on-Hodgkins lymphoma
-Major depression with sucidal ideation
-macrcytic anemia
-chronic low back pain
-cervical dissc disease s/p cervical laminectomy
-bilateral catracts s/p surgery
Social History:
Retired educator, wife with [**Name2 (NI) 8483**] in nursing home. Patient
lives alone. Former smoker
Family History:
unknown
Physical Exam:
99.9,89,156/71,20,94% on 3.5L
GEN: Thin, lying in bed NAD.
HEENT: Not assessed; bandages s/p CEA noted
CVS: Irregular rhythm, no m/r/g
PULM: Coarse inspiratory/expiratory breath sounds bilat in all
lung fields but w/good air movement.
ABD/GU: No palpable inguinal LAD.
NEURO: Grossly normal.
SKIN: Multiple ecchymoses bilat in UE's. Otherwise no cyanosis,
rashes or other obvious lesions.
EXT: trace bilateral LE edema
Pertinent Results:
.CBC: 9.1 27.8* 149 Diff: N 88.5* L 9.1* M 2.3 Eo 0 Bas 0.1
.PT,PTT,INR: 80.9,45.0,10.7
.Chem-7: 134,4.8,96,19,104,2.8,139
.ALT,AST,ALK,TBILI,ALB - 33,44,144,0.6,3.8
.D-dimer:979
.LDH:414
.CK, MB, Trp: Pend,4,0.20
.CXR: CHEST, ONE VIEW: Comparison with [**2156-12-24**]. The
patient is status post CABG. The cardiac and mediastinal
contours are stable. There are no consolidations, effusions,
pneumothorax, or pulmonary vascular congestion. IMPRESSION: No
acute cardiopulmonary process.
Brief Hospital Course:
A/P: 89-yo M w/extensive comorbidities who present with sudden
onset SOB while at his nursing home, likely to have UGIB given
his melena
...
# SOB: His shortness of breath was thought to be secondary to
his aspiration as he had been complaining of difficulty
swallowing after his recent CEA. He also did show increased
risk of aspiration on a bedside swallow examination during his
hospitalization. His chest xray on admission was negative for
signs of volume overload, although his oxygen saturation and
comfort improved with some diuresis. He was continued on
albuterol and ipratropium nebulizers with good relief. A V/Q
scan done on admission was low probability for pulmonary
embolism. He required 4L of oxygen at time of discharge to
maintain his oygen saturation.
...
# GIB. This was likely an UGIB due to supratherapeutic INR. He
had no history of NSAID use or EtOH use, his colonoscopy 3
years ago was negative per patient while at [**Hospital3 **].
He received 3 units of PRBC, although his hematocirt slowly
trended down with occasional melena. He was started on protonix
and his INR was reversed with FFP and vitamin K, but secondary
to his respiratory status, he was felt to be a poor candidate
for egd and colonoscopy.
....
# ARF: His initial presentation of acute renal failure was
likely secondary to dehydration as his FeNa was 1% in the
setting of home diuretics, rare urine eosinophils, but no
peripheral eosinophils were found. He responded well to
hydration, but then his creatinine worsened with likely
overdiuresis. Laboratory monitoring was held after the patient
became comfort measures.
...
#Elevated WBC: The patient was without a clear source of
infection, he was afebrile although with a WBC up to 14.2 with
78%PMN. His chest xray was clear, blood, urine, stool cultures
were negative.
.
#Elevated Lactate: His lactate peaked at 2.9 but trended down.
The etiology was unclear, he was monitored with serial abdominal
exams for possible bowel ischemia, given his leukocytosis,
although unlikely given his elevated INR
.
# ANEMIA
He received 3 units of PRBC, he anemia was likely secondary to
GI blood loss
-
...
# RECENT L CEA. His surgeons were contact[**Name (NI) **] in regards to
holding his plavix given his recent CEA and now acute GI blood
loss. He was to continue plavix, but as the patient was changed
to comfort measures, plavix was held.
..
# HTN/AFIB/CAD
His home lasix, and antihypertensive were held in the setting of
comfort measures only
...
# DEPRESSION
His home medications were held in the setting of comfort
measures only
...
# PPx
- Activity as tolerated
...
# FEN: He was evaluated to have aspiration risk, but given his
comfort measures status, he was continued on a regular diet as
tolerated
Code CMO
Disp: Home with Hospice
...
Medications on Admission:
Bactrim DS x 7 dd for UTI
Trazodone 25 mg
Sertraline 25 mg Tablet
Aspirin 81 mg Tablet, Delayed Release
Cyanocobalamin 500 mcg
Folic Acid 1 mg
Docusate Sodium 100 mg
Atorvastatin 80 mg
Coumadin 1 mg
Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO
Q4-6H:prn
Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-13**]
Puffs q4h:PRN
Acetaminophen 160 mg/5 mL Solution Sig: 650mgm PO Q4-6H:PRN
Albuterol Sulfate 0.083 % Solution One Inhalation
Q6H:PRN
Isosorbide Dinitrate 10 mg Tablet Sig
Clopidogrel 75 mg
Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Hydralazine 10 mg PO Q6H
Isosorbide Dinitrate 10 mg TID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: 1-20 mg PO q1hr
as needed for pain.
Disp:*100 mls* Refills:*0*
4. Ativan 0.5 mg Tablet Sig: 1-4 Tablets PO every four (4)
hours.
Disp:*180 Tablet(s)* Refills:*0*
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 417**] Hospice
Discharge Diagnosis:
GI Bleed
Discharge Condition:
Stable
Discharge Instructions:
If you experience increased pain, shortness of breath or other
concerning symptoms please contact your doctor
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2157-2-15**] 4:00
|
[
"414.00",
"428.0",
"276.51",
"584.9",
"311",
"202.80",
"V45.81",
"756.83",
"578.9",
"427.31",
"413.9",
"790.92",
"285.1",
"288.0",
"585.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6836, 6894
|
2793, 5595
|
229, 235
|
6947, 6956
|
2282, 2770
|
7115, 7273
|
1819, 1828
|
6278, 6813
|
6915, 6926
|
5621, 6255
|
6980, 7092
|
1843, 2263
|
186, 191
|
263, 1078
|
1100, 1684
|
1700, 1803
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,186
| 166,695
|
45957
|
Discharge summary
|
report
|
Admission Date: [**2140-7-19**] Discharge Date: [**2140-7-22**]
Date of Birth: [**2068-9-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 y.o. M hx pulmonary fibrosis, sarcoidosis, ? COPD p/w several
day hx of worsened dyspnea from baseline. Pt's baseline has
deteriorated over last few years to where he is able to walk
only 3 stairs or 25 yards before getting SOB. Since 4 days PTA
he has gotten progressively dyspneic with walking to the
bathroom from his bedroom which is only [**11-17**] setps and [**Doctor First Name **]
slept in his bathroom past 2 nights to avoid the walk. Pt denies
associated fever, chills. + slight chronic nonproductive cough.
No orthopnea, uses 1 pillor, no PND. Admist to vague L upper
chest discomfort, non-exertional, present at rest for days, no
associated N/V, palpitations. He initially called his
pulmonologist who prescribed spriveva 4 days PTA, no
improvement, called again today and recommeded coming in to the
ED. EMS noted house to be in disarray, social worker informed
that house has been condemned.
In ED, patient noted to have severe tachypnea with RR 36, O2 sat
99% on RA. Started on BiPAP, subsequent ABG 7.43/42/194.
Received ASA 325, solumedrol, levofloxacin, combivent nebs x3
for noted wheezing. EKG with some ST depression in II, III, aVF.
Once in the MICU, patient states he feels much better, denies
ongoing SOB. No chest pain, nausea, diaphoresis. Able to weane
to room air without drop in O2 sat.
.
ROS: no chills, night sweats, abdominal pain, diarrhea, urinary
sx's.
+ 40lb weight loss over 10 yrs (154->110s), unintentional since
dx sarcoidosis. Negative colonscopy last year, hx BPH.
Past Medical History:
1. Pulmonary sarcoidosis with pumonary fibrosis, dx [**2128**], s/p
lung bx
2. BPH
3. Hypercholesterolemia
4. Orthostatic hypotension
5. L eye ptosis since birth
6. Glucose intolerance
Social History:
Retired from import/export business in plumbing. Only out of
country travel was to Bermuda years ago. Smoking hx 1-1/2 ppd x
15 yrs, quit [**2117**]. No etoh or drugs. Lives alone
.
Family History:
mother died at [**Age over 90 **] y.o. hx [**Name (NI) 11964**], Father died at 75 yo,
stroke/cerebral hemorrhage. Patient has 2 brothers, healthy.
[**Name2 (NI) 4084**] married, no children
Physical Exam:
Temp 98.4, BP 144/79, HR 111, RR 26, O2 sat 100% on 2L NC
Gen: elderly, cachectic male, speaking in full sentences, no
accessory muscle use
HEENT: L eye ptosis, OP clear
Neck: no JVD
Lungs: bronchial BS at upper lung zones, no crackles or wheezes,
good air movement
CV: regular tachycardia, loud P2, nl s2, s2, no murmurs
Abd: cachectic, NT, ND, + BS, no HSM
Extr: thin, no edema, 2+ distal pulses
Neuro: L eye ptosis, otherwise non-focal.
Pertinent Results:
[**2140-7-19**] 08:55PM LACTATE-2.6*
[**2140-7-19**] 05:40PM CK(CPK)-152
[**2140-7-19**] 05:40PM CK-MB-6 cTropnT-<0.01
[**2140-7-19**] 01:25PM TYPE-ART RATES-/20 PO2-194* PCO2-42 PH-7.43
TOTAL CO2-29 BASE XS-3 INTUBATED-NOT INTUBA
[**2140-7-19**] 01:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2140-7-19**] 01:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-7-19**] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2140-7-19**] 12:45PM LACTATE-3.4* K+-3.5
[**2140-7-19**] 12:00PM GLUCOSE-111* UREA N-17 CREAT-0.9 SODIUM-140
POTASSIUM-5.8* CHLORIDE-98 TOTAL CO2-29 ANION GAP-19
[**2140-7-19**] 12:00PM CK(CPK)-200*
[**2140-7-19**] 12:00PM CK-MB-5 cTropnT-<0.01
[**2140-7-19**] 12:00PM ALBUMIN-3.5 CHOLEST-137
[**2140-7-19**] 12:00PM TRIGLYCER-78 HDL CHOL-59 CHOL/HDL-2.3
LDL(CALC)-62
[**2140-7-19**] 12:00PM WBC-23.9* RBC-4.08* HGB-12.9* HCT-38.0*
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.7
[**2140-7-19**] 12:00PM NEUTS-93.7* BANDS-0 LYMPHS-3.4* MONOS-2.7
EOS-0.1 BASOS-0.1
[**2140-7-19**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL
[**2140-7-19**] 12:00PM PLT COUNT-304
[**2140-7-19**] 12:00PM PT-13.5* PTT-29.7 INR(PT)-1.2*
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2140-7-19**] 3:18 PM
CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST
Reason: evaluate for PE
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
71 year old man with acute SOB
REASON FOR THIS EXAMINATION:
evaluate for PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Acute shortness of breath, evaluate for pulmonary
embolism.
COMPARISON: [**2140-5-25**].
TECHNIQUE: MDCT acquired axial images of the chest were obtained
with and without IV contrast. Multiplanar reformatted images
were also displayed.
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: The pulmonary
arteries appear opacified without evidence of pulmonary
embolism. Again seen is marked architectural distortion
throughout both lungs, predominantly the upper and mid lung
zones with dense fibrotic changes and volume loss consistent
with pulmonary fibrosis, by report, likely secondary to
sarcoidosis. Again seen is elevation of both hila. The
previously seen small left-sided pneumothorax appears to have
resolved. Several parenchymal and pleural-based nodular
opacities are again seen. Compared to prior study, there does
appear to be some increase in poorly defined opacities
distributed throughout the left lung, concerning for
superimposed infection. Again seen are enlarged mediastinal and
hilar lymph nodes, many of which appear calcified, not
significantly changed from prior study. Limited views of the
upper abdomen appear unremarkable.
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
Multiplanar reformatted images confirm the axial findings.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. New scattered foci of poorly defined opacities seen
predominantly within the left lung, concerning for superimposed
multifocal pneumonia.
3. Extensive fibrotic and architectural distortion within both
lungs, not significantly changed from prior study, consistent
with history of pulmonary fibrosis.
4. Interval improvement of small left-sided pneumothorax.
Discussed with Dr. [**Last Name (STitle) 1923**] following completion of study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: WED [**2140-7-20**] 9:57 PM
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Cardiology Report ECHO Study Date of [**2140-7-20**]
PATIENT/TEST INFORMATION:
Indication: LV function
Height: (in) 66
Weight (lb): 112
BSA (m2): 1.56 m2
BP (mm Hg): 147/72
HR (bpm): 100
Status: Inpatient
Date/Time: [**2140-7-20**] at 11:46
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W031-1:30
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**]
MEASUREMENTS:
Left Atrium - Four Chamber Length: 3.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 1.9 cm
Left Ventricle - Fractional Shortening: 0.41 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm)
Aorta - Arch: 3.0 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.80
Mitral Valve - E Wave Deceleration Time: 223 msec
TR Gradient (+ RA = PASP): *43 to 51 mm Hg (nl <= 25 mm Hg)
Pericardium - Effusion Size: 0.6 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA.
LEFT VENTRICLE: Mild symmetric LVH.
RIGHT VENTRICLE: Mildly dilated RV cavity. RV function
depressed.
AORTA: Normal aortic root diameter. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of
tamponade. Echocardiographic signs of tamponade may be absent in
the presence
of elevated right sided pressures.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The right ventricular cavity is mildly dilated.
Right ventricular
systolic function appears depressed. The aortic valve leaflets
(3) are mildly
thickened. The mitral valve leaflets are mildly thickened. There
is moderate
pulmonary artery systolic hypertension. There is a small
pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of
tamponade may be absent in the presence of elevated right sided
pressures.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2140-7-20**] 14:52.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
([**Numeric Identifier 97847**])
Brief Hospital Course:
71 y.o. M hx pulmonary fibrosis, sarcoidosis, ? COPD presenting
with worsened dyspnea from baseline.
.
# Dyspnea - Likely community aquired pneumonia in setting of
terrible base line lung functino (pulmonary fibrosis, sarcoid,
and COPD). Treated in ED with BIPAPA, solumedrol, levofloxacin
and nebs. Was admitted to the MICU. pt feeling back to baseline
by the time he arrived in MICU off BIPAP and on 3L nasal
cannula. Doing well over the course of the day. Next morning
had an episode of acute dyspnea after minimal exertion, resolved
spontaneously, associated with tachycardia to 110, hypertension
to 240/120s. Was called out to the floor. Did well and was able
to tirtate of oxygen. Will be treated with a steroid taper and
ten day course of levofloxacin. Echo obtained was consistent
with known pulmonary hypertension related to underlying
pulmonary disease.
.
# Dynamic ECG changes - CE's negative, .
Started on ASA, cont lipitor (LDL 62), no beta blockers given
likely COPD exacerbation.
.
# BPH - cont flomax
.
# hx of orthostatic hypotension - held minearalocorticoid as he
was hypertensive, consider restarting once BP improved.
.
# FEN - regular diet, replete electrolytes prn
.
FULL code
Medications on Admission:
Spireva inhaler
Flomax 0.4 mg PO qhs
Lipitor 10mg po qhs
tylenol daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days.
11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: Please start after finishing the 40 mg dose.
12. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: Please start after finishing the 30 mg doses.
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Please start after finishing the 20 mg doses.
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: Please start after finishing the 10 mg doses. When
finished with this you will stop taking steroids.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Pnemonia
COPD
Sarcodosis with pulmonary involvement
Pulmonary fibrosis
Discharge Condition:
good
Discharge Instructions:
Please reutrun to the ED or call your PCP if you have fevers or
increasing shortness of breath.
Followup Instructions:
Please call you PCP: [**Name10 (NameIs) **] PINES, [**Telephone/Fax (1) 37171**] for an
appointment to be seen with in 5 days of leaving [**Hospital3 **].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2140-7-22**]
|
[
"515",
"486",
"517.8",
"491.21",
"135"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12696, 12766
|
9922, 11128
|
278, 284
|
12881, 12888
|
2919, 4553
|
13032, 13312
|
2251, 2443
|
11250, 12673
|
4590, 4621
|
12787, 12860
|
11154, 11227
|
12912, 13009
|
6921, 9753
|
2458, 2900
|
231, 240
|
4650, 6895
|
312, 1826
|
9785, 9899
|
1848, 2035
|
2051, 2235
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,792
| 164,489
|
13477
|
Discharge summary
|
report
|
Admission Date: [**2102-9-3**] Discharge Date: [**2102-9-26**]
Date of Birth: [**2031-7-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Foot pain
Major Surgical or Invasive Procedure:
[**2102-9-3**] Left toe debridement
[**2102-9-20**] CABGx3 (LIMA->LAD, SVG->PDA, SVG->OM)
History of Present Illness:
Mr. [**Known lastname 40821**] is a 74 year old male who was admitted on [**2102-9-3**] for
a Left first digit infection, along with fever and chills.
Past Medical History:
DM
Hypothyroid
s/p PTCA [**2080**]
Social History:
retired
Divorced
3 children
tobacoo use in [**2047**]
Family History:
Mother with CABG in 70s, DM.
Physical Exam:
On discharge
NAD
Vac dressing to LLE, C/D/I
MSI C/D/I
RLE SVG sites C/D/I
CV RRR, no M/R/G
Lungs CTAB
Left AC PICC line
+pp, trace LE edema
Pertinent Results:
[**2102-9-26**] 06:25AM BLOOD WBC-4.9 RBC-3.42* Hgb-9.8* Hct-29.4*
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.3 Plt Ct-205#
[**2102-9-26**] 06:25AM BLOOD Plt Ct-205#
[**2102-9-26**] 06:25AM BLOOD UreaN-18 Creat-1.4* K-4.1
[**2102-9-26**] 06:25AM BLOOD Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 40821**] [**Last Name (Titles) 1834**] debridement of his left foot infection by
vascular surgery. He was placed on antibiotics for wound
cultures positive for proteus, enterococcus and strep viridans.
Post operatively he complained of chest pain, and had +troponins
and wall motion abnormalities on TTE without endocarditis. He
was seen in consultation by cardiology who recommended cardiac
catheterization which showed 90%LAD, 60%D1, 60%LCx, 100% RCA,
2+MR and an LVEF of 30%. He was seen in consultation by cardiac
surgery who recommended several days of antibiotics prior to
going to the OR for CABG. He was seen in consultation by
infectious disease who recommended long term IV unasyn. On
[**2102-9-20**] he [**Date Range 1834**] a CABG x3. He was transferred to the SICU
in critical byut statble condition.He was extubated and weaned
from his vasoactive drips by POD 1. He had no complications
postoperatively and was ready for discharge on [**2102-9-26**].
Medications on Admission:
Synthroid, INsulin
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*0 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Capsule, Sustained Release(s)
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
12. Ampicillin-Sulbactam Sodium [**2-28**] g Recon Soln Sig: Three (3)
grams Injection Q8H (every 8 hours).
13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: 12 units with breakfast
8 units at bedtime.
Discharge Disposition:
Extended Care
Facility:
Oaks Long Term Care Facility - [**Location (un) 5503**]
Discharge Diagnosis:
CAD
Left foot infection
Discharge Condition:
Good.
Discharge Instructions:
Shower daily, wash chest incision with ild soap and water, pat
dry. No lotions creams or powders, no baths.
Call for temperature more than 101.5, redness or drainage from
incision, or weight gain more than 2 pounds in one day or five
in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **](Cardiac Surgery) 4 weeks
Dr. [**Last Name (STitle) **](Vascular surgery) 2 weeks
PCP 2 weeks
Cardiologist 2 weeks
Completed by:[**2102-9-26**]
|
[
"414.01",
"997.1",
"244.9",
"682.7",
"707.15",
"790.7",
"410.71",
"250.80",
"730.07",
"362.01",
"440.23",
"731.8",
"250.70",
"250.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"88.47",
"38.93",
"36.15",
"37.22",
"99.04",
"88.48",
"88.72",
"39.61",
"77.68",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
3564, 3646
|
1225, 2213
|
330, 422
|
3714, 3722
|
952, 1202
|
4017, 4193
|
747, 777
|
2282, 3541
|
3667, 3693
|
2239, 2259
|
3746, 3994
|
792, 933
|
281, 292
|
450, 602
|
624, 660
|
676, 731
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,648
| 114,554
|
39827
|
Discharge summary
|
report
|
Admission Date: [**2192-11-3**] Discharge Date: [**2192-11-12**]
Date of Birth: [**2115-3-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2192-11-5**] Coronary Artery Bypass Graft x 5
History of Present Illness:
This 77 year old man was transferred from [**Hospital3 417**] for
management of three vessel disease requiring CT Surgery
evaluation. He presented there with recurrent chest pain
starting at 22:00 on the date of admission while lying in bed,
lasting 1 hour before calling EMS. + SOB. He had transient
chest pain the night prior. He denies any DOE, PND, orthopnea,
palpitations, ankle edema, dizziness that he recalls. He feels
like he may fatigue more easily with exertion lately.
En route, the monitor showed ST elevations in inferior wall with
reciprocal changes in lateral leads. He was given ASA, sl Nitro
x2, with positive EKG changes and resolution of CP. In the ED,
vitals were 98.2F, H76, R16, 138/78, 98%Patient taken emergently
to cath lab. He received ASA, 600mg Plavix load, 80mg lipitor
and a 4000 U IV Heparin bolus.
An intra aortic balloon was placed and he was painfree.
Past Medical History:
Hypertension
Benign prostatic hypertrophy
Social History:
lives with his wife. Is generally very active. Feels like he can
walk 1 mile and no trouble with flight of stairs at home.
-Tobacco history: 50 year smoking hx, up to 2 packs per day
-ETOH: ~6 beers a day
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother had cancer.
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: T=afebrile BP= 152/73 HR=70 RR= - O2 sat=100%
GENERAL: NAD, denies chest pain. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Left eye was 3.5 mm and R eye was
2mm (could not fully eval b/c of light brightness), EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma. No carotid bruits noted
NECK: Supple with JVP at jaw when lying flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, sound of balloon pump, otherwise 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. Exam limited to anterior b/c pt need to lie
flat given balloon pump
ABDOMEN: Soft, NTND. No HSM or tenderness. Can hear pumping of
IABP.
EXTREMITIES: No LE edema, pulses present but feet cool. No
c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII grossly intact. Oriented A&O x3, able to relate
history
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Pre-op labs:
[**2192-11-3**] 03:03AM BLOOD WBC-5.9 RBC-4.31* Hgb-13.6* Hct-39.7*
MCV-92 MCH-31.7 MCHC-34.4 RDW-13.4 Plt Ct-217
[**2192-11-3**] 03:03AM BLOOD Glucose-103* UreaN-15 Creat-0.7 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
[**2192-11-3**] 03:03AM BLOOD ALT-22 AST-26 LD(LDH)-166 CK(CPK)-222
AlkPhos-55 TotBili-0.3
[**2192-11-3**] 02:03PM BLOOD CK-MB-2 cTropnT-0.05*
[**2192-11-3**] 03:03AM BLOOD %HbA1c-5.5 eAG-111
[**2192-11-3**] 03:03AM PT-12.5 PTT-31.8 INR(PT)-1.1
[**2192-11-3**] 11:03AM CK-MB-3 cTropnT-0.04*
[**2192-11-3**] 02:02PM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2192-11-3**] 02:02PM URINE BLOOD-LG NITRITE-NEG PROTEIN->300
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
Post-op labs:
[**2192-11-12**] 04:50AM BLOOD WBC-9.5 RBC-2.80* Hgb-8.4* Hct-24.8*
MCV-89 MCH-29.9 MCHC-33.7 RDW-14.2 Plt Ct-486*
[**2192-11-12**] 04:50AM BLOOD Plt Ct-486*
[**2192-11-5**] 01:59PM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2*
[**2192-11-12**] 04:50AM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-133
K-3.7 Cl-99 HCO3-27 AnGap-11
[**2192-11-12**] 04:50AM BLOOD ALT-31 AST-23 AlkPhos-49 Amylase-165*
TotBili-0.5
[**2192-11-11**] 07:30AM BLOOD ALT-34 AST-32 AlkPhos-48 Amylase-200*
TotBili-0.5
[**2192-11-12**] 04:50AM BLOOD Lipase-269*
[**2192-11-11**] 07:30AM BLOOD Lipase-339*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 3.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 91 ml/beat
Left Ventricle - Cardiac Output: 7.21 L/min
Left Ventricle - Cardiac Index: 3.66 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 15
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 24
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 0.64
Mitral Valve - E Wave deceleration time: 202 ms 140-250 ms
TR Gradient (+ RA = PASP): 18 to 21 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Normal ascending aorta
diameter. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basal inferior
hypokinesis. The remaining segments contract normally (LVEF =
50-55%). 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. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. No surgically-significant valvular or proximal aortic
disease.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2192-11-3**] 12:10
Radiology Report CHEST (PA & LAT) Study Date of [**2192-11-11**] 4:14
PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 87668**] Reason: evaluate
effusions/atx
Final Report
Two views of the chest demonstrate marked cardiomegaly. Status
post CABG.
Left lower lobe atelectasis, small left pleural effusion.
Essentially no
change since prior study. Upper lung zones are clear.
DR. [**First Name11 (Name Pattern1) 3993**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3994**]
[**Hospital 93**] MEDICAL CONDITION: 77 yo man with ileus and dilated
cecum
REASON FOR THIS EXAMINATION: change air fluid levels and cecum
diameter.
Final Report:
Two views of the abdomen demonstrate multiple radiopaque
densities in the mid abdomen likely representing pills. Since
the prior study, there has been interval decompression of the
cecum. On the prior study, it measured 12 cm. Currently it
measures approximately 8.1 cm. There are multiple dilated small
bowel segments and air is seen throughout the transverse colon
and in the rectum. These findings likely represent the sequela
of postoperative ileus.
DR. [**First Name11 (Name Pattern1) 3993**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3994**]
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=======================================================Radiology
Report ABDOMEN (SUPINE & ERECT) [**2192-11-8**] 10:11 PM
Clip # [**Clip Number (Radiology) 87669**]
Reason: s/p CABG w/abdominal distention r/o ileus/obstruction
Final Report
ABDOMINAL RADIOGRAPH, SUPINE UPRIGHT VIEWS: There are multiple
loops of
dilated large and small bowel seen overlying the mid abdomen. A
single loop of small bowel in the left lower quadrant measures
3.5 cm which is above the normal limit. There is diffuse
dilatation of the cecum which measures approximately 11 cm. No
free air is seen in upright film to suggest perforation. These
findings are concerning for postoperative ileus. Sternotomy
wires are visualized overlying the midline thoracic vertebral
bodies and degenerative changes of the lumbar spine are evident.
IMPRESSION: Diffusely dilated loops of small bowel and colon.
Significantly dilated cecum measuring approximately 11 cm in
largest diameter. No free air to suggest perforation. These
findings are concerning for postoperative ileus.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] SENAPATI
Brief Hospital Course:
On transfer to [**Hospital1 18**] he was stable with an intra-aortic balloon
pump in place. Cardiothoracic surgery was consulted and saw him
for evaluation for revascularization. He had received a Plavix
loading dose of 300mg during catheterization so surgery was
delayed until Monday [**2192-11-5**] while Plavix washed out.
While awaiting surgery overnight on [**9-19**] he had a moderate
hematoma and bleeding from the balloon pump site but the
hematocrit remained stable at 36.
He also had hematuria with Foley insertion which was likely
related to minor trauma with placement given his known prostatic
hypertrophy. Urojet lidocaine was used to improve his comfort
level. Urology follow-up is recommended after pt is discharged.
He went to the Operating Room on [**11-5**] where revascularization
was performed, please see operativer ereport for details in
summary he had: coronary artery bypass grafting x5 with the left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein grafts to the posterior
descending artery, the obtuse marginal artery, and saphenous
vein Y-graft to the ramus intermedius artery and the diagonal
artery. His bypass time was 104 minutes, with a CROSSCLAMP TIME
of 83 minutes.
He tolerated the operation well, weaned from bypass on Propofol
and Neo Synephrine. He remained stable and the balloon pump was
removed after the operation in the CVICU. He was weaned from
the ventilator and and pressors. He was begun on beta blockers
and diuresed towards his preoperative weight.
The chest tubes and pacing wires were removed per cardiac
surgery protocols. Physical Therapy was consulted for strength
and mobility. He experienced atrial fibrillation which
converted to sinus rhythm after treatment with amiodarone and
lopressor. His oral lopressor was increased.
He did develop a post-operative ileus. General surgery was
consulted. NG tube was inserted and the patient remained NPO.
Ileus eventually resolved, and bowel function returned. Diet was
advanced as tolerated. The remainder of his post-op course was
uneventful.
By post-operative day 7 he was ready for discharge to home. All
follow-up appointments were advised.
Medications on Admission:
Proscar
Flomax
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take 400mg once a day until [**11-20**] then decrease to 200 mg
daily until follow up with cardiologist .
Disp:*40 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: with lasix.
Disp:*14 Tablet(s)* Refills:*0*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Grafts x 5
Myocardial Infarction
Hypertension
Benign prostatic hypertrophy
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
Leg Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call 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
Wound check [**Hospital Ward Name 121**] 6 with NP/PA [**11-19**] at 1100 am [**Telephone/Fax (1) 170**]
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**12-5**] at 1pm
Cardiologist: Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**12-17**] at 10:30am at [**Street Address(2) **],
Suite 205W, [**Hospital1 1474**], [**Numeric Identifier 8728**]. The location is in parking lot
near the ER entrance at [**Hospital3 417**] hospital.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10381**]) in [**5-21**] weeks
You will need a colonscopy in the next few weeks - Dr [**Last Name (STitle) **]
office is contacting Dr [**Name (NI) **] office to set up - they should be
contacting you
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2192-11-12**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,446
| 120,330
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9043
|
Discharge summary
|
report
|
Admission Date: [**2193-10-21**] Discharge Date: [**2193-10-24**]
Date of Birth: [**2108-6-1**] Sex: F
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
85-year-old female with history of pulmonary fibrosis, recurrent
UTIs pulmonary hypertension and pulmonary embolism (pulmonary
embolism and DVT in [**2192-12-13**] s/p IVC filter and six months
of warfarin stopped in [**Month (only) 205**] and then restarted in [**9-/2193**] given
admission with worsening hypoxia and persistent Pulm emboli thus
re-bridged to coumadin) presenting to the emergency department
with worsening weakness, increased oxygen requirement. (Although
baseline O2 requirement is 6L O2 and patient known to desat to
mid 80s at home). Over the last 24 hours patient has had to
titrate up her oxygen. Patient has had a mild cough, non
productive, and stuffy left nostril, but otherwise, denies
fevers or chills, nor chest pain and is currently on cefdinir
for UTI although unclear where this U/A was taken from (likely
PCP's office). Sick contact includes daughter whom she lives
with who has URI sx.
.
In ED initial VS were 98.2 77 127/60 24 100% NRB
Labs were remarkable for [**Year (4 digits) 263**] 2.2, Cre 1.4. (1.1), Hct 30 (27),
Lactate 4.4, neg Trop.
Imaging: CXR - wet read, no PNA
EKG: no acute changes from prior
.
In the ER, patient was hypoxic to 80% on 6L of nasal cannula. ED
team was concerned for PNA despite no findings of such on CXR
wet read as well as UTI although no U/A sent and no symptoms and
given lactate of 4.2 began treating for presumed urosepsis +/-
PNA source w/ levoflox and cefepime. Vanc not given while down
in ED. Patient refuses foley catheter.
.
Past Medical History:
- Severe idiopathic pulmonary fibrosis, on high flow oxygen,
Last FEV1 and vital capacity 0.72 and 0.87 (37 and 30% predicted
respectively)[**4-25**]
- pulmonary hypertension with biventricular dilatation
- DMII
- HTN
- HL
- severe lower back pain
- depression
- hiatal hernia
- small left upper lobe lung nodule
- thyroid nodule
- h/o pontine stroke ([**2186**]) - residual mild left hemiparesis
- submassive PE and DVT [**12-24**], on anticoagulation with IVC
filter placed at that time --> plan to stop soon.
- History of GI bleed, likely due to prior nonsteroidal
anti-inflammatory drug therapy.
- CAD
Social History:
She lives in [**Hospital1 392**] with her daughter [**Name (NI) **]. She has been a widow
since [**2159**]. She has two daughters, one who lives in
[**State 350**], and another who lives in [**State 5887**]. She has a
son who lives in [**Name (NI) 12000**]. She smoked only for 10 years and quit
40 years ago. She reports [**2-15**] glasses of wine per week.
Family History:
No family history of blood clots or strokes. She reports a
cousin has [**Name2 (NI) 500**] cancer but denies other cancer in the family.
She also notes several family members have heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.4 80 135/60 25 98% High Flow 15L 70%
GENERAL: AOx3, NAD
[**Name2 (NI) 4459**]: MMM. no LAD. JVD to mid neck.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: diffuse fine crackles B/L posteriors
ABDOMEN: soft, nontender, nondistended. no guarding or rebound
EXT: wwp, [**1-14**]+ B/L edema. DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: dry, no rash
NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L
extremities grossly intact. gait not assessed.
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
[**2193-10-21**] 07:05PM BLOOD WBC-6.8 RBC-2.85* Hgb-9.6* Hct-30.0*
MCV-106* MCH-33.6* MCHC-31.9 RDW-15.8* Plt Ct-251
[**2193-10-21**] 07:05PM BLOOD Neuts-93.3* Lymphs-3.3* Monos-2.3 Eos-0.8
Baso-0.3
[**2193-10-21**] 07:05PM BLOOD PT-22.1* PTT-34.6 [**Month/Day/Year 263**](PT)-2.1*
[**2193-10-21**] 07:05PM BLOOD Glucose-313* UreaN-28* Creat-1.4* Na-138
K-5.8* Cl-96 HCO3-31 AnGap-17
[**2193-10-21**] 07:05PM BLOOD cTropnT-<0.01
[**2193-10-22**] 12:57AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.6
[**2193-10-22**] 01:26AM BLOOD Type-[**Last Name (un) **] pO2-113* pCO2-65* pH-7.34*
calTCO2-37* Base XS-7 Comment-GREEN TOP
[**2193-10-21**] 07:14PM BLOOD Lactate-4.2* K-5.3*
[**2193-10-22**] 03:14AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2193-10-22**] 03:14AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2193-10-22**] 03:14AM URINE RBC-1 WBC-9* Bacteri-FEW Yeast-NONE Epi-4
TransE-1
MICRO:
[**10-21**], [**10-22**] BLOOD CULTURES PENDING
[**10-22**] URINE CULTURE **FINAL REPORT
[**2193-10-23**]**
URINE CULTURE (Final [**2193-10-23**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**10-22**] URINE LEGIONELLA NEGATIVE
IMAGING:
[**2193-10-22**] CXR: FINDINGS: Frontal and lateral views of the chest
were obtained. There are
relatively low lung volumes. Diffuse increased interstitial
markings are
grossly similar to prior, consistent with patient's pulmonary
fibrosis, with
possible of overlying edema. No large pleural effusion or
pneumothorax is
seen. The cardiac and mediastinal silhouettes are stable
compared to
[**2193-7-12**] and [**2193-9-29**]. The patient is rotated in position.
There is severe
compression of an upper lumbar spine vertebral body, also seen
on the prior
study from [**2193-1-10**].
Brief Hospital Course:
Ms. [**Known lastname 10113**] is an 85 year old female with history of idiopathic
pulmonary fibrosis, recurrent UTIs, pulmonary hypertension and
pulmonary embolism (pulmonary embolism and DVT in [**2192-12-13**]
s/p IVC filter and six months of warfarin stopped in [**Month (only) 205**] and
then restarted in [**9-/2193**] given admission with persistent
Pulmonary emboli) who presented with concern for fatigue,
increased O2 requirement at home. No etiology was found for an
second process in her lungs, rather it is possible she has had
mild progression of her severe pulmonary fibrosis.
.
# Idiopathic pulmonary fibrosis (IPF): Previous notes designate
that she easily drops sats with minimal pertubations, which she
was doing also during admission. No other exacerbating factors
were found including no obvious worsening pulmonary edema on
CXR, no fevers, WBC elevation, or productive cough to suggest
pneumonia, urine was clean without evidence of urinary tract
infection. She did have copious watery nasal discharge,
consistent with a viral upper respiratory infection. This made
it difficult for her to tolerate nasal cannula for oxygen
delivery because her nostrils were plugged. Most likely dx is
baseline severe hypoxemia due to IPF with mild pertubation from
a viral upper respiratory track infection.
Her primary pulmonologist, Dr. [**Last Name (STitle) 575**] was [**Last Name (STitle) 653**] and
he agreed that this was most likely due to progression of IPF.
He wanted to leave her prednisone at 20 mg daily rather than
increase the dose because it would not ultimately change her
prognosis or symptoms. Also, the MICU team and Dr. [**Last Name (STitle) 575**]
spoke with the patient about the advantages of hospice for her
end-stage pulmonary disease. She was continued on the bactrim
prophylaxis since on steroids.
.
# Lactic acidosis: Appears most likely due to dehydration plus
metformin given hemoconcentration, no leukocytosis or fevers and
the chronic elevations. Her primary care doctor [**First Name (Titles) **] [**Name (NI) 653**]
about changing to another oral hypoglycemic or even insulin. He
felt these would be appropriate options and added that her high
sugars are only due to prednisone therapy. She was started on
glipizide 5 mg daily for this and metformin was discontinued.
.
# Recent diagnosis of cystitis: Was on outpt cefdinir 300 mg [**Hospital1 **]
started on [**10-21**]. Repeat urinalysis here showed clearing of the
urine and urine culture was contaminated. She was given
ceftriaxone while in house and then discharged to complete
cefdinir therapy.
.
# Anemia: No melena or other source but given acute drop,
concerning for possible blood loss. History of GI bleed, likely
due to prior nonsteroidal anti-inflammatory drug therapy. Her
hematocrit stabilized and she did not require blood transfusions
and was continued on her proton pump inhibitor.
.
# Recent/recurrent pulmonary emboli: Continued coumadin with
goal [**Month/Day (4) 263**] [**2-15**]. She is status post IVC filter. Her [**Month/Day (3) 263**] was low
on discharge and so she was sent home with enoxaprin
subcutaneous (renally dosed) to bridge to warfarin. [**Month/Day (3) 263**]
followed by primary care physician and draw by visiting nurse.
.
CHRONIC ISSUES BY PROBLEM:
# Pulmonary hypertension: Repeat TTE in [**9-/2193**] was performed,
which showed worsened right ventricular function when compared
to prior TTE.
# Coronary artery disease (CAD): continued aspirin, Statin, and
metoprolol..
# DMII: Stopped metformin and started glipizide.
# Depression: Continued [**Year (4 digits) 31260**].
# Insomnia: Continued remeron.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientFamily/Caregiver.
1. Aspirin 162 mg PO DAILY
2. [**Year (4 digits) **] Oxalate 40 mg PO QAM
3. [**Year (4 digits) **] Oxalate 20 mg PO QPM
4. Ferrous Sulfate 325 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
hold for HR < 60 or SBP < 90
6. Mirtazapine 30 mg PO HS
7. Pantoprazole 40 mg PO Q12H
8. Simvastatin 20 mg PO DAILY
9. Sulfameth/Trimethoprim Suspension 20 mL PO DAILY
10. Warfarin 1 mg PO DAILY16
11. PredniSONE 20 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. cranberry *NF* 4200 MG Oral DAILY
14. cefdinir *NF* 300 mg Oral [**Hospital1 **]
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. [**Hospital1 **] Oxalate 40 mg PO QAM
3. [**Hospital1 **] Oxalate 20 mg PO QPM
4. Metoprolol Tartrate 12.5 mg PO BID
hold for HR < 60 or SBP < 90
5. Mirtazapine 30 mg PO HS
6. Pantoprazole 40 mg PO Q12H
7. PredniSONE 20 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Sulfameth/Trimethoprim Suspension 20 mL PO DAILY
10. Warfarin 1 mg PO DAILY16
11. Sodium Chloride Nasal [**1-14**] SPRY NU TID:PRN nasal congestion
RX *sodium chloride [Saline Nasal] 0.65 % 1 spray each nostril
twice daily Disp #*1 Bottle Refills:*0
12. cranberry *NF* 4200 MG Oral DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Docusate Sodium (Liquid) 100 mg PO BID
hold for diarrhea
RX *docusate sodium 100 mg 1 tab by mouth twice daily Disp #*60
Tablet Refills:*0
15. Senna 1 TAB PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
RX *fluticasone 50 mcg 1 spray each nostril daily Disp #*1
Bottle Refills:*0
17. Enoxaparin Sodium 80 mg SC DAILY
RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneously once daily Disp
#*30 Syringe Refills:*0
18. cefdinir *NF* 300 mg Oral [**Hospital1 **] Duration: 3 Days
19. GlipiZIDE 5 mg PO DAILY
RX *glipizide 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
Hypoxia
Pulmonary fibrosis
Recent pulmonary emboli
Secondary:
Diabetes Mellitus
Recent 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 Ms. [**Known lastname 10113**],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for difficulty breathing and low oxygen
saturations in your blood. We investigated for causes of this
such as urinary tract infection, pneumonia, or volume overload
in the lungs. However, none of these were found to be occuring.
We think that you had progression of your chronic pulmonary
fibrosis. This is not reversible and there are no treatments
for it. We can continue to provide oxygen therapy for you, but
ultimately, we think it would
be reasonable to have a palliative care evaluate you as an
outpatient.
We recommend keeping the face mask on with your nasal cannula at
all times (not just with activity) to help with your breathing.
Also, please have your VNA check and [**Hospital1 263**] level tomorrow.
We made the following changes to your medications:
STOPPED: Metformin
STARTED: Glipizide 5mg by mouth daily (for your diabetes inplace
of metformin)
STARTED: Enoxaparin (lovenox) 80mg daily until coumadin levels
are therpeutic
STARTED: Fluticasone nasal spray (flonase)
CONTINUE: Cefdinir as you were previously prescribed to complete
your planned coure
Followup Instructions:
Please followup with your primary care physician [**Name Initial (PRE) 176**] [**7-23**]
days regarding the course of this hospitalization.
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2193-11-5**] at 7:40 AM
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: TUESDAY [**2193-11-5**] at 8:00 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2193-11-5**] at 8:00 AM
|
[
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,138
| 129,098
|
2642
|
Discharge summary
|
report
|
Admission Date: [**2181-5-4**] Discharge Date: [**2181-5-25**]
Service: MEDICINE
Allergies:
Lisinopril / Atenolol / Iodine-Iodine Containing / Pletal /
Hydralazine And Derivatives / Tekturna / Cipro
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy
Central line placement
Tunneled HD catheter placement
History of Present Illness:
Mrs. [**Known firstname **] [**Known lastname 13257**] is a 86 year old female with a history of
breast cancer, DM, HTN, CKD Stage III/IV, PVD, HCC and cirrhosis
who presents with a chief complaint of abdominal pain. The pt
reports that she has had abdominal pain for weeks, but that on
[**5-3**] after eating lunch the pain got so bad "that she couldn't
stand it anymore" and was "shooting across the stomach." The pt
had never had pain similar to this before. Currently her pain is
a constant dull pain that is diffuse. In the ED, the patient's
daughter reported that her mother had no fevers at home but had
been having chills. On arrival to the floor the pt developed
nausea and non-bloody vomiting, but had not had these symptoms
prior. Pt's dtr denied any altered mental status. She did report
some diarrhea, no melena or constipation. The patient also
reports that she has had some dyspnea on exertion recently,
unable to relate how long. She currently feels like she is
"panting."
.
In the ED, triage vital signs were: 98.2 66 117/39 16 100% 2L.
Diagnostic paracentesis was performed, which was positive for
SBP. RUQ ultrasound showed gallbladder wall thickening and
possible acute cholecystitis. Foley was placed. Ceftriaxone,
flagyl, morphine and zofran were given. Cipro was started
originally, but pt began to develop "red blotches" ([**Name8 (MD) **] RN
notes) so cipro was stopped. Transplant surgery saw the patient
and recommended an ICU bed for monitoring of SBP and broad
spectrum abx for SBP and UTI, as well as HIDA scan to further
evaluate for cholecytitis.
.
.
On floor, patient began vomiting, reported mild shortness of
breath and reports that her abdominal pain is improving.
.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough. Denied chest
pain. No recent change in bowel or bladder habits. No dysuria.
Denied arthralgias or myalgias
Past Medical History:
- Cirrhosis, RFA Liver seg 6 lesion- 2.3cm - hepatocellular CA
[**3-2**]
- Chronic kidney disease, stage III/IV, baseline creatinine
2.4-2.8
- likely secondary to hypertensive nephrosclerosis and diabetic
nephropathy
- Diabetes mellitus, diagnosed [**2166**], last HbA1c 5.8% [**2181-1-2**]
- Peripheral vascular disease with claudication
- Hypertension with LVH
- Wide pulse pressure - (Nephrologist would like to keep
systolic slightly high in order to keep perfusion in setting of
stenotic vessels)
- Breast cancer status post modified radical mastectomy of the
left breast in [**2161**]
- Chronic obstructive pulmonary disease
- Mitral regurgitation
- 1st degree AV block
- Degenerative joint disease
- Gout, Pseudogout
- Left and right femoropopliteal bypass surgeries
- Left knee surgery x 2
- Cataract surgery
Social History:
Lives in [**Location 3146**], [**State 350**] with daughter and granddaughter,
who help her with ADLs. Widowed >30 years. No alcohol or
illicit drugs. Hx of smoking but quit in [**2166**].
Family History:
Mother - HTN, died of cerebral hemorrhage
Father - CV disease, may have died of cardiac arrest
Sister - Breast cancer, died at age of 32 from breast cancer.
Two
brothers passed away from myocardial infarction, one brother
passed away from melanoma, and another passed away from cancer
of
unknown etiology. The patient has one living sister who suffers
from hypertension and has had a myocardial infarction in the
past.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS - 97.6 145/49 77 22 99% on RA
GENERAL - elderly female, in no acute distress.
HEENT - PERRLA, EOMI, MM dry
NECK - supple no JVD elevation appreciated. RIJ central venous
catheter in place.
LUNGS - Crackles at bases bilaterally.
HEART - RRR, no m/g/r
ABDOMEN - slight TTP at site of drain in RUQ quadrant, +
guarding, +fluid wave. Large ascites.
EXTREMITIES - 2+ bilateral lower extremity edema.
SKIN - no rashes
NEURO - awake, A&Ox3, however sometimes makes non-sensical
statements. Moving 4 extremities, non-focal.
Pertinent Results:
Admission Labs:
[**2181-5-3**] 11:10PM BLOOD WBC-23.7*# RBC-2.75* Hgb-8.8* Hct-27.3*
MCV-99*# MCH-31.9 MCHC-32.2 RDW-19.9* Plt Ct-256
[**2181-5-4**] 07:35AM BLOOD WBC-12.7* RBC-2.13* Hgb-6.8* Hct-21.3*
MCV-100* MCH-32.0 MCHC-32.1 RDW-19.8* Plt Ct-107*#
[**2181-5-3**] 11:10PM BLOOD PT-15.4* PTT-30.5 INR(PT)-1.3*
[**2181-5-3**] 11:10PM BLOOD Glucose-225* UreaN-140* Creat-4.5*#
Na-132* K-5.3* Cl-102 HCO3-13* AnGap-22*
[**2181-5-3**] 11:10PM BLOOD ALT-15 AST-36 AlkPhos-160* TotBili-1.1
[**2181-5-5**] 03:30AM BLOOD ALT-13 AST-26 LD(LDH)-111 AlkPhos-56
TotBili-2.4* DirBili-1.2* IndBili-1.2
[**2181-5-3**] 11:10PM BLOOD Lipase-45
[**2181-5-4**] 05:44PM BLOOD CK-MB-3.48 cTropnT-0.030*
[**2181-5-3**] 11:10PM BLOOD Albumin-3.1*
[**2181-5-4**] 05:44PM BLOOD Albumin-2.6* Calcium-5.3* Phos-4.3
Mg-1.3*
[**2181-5-4**] 05:44PM BLOOD VitB12-1082* Folate-10.8
[**2181-5-12**] 05:31AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
MICROBIOLOGY:
URINE CULTURE (Final [**2181-5-9**]):
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION.
Piperacillin/Tazobactam Susceptibility testing
requested by DR.
[**First Name (STitle) 13258**] #[**Numeric Identifier 13259**] [**2181-5-7**].
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
URINE CULTURE (Final [**2181-5-7**]): NO GROWTH.
GRAM STAIN (Final [**2181-5-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2181-5-10**]):
ESCHERICHIA COLI. RARE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
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
ANAEROBIC CULTURE (Final [**2181-5-10**]):
CLOSTRIDIUM PERFRINGENS. SPARSE GROWTH.
Blood cultures 4/15, [**5-5**] - no growth
[**5-16**] - pending
IMAGING:
HIDA SCAN [**5-4**]:
IMPRESSION:
Acute cholecystitis as evident by the lack of tracer activity in
the gallbladder prior to and after the administration of
Morphine.
RUQ U/S [**5-3**]:
IMPRESSION:
1. Gallbladder is distended with biliary sludge and positive
[**Doctor Last Name 515**] sign. Gallbladder wall thickening may be secondary to
third spacing in the setting of ascites versus acute
cholecystitis. Findings may be concerning for acute
cholecystitis, however, clinical correlation is recommended in
the context that the patient's gallbladder was distended on MRI
of [**2181-3-29**] and positive [**Doctor Last Name 515**] may be related to the
presence of ascites/SBP. If required, a HIDA scan may be done
for further confirmation.
2. Nodular contour of the liver consistent with cirrhosis.
3. Ascites.
4. Main portal vein, right portal vein and left portal vein show
normal flow. Normal waveform in the main portal vein.
5. Hyperechoic focus 2.6 x 2.8 x 2.5 cm in the right lobe of the
liver likely corresponds to the RF ablation zone noted on prior
MRI. Hypoechoic focus 0.6 x 0.5 cm in the left lobe of the
liver.
Tube cholangiogram
IMPRESSION:
1. Percutaneous cholecystostomy tube in correct position with
pigtail within the gallbladder. There is no evidence of any
blockage of the drainage tubing with brisk opacification of both
the tubing and the gallbladder.
2. No intrahepatic biliary ductal dilatation. No evidence of any
filling
defect within the common bile duct with normal emptying into the
duodenum.
EKG [**2181-5-4**]:
Baseline artifact. Probable sinus bradycardia with atrial
premature beats and possible junctional escape beat.
Non-specific ST-T wave abnormalities. Compared to the previous
tracing of [**2181-5-3**] atrial premature beats and possible
junctional escape beat are new.
EKG [**2181-5-3**]:
Moderate baseline artifact. Normal sinus rhythm. Within normal
limits.
Compared to the previous tracing of [**2181-2-22**] no diagnostic
interval change.
CXR [**2181-5-16**]:
FINDINGS: As compared to the previous radiograph, there is
relevant
improvement. The areas of pre-existing bilateral parenchymal
atelectasis have substantially improved. The remaining
atelectasis are minimal. No pleural effusions. No evidence of
pulmonary edema. No pneumonia. Normal size of the cardiac
silhouette. Unchanged course and position of the two central
venous access lines on the right. Clips projecting over the left
axilla.
Brief Hospital Course:
86 year old female with a history of HCC, cirrhosis, DM, HTN,
CKD, presents with abdominal pain, found to have UTI, SBP and
cholecystitis treated with antibiotics and percutaneous
cholecystostomy, course complicated by acute tubular necrosis
necessitating dialysis. Patient and family decided to focus on
comfort, and return home with hospice.
.
# Acute cholecystitis/biliary sepsis: Patient initially
presented with abdominal pain and had RUQ U/S that was
concerning for acute cholecystitis; this was confirmed with HIDA
scan. Patient had a percutaneous cholecystostomy drain placed
by IR, after which she likely became bacteremic as she became
hypotensive and necessitated transfer to the MICU. Fluid
resuscitated and was able to be called out. Biliary fluid grew
pan-sensitive E coli for which patient was narrowed from
pip-tazo to ceftriaxone for which she completed 8 days of
treatment. Her exam markedly improved and she no longer had
abdominal pain. Her bilirubin initially trended down, then had
acute rise again as well as leukocytosis. Tube cholangiogram
was performed which showed correct placement of drain and no
obstruction in biliary system.
Started back on ceftriaxone and flagyl, then switched to PO
cefpodoxime for 10 days (last day [**5-25**]). Drain was removed prior
to discharge.
.
# Acute on Chronic Renal Failure: Urine output continued to be
low despite aggressive resuscitation and resolution of other
shock symptoms. As muddy brown casts were present on microscopy,
this was felt to be due to ATN. After discussion with the
patient and family, decision was made to start dialysis. The
patient had low blood pressures during dialysis and was not able
to have significant amounts of fluid removed. She was initiated
and then transitioned to MWF schedule. The decision was made to
discontinue treatment with dialyisis in order to retunr home and
focus on comfort.
.
# Bradycardia: Patient was bradycardiac to low 30s on admission.
Possible etiology electrolytes distrubances, sepsis and
fentanyl. Once electrolytes repleted and infection controlled,
patient had normal heart rates.
.
# Bacterial Peritonitis: Secondary to cholecystitis above.
Received albumin day 1 and day 3 of treatment. Antibiotics as
above.
.
# UTI: Urine growing E. Coli and Enterococcus; treated with
above abx.
.
# DM: Insulin sliding scale used while inpatient.
.
#. Cirrhosis: Diuretics (sprinolactone and furosemide) were held
in setting of shock/sepsis/ATN
.
#. Peripheral Vascular Disease: Held ASA 81 mg in acute setting.
.
#. Hypertension: Held home valsartan and metoprolol in setting
of shock, ATN and bradycardia.
.
# Gout: Held allopurinol in setting of acute on chronic renal
failure.
.
# Goals of Care: Discussion held with patient and her family
regarding goals of care. The decision was made to return home
with hospice. They have decided to discontinue dialysis.
Medications on Admission:
Diovan 160 mg Tab once a day
Aspirin 81 mg Tab, once a day with food
Allopurinol 100 mg every day
furosemide 80 mg once a day
omeprazole 20 mg once a day
spironolactone 25 mg -0.5 (One half) Tablet(s) by mouth every
other day
Lac-Hydrin 12 % Topical Cream apply to bottom of feet as
directed as needed for PRN
Metoprolol Succinate ER 100 mg 24 hr once a day
Lidoderm 5 % (700 mg/patch) apply 1 patch at bedtime as needed
for back / thigh pain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q30MIN (Every 30
minutes as needed) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
Primary: Acute cholecystitis, biliary sepsis, Acute kidney
injury causing Acute tubular necrosis causing dialysis
Secondary: Diabetes mellitus, cirrhosis, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 13257**],
It was a pleasure taking care of you during your
hospitalization. You were admitted with abdominal pain. You
were found to have an infection of your gallbladder. You had a
drain placed in the gallbladder to drain the infected fluid.
You were treated with antibiotics as well. Unfortunately
because of your infection, your kidneys were damaged and were no
longer functioning well. You were started on dialysis. After a
discussion with you and your family, the decision was made to
focus on your comfort and discontinue dialysis.
.
If you experience any concerns after discharge, please call
hospice.
Followup Instructions:
Should you experience any symptoms that concern you after
discharge, please call hospice.
|
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icd9cm
|
[
[
[]
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[
"38.95",
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icd9pcs
|
[
[
[]
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14210, 14280
|
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|
329, 414
|
14493, 14493
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4470, 4470
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275, 291
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4487, 10377
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14508, 14645
|
2414, 3233
|
3249, 3442
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,630
| 151,362
|
1022
|
Discharge summary
|
report
|
Admission Date: [**2169-5-3**] Discharge Date: [**2169-5-12**]
Date of Birth: [**2102-5-15**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Codeine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a 66 y/o with past medical history significant for COPD
(no O2 at home with PFT from [**2161**]-Increaded FEV1/FVC,decreased
DLCO) and [**1-6**] pack per day smoking history (for decades)
presents to the ED from her PCP's office with a four day history
of worsening SOB, cough, sputum production and hemoptysis. She
reports four day smoking cessation prior to symptoms and denies
chest pain/tightness/palpitation, sore-throats/head
congestion/runny nose, fevers/chills/night sweats/unintentional
weight loss, nausea/vomiting, diarrhea/constipation/melena,
changes in urination, light-headedness. In her PCP's office
prior to the ED she was found to be 76%RA which improved to 90s
with supplemental O2.
.
In the ED initial vitals were: T:96.8 HR:94 HTN:165/80 RR:20 O2
Sat:94%on 4L. On exam she had diminished breath sounds with
wheezes, after nebs. Was given steroids - methyl prednisone
125mg. CXR concerning for right middle lobe pneumonia, hence
started on ceftriaxone and azithromycin. ABG-7.25/78/99 and was
started on BiPAP but could only tolerate it for 20 minutes. Was
then given ativan with sats stable in the low 90s on 5L. Her
initial Peak flow was 75. Her vitals at the time of transfer to
the MICU were: 93, 21, 176/73 94% 5L.
.
In the MICU she continued to be hypoxic on RA thought to be from
pneumonia vs. pneumonitis vs. COPD exacerbation, not pulmonary
edema. Sputum cultures were negative and was continued on
steroids, nebs and anti-biotics (azithromycin was d/c and
levofloxacin was added on 2nd day. CT showed diffuse bronchial
wall thickening with associated diffuse tree-in-bronchial and
centrilobular nodular opacities likely due to infection. With
worsening pulmonary function, she was intubated and extubated
twice (most recently [**5-9**]), completed steroid burst and left
the MICU on 95% on nasal cannula. For BP control, her home HCTZ
was held, diuresed with furosemide and started on metop. Her
metformin was held for diabetes control and was started on
sliding scale. Pt.'s MICU was also complicated by
agitation/confusion/altered mental status change thought to be
delirium and received atypical anti-psychotics and anti-anxiety
medication.
On arrival to the floor, vital signs stable but breathing 92% on
1L, comfortable in bed and consistently requesting to be
discharged. Denies fever/chills/night sweats/recent weight loss
or gain, headache/rhinorrhea/congestion, cough/SOB, chest
pain/chest pressure/palpitations,nausea/vomiting,
diarrhea/constipation/abdominal pain, dysuria/frequency/urgency.
rashes/skin changes.
Past Medical History:
-asthma/COPD rx prednisone but never hospitalized
-new type 2 diabetes
-allergic rhinitis
-severe chronic insomnia / anxiety / depression
-GERD
-hypertension
-hyperlipidemia
-obesity,
-gait disorder
Social History:
Born in [**Location (un) 86**], MA and currently lives in [**Location 86**] independently
but her brother lives upstairs in the same building. Worked in
management for PNC for several years until she was placed on
disability 4-years ago for ?spinal mass. Has 30 year old
daughter [**Name (NI) 6739**] who does not live with her.
- Tobacco: 2-4 packs per day. Started smoking since 9 years old
and on average somed a pack per day for decades.
- Alcohol: Denies
- Illicits: Denies
Other:
Family History:
CAD, Stomach cancer, Sisters died of lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.1, 80, 122/78, 22, 92% 1L
General: alert, oriented to place and self, no acute distress,
fixating on going home with poor insight on medical condition.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Decreased breath sounds, wheezes and crackles diffusely.
Non-labored breathing. No ronchi.
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: Obese abdomen, soft, non-tender, non-distended, BS
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, mild clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM
Vitals:Tm-99.0, Tc:98.8, HR:66, BP:130/70(110-130/60-70), RR:19,
O2 sat:91%on RA
Physical Exam:
General: alert, oriented to place and self, no acute distress,
sitting comfortably in chair.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Decreased breath sounds, crackles in the left lower base.
Non-labored breathing but decreased air movement. No ronchi.
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: Obese abdomen, soft, non-tender, non-distended, BS
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, mild clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
.
[**2169-5-3**] 04:45PM BLOOD WBC-8.3 RBC-4.67 Hgb-14.2 Hct-43.6 MCV-93
MCH-30.5 MCHC-32.7 RDW-14.4 Plt Ct-185
[**2169-5-3**] 04:45PM BLOOD Neuts-86.5* Lymphs-7.7* Monos-4.9 Eos-0.3
Baso-0.6
[**2169-5-3**] 04:45PM BLOOD PT-15.2* PTT-28.6 INR(PT)-1.3*
[**2169-5-3**] 04:45PM BLOOD Glucose-151* UreaN-21* Creat-0.9 Na-143
K-3.7 Cl-99 HCO3-32 AnGap-16
[**2169-5-4**] 01:55AM BLOOD Albumin-3.6 Calcium-8.2* Phos-2.6* Mg-1.7
.
CTA:
1. No evidence of pulmonary embolus or acute aortic syndrome.
2. Diffuse bronchial wall thickening, with associated diffuse
tree-in-[**Male First Name (un) 239**] and centrilobular nodular opacities, most compatible
with a chronic bronchitis and superimposed acute upper lobe
bronchiolitis.
3. Hilar adenopathy, likely reactive.
[**2169-5-5**] 02:18AM BLOOD Neuts-89.8* Lymphs-7.2* Monos-2.8 Eos-0.1
Baso-0.1
[**2169-5-8**] 04:02AM BLOOD Neuts-73* Bands-3 Lymphs-14* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-4*
[**2169-5-8**] 04:02AM BLOOD Glucose-186* UreaN-35* Creat-0.8 Na-140
K-4.3 Cl-98 HCO3-31 AnGap-15
[**2169-5-9**] 03:45AM BLOOD Glucose-126* UreaN-27* Creat-0.9 Na-139
K-3.7 Cl-96 HCO3-35* AnGap-12
[**2169-5-10**] 03:35AM BLOOD Glucose-105* UreaN-19 Creat-0.8 Na-146*
K-3.2* Cl-100 HCO3-37* AnGap-12
[**2169-5-10**] 07:40PM BLOOD Glucose-127* UreaN-18 Creat-0.8 Na-145
K-3.8 Cl-101 HCO3-36* AnGap-12
[**2169-5-11**] 06:29AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-143
K-3.6 Cl-98 HCO3-37* AnGap-12
[**2169-5-9**] 08:56AM BLOOD Rates-/18 PEEP-5 FiO2-40 pO2-68* pCO2-52*
pH-7.49* calTCO2-41* Base XS-13
[**2169-5-9**] 11:50AM BLOOD Type-ART Temp-37.2 FiO2-100 pO2-152*
pCO2-61* pH-7.41 calTCO2-40* Base XS-11 AADO2-518 REQ O2-85
Intubat-NOT INTUBA Comment-FACE TENT
[**2169-5-10**] 04:07AM BLOOD Type-CENTRAL VE Temp-38.1 O2 Flow-5
pO2-40* pCO2-62* pH-7.42 calTCO2-42* Base XS-12 Intubat-NOT
INTUBA
Brief Hospital Course:
#.HYPOXIA: Patient was intubated secondary to hypoxic and
hypercarbic respiratory failure. CT scan showed tree-in [**Male First Name (un) 239**]
opacities inidcative of possible atypical pneumonia. She was
treated with levofloxacin and ceftriaxone for a total 7 day
course. She was also given 5 day course of pulse steroids for
COPD exacerbation, along with nebulizer treatments. There was
no evidence of PE on CTA. Required antipsychotics as well as
Precedex drip for agitation. Experienced an episode of severe
bradycardia with 15 second asystolic pause requiring two chest
compressions. Returned to sinus without complications and
Precedex was discontinued. She was able to be extubated on ICU
Day 6. When she left the MICU on 95% on nasal cannula and she
was successfully transitioned to breathing room air on the
floor. Her discharge O2 sats were 92% at rest and 89-91% with
activity on room air. She will follow up with pulmonary as an
outpatient.
.
#.DELIRIUM: Around the time of extubation, patient was agitated
and showing signs of delerium. Thought to be secondary to ICU
delirium vs. infectious process, hypoxia, prolonged ICU stay,
steroid administration. CT neg for intracranial process. She
was given seroquel for agitated delirium and ativan for anxiety.
Her mental status rapidly improved upon transition out of the
ICU.
.
#.HYPERTENSION: Stable and on home medication (Lisinopril and
metoprolol)
.
Medications on Admission:
Atenolol 25mg QD
HCTZ 25mg PO QD
ASA 81mg PO QD
Pravastatin 20mg QD
Metformin 500mg ER QD after dinner
Fluticasone 110mcg 1 puff PO BID
Combivent 2 puffs Q4H
Citalopram 20mg QHS
Xanax 0.5mg PRN
Pantoprazole 40mg PO BID
Multivitamin
Nicotine patch
Lidoderm patch [**12-4**] each evening
Discharge Medications:
Atenolol 25mg QD
HCTZ 25mg PO QD
ASA 81mg PO QD
Pravastatin 20mg QD
Metformin 500mg ER QD after dinner
Fluticasone 110mcg 1 puff PO BID
Combivent 2 puffs Q4H
Citalopram 20mg QHS
Xanax 0.5mg PRN
Pantoprazole 40mg PO BID
Multivitamin
Nicotine patch
Lidoderm patch [**12-4**] each evening
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
#Primary Diagnosis
-Chronic Obstructive Pulmonary Disease exacerbation
-Delirium
.
#Secondary diagnosis
-asthma
-type 2 diabetes
-allergic rhinitis
-severe chronic insomnia / anxiety / depression
-GERD
-hypertension
-hyperlipidemia
-obesity,
-gait disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for worsening difficulty
breathing, cough with blood streak sputum and cough. From the
emergency department you were so short of breath and your body
was starved of the oxygen it needs so you were intubated
(breathing tube was put down your throat and was connected to a
ventilator to help you breath/get enough oxygen). You were then
sent to the intensive care unit for further monitoring. You
remained intubated for several days and you were weaned off the
ventilator and placed on oxygen, eventually transitioning to
breathing room air. In the intensive care unit, you were also
very agitated and confused so you were given various medications
including (seroquel for agitation and ativan for anxiety) to
help calm you down and your mental status continued to clear as
you moved to the medicine floor. You should follow-up with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment with the lung
doctors(pulmonologists) to repeat your pulmonary function
studies. You should also try to quit smoking and you should work
with your primary care doctor on options to help you quit. You
are being discharged home with services since you have been
unstable on your feet and you need help walking around. You do
not need oxygen at home since you were oxygen saturation on
discharge was 92% on room air at rest and 89-91% on room air
with ambulation.
Followup Instructions:
Please follow-up with your primary care doctor, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6740**],
MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2169-6-26**] at 11:15AM
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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icd9cm
|
[
[
[]
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[
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|
[
[
[]
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8963, 9021
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6889, 8315
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9322, 9322
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5010, 5010
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4443, 4991
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240, 261
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9337, 9481
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3140, 3629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,023
| 184,428
|
19524+57040
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-1-2**] Discharge Date: [**2184-1-12**]
Date of Birth: [**2101-8-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Elective catheterization
Major Surgical or Invasive Procedure:
Cardiac Catheterization
[**1-5**] OP CABGx4(LIMA-LAD, SVG-Diag, SVG-OM, SVG-PDA)
History of Present Illness:
82 year old woman with a large abdominal aortic aneurysm,
measuring 7 x 6.7 x 9.7cm who is preoperative for endovascular
aneurysm repair with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. This surgery was
orignally scheduled for [**2183-12-25**] but was cancelled with the
patient was admitted to [**Hospital1 18**] on [**2183-12-24**] with left hip pain.
She is s/p left femoral neck fracture treated with a
hemiarthroplasty on [**2183-11-20**]. She was found to have an acute
left hip hematoma (previously had a pseudoaneurysm in same
location). During her admission, she had an acute episode of
tachycardia and dyspnea. This was in the setting of a hct of
23.9 on day of arrival. She ruled in for a NQWMI with a Troponin
of 0.63, ck 277. She had previously been seen in clinic by Dr.
[**Last Name (STitle) **] and had a stress test on [**12-22**] that showed a fixed septal
defect c/w her LBBB. EF 50% with normal wall motion. Pt was sent
to rehab with plans to return this week for cath at [**Hospital1 **]. She
has had no complaints of chest pain since admission to rehab.
The nurse reports that she has bilateral LE edema. She continues
to c/o of left hip pain rated [**7-13**] and she has been getting
Vicodin q4 hours.
Past Medical History:
1. Left femoral neck fracture status post hemiarthroplasty on
[**2183-11-20**].
2. Myelodysplastic syndrome requiring packed red blood cell and
platelet transfusion.
3. Diabetes.
4. Hypertension.
5. AAA
Social History:
She is married, does not smoke cigarettes. Does not do any
regular exercise or follow a particular diet.
Family History:
No family history of premature coronary disease or sudden death.
Physical Exam:
VS: T: 97.9 P: 72 BP: 130/70 O2: 100% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 4cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. R arm shows small 2cm hematoma
with small ooze. Intact distal radial pulse
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
[**2184-1-12**] 10:35AM BLOOD Hct-24.6*
[**2184-1-12**] 06:30AM BLOOD WBC-8.2 RBC-2.58* Hgb-8.0* Hct-23.4*
MCV-91 MCH-31.2 MCHC-34.3 RDW-14.3 Plt Ct-86*
[**2184-1-2**] 09:20AM BLOOD WBC-4.9 RBC-3.04* Hgb-9.5* Hct-28.1*
MCV-92 MCH-31.2 MCHC-33.8 RDW-15.6* Plt Ct-84*
[**2184-1-2**] 09:20AM BLOOD Neuts-85.6* Lymphs-7.2* Monos-4.7 Eos-2.2
Baso-0.2
[**2184-1-12**] 06:30AM BLOOD Plt Ct-86*
[**2184-1-8**] 04:00PM BLOOD PT-13.9* PTT-29.4 INR(PT)-1.2*
[**2184-1-2**] 09:20AM BLOOD PT-14.4* PTT-28.2 INR(PT)-1.3*
[**2184-1-2**] 09:20AM BLOOD Plt Smr-LOW Plt Ct-84*
[**2184-1-5**] 11:19AM BLOOD Fibrino-104*
[**2184-1-12**] 06:30AM BLOOD Glucose-160* UreaN-61* Creat-1.7* Na-136
K-4.3 Cl-100 HCO3-30 AnGap-10
[**2184-1-11**] 06:50AM BLOOD Glucose-180* UreaN-61* Creat-1.7* Na-134
K-5.4* Cl-99 HCO3-27 AnGap-13
[**2184-1-2**] 09:20AM BLOOD Glucose-159* UreaN-35* Creat-1.1 Na-138
K-4.5 Cl-103 HCO3-29 AnGap-11
[**2184-1-9**] 07:15AM BLOOD ALT-9 AST-15 LD(LDH)-501* AlkPhos-82
Amylase-20 TotBili-1.5
[**2184-1-3**] 05:56AM BLOOD ALT-11 AST-19 LD(LDH)-562* AlkPhos-73
TotBili-1.7*
[**2184-1-9**] 07:15AM BLOOD Lipase-36
[**2184-1-8**] 10:45AM BLOOD Lipase-27
[**2184-1-12**] 06:30AM BLOOD Calcium-7.9* Phos-4.3 Mg-2.1
[**2184-1-3**] 05:56AM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.3 Mg-1.2*
[**2184-1-3**] 05:56AM BLOOD %HbA1c-6.7*
[**2184-1-4**] 06:46AM BLOOD Triglyc-153* HDL-37 CHOL/HD-3.4
LDLcalc-59
CHEST (PA & LAT) [**2184-1-11**] 9:50 AM
CHEST (PA & LAT)
Reason: stable pnuemothoracies
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with b/l pnuemothoracies / please evaluate, to
see if stable
REASON FOR THIS EXAMINATION:
stable pnuemothoracies
HISTORY: Pneumothorax.
Four radiographs of the chest demonstrate persistent, small,
bilateral pneumothoraces. Finding is unchanged when compared
with [**2184-1-10**]. There is a persistent small left-sided pleural
effusion. There is mild blunting of the right costophrenic
angle. Patient is status post CABG. No consolidation is evident.
The trachea is midline.
IMPRESSION:
Persistent, small, bilateral pneumothoraces, unchanged.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: MON [**2184-1-12**] 9:15 AM
Cardiology Report ECG Study Date of [**2184-1-5**] 12:29:16 PM
Sinus rhythm. Incomplete right bundle-branch block. Since the
previous tracing
of [**2184-1-2**] intraventricular conduction delay and ST-T wave
changes appear
decreased.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 112 420/455 0 43 105
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 52973**]
(Complete) Done [**2184-1-5**] at 8:15:22 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2101-8-4**]
Age (years): 82 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG, ?OP
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.0
Test Information
Date/Time: [**2184-1-5**] at 08:15 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**1-7**] T): 2.6 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: No TS.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is mildly
depressed (LVEF=40-45 %). There is mild global right ventricular
free wall hypokinesis. There are complex (>4mm) atheroma in the
descending thoracic aorta. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
Post-Op-CABG: Good biventricular systolic fxn. No AI. MR 1 - 2+.
Aorta intact. Other parameters as pre-CABG.
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) **] [**2184-1-5**] 11:45
Brief Hospital Course:
A/P: 82 yo female with hx AAA, NSTEMI in setting of anemia
presents for pre-op cardiac catheterization in preparation for
AAA repair. Cath showed multi-vessel disease, and she was
evaluated for CABG. She was taken to the operating room on [**1-5**]
where she underwent an off-pump CABG x 4. She was transferred to
the ICU on neo and propofol. She was given 48 hours of
vancomycin as she was in the hospital preoperatively. She was
extubated on POD #1. She was transfused one unit and weaned from
her vasoactive drips by POD #2. She developed atrial
fibrillation and converted after receiving amiodarone. She was
transferred to the floor on POD #3. She was thrombocytopenic and
a HIT antibody was negative. Physical therapy worked with her
in relation to strength and mobility. She continued to progess
and was ready for discharge to rehab on POD #7. Plan for follow
with vascular surgery for endovascular stent.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*25 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
please take 400mg daily for 7 days then decrease to 200mg daily
and follow up with cardiologist .
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
12. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
13. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. Outpatient Lab Work
please check potassium, Cr, BUN, Hct on friday [**1-16**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
L. femoral neck fx. s/p hemiarthroplasty [**11-20**], L fem
pseudoaneurysm, s/p NSTEMI, Myelodysplastic syndrome requiring
PRBCs and platelets transfusion, DM, HTN, AAA 7.3x6.3 cm
infrarenal
Discharge Condition:
Good.
Discharge Instructions:
Call with [**Month/Year (2) **], 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:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] 2-3 weeks [**Telephone/Fax (1) 127**]
Dr. [**Last Name (STitle) 9851**] after discharge from rehab [**Telephone/Fax (1) 52974**]
Dr. [**First Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 18181**] - Monday [**2184-1-19**] at 12:45 [**Hospital **]
medical building [**Hospital Unit Name **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2184-1-12**] Name: [**Known lastname 9783**],[**Known firstname 634**] Unit No: [**Numeric Identifier 9784**]
Admission Date: [**2184-1-2**] Discharge Date: [**2184-1-12**]
Date of Birth: [**2101-8-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Acute systolic heart failure postoperatively with moderately
depressed LVEF.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6418**] Healthcare - [**Location (un) 407**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2184-1-13**]
|
[
"250.00",
"998.12",
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icd9cm
|
[
[
[]
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[
"36.13",
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icd9pcs
|
[
[
[]
]
] |
13799, 14002
|
8763, 9679
|
343, 426
|
12443, 12451
|
2971, 4457
|
12766, 13776
|
2074, 2141
|
10773, 12068
|
4494, 4573
|
12196, 12422
|
9705, 10750
|
12475, 12743
|
2156, 2952
|
279, 305
|
4602, 8740
|
454, 1708
|
1730, 1935
|
1951, 2058
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,011
| 166,293
|
52898
|
Discharge summary
|
report
|
Admission Date: [**2118-8-5**] Discharge Date: [**2118-8-11**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization [**8-9**] with IABP placement
History of Present Illness:
88 y/o Male w/ PMH of CAD status post CABG and MI in the past,
DM2, hypertension, diabetes, afib, chronic kidney disease,
status post nephrectomy recently admitted to [**Location (un) 620**] for CHF,
has known severe AS (EF 25-35%) presents with gradual worsening
DOE over the last month. There has been no acute change but
patient states no longer can lay flight at night which is a
change in the last two weeks. Denies cough. Afebrile. No Chest
pain. States quality of life has significantly diminished,
unable to do many activities that he used to. Cardiology at [**Hospital1 **]
[**Location (un) **] spoke with Dr. [**Last Name (STitle) **], and decided to admit to heart
failure service for evaluation of possible CORE valve. During
his last admission, it was recommended that he undergo
consideration ?AVR or CORE valve. Of note, at [**Hospital1 18**] [**Location (un) 620**], he
was given diuretics and improved. But given his worsening
symptoms, he would like evaluation for aforementioned
procedures. He has had trop bump to 0.234 which is similar to
prior. Down to 0.2 at [**Hospital1 18**] on [**2118-8-5**]. OF NOTE, on [**2118-7-23**] (s/p
fall w/ rib fractures), he elevated his Trops to 0.66 at [**Hospital1 18**]
[**Location (un) 620**] as well as CKMB to 9.70 and thus may have had an NSTEMI
on [**2118-7-23**] with down trending Troponins thus on Discharge they
were 0.234 however CKMB [**7-21**] 4>10>6>6 on [**7-21**]/18/19/30
which may have indicated a small reinfarction. However, this is
unclear from [**Hospital1 18**] [**Name (NI) 620**] documentation.
.
Of note patient states he is DNR/DNI, but has no documentation
at this time. Transfered from [**Location (un) 620**] with hx of chronic chf,
and aortic stenosis. Worsening sob, no fevers. Had chf flare
yesterday given lasix and sent back to nsgn home. Trop 0.234
similiar to prior. Pale sob with talking. Pt states he is dnr
but no paperwork to reflect that.
Labs at [**Hospital1 **] [**Location (un) **] (performed at 1430):
CBC: WBC 7.3, hgb 9.7, plt 415
Trop: 0.234
BNP: [**Numeric Identifier **]
Radiology at [**Hospital1 **] [**Location (un) **]: CXR (in our pacs system)- CHF
CLINICAL HISTORY: Shortness of breath. Comparison is made with
prior studies [**8-4**] and [**7-23**]. Right upper lobe opacity
is unchanged consistent with pneumonia. Moderate to large right
and moderate left pleural effusions with associated atelectasis
are grossly unchanged allowing the difference in positioning of
the patient. Mild cardiomegaly and tortuous aorta are stable.
The lungs are hyperinflated consistent with COPD. Sternal wires
are aligned. Patient is status-post CABG.
IMPRESSION: RIGHT UPPER LOBE PNEUMONIA. BILATERAL PLEURAL
EFFUSIONS WITH ADJACENT ATELECTASIS. COPD.
AT [**Hospital1 **] [**Location (un) **] ED:
EKG here: sinus arrhythmia at 73, LAD, RBBB, QTc 474
On exam: comfortable on 2L NC with RR 20, 94% sat. crackles at
the bases R>L. RRR w/2/6 systolic ejection murmur at RUSB. no
elevation in JVD. no LE edema. rest of exam benign.
.
ROS:
Positive per above.
Past Medical History:
CAD RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension
CARDIAC HISTORY:
-CABG: CABG in [**2104**] (LIMA-LAD, SVG-OM)
-PERCUTANEOUS CORONARY INTERVENTIONS: RCA stent x2 in [**2105**],
SVG-OM (3.5 x 18mm Cypher) stent placed in [**2110**]
OTHER MEDICAL HISTORY:
Type II DM
Right Kidney removed years ago
Prostatectomy
Tonsillectomy
Appendectomy
Hernia x2
LV aneurysm on Warfarin
Atrial fibrillation
Urinary retention
Anxiety
Social History:
Retired, lives with wife. Was [**Name2 (NI) **] fire chief of [**Location (un) **],
where he worked for 40+ yrs.
-Tobacco history: 100-150 PY smoking history, quit 10 years ago.
-ETOH: occasionally
-Illicit drugs: Denies
Family History:
Father died of CAD at the age of 57. Mother died in her 80's.
One brother died of pancreatic cancer in his 70's, the other of
unknown cancer, also in his 70's.
Physical Exam:
VS: 97.6 130/70 86 18 100 3L 61kg
GENERAL: NAD, AxOx3.
HEENT: JVP not appreciable. Sclera anicteric. EOMI. MMM
CARDIAC: RRR w/2/6 systolic ejection murmur at RUSB.
LUNGS: mildly labored, crackles at the bases R>L
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: pretibial edema no appreciable.
Pertinent Results:
LABS:
[**2118-8-5**] 06:55PM PLT COUNT-414#
[**2118-8-5**] 06:55PM NEUTS-70.6* LYMPHS-16.4* MONOS-6.0 EOS-6.3*
BASOS-0.6
[**2118-8-5**] 06:55PM WBC-6.7 RBC-3.34* HGB-9.2* HCT-29.4* MCV-88
MCH-27.6# MCHC-31.3 RDW-15.1
[**2118-8-5**] 06:55PM CK-MB-5 proBNP-[**Numeric Identifier 39011**]*
[**2118-8-5**] 06:55PM cTropnT-0.20*
[**2118-8-5**] 06:55PM CK(CPK)-86
[**2118-8-5**] 06:55PM estGFR-Using this
[**2118-8-5**] 06:55PM GLUCOSE-174* UREA N-30* CREAT-1.4* SODIUM-143
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-30 ANION GAP-13
.
.
ECHO (TTE) [**2118-8-6**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is severely depressed (LVEF= 20-25 %) with
akinesis of the distal [**12-7**] of the left ventricle and hypokinesis
in the remaining segments. There is some regional variation,
with preservation in function of the basal lateral and basal
anteroseptal walls. A left ventricular mass/thrombus cannot be
excluded. The remaining left ventricular segments are
hypokinetic. The aortic valve leaflets are moderately thickened.
Severe aortic stenosis (based on [**Location (un) 109**]; low gradient) is present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-6**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
The end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Low-gradient aortic
stenosis with calculated aortic valve area of 0.8 cm2 but mean
gradient of 14 mm Hg; low gradient may be due to severe left
ventricular contractile dysfunction. Depressed cardiac index.
Mild-to-moderate mitral regurgitation. Mild aortic
regurgitation.
Compared with the prior study (images reviewed) of [**2116-9-14**],
calculated aortic valve area is lower. Left ventricular systolic
function is less vigorous. The severity of mitral regurgitation
has increased.
.
.
CATH [**2118-8-9**]:
The resting hemodynamics showed a CO = 2.7 L/min; mean gradient
18.6 mmHg; HR 77; stroke volume 35 cc; SVI = 21.8 cc; [**Location (un) 109**] 0.62
cm2.
After 10 minutes of dobutamine, 20 mcg/kg/min, the CO 3.5 L/min;
mean gradient 22.3 mmHg; HR 79; stroke volume 43.6 cc; SVI =
27.1 cc; [**Location (un) 109**] 0.73 cm2.
.
Coronary angiography: right dominant
LMCA: 80% calcified
LAD: 100% calcified ostial occlusion
LCX: 100% OMB1 and OMB2. Small branches without perfusion
RCA: 40% in the mid RCA. There was diffuse disease in the
PDA and posterolateral branches up to 40-50% stenoses
SVG-OMB: Occluded by prior examination
LIMA-LAD: Patent LIMA to the LAD with diffuse disease of the
mid and distal LAD and diagonal branches
.
Interventional details
After dobutamine 20 mcg/kg/min, the patient developed profound
hypotension to 70-80s systolic that was treated with dopamine 10
mg/kg/min and neosynephrine 1-2 mcg/min. This resulted in a
systolic BP of approximately 90-100 mmHg.
An IABP was placed from the right femoral artery without
complications and resulted in an augmentation of the BP to 130
systolic.
Coronary arteriography was performed from the left femoral
artery
.
Assessment & Recommendations
1. Three Vessel coronary artery disease
2. Patent LIMA to the LAD; Occluded SVG to the OMB
3. Severe aortic stenosis with borderline contractile reserve
4. Hypotension after dobutamine infusion improved with IABP and
pressors
5. CCU Overnight
Brief Hospital Course:
Mr. [**Known lastname 12163**] was an 88-year-old man with severe ischemic
cardiomyopathy (EF 20-25%), severe AS (low gradient), CAD s/p
CABG, CKD, AF, DM, and COPD who was admitted to [**Hospital1 **] [**2118-8-5**]
with decompensated congestive heart failure. During his
hospitalization on the [**Hospital1 **] service, the patient was diuresed,
and his CHF medication regimen was optimized. His echo showed
an EF of 20-25% with global dysfunction with regional variation.
He had 1+ AR, [**12-6**]+ MR [**First Name (Titles) **] [**Last Name (Titles) **], and severe AS. He underwent
right and left heart catheterization for further evaluation.
Left heart catheterization showed native 3VD with 80% LMCA,
total occlusion of LAD and LCx, and 40% occlusion of RCA mid
vessel. LIMA-LAD patent with diffuse disease, SVG-OM occluded.
Right heart catheterization showed a cardiac output of 3.5
l/min/m2 and cardiac index of 1.7. PCWP was 26 mm Hg, and PAP
mean was 25 mm Hg. The patient received dobutamine in the cath
lab and became hypotensive with MAPS in 50s; he was started on
phenylephrine. IABP was placed from the right femoral artery
without complications and resulted in an augmentation of the BP
to 130 systolic and a mean gradient increase to 23 from 18 mm
Hg. He was transferred to the CCU for further management. The
patient had severe (low gradient) aortic stenosis with severe
ischemic CM and poor contractive reserve based on dobutamine
cath. The patient did not wish to explore further non-medical
interventions. On [**8-10**], the IABP was removed due to increasing
lactate and abdominal pain. Goals of care were transitioned to
comfort measures only on [**8-11**] per the patient??????s wishes. Pressors
and antibiotics were discontinued. He was given Dilaudid and
Ativan intravenously for pain and shortness of breath.
Scolpalamine was added for increased secretions. His blood
pressure remained approximately 70/40s throughout the day. In
the evening of [**8-11**], his heart rate slowed and blood pressure
dropped culminating in asystole. At 6:50PM, exam showed no
audible cardiac or breath sounds, pupils dilated and
non-reactive bilaterally, no palpable pulses, and no response to
painful stimuli. He was pronounced deceased. Family was at his
bedside and declined autopsy.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Senna 1 TAB PO BID
hold for diarrhea
2. Docusate Sodium 100 mg PO BID
hold for diarrhea
3. Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Acetaminophen 1000 mg PO Q8H
5. Amiodarone 200 mg PO DAILY
hold for SBP<100, HR<60
6. Aspirin 81 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Bumetanide 0.5 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Lisinopril 5 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
14. Warfarin 2 mg PO DAILY16
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"428.23",
"424.1",
"414.8",
"V49.86",
"585.9",
"458.29",
"V45.82",
"250.00",
"403.90",
"414.01",
"414.02",
"412",
"E888.9",
"790.92",
"V58.61",
"V66.7",
"496",
"807.05",
"427.31",
"285.9",
"428.0",
"E879.0",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.23",
"37.61",
"88.56",
"97.44"
] |
icd9pcs
|
[
[
[]
]
] |
11360, 11369
|
8278, 10592
|
270, 325
|
11420, 11429
|
4615, 8255
|
11485, 11495
|
4118, 4279
|
11328, 11337
|
11390, 11399
|
10618, 11305
|
11453, 11462
|
4294, 4596
|
211, 232
|
353, 3407
|
3429, 3863
|
3879, 4102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,971
| 180,861
|
15903
|
Discharge summary
|
report
|
Admission Date: [**2152-10-18**] Discharge Date: [**2152-11-2**]
Date of Birth: [**2091-12-26**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Aspirin
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Acute Respiratory Distress
Major Surgical or Invasive Procedure:
[**10-23**]-RIGHT UPPER LOBE WEDGE RESECTION completed by Drs. [**Last Name (STitle) **].
[**Doctor Last Name **] and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 34792**].
History of Present Illness:
Mr. [**Known lastname 6632**] is a 60 yo man with a history HCV cirrhosis s/p OLT
in [**2145**], with recurrent Hep C presented to [**Hospital1 18**] with one month
of DOE. CT chest showed possible basilar interstitial fibrosis
with evidence of pulmonary HTN, and moderate pulmonary HTN
estimated on TTE. As part of his evaluation, patient underwent
a bronchoscopy and VATS on [**2152-10-23**] with lung biopsy, pathology
revealing moderate-to-severe interstitial fibrosis with
honeycomb change and organizing pneumonia. He has also finished
a 5-day course of levofloxacin for treatment of community
acquired pneumonia.
When on the floor, pt was found by nursing to have significant
work of breathing, with O2 saturation in the 60s. Sats improved
after transitioning from 4 liters n/c to non-rebreather. Chest
film showed possible volume overload, and patient was given
furosemide 40 mg IV x 1, with good UOP. ABG was 7.41/35/61 on
nasal cannula and shovel mask, but had just been on
non-rebreather.
Upon assessment, vitals were significant for BP 170s/100s, and
HR in 100s, along with RR 30s and O2 sat 96% on non-rebreather.
He was transferred to the ICU.
On arrival to MICU, patient denied pain, but was still
significantly short of breath.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Hepatitis C c/b cirrhosis, HCC, s/p liver transplant [**2146-8-10**]
- most recent liver biopsy [**2151-10-7**] with stage II fibrosis and
grade 2 inflammation.
- started on PEG-IFN and ribavirin [**2152-1-22**]
Hypertension
DM
Anxiety
Depression
Back Pain, Hip Pain, s/p R hip replacement
Social History:
Disabled from work, unemployed, does not smoke. He smoked in the
past. Does not use alcohol. He is married
Family History:
Positive for cancer, nonspecific in his mother, father and
sister and diabetes in a grandmother.
Physical Exam:
Vitals: 109/49 HR 90 RR 35 100% on BiPAP, FiO2 100%
General: Alert, oriented, moderate respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffuse crackles bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. Paradoxical abdominal movements with
respiration.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact.
Pertinent Results:
CBC
[**2152-10-18**] 10:35AM BLOOD WBC-3.0* RBC-3.03* Hgb-10.2* Hct-32.5*
MCV-107* MCH-33.8* MCHC-31.5 RDW-15.3 Plt Ct-112*
[**2152-11-2**] 10:06AM BLOOD WBC-8.7# RBC-2.81* Hgb-9.0* Hct-27.9*
MCV-99* MCH-32.1* MCHC-32.3 RDW-17.1* Plt Ct-202
Chemistries
[**2152-10-18**] 10:35AM BLOOD UreaN-14 Creat-1.1 Na-134 K-5.0 Cl-99
HCO3-23 AnGap-17
[**2152-10-30**] 03:26AM BLOOD Glucose-289* UreaN-30* Creat-1.1 Na-137
K-5.1 Cl-103 HCO3-26 AnGap-13
[**2152-10-31**] 03:56AM BLOOD Glucose-130* UreaN-39* Creat-1.6* Na-141
K-5.7* Cl-109* HCO3-24 AnGap-14
[**2152-11-1**] 06:57PM BLOOD Glucose-91 UreaN-54* Creat-2.0* Na-138
K-5.8* Cl-108 HCO3-21* AnGap-15
[**2152-10-31**] 01:54AM BLOOD CK-MB-33* MB Indx-10.6* cTropnT-1.19*
ABG
[**2152-10-26**] 06:14AM BLOOD Type-ART pO2-61* pCO2-35 pH-7.41
calTCO2-23 Base NOT INTUBATED
[**2152-10-29**] 05:44AM BLOOD Type-ART pO2-99 pCO2-40 pH-7.45
calTCO2-29 Base XS-3
[**2152-11-2**] 01:23PM BLOOD Type-ART Tidal V-20 PEEP-10 FiO2-60
pO2-73* pCO2-49* pH-7.32* calTCO2-26 Base XS--1
Intubat-INTUBATED
[**2152-10-18**] 12:04PM BLOOD Lactate-1.4
Brief Hospital Course:
Patient's respiratory status deteriorated over the duration of
his stay. He was initially treated for community-acquired
pneumonia, but his lung biopsy was concerning for UIP with
superimposed BOOP vs. acute UIP exacerbation. Pt also with known
baseline pulmonary hypertension and volume overload. He
required intubation on [**10-29**] for decreasing oxygenation on NRB
and respiratory distress. He was initiated on vancomycin and
cefepime given clinical and radiographical deterioration. On
[**10-30**], patient desatted into the 50s on full vent support, FiO2
of 100% PEEP of 10, and had EKG findings consistent with acute
ischemic changes. Patient was started on nitric oxide at 20 PPM,
which was weaned off over the course of a day. This acute
decompensation was believed to be due to hypoxic pulmonary
vasoconstriction with subsequent R-to-L shunt through PFO,
complicated by acute right heart strain with ischemia. Pt's
respiratory status continued to be very tenuous, and he did not
show marked improvement with steroids. Subsequent BAL also did
not show PCP. [**Name Initial (NameIs) **] family meeting was held on [**2152-11-2**], and the
family elected to change his goals of care to comfort-focused
care. Non-palliative medications were discontinued and he was
started on a morphine gtt. At the family's request, he was
extubated. At 7:41 PM on [**2152-11-2**], he passed away with family
at bedside. Family declined autopsy.
Medications on Admission:
alprazolam 0.5 mg TID
amitriptyline 25 mg qhs
amlodipine 10 mg daily
atenolol 50 mg daily
citalopram 20 mg daily
epoetin alfa [Procrit] 40,000 units qweek (Wednesday)
insulin glargine [Lantus] 10 units qAM, 22 units qPM
lisinopril 5 mg daily
MS contin 15 mg [**Hospital1 **]
oxycodone-acetaminophen 5 mg-325 mg 1-2 tablets daily prn
sildenafil 50 mg prn sexual intercourse
sulfamethoxazole-trimethoprim 400 mg-80 mg qMWF
tacrolimus 3.5 mg [**Hospital1 **]
trazodone 50 mg qhs prn insomnia
omeprazole 20 mg daily
Colace 100mg [**Hospital1 **]
Ribavirin 400mg [**Hospital1 **]
Pegasys QFriday
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Idiopathic pulmonary fibrosis
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"516.31",
"284.12",
"V42.7",
"V43.64",
"716.96",
"300.4",
"416.8",
"276.1",
"V10.07",
"571.5",
"518.81",
"070.54",
"516.8",
"584.5",
"401.9",
"518.0",
"276.7",
"E933.1",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"33.24",
"96.04",
"38.97",
"32.20"
] |
icd9pcs
|
[
[
[]
]
] |
6550, 6559
|
4436, 5881
|
307, 495
|
6633, 6643
|
3337, 4413
|
6695, 6831
|
2654, 2753
|
6523, 6527
|
6580, 6612
|
5907, 6500
|
6667, 6672
|
2768, 3318
|
1797, 2198
|
241, 269
|
523, 1778
|
2220, 2513
|
2529, 2638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,591
| 137,893
|
15677
|
Discharge summary
|
report
|
Admission Date: [**2100-8-8**] Discharge Date: [**2100-8-18**]
Date of Birth: [**2023-11-21**] Sex: M
Service: MED
Allergies:
Iodine; Iodine Containing / Ambien
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
Nausea, vomiting, shortness of breath, right lower quadrant
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 year old man with mnultifactorial end stage renal disease Was
feeling well until one day prior to admission when he
experienced acute onset of nausea, vomiting, lightheadedness,
and shortness of breath followed by R sided abdominal pain.
Presented to [**Hospital3 36606**] Hospital where noncontrast CT
showed possible leaky abdominal aneurysm. Of note, pt recently
started HD, and earlier in summer pt had been noted to have
right renal mass on CT and tried multiple times to undergo an
MRI but was unable to tolerate it. He was transferred to ED
here for further workup, and contrast CT showed large
perirenal/RP bleed on R as well as kidneys with multiple cysts,
stable 4cm nonruptured nondissected AAA. During this time, his
hct dropped from 38 to 35. Work-up also significant for wbc of
14 with left shift, new onset afib, hyperglycemia, and slightly
elevated troponin. He was admitted to MICU for observation.
Past Medical History:
hypercholesterolemia, glucose intolerance, hx CRI [**1-4**] post-renal
(BPH) and ?renal (multiple cysts) causes, htn, hx bradycardia
Social History:
lives alone, 200 pack year tobacco hx
Family History:
not obtained
Physical Exam:
T97.6 BP 121/74 P65 R18 99%2LNC 2/10 abdominal pain
Gen: in pain but NAD, anxious
HEENT: PERRL, MM dry
CV: irreg irreg, no murmur/gallop/rubs no JVD
Pulm: CTAB, no wheezes/rales/rhonchi
Abd: soft, mod distended, severe ttp RLQ, mild discomfort other
quadrants, no ecchymoses, no rebound, no guarding
Ext: no edema/cyanosis
Neuro: A+Ox3, CN 2-12 intact, strength 5/5 UE, LE
Pertinent Results:
[**2100-8-8**] 02:30AM BLOOD WBC-14.2*# RBC-3.92* Hgb-11.5* Hct-35.7*
MCV-91 MCH-29.4 MCHC-32.3 RDW-16.7* Plt Ct-209
[**2100-8-9**] 09:23AM BLOOD Hct-27.1*
[**2100-8-15**] 05:45PM BLOOD Hct-31.8*
[**2100-8-17**] 07:00AM BLOOD WBC-13.4* RBC-3.52* Hgb-10.7* Hct-30.9*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.6* Plt Ct-233
[**2100-8-8**] 02:30AM GLUCOSE-189* UREA N-44* CREAT-6.9* SODIUM-141
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-21* ANION GAP-19
[**2100-8-8**] 02:30AM CK(CPK)-48
[**2100-8-8**] 02:30AM CK-MB-NotDone cTropnT-0.08*
CT abd/pelvis without contrast [**2100-8-8**]
1. Large right perirenal hemorrhage with extension into the
retroperitoneal
space as described. No definite cause is found, but suspicion is
that the
findings may relate to rupture of a renal lesion, perhaps that
mentioned on a previous renal ultrasound examination of [**2100-3-28**].
There is
no active extravasation of contrast or demonstration of a
vascular
pseudoaneurym.
2. Marked atherosclerotic disease of the abdominal aorta; a
suprarenal aortic
aneurysm measuring 4.3 cm in diameter is noted. No evidence of
aortic
leak or rupture, or acute dissection.
3. Calcified right hilar lymph nodes and calcified granulomas in
the spleen
likely relate to prior granulomatous disease.
4. Sigmoid diverticulosis without diverticulitis.
5. 1.3 cm cystic focus in uncinate process of pancreas.
Diagnostic
possibilities include IPMT or choledochal cyst. This can be
further assessed
with MRI examination, at which time the kidneys could be
evaluated as well.
MRI kidney [**2100-8-13**]
IMPRESSION: Right perinephric hematoma, with an approximately
3.5 cm mass
within the anterior aspect of the right kidney, probably
representing a renal
cell carcinoma. Small lymph nodes are noted within the area of
the right
renal vein measuring up to 5 mm. The renal vein and inferior
vena cava are
widely patent.
Brief Hospital Course:
1) Retroperitoneal bleed: Pt admitted to MICU for observation of
perirenal/ retroperitoneal bleed. Hct stable and patient was
hemodynamically stable throughout HD 1, however pt with
increasing abdominal pain and distension despite attempted pain
control. Pt sent for repeat CT scan which demonstrated a stable
retroperitoneal and perirenal bleed. Urology and renal were
consulted. HD 2 and 3, pt required 3 units total of prbcs for
continued drop in Hct although pt with subjective improvement of
symptoms; pt recieved hemodialysis on HD 3 but RIJ tunnel cath
is poorly functioning. IR evaluated pt for possible intervention
but decided to observe unless brisk (ie Hct drop >5) active
bleed or hemodynamically stable. By HD 3, pt with much improved
symptoms, stabilizing Hct, tolerating POs well. Pt transferred
to floor for continued observation. Over the next week he had
received a total of 10 units of blood to stabilize his
hematocrit at around 31. Hemolysis labs were checked and
negative. Part of the total transfusion may have covered blood
loss from the patient cutting his own vascath while confused the
evening of HD#6. The patient repeatedly became confused after
taking ambien/benzos so these medications were discontinued.
Urology's final recomendation was to f/u as outpt with Dr [**Last Name (STitle) 365**]
in clinic to discuss elective partial nephrectomy vs total
nephrectomy 6 weeks after bleeding stops. Interventional
radiology was reconsulted in light of the continuing bleed, and
offered the option of a total embolization of the right renal
artery to stop the bleeding, but the patient decided to take a
watchful waiting approach for now.
2. Pt had new onset atrial fibrillation at presentation. He was
noted to be intermittently in and out of atrial fibrillation
throughout hospitalization. M
He was continued on metoprolol for rate control and was not
anticoagulated given the risk of worsening the bleeding.
3. HTN: He was periodically hypertensive during hospitalization
but was managed with metoporolol and captopril, then changed to
enalapril for QD dosing at discharge.
4. ESRD: the patient had recently been diagnosed with renal
failure. Nephrology was consulted and he was dialyzed in the
hospital 3 days a week through a right internal jugular tunneled
catheter which had to be replaced multiple times. He was
continued on dialysis medications and supplements.
6. PPX: The patient was maintained on a PPI, pneumoboots were
used to prevent DVT, and colace and senna were used to prevent
constipation.
7. Code: The patient was DNR/DNI during hospitalization and
discussed this with Dr. [**Last Name (STitle) **], but is still interested in
pursuing medical treatment.
Medications on Admission:
1. AMBIEN 5MG PO
One by mouth at bedtime as needed
2. ATENOLOL 25MG PO
One a day
3. ATORVASTATIN 10MG PO
One daily
4. CLONAZEPAM 0.5MG PO
[**12-4**] to one tablet by mouth at bedt
5. LAB TESTING: BUN, CREATININE,...
Chloride, total co2, calcium, phos
6. NIFEDICAL XL 30MG PO
One by mouth every 12 hours
7. PENTOXIFYLLINE 400MG PO
One three times a day
8. PREVACID 30MG PO
One daily
10. TRIAMTERENE/HCT... 75-50MG PO
Take one daily
lasix
quinine
enalapril
nephrovite
renagel
B-50 complex
ASA
melatonin
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QD (once a day).
6. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
retroperitoneal bleed, likely from right renal mass
right renal mass, cannot rule out renal cell carcinoma
renal failure, on dialysis
Discharge Condition:
Pt had no pain and hematocrit was stable above 30 for two days.
He was motivated for discharge.
Discharge Instructions:
Please take all discharge medications.
Resume your usual dialysis diet, and go to dialysis 3 times per
week.
Activites as recommended by physical and occupational therapy.
Call your doctor or return to the ED if you have increased
abdominal pain, bruising on your flank or stomach, dizziness,
chest pain, shortness of breath or other concerns.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1300**] (Internal
Medicine) when discharged from rehabilitation to coordinate
care.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**] ([**Telephone/Fax (1) 6441**] (urology) in
clinic if you wish to discuss partial/total nephrectomy in 6
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
|
[
"427.31",
"401.9",
"272.0",
"285.1",
"459.0",
"593.81",
"585",
"593.9",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8339, 8409
|
3888, 6601
|
365, 371
|
8587, 8684
|
1973, 3865
|
9079, 9605
|
1551, 1565
|
7221, 8316
|
8430, 8566
|
6628, 7198
|
8708, 9056
|
1580, 1954
|
251, 327
|
399, 1324
|
1346, 1480
|
1496, 1535
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,126
| 125,421
|
33580+57846+57859
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2135-5-25**] Discharge Date: [**2135-6-2**]
Date of Birth: [**2055-7-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Flexeril / Naprosyn
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2135-5-25**] Mitral Valve Replacement(25mm [**Company 1543**] Porcine) and
Single Vessel Coronary Artery Bypass Grafting(LIMA to LAD).
History of Present Illness:
This is a 79 year old female with worsening shortness of breath
since [**2134-11-1**]. Echocardiogram in [**2135-2-1**] showed mitral
stenosis and regurgitation with an LVEF of 70%. Cardiac
catheterization showed 50% lesions in the LAD and RCA. Based
upon the above, she was referred for cardiac surgical
evaluation.
Past Medical History:
Mitral Stenosis/Regurgitation
Coronary Artery Disease
Hypertension
Hypercholesterolemia
History of TIA
Peripheral Vascular Disease
History of DVT
Anemia, Leukopenia
Temporal Arteritis
Post-herpetic Neuralgia
Cesearan Section
Appendectomy
Hysterectomy
Social History:
Quit tobacco 35 years ago. Denies ETOH. Lives alone. Retired
shopkeeper.
Family History:
Non-contributory.
Physical Exam:
PREOP EXAM
Vitals: 112/60, 72, 20
General: Frail elderly female, mildly short of breath
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally, decreased at bases
Heart: Regular rate and rhythm, mixed systolic and diastolic
murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema, few varicosities
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2135-5-25**] Intraop TEE:
PRE-BYPASS:
1. The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There are complex
(>4mm) atheroma in the aortic arch. The descending thoracic
aorta is mildly dilated. There are complex (>4mm) atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. Left coronary cusp is
heavily calcified. Peak gradient across the valve is less than
10 mm of Hg. By planimetry the valve area is around 2.2 cm2. No
aortic regurgitation is seen.
6. There is moderate valvular mitral stenosis (area 1.0-1.5cm2).
An eccentric, posterior directed jet of Moderate to severe (3+)
mitral regurgitation is seen. Severe MAC is seen focally at the
mid anterior and posterior annuli.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
1. A well-seated bioprosthetic valve is seen in the mitral
position with normal leaflet motion and gradients (mean gradient
= 5 mmHg). No mitral regurgitation is seen. Tarce central MR is
seen. A small paravalvular leak is seen at the postero-medial
part of the annulus (2 'O' Clock position)
2. [**Hospital1 **]-ventricular function is preserved.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent mitral valve replacement
and coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For
surgical details, please see seperate dictated operative note.
Following the operation, she was brought to the CVICU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. Given her history of
DVT, she was maintained on subcutaneous Heparin. She was started
on low dose beta blockade. She maintained stable hemodynamics
and transferred to the SDU on postoperative day two. She was
transferred back to the ICU on POD #3 after her blood pressure
fell to 70/40 and she was difficult to arouse. She improved and
was subsequently hypertensive requiring a nitro drip, her
anti-hypertensives were increased. She was transferred back to
the floor on POD #6. The remainder of her postoperative course
was uncomplicated. On POD#8 Mrs. [**Known lastname **] was ready to be
discharged to a rehabilitation facility for further
conditioning, activity, and increased strength.
Medications on Admission:
Lisinopril 10 qd, Vytorin 40/10 qd, Plavix 75 qd, Lasix 20 qd,
Fosamax, Amitriptyline, Singulair, Lidocain patch, Tizanidine,
Ultracet
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Amitriptyline 10 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Three (3) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metaxalone 800 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Metaxalone 800 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
18. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
19. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Mitral Stenosis/Regurgitation,Coronary Artery Disease - s/p
MVR/CABG
Hypertension
Hypercholesterolemia
History of TIA
History of DVT
Peripheral Vascular Disease
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-7**] weeks @ [**Hospital **] Clinic, call for appt
Dr. [**Last Name (STitle) **] in [**3-6**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-6**] weeks, call for appt
Completed by:[**2135-6-2**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12542**]
Admission Date: [**2135-5-25**] Discharge Date: [**2135-6-2**]
Date of Birth: [**2055-7-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Flexeril / Naprosyn
Attending:[**First Name3 (LF) 741**]
Addendum:
Discharge diagnoses amended to include chronic systolic heart
failure per Dr. [**Last Name (STitle) **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4886**] Long Term Health - [**Location (un) 4887**]
Discharge Diagnosis:
Mitral Stenosis/Regurgitation,Coronary Artery Disease - s/p
MVR/CABG
chronic systolic heart failure
Hypertension
Hypercholesterolemia
History of TIA
Peripheral Vascular Disease
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2135-8-12**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12542**]
Admission Date: [**2135-6-3**] Discharge Date: [**2135-6-4**]
Date of Birth: [**2055-7-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Flexeril / Naprosyn
Attending:[**First Name3 (LF) 741**]
Addendum:
Discharge diagnoses amended to include chronic systolic heart
failure per Dr. [**Last Name (STitle) **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4886**] Long Term Health - [**Location (un) 4887**]
Discharge Diagnosis:
Mitral Stenosis/Regurgitation,Coronary Artery Disease - s/p
MVR/CABG
Chronic systolic heart failure
Hypertension
Hypercholesterolemia
History of TIA
Peripheral Vascular Disease
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2135-8-9**]
|
[
"272.0",
"401.9",
"414.01",
"443.9",
"428.22",
"458.9",
"394.2",
"V12.51",
"416.8",
"428.0",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.63",
"88.72",
"36.15",
"38.93",
"39.61",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
8296, 8387
|
3193, 4274
|
319, 459
|
6302, 6309
|
1679, 3170
|
6645, 7365
|
1185, 1204
|
4459, 5984
|
8408, 8709
|
4300, 4436
|
6333, 6622
|
1219, 1660
|
260, 281
|
487, 805
|
827, 1079
|
1095, 1169
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,607
| 164,230
|
47502
|
Discharge summary
|
report
|
Admission Date: Discharge Date:
Date of Birth: [**2083-9-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Delusions
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, 52 M with known renal disease (baseline [**12-27**]),
schizoaffective/bipolar disorder presented [**4-24**] with psychosis to
ED, not taking his psych meds, found by EMS after called by his
pyschiatrist, found in disarray. In the ED, patient was in ARF
with BUN 93 and Cr 8.2. Patient was unable to relay any history
since franky psychotic, making grandiose statements such as "the
head of homeland security." His outpatient psychiatrist was
contact[**Name (NI) **] who confirmed his chronic renal disease, but it's
unclear how significatly his renal function is impaired at
baseline. He was given haloperidol 15mg for ongoing agitation
and has subsequently been quite sedated. He was also givne one
liter of fluids and made over 600cc of urine. When he arrived to
ICU, he was somnolent though rousable and snoring loudly. In the
ICU he has remained calm. His renal function stable and
evaluated by nephrology. Patient also had CK elevation c/w
rhabdo.
.
Upon arrival to the floor, patient speaking to himself, stating
someone stole 50M dollars, also wants to have "tea with the
queen". Patient denies any pain but says he would take care of
it with prayer. Otherwise unable to obtain any relevant history.
Past Medical History:
-HTN
-Renal disease, [**Last Name (un) 6722**] type or baseline GFR
-Schizoaffective disorder
-Bipolar disorder
-Probable gout, given med list
Social History:
Sees social worker [**Name (NI) 57756**] [**Name (NI) **] (Phone [**Telephone/Fax (1) 100427**]). Lives by
himself in the Trilogy building in [**Hospital1 778**], [**Location (un) 86**]. Is being
followed by psychiatrist Dr. [**Last Name (STitle) **].
Family History:
NC
Physical Exam:
PE: 97.2 135/77 79 20 100% RA
Gen: obese, speaking to himself, NAD
Heent: anicteric, OP moist
Chest: CTA anteriorly
CV: nl S1 S2, RRR, no [**11-29**] SM at LUSB.
Abd: obese, soft, non tender throughout, BS+
Ext: chronic venous statis changes, dry skin, non pitting edema
to knee, non tender, warm.
Neuro: responds to questions inappropriately, PERRL, unable to
assess. Moves all 4 ext.
Pertinent Results:
[**2139-4-24**] 09:11PM WBC-9.1 RBC-3.49* HGB-11.0* HCT-34.3* MCV-98
MCH-31.5 MCHC-32.0 RDW-15.2
[**2139-4-24**] 09:11PM GLUCOSE-110* UREA N-93* CREAT-8.2* SODIUM-139
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-16* ANION GAP-24
[**2139-4-24**] 09:11PM ALT(SGPT)-64* AST(SGOT)-63* CK(CPK)-1598* ALK
PHOS-127* AMYLASE-65 TOT BILI-0.5 LIPASE-52
.
[**2139-4-24**] 09:11PM CK-MB-42* MB INDX-2.6
[**2139-4-24**] 09:11PM cTropnT-0.11*
[**2139-4-24**] 09:11PM TSH-0.75
.
Negative urine and serum tox screen.
.
ECG: NSR, nl axis, PR 220, LVH no ST-T changes
.
CXR [**4-24**]:
Single portable semi-upright chest radiograph is reviewed
without
comparison. Evaluation is limited by technique, and lung volumes
are very low, limiting assessment of the cardiomediastinal
contours. Pulmonary vasculature is not enlarged. There is no
focal consolidation. There is no pleural effusion or
pneumothorax.
.
Bl foot x-rays [**4-24**]:
IMPRESSION: Minor degenerative changes of the feet bilaterally.
No evidence of soft tissue gas.
.
Head CT [**4-24**]:
Mild ventriculomegaly, involving the entire ventricular system.
Without prior comparison imaging, acuity of this finding, or
change in ventricular size cannot be assessed. This could be due
to atrophy or in porper clinical setting may indicate early NPH.
.
Renal U/S [**4-26**]: No evidence of hydronephrosis. Likely bilateral
renal cysts.
Brief Hospital Course:
52 M with psychosis, CRI p/w acute psychosis, ARF and very mild
rhabdomyolysis.
.
1. Psychosis -- Known bipolar and schizoaffective disorder. Tox
screens was unremarkable. CT head with mild ventriculomegaly.
TSH was wnl with 0.75. Acute psychosis likely in setting of
medication non-compliance. Patient still did not have capacity
throughout his hospital stay. He was responding with grandiose
ideas to nearly every question. He was Section 12 per
psychiatry. He was continued on risperdal 1mg qd. He received
haloperidol/ativan as needed for agitation. His QT was monitored
with EKGs. He was observed by a 1:1 sitter. He was medically
cleared for inpatient psych on [**4-28**]. He should follow up with his
outpatient psychiatrist after discharge.
.
2. ARF - Known CRI, likely due to HTN, baseline ~[**12-27**]. Cause for
ARF likely multifactorial. DDx included prerenal, ATN, rhabdo
(unlikely given only mildly elevated CKs). Protein/Cr ratio was
0.8, no eos, FEN 1%. SPEP was negative, UPEP was pending upon
discharge. Renal U/S was without hydronephrosis, but possible
bilateral renal cysts. UCx showed no growth. Renal was consulted
and felt that it is unlikely to be interstitial nephritis. He
was hydrated with IV fluids throughout most of his hospital stay
and was encourage to drink fluids. Cr was steadily trending down
since admission (from a peak creatinine of 8.2. Latest Cr was
4.4 on [**2139-4-28**]). He should follow up with his nephrologist after
discharge. The possibility of future dialysis should be
discussed in the near future.
.
3. Elevated CK - maximum was around 1600. Possibly very mild
rhabdo. He was hydrated with IV fluids. CK was trending down
since admission. K, Mg, Ca remained stable, phosphate was
elevated but stable.
.
4. Elevated Trop - no CP. Troponin of 0.12, stable, likely in
setting of ARF.
.
5. Anemia -- Mild anemia, no prior values, likely due to chronic
renal failure. Iron panel c/w iron deficiency--Iron 34, however
MCV elevated, but B12/folate elvated, Retic count 1.7, other
parameters wnl. Patient likely needs an outpatient colonoscopy
for further workup.
.
6. Transaminitis --mild elevations on admission, continuously
trending down since then. Likely [**12-26**] acute illness, ?fatty
liver. Hepatitis B and C antibody panel was negative. Hepatitis
B surface antigen was not sent with initial panel but it was
felt that further workup was not necessary given the mild
transaminitis that quickly resolved. Further workup should be
initiated as an outpatient if recurrent transaminitis should
occur.
.
7. Metabolic Acidosis - Mild AG. Likely secondary to ARF.
Decreasing throughout his hospital stay.
.
8. Hypothermia -- only on admission; resolved since then.
.
9. Mild ventriculomegaly -- Pt without focal or neuro deficit. ?
beginning NPH on CT. Patient should have a repeat head CT in a
few months after discharge.
.
10. HTN -- SBP 135-140 on admission. Held Metoprolol XL 100 qd.
Started patient on metoprolol 25mg [**Hospital1 **], then 50mg [**Hospital1 **] as an
inpatient and switched back to long acting BB upon discharge.
.
11. Gout -- Uric acid of 11.2 on admission. Asymptomatic
throughout his hospital stay. Colchicin and allopurinol were
held given acute on chronic renal failure. They should be
restarted and dose-adjusted as an outpatient once the patient's
renal function has fully recovered or earlier after
dose-adjustment if indicated.
.
12. FEN -- IV fluids, tolerating POs, repleted lytes prn
.
13. PPx -- sc heparin, PPI, bowel reg
.
14. Access -- PIV
.
15. Code -- full
.
16. Contacts: Psych is Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 100428**]; Dr [**Last Name (STitle) **] (PCP)
[**Telephone/Fax (1) 100429**]; Case manager [**First Name5 (NamePattern1) 57756**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 100427**]; renal Dr.
[**Last Name (STitle) 72152**] [**Telephone/Fax (1) 100430**].
Medications on Admission:
Meds: per ED records (they had called psychiatrist)
-Risperidone, dose unclear
-Metoprolol [**Name (NI) 8864**] 100mg daily
-ASA
-Allopurinol 300mg daily
-Colchicine 0.6mg daily
-Pantoprazole 40mg daily
.
Medications on Transfer:
Haloperidol 1-5 mg IV TID:PRN
Metoprolol 25 mg PO BID
Heparin 5000 UNIT SC TID
Aspirin EC 325 mg PO DAILY
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain, fever.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**] ([**Hospital1 **] 4)
Discharge Diagnosis:
Primary Diagnosis:
1. Acute psychosis
2. Bipolar disorder
3. Schizoaffective disorder
4. Acute on chronic renal failure
5. HTN
.
Secondary Diagnosis:
1. Gout
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Discharge Instructions:
You have been admitted for worsening of your psychosis and acute
worsening of your chronic kidney failure. You have received
medications for your psychosis and were evaluated and treated
for your kidney failure. Your kidney function improved
throughout your hospital stay and you were transferred to an
inpatient psychiatry unit once your medical issues have been
stable.
.
Your medications have been changed: Your Aspirin has been
discontinued. Your colchicin and allopurinol for gout have been
held. They should be restarted and dose-adjusted by your PCP
once your renal function has fully recovered.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed.
.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) 100431**]
D. [**Telephone/Fax (1) 47783**]) in [**11-25**] weeks after discharge from the inpatient
psychiatry unit. He should decide when to restart your gout
medicine.
.
Please also follow up with your psychiatrist Dr. [**Last Name (STitle) **] as needed
after your inpatient psychiatry hospitalization (Phone:
[**Telephone/Fax (1) 100432**]).
.
Please follow up with your kidney doctor Dr. [**Last Name (STitle) 72152**] (phone
[**Telephone/Fax (1) 100430**]) two weeks after discharge from the psychiatric
unit. You have already tentatively been scheduled for Monday,
[**5-18**], at 11AM at his office at [**Hospital6 2561**]. You may
need kidney replacement therapy (dialysis) in the future. Please
have your kidney doctor discuss this possibility with you in the
future.
|
[
"403.90",
"584.9",
"585.9",
"728.88",
"285.21",
"296.44",
"274.9",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8397, 8488
|
3838, 7731
|
298, 305
|
8691, 8754
|
2430, 3815
|
9688, 10558
|
2004, 2008
|
8118, 8374
|
8509, 8509
|
7757, 7962
|
8778, 9665
|
2023, 2411
|
249, 260
|
333, 1552
|
8660, 8670
|
8528, 8639
|
7987, 8095
|
1574, 1719
|
1735, 1988
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,342
| 128,690
|
33484
|
Discharge summary
|
report
|
Admission Date: [**2176-6-24**] Discharge Date: [**2176-7-1**]
Date of Birth: [**2108-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2176-6-24**] Coronary Artery Bypass Graft x 4
(Lima->LAD/SVG->Diag/OM/PDA)
History of Present Illness:
67 y/o male with diabetes, hypertension, and peripheral arterial
disease. He was asymptomatic but had positive stress test and
was referred for cardiac cath. Cath revealed severe three vessel
disease and was referred for surgery revascularization.
Past Medical History:
Diabetes Mellitus, Hypertension, Nephropathy, Peripheral
Arterial Disease RLE, LLE compound FX as child, s/p (L) CEA'[**73**]/
s/p fem. bypass, s/p tonsillectomy
Social History:
Social history is significant for the absence of current tobacco
use, quit 2 months ago, 2ppd x 50 yrs. There is no history of
alcohol abuse
Family History:
There is a family history of premature coronary artery disease,
brother had [**Name2 (NI) **] in 50s and died at 51 from "heart failure."
Physical Exam:
VS: 66 14 22/99 5'9" 210lbs
Gen: NAD
Skin: Unremarkable
HEENT: EOMI PERRL NCAT
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**6-24**] Echo: PRE-BYPASS: 1. The left atrium and right atrium are
normal in cavity size. No atrial septal defect is seen by 2D or
color Doppler. 2. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). 3. Right
ventricular chamber size and free wall motion are normal. 4. The
ascending aorta 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. 5. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. 6. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was
notified in person of the results. POST-BYPASS: 1. Regional and
global left ventricular systolic function are normal. 2. Right
ventricular systolic function is normal. 3. Aortic contours are
intact post decannulation.
[**2176-6-24**] 11:35AM BLOOD WBC-16.1*# RBC-3.51* Hgb-10.9* Hct-31.8*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.8 Plt Ct-227
[**2176-7-1**] 05:30AM BLOOD WBC-12.3* RBC-2.87* Hgb-8.9* Hct-26.6*
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 Plt Ct-336
[**2176-6-24**] 12:30PM BLOOD PT-13.4 PTT-36.7* INR(PT)-1.1
[**2176-6-24**] 12:30PM BLOOD UreaN-36* Creat-2.1* Cl-108 HCO3-25
[**2176-7-1**] 05:30AM BLOOD Glucose-110* UreaN-57* Creat-2.3* Na-137
K-4.6 Cl-101 HCO3-27 AnGap-14
[**2176-7-1**] 05:30AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.5
Brief Hospital Course:
Mr. [**Known lastname 38255**] was a same day admit after undergoing all
pre-operative work-up prior to admission. On [**6-24**] he was brought
directly to the operating room where he underwent a coronary
artery bypass graft x 4. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. He required aggressive chest PT while in ICU. On
post-op day two his chest tubes were removed and he was started
on beta blockers and diuretics. He was gently diuresed towards
his pre-op weight. Epicardial pacing wires were removed on
post-op day three. On post-op day four he was transferred to the
telemetry floor for further care. His creatinine trended up but
stabilized around 2.3 at time of discharge. Over the next
several days he slowly recovered while working with physical
therapy for strength and mobility. On post-op day seven he
appeared ready for discharge home with VNA services and the
appropriate follow-up appointments.
Medications on Admission:
Glyburide 5mg [**Hospital1 **], Metformin 850mg [**Hospital1 **] (?d/c'd), Lopressor 25mg
[**Hospital1 **], Aspirin 325mg qd, Lisinopril/HCTZ 20-25mg qd, ExForge
5/160mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
7. insulin sliding scale
please resume sliding scale insulin as prior to surgery
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
please have Bun/Creatinine drawn in 7 days
results to Dr [**Last Name (STitle) 2093**] [**Telephone/Fax (1) 50208**]
And Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Cornary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Diabetes Mellitus, Hypertension, Nephropathy, Peripheral
Arterial Disease RLE, LLE compound FX as child
PSH: s/p (L) CEA'[**73**]/ s/p fem. bypass, s/p tonsillectomy
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.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 2093**] 2 weeks
Dr. [**Last Name (STitle) 8098**] 2 weeks
Completed by:[**2176-7-1**]
|
[
"414.01",
"250.40",
"585.9",
"518.5",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5459, 5510
|
3025, 4127
|
334, 413
|
5784, 5790
|
1449, 3002
|
6090, 6244
|
1049, 1188
|
4350, 5436
|
5531, 5763
|
4153, 4327
|
5814, 6067
|
1203, 1430
|
282, 296
|
441, 690
|
712, 875
|
891, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,093
| 162,539
|
2799
|
Discharge summary
|
report
|
Admission Date: [**2124-12-10**] Discharge Date: [**2124-12-16**]
Date of Birth: [**2081-2-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 13730**]
Chief Complaint:
Hematemesis; Presenting with DKA and acute pancreatitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43 y/o AAF with a PMH of hereditary pancreatitis, DKA, HTN, and
peptic ulcer disease, presents as a transfer from the [**Hospital Unit Name 153**] for
GI bleed/pancreatitis/DKA.
The patient initially had generalized myalgias with URI symptoms
along with decreased PO intake about 4 days prior to admission.
Three days ago, the patient began having repeated episodes of
vomiting revealing bilious fluid over several hours. However,
after continued retching, she began to have coffee ground emesis
associated with severe epigastric pain radiating to her back and
subsequent melena, but no BRBPR The patient had continued
episodes of this hematemesis overnight on [**2124-2-8**], and then
decided to go to the ER. There, she was lavaged, fluid bolused,
and a CT scan with oral contrast (no IV contrast due to
creatinine of 3). She then got a CT scan which showed no free
air, no free fluid, no evidence of pseudocyst, and the pancreas
unremarkable. She was then transferred to the [**Hospital Unit Name 153**] due to her
DKA with a initial sugar in the 400s with associated metabolic
acidosis and intermittent hypotension ( in the 70s/30s). In the
[**Hospital Unit Name 153**], she was aggressively hydrated with normal saline at
200cc/hr, given an insulin drip at 1 unit/hr, made NPO, given
pain control for her presumed pancreatitis, and her crit
serially monitored. At 11/8, at 2am, her insulin drip was
discontinued and she was controlled with RISS, and her
hypotension improved to the 110s/80s on IVF (her intake was 9
liters over 24 hours and her output was 25-40 cc/hr) She was
then trensferred to the floors once she was hemodynamically
stable, her crit stabilized, and there were no signs of active
GI bleed.
Past Medical History:
1. Chronic Pancreatitis
2. HTN
3. Type I DM ?????? treated at [**Hospital **] Clinic
4. H/o narcotic seeking behavior, currently has narcotic
contract with PCP
5. h/o noncompliance
6. h/o chronic abd pain
Social History:
Tobacco: [**2-4**] ppd, Denies EtOH and drug abuse. States she lives
with fianc?????? and cat.
Family History:
Father died of pancreatic CA.
Physical Exam:
t98.5, bp94/50, hr97, r14, 100% ra
Ill appearing older than stated age female in NAD
PERRL. anicteric
No JVD. MMM.
Regular s1, s2. no m/r/g
LCA b/l
+bs. soft. exquisite tenderness in epigastric and LUQ regions to
light palpation. +rebound. +guarding.
no le edema.
Pertinent Results:
CBC/Coags:
[**2124-12-10**] 04:03PM WBC-18.0* RBC-4.04* HGB-12.5# HCT-35.6*
MCV-88 MCH-30.9 MCHC-35.0 RDW-13.7
[**2124-12-10**] 06:45AM PT-14.1* PTT-25.2 INR(PT)-1.3
Chemistries:
[**2124-12-10**] 04:03PM GLUCOSE-118* UREA N-31* CREAT-1.6* SODIUM-139
POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-27 ANION GAP-20
[**2124-12-10**] 04:03PM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.6
[**2124-12-10**] 06:45AM ALT(SGPT)-14 AST(SGOT)-15 ALK PHOS-121*
AMYLASE-64
[**2124-12-10**] 07:17PM TYPE-ART PO2-81* PCO2-37 PH-7.37 TOTAL CO2-22
BASE XS--3
[**2124-12-10**] 07:17PM LACTATE-0.6
[**2124-12-10**] 09:19AM -[**Last Name (un) **] PO2-30* PCO2-47* PH-7.24*
U/A:
[**2124-12-10**] 11:24AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2124-12-10**] 11:24AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-12-10**] 11:24AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
CXR: No acute cardiopulmonary process
CT abd/pelvis: No free intraabdominal gas or other evidence of
an acute pathologic abdominal process.
ECG: 120, sinus, nl axis, nl intervals, LVH, J pt elev in v2-v5,
unchanged from [**5-7**]
Brief Hospital Course:
43 y/o AAF with a history of hereditary pancreatitis, poorly
controlled diabetes, and peptic ulcer disease, admitted for
upper GI bleed as seen with her coffee grounds emesis and
melena. She also had associated epigastric tenderness with a
h/o pancreatitis with calcifications seen on the CT in the ER.
She was admitted to the [**Hospital Unit Name 153**] originally due to her DKA with
sugars in the 400s and her pancreatitis, possibly triggered by
the DKA. After her acidosis was corrected and her crit became
stable, she was transferred to the floor and monitored
carefully.
1) GI bleed: Pt had coffee grounds emesis after several
episodes of bilious vomiting, + melena with the emesis. h/o PUD
with "heartburn" before this episode. Possible sources of bleed
included [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, esophagitis, gastritis, or
hemorrhagic pancreatitis. CT scan with PO contrast showed no
evidence of free air/fluid or any other intrabdominal process.
NGL in ER cleared the blood after 300 cc, and her crit was not
falling although she was hemodynamically unstable. She was then
stabilized hemodynamically and her crit remained stable after
she was transferred to the floor. Gi followed her throughout
her course and had planned on doing an EGD originally in house,
but her crit had stabilized and she exhibited no more nausea,
vomiting, hematemesis, or melena. She is to follow up with GI
for an outpatient EGD and to be maintained on Protonix daily.
2) Diabetes: Most likely developed DKA originally from h/o poor
glucose control HbA1C at 18% two years ago) and previous URI
symptoms before her N/V. Initially sugars found to be in the
400s. Was put on an insulin drip and aggresively hydrated. The
insulin drip was stopped at 2 am on the 7th, and she was
switched to RISS. Her sugars were then controlled with NPH
insulin and eventually [**Last Name (NamePattern1) **] 18 units due to some high
glucose levels throughout her course. She will then resume her
previous insulin regimen. She will have a follow up appointment
with [**Last Name (un) **] to assess her insulin requirements.
3) Abdominal pain: most likely pancreatitis h/o of this in
her family, father presumable died from this condition in his
50s. CT scan showed evidence of calcification in the head of
the pancreas. She had the typical boring epigastric tenderness
radiating to the back with only moderately elevated amylase at
64 and a normal lipase. This however is consistent with a
chronic pancreatitis picture. Due to her risk of developing
necrotizing pancreatitis, she was started on levo/flagyl and her
abdominal exam monitored serially. Once her symptoms declined,
she was discontinued off the ABX and simply had pain control,
including a pain consult in which she was placed on Dilaudid PCA
for 2 days and then was resumed on her outpatient pain
medications oxycodone and 150mcg of fentanyl. She also was
hydrated and advaced her diet well to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] diet on discharge.
She is to continue her home pain meds.
Medications on Admission:
Lisinopril 40mg po qd
Sertraline 50mg po qd
NPH 32 U sc qam, qpm
Norvasc 5mg po qd
Fentanyl TD 50 mcg
Pancrease
Oxycodone 5mg po qd
Compazine 10mg po q6h
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Fentanyl 75 mcg/hr Patch 72HR Sig: Two (2) patches
Transdermal every seventy-two (72) hours.
Disp:*15 patches* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Pancrease 20,000-4,500- 25,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
three times a day.
6. Amlodipine Besylate 10 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. [**Last Name (NamePattern4) **] Sig: Eighteen (18) units Subcutaneous at bedtime.
Disp:*qs (1 month supply) units* Refills:*2*
10. Insulin Regular Human 300 unit/3 mL Syringe Sig: One (1)
dose Subcutaneous four times a day: see sliding scale.
Disp:*120 dose* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
upper GI bleed
volume depletion
diabetic ketoacidosis
pancreatitis (acute on chronic)
upper GI bleed
volume depletion
diabetic ketoacidosis
pancreatitis (acute on chronic)
Discharge Condition:
Fair- patient has a stable hematocrit and is able to tolerate [**First Name8 (NamePattern2) **]
[**Doctor First Name **] diet with her previous home pain medications (she was
started on [**Doctor First Name **] and has been approved by the free care
pharmacy for nonformulary use)
Discharge Instructions:
Please continue your home medications as prescribed. Please
return to the ER if you develop more nausea, vomiting, fevers,
chills, dark black stools or intolerance of oral intake. Please
continue prior home NPH and sliding scale regimen for the next 2
days and follow up with the procare pharmacy on [**12-18**] for NEW
prescription for [**Month/Year (2) **]. While on [**Last Name (LF) **], [**First Name3 (LF) **] not take NPH
but continue with regular insulin sliding scale prior to each
meal and at night. Refer to sliding scale prescribed by [**Last Name (un) **].
A physician will call you on [**12-18**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] appointment.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 5269**] [**Last Name (NamePattern1) 5270**], [**Name12 (NameIs) 1046**] Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-12-19**] 1:30
Provider: [**Name10 (NameIs) 3488**] [**Last Name (NamePattern4) 3489**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-12-19**] 2:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-1-5**] 2:20
[**Last Name (un) **] Diabetes Center to call you with f/u appt. ([**Telephone/Fax (1) 13733**])
[**Name6 (MD) 3488**] [**Last Name (NamePattern4) 3489**] MD, [**MD Number(3) 13732**]
Completed by:[**2124-12-18**]
|
[
"250.12",
"578.0",
"584.9",
"577.0",
"578.1",
"530.81",
"401.9",
"276.5",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8527, 8533
|
4002, 7112
|
332, 339
|
8750, 9032
|
2783, 3979
|
9776, 10649
|
2451, 2482
|
7317, 8504
|
8554, 8729
|
7138, 7294
|
9056, 9753
|
2497, 2764
|
236, 294
|
367, 2093
|
2115, 2322
|
2338, 2435
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,689
| 117,162
|
2832+55416
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-5-30**] Discharge Date: [**2115-6-1**]
Date of Birth: [**2052-4-18**] Sex: F
Service: [**Company 191**]
CHIEF COMPLAINT: Seizure
HISTORY OF PRESENT ILLNESS: A 63-year-old female with a history
of three vessel coronary artery disease, status post coronary
artery bypass graft x3, history of VF arrest, hypertension,
history of hepatitis, question history of glucose intolerance who
presents status post seizure. The patient was seen to collapse
at home. She was witnessed to have experienced a generalized
tonic clonic seizure that lasted about 10 minutes. She was
brought to the [**Hospital6 256**] where she was
conversant and then developed a 1 to 2 minute recurrent
generalized tonic clonic seizure with long postictal period. The
patient's temperature was 100.2?????? with a blood pressure of
218/100, respiratory rate of 22 and a glucose of greater than
500. The patient was given Ativan 6 mg, 3 liters of intravenous
fluids and regular insulin sliding scale and then an insulin
drip. She was found to have an anion gap x25 and her acetone was
negative. She had an arterial blood gas of pH of 7.08, PCO2 of
56 and PAO2 of 300. Chest x-ray was normal. The patient had
complained of polyuria and polydipsia for weeks. She was admitted
to the Medical Intensive Care Unit and watched overnight and then
transferred to the floor.
PAST MEDICAL HISTORY:
1. Three vessel coronary artery disease, status post
angioplasty in [**2108**] and status post coronary artery bypass
graft with left internal mammary artery to the LAD, saphenous
vein graft to D1 and saphenous vein graft to PDA in [**2108**].
The patient's cardiologist is Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **].
2. History of VF arrest
3. History of hypertension
4. History of hepatitis
5. Glucose intolerance
PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Community Health Center.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient was taking no medications at home.
Upon transfer from the Intensive Care Unit, the patient was
on a regular insulin sliding scale, aspirin 325 mg po q day,
Lopressor 25 mg po bid, heparin subcutaneous, Protonix 40 mg
po q day, glyburide 5 mg po q day, captopril 6.25 mg po tid
and atorvastatin 10 mg po q day.
SOCIAL HISTORY: The patient lives with her husband. The
patient denies smoking or alcohol.
FAMILY HISTORY: Noncontributory
PHYSICAL EXAM:
VITAL SIGNS: The patient had a temperature of 98.7?????? with a
pulse of 100, blood pressure of 160/73, respiratory rate of
20 and pulse oximetry of 99% on room air.
GENERAL: The patient was a well appearing female in no
apparent distress.
HEAD, EARS, EYES, NOSE AND THROAT: Extraocular movements
were intact. Pupils equal, round and reactive to light.
Moist mucous membranes.
NECK: The patient had no lymphadenopathy and no meningismus.
CARDIAC: Regular rate and rhythm, normal S1, S2 and no
murmurs, rubs or gallops.
PULMONARY: The patient's lungs were clear to auscultation.
ABDOMEN: The patient's belly was soft, nontender,
nondistended with normal bowel sounds.
EXTREMITIES: Venostasis changes.
NEUROLOGIC: The patient was alert and oriented x1. She had
1+ deep tendon reflexes at the patella. Her plantar reflexes
were mute. Light touch was grossly intact. The patient was
able to follow commands. The patient had [**4-21**] upper extremity
strength and [**4-21**] lower extremity strength.
PERTINENT LABORATORY FINDINGS: Upon transfer from the
Intensive Care Unit, the patient's white blood cell count was
14.6 with a hematocrit of 38.4 and platelets of 177. The
patient's creatinine was 0.5. She had blood cultures that
demonstrated no growth at the time of this dictation.
A head CT revealed a left frontal lobe hypodensity and
periventricular white matter disease.
SUMMARY OF HOSPITAL COURSE: The patient is a 63-year-old female
with uncontrolled hypertension and new diagnosis of diabetes
mellitus as well as three vessel coronary artery disease who
presented with a new seizure and postictal confusion.
NEUROLOGIC: Patient with an old stroke on head CT, as well as
marked hyperglycemia and hypertension with a new seizure
disorder. The seizure was probably multifactorial, but
hypertension and hyperglycemia were likely exacerbating factors.
Multiple LP attempts were performed in the Intensive Care Unit
without success. The patient had no further seizure activity and
neurology followed the patient while in hospital. Their feeling
was that a seizure focus with the addition of hyperglycemia was a
reasonable explanation. Her metabolic status was normalized and
her hypertension and diabetes were better controlled. She did
have some postictal confusion. She had an EEG that showed no
epileptiform activity. Her mental status improved throughout
the admission.
2. CARDIAC: Patient with three vessel coronary artery disease,
status post coronary artery bypass graft with a very poor cardiac
follow up. The patient was not taking any medications at home.
She experienced hypertensive urgency, if not hypertensive
emergency upon admission. She was started on aspirin, beta
blocker and ACE inhibitor, as well as a statin. Her beta blocker
and ACE inhibitor were titrated up to achieve adequate blood
pressure control. She will likely need these for management of
her cardiac risk.
The patient will have to follow up with her cardiologist, Dr.
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], in order to continue managing her coronary artery
disease. The importance of her following up with Dr. [**Last Name (STitle) **] and
her primary care physician was impressed upon both the patient
and her husband.
3. ENDOCRINE: Patient with better glycemic control on glyburide
as well as regular insulin sliding scale. She had initially
required an insulin drip in the Intensive Care Unit. She
received diabetic teaching when she arrived on the floor. She had
fairly reasonable glycemic control on glyburide and a regular
insulin sliding scale.
4. INFECTIOUS DISEASE: The patient presented with a low grade
temperature and elevated white blood cell count, but multiple
metabolic derangements and no obvious infection. She was not
given antibiotics and she remained afebrile after her admission.
5. PSYCHIATRIC: Patient with postictal confusion likely
exacerbated by other metabolic derangements. There was some
question as to possible psychiatric diagnosis underlying this
confusion. Further evaluation of this will be necessary to
evaluate whether this may have caused the patient to avoid
medical care for so long.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: The patient was discharged with follow ups
with her cardiologist, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], and her primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DISCHARGE MEDICATIONS:
1. Captopril 25 mg po tid
2. Glyburide 10 mg po q day
3. Lactulose 30 cc po q hs constipation
4. Senna 2 tablets po q hs
5. Colace 100 mg po bid
6. Tylenol 650 mg po q 4 to 6 hours prn pain
7. Lipitor 10 mg po q hs
8. Protonix 40 mg po q day
9. Lopressor 50 mg po bid
10. Aspirin 325 mg po q day
11. Regular insulin sliding scale
The patient will require short term rehabilitation. She was
discharged on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft
2. History of VF arrest
3. Hypertension
4. History of hepatitis
5. Diabetes
6. Seizure
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2115-5-31**] 14:28
T: [**2115-5-31**] 14:51
JOB#: [**Job Number 13814**]
cc:[**Last Name (NamePattern4) 13815**] Name: [**Known lastname 2132**], [**Known firstname 1013**] Unit No: [**Numeric Identifier 2133**]
Admission Date: [**2115-5-29**] Discharge Date: [**2115-5-31**]
Date of Birth: [**2052-4-18**] Sex: F
Service: [**Company 112**]
ADDENDUM:
Please, under Discharge Status include:
DISCHARGE MEDICATIONS:
2. Atenolol 25 mg p.o. q. day.
3. Glyburide 10 mg p.o. q. day.
4. Glucophage 500 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. She will follow-up in [**Hospital 112**] Clinic.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Last Name (NamePattern1) 2134**]
MEDQUIST36
D: [**2115-6-2**] 23:51
T: [**2115-6-6**] 11:01
JOB#: [**Job Number 2135**]
|
[
"780.39",
"250.20",
"V45.82",
"V45.81",
"401.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6815, 7115
|
2566, 2583
|
7640, 8405
|
8428, 8529
|
8553, 8851
|
2598, 3994
|
4023, 6793
|
166, 175
|
204, 1387
|
1409, 2455
|
2472, 2549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,254
| 111,404
|
28886
|
Discharge summary
|
report
|
Admission Date: [**2193-8-27**] Discharge Date: [**2193-9-11**]
Date of Birth: [**2151-4-14**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
progressive weakness, sensory loss
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. [**Known lastname **] is a 42 year male who presents with presents with
progressive weakness and sensory loss. Two weeks ago he noted
pruritus and an urticarial rash over his arms and legs, and
later
also his face. The urticaria resolved in seven days, but he then
noted numbness and paresthesias in his feet, then his hands
about
two days later. He had difficulty feeling where his feet were in
space. Over the last two days he noted weakness in his arms, as
in holding them over his head, as well as diminished grip
strength. He went to his PCP for evaluation who arranged for an
appointment in neurology clinic this morning, and sent extensive
lab evaluation. The patient notes that this morning he awoke
with
significant bifacial weakness, where water drips from his mouth
when trying to drink liquids. He is no longer able to close his
eyes completely.
After being seen in neurology clinic this morning by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1274**] he was referred to the ED for admission.
At present the patient reports his symptoms are stable from
above, but notes some ? difficulty with swallowing. He reports
DOE when climbing a flight of stairs or walking a long
distances.
One month ago he travelled to the Sichuan province of [**Country 651**] to
aide in earthquake relief. He has had diarrhea for the last week
[**3-10**] loose bm's per day. He was not ill in [**Country 651**]. He did have
fever and "sinus headache" 3-4 weeks ago, which he notes he gets
on somewhat regular occasion. He denies difficulty producing
speech, no urine or bowel incontinence. No recent f/c, wt loss
or
gain, no CP, intermittent palpitations in the last few days. +
DOE, no other rashes, no known tic exposure, no joint pain.
Past Medical History:
none
Social History:
married, works at [**Hospital1 112**] as a gastroenterologist. Never smoker
Family History:
NC
Physical Exam:
T 98.8, HR 111, BP 137/94-150/96, R 20, 96% RA
Gen- well appearing, NAD, obvious bifacial weakness
HEENT- NCAT, anicteric, MMM, OP Clear
neck- no carotid bruits
CV- tachycardic, no MRG
Pulm- CTA B
Abd- soft, nt, nd, BS+
Extrem- no CCE
NEurologic exam:
Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was notable for labial
dysarthria. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall [**4-8**] at 5
minutes. The pt. had good knowledge of current events. There
was no apraxia or neglect.
CN- PERRl 5-->3mm BILat, EOMI no nystagmus, prominent bifacial
weakness, unable to purse lips, + bell's phenomenon with attempt
to close his eyes, No diplopia with sustaine upgaze for 1minute.
unable to fully close left eye, intact corneal reflex, brisk gag
reflex. SCM and Trap [**6-10**]
Motor- no pronator drift. delt [**4-10**] bilaterally. (worse from exam
earlier today).
Sensation- dysesthesia/reduced PP throughout lower extremities
and upper extremities bilaterally, proprioception is absent at
the toes bilat, returns at ankles, no evidence of vibratory
loss.
no loss of prop at hands.
Reflexes- trace at left patellar.
Toes downgoing bilaterally.
Gait- wide based, unsteady, pos romberg.
Pertinent Results:
[**2193-9-4**] 05:50AM BLOOD WBC-8.2 RBC-5.35 Hgb-15.7 Hct-44.6 MCV-83
MCH-29.4 MCHC-35.3* RDW-13.9 Plt Ct-393
[**2193-9-3**] 06:35AM BLOOD WBC-8.7 RBC-5.40 Hgb-15.6 Hct-45.3 MCV-84
MCH-28.8 MCHC-34.4 RDW-14.5 Plt Ct-426
[**2193-9-2**] 05:40AM BLOOD WBC-7.0 RBC-5.09 Hgb-14.9 Hct-42.6 MCV-84
MCH-29.4 MCHC-35.1* RDW-14.4 Plt Ct-364
[**2193-9-1**] 11:16AM BLOOD WBC-7.6 RBC-5.29 Hgb-15.0 Hct-44.1 MCV-83
MCH-28.4 MCHC-34.1 RDW-13.7 Plt Ct-381
[**2193-8-30**] 02:00AM BLOOD WBC-7.7 RBC-4.98 Hgb-14.3 Hct-41.0 MCV-82
MCH-28.6 MCHC-34.8 RDW-13.6 Plt Ct-391
[**2193-8-28**] 01:15AM BLOOD WBC-7.5 RBC-4.75 Hgb-13.4* Hct-39.9*
MCV-84 MCH-28.2 MCHC-33.6 RDW-13.5 Plt Ct-340
[**2193-8-27**] 12:00PM BLOOD WBC-10.1 RBC-5.22 Hgb-14.7 Hct-43.2
MCV-83 MCH-28.2 MCHC-34.0 RDW-13.5 Plt Ct-403
[**2193-8-26**] 12:00PM BLOOD WBC-12.1* RBC-5.32 Hgb-15.4 Hct-45.9
MCV-86 MCH-29.1 MCHC-33.6 RDW-13.3 Plt Ct-390
[**2193-9-2**] 05:40AM BLOOD Neuts-16* Bands-0 Lymphs-65* Monos-14*
Eos-2 Baso-1 Atyps-2* Metas-0 Myelos-0
[**2193-8-27**] 12:00PM BLOOD Neuts-38* Bands-0 Lymphs-48* Monos-6
Eos-1 Baso-1 Atyps-6* Metas-0 Myelos-0
[**2193-8-26**] 12:00PM BLOOD Neuts-39* Bands-0 Lymphs-47* Monos-8
Eos-3 Baso-1 Atyps-2* Metas-0 Myelos-0
[**2193-9-2**] 05:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2193-8-27**] 12:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Schisto-OCCASIONAL
[**2193-8-26**] 12:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2193-9-4**] 05:50AM BLOOD Plt Ct-393
[**2193-9-3**] 06:35AM BLOOD Plt Ct-426
[**2193-9-3**] 06:35AM BLOOD PT-13.1 PTT-31.2 INR(PT)-1.1
[**2193-9-2**] 05:40AM BLOOD Plt Smr-NORMAL Plt Ct-364
[**2193-9-2**] 05:40AM BLOOD PT-13.0 PTT-44.5* INR(PT)-1.1
[**2193-9-1**] 11:16AM BLOOD Plt Ct-381
[**2193-8-30**] 02:00AM BLOOD Plt Ct-391
[**2193-8-29**] 04:19AM BLOOD Plt Ct-374
[**2193-8-28**] 01:15AM BLOOD Plt Ct-340
[**2193-8-27**] 12:00PM BLOOD Plt Ct-403
[**2193-8-26**] 12:00PM BLOOD Plt Smr-NORMAL Plt Ct-390
[**2193-8-28**] 01:15AM BLOOD ESR-8
[**2193-9-4**] 05:50AM BLOOD Glucose-106* UreaN-22* Creat-1.0 Na-132*
K-4.4 Cl-101 HCO3-22 AnGap-13
[**2193-9-3**] 06:35AM BLOOD Glucose-103 UreaN-19 Creat-0.9 Na-131*
K-4.3 Cl-99 HCO3-22 AnGap-14
[**2193-9-2**] 05:40AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-131*
K-4.2 Cl-100 HCO3-22 AnGap-13
[**2193-9-1**] 11:16AM BLOOD Glucose-176* UreaN-18 Creat-1.1 Na-136
K-4.0 Cl-105 HCO3-21* AnGap-14
[**2193-8-30**] 02:00AM BLOOD Glucose-115* UreaN-13 Creat-1.0 Na-135
K-4.0 Cl-105 HCO3-20* AnGap-14
[**2193-8-29**] 04:19AM BLOOD Glucose-114* UreaN-11 Creat-1.0 Na-135
K-3.7 Cl-107 HCO3-20* AnGap-12
[**2193-8-28**] 01:15AM BLOOD Glucose-133* UreaN-11 Creat-0.9 Na-138
K-3.7 Cl-106 HCO3-22 AnGap-14
[**2193-8-27**] 12:00PM BLOOD Glucose-118* UreaN-9 Creat-1.0 Na-137
K-3.7 Cl-104 HCO3-20* AnGap-17
[**2193-8-26**] 12:00PM BLOOD UreaN-12 Creat-1.0
[**2193-9-4**] 05:50AM BLOOD ALT-124* AST-60*
[**2193-9-3**] 06:35AM BLOOD ALT-154* AST-77* AlkPhos-85 TotBili-0.5
[**2193-9-2**] 05:40AM BLOOD ALT-200* AST-117* AlkPhos-81 TotBili-0.5
[**2193-8-30**] 02:00AM BLOOD ALT-85* AST-58* AlkPhos-74 TotBili-0.7
[**2193-8-26**] 12:00PM BLOOD ALT-93* AST-61* LD(LDH)-370* CK(CPK)-208*
AlkPhos-85 TotBili-0.6
[**2193-9-4**] 05:50AM BLOOD Calcium-9.5 Phos-5.1* Mg-2.6
[**2193-9-3**] 06:35AM BLOOD Calcium-9.4 Phos-5.6* Mg-2.6
[**2193-9-2**] 05:40AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.5
[**2193-9-1**] 11:16AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.6
[**2193-8-30**] 02:00AM BLOOD Phos-4.1 Mg-2.5
[**2193-8-29**] 04:19AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.6
[**2193-8-26**] 12:00PM BLOOD TotProt-8.0 Albumin-4.4 Globuln-3.6
Cholest-142
[**2193-8-26**] 12:00PM BLOOD Hapto-<20* Ferritn-824*
[**2193-8-26**] 12:00PM BLOOD Triglyc-438* HDL-20 CHOL/HD-7.1
LDLmeas-54
[**2193-8-31**] 09:18PM BLOOD TSH-2.9
[**2193-8-28**] 01:15AM BLOOD TSH-2.5
[**2193-8-31**] 09:18PM BLOOD T4-13.5*
[**2193-9-1**] 11:16AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE
[**2193-8-26**] 12:00PM BLOOD HBsAg-NEGATIVE
[**2193-8-28**] 01:15AM BLOOD CRP-1.6
[**2193-8-26**] 12:00PM BLOOD HIV Ab-NEGATIVE
[**2193-9-1**] 11:16AM BLOOD HCV Ab-NEGATIVE
[**2193-8-30**] 02:03AM BLOOD Type-[**Last Name (un) **] pH-7.43
[**2193-8-30**] 02:03AM BLOOD freeCa-1.10*
CAMPYLOBACTER JEJUNI AB <0.90
REFERENCE RANGE: <0.90
INTERPRETIVE CRITERIA:
<0.90 ANTIBODY NOT DETECTED
0.90-1.10 EQUIVOCAL
>=1.10 ANTIBODY DETECTED
CMV IgG ANTIBODY (Final [**2193-9-3**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
60 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV Viral Load (Final [**2193-9-4**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
LYME BY WESTERN BLOT
HI
Test Requested LO Result Expected
Values
-------------- -- ------
---------------
Lyme Disease Ab, Western Blot, S
IgG Western Blot Negative
Negative
IgG band(s) (Kilodalton)
p41
IgM Western Blot Positive
Negative
IgM band(s) (Kilodalton)
p23, p41
Interpretation
--------------
Consistent with early infection with Borrelia burgdorferi.
A new serum specimen should be submitted in 14-21 days to
demonstrate seroconversion of IgG.
[**2193-9-4**] 5:50 am SEROLOGY/BLOOD
LYME SEROLOGY (Preliminary):
Sent to [**Hospital1 **] Laboratories for Lyme Western Blot testing.
CSF Lyme:
LYME, TOTAL EIA WITH REFLEX TO CSF RATIO
Test Result Reference
Range/Units
LYME DISEASE AB SCREEN 0.8 INDEX
REFERENCE RANGES FOR BORRELIA BURGDORFERI ANTIBODY, TOTAL,
EIA:
LESS THAN 1.0 NEGATIVE
1.0-1.1 EQUIVOCAL
1.2 OR GREATER POSITIVE
Test Result Reference
Range/Units
LYME DISEASE CSF RATIO SEE BELOW INDEX
TNP-REFLEX TESTING NOT REQUIRED.
TNP-RESULTS OF ANTIBODY INDEX ARE NOT VALID FOR PATIENTS
WITH NO DETECTABLE B. BURGDORFERI ANTIBODY IN SERUM. IF
CLINICALLY INDICATED, ORDER B. BURGDORFERI PCR TEST CODE
108472P.
REFERENCE RANGES FOR BORRELIA BURGDORFERI CSF RATIO:
LESS THAN 0.76 NEGATIVE
0.76-1.13 NO SIGNIFICANT DIFFERENCE
GREATER THAN 1.13 INCREASED
CA [**04**]-9
Test Result Reference
Range/Units
CA [**04**]-9 9 0-37 SEE NOTE
UNITS: U/ML BY [**Doctor Last Name **] CENTAUR
TEST PERFORMED AT:
[**Company **], [**State **], [**Hospital1 **], [**Last Name (LF) **],
[**Name6 (MD) **] [**Last Name (NamePattern4) 67457**], M.D., DIRECTOR
Comment: CHEM# [**Serial Number 69708**]Z
PARVOVIRUS B19 ANTIBODIES (IGG & IGM)
Test Result Reference
Range/Units
PARVOVIRUS B19 (IGG) NEGATIVE SEE BELOW
ANTIBODY
REFERENCE: 1.2 OR GREATER INDICATES ANTIBODY
Test Result Reference
Range/Units
PARVOVIRUS B19 (IGM) NEGATIVE SEE BELOW
ANTIBODY
REFERENCE: 1.2 OR GREATER INDICATES ANTIBODY
Serum West [**Doctor First Name **] and Ehrlichia, and CSF West [**Doctor First Name **] pending
WBC RBC Polys Lymphs Monos
[**2193-8-27**] 03:40PM 11 6 0 0 0
Glucose = 69 Protein = 107
Brief Hospital Course:
42 yo man was admitted with progressive weakness and numbness,
found to have cytoalbuminologic dissociation on LP, suspected to
have GBS, and treated with 5 day course of IVIG, which began
improving his weakness. As part of his initial workup he had
Lyme and CMV titers drawn (before he received any IVIG). He
turned up Lyme IgM (+) with 2 band of IgG positivity as well as
CMV IgM and IgG positive. As his CSF Lyme was still pending, he
was started on Ceftriaxone 2 g IV Q24hrs. A repeat serum Lyme
serology was sent [**9-4**], which to date is still pending. After pt
had received 7 days of IV cerftriaxone, his CSF Lyme came back
negative, and he was swithed to oral doxycycline, which he
should continue for 14 more days. His CMV positivity was thought
to be possibly the contributing factor to his GBS, as well as to
his transammoniits, both of which appear to be resolving.
On neurological exam on discharge, he still has significant
facial weakness B/L, but can now show twinges of movement, which
represents an improvement. Strength in his UE's are essentially
full bilaterally, and strength in his LE's are as follows: 4+ in
the IP's B/L, 4 in the Hamstrings B/L, 5- in the Quads B/L, 5 in
the plantar flexors B/L, and 3 at the right dorsiflexor and 4-
at the left dorsiflexor.
His sensory exam on discharge is significant for decreased
sensation to PP in the LE's B/L to the hip, and decreased in the
UE's the the mid foreard. His reflex exam is significant for no
reflexes in either the UE's or LE's B/L.
He has had a persistent tachycardia to the 100's to 110's
that we feel is likely secondary to dysautonomia secondary to
the GBS. He has been maintained on 25 mg metoprolol TID.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection 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).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
8. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QID (4 times a day).
9. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
GBS
Discharge Condition:
still with B/L LE and UE weakness and facial weakness, but
improving.
Discharge Instructions:
You have been diagnosed with guillian-[**Location (un) **] syndrome, which
affects your motor strength and sensation, and were treated with
5 days of IVIG, after which you improved. You were also found to
be Lyme IgM positive and are undergoing continuing treatment
with IV antibiotics. Please return to the ER if you experience
any new focal weakness, changes in sensation, vision,
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Month (only) 6436**] ([**Month (only) **]) [**Telephone/Fax (1) 1144**]
Completed by:[**2193-9-10**]
|
[
"357.0",
"078.5",
"088.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
13964, 14034
|
11431, 13136
|
351, 358
|
14082, 14154
|
3896, 11408
|
14585, 14719
|
2282, 2286
|
13191, 13941
|
14055, 14061
|
13162, 13168
|
14178, 14562
|
2301, 2537
|
277, 313
|
386, 2145
|
2569, 3877
|
2554, 2554
|
2167, 2173
|
2189, 2266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,112
| 138,411
|
11019
|
Discharge summary
|
report
|
Admission Date: [**2104-12-8**] Discharge Date: [**2105-1-9**]
Date of Birth: [**2027-8-4**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
R iliac vein bleeding
Major Surgical or Invasive Procedure:
right iliac vein packing
History of Present Illness:
77 year old female transferred from [**Hospital1 **] [**Location (un) 620**] s/p right hip
acetabular clean out and removal of infected hardware on [**12-8**]
(presumed to be seeded from septic shoulder) for evaluation of
intraoperative bleeding. Wound left open and packed and
angiogram negative at OSH. Transferred emergently to [**Hospital1 18**]
where right iliac vein was packed x's 2. Had IVC filter placed
on [**12-9**] in setting of Afib and not able to anticoagulate d/t
bleed.
.
While in the SICU the patient has had intermittent episodes of
hypotension supported by fluids, blood, and neosynephrine
([**Date range (1) 35685**]), felt to be d/t blood loss vs. sepsis. Also with
repeated episodes of A fib, the first treated with diltiazem
gtt, the second amiodarone load, and the third repeat amiodarone
load. Of note, the patient first became febrile to 101.5 on
[**12-11**] and ppx cefazolin was changed to vanc/levo/flagyl and PICC
and swan pulled. She grew Serratia and Enterobacter in sputum
and blood cultures from [**12-11**]. Subsequent OSH records were
available showing MSSA in wound (? bld) and vancomycin was
changed to Ancef. Patient self extubated on [**12-12**] and was
immediately reintubated but then electively extubated on [**12-14**].
Was doing fairly well until the patient developed sustained VT
times 2 last night, the first of which she spontaneously
converted out of and the second of which required shock,
intubation, and pressors. Since then the patient has remained
hypotensive with SBP 70-90's and bradycardic with HR in 50's.
.
Currently the patient is intubated and sedated and unable to
answer ROS questions.
Past Medical History:
Hyperlipidemia
CHF (EF 55%)
Gout
Anemia
Afib s/p cardioversion
Cardiomyopathy
L hip fracture [**2103-6-10**]
Asthma
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
Vitals: 98/57 (74), range 78-110/40-60), 58 (53-110), 100%
Vent: 420/16/0.6/10 --> 7.48/35/113
I/O's: 5L/450 out, LOS 7L pos
HEENT: head symmetric and atraumatic, PERRL, anicteric sclera
Neck: LIJ in place,
Cardiac: bradycardic, regular, NL S1 and S2, III/VI SEM at LUSB
Lungs: diffuse rhonchi anteriorly, no wheeze
Abd: soft, obese, NTND, NABS, no HSM, no rebound or guarding
Ext: cold, purplish pads of toes on right and left, 3+ pitting
edema to hips, UE with diffuse anasarce
Neuro: sedated, intubated, able to move all ext
Pertinent Results:
[**2104-12-8**] 10:12PM TYPE-ART PO2-150* PCO2-44 PH-7.39 TOTAL
CO2-28 BASE XS-1
[**2104-12-8**] 10:12PM GLUCOSE-122* LACTATE-0.8
[**2104-12-8**] 10:12PM freeCa-1.20
[**2104-12-8**] 09:46PM TYPE-ART PO2-367* PCO2-41 PH-7.42 TOTAL
CO2-28 BASE XS-2
[**2104-12-8**] 09:15PM GLUCOSE-129* UREA N-11 CREAT-0.5# SODIUM-131*
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-9
[**2104-12-8**] 09:15PM CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-1.6
[**2104-12-8**] 09:15PM WBC-15.6* RBC-3.23* HGB-9.3* HCT-27.4* MCV-85
MCH-28.8 MCHC-34.0 RDW-17.6*
[**2104-12-8**] 09:15PM PLT COUNT-244
[**2104-12-8**] 09:15PM PT-13.6* PTT-31.5 INR(PT)-1.2*
[**2104-12-8**] 08:01PM TYPE-[**Last Name (un) **] PO2-55* PCO2-50* PH-7.34* TOTAL
CO2-28 BASE XS-0 COMMENTS-CENTRAL VE
[**2104-12-8**] 08:01PM GLUCOSE-114* LACTATE-1.5 NA+-128* K+-4.1
CL--104
[**2104-12-8**] 08:01PM HGB-9.8* calcHCT-29 O2 SAT-86
[**2104-12-8**] 08:01PM freeCa-1.09*
[**2104-12-8**] 08:01PM WBC-12.5*# RBC-3.26* HGB-9.7*# HCT-27.2*#
MCV-84# MCH-29.8# MCHC-35.6* RDW-17.3*
[**2104-12-8**] 08:01PM PLT COUNT-233
[**2104-12-8**] 08:01PM PT-13.6* PTT-31.1 INR(PT)-1.2*
.
CXR [**2105-1-7**]:
Large pneumoperitoneum persists, smaller since 6:31 p.m. on
[**1-6**]. The tip of an enterostomy or gastrostomy tube
projects over the left paramedian abdomen and appears to
cannulate either a loop of bowel or a length of tubing, which is
directed superiorly projecting over a collection of air above
the diaphragm presumably in the thoracic portion of a gastric
hiatus hernia. As I discussed with Dr. [**Last Name (STitle) **], I am unfamiliar
with any such appliance, and it is important to review these
radiographs with the surgical team in light of their description
of patient's abdominal procedure yesterday.
.
Moderately severe pulmonary edema has improved slightly since
[**1-6**] accompanied by persistent small-to-moderate
bilateral pleural effusion and mild cardiomegaly. There is no
pneumothorax. Tracheostomy tube is in standard placement. Right
internal jugular line tip projects over the upper right atrium.
.
Note is made of the comminuted healing fracture of the right
upper humerus. A caval umbrella filter projects over the
inferior vena cava, close to the level of the renal veins.
.
CT Torso [**2105-1-7**]:
IMPRESSION:
1. Large amount of free intraperitoneal air.
2. Gastrostomy tube is seen adjacent to the anterior wall of the
stomach. Injection of contrast material showed no leak. There is
a discrepancy in gastric wall thickness covering the gastrostomy
tube retainer compared to the thickness of the gastric wall
elsewhere. While this is most likely located within the stomach,
with thinning of the anterior aspect of the gastric wall due to
tethering by the gastrostomy tube, location of the PEG tube
retainer within the gastric wall cannot be completely excluded.
Consultation with the surgery service who placed the tube should
be performed prior to using the tube for tube feeds.
3. Large bilateral pleural effusions. Right effusion appears
simple. The left effusion may be loculated given posterior
tethering of the left lung. No frank enhancing septations are
identified.
4. Small amount of pneumomediastinum.
5. Tracheostomy tube cuff appears slightly hyperinflated.
6. Patchy areas of ground-glass opacity in aerated portions of
both lungs with superimposed more confluent areas of opacity.
Findings could be due to asymmetrical pulmonary edema or
superimposed infection.
7. Bone destruction and fluid collection in right
acetabulum/proximal right femur consistent with known hardware
infection. Post-traumatic changes in the right shoulder. L2
compression deformity, as described on prior [**2104-12-27**]
MRI.
.
MRI brain [**2105-1-1**]:
IMPRESSION: Limited due to significant amounts of patient motion
artifact. The internal carotid arteries as well as the basilar
artery appear patent. There is some flow signal present also
within the middle cerebral, anterior, and posterior cerebral
arteries.
.
TTE [**2104-12-31**]:
Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is hard to assess given the limited views but
susptect it is mildly decreasedl (LVEF 45-55%). [Intrinsic left
ventricular systolic function is likely more depressed given
the severity of valvular regurgitation.]
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is hard t oassess given the limited views but suspect
normal
function.
4.The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (area 1.2-1.9cm2) Mild to moderate
([**2-11**]+) aortic regurgitation is seen. 5.The mitral valve
leaflets are moderately thickened. There is severe thickening of
the mitral valve chordae. Moderate to severe (3+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension.
6.There is an anterior space which most likely represents a fat
pad.
.
Sputum culture [**2105-1-2**]:
GRAM STAIN (Final [**2105-1-2**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2105-1-4**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. HEAVY GROWTH.
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.
Please contact the Microbiology Laboratory ([**8-/2404**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
Blood culture and sputum culture [**2104-12-11**]:
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
| ENTEROBACTER SPECIES
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ 2 S <=1 S
IMIPENEM-------------- S <=1 S
LEVOFLOXACIN----------<=0.25 S <=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I <=1 S
Brief Hospital Course:
Briefly, this is a 77 year old female with CHF, Afib, anemia,
s/p hip fracture, seeding of hardware from septic shoulder s/p
removal, who was transferred here for concern of intraoperative
bleeding. She was initially admitted to the vascular service and
taken to the OR where bleeding of the R iliac artery was
controlled with packing. She was taken to the OR again the
following day, [**2104-12-9**], with exploration of right hip wound,
removal of surgical packs, irrigation and closure of wound.
Subsequent hospital course while on vascular surgery was c/b
difficult to control Afib, VT requiring shock, hypotension,
sepsis, and CHF. She was transferred to the MICU at this time.
The following is her MICU course:
.
# Respiratory Failure: The pt was initially intubated on [**12-8**]
s/p OR due to hypoxia and respiratory failure. She was
extubated on [**12-15**] but again reintubated on [**12-17**] due to VT
arrest. She remained reintubated, and the reason for her
failure to wean was felt to be multifactorial. Initially the pt
had PNA which was treated with a 14 day course of Vancomycin.
She also had pulmonary edema and large bilateral pleural
effusions felt to be CHF-related. In addition, the pt was
deemed to have ICU myopathy based on NIF of -5. The pt was
aggressively diuresed because at one point she was 15 L
positive. At the time of discharge, she was 3 L negative. At
times during diuresis with Lasix, she became hypotensive with
SBP in 70s, requiring levophed to help with further diuresis.
She continued to require ventilator support due to pleural
effusions and muscular weakness (ICU myopathy). She is on
Vancomycin currently for a 2 week course (start date [**1-2**]).
Her Vanc level was elevated at 25 prior to discharge, so her
random vanc level should be rechecked on [**1-9**]. If her level is
still >15, then her Vancomycin 750 mg q 24 hr dosing will need
to be adjusted. The pt was also treated with 1 week of
meropenem whichw as discontinued at the time of discharge due to
no gram negative growth in any culture. The pt had trach placed
on [**2105-1-6**]. Continue diuresis as able.
.
# ID: The pt was hypotensive on transfer, felt to be due to
sepsis in the setting of fever, WBC of 20, and enterobacter and
serratia in her blood culutres from [**12-11**]. She was treated with
2 weeks of Vancomycin and meropenem at that time. Her blood
pressures remained borderline and she intermittently required
levophed and 250 cc IV fluid boluses while being diuresed. On
[**1-2**], the pt spiked a temp and again had an increased WBC and
was restarted on Vanc/Meropenem for presumed VAP and possible
sepsis (had increased resp. secretions). Second vanc/meropenem
course is as per above. [**Last Name (un) **] stim was WNL.
.
#Rhythm: The pt remained in afib through most of her course,
with the exception of sustained VT upon transfer to the MICU.
As per above, the pt required shock and 2 amio boluses. She
remains on amiodarone and coumadin. Her coumadin was restarted
after trach, so INR will need to be monitored. Her metoprolol
had been stopped due to hypotension.
.
#CHF: The pt had an EF of 45%, repeat TTE showed EF 35%, and
then repeat TTE showed EF again of 45%. The pt was started on
digoxin for her CHF. She was also diuresed with IV Lasix as per
above until she was overall negative in her fluid balance. She
was started on po lasix 10 mg [**Hospital1 **] prior to discharge. She was
also started on low dose metoprolol.
.
#Weakness: The pt was deemed to have ICU myopathy by the
neurology service. MRI/MRA of the brain was a poor study but
did not reveal etiology of the weakness. C spine MRI also did
not reveal any etiology of the weakness. Her weakness seems to
be more proximal in nature, hence explaining the initial concern
for "man in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]" syndrome. However, as per above, MRI of
the head did not validate this concern. The pt will need rehab
for strengthening.
.
#FEN: PEG was placed on [**2105-1-6**] by general surgery. Initial
radiology reads were concerning for PEG placement.
Pneumoperitoneum on xray reads is expected s/p PEG placement.
Surgery felt the PEG was in proper position without complication
(after CT of the abdomen was performed), so tube feeds were
initiated in the pt without difficulty.
.
# Code: DNR--discussed with family
.
# Comm: Sister [**Name (NI) 18404**] [**Name (NI) **] [**Telephone/Fax (3) 35686**], PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
two daughters (pts niece - [**Name (NI) **] and [**Name (NI) **]) are HCP's. [**Location (un) **]
lives in the area, [**Doctor First Name **] lives in MD.
.
Medications on Admission:
-Hydromorphone 0.5-2 mg IV Q2-4H:PRN
-Insulin SC (per Insulin Flowsheet)
-Ipratropium Bromide MDI 4 PUFF IH Q4H on vent
-Levothyroxine Sodium 75 mcg PO DAILY
-Acetaminophen 325-650 mg PO Q4-6H:PRN T>101.5
-Lorazepam 0.5-1 mg IV Q4H:PRN
-Amiodarone HCl 200 mg PO DAILY
-Magnesium Sulfate 2 gm / 100 ml NS IV PRN Mag <2.0
-Atorvastatin 20 mg PO DAILY
-Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
-Bisacodyl 10 mg PO/PR DAILY:PRN
-Miconazole Nitrate Vaginal 1 Appl VG HS Duration: 7 Days
-Calcium Gluconate 2 gm / 100 ml NS IV PRN i Ca <1.12
-Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP INFUSION
-Digoxin 0.125 mg PO DAILY
-Pantoprazole 40 mg IV Q24H
-Docusate Sodium 100 mg PO BID
-Potassium Chloride 20 mEq / 50 ml SW IV PRN K <4.0
-Furosemide 10 mg IV BID
-Propofol 5-30 mcg/kg/min IV DRIP TITRATE TO sedation
-Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:
-Senna 1 TAB PO BID Order date: [**12-21**] @ 1128
-Warfarin 4 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for T>101.5.
2. Levothyroxine 75 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 150 mg/15 mL Liquid [**Month/Year (2) **]: One Hundred (100) mg
PO BID (2 times a day).
5. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
6. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Four (4)
Puff Inhalation Q4H (every 4 hours) as needed for on vent.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day).
10. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q6H (every
6 hours) as needed.
11. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
13. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
unit Injection TID (3 times a day): until INR therapeutic at
[**3-14**].
14. Loperamide 2 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO TID (3 times
a day) as needed.
15. Warfarin 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. respiratory failure post tracheostomy
2. atrial fibrillation
3. ventricular tachycardia
4. hypotension, initially from sepsis, then from overdiuresis
5. MRSA pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please return to ED or call your doctor if you have chest pain,
shortness of breath, cough, dizziness, tenderness in your
joints, fever or if there are any concerns at all
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) 20**] B. [**Telephone/Fax (1) 3259**] within
2 weeks of your discharge
2. Please follow up with your orthopedic surgeon
Completed by:[**2105-1-9**]
|
[
"518.5",
"996.67",
"998.11",
"995.92",
"274.9",
"427.31",
"038.49",
"428.0",
"482.41",
"359.81",
"V09.0",
"038.44",
"285.1",
"568.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.59",
"88.48",
"99.69",
"96.04",
"31.1",
"99.04",
"88.42",
"89.64",
"96.72",
"38.93",
"43.11",
"38.7",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
17176, 17251
|
9860, 14559
|
291, 318
|
17466, 17475
|
2777, 9837
|
17695, 17921
|
2197, 2214
|
15548, 17153
|
17272, 17445
|
14585, 15525
|
17499, 17672
|
2229, 2758
|
230, 253
|
346, 2008
|
2030, 2148
|
2164, 2181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,266
| 134,204
|
34458+57926
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-8-14**] Discharge Date: [**2175-8-23**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Ascending Aortic Aneurysm
Major Surgical or Invasive Procedure:
Repair of Ascending Thoracic Aortic Aneurysm & Aortic Valve
Replacement (27mm Pericardial) [**2175-8-16**]
History of Present Illness:
This 88 yo male was found on a CT after MVA to have an
incidental 7cm ascending aortic aneurysm. He was scheduled for
elective repair, but admitted early for bradycardic episodes.
Past Medical History:
Glaucoma
Hypertension
LT hydrocoele
h/o pulmonary contusions secondary to MVA
Social History:
The patient is married and lives at home independently with his
wife. [**Name (NI) **] is a non-smoker.
[**3-11**] glasses of wine a week
Family History:
Non-contributory.
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79203**] (Complete) Done
[**2175-8-16**] at 11:07:09 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2087-1-20**]
Age (years): 88 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for repair of ascending aortic
aneurysm and AVR
ICD-9 Codes: 440.0, 441.2, 424.1, 424.0
Test Information
Date/Time: [**2175-8-16**] at 11:07 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW2-: Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.9 cm <= 3.0 cm
Aorta - Ascending: *6.8 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm
Aorta - Abdominal: 0.0 cm <= 2.0 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH with normal cavity
size. Mild symmetric LVH. Suboptimal technical quality, a focal
LV wall motion abnormality cannot be fully excluded. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Markedly dilated ascending aorta.
Mildly dilated aortic arch. Simple atheroma in aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending
aorta. Focal calcifications in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. AR vena contracta is >0.6cm. Severe (4+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderately
thickened mitral valve leaflets. Mild mitral annular
calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. Frequent atrial premature beats. Results were
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE CPB No spontaneous echo contrast or thrombus is seen in the
body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. 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 ventricle
displays normal free wall contractility although the apical
region is only poorly seen. The ascending aorta is markedly
dilated. The aortic arch is mildly dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. The aortic
regurgitation vena contracta is >0.6cm. Severe (4+) aortic
regurgitation is seen. The mitral valve leaflets are mildly to
moderately thickened. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in
person of the results in the operating room at the time of the
study.
POST CPB The patient is being A-V paced. The patient is
receiving epinephrine by infusion. The right ventricle displays
normal function. The left ventricle dispalys dysynchronous
septal motion - probably secondary to pacing. Overall function
is decreased compared to pre bypass study. Later in the
post-bypass period, severe inferior wall hypokinesis was seen.
There was also some inferoseptal dyskinesis. The overall EF was
about 35 to 40% at that time. A bioprosthesis is located in the
aortic position. It is well seated with normal leaflet function.
The mean gradient through the valve is 4 mm Hg with a maximum
gradient of 8 mm Hg with a cardiac output of about 4
liters/minute. There is a trace valvular paravalvular leak seen.
Mitral regurgitation remains mild. Graft material is seen in
situ in the ascending aorta. The descending thoracic aorta and
distal aortic arch appear intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2175-8-16**] 15:23
?????? [**2169**] CareGroup IS. All rights reserved.
[**2175-8-14**] 09:08PM PT-14.1* PTT-30.9 INR(PT)-1.2*
Brief Hospital Course:
Mr.[**Known lastname **] was transferred from an outside ED after presenting with
SOB and "CHB", although he was stable. He was stable after
transfer as well. The urology service saw him for a left
scrotal mass which was deemed a hydrocele. EPS was consulted
for his episodes of asymptomatic bradycardia to the 30s with AV
block ( ? 2nd degree v. junctional). No treatment was
recommended. His CXR showed resolving pulmonary contusions with
small effusions and no evidence of CHF. A preoperative echo had
demonstrated an LVEF of ~50%.
On [**8-16**] he went to the OR for surgery. AVR and graft
interposition were performed.(See operative note for details.)
He weaned from CPB on Milrinone, epinephrine, neosynephrine and
propafol.His CV status stabilized with volume and pressors and
these were gradually weaned off in the first 48 hours. He was
extubated on POD 2 . He was confused but otherwise intact. He
was subsequently transferred to the floor.
All AV node blockers were withheld due to his underlying
dysrhythmia and there were rare episodes of bradycardia after
surgery. There continues to be episodes of blocked APCs and some
Mobitz I block, but no high grade AV node block.The EP service
has been following the patient and recommends no further
intervention/treatment at this time.
Mr. [**Known lastname **] continues to be diuresed toward his preoperative weight
with daily Lasix. He is alert and oriented. Wounds are healing
well and all pacing wires and CTs have been removed. He has
episodic periods of blanching of the fingers with coolness,
which he states is chronic, although he doesn't carry a
diagnosis of Raynaud's.
Discharge medications, follow up and instructions are as noted.
He is transferred to a rehabilitation facility for further
recovery before returning home.
Medications on Admission:
Lisinopril
Finasteride 0.4mg/D
ASA325 mg
Timolol Ophth. gtt
Alphagon ophth. gtt
dorzolamide ophth. gtt
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
Disp:*1 1* Refills:*2*
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 * Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 * Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Tab Sust.Rel.
Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Ascending thoracic aortic aneurysm
Aortic insufficiency
Hypertension
glaucoma
BPH
Discharge Condition:
good
Discharge Instructions:
Shower daily, no baths or swimming.
No creams,lotions or powders to incisions.
Report any temperature greater than 101
Report any drainage or redness of incisions
Take all medications as ordered
No lifting more rthan 10 pounds for 10 weeks
No driving for 4 weeks and off all narcotics
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]), call for appt.
Dr [**First Name4 (NamePattern1) 13291**] [**Last Name (NamePattern1) 32683**] in 2 weeks, call for appt.
Completed by:[**2175-8-23**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12745**]
Admission Date: [**2175-8-14**] Discharge Date: [**2175-8-23**]
Date of Birth: [**2087-1-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Dr. [**Last Name (STitle) **] wishes Mr. [**Name14 (STitle) **] to follow up with the EP service. A
followup appointment was made with them for 2 weeks.
Chief Complaint:
Ascending Thoracic Aneurysm with Aortic insufficiency
Major Surgical or Invasive Procedure:
Repair of Ascending Thoracic Aortic Aneurysm & AVR [**2175-8-16**]
History of Present Illness:
Incidental TAA found on CT after a MVA.
Past Medical History:
Glaucoma
Hypertension
LT hydrocoele
h/o pulmonary contusions secondary to MVA
Social History:
The patient is married and lives at home independently with his
wife. [**Name (NI) **] is a non-smoker.
[**3-11**] glasses of wine a week
Family History:
Non-contributory.
Physical Exam:
A&O x 3.
Lungs- clear.
Cor- SR 70's. Rare episode dropped APCs with bradycardia to 40s.
BP 139/60
Exts- No CCE. Wounds clean and dry. Sternum stable.
Pertinent Results:
[**2175-8-23**] 05:10AM BLOOD WBC-8.9 RBC-2.92* Hgb-9.8* Hct-28.4*
MCV-97 MCH-33.4* MCHC-34.4 RDW-12.9 Plt Ct-200
[**2175-8-23**] 05:10AM BLOOD Plt Ct-200
[**2175-8-23**] 05:10AM BLOOD Glucose-101 UreaN-29* Creat-1.3* Na-143
K-4.2 Cl-106 HCO3-32 AnGap-9
Brief Hospital Course:
See initial summary of [**8-23**].
Medications on Admission:
See initial summary of [**8-23**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
Disp:*1 1* Refills:*2*
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 * Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 * Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Tab Sust.Rel.
Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 7011**] Nursing & Rehabilitation Center - [**Location (un) 4554**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2175-8-23**]
|
[
"441.2",
"424.1",
"600.00",
"276.6",
"426.12",
"287.5",
"861.21",
"285.9",
"276.2",
"458.29",
"401.9",
"998.0",
"603.9",
"E819.9",
"365.9",
"428.0",
"276.8",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"35.21",
"96.71",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
13453, 13722
|
12174, 12210
|
11279, 11348
|
10053, 10060
|
11896, 12151
|
10393, 11169
|
11692, 11711
|
12294, 13430
|
9948, 10032
|
12236, 12271
|
10084, 10370
|
4150, 6674
|
11726, 11877
|
11186, 11241
|
11376, 11417
|
11439, 11518
|
11534, 11676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,204
| 175,237
|
6938
|
Discharge summary
|
report
|
Admission Date: [**2155-12-16**] Discharge Date: [**2155-12-24**]
Date of Birth: [**2079-8-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Fever, altered mental status
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
This is a 76 year-old man with a history of DM II, CAD/CHF (EF
45%) and HD dependent ESRD who presents to the ED from dialysis
with fever, gait instablitiy, and altered mental status.
Pt was in dialysis today when he was noted to be more confused
than his baseline. He was also noted to have difficulty
ambulating with ? leg/knee pain. In ED, VS were 101.8 (rectal),
HR 11, BP 208/93, RR 22 O2 sat 97%. He was a+o x1. Pt appeared
confused but was protecting airway, following commands. He
denied abd pain, tenderness. Urinary catheter was noted to have
pus. The patient was given Given 1 L IVF, 2g ceftriaxone, 1g
vancomycin. CT head was obtained and was negative for acute
bleed. EKG was without change compared to previous. CXR
preliminary read showed volume overload. UA was postive for
>1000 WBC.
Of note, the patient was admitted in [**3-/2155**] with a similar
presentation of altered mental status and fever to 101 without
source.
Upon transfer to the ICU, the patient had no complaints. He was
oriented x2. He reported feeling well. He denies any recent
illness was well as abdominal pain, chest pain, shortness of
breath, cough, urinary frequency, lightheadedness, focal
weakness, vision changes, headache, rash or skin changes.
Past Medical History:
Diabetes type 2.
# End-stage renal disease, on hemodialysis.
# CHF with EF of 45-55%.
# Hypertension.
# Status post nodular cavitating lung disease with positive
rheumatoid factor. Followed by Dr. [**Last Name (STitle) 575**] in [**2151**].
# MRSA bacteremia in [**2149-6-7**].
# CAD.
# COPD.
# Secondary hyperparathyroidism
Social History:
The patient is married to a retired nurse ([**Location (un) **]). He has six
children.
Family History:
non-contributory
Physical Exam:
Vitals: T:98.8 BP:171/76 HR:94 RR:18 O2Sat: 96% on RA
GEN: thin, elderly man, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: JVP 7cm, no bruits, no CAD, trachea midline
COR: RRR, normal S1 S2, 2-3/6 SEM at LUSB
PULM: Lungs with bilateral rales up to [**2-9**] lower lung fields.
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: radial pulses +2, RUE with forearm fistula +thrill.
diminished pedal pulses. Trace pedal edema bilaterally. No joint
swelling, tenderness.
NEURO: alert, oriented x1 (to person, place, not year). Unable
to name president. CN II ?????? XII grossly intact. Moves all 4
extremities. Responds to commands, answers questions
appropriately. Strength 4/5 in upper and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
LE with chronic venous statsis changes.
Pertinent Results:
[**2155-12-16**] 01:35PM BLOOD WBC-8.1 RBC-3.93* Hgb-11.6* Hct-35.7*
MCV-91 MCH-29.5 MCHC-32.5 RDW-14.0 Plt Ct-381
[**2155-12-19**] 05:40AM BLOOD WBC-8.9 RBC-3.54* Hgb-10.4* Hct-32.3*
MCV-91 MCH-29.4 MCHC-32.2 RDW-13.8 Plt Ct-321
[**2155-12-17**] 03:15PM BLOOD Glucose-152* UreaN-19 Creat-5.8*# Na-137
K-5.3* Cl-95* HCO3-31 AnGap-16
[**2155-12-19**] 05:40AM BLOOD Glucose-164* UreaN-17 Creat-4.9*# Na-141
K-4.0 Cl-98 HCO3-34* AnGap-13
[**2155-12-16**] 01:35PM BLOOD ALT-18 AST-73* AlkPhos-97 TotBili-0.4
[**2155-12-18**] 06:49PM BLOOD CK-MB-2 cTropnT-0.35*
[**2155-12-19**] 05:40AM BLOOD CK-MB-3 cTropnT-0.33*
[**2155-12-16**] 01:43PM BLOOD Glucose-148* Lactate-3.6* Na-143 K-5.2
Cl-92* calHCO3-33*
[**12-16**] CT head
There is no hemorrhage, hydrocephalus, shift of
normally midline structure, or evidence of major vascular
territorial infarct.
The [**Doctor Last Name 352**]-white matter differentiation is preserved.
Hypodensities in the
periventricular and subcortical white matter reflect chronic
microvascular
ischemic change. Note is made of a prominent cleft vs. old left
cerebellar
infarct, unchanged. Incidental note is made of a cavum septum
pellucidum et
[**Last Name (LF) 26095**], [**First Name3 (LF) **] anatomic variant. The visualized paranasal sinuses
and mastoid air
cells remain normally aerated. The cavernous carotids are
calcified.
IMPRESSION: No hemorrhage.
[**12-16**] CXR
IMPRESSION: Patchy bilateral airspace opacities, which is likely
related to
fluid overload. Infection is not excluded. Repeat radiography
following
appropriate diuresis is recommended to assess underlying
infection.
[**12-17**] CXR
There is no interval change in perihilar vascular indistinct and
extensive
patchy opacities involving the entire lungs. This may represent
volume
overload although widespread infection in appropriate clinical
setting cannot
be excluded. The absence of pleural effusion somehow questions
the diagnosis
of pulmonary edema favoring infection but cannot absolutely
exclude it.
Cardiomegaly is present. Mediastinum is unremarkable.
[**12-18**] Renal US
IMPRESSION:
1. No evidence of renal obstruction. Equivocal non-obstructing
tiny stones
in the lower pole of the left kidney.
2. Abnormal appearance of the bladder, with thickened, irregular
wall.
Further evaluation with CT or MRI is recommended.
3. Bilateral atrophic kidneys may relate to prior infections or
chronic
medical renal disease.
[**12-18**] CT pelvis
IMPRESSION:
1. Bladder wall thickening is difficult to evaluate as the
bladder is
collapsed due to Foley catheter. If this is of clinical concern,
repeat
ultrasound after clamping of Foley catheter is recommended.
2. Enlarged gallbladder, but given asymptomatic nature, and lack
likely due
to fasting state.
3. Atrophic kidneys, as in the prior studies.
4. Bilateral atelectasis, but airspace opacification
(aspiration, early
infectious consolidation) cannot be excluded.
[**2155-12-20**] 06:55AM BLOOD WBC-9.3 RBC-3.29* Hgb-9.6* Hct-29.8*
MCV-91 MCH-29.2 MCHC-32.2 RDW-14.6 Plt Ct-349
[**2155-12-21**] 07:00AM BLOOD WBC-9.1 RBC-3.34* Hgb-9.7* Hct-30.2*
MCV-91 MCH-29.2 MCHC-32.2 RDW-14.5 Plt Ct-337
[**2155-12-22**] 05:00AM BLOOD WBC-7.8 RBC-4.07* Hgb-12.0* Hct-37.1*
MCV-91 MCH-29.4 MCHC-32.3 RDW-13.9 Plt Ct-356
[**2155-12-23**] 05:40AM BLOOD WBC-8.5 RBC-3.76* Hgb-10.9* Hct-33.3*
MCV-89 MCH-28.9 MCHC-32.7 RDW-14.2 Plt Ct-376
[**2155-12-19**] 05:40AM BLOOD Glucose-164* UreaN-17 Creat-4.9*# Na-141
K-4.0 Cl-98 HCO3-34* AnGap-13
[**2155-12-20**] 06:55AM BLOOD Glucose-64* UreaN-24* Creat-6.5*# Na-136
K-4.4 Cl-95* HCO3-30 AnGap-15
[**2155-12-21**] 07:00AM BLOOD Glucose-60* UreaN-16 Creat-4.9*# Na-136
K-4.2 Cl-94* HCO3-31 AnGap-15
[**2155-12-22**] 05:00AM BLOOD Glucose-82 UreaN-27* Creat-6.4*# Na-133
K-4.8 Cl-92* HCO3-28 AnGap-18
[**2155-12-23**] 05:40AM BLOOD Glucose-88 UreaN-36* Creat-8.1*# Na-135
K-4.8 Cl-92* HCO3-29 AnGap-19
[**2155-12-18**] 06:49PM BLOOD CK-MB-2 cTropnT-0.35*
[**2155-12-19**] 05:40AM BLOOD CK-MB-3 cTropnT-0.33*
[**2155-12-19**] 05:40AM BLOOD Triglyc-112 HDL-28 CHOL/HD-3.6 LDLcalc-52
[**2155-12-16**] 2:45 pm URINE CATHETER.
**FINAL REPORT [**2155-12-18**]**
URINE CULTURE (Final [**2155-12-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Blood cultures x2 [**12-16**] negative
Blood cultures x2 [**12-20**], [**12-23**] NGTD
MRSA screen [**12-17**] positive
Brief Hospital Course:
76 year-old gentleman with a history of Type 2 diabetes, Chronic
Kidney disease, Congestive heart failure who presents with
fever, altered mental status, pyuria and pulmonary congestion.
.
1. Fever: Urinalysis showing pyuria with >1000 WBC. Patient was
afebrile during admission, without dysuria or suprapubic
tenderness. He was initially started on Ciprofloxacin, however
on hospital day 2 Urine culture showed E.coli resistant to
Ciprofloxacin. Patient was started on Ceftriaxone on [**12-18**].
Nephrology was consulted, who continued him on his dialysis
regimen. They recommended a renal US to rule out obstruction,
which was negative for obstruction but showed an abnormal
appearing bladder. CT pelvis confirms a thickened bladder wall,
though no obstruction. Patient continued to have fevers, so
Vancomycin was added on [**12-20**]. Chest x-ray showed Left lower
lobe consolidation. Vancomycin was discontinued on [**12-23**], as it
was thought unlikely that patient had MRSA pneumonia. Culture
data was negative. Blood cultures were all NGTD.
Please continue Cefpodoxime for 8 days, for a total of 2 weeks
treatment for UTI and pneumonia.
Of note, patient at baseline gets febrile during/after dialysis.
This is attributed to a reaction to one of the dialysis
catheters. As an outpatient this is treated with Tylenol and
Benadryl. No need for readmission unless fevers persist over 12
hours after dialysis, or patient has other focal symptoms.
2. Systolic congestive heart failure: Increased vascular
congestion on chest x-ray. Patient has a history of CHF with EF
last documented at 45% ([**3-15**]). No oxygen requirement and trace
peripheral edema on exam. No concern for acute change in cardiac
function. Patient was not diuresed, as he appeared euvolemic
during hospitalization.
3. Altered mental Status: Patient initially presented with
confusion, however this resolved on admission. There was no
evidence of CNS injury on CT and symptoms most likely delerium
in the setting of UTI. With prolonged stay in the hospital,
patient continued to be A+Ox2, though more confused overall.
This was attributed to hospital associated delirium. He was more
confused during and after dialysis, which according to his wife
occurs at baseline.
.
4. Chronic kidney disease: Gets Dialysis T Th Sa. Patient was
evaluated by nephrology, and received dialysis. Appeared
euvolemic on exam.
.
5. Type 2 diabetes: Well controlled throughout hospitalization.
Home regimen was held, and sugars were controlled with sliding
scale insulin only. Please continue outpatient regimen of
glipizide.
Medications on Admission:
Amlodipine 5 mg Daily
Glipizide 5 mg [**Hospital1 **]
Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]
Ranitidine HCl [Zantac] 150 mg Tablet qhd
Cinacalcet 90 mg DAILY.
Aspirin Child 81 mg (chewable) QD
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
6. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO
qHemodialysis for 8 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
Discharge Diagnosis:
Primary diagnosis:
1. Urinary tract infection
2. Left lower lobe pneumonia
3. Chronic kidney disease
4. Chronic systolic heart failure
Secondary diagnosis
1. Type 2 diabetes
2. Hypertension
Discharge Condition:
Alert and oriented x2. Patient gets febrile and weak after
dialysis, but back to baseline within 6-12 hours thereafter.
Discharge Instructions:
You were admitted with fevers and changes in your thinking. You
were found to have a urinary tract infection. We treated you
with antibiotics. You received dialysis. You had a CT scan of
your pelvis that showed no obstruction in your kidneys, though
you have a thickened bladder wall.
You had some changes on your EKG, that are concerning for your
heart. You will need a stress test as an outpatient.
Your chest x-ray showed a Left sided pneumonia. The antibiotics
for your urinary infection will also treat your pneumonia.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
If you develop pain with urination, blood in your urine, fevers,
chills, chest pain, or shortness of breath, please see your
doctor or go to the emergency room.
Followup Instructions:
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] on the [**Location (un) **]
of [**Company 191**] on [**12-26**] Friday
at 3:30pm. The clinic number is [**Telephone/Fax (1) 1300**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2155-12-24**]
|
[
"V45.11",
"496",
"585.6",
"403.91",
"414.01",
"041.4",
"599.0",
"780.09",
"428.22",
"428.0",
"250.00",
"486",
"588.81",
"V02.54",
"719.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11855, 11906
|
8082, 9891
|
345, 355
|
12141, 12263
|
2985, 8059
|
13098, 13456
|
2092, 2110
|
10930, 11832
|
11927, 11927
|
10701, 10907
|
12287, 13075
|
2125, 2966
|
277, 307
|
383, 1623
|
11946, 12120
|
9906, 10675
|
1645, 1972
|
1988, 2076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,327
| 114,691
|
33351
|
Discharge summary
|
report
|
Admission Date: [**2148-2-28**] Discharge Date: [**2148-3-28**]
Date of Birth: [**2106-1-28**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Adhesive Bandage / Dicloxacillin
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Cirrhosis on [**Male First Name (un) **] list s/p aborted trx due to pulmonary
HTN.
Major Surgical or Invasive Procedure:
Right heart catheterization x2
Paracenteses x2
Intubation
History of Present Illness:
Mr. [**Known lastname 19420**] is a 41 year-old man, well known to this service,
with history of cirrhosis secondary to EtOH + HCV, pulmonary
HTN, severe ascites, and recurrent encephalopathy, now being
transferred from the SICU s/p aborted liver trx due to elevation
in pulmonary pressures to 52/25 (mean 36).
.
Mr. [**Known lastname 19420**] was recently admitted from [**2-11**] to [**2147-2-22**] to medicine
service for pancreatitis presumed secondary to gallstones. ERCP
was not performed during that admission as he improved and it
was felt that since he was doing well, the risks outweighed the
benefits. Since d/c, he did well, but did present to ED on [**2-26**]
with abdominal pain and distended abdomen from worsening
ascites. 6L paracentesis was performed and he was given 75 g of
albumin. Of note, creatinine at that visit was 1.8, up from 1.2
from recent discharge. He has been maintained on lasix 20 qd,
aldactone 50 qd. On this admission, his creatinine was noted to
be 2.2, which rose to 2.4, but is now down to 1.8 s/p IVFs.
Past Medical History:
- HCV and EtOH cirrhosis on [**Month/Day (4) **] list
- h/o SBP early [**7-27**] on Cipro prophylaxis
- Grade II esophageal varices
- Recurrent hepatic encephalopathy on vegetarian diet
- Pulmonary HTN
- Hypothyroidism
- Anxiety disorder
- H/o EtOH abuse, IVDU
- Osteoporosis of hip and spine per pt
- Anemia w/ hx of guaiac positive stool.
- Pulmonary HTN
Social History:
He lives with his mother. [**Name (NI) **] quit smoking [**5-28**], was smoking
[**12-23**] ppd. Quit drinking EtOH 11 years ago. Prior remote hx of IVD
as teen. No current drug use.
Family History:
Mother with DM and HTN. Father with rheumatic heart disease.
Physical Exam:
T 98.2, BP 95/64, HR 74, RR 20, satting 97% RA
Gen: Pleasant, conversant, NAD.
HEENT: Sclera icteric
Pulm: Clear to auscultation bilaterally
CV: RRR. No m/r/g.
Abd: Very distended and firm with ascites. No pain.
Ext: 3+ edema bilaterally lower extremities.
Neuro: No asterixis.
Pertinent Results:
Labs at Admission:
[**2148-2-28**] 03:00AM BLOOD WBC-8.3 RBC-2.18* Hgb-6.9* Hct-21.1*
MCV-97 MCH-31.5 MCHC-32.6 RDW-20.0* Plt Ct-80*
[**2148-2-28**] 03:00AM BLOOD Neuts-82.5* Lymphs-8.1* Monos-6.7 Eos-2.7
Baso-0
[**2148-2-28**] 03:00AM BLOOD PT-24.2* PTT-58.5* INR(PT)-2.4*
[**2148-2-28**] 03:00AM BLOOD Glucose-97 UreaN-37* Creat-2.2* Na-126*
K-3.7 Cl-96 HCO3-17* AnGap-17
[**2148-2-28**] 03:00AM BLOOD ALT-16 AST-54* AlkPhos-149* Amylase-108*
TotBili-15.1*
[**2148-2-28**] 03:00AM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.3# Mg-2.2
Iron-92
Brief Hospital Course:
42 year-old man well known to our service, with history of
cirrhosis secondary to EtOH + HCV, pulmonary HTN, severe
ascites, and recurrent encephalopathy, s/p transfer from SICU
post aborted liver trx due to elevation in pulmonary pressures,
then transferred to MICU for diuresis on Lasix gtt. He is now
transferred to back to [**Doctor Last Name 3271**] [**Doctor Last Name 679**] following 13L fluid removal
for further medical management.
.
# New leukocytosis: Pt with large bump in WBC toward end of
stay, downtrending on day of discharge. Unclear etiology, as has
remained afebrile and clinically feels well. C.Diff negative,
multiple therapeutic taps negative for SBP. No cultures negative
to date.
.
# Elevated PAPm: Repeat right heart cath on [**3-11**] (after
diuresis) showed mean PA pressure of 52 with wedge pressure in
high 20s. Following MICU admission with Swann in place for
diuresis, PAPm is much improved now s/p diuresis on Lasix gtt.
BNP is also improving. His length of stay fluid balance in the
MICU is -13.5L, and his PCWP/PAPm has improved to 15/29 (from
28/52). As PAPm has improved significantly following diuresis
with concomittant improvement in PCWP, it is possible that fluid
overload may be contributing more to elevated PAPm than
pulmonary hypertension.
Off Lasix gtt, negative fluid balance was difficult to obtain,
and pt was placed on increasing doses of IV then eventually PO
diuretics to achieve improved UOP. Increases doses were limited
by rising Cr. Pt was finally dicharged on Spironolactone 200mg
PO qam, 100mg PO qpm, and Lasix 200mg PO qam, 100mg PO qpm, with
goal I/O negative -1L. Per outpt pulmonologist Dr.[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **],
resumed home Iloprost while inpatient. Pt is now re-listed on
liver [**Last Name (NamePattern1) **] list (pt aware) in setting of improved
pulmonary hypertension.
.
# Cirrhosis: MELD score was previously 34-36, which led to
attempted liver [**Last Name (NamePattern1) **]. Now s/p diuresis for elevated
pulmonary pressure. Cirrhosis has been c/b ascites,
encephalopathy and SBP. No asterixis at present. Pt has had 3
therapeutic [**Doctor First Name 4397**] thus far- [**3-1**] (6L off), [**3-5**] (5L off), [**3-14**]
(6L off), [**3-21**] (~5.5L.), [**3-26**] (~4L). MELD score at discharge
stable at 33. Pt was continued on Lactulose 30ml PO QID,
Rifaximin 200mg PO TID for hx hepatic encephalopathy. Continue
Ciprofloxacin 250mg PO q24 for SBP prophylaxis. Continue
Ursodiol 600mg PO QAM for elevated bilirubin/pruritis. On Lasix
and Spironolactone. Pt is now re-listed on liver [**Month/Day (4) **] list
(pt aware) as PAPm now improved to <35 (actual 29). Nadolol held
given borderline pressures, re-consider as outpt.
.
# Acute renal failure: This was thought to be secondary to
volume overload +/- HRS at time of transfer from SICU. In MICU,
Cr improved significantly, down to 1.2 from 2 with diuresis,
suggesting improved renal perfusion. On floor, Cr likely
bumping with diuresis, has been stable between 1.8-2.2. Pt was
discharged on high doses of Spironolactone/Lasix as above. Also
continue Midodrine 7.6mg PO TID for renal perfusion; holding
Octreotide d/t concern this might further elevate pulmonary
arterial pressures.
.
# Hypothyroid: stable. Last TSH [**2147-12-29**] wnl. Continue outpatient
Synthroid 88mcg PO qday.
.
# Anemia: normocytic; felt to be due primarily to marrow
suppression. S/p transfusion 1U PRBCs [**3-1**], [**3-5**], and [**3-8**]; 2U
PRBCs on [**3-10**]. Pt was guiaic positive on [**3-10**] and [**3-11**], hapto
<20, LDH WNL, retic count 2.4. Patient with h/o diverticulosis
per [**2142**] colonoscopy.
Crit has been stable in mid-20s.
- Trend daily crits
- Consider repeat colonoscopy as outpt
- Transfuse if hct<21 or actively bleeding
.
# Hand/leg cramping: Thought to be related to increasing doses
of diuretics. Magnesium was increased with some benefit. Pain
was controlled with Codeine 15-30mg PO q12 PRN cramping/pain. Pt
was discharged with a limited prescription.
.
# FEN: Pt had previously had a Dobhoff, which clogged [**3-9**], and
was removed [**3-10**]. Now tolerating POs, but per nutrition will not
get adequate intake given liver disease and low
protein/vegetarian diet. Dobhoff replaced again [**3-21**], as pt
inadvertantly had it pulled out. Additionally, pt accidentally
pulled Dobhoff out 10inches toward end of stay while sleeping.
Replaced by GI fellow, with bridle now in place. Likely not
post-pyloric but adequate. On fluid restriction 1200ml d/t
concern of volume overload. On Mag, Zinc, Vit D.
.
# Proph: Pneumoboots, compression stockings, PPI, Lactulose
scheduled
# Code: FULL
# Dispo: home with services.
Medications on Admission:
1. Ciprofloxacin 250 mg qday
2. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID
3. Levothyroxine 88 mcg qday
4. Nadolol 10 mg qday
5. Omeprazole 20 mg qday
6. Rifaximin 200 mg tid
7. Zinc Sulfate 220 mg [**Hospital1 **]
8. Furosemide 20 mg qday
9. Spironolactone 25 mg qday
10. Ursodiol 600 mg qAM, 300 mg qPM
12. Acidophilus Oral
13. Iloprost Inhalation
14. Magnesium Oral
15. Calcium Oral
16. Cholecalciferol (Vitamin D3) Oral
17. White Petrolatum-Mineral Oil Ophthalmic
Discharge Medications:
1. Outpatient Lab Work
Please have INR, Total bilirubin, Creatinine, Sodium, Albumin
checked daily in am, starting on Thursday, [**3-28**]
2. Tube Feeds
Pt requires tube feeds below as nutritional status is poor in
setting of liver disease. PO intake alone is inadequate.
.
Nutren 2.0 Full strength;
Starting rate: 30 ml/hr; Advance rate by 10 ml q4h Goal rate: 30
ml/hr
Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water q4h
Other instructions: No residuals with post pyloric feeding tube
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
[**Month/Day (4) **]:*1 bottle* Refills:*1*
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
[**Month/Day (4) **]:*30 Tablet, Chewable(s)* Refills:*1*
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO Q AM ().
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
[**Month/Day (4) **]:*30 Tablet(s)* Refills:*2*
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times
a day): Titrate to >6 BM daily.
15. Iloprost 10 mcg/mL Solution for Nebulization Sig: 2.5 MLs
Inhalation 6 times per day ().
16. Tube Feed Supplies
Pump, pole, backpack, 60cc syringes, feeding bags
Quantity sufficient for 1 month with 11 refills
17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
[**Month/Day (4) **]:*60 Tablet(s)* Refills:*2*
19. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
20. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO QPM (once a day
(in the evening)).
[**Month/Day (4) **]:*90 Tablet(s)* Refills:*1*
21. Furosemide 40 mg Tablet Sig: Five (5) Tablet PO QAM (once a
day (in the morning)).
[**Month/Day (4) **]:*150 Tablet(s)* Refills:*1*
22. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO twice a day
as needed for pain for 7 days.
[**Month/Day (4) **]:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary:
Cirrhosis secondary to alcohol use and Hepatitic C infection
Pulmonary hypertension
Recurrent hepatic encephalopathy
Recurrent ascites secondary to liver disease
Secondary:
Hypothyroidism
Anxiety
Discharge Condition:
hemodynamically stable, afebrile, satting well on RA, AOx3
Discharge Instructions:
You were admitted for possible liver transplantation. While you
in the OR, you were found to have elevated pressure in your
pulmonary system, and your [**Month/Day (4) **] was put on hold
temporarily. These pressures improved with diuresis, and you
were placed back on the [**Month/Day (4) **] list. You are still on the
[**Month/Day (4) **] list and should continue to be adherent to your
medication regimen and follow up with your appointments.
.
The following changes have been made to your medications:
INCREASE Lasix to 200mg PO every morning, 100mg PO every evening
INCREASE Spironolactone to 200mg PO every morning, 100mg PO
every evening
DECREASE Ursodiol to 600mg PO every morning only
INCREASE Magnesium oxide to 200mg PO twice daily
CONTINUE Simethicone 40-80mg PO 4 times daily as needed for gas
or bloating
CONTINUE Miconazole powder as needed for itching
CONTINUE Midodrine 7.5mg PO three times daily
CONTINUE Codeine 15-30ml PO twice daily AS NEEDED for
breakthrough pain x 1 week
You can use Tylenol 325-650mg PO AS NEEDED for pain also, just
limit your total daily dose to 2000mg maximum.
.
If you experience any fever, chills, abdominal pain, worsening
swelling, nausea, vomiting, diarrhea, shortness of breath, or
ED.
Followup Instructions:
MD: [**First Name8 (NamePattern2) 2943**] [**Doctor Last Name 696**]
Specialty: Liver
Date and time: [**2148-3-29**] at 1pm
Location: [**Hospital Ward Name 517**] [**Last Name (NamePattern1) 439**] [**Hospital Ward Name **] Bldg
Phone number: [**Telephone/Fax (1) 2422**]
Completed by:[**2148-4-15**]
|
[
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"571.2",
"327.23",
"707.03",
"789.59",
"416.8",
"287.5",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.21",
"99.15",
"96.71",
"96.6",
"54.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10920, 10976
|
3061, 7771
|
395, 454
|
11226, 11286
|
2498, 3038
|
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2123, 2185
|
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7797, 8285
|
11310, 12548
|
2200, 2479
|
272, 357
|
482, 1527
|
1549, 1907
|
1923, 2107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,863
| 120,443
|
10841
|
Discharge summary
|
report
|
Admission Date: [**2196-1-8**] Discharge Date: [**2196-1-9**]
Date of Birth: [**2137-3-19**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / Lasix
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
perforated viscus
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58 yo male Jehovas Witness with metastatic cholangio CA, acute
onset of abd pain, tx from outside hospital with minimal
free-air on CT, hypotension, tachycardia.
Past Medical History:
1. Metastatic cholangiocarcinoma- diagnosed in [**2-20**] status post
surgical resection in [**2191-4-22**] s/p 5-FU and XRT in [**2190**] with
lung nodules. Plan was to begin chemotherapy at the end of this
summer but then he presented to Dr.[**Name (NI) 24634**] office SOB and was
admitted [**2195-9-15**] and did not recieve further chemotherapy.
2. Eye surgery [**2166**]
3. Repair of cranial blood vessel in [**2147**]
4. Tonsillectomy and adenoidectomy in [**2145**].
5. Myringotomy and placement of ventilation tube [**6-25**] for Left
chronic serous otitis media and Eustachian tube dysfunction.
6. S/p recent admission [**9-14**]- [**9-25**] for upper GI bleed, ischemic
hepatopathy and strep viridans and VEILLONELLA bacteremia.
7. Heparin induced thrombocytopenia
8. H/o small bowel obstruction
Social History:
Pt works in consulting and teaches. Very active in the Jehova
whitness community. Lives with wife. Very supportive and
extending family. No alcohol, tobacco, or other drugs. He does
not want to have any blood products. His code status is
DNR/DNI.
Family History:
non-contributory
Physical Exam:
NAD
CTA b/l
RRR, S1S2
soft, diffusely tender, + distension, no peritoneal signs
AxOx3
Pertinent Results:
[**2196-1-8**] 04:00AM BLOOD WBC-29.2* RBC-4.43* Hgb-12.0* Hct-39.0*
MCV-88 MCH-27.1 MCHC-30.7* RDW-17.1* Plt Ct-449*
[**2196-1-9**] 05:30AM BLOOD WBC-28.1* RBC-3.60* Hgb-9.7* Hct-32.0*
MCV-89 MCH-26.9* MCHC-30.2* RDW-17.1* Plt Ct-257
[**2196-1-8**] 04:00AM BLOOD Neuts-64 Bands-26* Lymphs-8* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
Brief Hospital Course:
This patient was admitted to the [**Hospital1 18**] SICU on [**2196-1-8**] with the
diagnosis of perforated viscus. He was kept NPO and started on
Vancomycin and Zosyn. On HD 2, after serious consideration of
his options, given his very grave condition, the patient decided
to be made DNR/DNI. A PICC line was placed because he wanted to
continue home antibiotics. His diet was advanced and his pain
was controlled with morphine. He was discharged home later that
day on IV antibiotics and plenty of morphine.
Discharge Medications:
1. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 1 months.
Disp:*60 Recon Soln(s)* Refills:*0*
2. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 1 months.
Disp:*30 grams* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: 10-20mg PO Q
hour as needed for pain for 1 months.
Disp:*60 ml* Refills:*0*
4. Ativan 2 mg Tablet Sig: One (1) Tablet PO 2h for 1 months.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
metastatic cholangiocarcinoma, perforated bowel
Discharge Condition:
stable
Discharge Instructions:
Please call your oncologist or come to the ED with any worsening
abdominal pain, nausea, vomiting, fevers > 101.4, or any other
concerns. Please continue your IV antibiotics. Please take
your pain medication as directed.
Followup Instructions:
Provider: [**Name10 (NameIs) 17515**] CHAIR 1D Date/Time:[**2196-1-18**] 9:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2196-1-18**]
9:00
Provider: [**Name10 (NameIs) 17515**] CHAIR 2C Date/Time:[**2196-1-19**] 9:00
Completed by:[**2196-3-7**]
|
[
"155.1",
"569.83",
"197.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3155, 3206
|
2108, 2624
|
295, 302
|
3298, 3307
|
1745, 2085
|
3578, 3885
|
1606, 1624
|
2647, 3132
|
3227, 3277
|
3331, 3555
|
1639, 1726
|
238, 257
|
330, 493
|
515, 1323
|
1339, 1590
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,617
| 199,984
|
3281
|
Discharge summary
|
report
|
Admission Date: [**2191-6-8**] Discharge Date: [**2191-6-11**]
Service: MEDICINE
Allergies:
Codeine / Diltiazem / Doxycycline / Hydrocodone / Bactrim Ds
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest Pain - transfer for Cath
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mrs. [**Known lastname 15308**] is a 71 year old woman with past history of HTN,
atrial fibrillation (on flecainide, not anticoagulated due
history of falls), GERD, hyperlipidemia, hypothyroidism, asthma
who presented to [**Hospital1 **] [**Location (un) 620**] at 0300 on [**6-8**] with chest pain.
Mrs. [**Known lastname 15308**] stated that she has been feeling unwell for
approximately 3 days with symptoms of UTI and intermittant chest
pressure, but maintained her daily activities. On night prior
to admission, she noted worsening in her dysuria and some
hematuria. At about 0130 in the morning on [**6-8**], she developed
worsening substernal chest pain, non-radiating, approx [**2191-6-16**]
associated with SOB. SOB was not similar to previous asthma
episodes and was not responsive to albuterol inhaler. Denies
palpitations, N/V at that time, numbness or syncope. She went
to [**Hospital1 **] [**Location (un) 620**] where she was found to have ST elevation in V2
with lateral ST depressions. She was given aspirin, not plavix
loaded, and SL NTG x 1 with resolution in her pain and ST
changes. Initial CK was 28 and Troponin T < 0.01. She also had
a UA and was given Levoquin 750 mg x 1 for treatment of UTI.
She was admitted to the ICU for further management. CK and
Troponins were trended CK 28 (ED) --> 35 --> 35; Troponin <.01
--> 0.195* --> 0.151. She had worsening chest pain at this time
with episode of nausea and emesis. She was started on a heparin
gtt, given SL nitro with little improvement in pain and started
on nitro gtt with resolution of pain to [**2-20**]. Metoprolol
started. Cipro was started for her UTI. She is transferred to
[**Hospital1 18**] for possible cardiac cath.
.
On further discussion with patient, she states that she has had
intermittant bilateral lower extremity edema and worsening SOB
over the past months. She was recently prescribed Lasix 20 mg
qweekly prn for her peripheral edema. She also has recently
started sleeping on 3 pillows (from 2). Denies palpitations or
syncope. Shortness of breath is different from her asthma, but
is able to walk multiple laps around her retirement community
and sustain 30 minutes of light activity without chest pain.
.
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 paroxysmal
nocturnal dyspnea, palpitations, syncope or presyncope.
Past Medical History:
1) Asthma
2) Paroxysmal atrial fibrillation
3) Gastroesophageal reflux disease
4) Gastritis
5) Hypothyroidism
6) Recurrent urinary tract infections
7) Lyme disease - treated in [**2189**]
8) Herpes zoster
9) Anaphylactic reaction to beestings
10) Migraines
11) Skin cancers
12) Falls - The patient suffered a serious fall in [**2178**]
resulting in a compression fracture of her spine and a
dislocated shoulder
13) Urinary incontinence s/p bladder suspension
PAST SURGICAL HISTORY:
1. Status post bilateral cataract removal
2. Status post cholecystectomy
3. Status post tonsillectomy
4. Status post removal of two [**Hospital1 15309**] neuromas
5. Status post bladder suspension
6. Status post bunionectomy
ALLERGIES:
1. Codeine
2. Diltiazem - The patient reports that this caused hives.
3. Doxycycline - The patient reports that this caused severe
nausea and vomiting.
4. Beestings - The patient has an anaphylactic reaction to
beestings.
Social History:
Retired real estate broker/homemaker; lives in [**Doctor Last Name 5749**] [**Doctor Last Name **]
retirement community (independently). Divorced with four
children.
-Tobacco history: Distant (>50 years ago)
-ETOH: history of nightly [**Doctor Last Name 6654**], none currently
-Illicit drugs: Denies
Family History:
The patient's father had rheumatic fever as a young child and
had heart problems throughout his life. He died in his 60s. Her
mother died of colon cancer. The patient has two half siblings
who are well.
Physical Exam:
VS: T= 98.4 BP= 114/65 HR= 77 RR= 23 O2 sat= 96% RA
GENERAL: WDWN female 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 elevation of JVP. No LAD. No thyromegally.
No carotid bruits.
CARDIAC: regular rate, irregular, normal S1, S2. no m/g/r
appreciated. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles up
[**2-14**] of lungs with occasional expiratory wheeze, otherwise CTAB.
no rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ECHO [**2191-6-9**] - The left atrium is mildly dilated. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with septal
akinesis and thinning, and mid to distal apical/inferior/lateral
hypokinesis. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %). Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. 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
[**2185-6-17**], the regional left ventricular systolic dysfunction is
new.
Admission Labs:
[**2191-6-8**] 08:41PM BLOOD WBC-10.5# RBC-3.68* Hgb-11.8* Hct-35.5*
MCV-97 MCH-32.2* MCHC-33.3 RDW-13.9 Plt Ct-221
[**2191-6-8**] 08:41PM BLOOD Glucose-135* UreaN-14 Creat-0.6 Na-134
K-3.6 Cl-104 HCO3-24 AnGap-10
[**2191-6-8**] 08:41PM BLOOD ALT-39 AST-49* CK(CPK)-53 AlkPhos-65
TotBili-1.1
[**2191-6-8**] 08:41PM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
Lipids:
[**2191-6-9**] 04:30AM BLOOD Triglyc-61 HDL-67 CHOL/HD-1.8 LDLcalc-39
LDLmeas-<50
Brief Hospital Course:
71F with hsitory of HTN, Afib on flecainide, dyslipidemia,
asthma and hypothyroidism presented to OSH with chest pain,
found to have EKG changes with ST elevation and positive cardiac
enzymes, now chest pain free on Nitro gtt; transferred for
possible cardiac cath.
# NSTEMI - Mrs. [**Known lastname 15308**] was transferred from OSH for possible
cardiac cateterization after presenting with chest pain,
determined to have NSTEMI. She was transferred on heparin gtt
and nitro gtt, which were continued on admission. Her
flecainide was initially continued, but then discontinued in
setting of ACS; she was started on metoprolol for rate control.
She was chest pain free on the nitro gtt and this was
discontinued on hospital day 1 due to hypotension. She remained
chest pain free after discontinuation of nitroglycerin. She was
loaded with plavix, started ASA, and continued on her statin.
Repeat echo showed septal akinesis and mid-to-distal
apical/inferior/lateral hypokinesis as reported from [**Hospital1 **] [**Location (un) 620**].
After discussions with patient, she decided to undergo cardiac
catheterization. Cardiac catheterization showed a recanalized
lesion in the LAD, no interventions were made. One
consideration for possible etiology of her symptoms is
thrombolic emboli into one of the coronary arteries. She had no
complications from the procedure. She was discharged on
increased statin dose, metoprolol [**Hospital1 **], high dose aspirin and
plavix. She was instructed to follow-up with her cardiologist
in [**2-12**] weeks.
# ATRIAL FIBRILLATION: Known atrial fibrillation, controlled
with flecainide as outpatient, not on anticoagulation due to
falls. Flecainide was discontinued in setting of ACS and she
was started on amiodarone and metoprolol. TFTs were consistent
with thyroid replcement therapy for known hypothyroidism. She
was intermittantly in afib with no RVR. She was discharged in
normal sinus rhythm to complete a 6-day course of amiodarone 400
mg [**Hospital1 **] then decrease to 200 mg [**Hospital1 **] for 3 weeks. She is to
follow-up with her cardiologist in [**2-12**] weeks to discuss further
management and discussion for possible anticoagulation in the
future. Due to history of falls with multiple broken bones in
previous years, oral anticoagulation was not initiated during
her admission and should be readdressed as an outpatient. One
consideration for possible etiology of her symptoms and findings
of recanalized LAD lesion on cath is thrombolic emboli into one
of the coronary arteries.
# UTI - Symptommatic and postive UA at [**Hospital1 **] [**Location (un) 620**], negative
cultures. She was treated with a 3-day course of Cipro for her
UTI with resolution in symptoms.
# Asthma - Continued advair and albuterol prn.
# Hypothyroidism - Continued outpatient medications on
admission. Obtained TFTs with starting of amiodarone, decreased
Levothyroxin to 75 mg qday. Continued Liothyronine at outpatient
doses. Instructed patient to follow-up with her primary care
physician as an outpatient for repeat thyroid function testing
and titration of medication as tolerated.
# GERD/Gastritis - currently well controlled with no symptoms.
Originally placed on protonix, but discontinued with starting of
plavix. Discharged on reglan prn as previously prescribed.
# Glaucoma - Continued on alphagan and xalatan.
Medications on Admission:
- Albuterol Inhaler prn
- Flecainide 75 mg PO BID
- Advair 500/50 [**Hospital1 **]
- Lasix 20 mg qweekly prn
- Aspirin 81 mg qday
- Zocor 40 mg qday
- Levoxyl 100 mcg qday
- Liothyronine 12.5 mg qday
- Reglan prn
- Detrol [**Hospital1 **]
- Vitamin D bimonthly
- Vitamin B12 bimonthly
- Alphagan qday
- Xalatan
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
7. Liothyronine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation every 4-6 hours as needed for SOB.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO Qweekly PRN as
needed for shortness of breath or weight gain 3lbs.
11. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) inj
Injection 2x/month.
12. Vitamin D Oral
13. Alphagan P 0.1 % Drops Sig: One (1) Drop Ophthalmic ASDIR:
please take as you were prior to hospitalization.
14. Xalatan 0.005 % Drops Sig: One (1) drop Ophthalmic at
bedtime.
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
Start after finishing 6 days of amiodarone 400mg twice a day.
Take for three weeks then decrease to 200 mg daily.
Disp:*60 Tablet(s)* Refills:*0*
16. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
17. Reglan 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed: Take as previously prescribed.
18. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: Take as previously prescribed.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Coronary Artery Disease with LAD stenosis
2. Urinary Tract Infection
3. Atrial Fibrillation
SECONDARY DIAGNOSIS:
Asthma
Hypothyroidism
S/P Bladder Suspension
GERD/Gastritis
s/p Cholecystectomy
H/O Lyme Disease [**2189**]
H/o Herpes Zoster
Migraines
DJD with compression fractures
Dylipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with chest pain. We did a
cardiac catheterization, but did not need to place stents in
your heart. You were doing much better with regard to your
symptoms upon discharge. You were also treated for a urinary
tract infection in the hospital.
The medication for your irregular heartbeat (atrial
fibrillation) has been changed from flecainide to amiodarone.
You will need to take amiodarone 400mg twice a day for one week,
then switch to 200mg twice a day until you see your cardiologist
OR for 3 weeks (whichever occurs first); then decrease to 200 mg
daily. Because you are starting plavix and increasing your
aspirin, you were not placed on coumadin (which you have taken
historically).
The following changes have been made to your medications:
-Stop flecanide
-Start metoprolol 12.5mg twice a day
-Start amiodarone 400mg twice a day for one week, then switch to
200mg twice a day until you see your cardiologist or 3 weeks
(whichever occurs first); then decrease to 200 mg daily
-Increase Aspirin 81mg to 325mg daily
-Start plavix 75mg daily
-Increase Simvastatin to 80 mg daily
-Decrease Levothyroxine (Levoxyl) to 75 mcg daily
Please follow up with your cardiologist and discuss whether it
would be useful to start on a medication called Lisinopril.
If you experience chest pain, shortness of breath, incresed
swelling in your extremities, cough, symptoms of recurrent
urinary tract infection, palpitations, light-headed feeling or
any other symptoms that concern you please contact your
physician or go to the nearest emergency room for evaluation.
Followup Instructions:
You must follow up with your cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 4105**]) within 1 to 2 weeks. We were unable to make this
appointment for you because you were discharged on the weekend,
but make this appointment first thing Monday morning. Medication
adjustments may need to be made.
Additionally, it is recommended that you make an appointment
with your primary care physian after being discharged from the
hospital.
Your previously scheduled appointments at [**Hospital1 18**] are listed
below:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2191-6-20**]
9:30
Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2191-9-12**] 1:00
|
[
"244.9",
"365.9",
"V15.51",
"493.90",
"410.71",
"414.01",
"427.31",
"401.9",
"715.90",
"V15.88",
"530.81",
"599.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
12621, 12627
|
7031, 10417
|
297, 323
|
12999, 12999
|
5511, 6549
|
14764, 15609
|
4355, 4559
|
10779, 12598
|
12648, 12648
|
10443, 10756
|
13150, 14741
|
3557, 4017
|
4574, 5492
|
227, 259
|
351, 3052
|
12784, 12978
|
6565, 7008
|
12667, 12763
|
13014, 13126
|
3074, 3534
|
4033, 4339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,578
| 104,431
|
21788+57259
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-9-16**] Discharge Date: [**2200-9-23**]
Date of Birth: [**2127-7-19**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Iodine
Attending:[**First Name3 (LF) 7303**]
Chief Complaint:
left knee osteoarthritis
Major Surgical or Invasive Procedure:
left total knee replacement
History of Present Illness:
73y/o with Dementia, parkinsons, Schizophrenia vs
schizo-affective disorder, HTN CKD III, h/o DVT admitted [**9-16**]
for elective left total knee replacement.
Past Medical History:
- Schizophrenia vs schizo-affective disorder
- Hypertension
- CKD III, baselien 1.5-1.7
- DVT - left leg (pre-[**2194**]) unclear associated factors
- Right knee periprosthetic undisplaced medial condyle fracture
of the femur ([**11/2199**])
- Dementia
- major depressive disorder
- osteroarthritis both knees
- PVD
- Parkinsons?--resting tremor
- ?p Afib-daughter thinks
- Diabetes Insipidus [**12-23**] lithium
- LGIB, believed diverticular [**5-29**] in the setting of high INR
- iliac aneurysm noted [**5-29**]
Social History:
Long-term resident of [**Hospital1 **] Senior Care of [**Location (un) 55**].
Ambulates with walker and assistance, history of falls. Denies
EtOH, tobacco, IV, illicit, or herbal drug use.
Family History:
unknown
Physical Exam:
PHYSICAL EXAM AT THE TIME OF DISCHARGE:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
[**Last Name (un) 938**]/FHL/TA/GS intact
SILT distally
LLE with 3+ edema
Pertinent Results:
Labs on admnission:
[**2200-9-16**] 07:01PM BLOOD WBC-8.2 RBC-3.74* Hgb-11.0* Hct-34.0*
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.9 Plt Ct-156
[**2200-9-17**] 11:26AM BLOOD Neuts-83.3* Lymphs-6.4* Monos-9.6 Eos-0.5
Baso-0.2
[**2200-9-16**] 07:01PM BLOOD PT-12.1 PTT-25.0 INR(PT)-1.0
[**2200-9-16**] 07:01PM BLOOD Glucose-127* UreaN-32* Creat-2.1* Na-150*
K-4.2 Cl-116* HCO3-27 AnGap-11
[**2200-9-16**] 07:01PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
Imaging:
CT head: No acute intracranial process. Note that if concern
persists for
acute infarct, MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**] imaging would be more
sensitive.
Brief Hospital Course:
The patient was admitted on [**2200-9-16**] and, later that day, was
taken to the operating room by Dr. [**Last Name (STitle) 5322**] for left total knee
arthroplasty without complication. Please see operative report
for details. Postoperatively patient underwent a delayed
extubation in the PACU for a delayed wake up. The patient
received IV antibiotics for 24 hours postoperatively. POD1
patient became somnelent and found to have hypercarbia on ABGs.
She was immediately transferred to ICU. The rest of the
hospital course is summarized below by systems. The drain was
removed without incident on POD#1. TheThe surgical dressing was
removed on POD#2 and the surgical incision was found to be
clean, dry, and intact without erythema or purulent drainage.
.
1. Acute hypercarbic respiratory failure: On POD#1, the patient
was found at 4:30am, unresponsive to sternal rub. The patient
was given Narcan at 5:05am and at 5:30 a.m. with dramatic
improvement in mental status. Subsequently, ABG was 7.24/71/66.
However, the patient's mental status again worsened, and she was
again found to be unresponsive during ortho rounds, arousable to
sternal rubs. ABG was 7.20/76/52. In the setting of hypercarbic
respiratory failure, BiPAP was initiated and the patient was
transfered to [**Hospital Unit Name 153**] for further care. The patient briefly
required BiPAP but then her alertness and respiratory status
improved. Prior to transfer out of the ICU, her ABG was
7.40/42/97. On the floor she continued to maintain her sats.
.
2. Altered mental status: As the patient became more alert, she
became increasingly agitated and paranoid. Psychiatry was
consulted. Psychiatry obtained collateral information from the
patient's daughter, who stated that the patient had been
suffering from psychotic symptoms for decades. The patient takes
Risperdal, Effexor, and Abilify at home, but was refusing all PO
medications. Per psychiatry recommendations, her agitation and
psychosis were treated with olanzepine IM. As the patient's
psychosis improved, she stopped refusing PO, and she was
restarted on her home medications.
.
3. S/p left total knee replacement: The surgical dressing was
removed on POD#2 and the surgical incision was found to be
clean, dry, and intact without erythema or purulent drainage.
Her drain was removed POD2. Foley catheter was removed without
incident. While in the hospital, the patient was seen daily by
physical therapy. CPM was advanced daily. The patient's
weight-bearing status was WBAT. The patient is to continue using
the CPM machine advancing as tolerated to 0-100 degrees.
.
4. Atrial fibrillation: The patient reportedly has a history of
paroxysmal atrial fibrillation. The hematology service was
consulted for recommendations with regard to anticoagulation and
recommended a discussion of the risks and benefits in the
outpatient setting. Pain was well controlled with a PO regimen.
The patient's weight-bearing status was WBAT. The patient is
to continue using the CPM machine advancing as tolerated to
0-100 degrees. The operative extremity was neurovascularly
intact and the wound was benign.
.
5. Acute on chronic renal failure: Post-operatively, the
patient's creatinine rose from baseline 1.9, reaching 2.9 on
[**2200-9-19**]. This was thought to be pre-renal. In the [**Hospital Unit Name 153**], the
patient pulled out all of her IV's and remained too agitated to
establish access, making it impossible to give the patient
fluids. Creatinine returned to baseline in mid 2s prior to
discharge.
.
6. Hypertension: The patient's hypertension was poorly
controlled in the setting of agitation and refusing PO meds. Her
hypertension was managed IV hydralazine and metoprolol. As the
patient's mental status improved, she restarted her home
medications.
7. Heme: Patient received 1 unit pRBC for a hct of 26 POD2.
Hct was thereafter stable in low 30s.
8. AC: The patient was initially anticoagulated with Lovenox
and warfarin. This was changed to heparin gtt in the setting of
renal dysfunction. The hematology service was consulted given
the patient's history of DVT and GI bleed. Hematology
recommended anticoagulation with Heparin IV gtt with bridge to
Warfarin (goal INR 2-2.5) for 3 weeks postoperatively. If an
only if her renal function returns to a GFR >15, Lovenox can be
reinstituted for the 3 week duration with Anti-Factor Xa levels
to be checked after the second dose for a goal of 0.6-1.
Medications on Admission:
metoprolol 25mg PO TID, lisinopril 15mg PO daily,
Carbidopa-Levodopa 25-100 2 TAB PO hs, venlafaxine 75mg PO BID,
pantoprazole 40mg PO q24h, oxybutynin 5mg daily, bisacodyl 10mg
PO/PR daily prn, calcium carbonate 500mg PO TID, Vitamin D 400 U
PO daily, multivitamin daily, senna 1 tab PO BID prn, docusate
100mg PO BID
Warfarin,
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Risperidone 1 mg/mL Solution Sig: One (1) PO QAM (once a day
(in the morning)).
7. Risperidone 1 mg/mL Solution Sig: 1.25 PO HS (at bedtime).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Aripiprazole 15 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. 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.
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 6
weeks: INR 2-2.5.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
left knee osteoarthritis
Discharge Condition:
stable
Discharge Instructions:
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by Dr. [**Last Name (STitle) 5322**] 2 weeks after your
surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 2 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue your coumadin for 6 weeks to
prevent deep vein thrombosis (blood clots). Your INR should be
[**12-24**], and you will likley need 1mg coumadin daily depending on
your INR level.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous exercise or heavy lifting until follow up
appointment. Continue to use your CPM machine as directed.
Physical Therapy:
LLE WBAT. CPM 0-100 as tolerated.
Treatments Frequency:
Wound checks, coumadin dialy (INR2-2.5), staples out by Dr.
[**Last Name (STitle) 5322**].
Coumadin dosing when discharged to acute rehab to be completed
by Dr. [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 719**] Fax: [**Telephone/Fax (1) 716**]
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-10-1**] 12:45
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**]
Completed by:[**2200-9-22**] Name: [**Known lastname 10645**],[**Known firstname 565**] Unit No: [**Numeric Identifier 10646**]
Admission Date: [**2200-9-16**] Discharge Date: [**2200-9-23**]
Date of Birth: [**2127-7-19**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Iodine
Attending:[**First Name3 (LF) 942**]
Addendum:
VNA or rehab to take out staples 2 weeks postop. If this cannot
be done she will then need a 4 week follow up appointment.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] of [**Location (un) 729**]
Discharge Instructions:
1. Please return to the emergency department or notify MD if you
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by rehab/VNA 2 weeks after your
surgery. If the rehab cannot take out the staples please
schedule a 4 week follow up appointment.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 2 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue your coumadin for 6 weeks to
prevent deep vein thrombosis (blood clots). Your INR should be
[**12-24**], and you will likley need 1mg coumadin daily depending on
your INR level.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous exercise or heavy lifting until follow up
appointment. Continue to use your CPM machine as directed.
Physical Therapy:
LLE WBAT. CPM 0-100 as tolerated.
Treatments Frequency:
Wound checks, coumadin dialy (INR2-2.5), staples out by rehab or
VNA 2 weeks post op. She will need a 2 week follow up
appoinment if rehab cannot take out staples.
Coumadin dosing when discharged to acute rehab to be completed
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 7151**] Fax: [**Telephone/Fax (1) 10647**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 945**]
Completed by:[**2200-9-23**]
|
[
"599.0",
"585.3",
"584.9",
"403.90",
"V58.61",
"V12.51",
"715.36",
"295.90",
"296.30",
"427.31",
"518.81",
"253.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54"
] |
icd9pcs
|
[
[
[]
]
] |
12046, 12116
|
2153, 3696
|
296, 325
|
8565, 8574
|
1497, 1942
|
11246, 12023
|
1275, 1284
|
6985, 8401
|
8517, 8544
|
6632, 6962
|
12140, 13891
|
1299, 1478
|
14539, 14573
|
14595, 15120
|
232, 258
|
13903, 14521
|
353, 514
|
1952, 2130
|
3711, 6606
|
536, 1053
|
1069, 1259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,882
| 187,417
|
41339
|
Discharge summary
|
report
|
Admission Date: [**2164-3-4**] Discharge Date: [**2164-3-7**]
Date of Birth: [**2091-12-6**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Coma.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The pt is a 72 year-old right-handed woman with no known
significant past medical history (has not been to a physician in
years) who presented after being found down and transferred from
an OSH with evidence on CT of a right intraparenchymal bleed.
The patient was visiting her family from [**State 108**] for a family
funeral. She arrived a few days ago. She apparently had a mild
headache yesterday but no other significant complaints. She was
last seen last night after dinner, and was heard going to the
bathroom at 3am. This morning her niece (who she is staying
with in [**Location (un) 14663**]) found her on the floor on her back, wedged
between the bed and the wall. She noted the patient was awake
and her eyes were open, she was covered in emesis. She was
slurred but able to answer some questions and appeared to know
what was happening. EMS was called and she was taken to [**Hospital 4683**] where she was found (by report) to have a right lateral
gaze, posturing and contracted right side, with a flaccid left
side. There she was still able to speak, and asked where one of
her relatives was. She was apparently intubated for airway
protection and a CT was done that showed a large right sided
lobar hemorrhage with 10mm of midline shift. She was
transferred to [**Hospital1 18**] for further management.
On arrival she was initially seen by the neurosurgery team.
They had a discussion with the family and it was decided that
they would not want any full surgery such as a craniotomy. They
did agree to an EVD but with the stipulation that if this
procedure was done and she worsens no further aggressive actions
would be taken. The EVD was done in the ED by Dr. [**First Name (STitle) **], who
reported an pressure of about 15cm. Neurology was called for
further
management.
On neuro ROS, and general ROS not available. She reportedly has
not been feeling "herself" over the last few weeks but it is not
clear what this means.
Past Medical History:
- None known she has not seen a doctor for many years
Social History:
Lives with a boyfriend in [**Name (NI) 108**]. Recently retired from office
work. Is very active, goes on hikes, very independent. She has
a smoking history, likely quit 2 years ago. Unclear how long,
occasional EtOH, no drugs.
Family History:
Sarcoma in her sister, father with celiac disease, mother had
stroke in old age.
Physical Exam:
Vitals: T: 96.8 P:80 R: 16 BP:130/65 SaO2:100
General: intubated, sedated
HEENT: site of EVD draped, attached to drain, mild scleral
injection b/l .
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally, mech breath sounds
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: slight skin breakdown in inguinal area
Neurologic: (off sedation for ~15min)
-Mental Status: intubated and sedated, moves legs spontaneous,
and seemingly to loud voice, attempts to open eyes.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk.
III, IV, VI: + dolls eyes
V,VII: corneals intact bilaterally r>l
IX, X: gag and cough
-Motor: Normal bulk, increased tone in legs, right arm (maybe
paratonia)
Spontaneous movement of right arm, and both legs, extensor
postures of left arm.
-Sensory: Appears to have response at all 4 extremities to
noxious stimulation
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was extensor bilaterally.
-Coordination and gait: not testable
Pertinent Results:
[**2164-3-6**] 04:13AM BLOOD WBC-12.1* RBC-3.59* Hgb-12.0 Hct-33.0*
MCV-92 MCH-33.4* MCHC-36.4* RDW-13.0 Plt Ct-134*
[**2164-3-5**] 03:57AM BLOOD PT-12.5 PTT-22.6 INR(PT)-1.1
[**2164-3-6**] 04:13AM BLOOD Glucose-140* UreaN-9 Creat-0.5 Na-140
K-3.6 Cl-106 HCO3-27 AnGap-11
[**2164-3-5**] 03:57AM BLOOD ALT-31 AST-46*
[**2164-3-4**] 10:45AM BLOOD Lipase-146*
[**2164-3-6**] 04:13AM BLOOD Calcium-8.2* Phos-1.5* Mg-2.1
[**2164-3-4**] 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-3-4**] 10:45AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2164-3-4**] 10:45AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2164-3-4**] 10:45AM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
[**2164-3-4**] 10:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CT Head
FINDINGS: Again seen is a large, 5.6 cm TV x 4.7 cm AP x 5.8 cm
SI multiloculated region of acute hemorrhage in the right
frontal lobe. This extends contiguously into the anterior body
of the corpus callosum, caudate head, and right thalamus.
Overall extent of the bleed is unchanged, accounting for
differences in scan angulation. There is continued surrounding
vasogenic edema, with persistent 10 mm leftward subfalcine
herniation, and 3 mm leftward shift at the level of the third
ventricle. There is evidence of intraventricular extension, with
a large amount of hemorrhage layering in the bilateral occipital
horns. There is continued sulcal effacement extending throughout
the right cerebral hemisphere. No new foci of hemorrhage, edema,
or large vascular territorial infarct are identified. The
ventricles maintain a normal caliber, without evidence of
hydrocephalus. There is no evidence of transtentorial or
tonsillar herniation. Examination is degraded by patient motion.
No fractures are identified. The paranasal sinuses and mastoid
air cells are clear. Orbits and intraconal structures are
preserved.
IMPRESSION: Stable appearance of large right frontal hemorrhage
with intraventricular extension, 10 mm leftward subfalcine
herniation, and associated diffuse cerebral edema.
Brief Hospital Course:
Mrs. [**Known lastname **] was made CMO by her children, who stayed with her
through the night. Her EVD was removed and she was terminally
extubated. She expired the following day.
Time of death 08:10 AM with family at her side. Patient's
daughter [**Name (NI) 75900**] [**Name (NI) **] refused autopsy.
Medications on Admission:
None.
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"277.30",
"431",
"V66.7",
"V49.86",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"02.39",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6503, 6512
|
6114, 6420
|
308, 315
|
6558, 6562
|
3899, 6091
|
6613, 6710
|
2647, 2729
|
6476, 6480
|
6533, 6537
|
6446, 6453
|
6586, 6590
|
3337, 3880
|
2744, 3205
|
263, 270
|
343, 2305
|
3220, 3320
|
2327, 2383
|
2399, 2631
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 167,225
|
22414
|
Discharge summary
|
report
|
Admission Date: [**2131-1-4**] Discharge Date: [**2131-1-12**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
DKA, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
25 yo woman with a h/o DMI (A1C 11.1 since [**11-8**]), HLP, anxiety,
presents with increased anxiety, diarrhea/stool incontinence,
polydipsia, polyuria, p/w hyperglycemia. Patient reports
elevated blood sugars this morning to the 200s, then upon
recheck were critically elevated. The patient reported very mild
abdominal pain, nausea, vomitting (nonbloody, nonbilious), the
pt denied diarrhea but admitted to [**2-1**] BMs that were soft,
nonbloody, nonblack.
blood sugarts, urinary frequency, bowel incontinence/urgency. FS
200s this am, then critically high.
In the ED, initial vs were: 98.9 128 111/62 18 100, FS of 600.
Pt was rectal heme pos. CXR was negative for any acute
cardiopulmonary process. ECG with sinus tach. Pt was given
dilaudid 0.5mg IV x 2, zofran 4mg IV x 1, and ativan 0.5mg PO x
1. Has received 4L NS. Also received 10 units IV then Insulin at
6mg/hr. ECG with sinus tach. ? peaked t's one lead. Last FS
prior to transfer was 395.
.
On the floor, the patient was anxious and complaining of thirst.
Did report mild abdominal pain, urinary urgency, chronic chills,
occasional sweats (chronic)
.
Review of sytems:
(+) Per HPI
(-) Denies fever, recent weight loss or gain. Denies headache,
cough. Denied chest pain or tightness, palpitations. Denied
constipation. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Diabetes Type I: diagnosed age 16 in [**2120**] after her first
pregnancy. Most recent Hgb A1C 10.9 % ([**8-9**])
- Previous admissions for nausea/vomiting with h/o esophagitis
and with concern for diabetic gastroparesis
- Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**]
- Stage I diabetic nephropathy
- Anxiety/panic attacks
- Depression
- Hyperlipidemia
- S/P MVA [**5-4**] - lower back pain since then. Per patient
received oxycodone from her primary provider
[**Name Initial (PRE) **] [**Name Initial (PRE) 58252**]
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
- Genital Herpes
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own apartment near [**University/College 5130**]. She is currently unemployed
and received disability. She has a 6 year old son. [**Name (NI) **] cousin
recently had fevers, myalgias. Her mother and sisters live
nearby. She denies tobacco, alcohol or illicit drug use. One
current male sexual partner, uses depot shot for birth control.
Family History:
Her grandmother had type I diabetes. No Hx of CAD, HTN.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress, anxious
[**Name (NI) 4459**]: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
KUB
FINDINGS: A relative paucity of bowel gas is observed within the
abdomen,
with a non-obstructive pattern. No free intraperitoneal air is
identified.
IMPRESSION: Non-obstructive bowel gas pattern.
[**2131-1-4**] 01:01PM BLOOD Glucose-625* UreaN-22* Creat-1.4* Na-136
K-6.1* Cl-91* HCO3-12* AnGap-39*
[**2131-1-4**] 03:50PM BLOOD Glucose-395* UreaN-21* Creat-1.0 Na-145
K-4.0 Cl-112* HCO3-10* AnGap-27*
[**2131-1-4**] 08:35PM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-140
K-6.4* Cl-110* HCO3-16* AnGap-20
[**2131-1-4**] 10:16PM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-137
K-5.6* Cl-109* HCO3-16* AnGap-18
[**2131-1-4**] 11:39PM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-136
K-3.7 Cl-109* HCO3-15* AnGap-16
[**2131-1-5**] 03:38AM BLOOD Glucose-134* UreaN-9 Creat-0.8 Na-137
K-3.6 Cl-110* HCO3-18* AnGap-13
[**2131-1-5**] 01:27PM BLOOD Glucose-248* UreaN-6 Creat-0.9 Na-127*
K-4.1 Cl-98 HCO3-12* AnGap-21*
[**2131-1-5**] 07:44PM BLOOD Glucose-113* UreaN-5* Creat-0.8 Na-132*
K-3.2* Cl-97 HCO3-16* AnGap-22*
[**2131-1-6**] 04:07AM BLOOD Glucose-162* UreaN-5* Creat-0.7 Na-136
K-3.7 Cl-103 HCO3-21* AnGap-16
[**2131-1-6**] 05:15PM BLOOD Glucose-235* UreaN-4* Creat-0.9 Na-132*
K-6.2* Cl-103 HCO3-19* AnGap-16
[**2131-1-7**] 02:06AM BLOOD Glucose-210* UreaN-3* Creat-0.7 Na-135
K-3.2* Cl-99 HCO3-26 AnGap-13
[**2131-1-7**] 03:05PM BLOOD Glucose-146* UreaN-2* Creat-0.7 Na-135
K-3.2* Cl-99 HCO3-26 AnGap-13
[**2131-1-7**] 10:00PM BLOOD Glucose-102* UreaN-4* Creat-0.6 Na-135
K-3.6 Cl-100 HCO3-24 AnGap-15
[**2131-1-8**] 06:30AM BLOOD Glucose-287* UreaN-4* Creat-0.7 Na-132*
K-4.8 Cl-97 HCO3-21* AnGap-19
[**2131-1-4**] 03:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022
[**2131-1-4**] 03:50PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2131-1-4**] 03:50PM URINE RBC-[**10-20**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-[**2-2**]
Brief Hospital Course:
MICU course
Patient was admitted to the MICU with DKA. She was treated with
insulin gtt and her gap closed. She was transitioned to
subcutaneous insulin. She continued to have nausea and vomiting.
Her gap reopened and she was started again on the insulin gtt
with dextrose-containing IVF. She was later transistioned back
to insulin subQ but IVF with D5 were continued as patient with
poor PO intake. She was transfered to the floor on [**1-7**] but
transfered back to the MICU on [**1-9**] for poor glucose control and
widening gap. She was transiently placed back on an insulin
gtt. [**Last Name (un) **] recommened glargine 20units QHS and HISS to started
at a blood sugar of 80 and to be given prior to meals. Her
sliding scale was made more conservative at bedtime. The
consulting services continued to follow.
.
Floor course
1.) Poorly controlled DM1: The patient was administered IVF and
electrolytes were repleted as needed. After some
nausea/vomiting the morning of [**1-8**], she was able to increase PO
intake with a diabetic diet. Glargine was changed to QHS. She
was placed on a humalog sliding scale after PO intake was deemed
adequate. Overnight on [**1-8**] her glucose control was poor and she
returned to the MICU for insulin drip. The patient returned
the the floor on [**1-10**] with an aggressive humalog scale.
Glargine was titrated up from 20 to 25 units. However, the
patient developed morning fasting hypoglycemia on this regimen
therefore glargine was decreased back to 20units QHS with
sliding scale to avoid lows. We strongly encouraged the patient
to follow up with [**Last Name (un) **] as an outpatient in hopes of gaining
better control of her DM1 and avoiding subsequent
rehospitalizations however she declined. She was given the
option to follow up with [**Last Name (un) **] as an outpatient, but declined.
She was instructed to increase her glargine by 2 units every two
days if her AM fasting finger stick glucose was greater than 140
and to follow up closely with her PCP or [**Name9 (PRE) **].
2.) Nausea/vomiting: Consistent with DKA. PO intake was
adequate without additional nausea/vomiting after the morning of
[**1-8**], after her DKA resolved. She was scheduled to see GI as an
outpatient on discharge.
3.) Anxiety/Depression: This seems to have been a contributing
factor to the patient's recurrent admissions for DKA. Psych was
consulted and recommended an increased dose of SSRI, as well as
close outpatient follow up. Ativan was continued. They felt the
patient was competent to care for her self and to make her own
medical decisions. She was scheduled for an appointment with
her outpatient psychiatrist on discharge.
4) Sinus Tachycardia: The patient had sinus tachycardia of
100-140 throughout most of her stay. This resolved with symptom
management once her nausea and vomiting abated and was likely
reactive in the setting of pain, anxiety, nausea and
hypovolemia. Thyroid function was normal.
5) Chronic Low back pain: This was initially treated with
diluadid in the ICU. however on transfer to the floor,
narcotics were discontinued. Pain control was achieved with
tylenol/toradol/warm compresses and a lidoderm patch. She will
follow up with her PCP.
6) Thiamine deficiency: The patient was noted to have thiamine
deficiency. She was started on Thiamine repletion.
Medications on Admission:
Aspirin 81 mg PO DAILY
Lorazepam 1 mg PO TID
Metoclopramide 10 mg PO TID
Pantoprazole 40 mg PO Q24H
Sertraline 50 mg PO DAILY
traZODONE 50 mg PO HS
Zetia PO Daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Anxiety/Insomnia.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: 12 hours on, 12 hours off .
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
10. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime: If your blood glucose is over 140 in
the morning before you eat, please increase by 2 units every 2
days.
11. Insulin Aspart 100 unit/mL Solution Sig: One (1) per sliding
scale Subcutaneous qachs: Please take per sliding scale - see
attached.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Diabetic ketoacidosis, Diabetes Mellitus Type I
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of elevated blood
sugars. You were found to have Diabetic Ketoacidosis and
required an insulin drip, IV fluids and a stay in the ICU.
During your stay you had much nausea and vomiting. This was
determined to be secondary to the Diabetic Ketoacidosis, and
improved with better control of your symptoms.
You were seen by the [**Last Name (un) **] endocrinologists. They have changed
your insulin regimen so that you should take only 20 units of
lantus (glargine) at night. They would like you to follow up
with them as an outpatient. Please call [**Telephone/Fax (1) 2384**] to
schedule an appointment.
Medication Changes:
DECREASE Lantus dose to 20 units at night - if your fasting
morning glucose is greater than 140, increase the Lantus dose by
2 units every 2 days.
CONTINUE current Humalog sliding scale - see attached
STOP Metoclopramide (or Reglan)
INCREASE Sertraline to 100mg daily (two tablets daily)
START Thiamine 100mg daily
START Lidocaine patches - 12 hours on, 12 hours off for back
pain
START Ibuprofen over the counter as needed for pain
Followup Instructions:
Please keep the following appointments:
Appointment #1
MD: [**Name (NI) 58266**] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2131-1-16**] 9:00am
Location: [**University/College 7541**], [**Location (un) 686**] MA
Phone number: [**Telephone/Fax (1) 58261**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58267**]
Specialty: Pyschiatrist
Date/ Time: [**2131-1-23**] 1:00pm
Location: [**University/College 7541**] [**Location (un) 551**], [**Location (un) 686**] MA
Phone number: [**Telephone/Fax (1) 58268**]
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2131-3-16**] 1:50
Completed by:[**2131-1-13**]
|
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"250.43",
"338.29",
"250.13",
"276.52",
"240.9",
"272.4",
"276.1",
"300.4",
"V70.7",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10196, 10202
|
5341, 8689
|
288, 295
|
10313, 10313
|
3419, 5318
|
11598, 12365
|
2812, 2869
|
8903, 10173
|
10223, 10292
|
8715, 8880
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10458, 11121
|
2884, 3400
|
11141, 11575
|
228, 250
|
1458, 1653
|
323, 1440
|
10327, 10434
|
1675, 2361
|
2377, 2796
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,462
| 186,875
|
32800
|
Discharge summary
|
report
|
Admission Date: [**2162-2-27**] Discharge Date: [**2162-3-9**]
Date of Birth: [**2094-12-2**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Shortness of breath, abdominal distension
Major Surgical or Invasive Procedure:
right portal vein embolization
TPA infusion
venogram
Mechanical thrombectomy and Balloon dilatation
History of Present Illness:
Mr. [**Known lastname 22782**] is a 67 year old gentleman with a history of
colonic adenocarcinoma metastatic to the liver, who recently
underwent embolization of the R portal vein in preparation for
planned liver resection. He did well immediately post procedure
and was discharged home the next day, but since then has noticed
gradually increasing distension of his abdomen and shortness of
breath. He currently weighs 98 kg, and reportedly was 93 kg at
time of discharge. He reports a baseline soreness in his
abdomen
but no new or increasing abdominal pain. His appetite is
slightly decreased but he denies any pain, nausea, or vomiting
with PO intake. He does report more frequent diarrhea which is
unusual for him, but denies hematochezia. His shortness of
breath has increased progressively, to the point where he is now
very short of breath with climbing 2 flights of stairs, but
denies any chest pain or orthopnea. He denies any fevers but
does report feeling more frequently cold.
On Friday [**1-/2083**] Mr [**Known lastname 22782**] had a scheduled CT scan in [**Location (un) 9012**]
to
follow his liver after embolization. By report there no delayed
phase filling of the liver, and there was thrombosis of the R
portal vein and portal vein proper extending to the confluence
of
the splenic and superior mesenteric veins. The radiologist
immediately notified Dr. [**Last Name (STitle) **], who told Mr. [**Known lastname 22782**] to return to
[**Hospital1 18**] for evaluation and treatment.
Past Medical History:
PMH:
Colon CA s/p R colectomy and wedge liver biopsy, 5/35 lymph
nodes
positive, s/p chemotherapy with FOLFOX 6 and Avastin and
subsequently with FOLFIRI plus Erbitux.
Hypertension
Depression
Prostate CA
PSH:
R hemicolectomy/wedge liver bx [**5-5**]
Radical prostatectomy [**2152**] for prostate CA
Social History:
Works as a salesman, residing in [**State 3908**]. 3 children.
Quit smoking in [**2118**]. Occasionally drinks a glass of wine. No
history of IV of recreational drug use.
Family History:
Noncontributory.
Physical Exam:
VS: 98.6 79 125/86 16 98% on RA
Gen: Well appearing, in no acute distress
HEENT: PERRLA, EOMI, anicteric, oral mucosa pink/moist
Neck: Supple, no LAD or JVD
Chest: Mild crackles b/l lung bases
Heart: S1S2 RRR no M/G/R
Abdomen: Soft, distended, nontender, hypoactive muffled bowel
sounds, + fluid wave, well healed midline scar. No
hepatosplenomegaly.
Ext: No clubbing, cyanosis, or edema, pulses 2+ at all four
extremities
Neuro: Grossly intact
Pertinent Results:
[**2162-2-27**] WBC-5.5 RBC-3.70* Hgb-11.2* Hct-35.2* MCV-95 MCH-30.3
MCHC-31.8 RDW-15.0 Plt Ct-163#
[**2162-3-3**] WBC-9.5 RBC-3.02* Hgb-9.2* Hct-28.8* MCV-95 MCH-30.5
MCHC-32.0 RDW-15.2 Plt Ct-120*
[**2162-3-4**] WBC-5.7 RBC-2.79* Hgb-8.3* Hct-26.3* MCV-94 MCH-29.8
MCHC-31.6 RDW-15.1 Plt Ct-106*
[**2162-3-5**] WBC-5.2 RBC-2.66* Hgb-8.0* Hct-24.5* MCV-92 MCH-30.2
MCHC-32.8 RDW-16.1* Plt Ct-90*
[**2162-3-8**] WBC-2.9* RBC-2.73* Hgb-8.3* Hct-25.1* MCV-92 MCH-30.4
MCHC-33.0 RDW-16.1* Plt Ct-110*
[**2162-2-27**] PT-16.0* PTT-35.7* INR(PT)-1.4*
[**2162-3-5**] PT-21.2* PTT-42.4* INR(PT)-2.0*
[**2162-3-8**] PT-34.2* PTT-42.2* INR(PT)-3.6*
[**2162-3-9**] PT-32.1 PTT-45.4 INR(PT)-3.3
[**2162-3-1**] Fibrino-452*
[**2162-3-2**] Fibrino-392
[**2162-3-2**] Fibrino-440*
[**2162-2-27**] Glucose-91 UreaN-14 Creat-0.7 Na-139 K-3.8 Cl-103
HCO3-24 AnGap-16
[**2162-3-8**] Glucose-84 UreaN-10 Creat-0.6 Na-137 K-3.6 Cl-107
HCO3-24 AnGap-10
[**2162-2-27**] ALT-26 AST-36 AlkPhos-94 Amylase-110* TotBili-0.5
[**2162-3-2**] ALT-46* AST-120* AlkPhos-86 Amylase-78 TotBili-1.2
[**2162-3-7**] ALT-32 AST-44* AlkPhos-101 TotBili-0.5
[**2162-3-8**] ALT-32 AST-36 AlkPhos-99 TotBili-0.7
[**2162-2-27**] Lipase-95*
[**2162-3-2**] Lipase-37
[**2162-3-3**] Lipase-24
[**2162-2-27**] Albumin-3.5 Calcium-8.7 Phos-3.1 Mg-2.0
[**2162-3-4**] Albumin-2.7* Calcium-7.8* Phos-2.0* Mg-1.8
[**2162-3-7**] Albumin-2.5* Calcium-7.7* Phos-3.3 Mg-1.9
[**2-28**] CTA: 1. New interval filling defect encompassing and
expanding the right portal vein, main portal vein, extending
partially into the left portal vein consistent with acute
thrombus. A large filling defect also now occludes the superior
mesenteric vein nearly completely. A partially occlusive defect
is noted to extend for several cm into the splenic vein.
2. New moderate abdominal and pelvic ascites.
3. Diverticulosis without diverticulitis.
4. Multiple irregular low-attenuation areas within the liver,
consistent in appearance of liver metastasis, predominantly
within the right lobe. Several foci within the left lobe are too
small to characterize.
[**3-1**] Portal vein thrombolysis: Portal vein thrombosis with
possible cavernous transformation of portal vein.
No results after mechanical thrombectomy and PTA.
Inraportal injection of 8 milligram of TPA.
Continuous infusion overnight at the rate of 0.5 mg per hour and
200 mg of heparin per hour through the vascular sheath.
[**3-2**] Portal venogram: Followup of TPA portal venogram
demonstrated persistent occlusion of the portal vein. Removal of
vascular sheath after embolization of tract with Gelfoam.
[**3-4**] CXR: Small bilateral pleural effusions are new. New
elevation of the right lung base could be due in part to
subpulmonic effusion or more likely elevated hemidiaphragm
perhaps reflecting subdiaphragmatic mass effect. This is
accompanied by increasing moderate atelectasis at the right lung
base. Upper lungs are clear. There is no pulmonary edema. Heart
size is normal. A right supraclavicular central venous infusion
port tip projects over the mid SVC. No pneumothorax
[**3-4**] DOPPLER EXAMINATION OF THE LIVER: The portal vein appears
dilated and is filled with echogenic material. No flow is seen
within the main, right and left portal vein. Normal flow is
identified in the main hepatic artery as well as the right and
left hepatic artery. Normal flow is seen in the hepatic veins.
There is normal flow in the inferior vena cava. In the periphery
of the left lobe of the liver portal venous flow can be seen in
smaller branches. There is splenomegaly of 16.9 cm. There is a
small-to-moderate amount of ascites throughout the abdomen.
IMPRESSION:
1. Portal vein thrombosis involving the main, right and left
portal veins. Allowing for differences in technique this appears
not significantly changed from prior CT examination of [**2162-2-28**].
2. Normal flow in the hepatic artery and its branches as well as
the hepatic veins.
3. Splenomegaly and a moderate amount of ascites throughout the
abdomen.
[**3-7**] CXR: Right-sided Port-A-Cath is again seen. There is again
seen elevation of the right hemidiaphragm, which may be due to
subpulmonic effusion versus eventration however, this is
unchanged. Atelectases at both lung bases are again seen. There
are no signs for overt pulmonary edema.
Brief Hospital Course:
Mr. [**Known lastname 22782**] was admitted to Dr.[**Name (NI) 1369**] surgical service, and was
put on a heparin drip for the portal vein thrombosis. A chest
x-ray and CTA were performed; for details, please see results
section. The heparin drip was modified based on frequent (every
6 hour) PTT values. The patient was made NPO with IVF at
midnight on [**3-1**] for thrombolysis; his heparin drip was held the
morning of [**3-1**] for an afternoon procedure. Unsuccessful
attempts to open the portal vein with angiojet, balloon
dilatation, mechanical thrombolysis, and local TPA infusion were
made (overnight 3/3-4). The patient underwent unsuccessful
thrombolysis, and a TPA infusion was administered through the
sheath; the patient was admitted to the SICU following the
procedure, and the heparin drip was continued. The patient
returned on [**3-2**] for a venogram to reevaluate the thrombosis.
The patient's coagulation profile was constantly monitored for
consumptive coagulopathy, which was not noted, and remained
stable. The patient was tranferred back to [**Hospital Ward Name 121**] 10 on [**3-2**] for
continued monitoring. The patient had low urine output on
transfer, and was bolused; urine electrolytes were obtained
(FeNA 0%), and urine output was closely monitored. The patient
was put on lovenox and coumadin, and his diet was advanced.
Serial hematocrits were stopped as the patient's laboratory
values were stable. Mr. [**Known lastname 76380**] urine output remained low,
however, and on [**3-4**]-7, he required several more boluses to
maintain adequate output. An ultrasound was performed on [**3-4**] to
reevaluate, however remained stable; for details, please see
results section. The patient began experiencing some wheezing
and shortness of breath, for which he received nebulized
treatments, and serial chest x-rays were performed. The chest
x-rays showed some atelectasis, and the patient was encouraged
to use incentive spirometry and to get out of bed and ambulate.
On [**3-5**], the patient's urine output had stabilized and improved,
and the patient's Foley catheter was removed. The patient's
coumadin was dosed appropriately with daily coagulation profiles
that were obtained. Over the weekend on [**4-15**], the patient
continued to experience progressive edema. An ECG was obtained
on [**3-7**] to evaluate cardiac function, the ECG was within normal
limits.
He received Lasix 20 mg IV x 1 on [**3-7**] with slight improvement of
lower extremity edema. He is advised to continue with leg
elevation and wearing TEDS hose as tolerated, no further
diuresis is recommended at this time.
On [**3-8**] his INR was found to be 3.6. Coumadin was held on [**3-8**]
and [**3-9**]. INR on [**3-9**] is 3.3. Since this is trending down, it
was deemed safe for him to travel back to [**Location (un) 9012**].
INR should be drawn on [**3-10**] with results to his PCP same day.
Goal INR is [**1-31**]. If INR result is less than 3.0 he is advised to
resume Coumadin at a 3 mg dose.
Also of note Mr [**Known lastname 22782**] has been found to be HIT positive and has
been advised of this heparin allergy and that he is to never
receive Heparin products.
Medications on Admission:
Lexapro 10 mg daily
Ambien 5-10 mg daily
Discharge Medications:
1. Outpatient [**Name (NI) **] Work
PT/INR
Dx: Initiation of Coumadin Therapy for Portal vein Thrombus
Send results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital 76381**] Medical Clinic
Goal INR [**1-31**]
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*10 Suppository(s)* Refills:*4*
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
***HIT positive***
metastatic colon cancer
portal vein thrombosis
ascites
s/p embolization R portal vein
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You see blood or dark/black material if you vomit or have a
bowel movement or nosebleed that won't stop.
* Your skin, or the whites of your eyes become yellow.
* 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) 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.
* Have PT/INR drawn on Wednesday [**3-10**] at home and have results
sent to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 76382**] Medical Center.
When INR is less than 3 you may resume Coumadin at 3 mg daily.
This will continue to be monitored with a goal INR of [**1-31**]
* You have a Heparin Allergy. Under no circumstances should you
receive heparin.
* Elevate legs when sitting or laying down
Followup Instructions:
Please follow up with your oncologist in [**State 3908**] in [**12-30**] weeks;
your oncologist and Dr. [**Last Name (STitle) **] should arrange an appropriate
timeline for your start of chemotherapy.
Please have your INR followed by your PCP in [**Name9 (PRE) 3908**]; you must
have blood work drawn frequently for coordination of your
anticoagulant dosage. Have blood drawn [**3-10**] and restart Coumadin
when INR is less than 3. Goal INR is [**1-31**]
You should have a CTA performed in [**5-4**] weeks to evaluate your
portal vein thrombosis. This can be done in [**State 3908**] and results
sent to Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 673**]/ fax [**Telephone/Fax (1) 697**])
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2162-3-9**]
|
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icd9cm
|
[
[
[]
]
] |
[
"39.79",
"00.40",
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"54.91",
"88.64",
"99.10"
] |
icd9pcs
|
[
[
[]
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] |
11402, 11408
|
7342, 10538
|
315, 417
|
11557, 11566
|
3003, 7319
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1988, 2290
|
2306, 2482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
291
| 126,219
|
17443
|
Discharge summary
|
report
|
Admission Date: [**2107-9-13**] Discharge Date: [**2107-9-16**]
Date of Birth: [**2034-2-7**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Penicillins / Shellfish / Latex / Bee
Pollen
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
nausea and vomitting and altered mental status.
Major Surgical or Invasive Procedure:
Whole brain radiation.
History of Present Illness:
73F w/ metastatic lung cancer to brain, on radiation therapy,
here with severe nausea and vomiting since this morning; sent
from Rad [**Hospital **] clinic with severe hypertension and nausea/vomiting
concerning for increased intracranial pressure. She was recently
admitted to [**Hospital1 18**] from [**Date range (3) 48728**] with hypoxia and back
pain; nausea and vomiting. Patient's symptoms completely
resolved with dexamethasone, complicated by steroid-induced
psychosis. Also initiated whole-brain radiation while in-house
and continued to see rad onc following discharge. She had been
on a dexamethasone taper following discharge. Currently on 2g
[**Hospital1 **].
.
Pt somnolent but arousable. States that she has not had any
other symptoms, including headaches, changes in vision,
dizziness, weakness, or numbness. Reports exhaustion from not
being able to sleep for 1.5d due to vomiting and nausea. States
that she was vomiting "all day yesterday" and "every half hour"
this morning. Pt reports fatigue and sleepiness. Pt A&O to
"hospital, somewhere near [**Location (un) 620**], year [**14**]--, 20-- don't know".
.
In the ED, triggered for hypertension.
Initial vitals were: 16:30 0 98.9 65 170/111 16 97% 2L Nasal
Cannula.
BP --> 16:45 225/119 --> 17:00 179/100
Patient was somnolent but arousable. Neuro exam somewhat limited
by Pt's lack of participation, pupils pinpoint CN 2-12 intact.
Lungs: bibasilar crackles.
EKG: normal sinus rhythm, HR 70, left shifted axis, normal
intervals. 1mm PR depression in V2, V2. Peaked T waves V2, V3. T
wave inversion V1. Consistent with prior.
Labs: show elevated K to 5.6, hemolyzed. Repeat lab -> K 4.0.
CT head w/out contrast: vasogenic edema unchanged, but right
parietal hyperdense lesion is more conspicuously hyperdense and
slightly increased in size than on the prior. This degree of
increased hyperdensity would not be expected in the interval and
raises concern for intralesional hemorrhage.
.
Neurosurgery consulted: feel that Pt's N/V related to WBXRT and
decadron taper. Recommended no acute neuro intervention.
Increase dexa to at least 6mgQ6h standing.
She was started on dexamethasone 6mg IV q6hrs.
On re-exam, Pt's BP improved to 140s/80s w/ only dexamethasone.
Pt is sleeping peacefully.
Past Medical History:
1. Coronary artery disease -S/p inferior/posterior STEMI with
RV involvement [**3-20**] with BMS to distal RCA. Repeat BMS x 2 to
same RCA lesion in [**4-/2106**]
2. Stage IV lung cancer metastatic to brain
3. Hyperlipidemia
4. Rheumatoid arthritis
5. Hypertension
6. Lumbar DJD
7. Basal cell carcinoma of the nose
Social History:
She is widowed and lives alone in senior housing.
She has four children, two daughters and two sons. One son lives
out of state but the others are local. Originally from [**Location (un) 48726**]. She smoked one pack a day of cigarettes for the past 60
years and continues to smoke. Alcohol rare.
Her daughter, [**Name (NI) 1439**] may be reached at [**Telephone/Fax (1) 48724**]. Her
daughter
[**Name (NI) **] may be reached at [**Telephone/Fax (1) 48727**].
Family History:
Mother died of [**Name (NI) 2481**] disease. Father died
at age 54 from an MVA. She has six brothers, one deceased from
cancer ?prostate, another had Alzheimer's disease. One sister
alive and well.
Physical Exam:
Admission Physical Exam:
Vitals: afebrile 149/84 92 14 95% RA
General: Alert, orientedx1-2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. PERRLA
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally. Mild bibasal crackles.
CV: Regular rate and rhythm, normal S1 + S2, SEM II/VI
nonradiating
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. 1+ pitting
edema on lower extremity to shins bilateral.
.
Discharge Physical Exam:
Vitals: 95.4, 142/84, 53, 20, 96%RA
I/O: 780/470 + large BM this AM
Physical Exam:
General: A&O X 2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. PERRL.
Neck: supple, no JVD, no LAD
Lungs: Clear to auscultation bilaterally.
CV: RRR, normal S1 + S2, SEM II/VI nonradiating
Abdomen: soft, NT/ND, bowel sounds (+), no rebound/guarding, no
HSM
Ext: warm, well perfused, 2+ pulses, no clubbing. no edema.
Pertinent Results:
Labs at Discharge:
[**2107-9-15**] 06:20AM BLOOD WBC-13.6* RBC-4.13* Hgb-12.4 Hct-37.1
MCV-90 MCH-30.0 MCHC-33.4 RDW-16.6* Plt Ct-316
[**2107-9-15**] 06:20AM BLOOD PT-12.1 PTT-22.1 INR(PT)-1.0
[**2107-9-15**] 06:20AM BLOOD Glucose-117* UreaN-32* Creat-0.7 Na-135
K-4.9 Cl-99 HCO3-25 AnGap-16
[**2107-9-15**] 06:20AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.3
.
Studies & Imaging:
[**2107-9-13**] ECG: Baseline artifact. Sinus rhythm with atrial
premature beats. Left axis deviation. Left anterior fascicular
block. Inferior myocardial infarction, age indeterminate.
Compared to the previous tracing of [**2107-9-4**] the atrial premature
beats are new.
Rate PR QRS QT/QTc P QRS T
70 154 76 388/405 66 -55 46
.
[**2107-9-13**] CT HEAD W/O CON: Increased size of the hyperattenuated
focus with a more amorphous appearance raises suspicion for a
possible intralesional hemorrhage of the right parietal
metastasis. Otherwise, unchanged degree of vasogenic edema in
the right parietal lobe. The other masses demonstrated on the
previous MR are not well identified on this nonenhanced CT
study.
.
[**2107-9-15**] ECG: Sinus rhythm with premature atrial and ventricular
complexes. Marked left axis deviation. Inferior myocardial
infarction of indeterminate age. Delayed R wave progression.
Compared to the previous tracing of [**2107-9-13**] the findings are
similar.
Rate PR QRS QT/QTc P QRS T
72 150 76 376/397 62 -53 29
Brief Hospital Course:
This is the brief hospital course for a 73 year-old female with
non-small cell lung carcinoma metastatic to the brain who
presented here for evaluation of nausea, vomitting, and altered
mental status. The following medical issues were addressed
during this admission:
.
# BRAIN METASTASES: She presented with nausea, vomitting, and
hypertension. CT scan was suspicious for intralesional brain
hemorrhage in the right parietal metastasis and notable for an
unchanged degree of vasogenic edema in that same parietal lobe.
Her nausea and vomitting were thought to be due to her
intracranial processes and changes caused by weaning from
decadron and the most recent episode of whole brain radiation
which the patient underwent. She was started on 6 mg
Dexamethasone every 6 hours per neurosurgery recommendations,
and after discussion with the cardiology service primary
medicine team, and her family, her Plavix was discontinued as
the risks of intracranial bleeding was thought to outweigh the
benefits of blood thinning to prevent myocardial ischemia and
stent re-stenosis.
.
# HYPERTENSION: She presented with systolic blood pressures in
the 220s. This was thought to be due to her intracranial process
following weaning from decadron and also cerebral changes
post-whole brain radiation. She was started on 6 mg
Dexamethasone every 6 hours per neurosurgery recommendations,
and her systolic blood pressures normalized to 110s to 140s.
.
# ALTERED MENTAL STATUS: Psychiatry was consulted given the
patient's history of steroid induced psychosis, and they
recommended starting Seroquel nightly at 12.5mg and once the
patient's QTC was checked for prolongation, she was increased to
a dose of 25mg nightly prior to bedtime.
.
# RHEUMATOID ARTHRITIS: This issue was stable and the patient
remains on her Methotrexate and steroids for disease control.
.
# CORONARY ARTERY DISEASE: This issue was stable and the patient
continues on ASA 81 mg daily, but has been discontinued from her
clopidogrel dose for reasons listed above.
.
# HYPERLIPIDEMIA: This issue was stable and the patient
continues on simvastatin 40 mg daily.
.
The patient was discharged home to the facility in [**Location (un) 745**] where
she was prior to admission. She was upset that she was not going
home, but cooperated. She will have 2 more radiation treatments
for her brain disease, and remains DNR/DNI.
Medications on Admission:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
q5min as needed for chest pain.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
12. haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for agitation.
13. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours): initiating taper on [**9-7**] of 3mg q12 for 5 more days, 2g
[**Hospital1 **] x7d, 1g [**Hospital1 **] x7d, 1g qd x7d and then stop
.
Disp:*90 Tablet(s)* Refills:*0*
14. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
15. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig:
Six (6) Tablets, Dose Pack PO once a week: Take weekly on
Sunday.
16. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
17. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
spoonful PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
12. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
13. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig:
Six (6) Tablets PO Q sundays.
14. haloperidol 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for acute agitation: Please only use if acute
agitated.
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever or pain.
16. nitroglycerin 0.3 mg Tablet, Sublingual Sig: 1-2 tablets
Sublingual every 5-10 minutes as needed for chest pain for 3
doses.
17. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
18. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Expired
Facility:
[**Hospital 745**] health care center
Discharge Diagnosis:
Non-small cell lung carcinoma
Metastases to brain
Coronary Artery Disease
Hypertension
Steroid Psychosis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory- requires assistance or aid
(walker/cane).
Discharge Instructions:
Dear [**Known firstname **],
It was a pleasure to take care of you during your hospital stay.
You were admitted to the hospital because your family and
neighbors noticed a change in your mental status. Tests were run
to look inside your brain at the sites where the cancer is. The
tests did NOT show any current areas of bleeding, but this will
be a constant concern for you from here on out. For this reason,
your doctors have decided, along with your children, that it is
in your best interest to no longer take the medication called
Plavix. This medicine is a blood thinner and can predispose you
to brain bleeding. You were originally on the medication because
of your heart disease. Stopping the medication will place you at
a high risk of getting a blockage in one of your heart's
artery's again. We discussed this with your children and your
other doctors here at the hospital, and everyone agreed that the
risks of taking this medication heavily outweighed the benefit.
Please STOP the following medications:
-Plavix (Clopidegrel)
Please INCREASE the dose of the following medications:
-Quetiapine (Seroquel) now 25mg every night at bedtime
Followup Instructions:
You are already scheduled for the remaining two radiation
treatments. Please have the staff at [**Location (un) 745**] arrange
transportation for you to these appointments and back. The
appointments are:
.
Tuesday, [**2107-9-21**] @ 2:45PM
Wednesday, [**2107-9-22**] @ 2:45PM
.
Both of the appointments are at [**Hospital1 1170**] in [**Location (un) 86**] on the [**Hospital Ward Name **] in the department of
radiation oncology.
.
You may be contact[**Name (NI) **] by your oncologist for additional
follow-up. Meanwhile, the physicians at the [**Location (un) 745**] facility will
be caring for your immediate, acute medical needs.
Completed by:[**2107-10-21**]
|
[
"787.01",
"V49.86",
"V45.82",
"414.01",
"162.9",
"253.6",
"272.4",
"714.0",
"401.9",
"348.5",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
12101, 12159
|
6219, 7667
|
379, 404
|
12308, 12308
|
4785, 4785
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|
3530, 3730
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12486, 13638
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292, 341
|
4804, 6196
|
432, 2694
|
12323, 12462
|
2716, 3034
|
3050, 3514
|
4344, 4412
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,725
| 196,069
|
49724
|
Discharge summary
|
report
|
Admission Date: [**2145-6-19**] Discharge Date: [**2145-6-24**]
Date of Birth: [**2071-7-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
INTERMITTENT HEADACHES
Major Surgical or Invasive Procedure:
CRANIOTOMY FOR SUB DURAL COLLECTION
History of Present Illness:
73 YO [**Male First Name (un) 4746**] FELL OUT OF BED 1 MONTH AGO - He presented to the
emergency room
the day before complaining of right-sided weakness,
difficulty finding words, headaches, and micrographia. A CT
showed a subacute subdural hematoma, and it was decided to
take him to the operating room.
Past Medical History:
PROSTATITIS
HEARING LOSS
HYPERTENSION
HIGH CHOLESTEROL
MILD ASTHMA
Social History:
LIVES WITH WIFE AT HOME
DENIES TOBACCO
PEDIATRIC RADIOLOGIST AT [**Hospital3 **]
Family History:
SUDDEN CARDIAC DEATH
Physical Exam:
VS AFEBRILE 104/70, 77, 18
GEN: AAOX3 NAD ON ARRIVAL
HEENT: PERRL EOMI
CHEST: CTA
CVS: RRR NO MURMUR
ABD: SOFT NT/ND
EXT: PULSES 2+, NO C/C/E
NEURO: AWAKE ALERT ORIENTED X 3, +DIFFICULTY WITH WORD FINDING,
CN II- XII INTACT, STRENGTH FULL B/L UE AND LE. PR DOWNGOING
BILATERALLY.
HEAD CT ON ARRIVAL LARGE LEFT FRONTAL SDH WITH MIDLINE SHIFT
Pertinent Results:
[**2145-6-19**] 11:00AM GLUCOSE-116* UREA N-19 CREAT-1.0 SODIUM-143
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-26 ANION GAP-15
[**2145-6-19**] 11:00AM WBC-6.4 RBC-3.99* HGB-12.7* HCT-37.0* MCV-93
MCH-31.8 MCHC-34.3 RDW-13.0
[**2145-6-19**] 11:00AM PLT COUNT-204
[**2145-6-19**] 11:00AM PT-11.9 PTT-24.2 INR(PT)-0.9
Brief Hospital Course:
PATIENT WAS ADMITTED AND BROUGHT TO THE OPERATING ROOM FOR
EVACUATION OF SUBDURAL COLLECTION.
PREOPERATIVE DIAGNOSIS: Subacute left subdural hematoma.
POSTOPERATIVE DIAGNOSIS: Subacute left subdural hematoma.
FIRST ASSISTANT: Dr. [**Last Name (STitle) 103967**]
PROCEDURES PERFORMED: Left craniotomy for evacuation of
subdural hematoma and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain.
INDICATIONS: The patient is a 73-year-old male status post
fall about 3 weeks ago. He presented to the emergency room
the day before complaining of right-sided weakness,
difficulty finding words, headaches, and micrographia. A CT
showed a subacute subdural hematoma, and it was decided to
take him to the operating room.
DESCRIPTION OF PROCEDURE: The patient was identified and
taken to the OR. There, he was intubated and the appropriate
antibiotics were given IV. Following that, the left head area
was shaved and then prepped and draped in the usual surgical
fashion. Then, a slightly curved incision was performed on
the left frontal area using a #10 blade. Prior to that,
lidocaine with epinephrine was used for infiltrating the skin
incision. Then, using the periosteal, we removed the skin
away and [**Doctor Last Name 10747**] clips were used for hemostasis as well as
bipolar.
Then, we used the TPS drill to perform a bur hole close to
the midline. After that, a small craniotomy was performed
using the craniotome. The dura was opened in a cruciate
fashion and what looked like subacute-to-chronic subdural
hematoma started to come out. Careful and copious lactated
Ringer's irrigation was used until clear CSF was coming from
the area of the subdural hematoma and the brain was noted
there. Following that, we placed a flat [**Doctor Last Name 406**] drain within
the cavity of the subdural hematoma and the bone flap was
placed in position. The drain was tunneled through a separate
skin incision. The wound was irrigated with bacitracin
solution, and it was approximated using 0 Vicryl for the
galea and staples for the skin. The patient tolerated the
procedure well. A sterile dressing was applied on the wound.
A separate suture was used to keep the drain in place.
I was present and performed the major part of the operation.
ESTIMATED BLOOD LOSS: Minimal.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Name8 (MD) 103968**]
AFTER MEETING RR CRITERIA PATIENT WAS TRANSFERRED TO [**Hospital Ward Name **] 5 FOR
FURTHER RECOVERY - HE ADVANCED IN DIET AND ACTIVITY - WAS SEEN
AND [**Name (NI) 103969**] BY PT AND DEEMED SAFE TO DISCHARGE HOME WITH
FAMILY - WIFE IS AWARE THAT HE WILL REQUIRE 24 HOUR A DAY
OBSERVATION AS HE IS IMPULSIVE AND GETS OOB WITHOUT ASSITANCE.
HE HAS REMAINED AFEBRILE AND HIS INCISION IS CLEAN AND DRY - HE
DOES HAVE SOME SLIGHT VISUAL DIFFICULTIES AND WILL HAVE
OUTPATIENT BRAIN CT AND MRI WITH DIFFUSION PER DR.
[**Last Name (STitle) **]. THESE APPOINTMENTS HAVE BEEN SCHEDULED THROUGH
THE OFFICE.
Medications on Admission:
LIPITOR
LISINOPRIL
ALBUTEROL
ASTHMACORT
ASA
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*1*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
S/P CRANIOTOMY FOR SUB DURAL HEMATOMA
Discharge Condition:
STABLE - SLIGHT VISUAL IMPAIRMENT AND SOME IMPULSIVITY
Discharge Instructions:
KEEP INCISION CLEAN AND DRY. TAKE MEDICATION AS ORDERED. DO NOT
SHOWER UNTIL YOUR STAPLES HAVE BEEN REMOVED. NO DRIVING, WORKING
OR EXERCISING UNTIL YOU HAVE PERMISSION FROM THE SURGEON. CALL
THE OFFICE FOR ANY CONCERNS, REDNESS OR DRAINAGE FROM/OF THE
INCISION, FEVER, DIZZINESS, NAUSEA, VOMITTING, UNCONTROLLED
HEADACHES EXCESSIVE SLEEPIINESS.
Followup Instructions:
DR.[**Last Name (STitle) **] [**Telephone/Fax (1) **] TO BE SEEN IN THE OFFICE IN 2
WEEKS
YOU WILL NEED AN OUTPATIENT CAT SCAN AND MRI OF THE BRAIN - THIS
WILL BE ARRANGED BY THE OFFICE. RETURN TO [**Hospital Ward Name **] 5 FOR STAPLE
REMOVAL ON [**2145-7-2**] BETWEEN THE HOURS OF 9AM AND 12 NOON.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2145-6-24**]
|
[
"272.0",
"E884.4",
"401.9",
"852.20",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
5257, 5315
|
1661, 4674
|
342, 380
|
5397, 5453
|
1320, 1638
|
5847, 6274
|
921, 943
|
4768, 5234
|
5336, 5376
|
4700, 4745
|
5477, 5824
|
958, 1301
|
280, 304
|
408, 717
|
739, 807
|
823, 905
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,031
| 198,189
|
23296
|
Discharge summary
|
report
|
Admission Date: [**2129-12-13**] Discharge Date: [**2130-1-13**]
Date of Birth: [**2060-3-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Transfer from outside hospital for further management of biliary
leak status post cholecystectomy.
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
Endotracheal intubation
Tracheostomy secondary to difficulty weaning
Central venous line placement
Paracentesis
History of Present Illness:
69 year-old female with h/o obesity, afib/flutter, asthma, [**Hospital **]
transferred from OSH [**12-13**] for further management of biliary
leak s/p CCY [**11-19**]. Ms. [**Known lastname 59817**] was initially admitted to
[**Hospital3 417**] Hospital with confusion and slurred speech.
CT/MRI/MRA of head revealed no acute disease. She also had afib
with RVR and was treated with digoxin, then diltiazem and
lopressor.
During her OSH, she developed lower abdominal pain. A CT
revealed free fluid around the liver, spleen, and pelvis. She
was afebrile, but with a WMC of 20. Zosyn and Flagyl were
initiated. She was transferred to [**Hospital3 4107**] on [**12-10**],
where an abdominal ultrasound confirmed ascites. A diagnostic
paracentesis was remarkable for bilious fluid. MRCP normal. A
HIDA suggested biliary leak. She was transferred on [**12-13**] to
[**Hospital1 18**] surgery with plan for ERCP.
Past Medical History:
Obesity
Atrial fibrillation/flutter
Hypertension
Depression/anxiety
Asthma
S/P cholecystectomy on [**2129-11-19**]
S/P colonoscopy with polypectomy [**9-/2129**]
S/P appendectomy
Social History:
Patient denies EtOH consumption.
Family History:
Non-contributory
Physical Exam:
Per [**Hospital Unit Name 153**] admission note on [**2129-12-14**]:
T97 BP 106-126/60-70 P 75-88 R 22-26 O2 95@3LNC
Gen - pleasant, NAD, A+Ox3
HEENT - PERRL, MM slightly dry
Cor - irreg, no murm
Chest - scattered end expiratory wheezes
GI - obese, soft, NT to deep palp, no rebound or guarding, L
biliary drain in place with minimal fluid, R incision site from
Lap CCY intact without drainage.
Ext- no c/c/e, DP +2 b/l
Pertinent Results:
ADMISSION DATA:
Labs [**12-14**]:
WBC 22.9 Hct 31.6 Plt 826 PT 14.2 PTT 25.1 INR 1.3
Na 132 K 4.1 Cl 92 HCO3 29 BUN 89 Cr 2.8 Glu 208
ALT 13 AST 19 AP 223 TB 2.5 [**Doctor First Name **] 30 Lip 30
Biliary fluid at OSH 4300 wbc, 13 rbc, 50N 11L 39M
EKG [**12-14**]: Afib at 86, nl axis, Q in 3, ST depression in I, II,
aVL. TWI in precordial leads.
CXR [**12-14**]: Small lung volumes, high diaphragm.
*****************
PERTINENT RESULTS IN HOSPITAL:
[**2129-12-15**] Peritoneal fluid:
WBC 47 RBC 3 Polys 97
TotProt 2.0 LD(LDH) 1414
[**2129-12-21**] Peritoneal fluid:
WBC [**Numeric Identifier 59818**] RBC [**Numeric Identifier **] Polys 97
TotPro 1.2 Glucose 26 LD(LDH) [**Numeric Identifier 59819**] Amylase 28 TotBili 7.7
Albumin <1.0
MICRO:
[**2130-1-11**] STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY-PENDING;
[**2130-1-10**] BLOOD CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING;
[**2130-1-10**] BLOOD CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING;
[**2130-1-10**] MRSA SCREEN
MRSA SCREEN-NEGATIVE
[**2130-1-10**] MRSA SCREEN
MRSA SCREEN-PENDING;
[**2130-1-10**] STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE;
[**2130-1-9**] CATHETER TIP-IV NEGATIVE
[**2130-1-6**] URINE CULTURE-NEGATIVE
[**2130-1-6**] BLOOD CULTURE NEGATIVE
[**2130-1-6**] BLOOD CULTURE NEGATIVE
[**2130-1-4**] SPUTUM - {GRAM NEGATIVE ROD(S), YEAST};
[**2130-1-3**] SPUTUM - {ENTEROBACTER CLOACAE, YEAST};
[**2130-1-1**] CATHETER TIP- {ENTEROBACTER CLOACAE};
[**2130-1-1**] URINE CULTURE- {KLEBSIELLA PNEUMONIAE,
ENTEROBACTER CLOACAE};
[**2129-12-31**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-FINAL {ENTEROBACTER CLOACAE};
BLOOD/AFB CULTURE-FINAL;
[**2129-12-31**] BLOOD CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
{ENTEROBACTER CLOACAE};
[**2129-12-31**] BLOOD CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
{ENTEROBACTER CLOACAE};
[**2129-12-23**] BRONCHOALVEOLAR LAVAGE
GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST};
[**2129-12-21**] PERITONEAL FLUID
{YEAST, PRESUMPTIVELY NOT C. ALBICANS, ENTEROCOCCUS
GALLINARUM,
YEAST, PRESUMPTIVELY NOT C. ALBICANS}; ANAEROBIC
CULTURE-FINAL;
[**2129-12-21**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE;
[**2129-12-19**] SPUTUM
RESPIRATORY CULTURE-FINAL {YEAST};
FUNGAL CULTURE-FINAL {YEAST};
[**2129-12-16**] URINE CULTURE - {YEAST};
[**2129-12-16**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY-POSITIVE
[**12-14**] CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung
bases demonstrate minor dependent atelectatic changes. There is
a large amount of free fluid within the abdomen with evidence of
cholecystectomy, consistent with the clinical history of biliary
leak. The liver, spleen, splenules, adrenals, pancreas, and
opacified loops of large and small bowel are unremarkable. Note
is made of a lobulated contour of the left kidney and a slight
rotation of the right kidney which are otherwise unremarkable.
Atherosclerotic calcifications are noted in the abdominal aorta.
Nonspecific stranding is noted in the omentum anteriorly. There
are no pathologically enlarged mesenteric or retroperitoneal
lymph nodes.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is extensive sigmoid
diverticulosis without evidence of diverticulitis. There is a
Foley present within the collapsed bladder. The rectum is
unremarkable. There is no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic
lesions. Degenerative changes are noted in the thoracic and
lumbar spines.
IMPRESSION:
1) Large amount of free fluid in the abdomen and pelvis
consistent with clinical history of bile leak.
2) Status post cholecystectomy.
3) Nonspecific stranding in the anterior omentum, in the absence
of a known primary, this may represent reactive changes.
-----------------
[**12-16**] ERCP FINDINGS: Eight fluoroscopic spot film images were
obtained from endoscopy performed by gastroenterology staff.
Cannulation of the common bile duct was performed with
opacification of biliary tree. Extravasation of extra biliary
contrast was identified, likely into the intraperitoneal cavity
within the region of the cystic duct. There was no evidence of
intra or extra hepatic biliary dilatation or filling defects.
Final films showed placement of a plastic stent within the
common bile duct.
IMPRESSION:
Extravasation of contrast from the biliary tree within the
region of cystic duct. Placement of plastic biliary stent.
-----------------
[**12-18**] CHEST CT: An ET tube and NG tube are noted. There are
multifocal bilateral patchy air space consolidations within the
lungs, consistent with bilateral pneumonia. No cavitation is
seen to suggest lung abscess. There is a small right pleural
effusion. There is no axillary, hilar, or mediastinal pathologic
lymphadenopathy. There is no pericardial effusion.
Calcifications are seen within the aortic arch and descending
aorta.
ABDOMEN CT W/ORAL CONTRAST: Again noted is a moderate amount of
ascites within the upper abdomen, surrounding the liver and the
spleen. This has not changed in volume since the prior exam. The
liver, spleen, pancreas, adrenal glands, and kidneys are
unremarkable allowing for the unenhanced technique. A metallic
stent is seen within the biliary tree. There is no sign of
intrahepatic ductal dilatation. The opacified loops of bowel are
normal in caliber. A drainage catheter enters the left lower
quadrant.
PELVIS CT W/ORAL CONTRAST: Contrast has reached the rectum
without obstruction. A rectal tube and Foley catheter are in
place. There is a small amount of residual fluid within the
pelvis, but overall, the volume of fluid has decreased markedly
since the placement of the drainage catheter. Diffuse, severe
anasarca is noted.
BONE WINDOWS: Degenerative changes are seen throughout the
spine. There are no suspicious lytic or sclerotic bony lesions.
CT RECONSTRUCTIONS: These images redemonstrate the above
findings.
IMPRESSION
1. Bilateral pneumonia.
2. Overall decrease in volume of fluid within the pelvis.
3. No change in the volume of fluid surrounding the liver and
spleen.
[**12-21**] CT GUIDED DRAINAGE OF BILOMA
TECHNIQUE: Informed consent was obtained from the patient's
daughter by a telephone call. A preprocedure time out was
obtained to confirm the identity of the patient and the
procedure which she has to undergo. With the patient in a supine
position, limited axial CT images were obtained to delineate the
collection to be drained. The patient's skin was prepped and
draped in the usual sterile fashion and 1% Lidocaine was used
for local anesthesia. Under direct CT guidance, a 12 French
pigtail catheter was inserted into the perihepatic large fluid
collection and 2 liter of pussy bile-like fluid were aspirated.
A sample was sent for microbiology and for chem cell analysis.
The catheter was left to drain and locked in position. On post
procedure CT images there is full collapse of the fluid cavity.
The small 8 French pigtail in the left pelvis is not located in
the fluid collection and the information was discussed in a
telephone call with the patient's caring physician.
The patient tolerated the procedure well and there were no
immediate complications.
[**12-27**] CT ABDOMEN WITHOUT IV CONTRAST:
Diffuse air space opacification is again seen at the left lung
base. There are small bilateral pleural effusions without
cardiomegaly.
The previously seen large subcapsular fluid collection is no
longer present. A percutaneous drainage catheter remains in
place, though its tip is against the lateral abdominal wall. A
stent is seen within the common bile duct. There is also a small
amount of biliary air within the liver secondary to stent
placement. The liver is otherwise unremarkable. The patient is
post cholecystectomy. The pancreas, spleen, adrenals, and
kidneys are unremarkable allowing for the nonenhanced technique.
An NG tube is seen within the stomach. No free fluid or free air
is seen within the abdomen. There are several small scattered
mesenteric lymph nodes, which does not meet CT criteria for
pathologic enlargement.
CT OF THE PELVIS WITHOUT IV CONTRAST:
There is significant streak artifact, which limits evaluation of
the pelvic structures. A rectal tube and Foley catheter are in
place. The rectum and sigmoid are collapsed. No definite free
fluid or lymphadenopathy is seen within the pelvis. There are no
focal pelvic fluid collections.
The osseous structures demonstrate marked degenerative changes
throughout the lower thoracic and lumbar spine with osteophyte
formation and facet arthropathy. The soft tissues demonstrate
inflammatory changes in the right lower chest wall and upper
abdominal wall in the region of the percutaneous drainage
catheter insertion site. This is unchanged from the prior study.
IMPRESSION:
1. Continued air space opacification at the left lower lobe.
2. No new focal fluid collection within the abdomen. The
previously seen large biloma is no longer present. There is a
small amount ascites around the spleen.
[**12-31**] CT CHEST W/O&W IV CONTRAST: Image quality is degraded by
patient body habitus. Allowing for this, there is no
intraluminal filling defect consistent with pulmonary embolus to
the level of the first order subsegmental branches bilaterally.
Heart and great vessels appear grossly normal. No pathologically
enlarged mediastinal, hilar, or axillary lymph nodes are
identified. There are multifocal parenchymal opacities within
the upper lobes, right middle lobe, and lingula suspicious for
pneumonia. There are small bilateral pleural effusions, as well
as persistent atelectasis or consolidation at the right lower
lobe.
CT RECONSTRUCTIONS: Multiplanar reformatted images were reviewed
and confirm the above findings.
IMPRESSION:
1) No evidence of pulmonary embolism.
2) Multifocal parenchymal opacities concerning for pneumonia.
3) Small bilateral pleural effusions.
[**1-3**] ECHO
1.The left atrium is moderately dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension.
5. No obvious cardiac mass or vegetations seen.
[**2130-1-9**]
CT CHEST: An endotracheal tube is seen in place and intact, with
the tip approximately 2 cm above the tracheal bifurcation. A
nasogastric tube is seen in place and intact, extending through
the esophagus, and coiled in the fundus of the stomach.
Within bilateral lungs, there is patchy air space disease, with
no distinct evidence of nodules or masses. Bilateral pleural
effusions, left greater than right, are stable when compared
with the prior exam dated [**2129-12-31**]. There is no mediastinal,
paratracheal, or hilar lymphadenopathy. The paracardium is
normal in appearance, with no evidence of pericardial effusion.
The airways are patent to the level of the segmental bronchi
laterally.
CT ABDOMEN W/ORAL & IV CONTRAST: This study is limited secondary
to patient body habitus, which is producing significant artifact
on the imaging.
The liver parenchyma is normal in appearance, with no focal or
textural abnormalities. Clips are noted within the gallbladder
fossa, consistent with the patient's history of cholecystectomy.
There is a small focus of pneumobilia extending within the left
intrahepatic bile duct. The pancreas is normal in appearance.
There is a small perisplenic fluid collection, which is
decreased in size when compared with the prior exam. Bilateral
adrenals are normal. Bilateral kidneys enhance symmetrically,
with no evidence of nodules or masses. Intraabdominal loops of
large and small bowel are normal. There is no mesenteric or
peri-aortic lymphadenopathy identified. There no free fluid.
Within the right lower thorax, and lower abdomen, there is
significant interstitial fluid, which is unchanged since the
prior exam.
CT PELVIS W/ORAL & IV CONTRAST: Intrapelvic loops of large and
small bowel, and rectum normal in appearance. A Foley catheter
is in place and intact within the bladder.
BONE WINDOWS: There is significant degenerative joint disease,
extending along the spine. There are no suspicious lytic or
sclerotic lesions identified.
REFORMATTED IMAGES: Coronal and sagittal reconstructions were
obtained for better delineation of the anatomy.
IMPRESSION
1. The examination of the chest is limited by artifact from
breathing and patient's body habitus. No definite pulmonary
embolus is visualized.
2. Multifocal patchy opacities in bilateral lungs concerning for
pneumonia, which are unchanged when compared with prior exam
dated [**2129-12-31**].
3. Bilateral pleural effusions, left greater than right,
unchanged since prior exam.
4. Significant interstitial edema within the right lower thorax,
and right upper abdominal wall.
5. Small, decreasing perisplenic fluid collection.
Brief Hospital Course:
69 year-old female with HTN, atrial fibrillation, asthma, recent
CCY complicated by a bile leak/ascites, transferred to [**Hospital1 18**] for
further care. Her hospital course will be reviewed by problems.
1. Billiary leak/ascites: Ms. [**Known lastname 59817**] was admitted to the
[**Hospital Unit Name 153**] on [**12-13**] for possible ERCP in the AM. The ERCP was
initially cancelled secondary to dyspnea and increasing
abdominal distension. A large volume tap with U/S guidance on
[**12-15**] produced 3L of bilious ascites and an 8 F pigtail was
left in place (d/c'd [**12-24**]). An ERCP was finally performed on
[**12-16**] (patient electively intubated for procedure), which
revealed a cystic duct leak. A stent was placed, with the intent
to leave in place for 6-8 weeks. Her [**Hospital Unit Name 153**] course was further
complicated by ARF requiring large amounts of crystalloid, IV
albumin, respiratory failure [**2-28**] acidosis, fluid overload,
pneumonia leading to initiation of Vancomycin/Zosyn (also on
Flagyl), malnutrition on TPN, and C.difficile.
A CT abdomen on [**12-18**] revealed moderate ascites, stent in place,
no ductal dilation, and 2 fluid pockets. She was transferred to
TSICU on [**12-20**] for further management. A repeat CT-guided
drainage was performed on [**12-21**] with 2 liters of purulent
bilious fluid drained. Cultures grew enterococcus, resistant to
Zosyn which was D/C'd. Vancomycin was also D/C'd and Linezolid
started. On [**12-26**], she was hypotensive requiring fluid boluses,
and also required a short course of Levophed. A CT abdomen on
[**12-27**] showed no new fluid collection. Repeat CTs on [**12-31**] and
[**1-9**] revealed no new collections.
Per biliary, the plan is for a repeat ERCP with stent removal
within 1 month of hospital discharge. They will communicate with
rehab regarding date of procedure. Contact fellow is Dr. [**Last Name (STitle) **]
[**Name (STitle) 59820**] (Gastroenterology).
2. ID/Sepsis: Patient initially transferred on Zosyn and Flagyl
from OSH. Course as follows:
[**12-15**], paracentesis with drainage of bilious fluid.
[**12-16**], ERCP confirmed biliary duct leak
[**12-16**], C. difficile positive. Patient already on Flagyl.
[**12-18**], high WBC (?PNA vs c. diff vs intraabdominal process). CT
chest with b/l patchy infiltrates, CT [**Last Name (un) 103**] with ascites.
Vancomycin added for concern of VAP.
[**12-15**] and [**12-16**], urine with yeast and sputum from ETT with
yeast. Fluconazole started on [**12-19**]. Vanco d/c'd.
[**12-20**], transferred to TSICU on Zosyn, Flagyl, Fluconazole.
[**12-21**], CT-guided drainage of RUQ purulent collection
[**12-21**], peritoneal fluid with yeast and enterococcus, resistant
to Zosyn, which was D/C'd. Linezolid started.
[**12-30**], Flagyl D/C'd. RUA drain removed.
[**12-31**], episode of hypotension, with rapid afib. She was placed
on Levophed and Dilt drip. CT was negative for PE. Urine and
blood cultures preliminary returned as GNR on [**1-1**], and patient
was placed on Levo and Zosyn for double coverage. Fluc was
d/c'd.
[**1-2**], central line resited.
[**1-2**], transferred to MICU for management of a fib and GNR
bacteremia, at which time abx changed to Levo, [**Last Name (un) **] and
Linezolid.
[**1-3**], ID and sensitivities odf urine and blood cultures came
back as Enterobacter.
[**2130-1-5**], ID consulted. Levo and Linezolid D/C'd. Continued on
Meropenem with plan to complete a 14-day course of Meropenem,
timed fomr the first negative blood culture on [**2130-1-2**]. Last
doses on [**1-15**].
[**2130-1-8**], recurrent hypotension, felt likely secondary to early
sepsis, possibly secondary to line infection. Fluid
resuscitated, Levophed started, then switched to Neosynephrine
given tachycardia (atrial fibrillation). Central venous line
resited given concern for infection. Recent cultures all
negative to date. Repeat CT [**Last Name (un) 103**]/chest performed on [**1-9**]
without new focus of infection. Pressor therapy discontinued on
[**2130-1-10**], hemodynamically stable since.
*** To complete a 14 day course of Meropenem --> switch to
Imipenem as Meropenem not available at rehab center. Last dose
on [**2130-1-15**].
*** To complete a 14-day course of Vancomycin. Started on
[**2130-1-9**], last dose on [**2130-1-22**].
3. Respiratory: Ms. [**Known lastname 59817**] was electively intubated prior to
ERCP on [**12-16**]. However, her course was complicated by fluid
overload, pneumonia, and difficulty weaning. On [**12-18**], a CT
chest revealed b/l patchy infiltrates, suspicious for VAP and
Vancomycin was started. A sputum culture then grew yeast on
[**12-19**], at which time vancomycin was stopped and fluconazole
started. A bronchoscopy was performed on [**12-23**], with a BAL
positive for yeast, already on Fluconazole. Given inability to
wean off ventilator, a percutaneous trach was performed on
[**12-30**]. In the MICU, the patient was weaned from AC to PS and has
been tolerating the trach collar during the day, and PS at
night. She was kept on her standing MDIs throughout. She was
also evaluated by Speech and Swallow, and tolerated the PM valve
when in line with the ventilator. Plan is to continue to wean
off ventilator. Passy Muir valve.
4. CVS:
Rhythm: Patient with known history of atrial fibrillation. Per
records, on Coumadin at home (per patient, 1 mg PO qhs).
Anticoagulation held in hospital for procedures, then in the
setting of a dropping Hct, without a clear source of bleeding.
Intravenous Heparin was restarted on [**2130-1-8**], held on [**2130-1-11**]
secondary to blood streaked stools and a slight drop in Hct.
Restarted on [**2130-1-13**]. Plan is to restart Coumadin at rehab when
Hct stable.
Pump: Given the patient's significant fluid overload, an echo
was performed on [**1-3**] to assess LV systolic function. The study
revealed an LVEF >55% and 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) 53183**] well to Lasix
diuresis in hospital. Diuresis, however, was limited by a
metabolic alkalosis (felt likely [**2-28**] contraction alkalosis).
Finally, during her hospital stay, she required 3 short courses
of Levophed for pressure support. Patient was on Lasix at home
prior to admission, dose unclear.
5. Acute on CRI: Upon admission, the patient was oliguric, with
a creatinine of 2.8, which [**Month/Day (2) 53183**] slowly to IVF and albumin.
However, given aggressive fluid administration, the patient
became grossly fluid overloaded and diuresis was initiated once
creatinine and volume status were stable ([**12-24**]). The patient
has [**Month/Year (2) 53183**] well to Lasix IV prn (40 mg IV prn). Close to
discharge, she developed a metabolic alkalosis, felt likely
secondary to contraction alkalosis, forcing cut back on
diuresis. Her creatinine on [**1-13**] is 0.4. Would plan to
reinitiate gentle diuresis as BP tolerates, while keeping a
close eye on HCO3 values.
5. GI: On [**12-16**], a C.diff toxin came back positive. The patient
was already on Flagyl from the OSH. She completed a 14-day
course of Flagyl (last doses on [**2129-12-30**]). Repeat C. difficile
assays negative.
6. Anemia: Variable in hospital due to massive fluid shifts.
She was transfused a total of 8 units of PRBCs in hospital. Last
transfusion on [**2130-1-13**] (1 unit of PRBC). Goal Hct>25. Stools
guaiac negative initially, positive while on Heparin. [**Month (only) 116**] need
out-patient GI work-up.
7. FEN: The patient was intermittently on TPN until [**12-22**], after
which tube feedings were initiated. She passed a swallowing
evaluation on [**1-12**] for thick fluids/pureed and diet was
advanced.
CODE: Patient was full code during this admission.
Medications on Admission:
Medications on transfer:
Discharge Medications:
1. Fluoxetine HCl 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal rash.
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
5. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-28**] PO Q4-6H (every 4
to 6 hours) as needed.
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-28**]
Puffs Inhalation Q4H (every 4 hours).
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
10. Lorazepam 0.5-1 mg IV Q6H:PRN
11. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q8H (every 8 hours) for 2 days: Last dose on [**2130-1-15**] to
complete 14-day course.
12. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous
Q12H (every 12 hours) for 9 days: Last doses on [**2130-1-22**] to
complete 14-day course. .
13. Regular insulin sliding scale
14. Heparin IV sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Peritonitis
Sepsis
Pneumonia
Respiratory failure requiring tracheostomy
Enterobacter bacteremia
Atrial fibrillation
Anemia
Discharge Condition:
Patient discharged in stable condition.
Discharge Instructions:
Patient discharged to Rehab care facility.
Followup Instructions:
Folllow-up ERCP for stent removal to be scheduled by
Gastroenterology (biliary). Dr. [**Last Name (STitle) 59820**] (gastroenterology fellow)
will contact rehab to confirm date of follow-up.
She will need follow-up with PCP [**Name Initial (PRE) 176**] 1 month of hospital
discharge.
Completed by:[**2130-1-13**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,588
| 176,270
|
26907
|
Discharge summary
|
report
|
Admission Date: [**2169-12-20**] Discharge Date: [**2169-12-27**]
Date of Birth: [**2101-6-26**] Sex: F
Service: MEDICINE
Allergies:
Prednisone / Aspirin / Codeine / Sulfa (Sulfonamides) / Ivp Dye,
Iodine Containing / Bactrim / Procardia
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer from [**Hospital 1727**] Medical Center for IP intervention
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
Ms. [**Known lastname 66188**] is a 66 year old woman with history of COPD and
tracheobronchomalacia s/p Y stent, now transferred to [**Hospital1 18**] from
[**Hospital 1727**] Medical Center for interventional pulmonary intervention.
She initially presented to [**Hospital 66189**] Hospital on [**2169-11-18**] with
dyspnea, sputum, and increased secretions, and was diagnosed
with community-acquired pneumonia as an outpatient, which she
subsequently failed. Sputum grew MRSA, and she was then
transferred to MMC for furhter evaluation and management.
.
Her hospital course at MMC was notable for the following
problems:
.
1. Respiratory failure/MRSA pneumonia. Transferred to MMC on
vancomycin, which was changed to linezolid when blood cultures
grew VRE. At MMC, she was difficult to ventilate, given problems
with auto-PEEP; she did well on CPAP 20/12.
.
2. Hypotension. In setting of MRSA pneumonia and VRE bacteremia.
On phenylephrine
.
3. Tracheal bleeding. Had acute bleeding from tracheostomy;
bronchoscopy demonstrated friable granulation tissue. No other
bleeding episodes.
.
4. VRE bacteremia. Culture on ??? grew VRE (drawn from PICC).
PICC pulled, CVL placed, surveillance cultures negative to date.
Linezolid to finish 7-day course on [**12-21**].
.
5. History of DVT/Pulmonary Embolism in [**2167**]. She had been on
coumadin since [**2167**] for treatment; coumadin was held, and she
was transitioned to heparin on [**12-20**] for IP procedure.
.
6. Agitation. Agitation during the hospitalization controlled
with scheduled phenobarbital and PRN pushes.
.
Per the discharge summary, at the time of discharge, her chest
x-ray demonstrated "stable appearance of multiple patchy
opacities persistent in the left lung with volume loss in the
left lung and slight shift of the mediastinum to the left,
unchanged from prior, as well as persistant left pleural
effusion".
.
On arrival to the floor, an A-line was placed and chest x-ray
was performed. Chest X-ray showed complete white out of the left
lung, consistent with complete collapse. Tidal volume was
immediately decreased, the patient received deep sedation, and
IP was called in for emergent bronchoscopy (the ICU bronchoscope
did not fit in her tracheostomy tube). Bronch demonstrated
granulation tissue on both arms of the Y-stent (L>R) and
increased mucus in left main bronchus, which was suctioned.
Past Medical History:
- COPD on home oxygen
- Tracheomalacia s/p Y stent in fall [**2168**]
- Obstructive sleep apnea
- Hypertension
- Recurrent DVTs on anticoagulation
- Anemia
- Recurrent MRSA and Klebsiella pneumnonias
- Steroid-induced myopathy
- Chronic anemia
- History of fibromyalgia
Social History:
Lived with husband in [**Name (NI) 1727**]. >40 pack-year history of smokign.
Rare EtOH use. Denies drug use
Family History:
Noncontributory
Physical Exam:
VITALS: T98.3F, BP 122/69, HR 87, RR 25, SaO2 100%
VENT: TV 400, RR 25 (breathing ~40), FiO2 100%, PEEP 12
GENERAL: Sedated, breathing over vent, mild respiratory distress
HEENT: Pupils sluggish bilaterally but reactive
NECK: Unable to appreciate JVD
CARD: RRR normal S1/S2, no m/r/g appreciated
RESP: Vent sounds bilaterally R>L, rhonchi at left lung base
ABD: Soft, midline scar, healing G-tube site, non-tender,
non-distended, + bowel sounds
EXT: 2+ DP pulses bilaterally, warm, well perfused; clubbing
present; no cyanosis or edema
NEURO: Sedated
Pertinent Results:
7.46/38/155/28 on FiO2 100%, TV 450, RR 18
.
Na 131 K 4.3 Cl 95 HCO3 25 BUN 16 Creat 1.0 Gluc 105Ca: 8.4 Mg:
2.3 P: 4.1
.
CK: 15 MB: Notdone Trop-T: <0.01
.
ALT: 35 AST: 39 AP: 124 Tbili: 0.5 Alb: 2.5 LDH: 280
.
WBC 24.8
N:88.8 L:8.1 M:2.7 E:0.3 Bas:0.1
Hgb 9.0
Hct 27.4
Plt 822
.
PT: 21.4 PTT: 59.7 INR: 2.0
Fibrinogen: 614
.
STUDIES:
.
CXR [**12-20**]:
Leftward shift of mediastinum with complete opacification of the
left lung field new compared to previous exams. S/p trach and Y
stent. NG in good position. Right CVL line probably in good
position. Right lung grossly clear.
Brief Hospital Course:
68yF with history of COPD, tracheomalacia s/p Y-stent,
tracheostomy, recurrent MRSA pneumonia, transferred from OSH for
IP intervention and found to have collapsed left lung. Patient
was evaluated by interventional pulmonology. Her Y-stent was
stenosed and subsequently removed. The patient underwent
debridement. She was thought to have no meaningful recovery
from a pulmonary stand-point and continued to require
significant sedation to allow her to tolerate the ventilator. A
CT of the chest was performed to evaluate for underlying
malignancy but did not show clear malignant cause of her
respiratory failure. On [**12-27**] the family decided to provide
comfort measures only and mechanical ventilation was
discontinued and a few hours later, at 21:17, the patient
expired. Primary cause of death was cardiopulmonary arrest,
immediate cause was chronic respiratory failure. The family was
present.
Medications on Admission:
Heparin gtt on protocol
Linezolid 600mg IV q12h (through [**12-21**])
Paroxetine 40mg PO daily
Methadone 10mg PO Q8H
Phenobarbital 65mg IV Q12H with 65mg IV Q1H pushes PRN
Omeprazole suspension 20mg PO Q24H
Albuterol INH Q6H
Ipratropium INH Q6H
Colace
Senna
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
Discharge Condition:
deceased
Discharge Instructions:
Expired
Followup Instructions:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"518.0",
"496",
"518.83",
"V58.61",
"327.23",
"E932.0",
"599.0",
"359.4",
"519.19",
"482.41",
"253.6",
"790.7",
"280.0",
"785.6",
"V55.0",
"V09.80",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"99.04",
"40.11",
"96.72",
"33.22",
"32.01",
"31.99",
"33.21",
"96.6",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
5758, 5767
|
4507, 5420
|
443, 457
|
5834, 5845
|
3902, 4484
|
5901, 6049
|
3297, 3314
|
5729, 5735
|
5788, 5813
|
5446, 5706
|
5869, 5878
|
3329, 3883
|
335, 405
|
485, 2861
|
2883, 3155
|
3171, 3281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,232
| 181,525
|
32359
|
Discharge summary
|
report
|
Admission Date: [**2110-3-28**] Discharge Date: [**2110-4-1**]
Date of Birth: [**2053-12-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Percocet / Simvastatin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Severe 3-vessel coronary artery disease/ Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2110-3-28**]
Coronary artery bypass grafting x2: Left internal mammary
artery to left anterior descending coronary; reverse saphenous
vein single graft from aorta to the third obtuse marginal
coronary artery.
History of Present Illness:
56 year old diabetic male with significant medical history of
hyperlipidemia and coronary artery disease s/p multiple PCI's of
the LAD. He reports dyspnea after minimal exertion relieved with
rest. This has been ongoing for years. He has modified daily
activities to avoid symptoms. He completed a stress test on
[**2110-1-14**], he exercised for 4 minutes according to the
standard [**Doctor First Name **] protocol achieving a peak HR of 115 BPM and BP of
182/68 mm HG stopping due to dyspnea. There were non-specific ST
changes at peak exercise. Imaging
revealed anterior, septal and apical ischemia. It also showed
mildly increased LV filling pressures during exercise and a
normal LVEF despite septal hypokinesis. He was referred for
cardiac catheterization for further evaluation which showed
significant in stent restenosis in proximal LAD, 80% mid
stenosis
in large dominant Cx,and mild diffuse disease in small RCA. He
was referred to cardiac surgery for revascularization.
Past Medical History:
Hyperlipidemia
CAD
[**6-/2099**] BMS x 3 to LAD
[**11/2099**] BMS to ISR LAD
[**1-/2102**] 2.5 x 13mm Pixel stent to Ramus
[**2106-12-8**] PTCA ISR proximal LAD
IDDM
Retinopathy
Neuropathy
GERD
Left pleural lipoma
Left shoulder arthritis-planning to start physical therapy
[**2106-11-4**] Vitreous hemorrhage s/p left eye vitrectomy
[**8-/2109**] Right eye vitrectomy c/b retinal detachment
[**10/2109**] Right eye surgery
[**12/2109**] Right eye surgery now with decreased vision
Right hip surgery at age 14
Social History:
Race:Caucasian
Last Dental Exam:a few years ago
Lives with:wife
Occupation:[**Name2 (NI) 75591**] Teacher/Driver's Ed Teacher
Tobacco:denies
ETOH:moderate
Family History:
Paternal uncles with premature CAD and Sister with CAD in her
60's.
Physical Exam:
Pulse:58 Resp:18 O2 sat:98/RA
B/P Right:148/65 Left:164/71
Height:5'[**09**]" Weight:260lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right:cath site Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2110-3-30**] 09:15AM BLOOD WBC-12.7* RBC-3.41* Hgb-10.5* Hct-29.7*
MCV-87 MCH-30.7 MCHC-35.2* RDW-13.3 Plt Ct-191
[**2110-3-31**] 05:40AM BLOOD UreaN-23* Creat-0.7 Na-137 K-4.1 Cl-103
[**2110-3-31**] 05:40AM BLOOD Mg-2.1
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2110-3-28**] where the patient underwent a coronary
artery bypass grafting x2 with left
internal mammary artery to left anterior descending coronary;
reverse saphenous vein single graft from aorta to the third
obtuse marginal coronary artery. See operative note for full
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 on no inotropic or 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. Lantus insulin
doses were adjusted due to hyperglycemia. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home with visiting nurse services in good condition with
appropriate follow up instructions.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth qam
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
Tablet - 1 Tablet(s) by mouth qam
BIMATOPROST [LUMIGAN] - (Prescribed by Other Provider) - 0.01 %
Drops - one drop each eye daily at bedtime
BRIMONIDINE-TIMOLOL [COMBIGAN] - (Prescribed by Other Provider)
- 0.2 %-0.5 % Drops - one drop left eye twice a day
INSULIN ASPART [NOVOLOG FLEXPEN] - (Prescribed by Other
Provider) - 100 unit/mL Insulin Pen - 22 units at breakfast,
10-22 units at 12pm, 32 units at dinner
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 50 units twice a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet -
one
Tablet(s) by mouth every am and two tablets every pm. LD
[**2110-3-15**] pre procedure per Dr. [**First Name (STitle) **] .
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth daily
Discharge Medications:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. metformin 500 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
11. metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)). Tablet(s)
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
13. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 10 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
14. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous Q AM.
Disp:*15 units* Refills:*0*
16. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
Disp:*15 * Refills:*0*
17. insulin aspart 100 unit/mL Solution Sig: 10-32 units
Subcutaneous three times a day: 22 units at breakfast, [**11-1**]
units at 12 PM, 32 units at dinner - check FS TID and adjust
according to BS results and food intake.
Disp:*15 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1 + Edema
left> right
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] on [**2110-4-22**] at 1:45 PM
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 4/22 at 9:15 AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-15**] weeks [**Telephone/Fax (1) 8506**]
Wound check in 1 week in Lowr [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] on [**2110-4-8**]
at 10:30 AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2110-4-1**]
|
[
"536.3",
"996.72",
"V58.67",
"272.4",
"V45.82",
"414.01",
"715.91",
"278.00",
"357.2",
"250.50",
"250.60",
"V17.3",
"530.81",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
7675, 7733
|
3297, 4659
|
360, 575
|
7800, 8030
|
3049, 3274
|
8870, 9540
|
2312, 2382
|
5687, 7652
|
7754, 7779
|
4685, 5664
|
8054, 8847
|
2397, 3030
|
259, 322
|
603, 1590
|
1612, 2123
|
2139, 2296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,546
| 192,029
|
45850
|
Discharge summary
|
report
|
Admission Date: [**2194-2-12**] Discharge Date: [**2194-2-25**]
Date of Birth: [**2112-3-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubation
Central line insertion
PICC line placement
PEG placement [**2194-2-24**]
History of Present Illness:
81 yo male with history of dementia, known aspiration with prior
episodes of aspiration pneumonia was transferred from his
residence at [**Hospital3 2558**] to [**Hospital1 18**] ED with altered mental
status, and hypoxemia. There, he was reported to be in 80's on
4L nasala canula and tachypneic to 30's. Of note, he has
reportedly been on levaquin and flagyl for a planned 10d course
since [**2194-2-7**].
.
His ED course was notable for SBP in 80s, tachycardia to 120s,
RR in 30s, afebrile, and sat well on NRB. He had an EKG w/ sinus
tach, Twave flattening diffusely. He remained hypotensive
despite 5L IVF; ultimately a femoral central line was placed and
he was started on levophed. In that setting, he went into rapid
atrial fibrillation; cardioverted -> back to NSR. His infectious
work up was notable for a worsening retrocardiac opacity by
chest film, evidence for UTI with UA demonstrating mod LE, >50
WBCs, and many bacteria. Initial WBC of 14.7 with left shift.
Initial lactate of 2.7. Sodium of 163 (down from 170 at nursing
home records). He was empirically treated with ceftazadime,
levaquin, and flagyl. He was transferred to the MICU for further
management.
Past Medical History:
Dementia
Seizure disorder
Depression
Osteoarthritis
IBS
Vitamin B12 deficiency
[**1-27**] ORIF
Recurrent aspiration
Chronic hypernatremia
Social History:
Full time residence at Cooledge house facility; [**Name (NI) 86**], MA
Brother [**Name (NI) **] is HCP, lives in FL
Family History:
Non-contributory
Physical Exam:
MICU Admission:
VS: 97.0, 98, 78/36, 18, 100%
.
vent: AC: 600x14, 5, 100%
.
gen intubated, sedated; opens eyes to voice. No purposeful
movements
heent dry mucous membranes
neck supple, no JVD
cv rrr, no m/r/g
resp coarse breath sounds bilaterally with decreased breath
sounds at bases
abd obese, soft, nt, nabs; reported guaiac pos brown stool in ED
extr trace, symmetric edema; warm extremities\; 2+ dp pulses
Pertinent Results:
Labs:
[**2194-2-12**] 10:15PM BLOOD WBC-14.7*# RBC-2.93* Hgb-9.2* Hct-28.9*
MCV-98 MCH-31.3 MCHC-31.8 RDW-16.9* Plt Ct-171
[**2194-2-25**] 05:33AM BLOOD WBC-11.3* RBC-2.66* Hgb-8.5* Hct-24.8*
MCV-93 MCH-31.8 MCHC-34.1 RDW-16.2* Plt Ct-463*
[**2194-2-12**] 10:15PM BLOOD Neuts-92.6* Bands-0 Lymphs-5.4*
Monos-1.5* Eos-0.5 Baso-0.1
[**2194-2-13**] 02:11AM BLOOD Glucose-173* UreaN-58* Creat-1.9* Na-165*
K-3.8 Cl-138* HCO3-16* AnGap-15
[**2194-2-25**] 05:33AM BLOOD Glucose-84 UreaN-20 Creat-0.9 Na-142
K-3.8 Cl-109* HCO3-27 AnGap-10
[**2194-2-12**] 10:15PM BLOOD ALT-13 AST-14 CK(CPK)-169 AlkPhos-60
Amylase-17 TotBili-0.2
[**2194-2-12**] 10:15PM BLOOD CK-MB-3 cTropnT-0.07*
[**2194-2-13**] 03:21AM BLOOD Cortsol-29.9*
[**2194-2-13**] 04:26AM BLOOD Cortsol-36.1*
.
Bl cx [**2194-2-12**] and [**2194-2-13**]: [**3-28**] MSSA. Multiple surveillance
cultures negative.
U CX MSSA, enterococcus
Sputum: MSSA
.
Echocardiogram on [**2194-2-17**]:
Conclusions:
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%). Due
to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated.
Right ventricular systolic function is borderline 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. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen. If clinically
indicated, a TEE would be better to exclude small valvular
vegetations.
Right lower extremity ultrasound on [**2194-2-13**]:
IMPRESSION: No acute DVT. Chronic recanalized DVT seen in the
right common femoral vein, which is improved since the prior
study of [**2189-4-7**], as its incompressibility extends from
the right common femoral vein to the proximal superficial
femoral vein bifurcation on today's exam.
Left lower extremity ultrasound on [**2194-2-14**]:
IMPRESSION: No evidence of DVT.
Renal Ultrasound [**2194-2-13**]:
IMPRESSION:
1. Moderate left-sided hydronephrosis.
2. Multiple simple left-sided renal cysts.
Head CT on [**2194-2-13**]:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Ventriculomegaly without definite transependymal edema to
suggest acute hydrocephalus. Please correlate clinically to
exclude causes of
noncommunicating hydrocephalus.
CXR on [**2194-2-12**]:
AP UPRIGHT CHEST: Cardiac and mediastinal contours are stable.
There remains a dense retrocardiac left lower lobe opacity as
well as other smaller regions of opacity in the left mid and
lower lung. Some of these appear slightly worsened since the
prior study. There is some bronchial wall thickening. Pulmonary
vascularity is overall within normal limits. No pleural
effusions are clearly seen. Degenerative change of the spine is
noted.
IMPRESSION: Retrocardiac left lower lobe opacity as well as
other patchy left lung opacities which appear slightly worse
since the prior study, could be regions of infection or
aspiration.
Video Swallow Study [**2194-2-21**]:
Patient demonstrated aspiration with thin and nectar-thin
liquids. Residue was also noted throughout the pharynx with
thicker consistencies, with large amount of secretions.
Brief Hospital Course:
81yo man with history of Dementia, aspiration, pneumonia
presents from nursing home with worsened mental status, hypoxia,
hypotension, and hypernatremia. Found to have MSSA bacteremia,
PNA and UTI with MSSA and enterococcus.
.
1. Sepsis: Pt presented with sepsis likely secondary to
aspiration pneumonia (cx +MSSA) and a UTI (MSSA, enterococcus).
He initially required pressors, intubation for support. Treated
initially w/vanc, zosyn, flagyl and narrowed to nafcillin given
culture data. Pt has history of severe aspiration, requiring
intubation in the past. He was successfully extubated [**2-18**] but
remains NPO given aspiration risk. ID is following for tx
guidance. Will complete 14 day course of antibiotics on
[**2194-2-26**]. All blood surveillance cultures since [**2194-2-14**] have
been no growth to date. Repeat urine culture showed 10-100K
enterococcus, likely colonization in the setting of foley
catheter. Foley was changed and repeat urine culture is
pending.
.
2. Hypernatremia: Mr. [**Known lastname 97639**] presented to the MICU with an
initial serum sodium of 165. Per conversations with his PCP, [**Name10 (NameIs) **]
is chronically hypernatremic, but likely had exacerbation of his
baseline levels with decreased availability of free water at his
nursing home. He was treated with D5 infusion and free water
boluses and monitored for MS changes. His sodium has stabilized
and he continues with daily free water via NGT and later via
PEG.
.
3. RLE edema- RLE w/chronic common femoral vv DVT,
recannalized. LLE neg for DVT. No treatment initiated at this
time.
.
4. RUE edema: at site of new PICC placement. RUE US without
evidence of DVT. CXR shows PICC in correct site.
.
5. Decubitus ulcers- Pt with chronic decubitus ulcers with
minimal skin breakdown. Per wound care, no change since prior
admission. Was followed throughout his hospital course by wound
care, who is managing his dressings. Kinair mattress while
inpatient.
.
6. Anemia: baseline HCT high 20s-low30s. Had received 1uPRB for
HCT drifting down, likely dilutional. Stools were guaiac
negative.
.
7. Dementia: Patient is baseline demented. Per family, no change
in mental status.
We discontinued celexa, remeron, zyprexa in this setting.
.
8. History of seizure disorder: On phenobarbital at baseline.
Continued on phenobarb during hospitalization. No seizure issues
during hospital course. Continue home regimen.
.
9. FEN- The patient has had chronic episodes of aspiration
pneumonia requiring hospitalization. His video swallow
evaluation showed evidence of aspiration with all consistencies
of food. Discussions with HCP/brother, who wanted a PEG tube
placed. A PEG tube was placed and the patient continues to
receive nutrition/meds via PEG tube.
.
10. Prophylaxis - Heparin SC tid, Bowel regimen, PPI, aspiration
and fall precautions.
.
11. Access- femoral line discontinued, L subclavian placed [**2-17**]
and d/c'd. PICC line placed in RUE. Plan for d/c PICC once
antibiotic course complete.
.
12. Code- Full, confirmed with HCP during this admission
Medications on Admission:
1. Phenobarbital 30 mg [**Hospital1 **]
2. Docusate Sodium 50 mg/5 mL PO BID
3. Lansoprazole 30 mg qD
4. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID
5. Augmentin 500-125 mg po q8 (completed [**2194-1-6**])
6. PICC line care
7. IV 1/2NS at 75cc/hr at least 1000cc per day
8. Heparin 5000 sc TID
9. Heparin Lock Flush 10mL qD
10. Multivitamin qD
11. Artificial Tears
12. Vitamin B-12 1,000 mcg/mL qmonth
13. Celexa 20 mg
14. Zyprexa 7.5 mg
15. Imodium A-D 2 mg [**Hospital1 **] prn
16. Mirtazapine 30 mg HS
Discharge Medications:
1. Phenobarbital 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
3. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
4. Nafcillin 2 g Piggyback [**Last Name (STitle) **]: Two (2) grams Intravenous every
four (4) hours for 2 days.
5. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection Injection TID (3 times a day).
6. Multi-Vitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
7. Loperamide 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for diarrhea.
8. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for SOB or wheeze.
9. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
10. Nystatin 100,000 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
- Sepsis, bacteremia, aspiration pneumonia, UTI
- Respiratory failure
- Hypernatremia
.
Secondary diagnosis:
- Dementia
- Decubitus ulcers
Discharge Condition:
Stable, breathing on room air
Discharge Instructions:
You have been admitted to the hospital with a very severe
infection called sepsis and are completing a course of
antibiotics.
Continue to take all medications as directed.
Attend all follow up appointments.
If you develop fever, chills, chest pain, or shortness of breath
or any other symptom that concerns you, seek medical attention
Followup Instructions:
Make a 1 week follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6680**]
[**Telephone/Fax (1) 608**]
Have your PCP follow up your urine culture and surveillance
blood cultures. Have your PCP help determine when to restart
Vit B 12 treatment.
|
[
"294.8",
"482.41",
"276.0",
"518.81",
"599.0",
"995.92",
"038.11",
"285.9",
"427.31",
"507.0",
"707.03",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"43.11",
"96.72",
"96.6",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10919, 10989
|
6033, 9098
|
326, 412
|
11191, 11223
|
2396, 6010
|
11609, 11899
|
1930, 1948
|
9667, 10896
|
11010, 11010
|
9124, 9644
|
11247, 11586
|
1963, 2377
|
275, 288
|
440, 1618
|
11138, 11170
|
11029, 11117
|
1640, 1780
|
1796, 1914
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,238
| 181,001
|
43514
|
Discharge summary
|
report
|
Admission Date: [**2157-12-12**] Discharge Date: [**2157-12-14**]
Date of Birth: [**2078-10-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Mr. [**Known lastname 9499**] is a 79 year old man with h/o HIV/AIDS (Kaposi's
sarcoma, last CD4 212 in [**10-9**], VL undetectable), DM, CKD, HTN,
HLD, anemia, who presents with N/V x 2 days.
.
The patient was recently started on Vicodin for pain control of
a ruptured lumbar disc. He notes 4-5days of constipation, and
then developed 2 days of nausea/vomiting and abdominal
discomfort. No h/o prior GIB in the past, no recent NSAID or
steroid use, no prior scopes.
.
In the ED, initial VS: 98.2 102 142/91 18 100%. He had coffee
ground emesis in the ED, as well as 1 episode of melena. Exam
notable for grossly guaiac positive melanotic stool and Kaposi's
lesions on b/l LE. Labs notable for HCT 28 (down from baseline
mid30s), Cr 3 (up from baseline 2). NGL was negative (250cc,
clear return). Patient was evaluated by GI, decided not to scope
at that time. Given 2L IVF. Initially was going to be admitted
to the floor, but repeat HCT down to 21, so transfused 2units
pRBCs and admitted to the MICU for closer monitoring overnight.
GI aware of further HCT drop, but will hold on scope unless
patient becomes HD unstable overnight. Patient was given
Protonix bolus and started on gtt. Also given Zofran. Vitals
prior to transfer 98.2, 94, 142/59, 19, 100% RA, 2 PIVs in
place. Ortho Vitals (Down BP128/49 HR 87) (up BP 127/55 HR103).
.
On the floor, patient currently c/o lower back pain. Some GI
discomfort, but no pain. Mild nausea. 10-point ROS otherwise
negative.
Past Medical History:
HIV/AIDS (CD4 212 in [**10-9**], VL undectable, prior invasive
Cryptococcal infection)
Kaposi's sarcoma
CKD, baseline Cr 2.0
DM (followed at [**Last Name (un) **])
HLD
HTN
Vitamin D deficiency
Social History:
Lives alone. Has 2 daughters, who help look after him.
- Tobacco: none, quit 20 years ago
- EtOH: glass of wine with dinner daily
- Drugs: none
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.8 85 152/60 17 100%
Appearance: alert, NAD, obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Rectal: heme positive on ED exam
.
DISCHARGE PHYSICAL EXAM
VSS
GEN: NAD, cachetic appearing
HEART: RRR, no m/r/g
LUNG: CTA BL
ABD: soft, NT/ND, +BS
EXT: hyperpigmented with ulceration and scap formation over
bilateral shin
Pertinent Results:
ADMISSION LABS
[**2157-12-12**] 01:45PM BLOOD WBC-7.8# RBC-2.92* Hgb-10.0* Hct-28.3*
MCV-97 MCH-34.1* MCHC-35.2* RDW-13.0 Plt Ct-242
[**2157-12-12**] 01:45PM BLOOD Neuts-84.0* Lymphs-12.3* Monos-3.1
Eos-0.3 Baso-0.4
[**2157-12-12**] 01:45PM BLOOD PT-13.2 PTT-21.1* INR(PT)-1.1
[**2157-12-12**] 01:45PM BLOOD Glucose-323* UreaN-112* Creat-3.0* Na-138
K-4.9 Cl-102 HCO3-20* AnGap-21*
[**2157-12-12**] 01:45PM BLOOD ALT-34 AST-34 AlkPhos-81 Amylase-231*
TotBili-0.2
[**2157-12-12**] 01:45PM BLOOD Lipase-71*
[**2157-12-13**] 02:49AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1
.
DISCHARGE LABS
[**2157-12-14**] 05:55AM BLOOD WBC-4.5 RBC-3.42* Hgb-11.0* Hct-31.7*
MCV-93 MCH-32.2* MCHC-34.7 RDW-14.3 Plt Ct-177
[**2157-12-14**] 05:55AM BLOOD PT-12.0 PTT-20.9* INR(PT)-1.0
[**2157-12-14**] 05:55AM BLOOD Glucose-47* UreaN-51* Creat-1.8* Na-146*
K-3.4 Cl-111* HCO3-25 AnGap-13
[**2157-12-14**] 05:55AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.0
.
PERTINENT LABS
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2157-12-14**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
.
PERTINENT STUDIES
[**2157-11-29**] Lumbar film:
Age-indeterminate compression deformities of T12 and L2.
Multilevel degenerative changes. If there is concern for an
occult fracture, recommend further evaluation with MRI.
.
[**2157-12-13**] EGD:
- Grade 2 esophagitis in the middle third of the esophagus and
lower third of the esophagus compatible with erosive esophagitis
- Moderate hiatal hernia
- Mild erythema and congestion in the whole stomach compatible
with gastritis
- Granularity, friability, erythema and congestion in the
duodenal bulb compatible with duodenitis with several
superficial nonbleeding ulcers
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname 9499**] is a 79 year old man with h/o HIV/AIDS, DM, HTN, CKD,
who presents with N/V, found to have melanotic stool and HCT
drop concerning for acute GIB.
ACTIVE ISSUES
#. Acute GIB with resulting acute blood loss anemia: Pt
presented with cough-ground emesis with melanotic stool,
concerning for upper GI bleed. He received a total of 2 units
pRBC and maintained stable HCT afterwards. EGD was performed in
the MICU, which showed esophagitis, gastritis, and inflammation
of the duodenal bulb with several superficial ulcers. H.pylori
antibody was negative. Pt was treated with [**Hospital1 **] PPI. His diet
was advanced to regular and he tolerated well. Given the
severity of inflammation, a repeat endoscopy in 8 weeks is
expected.
#. Like obstructive sleep apnea: while sleeping in the ICU, the
patient snored loudly and desaturated to the 70s on continuous
O2 monitoring. He improved with CPAP. Would recommend a sleep
workup.
#. Acute on chronic renal failure: Pt presented with Cr of 3.0,
above his baseline of 2.0. His Cr improved to 1.8 on discharge
after blood transfusion. It appears likely prerenal etiology.
CHRONIC ISSUES
#. HIV/AIDS: Pt has documented HIV/AIDS with cryptococcal
infection and Kaposi's sarcoma. His last CD4 was 212 in [**10-9**],
VL was undetectable. We restarted pt on HAART medications after
EGD.
# LBP: Pt was recently found to have ruptured lumbar disc on XR,
and was started on narcotics for pain control.
# HTN: Pt takes Hydrochlorothiazide and Valsartan at home. His
blood pressure was within low normal range. We only restarted
his hydrochlorothiazide given his risk of hypotension likely
secondary GIB.
TRANSITIONAL ISSUES
# CODE STATUS: FULL
# COMMUNICATION: daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 93655**] (h),
[**Telephone/Fax (1) 93656**] (c)
# MEDICATION CHANGES:
- HELD Valsartan till further evaluation
- HELD Aspirin given acute GIB
- STARTED pantoprazole 40 mg [**Hospital1 **]
# PENDING STUDIES AT DISCHARGE: None
# FOLLOWUP PLANNING
- ID/PCP followup in one week
- repeat endoscopy in 8 weeks
- discuss the risk and benefit for screening colonoscopy as
part of workup for anemia
Medications on Admission:
CITALOPRAM [CELEXA] - 40 mg Tablet - one Tablet(s) by mouth once
a day
CLOBETASOL - 0.05 % Ointment - apply to affected area on legs
once daily apply at different time from Amlactin
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
One Capsule(s) by mouth every 2 weeks.
FLUCONAZOLE - 200 mg Tablet - Two Tablet(s) by mouth once daily.
FLUTICASONE - 50 mcg Spray, Suspension - Two sprays ea nostril
twice daily.
GLYBURIDE - 5 mg Tablet - One Tablet(s) by mouth in the AM and 2
in the PM.
HYDROCHLOROTHIAZIDE - 25 mg Tablet - One Tablet(s) by mouth once
daily.
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - WASH HEAD WITH SHAMPOO
EVERY 2-3 DAYS
LAMIVUDINE [EPIVIR HBV] - 100 mg Tablet - One Tablet(s) by mouth
once daily.
NEVIRAPINE [VIRAMUNE] - 200 mg Tablet - 2 Tablet(s) by mouth
once
a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-30**]
Tablet(s) by mouth every four (4) hours as needed for Pain
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - One Tablet(s) by mouth
[**Hospital1 **].
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - One Tablet(s) by mouth
once daily.
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM DS] - 800 mg-160 mg
Tablet
- One Tablet(s) by mouth daily.
TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Ext Release 24 hr - Two
Capsule(s) by mouth daily.
VALSARTAN [DIOVAN] - 40 mg Tablet - One Tablet(s) by mouth
daily.
Medications - OTC
AMMONIUM LACTATE [AMLACTIN] - 12 % Cream - apply to affected
area
on legs once daily apply at different time of day from
clobetasol
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - One Tablet(s)
by
mouth once daily for cardiovascular prophylaxis.
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet - One Tablet(s)
by mouth once daily. Vitamin B12.
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
Up to 30 units every bedtime as directed by [**Hospital **] Clinic.
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - 1,000 mg Capsule - 1
Capsule(s) by mouth twice per day. Prescribed by [**Hospital **] Clinic.
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical DAILY
(Daily).
3. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
5. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nevirapine 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
9. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO once a day.
12. AmLactin 12 % Cream Sig: One (1) Topical once a day.
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
15. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO q two
weeks.
18. glyburide 5 mg Tablet Sig: One (1) Tablet PO qAM.
19. glyburide 5 mg Tablet Sig: Two (2) Tablet PO qPM.
20. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Thirty (30) units Subcutaneous at bedtime.
21. ketoconazole 2 % Shampoo Sig: One (1) Topical q2-3 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- duodenitis, gastritis, esophagitis
Secondary diagnosis
- HIV/AIDS
- chronic kidney disease
- diabetes
- hyperlipidemia
- hypertension
- Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 9499**],
You came to our hospital for abdominal discomfort with nausea,
vomiting and had bloody vomiting and dark blood-containing stool
in the ED. You underwent an endoscopy through your mouth. We
found that you have inflammation in your esophagus, stomach and
duodenum. You have been treated with medication to lower the
amount of acid in your blood. Your blood count has been stable
over 24 hours, and you are now eating fine. We felt that it is
safe for you to go home and continue the treatment at home.
.
Please note that the following medication has been changed:
- Please STOP taking valsartan until further instruction by your
doctors
- Please STOP taking aspirin until further instruction by your
doctors
- Please START to take pantoprazole 40 mg tablets by mouth twice
a day
.
Please make sure to meet Dr. [**Last Name (STitle) 2148**] on [**12-20**] for followup.
Please make sure that you have followup endoscopy in 8 weeks
after discharge.
.
It has been a pleasure taking care of you here at [**Hospital1 18**]. We
wish you a speedy recovery.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2157-12-20**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Your appointment for endoscopy is as follows:
Department: ENDO SUITES
When: FRIDAY [**2158-2-17**] at 12:30 PM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2158-2-17**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
|
[
"176.9",
"530.10",
"724.2",
"584.9",
"585.3",
"276.52",
"327.23",
"042",
"535.51",
"535.61",
"285.1",
"268.9",
"403.90",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10734, 10740
|
4741, 6595
|
327, 332
|
10975, 10975
|
2982, 4718
|
12241, 13076
|
2226, 2244
|
8981, 10711
|
10761, 10954
|
6982, 8958
|
11126, 12218
|
2259, 2963
|
6774, 6956
|
6618, 6760
|
267, 289
|
360, 1832
|
10990, 11102
|
1854, 2049
|
2065, 2210
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,896
| 171,405
|
37286
|
Discharge summary
|
report
|
Admission Date: [**2121-3-12**] Discharge Date: [**2121-3-22**]
Date of Birth: [**2054-9-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**3-14**]- left heart catheterization, coronary angiogram
[**3-17**]- Coronary Artery Bypass Graft x 4 (Left internal mammary to
left anterior descending, Saphenouse vein graft to obtuse
marginal, Saphenous vein graft to diagonal, Saphenous vein graft
to Ramus)
History of Present Illness:
This 66 year old white female with a past medical history
signficant for NSTEMI and percutaneous interventions to the LAD
and OM1, presented [**Last Name (un) 83915**] outside ED after awaking from sleep with
angina. She had some EKG changes, although difficult they were
somewhat difficult to interpret given baseline her left bundle
branch block. She ruled out for MI by cardiac enzymes. Cardiac
catheterization showed triple vessel disease and cardiac surgery
is consulted for possible surgical revascularization.
Past Medical History:
Coronary Artery Disease
s/p Myocardial Infarction
s/p Cypher DES to mid LAD, POBA of OM1
Insulin dependent Diabetes mellitus
Hypertension
Hyperlipidemia
left bundle branch block
Peripheral neuropathy
Gastroesophageal reflux disease
s/p C-section x3
s/p cholecystectomy
s/p appendectomy
s/p hysterectomy
Social History:
Former elementry school cook manager, retired 7 yrs ago.
Lives at home with husband, children/grandchildren in area.
-Tobacco history: quit 20 yrs ago, 19 pack year history
-ETOH: occ
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mom with hx of stroke. Leukemia in family.
Physical Exam:
Admission:
Pulse:71 Resp: 17 O2 sat: 98% RA
B/P Right:140/50 Left: 130/50
Height: 5'8" Weight:86.2kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] RLQ and hypogastrium incision
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: dressing Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: + Left: -
Brief Hospital Course:
Following ruling out for an infarction she underwent
catheterization. She was referred for revascularization. On
[**3-17**] she was taken to the Operating Room where quadruple
bypass grafting was performed. See operative note for details.
She weaned from by pass on Propofol and Neo Synephrine
infusions. She remained stable, weaned from pressors easily and
was extubated. Beta blockade was begun and diuresis towards her
preoperative weight.
CTs and pacing wires wre removed according to protocols.
Physical Therapy was consulted for strength and mobility. She
had some brief atrial fibrillation which was treated with
Amiodarone and Lopressor. She did convert to sinus rhythm
shortly thereafter. Lantus and humalog were titrated for blood
glucose control. The patient did receive two units of packed
red blood cells for a hematocrit of 24%. Hematocrit rose
appropriately. By the time of discharge on POD 5 the patient
was ambulating freely, the wound was healing and pain was
controlled with oral analgesics. She was discharged home in
good condition with VNA services. All follow up instructions
were explained. She is to keep a log of her blood sugars and
present it to her PCP this week.
Medications on Admission:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcium Oral
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
-- PT STOPPED TAKING RECENTLY
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous at bedtime.
Disp:*300 units* Refills:*2*
10. Vitamin D Oral
11. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
four times a day: Please check sugars before meals and bedtime
and give humalog based on your sliding scale dosing.
Disp:*200 units* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual q5min as needed for chest pain.
Disp:*25 pills* Refills:*1*
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 24H (Every 24 Hours).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Insulin Glargine 100 unit/mL Cartridge Sig: Sixteen (16)
units Subcutaneous at bedtime.
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/fever.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for under abd fold .
Disp:*qs * Refills:*0*
15. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous dinner: 25 units glargine at dinner.
Disp:*qs * Refills:*2*
16. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: dose according to sliding scale.
Disp:*qs * Refills:*2*
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
18. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Diabetes mellitus
Hypertension
Hyperlipidemia
s/p Myocardial Infarction
s/p DES to mid LAD, POBA of OM1
left bundle branch block
Peripheral neuropathy
Gastroesophageal reflux disease
s/p C-section x3
s/p cholecystectomy
s/p appendectomy
s/p hysterectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with ultram 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:
you have an appointment with:
Surgeon Dr. [**Last Name (STitle) **] on [**4-30**] at 1pm ([**Telephone/Fax (1) 170**])
Please call to schedule appointments:
Primary Care Dr. [**First Name (STitle) 333**] [**Last Name (NamePattern4) 83916**] this week- bring a log of
blood sugars ([**Telephone/Fax (1) 40076**])
Cardiologist Dr. [**Last Name (STitle) 8579**] in [**1-18**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2121-3-22**]
|
[
"412",
"V58.67",
"426.3",
"401.9",
"427.31",
"V15.82",
"411.1",
"V45.82",
"V45.79",
"272.4",
"276.6",
"V88.01",
"414.2",
"250.61",
"530.81",
"414.01",
"357.2",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"39.61",
"36.13",
"37.23",
"99.20",
"88.56",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7057, 7127
|
2557, 3765
|
332, 597
|
7486, 7580
|
8204, 8729
|
1708, 1838
|
5103, 7034
|
7148, 7465
|
3791, 5080
|
7604, 8181
|
1853, 2534
|
282, 294
|
625, 1143
|
1165, 1469
|
1485, 1692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,850
| 166,046
|
7714
|
Discharge summary
|
report
|
Admission Date: [**2158-7-24**] Discharge Date: [**2158-8-9**]
Date of Birth: [**2116-4-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Transaminitis, N/V/Abd pain, PEG Site cellulitis
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
42M with PMH significant for Hep C and obesity s/p recent
gastric bypass in [**3-16**] with subsequent chronic nausea,
vomiting, and abdominal pain requiring PEG placement, presenting
to the ED with persistent and worsening symptoms. He has lost
130lbs since his operation in [**3-16**], from 280lb to 150lb. Mr.
[**Known lastname 28011**] has had several admissions to [**Hospital1 2177**] for his symptoms, and
per report, has not had any diagnoses that adequately explain
his symptoms. He presented to [**Hospital1 18**] ED on [**7-15**], and had an
abdominal CT notable for two focal low-density,
well-circumscribed lesions, approximately 3 x 3 cm and 2 x 2 cm,
likely representing a post-operative seroma and much less likely
an abscess. He was d/c'ed with Zofran for his symptoms. Over the
past week, Mr. [**Known lastname 28012**] symptoms of N/V and abominal pain
continued to worsen. The abdominal pain was described as
epigastric, radiating around his left flank. He has had mainly
dry heaves, as he has been unable to take any PO, or tolerate
tube feeds over the last week. He also c/o constipation, with
last stool 5 days ago, and described as yellow and well-formed.
He has been drinking fluids when he tolerates them, but less so
over the last few days. Of note, Mr. [**Known lastname 28011**] has been taking
[**7-20**] Extra Strengh tylenol pills per day over the last [**1-13**]
weeks. He denies any significant EtOH use or ingestions,
including mushrooms. He denies any fevers, CP, SOB, URI
symptoms, or dysuria. He did have a tooth extraced at the
dentist last week.
.
In the ED, initial VS were T: 96.6F, HR: 118, BP: 141/84, RR:
20, SaO2: 100% RA. Initial labs were notable for elevated wbc to
19.3 with 82N, a significant transaminitis (AST 406, ALT 519,
Alk phos 202, Tbili 0.7, normal pancreatic enzymes), and a
markedly elevated anion gap on Chem-10 (AG 27) with bicarb <5.
Coags 13.7/39.3/1.2. His LFTs were normal at his ED visit of
[**2158-7-15**]. Serum tox was notable for elevated acetaminophen level
to 21.3, and urine tox was positive for opioids. Pt had large
serum acetone, serum osm 297, and urine ketones of 150 with
otherwise normal UA. Pt underwent abd/pelvis CT which
demonstrated fluid collections anterior to stomach, 4.5 x 3.1 cm
and 3.4 x 2.4 cm, thought to most likely represent normal
post-operative seromas, unchanged from prior CT of [**2158-7-18**].
Surgery was consulted in ED, who agreed that CT changes c/w
normal post-operative changes, and not with abscess. A L SC line
was placed, he was administered 4L NS, given Levofloxacin 500mg
IV, Metronidazole 500mg IV, and IV N-acetylcysteine 9.8gm IV per
weight-based protocol. He was started on D5 1/2NS at 125mL/hr.
Toxicology was consulted for APAP ingestion, who recommended q4h
NAC protocol with q4h monitoring of LFTs, APAP level, and coags.
Subsequent 1am labs demonstrated improving LFTs (AST 282, ALT
279, Aphos 145, Tbili 0.4) and APAP level (8.8). An initial ABG
was done at this time, and confirmed a metabolic acidosis at
7.13/20/133. AG closing to 21. He was transferred to the [**Hospital Unit Name 153**]
for further management with the preliminary diagnosis of
acetaminophen toxicity overlying subacute starvation
ketoacidosis in setting of recent gastric bypass
Past Medical History:
1) h/o gastric bypass [**3-16**]
2) Hepatitis C: Believes he contracted this at age 13 during
blood transfusions. Also has many tattoos. Denies any h/o IVDU.
3) DM: States blood sugars have been well controlled since
operation, in 120s-130s. Diet-controlled.
4) HTN
5) h/o CCY [**2150**]
Social History:
Non-smoker, denies significant EtOH history, and no EtOH since
bypass operation. Denies ever using IV drugs. Has several
tattoos.
Family History:
history of colon cancer in 2 uncles
Physical Exam:
VS: T: 96.6F BP: 118/68 HR: 56 RR: 18 SaO2: 98% RA
Gen: Well Caucasian male, looking stated age
HEENT: Sclerae anicteric, PERRLA, disconjugate gaze
Neck: Supple, no LAD or thyromegaly
CV: Tachycardic, regular rhythm, nl S1 and S2, no m/r/g
Chest: CTA B/L
Abd: Soft, non-distended, non-tender, PEG site non-erythematous,
no discharge, +BS, no appreciable HSM or ascites, no spider
angiomata or caput medusae.
Extr: 2+ DPs, - CCE
Neuro: A&Ox3, no focal deficits, no asterixis.
Pertinent Results:
CT OF THE ABDOMEN WITH IV CONTRAST: The visualized lung bases
are clear. The patient is status post Roux-en-Y gastric bypass.
There has been placement of a percutaneous gastrostomy in the
excluded portion of the stomach. There is free passage of oral
contrast through the excluded portion of the stomach, duodenum,
native jejunum and through the jejunostomy to the descending
colon without evidence of obstruction. The afferent limb of
jejunum is noted to be mildly distended prior to the jejunostomy
up to 2.5 cm diameter but not
frankly dilated. The included gastric pouch and efferent limb of
jejunum are not opacified. There has been no significant change
in two well-marginated discrete fluid collections anterior to
the antrum of the stomach, the larger measuring 4.5 x 3.1 cm and
the smaller 3.4 x 2.4 cm. These are more likely considered to
represent seromas, however abscess cannot be definitively
excluded. There is mild expected stranding around the tract of
the percutaneous gastrostomy. No new fluid collection or abscess
is identified. The liver, spleen, adrenal glands and kidneys are
unremarkable. The gallbladder is surgically absent. There is no
free intra-abdominal air.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, prostate, seminal
vesicles, urinary bladder and pelvic loops of bowel are
unremarkable. There is no free pelvic fluid or lymphadenopathy.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions
are
identified.
IMPRESSION:
1. Status post Roux-en-Y gastric bypass and placement of
percutaneous
gastrostomy into the excluded portion of the stomach. Mild
distention of the afferent jejunal limb prior to the jejunostomy
but no evidence of obstruction.
2. No change in two discrete fluid collections anterior to the
antrum of the stomach which are thought more likely to represent
seromas, however abscess cannot be definitively excluded.
.
CXR:
The heart size and cardiomediastinal contours are within normal
limits. There has been placement of a left subclavian central
catheter which terminates in the proximal third of the SVC.
There is no pneumothorax. The lungs are clear without focal
consolidation or pleural effusion. Surrounding soft tissues and
osseous structures are within normal limits.
IMPRESSION: Left subclavian central catheter terminates in the
proximal SVC. No pneumothorax.
Brief Hospital Course:
1) Acetaminophen toxicity: Initial acetaminophen level 21.3,
with ingestion taking place over last 2 weeks and evidence of
hepatotoxicity, meeting criteria for NAC protocol. Received dose
1 of IV mucomyst in ED per protocol, tox aware. LFTs and APAP
level trending down.
- Pt completed IV NAC at 4.9gm IV q4h x total 12 doses
- q12h LFTs->trending down, daily APAP levels->undetected
- Hold other hepatotoxic agents
2) Transaminitis: Most likely entirely [**1-12**] acetaminophen
toxicity. Pt does have Hep C, but LFTs normal 1 week ago. No
other concurrent ingestions, no EtOH use, low suspicion of
overlying viral hepatitis.
- Will treat acetaminophen toxicity as above
- If levels do not consistently and predictably decrease, will
send hepatitis panel and explore other possible etiologies
- Hold hepatotoxic agents
3) Anemia: Spurious hct drop with orthostasis today, some
element of hemodilution suspected as pt. aggressively volume
resuscitated with +5L since admission but also blood loss via GI
tract as stool OB +, hemolysis labs negative. EGD did not reveal
obvious source of bleeding, rec. MRA to assess for ischemia to
blind loop of jejunum as source of abd pain/bleeding but pt. can
not be MRI'd [**1-12**] cochlear implant so CTA might be a good choice
to assess celiac axis. Pt had colonscopy after many-many preps
and attempts, finally clear and result: WNL.
5) N/V/Abd pain: Unclear etiology, as this is not common sequela
of bariatric surgery. Possilbe obstruction from
adhesions/stenosis, possible gastroparesis. Has had inpatient
work-ups in past at [**Hospital1 2177**] with no clear diagnosis, per pt.
Anastamotic leak/stenosis not evident on EGD. Possibly related
to blind loop ischemia.
- pt to have capsule endoscopy in [**3-16**] weeks as an outpatient.
- also had PEG site cellulitis which resolved with keflex
- pt improved with heavy laxitives (5 gallons of golytely) which
appears to have cleared his constipation.
6) Leukocytosis: now resolved. Unclear etiology. Aside from
abdominal symptoms, no localizing symptoms. CXR and UA
demonstrate no evidence of PNA or UTI, respectively. Did have
tooth removed last week, raising possibility of transient
bacteremia, but this should have resolved by now unless seeding
another source. Pt is s/p CCY, abdominal CT not demonstrating
any clear source of infection, other than fluid collection that
appears to represent seroma.
- - blood cultures
7) Hepatitis C: States infected age 13, no apparent LFT
abnormalities from 1 week ago, no stigmata of chronic liver
disease.
8) DM: Diet-controlled, better control since bariatric surgery
- SSI, qid FS
9) Depression/Anxiety:
- Holding seroquel until LFTs normalize
- Continue ativan for anxiety
10) Contact: Wife, [**Name (NI) 28013**] [**Telephone/Fax (1) 28014**]
11) Dispo: c/o to floor
Discharge Medications:
1. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Conspitation
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital if you experience: black tarry stools,
rectal bleeding, nausea, vomitting
Followup Instructions:
Please make an appointment at the [**Hospital1 18**] GI Motility Center in
[**3-16**] weeks for a capsule endoscopy at ([**Telephone/Fax (1) 2233**]
Please make an appointment with your doctor, [**Doctor Last Name **],[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 13985**] [**Telephone/Fax (1) 13987**] within the next few weeks
|
[
"300.4",
"V45.3",
"536.41",
"276.0",
"965.4",
"E850.4",
"280.0",
"401.9",
"564.00",
"578.9",
"070.54",
"682.2",
"787.01",
"250.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
10233, 10239
|
7024, 9844
|
319, 332
|
10295, 10301
|
4664, 7001
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10446, 10794
|
4116, 4153
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9867, 10210
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10260, 10274
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10325, 10423
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4168, 4645
|
231, 281
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360, 3640
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3662, 3953
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3969, 4100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,939
| 196,879
|
7904
|
Discharge summary
|
report
|
Admission Date: [**2184-3-16**] Discharge Date: [**2184-3-19**]
Date of Birth: [**2110-4-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
abd pain and sycope
Major Surgical or Invasive Procedure:
colonoscopy
EGD
History of Present Illness:
73 y/o M w/past hx of CAD, mycotic aneurysm post-cath s/p iliac
artery rsxn [**2172**], s/p R iliac aneurysm repair [**2177**], s/p fem-fem
bypass [**2169**], diverticulosis, angiodysplasias, ?Crohn's, afib on
coumadin, who presented to [**Hospital3 417**] Medical Center today
after a syncopal episode. He reported being in his USOH until
today at lunch when he had a hot dog and hot chocolate.
Immediately after eating he developed severe epigastric pain.
He stood up and then passed out (denies prodrome), falling to
the floor and losing consciousness for a couple of minutes
(witnessed fall.) He then called EMS and went to the hospital.
He also had an episode of non-bloody, non-bilious vomiting.
*
At the OSH, he was initially hypotensive to the 90s/50s which
improved to 120s after IVF. In their ED, he had 3 episodes of
melena/"approx 5 L bloody diarrhea" per their notes. He was
bolused with nexium and placed on a drip. His INR was 2.3 and
so he was given vitamin K 10 units SQ. He was transfused 2U
PRBCs for Hct 34. NGT was placed. He had an abd CT w/IV
contrast that showed ? of R common iliac pseudoaneurysm vs
dissection vs focal hemorrhage, with track from iliac artery to
distal small bowel. Reattempt at CT w/po contrast was unable to
opacify bowel; per their radiologist, CT was unable to r/o
ilioenteric fistula. At this point he was transferred here,
given that his vascular surgeon (Dr. [**Last Name (STitle) 1391**] is here and given
concern for ilioenteric fistula. His creatinine was 1.6 so he
was given a liter of D5W w/3 amps bicarb and mucomyst.
*
In our ED, he was hypertensive in the 150s-160s but was
otherwise unchanged. He has had no further episodes of melena.
He is currently without complaints and his epigastric pain has
resolved completely. Here, his hematocrit is 33 (down from 34
at the other hospital that was pre-transfusion of 2 units), INR
2.6 (up from 2.3 s/p vitamin K), and creatinine is improved to
1.1. Cardiac enzymes negative. He was evaluated by vascular
surgery who recommended a repeat CT scan with IV contrast after
hydration. GI was notified as well.
Past Medical History:
1. Diverticulosis (on colonoscopy 2 yrs ago)
2. Angiodysplasias
3. PVD - fem-fem bypass (goretex)
4. CAD - had cath [**2172**] w/PTCA to LAD and D1. afterward
developed mycotic aneurysm which required iliac artery resxn.
subsequently developed R iliac artery aneurysm in [**2177**] which was
resected.
5. ATN secondary to gentamicin
6. Hypercholesterolemia
7. s/p EGD in [**2182**], underwent dilation (per pt)
8. Afib
9. Crohn's (has been on asacol in past but not currently)
Social History:
Lives in [**Location 15289**] with his wife. PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 9872**] at [**Hospital1 1474**]. Smoked 1 ppd x 30 yrs, quit 30 yrs ago.
No EtOH. Works as a food broker. Has 36 y/o daughter who lives
near here.
Family History:
Brother died of MI at age 39, brother died last year of eastern
equine encephalitis, sister died from breast Ca, sister died
from leukemia, mother died from CVA, father died from lung Ca.
Physical Exam:
T: 97.9 BP: 167/108 P: 72 R: 12 O2 sat: 98% on 4LNC
Gen: well-appearing elderly male in NAD
HEENT: NC, AT, perrl, eomi, anicteric, MMM, NGT in place
Neck: supple, no LAD, JVD flat
Lungs: CTA bilaterally, somewhat decreased air movement
throughout but no w/r/c
CV: RRR, II/VI SEM at LSB
Abd: soft, nt/nd, normoactive bowel sounds.
Ext: trace pedal edema. 1+ dp/femoral pulses bilaterally.
Neuro: CN II-[**Doctor First Name 81**] intact, MAEW.
Pertinent Results:
[**2184-3-16**] 01:45AM BLOOD PT-25.4* PTT-28.6 INR(PT)-2.6*
[**2184-3-16**] 05:37AM BLOOD WBC-9.2 RBC-3.93* Hgb-10.8* Hct-32.3*
MCV-82 MCH-27.5 MCHC-33.5 RDW-14.4 Plt Ct-213
[**2184-3-19**] 06:25AM BLOOD WBC-7.7 RBC-3.95* Hgb-11.0* Hct-32.1*
MCV-81* MCH-27.8 MCHC-34.3 RDW-14.6 Plt Ct-210
.
CT-A abdomen and pelvis [**2184-3-17**]:
1. Pseudoaneurysm sac arising from the mid portion of the right
common iliac artery measuring up to 3.7 cm with arterial-phase
filling of the
pseudoaneurysm posteriorly most likely from retrograde filling
via the distal right external and right common iliac arteries.
The pseudoaneurysm sac points medially from the mid portion of
the right common iliac artery. There is a focal 2- to 3-cm
segment of adherent mid small bowel, which in the clinical
setting described is suspicious for the possibility of arterial
enteric fistula. The absence of extravasation of contrast on
this arterial- phase scan by no means exclude this possibility.
If the patient is hemodynamically stable further imaging with
nuclear medicine red cell labeled scan may provide further
information if delayed bleeding from the area along bowel can be
demonstrated.
.
2. Moderate diverticulosis in the lower left and sigmoid colon
without
evidence of acute inflammatory change to suggest a likely cause
of PR bleeding at present.
.
3. Chronic mild thickening of the distal 20 cm of the distal
ileum and
terminal ileum with adjacent thickening of the serosal fat.
Appearance is
most consistent with chronic Crohn's disease without findings to
suggest acute inflammatory change or stricture.
.
4. Findings in the included portion of the proximal left femur
most
consistent with early Paget's disease.
.
[**2184-3-17**] ECG: Sinus rhythm. Prolonged A-V conduction. Right
bundle-branch block. Left anterior hemiblock. Voltage for left
ventricular hypertrophy. Compared to the previous tracing of
[**2184-3-15**] the QRS interval has widened. Otherwise, no significant
change.
.
[**2184-3-14**] ECG: Sinus rhythm. First degree A-V block. Right
bundle-branch block with left anterior fascicular block.
Non-specific T wave changes. No previous tracing available for
comparison.
Brief Hospital Course:
73 y/o M w/past hx of CAD, mycotic aneurysm post-cath s/p iliac
artery rsxn [**2172**], s/p R iliac aneurysm repair [**2177**], s/p fem-fem
bypass [**2169**], diverticulosis, angiodysplasias, Crohn's, afib on
coumadin, who presented to [**Hospital3 417**] Medical Center [**2184-3-16**]
after a syncopal episode. There, the patient was found to have
BRBPR and had a CT scan which showed possible communication
between an iliac psuedoaneurysm and the small bowel. He was
transferred to [**Hospital1 18**] because his primary vascular surgeon, Dr
[**Last Name (STitle) 1391**], is here. He was transfused with 2 units of PRBC in
the ED, but subsequent hematocrits did not increase
appropriately. Nasogastric lavage recovered no blood, suggsting
that the lower GI tract was the source of bleeding. On
admission, Vascular and GI were made aware as concerned for
possible ilio-enteric fistula and lower GI bleed from the
fistula or diverticulosis. While on the floor the morning of
admission, he had two large bloody BMs with clots and stool, and
began to feel symptoms of orthostasis. Given the concern for
impending hemodynamic instability and the need for multiple
further studies, the pt. was transferred to the MICU for urgent
EGD and colonoscopy.
.
In the MICU, coumadin was held and the pt's anticoagulation was
reversed with FFP. He had an EGD that showed a Schatski's ring
and no evidence of bleeding except some NG trauma. Colonoscopy
showed multiple diverticuli, but no source of active or old
bleeding. CTA of abdomen was also done, but ilio-enteric fistula
could still not be ruled out. He received one unit of PRBC.
After transfer back to the floor his hematocrit remained stable
and he did not require any more transfusions. The pt. did not
have any syncopal episodes symptoms during his hospital course,
and his initial syncope was thought to be vasovagal or
LGIB-related. His home blood pressure medications were
re-started, as he was hemodynamically stable and began to have
high blood pressures.
.
The pt. was discharged in a stable condition, with no signs of
active bleeding or orthostasis, ambulatory, and with good PO
intake. He was told not to take his coumadin for the time
being, and to discuss re-starting coumadin with his primary care
provider. [**Name10 (NameIs) **] was discharged with follow-up appointments
scheduled for a repeat CT-A, with his primary care provider, [**Name10 (NameIs) **]
with Dr. [**Last Name (STitle) 1391**] from vascular surgery for pseudoaneurysm
management.
Medications on Admission:
Atenolol 50 mg [**Hospital1 **]
Lasix 20 mg daily
Nifedipine (adalat CC) 60 mg SA daily
Simvastatin 20
Losartan 50
Coumadin 5 mg po qhs
Norpace 200 q12
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Disopyramide 100 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO Q12H (every 12 hours).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Lower gastrointestinal bleed
Diverticulosis
Right iliac artery pseudoaneurysm
Secondary diagnoses:
Paroxysmal atrial fibrillation
Coronary artery disease
Peripheral vascular disease
Crohns disease
Discharge Condition:
Stable
Discharge Instructions:
Return to emergency department if you develop bright red blood
in your stools, begin to have very black, tarry stools, have
lightheadedness, chest pain, shortness of breath, palpitations,
or any other worrisome symptoms.
.
Please keep your follow-up appointments including the CT of
abdomen.
.
Please take medications as instructed. We stopped your coumadin
because of bleeding. Discuss with your primary care physician
when to restart coumadin if at all.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2184-3-22**] 1:30.
[**Hospital Ward Name **] [**Location (un) 470**]. Please arrive by 12:30 PM for contrast
(IV) preparation. Do not take solid food three hours prior to
CT of abdomen. You may take your morning medications with water
in AM.
.
You have an appointment with Dr. [**Last Name (STitle) 9872**] on Tuesday [**2184-3-23**] at
2:00 PM.
.
You have an appointment with Dr. [**Last Name (STitle) 1391**] on [**2184-3-24**] at 1:00 PM.
Phone number: ([**Telephone/Fax (1) 4852**]. He will go over CT of abdomen
result with you.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"276.50",
"414.01",
"442.2",
"584.9",
"555.9",
"427.31",
"401.9",
"553.3",
"285.1",
"530.3",
"V45.82",
"530.81",
"569.84",
"440.20",
"272.0",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"99.07",
"45.13",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9345, 9351
|
6188, 8713
|
308, 325
|
9611, 9620
|
3981, 6165
|
10126, 10870
|
3309, 3498
|
8915, 9322
|
9372, 9469
|
8739, 8892
|
9644, 10103
|
3513, 3962
|
9490, 9590
|
249, 270
|
353, 2477
|
2499, 2978
|
2994, 3293
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,265
| 160,946
|
53503
|
Discharge summary
|
report
|
Admission Date: [**2194-6-16**] Discharge Date: [**2194-6-24**]
Date of Birth: [**2123-6-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheal stenosis
Major Surgical or Invasive Procedure:
[**2194-6-16**]: Cervical tracheal resection and reconstruction,
flexible bronchoscopy with bronchoalveolar lavage, sternothyroid
muscle flap buttress.
[**2194-6-23**]: Flexible Bronchoscopy
History of Present Illness:
The patient is a 70-year-old gentleman who has had longstanding
tracheostomy and has failed decannulation. He has a significant
stenosis at the
level of the cricoid and first ring. He failed an attempt at
dilation and required replacement of a tracheostomy following
decannulation. He is here for surgical resection.
Past Medical History:
-COPD on O2 x 6yr, underwent trach at [**Hospital **] Hospital in [**1-14**]
that was later decannulated [**4-14**].
-CAD s/p CABG x3/tissue AVR'[**88**] ([**Hospital1 112**])
-PAF s/p multiple DCCV on coumadin
-HTN
-back surgery '[**61**]
-RLE osteo '[**61**]
-spinal decompression '[**86**]
-EtOH abuse (sober x 6 mos)
Social History:
Married, came from [**Hospital1 **] rehab.
Cigarettes [x] ex-smoker Pack-yrs: 100+, quit: [**2188**]
ETOH: [x] No (sober 6 months) previously 4 drinks/day
Family History:
Mother smoker died of lung cancer
Father smoker died of lung cancer
Physical Exam:
Discharge Physical Exam
VS: T: 97.9 HR: 77 AF BP: 130/70 SatsL 97 1.5 L Wt: 88.8
General: 71 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple. no stridor
Card: RRR, normal S1,S2 II/VI SEM
Resp: decreased breath sounds bilateral 1/4 up. no wheezes or
crackles
GI: benign
Extr: warm no edema
Incision: cervical clean dry intact, no erythema. margins well
approximated
Neuro: awake, alert oriented.
Pertinent Results:
[**2194-6-23**] WBC-4.9 RBC-3.31* Hgb-10.1* Hct-30.3 Plt Ct-214
[**2194-6-16**] WBC-6.8# RBC-3.63* Hgb-10.9* Hct-32.8 Plt Ct-218
[**2194-6-24**] PT-15.3* INR(PT)-1.3
[**2194-6-23**] PT-14.5* PTT-26.9 INR(PT)-1.3
[**2194-6-19**] PT-13.4 PTT-27.9 INR(PT)-1.1
[**2194-6-24**] Glucose-93 UreaN-14 Creat-0.5 Na-143 K-3.4 Cl-105
HCO3-33
[**2194-6-23**] Glucose-93 UreaN-13 Creat-0.6 Na-143 K-3.4 Cl-104
HCO3-32
[**2194-6-16**] Glucose-91 UreaN-7 Creat-0.6 Na-140 K-4.3 Cl-105
HCO3-26
[**2194-6-24**] Calcium-8.5 Phos-3.3 Mg-1.8
CXR:
[**2194-6-22**]: There is background COPD. The patient is status post
sternotomy and placement of prosthetic valve, with cardiomegaly
and a relatively transverse orientation of the heart. There is
bibasilar patchy opacity -- this most likely represents
atelectasis, though small pneumonic consolidation would be
difficult to exclude. There are small bilateral effusions and/or
pleural thickening. No CHF. A focal rounded area of relative
lucency is seen along the right heart border in the
cardiophrenic region -- this likely represents artifact due to
surrounding opacity, but attention to this area on followup
films is recommended.
Compared with [**2194-6-19**] at 5:48 a.m. and allowing for technical
differences, there has been possible minimal improvement at the
left base and slight interval decrease in the degree of upper
zone redistribution. Otherwise, I doubt significant interval
change.
Brief Hospital Course:
Mr. [**Known lastname 8389**] was taken to the operating room on [**2194-6-16**] by Dr.
[**Last Name (STitle) **] for cervical tracheal resection and reconstruction,
flexible bronchoscopy with bronchoalveolar lavage, and
sternothyroid muscle flap buttress. He was transferred to the
ICU intubated on pressors. Pressors were weaned off overnight.
POD 1 he was started on Lasix which continued until [**2194-6-19**],
when he was able to extubate. Bedside bronchoscopy was done
prior to extubation for thick secretions. He transferred to the
floor [**2194-6-20**]. Below is a systems review of his hospital course:
Pulm: After extubation he continued use of incentive spirometry
with nebulizers.
He was able to mobilize secretions. He remained afebrile without
WBC count on the floor. Flexible bronchoscopy was performed in
the OR on [**2194-6-23**] revealing patent airway and intact
anastomosis. Guard suture was removed. Home oxygen 2 Liters, he
titrated down to 1.5 L with oxygen saturations of 96-97%.
CV: He remained in rate controlled atrial fibrillation 70-80's.
Hemodynamically stable 120-140.
GI/nutrition: The patient failed initial swallow evaluation
[**2194-6-20**] and remained NPO. Repeat swallow on [**2194-6-23**]. He was
started on a soft solid, thickened puree diet. Small frequent
meals. Medications, Small pills swallowed whole with applesauce,
larger pills crushed in applesauce or split in half. Home
medications were resumed once taking PO's. Aggressive bowel
regime with good results.
GU: His [**Known lastname 8389**] was placed after surgery, DC'ed [**2194-6-20**] and
replaced that day due to urinary retention. Flomax was started.
His [**Known lastname 8389**] was DC'ed [**2194-6-24**] midnight flomax was increased to [**Hospital1 **]
he voided.
Renal: renal function within normal limits. Home diuretics were
continued with good urine output. Electrolytes were replete as
needed.
Endo: Insulin sliding scale with blood sugars to maintain blood
sugars < 150
Heme: Coumadin 4mg resumed [**2194-6-23**] without bridge. INR [**2194-6-24**]
1.3 for Goal INR 2.0-2.5 for chronic atrial fibrillation.
Pain: well control with IV Dilaudid transition to PO oxycodone.
Brief episodes of anxiety responded well to his home dose of prn
lorazepam.
Disposition: He was followed by physical therapy who recommended
rehab. He continued to make steady progress and was discharged
to [**Hospital1 **] [**Location (un) 701**] [**Telephone/Fax (1) 109992**] on XXX. He will
return [**2194-7-9**] for flexible bronchoscopy with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **].
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 2.5 mg/0.5
mL Solution for Nebulization - 1 trach q 2h as needed
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other
Provider)
- 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth
every 6 hours
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 500 mcg-50 mcg/Dose Disk with Device - 1 inh po once
a day
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth q 4h as needed
SPIRONOLACTONE - (Prescribed by Other Provider) - 25 mg Tablet
-
1 Tablet(s) by mouth daily
TAMSULOSIN - (Prescribed by Other Provider) - 0.4 mg Capsule,
Ext Release 24 hr - 1 Capsule(s) by mouth at bedtime
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by
Other Provider) - 18 mcg Capsule, w/Inhalation Device - 1 inh po
once a day
WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 2
Tablet(s) by mouth QPM
LOPERAMIDE [LO-PERAMIDE] - (Prescribed by Other Provider) - 2
mg
Tablet - 1 Tablet(s) by mouth q 6h as needed
MICONAZOLE NITRATE - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for SOB.
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
6. furosemide 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once a day:
Daily weight adjust dose accordingly.
7. spironolactone 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
10. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Ext Release 24 hr PO twice a day.
12. warfarin 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4
PM: Dose to maintain INR 2.0-25. for Afib.
13. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. loperamide 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6)
hours as needed for loose stools.
15. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Tracheal stenosis s/p tracheal resection and reconstruction
COPD on O2 2L x 6yr,
Coronary Artery Disease s/p CABG x3/AVR (tissue)[**2188**]
Atrial Fibrillation s/p multiple DCCV on Coumadin
Hypertension
RLE osteo [**2161**]
EtOH abuse (sober x 6 mos)
PSH: Back surgery [**2161**]
spinal decompression [**2186**]
Tracheostomy ([**2194-1-22**] - decannulated [**4-14**]), replacement of
tracheostomy ([**2194-5-15**])
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:
Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101.5, chills
-Increased shortness of breath, stridor, chest pain or cough
-Neck incision develops increased redness or drainage
Activity:
-Shower daily. Wash incisions with mild soap & water, rinse pat
dry
-No tub bathing until incision healed
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] [**2194-7-9**] for flexible
bronchoscopy.
Please report to the [**Hospital Ward Name 517**] Clinical Center at 9:00 for a
10:30 procedure
NOTHING TO EAT OR DRINK AFTER MIDNIGHT [**2194-7-9**] for flexible
bronchoscopy
Completed by:[**2194-6-24**]
|
[
"V58.61",
"V45.81",
"427.31",
"496",
"519.02",
"519.19",
"V42.2",
"V46.2",
"E879.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"31.74",
"33.22",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9180, 9252
|
3415, 4010
|
328, 522
|
9713, 9713
|
1959, 3392
|
10275, 10600
|
1407, 1477
|
7284, 9157
|
9273, 9692
|
6057, 7261
|
4028, 6031
|
9896, 10252
|
1492, 1940
|
271, 290
|
550, 870
|
9728, 9872
|
892, 1215
|
1231, 1391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,672
| 193,172
|
35002
|
Discharge summary
|
report
|
Admission Date: [**2167-9-19**] Discharge Date: [**2167-10-31**]
Date of Birth: [**2111-10-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Persistent respiratory failure
Major Surgical or Invasive Procedure:
Was transferred already intubated
History of Present Illness:
55 year old woman with hx of obesity presented to [**Hospital 1727**] Medical
Center on [**2167-9-10**] after falling down stairs while at home. She
suffered a traumatic T5-8 fracture with retropulsion of
fragments. Per medical records and discussion with her brother,
she was awake for the fall (no LOC) and the fall was triggered
by unsteady gait, potentially influenced by alcohol.
Her fracture was managed concervatively. She was placed in a
torso brace but her course was complicated by respiratory
failure requiring intubation. At that time a CT was negative for
PE but showed bilateral bibasilar consolidations vs atelectasis.
At that time an ABG was 7.2/89/57 (unknown FIO2 but likely >6L
facemask). She was intubated on [**2167-9-12**] at 08:40. The
respiratory failure was thought likely to be related to pain med
induced hypoventilation, bronchospasm, or restricted breathing
due to the back brace. The [**Hospital 228**] hospital course was
complicated by difficulty weaning form the ventilator. Her
periodic agitation was managed with seroquel. Prior to transfer
her vent settings were: SIMV 12x600 [**10-18**] FIO2 0.45.
The neurosurgery service evaluated her and recommended
concervative management of her fracture including a back brace
and outpatient neurosurgery followup. The CT chest showed
notable narrowing of her central airways and the patient was
referred for Interventional Pulmonary evaluation for airway
stenting.
Past Medical History:
s/p TAH
s/p appendectomy
remote benign breast mass
Social History:
regional manager at insurance company. Lived with boyfriend >
10 years. Boyfriend has POA. has not been in contact with her
brother in ~1 year, however, brother has visited her frequently
while in the hospital. drinks EtOH. unknown cigarrette smoking.
Family History:
NC
Physical Exam:
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL, Sclera edema
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Rhonchorous: bilaterally)
Abdominal: Soft, Non-tender, Bowel sounds present, Distended,
Obese
Extremities: Right: Trace, Left: Trace, Cyanosis
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Sedated, Tone: Not
assessed
Pertinent Results:
******Pertinent Lab Results*******
[**2167-9-20**] 01:00AM BLOOD WBC-9.7 RBC-3.58* Hgb-9.7* Hct-30.7*
MCV-86 MCH-27.0 MCHC-31.5 RDW-13.3 Plt Ct-333
[**2167-10-29**] 03:23AM BLOOD WBC-5.1 RBC-2.77* Hgb-7.2* Hct-23.7*
MCV-86 MCH-26.0* MCHC-30.4* RDW-14.8 Plt Ct-187
[**2167-9-20**] 01:00AM BLOOD PT-13.8* PTT-22.4 INR(PT)-1.2*
[**2167-10-11**] 05:01AM BLOOD PT-72.4* PTT-42.1* INR(PT)-9.0*
[**2167-10-28**] 04:05AM BLOOD PT-13.3 PTT-32.4 INR(PT)-1.1
[**2167-9-20**] 01:00AM BLOOD Glucose-103 UreaN-6 Creat-0.6 Na-150*
K-3.8 Cl-109* HCO3-30 AnGap-15
[**2167-10-29**] 03:23AM BLOOD Glucose-105 UreaN-17 Creat-0.5 Na-147*
K-3.8 Cl-108 HCO3-35* AnGap-8
[**2167-9-20**] 01:00AM BLOOD ALT-30 AST-19 LD(LDH)-222 AlkPhos-149*
TotBili-0.7
[**2167-10-15**] 07:34AM BLOOD ALT-25 AST-19 LD(LDH)-192 AlkPhos-106
TotBili-0.2
[**2167-9-20**] 01:00AM BLOOD Albumin-3.0* Calcium-8.6 Phos-4.1 Mg-2.1
[**2167-10-29**] 03:23AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
[**2167-9-30**] 03:06PM BLOOD FSH-4.1 Prolact-48*
[**2167-10-14**] 03:20PM BLOOD Prolact-37* TSH-0.39
[**2167-10-15**] 07:34AM BLOOD FSH-28*
[**2167-10-14**] 03:20PM BLOOD T3-110 Free T4-1.2
[**2167-10-15**] 07:34AM BLOOD T4-7.4
[**2167-9-21**] 03:01AM BLOOD Cortsol-4.5
[**2167-10-15**] 07:34AM BLOOD Cortsol-13.7
[**2167-9-20**] 05:01PM BLOOD Lactate-.8
[**2167-9-20**] 11:00PM BLOOD freeCa-1.18
[**2167-10-9**] 02:51AM BLOOD freeCa-1.24
******Microbiology******
[**2167-9-20**] 8:10 am URINE Source: Catheter.
Clinical significance of isolate(s)
uncertain. Interpret with caution.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
LACTOBACILLUS SPECIES. 10,000-100,000 ORGANISMS/ML..
[**2167-9-20**] 7:05 am SPUTUM Source: Endotracheal.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
LEGIONELLA CULTURE (Final [**2167-9-27**]): NO LEGIONELLA
ISOLATED.
[**2167-9-30**] 11:20 am Mini-BAL BRONCHIAL LAVAGE.
SENSITIVITIES: MIC expressed in
MCG/ML
____________________________________________________
KLEBSIELLA OXYTOCA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 16 I 4 S
CEFAZOLIN------------- 16 I <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 2 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
[**2167-10-8**] 8:55 pm SPUTUM Source: Endotracheal.
KLEBSIELLA OXYTOCA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 8 S 4 S
CEFAZOLIN------------- 8 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 2 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
[**2167-10-14**] 2:00 am SPUTUM Source: Endotracheal.
RESPIRATORY CULTURE (Final [**2167-10-16**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA OXYTOCA. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 80037**],[**2167-10-13**].
gram stain reviewed: 2+ (1-5 per 1000X FIELD): GRAM
NEGATIVE
ROD(S). were observed [**2167-10-15**].
[**2167-9-22**] 9:55 am STOOL CONSISTENCY: FORMED Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2167-9-23**]):
Feces negative for C.difficile toxin A & B by EIA.
[**2167-10-15**] 7:34 am STOOL CONSISTENCY: FORMED Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2167-10-15**]):
Feces negative for C.difficile toxin A & B by EIA.
[**2167-10-29**] 5:52 am STOOL CONSISTENCY: WATERY Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Pending):
******IMAGING******
UNILAT UP EXT VEINS US RIGHT PORT Study Date of [**2167-9-20**] 11:50
AM
1. Non-occlusive right axillary deep vein thrombus.
2. Non-occlusive right basilic superficial thrombosis.
Portable TTE (Complete) Done [**2167-9-21**] at 3:37:45 PM FINAL
The left atrium and right atrium are normal in cavity size.
Suboptimal saline contrast study does not suggest an
intracardiac shunt. 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 and
free wall motion are normal. The aortic valve leaflets appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. .The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild-moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Preserved global
biventricular systolic function. Mild-moderate pulmonary artery
systolic hypertension.
CT CHEST W/O CONTRAST Study Date of [**2167-10-5**] 5:23 PM
1. Improving bilateral consolidations and effusions. No
loculated effusion
identified. Persistent atelectasis/consolidation at the lower
lobes
bilaterally with small effusions, possibly secondary to
aspiration.
2. Evidence of tracheobronchomalacia.
3. Evidence of slight overinflation of the tracheostomy cuff.
4. Cholelithiasis.
5. Right thyroid nodule. Ultrasound for further evaluation as
clinically
indicated would be recommended when patient is stable.
CT ABDOMEN W/CONTRAST Study Date of [**2167-10-20**] 3:39 PM
1. No acute intra-abdominal process, without evidence of
obstruction.
2. Atelectasis of both lung bases, with suggestion of
tracheobronchomalacia, which may be related to chronic
tracheostomy. This can be further evaluated with a CT trachea.
3. Cholelithiasis.
4. Diverticulosis without diverticulitis.
CHEST (PORTABLE AP) Study Date of [**2167-10-28**] 3:21 AM
Chest radiographs from [**10-27**] and [**2167-10-26**]. The
study is limited due to motion artifact, but overall, there is
no change in bilateral significant atelectasis involving lower
lobes and right middle
lobe. The upper lungs are ventilated. The tracheostomy is low
with its tip
projecting less than 2 cm above the carina. Pleural effusion
cannot be
excluded.
Brief Hospital Course:
55 year old woman with history of EtOH abuse presenting
following mechanical fall and traumatic T spine fracture. She
was intubated at an outside hospital [**2167-9-12**] for unclear
etiology and was transferred while intubated.
# Respiratory failure and Ventilator Associated PNA: Upon
transfer, the patietn was already intubated for initial unclear
etiology. With further evaluation, the cause was likely
multifactorial and she was found to have a significant pneumonia
soon after transfer. Initial blood and sputum cultures were
negative. Given poor status, patient was started [**2167-9-20**] on
Vancomycin, Aztreonam, Flagyl and Levofloxacin. [**2167-9-23**]
Metronidazole was discontinued. [**9-25**] Aztreonam was
discontinued. [**9-27**] Levofloxacin was discontinued. During this
time, she continued to be diuresed and had stress-dose steroids
and required vasopressor support.
Interventional Pulmonology was consulted to perform bronchoscopy
and provide further information regarding difficulty in weaning
patient and BAL was performed on [**9-30**]. The [**2167-9-30**]
pansensitive KLEBSIELLA OXYTOCA and KLEBSIELLA PNEUMONIAE grew
from BAL. She was optimized with inhalers including Albuterol
and Ipratroprium. She continued to be of a marginal respiratory
status and given failure to wean from the vent, she underwent
tracheostomy on [**2167-10-2**]. On [**2167-10-8**] she was restarted on
Vancomycin 1000 mg IV Q 12H, Aztreonam [**2159**] mg IV Q8H, and
Levofloxacin 750 mg IV Q24H for concern for recurrent VAP and
aspiration. Aztreonam and Vancomycin were stopped on [**10-10**]. On
[**10-11**] Levofloxacin was changed to Ceftriaxone. Ceftriaxone was
discontinued [**2167-10-15**]. Given concern for recurrent aspiration,
ENT was consulted to evaluate the patient. On [**2167-10-27**] VC exam,
revealed an inability to adduct the true vocal cords
posteriorly, raising concern for high aspiration risk.
Despite this, from that point on, Ms. [**Known lastname 42611**] has continued to
improve and has tolerated her tubefeeding with minimal
residuals. She continues to have intermittent mucous plugging
with appropriate desaturations, but these resolve with deep
suctioning. [**10-27**] the patient had further evaluation for
Passe-Muir valve. They left the following recommendations
including always deflate cuff prior to placing the Passy-Muir
valve; monitor O2 Sats / respiration while valve is in place; do
not allow the patient to sleep with the valve in place; patient
must be supervised wtih valve in place; and requires frequent
suctioning via yankauer with PMV in place. Ultimately, the PMV
wear schedule is up to the discretion of then nurse and/or
respiratory therapist. Scopalomine was started [**2167-10-26**] to
decrease secretions but was later discontinued due to possible
etiology of delirium.
# Hypotension. Patient was hypotensive upon presentation and
throughout a large portion of her hospital course. This was
intially concerning for hypovolemia and she was responsive to
transfusion. There was also concern for sepsis, and she was
treated with broad spectrum antibiotics as above. Ultimately,
she was successfully weaned from her pressor support on [**2167-10-9**].
# Oliguria: Initially patient was oliguric, which was likely
secondary to hypotension. Initial BUN:Cr was 6:0.6. Her
oliguria improved with fluid resuscitation and her renal
function continued to be stable throughout her stay.
# RUE DVT: Noted soon after arrival as site of prior PICC.
Started on heparin gtt on [**9-22**]. She was then transition to
Warfarin po. Initially she was therapeutic in one day; may be
related to poor nutritional status. Her INR ultimately
increased to 9 on [**2167-10-11**] and was difficult to maintain within
the appropriate range. Thus, she was transitioned to SQ Lovenox
and will be discharged on this medication. Given the provoked
DVT, patient should remain anticoagualated for at least 6
months.
# Abdominal distention: Noted on admission, presumed to be
chronic condition not requiring immediate medical attention. CT
abdomen only showed appendiceal mucocele without inflammation,
not concerning, most likely chronic. No concern for acute
intra-abdominal process. Originally constipated then began
having regular and somewhat loose bowel movements. C. diff
toxin was checked three times and was negative with each screen.
All abdominal labs inculding LFTs, amylase and lipase were
within normal limits.
# Anemia: Patient with initial HCT 30.7 but then dropped to 25
for unclear etiology. Given 1 unit PRBC with good results.
Original and ongoing anemia attributed partially to chronic
disease, as well as malnutrition. Stool was guaiaced and
negative. Upon discharge, her HCT was stable with results as
above.
# Spine fracture: Neurologically intact distal to the lesion.
Prior notes from MMC neurosurgeons indicated no surgical
procedure needed and would continue with spine brace.
Orthopedic Spine Service continued to follow and recommended no
surgical intervention. Ms. [**Known lastname 42611**] is to continue to wear her
current brace while out of bed or upright. Upon discharge, the
follow-up plan is for Ms. [**Known lastname 42611**] to see Dr. [**Last Name (STitle) 1007**] in 6 weeks and
remain in TLSO until then. No further imaging given extubated
and asymptomatic except for back pain over mid t-spine. She
should have new brace fitted upon discharge as she has lost
significant weight during hospital stay.
# Hypernatremia: Noted to be 150 on presentation secondary to
free water deficit. G-tube flushes were increased and her
sodium normalized appropriately.
# Concern for secondary adrenal insufficiency: The patient's
cortisol while intubated and on vasopressors only 2-4 range.
Question secondary adrenal insufficiency from a central source,
which could be further worked up at a later time. After trach
and weaning from pressor support, steroids were weaned without
changing eiter blood pressure or electrolyte balance.
# Ileus/Vomiting: Intially, patient tolerated tubefeeding but
later developed an ileus as seen on imaging and demonstrated
with decreased stool output. Given the duration of her ileus,
she was started on TPN [**2167-10-23**]. This was discontinued on
[**2167-10-28**]. Upon discharge we were continuing to increase her TF
goal to full strength replete with fiber at 60cc/hour. She was
also on Reglan 20mg IV Q 8 hours until she obtained goal rates
for tubefeeding. Ideally, Reglan should be discontinued as soon
as possible given his potential for delirium.
# Atrial tachycardia: Developed during hospital course.
Initially thought to be sinus tachycardia. She was evaluated
for PE with CTA, fluid challenged, thryoid was assessed and pain
medication was modified to alleviate her presumed sinus
tachycardia. Finally, EP was consulted, Adenosine was given and
she was diagnosed atrial tachycardia rather than sinus
tachycardia. Her initial HR was was in the 160s but then
improved to the 120s. She was loaded with Amiodarone [**10-22**].
Upon discharge, patient is well controlled on PO Amiodarone 200
TID and PO metoprolol 37.5mg TID. The plan will be to continue
continue amiodarone 200 TID for three weeks and then switch to
qday for 1 week and then discontinue amiodarone. The date of
discontinuation is [**2167-11-23**]. Upon discharge she will follow-up
with Dr. [**Last Name (STitle) **]. She was originally seen by Dr. [**Last Name (STitle) 2232**] while
inpatient. At this appointment, they may decide to discontinue
her Metoprolol as well as her Amiodarone.
# Sedation/Altered Mental Stats: Several days into hospital
course, patient developed delirium and agitation most likely
secondary to long hospital course and multiple psychotropic
medications as well as history of EtOH abuse. She was initially
treated with benzodiazepines and haldol without appropriate
effect. Given continued problems, psychiatry was ultimately
consulted. They recommended holding all benzodiazepines,
opiates and antihistamines and using both scheduled Risperdal
and Risperdal 0.5mg PO BID PRN. Her delirium improved greatly
after this point. Given continued Risperdal, her EKG was
monitored approximately every other day to assess for QTc
prolongation. At the time of discharge the patient was oriented
to person, time and year, but not location.
# Tracheomalacia. Noted on CT Scan [**2167-10-5**]. Reevaluation
bronchoscopy by IP was performed and it was determined the
patient was not a candidate for stent. There was no continuing
issues and patient should follow-up with Pulmomonary as an
outpatient.
# Thyroid Nodule: Noted on CT [**2167-10-5**] as a right thyroid nodule.
Ultrasound for further evaluation as clinically indicated would
be recommended when patient is stable. This should be followed
up as an outpatient.
# Glycemic control: No history of diabetes mellitus. Given
initial steroids, then TPN and tubefeeding, patient was kept on
a insulin sliding scale with appropriate control.
Medications on Admission:
Home Medications:
Ativan prn
Prilosec OTC
Medications on transfer:
dexmedetomidine
senna 2 tabs qhs
zofran 4 mg IV q6hr:prn
tinzaparin 4500 units q24
acetaminophen 650 mg q6prn
famotidine 20 mg IV daily
colace 100 mg [**Hospital1 **]
albuterol/ipratropium INH q4
seroquel 50 mg [**Hospital1 **]
lactated ringer's @75cc/hr
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**]-[**Location (un) 86**]
Discharge Diagnosis:
Respiratory failure, spinal fracture, tracheomalacia,
status-post tracheostomy
Discharge Condition:
Stable
Followup Instructions:
You have an appointment with an Otolaryngologist (ENT), Dr.
[**Last Name (STitle) **], on Tuesday, [**11-10**] at 3:30pm for evaluation of
your vocal cords. His office is located at the [**Hospital **] Medical
Center, [**Last Name (NamePattern1) **], [**Location (un) 895**], Suite 6E, [**Location (un) 86**], MA. If you
need to reschedule this appointment, please call [**Telephone/Fax (1) 41**].
You have an appointment with a Cardiologist, Dr. [**Last Name (STitle) **], on
[**11-17**] at 1:20pm at [**Hospital1 18**] in the [**Hospital Ward Name 23**] Building, Floor
7. If you need to reschedule this appointment, please call
[**Telephone/Fax (1) 62**].
You have an appointment with Interventional Pulmonary, Dr.
[**Last Name (STitle) **], on Monday, [**11-23**] at 1pm followed bronchoscopy at
2pm. This office is on the [**Hospital Ward Name **] of [**Hospital1 18**] in the [**Hospital Ward Name 121**]
buliding, [**Hospital1 **] 116. If you need to reschedule this appointment,
please call [**Telephone/Fax (1) 7769**]. As you are having [**Last Name (LF) 80038**], [**First Name3 (LF) **]
NOT EAT for 8 hours prior to your appointment. You will also
have sedation at this appointment, and will need someone else to
safely drive you home.
You have an appointment on Wednesday, [**11-25**] at 1:15PM
with Dr. [**Last Name (STitle) 1007**], a Spinal Orthopedist. His office is located on
the [**Hospital Ward Name 516**], [**Location (un) **] of the [**Hospital Ward Name 23**] Building. If you need
to reschedule this appointment, please call [**Telephone/Fax (1) 1228**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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405, 1856
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1878, 1930
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1946, 2203
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,568
| 120,038
|
28620
|
Discharge summary
|
report
|
Admission Date: [**2123-9-1**] Discharge Date: [**2123-9-8**]
Date of Birth: [**2066-11-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
55yo M w/ malignant left main stem lesion-final path pending.
Debrided in OR w/ bleeding. Intubated and transferred to CSRU.
Major Surgical or Invasive Procedure:
8/23/06flexible brochoscopy
[**2123-9-1**]-rigid bronchoscopy-malignant left mainstem brochial
lesion- Debrided in OR w/ complication of bleeding
[**2123-9-2**]- flexible bronchoscopy to evaluate bleeding
[**2123-9-3**]- flexible bronchoscopy- to monitor bleeding- none - plan
to extubate over 24hours
[**2123-9-7**] Rigid bronchoscopy, flexible bronchoscopy, tumor
destruction with argon plasma ablation, tumor excission and
ablation, endotracheal intubation.
History of Present Illness:
55yo M admitted w/ malignant left main stem lesion-final (path
pending) for rigid bronchoscopy for evaluation and biopsy of
left obstructing tumor. During Bronchoscopy, in process of tumor
debridement in OR case complicated by bleeding. Patient
intubated and transferred to ICU.
Past Medical History:
malignant left main stem lesion-final path pending.
Malignant left main stem bronchial lesion- lung cancer
Debrided in OR w/ bleeding. Intubated
PMHX: Gastric esophogeal reflux disease.
SHX: cervical lymph node Bx-malignant
Social History:
has girlfriend
lives in [**Name (NI) 7168**]
former smoker
Family History:
non-contrib
Physical Exam:
General- intubated and sedated male- s/p rigid bronchoscopy
HEENT- PERRLA, ETT in place, some blood in oralpharynx
REsp- [**Month (only) **]'d BS left, distant ronchi
COR-RRR
Abd, soft, +BS, non-distended
Ext- No C/E/E
Neuro- sedated on propofol
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2123-9-8**] 08:40AM 14.9* 4.08* 11.7* 33.0* 81* 28.7 35.5*
13.6 316
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2123-9-8**] 08:40AM 316
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2123-9-7**] 06:10AM 103 11 0.6 138 4.5 100 28 15
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2123-9-7**] 06:10AM 8.4 3.6 2.3
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS
[**2123-9-3**] 03:09PM ART 69* 48* 7.39 30 2
[**2123-9-3**] 01:57PM ART 73* 47* 7.39 30 2
[**2123-9-3**] 01:15PM ART 7.34*
[**2123-9-3**] 03:17AM ART 109* 50* 7.40 32* 4
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose K
[**2123-9-3**] 01:15PM 99 4.0
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat
[**2123-9-3**] 03:09PM 93
[**2123-9-3**] 01:57PM 94
[**2123-9-3**] 03:17AM 98
CALCIUM freeCa
[**2123-9-3**] 01:15PM 1.13
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-9-6**] 7:24 PM
Reason: INFILTRATE
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with malignant airway obstruction of L mainstem
HISTORY: Malignant airway obstruction.
IMPRESSION: AP chest compared to [**8-31**] through 27:
There has been no appreciable interval change in the collapse of
the left lung producing leftward mediastinal shift and elevation
of the hemidiaphragm. There is more pronounced or more distinct
micronodulation in the right lung, posible advancing metastases
.
Chest CT [**2123-9-1**]- 1733
IMPRESSION:
1. Large right thyroid mass. It is amenable to percutaneous
biopsy.
2. Irregular lesions posterior and inferior to the left thyroid
lobe likely representing abnormal lymph nodes.
3. The left lung collapse and effusion are better evaluated on
the chest CT performed at the same time.
Operative report
[**2123-9-1**]
Bronchoscopy- rigid
SUMMARY OF PROCEDURE: Complete left mainstem bronchus
obstruction with a mass, with partial debridement resulting
in large volume hemoptysis necessitating intubation and
intensive care unit transfer. The patient will be brought
back to the operating room following control of hemoptysis
for completion of the main stem bronchus intervention.
.......................
[**2123-9-2**]
Bronchoscopy- flexible
Ongoing mild hemoptysis in the left main stem
bronchus. We will keep the patient intubated overnight and
reassess with bronchoscopy on [**2123-9-3**].
.................
[**2123-9-3**]
Flexible bronchoscopy IMPRESSION: Lung cancer with central
obstruction and
secondary massive endobronchial bleed. ET tube was placed 3
cm above the carina.
..........................
[**2123-9-7**]
PROCEDURE: Rigid bronchoscopy, flexible bronchoscopy, tumor
destruction with argon plasma ablation, tumor excission and
ablation, endotracheal intubation.
IMPRESSION: Metastatic renal cell cancer to the lungs with
central airway obstruction, complicated with massive
hemoptysis.
COMPLICATIONS: Bleeding more than 50 ml and hypoxemia
resolved at the end of the procedure.
Brief Hospital Course:
55yo M w/ malignant left main stem lesion-final path pending.
Debrided in OR w/ bleeding. Intubated and transferred to CSRU.
PMHX: GERD
SHX: cervical lymph node Bx-malignant
Meds: PPI
.
[**9-1**] PATH: Inflamed and necrotic fibrinopurulent exudate
(possible renal cell ca)
[**9-3**] extubated
[**9-6**] bronch w/ cauterization (profuse bldg during procedure)
[**9-7**] O2 sat on walking test: 82-84% RA. RAD-ONC consult- to f/u
w/ [**Hospital 1474**] Hospital, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1057**], MD [**Telephone/Fax (1) 60186**] for palliative
XRT once pathology confirmed. No indication for emergent XRT.
[**9-8**]-Temp 101, WBC 14.9 from 15.4 today.O2 sat 91-92%RA. Patient
stable w/ no current signs of hemoptysis. Per IP patient to be
followed at [**Hospital 1474**] Hospital RAD -Onc as above. Pt discharged
in stable condition in company of girlfriend to home. Home O2
arranged for patient through [**Hospital **] Medical.
Above info given to patient, discharge instructions given and
reviewed w/ patient by [**Name6 (MD) 69259**] and RN.
Medications on Admission:
PPI
Discharge Medications:
1. oxygen
oxygen
1-2 L.min continuous for portability pulse dose system
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-11**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 1* Refills:*2*
4. Acetaminophen 160 mg/5 mL Solution Sig: 10-20 cc PO Q6H
(every 6 hours) as needed for fever.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for cough.
Disp:*60 Tablet(s)* Refills:*0*
8. Pepcid 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
malignant left main stem lesion-final path pending.
Malignant left main stem bronchial lesion- lung cancer
Debrided in OR w/ bleeding. Intubated
PMHX: Gastric esophogeal reflux disease.
SHX: cervical lymph node Bx-malignant
Discharge Condition:
good
Discharge Instructions:
CAll Dr. [**Last Name (STitle) **]/INterventional Pulmonary for: fever, shortness of
breath, chest pain.
Take medications as stated on discharge instructions.
Maintain activity as able.
HOme oxygenation has been ordered from [**Hospital **] Medical.
Call for issues w/ oxygen system
Followup Instructions:
Interventional Pulmonary appt--[**2123-9-20**] at 1:30 pm,
[**Hospital1 **] 2 Special Procedures unit--[**Telephone/Fax (1) 69260**].
Please go to Radiology - Clinical Center [**Location (un) 470**] at 1pm, [**9-20**], [**2123**] for CXRY pdrior to appt.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2123-9-10**]
|
[
"162.2",
"E878.8",
"998.11",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"32.01",
"96.71",
"33.24",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7005, 7011
|
5029, 6112
|
444, 907
|
7279, 7285
|
1851, 3007
|
7616, 7992
|
1557, 1570
|
6166, 6982
|
3044, 5006
|
7032, 7258
|
6138, 6143
|
7309, 7593
|
1585, 1832
|
279, 406
|
935, 1217
|
1239, 1465
|
1481, 1541
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,093
| 166,561
|
48910
|
Discharge summary
|
report
|
Admission Date: [**2115-5-20**] Discharge Date: [**2115-5-29**]
Date of Birth: [**2062-3-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
L thoracentesis x2
History of Present Illness:
53 y/o F h/o HIV (no HAART [**4-6**] CD4 490, VL > 100K), Stage IV
NSCLC presented to the ED with SOB x10 days with progressive
DOE, orthopnea and cough productive of occasional sputum.
.
In the ED patient had CXR and CTA that demonstrated no PE, but
significant progression of disease with enlarging r-hilar mass
extending to the subcarinal area with lymphadenopathy and
metastases. Small pericardial effusion.
.
On floor patient remained hypoxic with persistent O2 requirement
of 3L. Had transient episodes of desaturation without clear
explanation. Team felt pleural effusion likely contributing to
hypoxia. Thoracentesis performed on [**5-22**] w/ removal of 1.4L of
fluid from chest and again [**5-26**] removing 1200cc of bloody fluid
w/o complication. Patient underwent pleurodesis on AM prior to
arrival in ICU. That afternoon patient became increasingly
hypoxic with desat to 86%, tach to 120-130s. CXR looks a bit
better. Gave nebs and MSo4, ativan 1mg. On NRB now, ABG with
hypoxia. EKG unchanged. Admitted to the ICU for mgmt of
hypoxia.
.
ROS:
(+) SOB, sick contacts
(-) F/C, N/V/D, bowel/bladder changes.
Past Medical History:
POncH
# Stage IV NSCLC (dx [**2114-12-5**])
- s/p pigtail drainage [**3-2**] malignant pericardial effusion
- s/p carboplatin, gemcitabine x 4 cycles (last in [**2115-3-5**]) c/b
neutropenia, thrombocytopenia
.
PMH
# HIV ([**2115-3-20**]: CD4 471, VL >100,000)
- No HAART
- No h/o OI
# Asthma
# Anemia
# Depression
Social History:
# Personal: Lives with boyfriend
# Tobacco: No current. Past use averaging 1pack/3 days
# Alcohol: No current
# Recreational drugs: Cocaine abuse per OMR.
Family History:
Noncontributory
Physical Exam:
# VS T 98.1 BP 115/80 HR 113 RR 22 O2 99%4L
.
Gen: NAD
HEENT: NCAT, PERRL, EOMI, OP clear, MMM
CV: RRR, S1/S2, no m/r/g.
CHEST: Significantly decreased breath sounds at L fields; mild
crackles at right; globally diminished.
Abd: Soft, NTND, BS+, no HSM.
Ext: No edema, WWP
Neuro: CN II-XII grossly intact
Pertinent Results:
# CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2115-5-20**] 10:21 PM
1. No PE.
2. Extensive progression of disease with now large left pleural
effusion, enlarging right hilar mass extending to the subcarinal
region with associated lymphadenopathy and innumerable pulmonary
metastases. Small pericardial effusion.
.
# CHEST (PORTABLE AP) [**2115-5-20**] 9:02 PM
New large left pleural effusion, and associated left lower lobe
opacity which may represent atelectasis versus underlying
consolidation.
.
# CHEST (PA & LAT) [**2115-5-21**] 10:55 AM
Status post thoracocentesis with decrease in left pleural
effusion and no pneumothorax.
.
# MR HEAD W & W/O CONTRAST [**2115-5-21**] 10:04 AM
1. Scattered subcentimeter enhancing lesions predominantly at
the [**Doctor Last Name 352**]/white matter junction are worrisome for
infection/toxoplasmosis versus metastatic disease and clinical
correlation is advised.
2. Marrow signal from the cervical spine is unusual with loss of
normal signal on T1, this is a nonspecific finding and may
represent skeletal metastases and a bone scan would be helpful
for further evaluation.
.
# TTE [**2115-5-21**] at 12:47:29 PM
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is abnormal
septal motion/position. 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. The pulmonary
artery systolic pressure could not be determined. There is a
small loculated pericardial effusion around the right atrium.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Small
pericardial effusion around right atrium (largest diameter 1.0
cm) . It appears trivial around the remainder of the heart.
Compared with the prior study (images reviewed) of [**2115-4-10**],
the pericardial effusion around the right atrium is better seen.
Otherwise, the findings are similar.
.
# PLEURAL FLUID [**2115-5-21**]: POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic non-small cell carcinoma (NSCC).
.
# CHEST (PA & LAT) [**2115-5-22**] 8:53 AM: Interval reaccumulation of
left pleural effusion.
.
# BONE SCAN [**2115-5-22**]: No evidence of osseous metastases;
bladder uptake obscurs the central pelvis.
.
# CHEST (PA & LAT) [**2115-5-24**] 11:38 AM
Large left pleural effusion has increased since [**5-22**],
producing more rightward mediastinal shift, secondary
atelectasis in both the left lower lung and the central right
lung. No pneumothorax. Cardiac silhouette is obscured but there
has been a slight increase in caliber of mediastinal veins
suggesting elevated central venous pressure. Tip of the right
subclavian line ends low in the SVC. Multiple lung nodules are
largely obscured by atelectasis and effusion.
.
# CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2115-5-25**] 11:24 PM
1. No evidence of pulmonary embolism.
2. Further interval increase in size of left-sided pleural
effusion.
3. Large right hilar mass extending into the subcarinal region
and associated lymphadenopathy and innumerable pulmonary
metastases.
.
# CHEST (PORTABLE AP) [**2115-5-26**] 7:33 AM: Increasing left
effusion with mediastinal shift.
.
# CHEST (PORTABLE AP) [**2115-5-26**] 10:10 AM: Reduction in left
effusion. No pneumothorax.
#LE USD: [**2115-5-27**]: IMPRESSION: No evidence for DVT.
#TTE [**2115-5-28**]: There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is mild pulmonary artery systolic
hypertension. There is a small to moderate pericardial effusion
anterior and posterior to the atria but very small anterior to
the RV. There is brief right atrial diastolic collapse.
Compared with the prior study (images reviewed) of [**2115-5-21**],
the amount of pericardial effusion has increased. The is no
clear echocardiographic evidence of tamponade.
#KUB [**2115-6-26**]: IMPRESSIONS: No intra-abdominal free air. No
evidence of obstruction.
Brief Hospital Course:
53F h/o HIV (no HAART, [**4-6**] CD4 490, VL > 100K), Stage IV NSCLC,
with L pleural effusion per CT.
.
# SOB: Thought secondary to progression of her underlying
disease and recurrent pleural effusions. Patient had repeat
thoracentesis x2 on the floor as per HPI and later pleurodesis
after the effusions recurred. Hypoxia post-pleurodesis thought
[**3-2**] to disease progression vs. adverse reaction to talc used on
pleurodesis. Patient was increasingly tachypneic without relief
after bronchodilators or lasix. Discussion was had with family
and patient who agreed with plan for no-intubation. Briefly
tried on Bipap but was persistently tachypneic. After much
discussion patient and family opted to be comfort measures only.
Patient was made CMO and passed approximatley 12-24 hours
thereafter.
.
# Brain mets: New brain mets per MRI head with gad.
- [**5-22**]: Rad onc consult pending for question whole brain XRT
- [**5-23**]: Holding XRT pending chest treatment. Toxo IgG, IgM
pending but unlikely toxo given last high CD4 count; however,
current CD4 359 (viral load pending)
- [**5-24**]: Held whole brain XRT pending chest XRT completion.
- Further treatments deferred.
.
# ?Osseous progression: Bone scan ordered, pending for [**5-22**].
- [**5-23**]: Pending official read.
- [**5-24**]: No evidence of osseous metastases; bladder uptake
obscurs the
central pelvis.
- Further work-up deferred.
.
# Stage IV NSCLC: Held chemotherapy in acute illness.
- [**5-24**]: Alimta holding until after XRT.
.
# Anemia: Hct 29. Consent, type/screen.
.
# HIV: Last CD4 490, VL >100,000; no HAART. Repeat CD4, VL.
- [**5-24**]: Pending VL. CD4 359 (decreasing).
.
# DEPRESSION: Continued on outpatient quetiapine, citalopram.
Medications on Admission:
Seroquel 100 mg [**Hospital1 **]
Citalopram 10 mg daily
Ibuprofen 200 mg, [**1-30**] tab TID PRN
Albuterol 90 mcg/Actuation Aerosol Inhaler 1-2 puffs INH PRN
Ipratropium HFA 17 mcg/Actuation Aerosol Inhaler 1 puff INH Q6H
PRN
.
ALL: NKDA
Discharge Medications:
none.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis
# Stage IV NSCLC (dx [**2114-12-5**])
.
Secondary diagnosis
# HIV
# Asthma
# Depression
Discharge Condition:
Deceased
Discharge Instructions:
None.
Followup Instructions:
None.
|
[
"V08",
"493.92",
"162.8",
"285.9",
"311",
"197.2",
"198.3",
"276.1"
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icd9cm
|
[
[
[]
]
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[
"34.91",
"34.21",
"34.04",
"34.92",
"92.29"
] |
icd9pcs
|
[
[
[]
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8734, 8743
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6677, 8416
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319, 339
|
8893, 8903
|
2374, 6654
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8957, 8965
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2017, 2034
|
8704, 8711
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8764, 8872
|
8442, 8681
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8927, 8934
|
2049, 2355
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276, 281
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367, 1489
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1511, 1828
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1844, 2001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,670
| 142,198
|
49640
|
Discharge summary
|
report
|
Admission Date: [**2101-12-19**] Discharge Date: [**2101-12-27**]
Date of Birth: [**2045-7-13**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Bacitracin / Bactrim / Pseudovent / Morphine /
Erythromycin Base / Iodine Containing Agents Classifier /
Hydralazine
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
Fever, Right Hip Pain, and Abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous Nephrostomy Tube Placement
Hemodialysis
History of Present Illness:
56 year-old man s/p renal transplant in [**2080**] for IgA nephropathy
who presents with fever, abdominal pain, hip pain, and nausea.
Pt awoke yesterday with N/V. He also had fevers and chills. He
presented to renal clinic where he was found to be febrile to
101.8 and oliguric and was referred to the ED for further care.
.
Recently discharged on [**12-13**] after admisson for acute kidney
injury notable for increase in creatinine from 4.7 to 5.6 over
the course of the admission, observation of severe
hydronephrosis on renal ultrasound and cystogram revealing no
ureteral obstruction.
.
Patient was febrile on arrival to the ED with inital vitals of
T:101.8F P:92, BP:100/52, R:18 O2 sat:100% RA. His labs were
notable for WBC 13 with 95% PMNs, Hct 25.5 (b/l mid-high 20s),
BUN/creatinine 75/6.9, with anion gap 14. ESR was 85, and CRP
was 152.4. Lactate 1.4. He had a grossly positive UA. and a CT
abdomin notable for severe hydronephrosis of transplanted kidney
and imaging concerning for tiny foci of air - possible early
sign emphysematous pyelonephritis. He received 1g vancomycin,
4.5g pip/tazo, percocet 1 tab and 1g PO AND 1300 mg PR
acetaminophen. He also received kayexelate 15g x1 for
hyperkalemia of 5.4, and ondansetron 4 mg IV x1 for nausea. He
was evaluated by orthopedics for concern of septic arthritis of
the right hip, who advised right hip aspiration in IR for
analysis. Urology has also evaluated Mr. [**Known lastname **] and recommends
percutaneous nephrostomy tube placement.
.
On the floor, the patient remained febrile initially to 102.2
and reported nausea and abdominal pain. His antibiotic regimen
was expanded to include meropenem and ciprofloxacin.
.
On evaluation this morning, Mr. [**Known lastname **] continues to be tachypnic
with kussmaul breathing. These was markedly little urine in his
foley bag. Mr. [**Known lastname **] continues to complain of adbominal pain
overlying his graft site.
Past Medical History:
- IgA Nephropathy s/p LRRT in [**2080**], now with stage 3-4 CKD
- hx chronic MRSA osteomyelitis of R tibia s/p skin grafting
- Multiple SCC including one metastatic to the rt. femoral
nodes; s/p femoral triangle node dissecion with resultant
chronic RLE edema, states 4448 biopsies done
- HTN
- Enlarged prostate
- Restless leg syndrome
- GERD with Barrett's Esophagus, yearly EGDs
- Gout
- Hypertriglyceridemia
- Anxiety
Social History:
Pt is currently on disability. He used to work at [**Company **] and did so for 20 years. He smoked 1 pack/day for 10
years but stopped in [**2064**]. No alcohol. He denies illicit drug
use. He currently lives at home in [**Location (un) 1456**] with his wife and
daughter. [**Name (NI) **] has another daughter who is in college.
Family History:
Father: died of stroke at age 63
Sister: [**Name (NI) **] lymphoma at age 30
Grandmother and grandfather: CA (unknown type and age)
Maternal aunt: DM
Mother: healthy
Physical Exam:
Vitals: T:100.8 BP:126/60 P:91 R:20 O2:96% RA
General: Mild distress, tremulous, awake, alert, appropriate,
answering questions
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: + mild wheeze bilaterally, no crackles or rhonchi
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, +TTP over RLQ (transplant site), sutures from
skin cancer removal present over transplanted kidney without
induration or erytheam. NABS x4. No tenderness elsewhere. No
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Diffuse dry skin with scattered chronic lesions
Pertinent Results:
[**2101-12-19**] 03:00PM BLOOD WBC-13.2*# RBC-2.46* Hgb-7.9* Hct-25.5*
MCV-104* MCH-32.0 MCHC-30.9* RDW-17.2* Plt Ct-297
[**2101-12-20**] 12:00AM BLOOD WBC-9.8 RBC-2.10* Hgb-7.1* Hct-22.1*
MCV-106* MCH-33.6* MCHC-31.9 RDW-17.5* Plt Ct-229
[**2101-12-20**] 05:30AM BLOOD WBC-12.8* RBC-2.27* Hgb-7.7* Hct-23.2*
MCV-102* MCH-33.8* MCHC-33.2 RDW-17.5* Plt Ct-227
.
[**2101-12-19**] 03:00PM BLOOD Glucose-89 UreaN-75* Creat-6.9*# Na-139
K-5.4* Cl-109* HCO3-16* AnGap-19
[**2101-12-20**] 12:00AM BLOOD Glucose-91 UreaN-78* Creat-7.5* Na-138
K-5.3* Cl-111* HCO3-12* AnGap-20
[**2101-12-20**] 05:30AM BLOOD Glucose-98 UreaN-85* Creat-7.5* Na-138
K-5.6* Cl-107 HCO3-12* AnGap-25*
.
[**2101-12-19**] 03:00PM BLOOD Calcium-8.8 Phos-4.8* Mg-1.0*
[**2101-12-20**] 12:00AM BLOOD Albumin-3.2* Calcium-7.6* Phos-4.5
Mg-0.9*
.
[**2101-12-20**] 05:30AM BLOOD Calcium-7.4* Phos-5.1* Mg-1.1*
[**2101-12-19**] 03:00PM BLOOD CRP-152.4*
.
[**2101-12-20**] 04:25AM BLOOD Type-ART Temp-38.2 pO2-81* pCO2-29*
pH-7.30*
.
calTCO2-15* Base XS--10 Intubat-NOT INTUBA
[**2101-12-20**] 04:25AM BLOOD Hgb-7.3* calcHCT-22
.
CT Abdomen [**2101-12-19**]
IMPRESSION: Severe hydronephrosis of the enlarged transplant
kidney with
moderate perinephric stranding; locule of gas in the collecting
system may be
secondary to catheterization although early emphysematous
pyelonephritis
cannot be ruled out.
Findings were discussed with [**First Name4 (NamePattern1) 18659**] [**Last Name (NamePattern1) **] at 19:30 on [**2101-12-19**].
.
Renal U/S [**2101-12-19**]
IMPRESSION:
1. Severe hydronephrosis.
2. Presistently elevated resistive indices.
.
[**2101-12-22**] Renal U/S
IMPRESSION:
1. Persistent massive hydronephrosis with cortical thinning and
newly
identified echogenic material within the renal transplant
collecting system
compatible with hematoma, versus debris such as related to
infectious or
inflammatory process. Nephrostomy tube in place.
2. Resistive indices persistently elevated.
.
[**2101-12-26**] Vein Mapping
FINDINGS: On the right side, the cephalic vein presented patent
in the upper forearm with diameters ranging between 0.35 and
0.39. Thrombosis and
occlusion of the right cephalic vein is noticed at the
antecubital fossa.
The right basilic vein is patent and compressible with diameters
ranging
between 0.15-0.40 cm.
The left cephalic vein is patent in the upper arm with diameters
ranging
between 0.23 and 0.25 cm. Thrombosis is seen in the left
cephalic vein at the antecubital fossa.
The left basilic vein is patent and compressible with diameters
ranging
between 0.21 and 0.55 cm.
Normal phasicity is noticed in the bilateral subclavian veins,
which is an
indirect sign of central venous patency.
The bilateral brachial arteries presented with normal triphasic
Doppler
waveforms.
COMPARISON: None available.
IMPRESSION:
1. Patency of the bilateral basilic veins, with diameters
described above.
2. Thrombosis is seen in the bilateral cephalic veins, localized
to the
antecubital fossa.
3. Bilateral subclavian veins present preserved waveforms,
suggestive of
central venous patency.
Brief Hospital Course:
Mr. [**Known lastname **] is a 56 year-old man with an allogenic renal
transplant and recent hospitalization for ARF who was admitted
for pyelonephritis.
.
# Pyelonephritis: Mr. [**Known lastname **] presented with adbominal pain, fever
to 102, and kussmaul respiration in the setting of renal failure
and pyelonephritis concerning for urosepsis. He was noted on CT
scan to have findings concering for emphysematous pyelonephritis
with severe hydronephrosis. In addition, his blood culture was
positive for gram negative rods within the first 12 hours of his
admission, which was concerning for urosepsis. He was started on
meropenem and ciprofloxacin. Interventional radiology was
consulted for nephrostomy tube placement which revealed bloody
output. Mr. [**Known lastname **] had pulmonary edema on chest x-ray and exam
and he required intravenous fluid boluses to support his blood
pressure. These interventions in the setting of his renal
failure worsened his respiratory status and his arterial blood
gas was concerning for worsening metabolic acidosis and
respiratory fatigue. He was transfered to the MICU were he
received two cycles of hemodialysis and two units of PRBCs. His
respiratory function improved significantly after hemodialysis
and he was transfered back the the medical floor. Mr. [**Known lastname **]
received a thrid course of hemodialysis on the medicine flood
and was subequently rested from dialysis to monitor the function
of his allograft. His creatinine was observed to continue to
fall following the cessation of hemodialysis and his dialysis
catheter was removed prior to discharge. Both his urine and
blood were culture positive for enterobacter aerogenes sensitive
to ciprofloxacin and meropenem. The infectious disease service
was consulted and recommended continuing meropenem for 2 weeks
and ciprofloxacin for 4 weeks. He will follow up in the
infectious disease, renal, urology and interventional radiology
clinics.
.
# Acute on Chronic Renal Failure: Mr. [**Known lastname **] has had a number of
recent insults to his allograft kidney with a steady rise in his
creatinine from the mid 2s as recently as this past summer to a
peak of 8.8 durring this admission. It is likely that chronic
hydronephrosis with pyelonephritis and urosepsis likely acutely
worsened his pre-existing renal failure. His creatinine improved
steadily following his three rounds of HD and remained improved
following several days without dialysis. On the day of
discharge, his creatinine was 4.6 suggesting that his allograft
was still functioning. He will follow closely as an outpatient.
.
# Anemia: Mr. [**Known lastname **] is chronically anemia in the setting of his
renal disease, and he was thus continued on his home dose of
Procrit. Mr. [**Known lastname **] became acutely anemic following his
percutaneous nephrostomy that resulted in significant volume
hematuria. He Hct nadir was an Hct of 21 and he received a
total of 3 units of PRBC throughout his admission with
stabilization of his Hct at around 25.
.
# PVD: Plavix was continued at his home dose throughout
admission and upon discharge. In discussion with his vascular
surgeon, it was determined that his aspirin could be held. Thus
aspirin was held throuhgout his admission and upon discharge
with instructions to discuss this with his vascular surgeon.
.
# HTN: His antihypertensives where held initally for concern of
hypotension in the setting of urosepsis. His home
antihypertensives were resumed upon discharge
.
# Restless leg syndrome: He was continued on his home renally
dosed gabapentin
.
# GERD with Barrett's Esophagus: He was continued on his home
dose of pantoprazole
.
# Hyperlipidemia: He was continued on his home dose of
simvastatin
Medications on Admission:
azathioprine 50 mg PO DAILY
calcitriol 0.25 mcg PO EVERY OTHER DAY
clopidogrel 75 mg PO DAILY
cyanocobalamin (vitamin B-12) Injection
diltiazem HCl 240 mg Tablet Sustained Release 24 hr PO daily
Procrit Injection
furosemide 40 mg PO every 3 days
gabapentin 300 mg PO Q24H
lorazepam 1 mg PO at bedtime as needed for insomnia.
nadolol 20 mg PO DAILY
Percocet 5-325 mg PO every eight (8) hours as needed for pain
pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO PO Q24H
prednisone 4 mg PO daily
simvastatin 40 mg PO DAILY
terazosin 3 mg PO BID
aspirin 325 mg PO DAILY
ferrous sulfate 300 mg (60 mg Iron) PO DAILY
calcium acetate 667 mg PO TID W/MEALS
hydralazine 25 mg PO TID
Discharge Medications:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 weeks: Day 1=[**2101-12-20**], will conintue for
4 weeks or per Infectious Disease Clinic.
Disp:*56 Tablet(s)* Refills:*0*
2. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 2 weeks: Day 1=[**2101-12-20**],
Will continue for 2 weeks or per Infectious Disease Clinic .
Disp:*28 Recon Soln(s)* Refills:*0*
3. azathioprine 75 mg Tablet Sig: [**2-12**] (one half) Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. cyanocobalamin (vitamin B-12) Injection
7. diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
8. Procrit Injection
9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a
day.
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day.
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. terazosin 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
16. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Pyelonephritis
Acute Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for fever and abdominal pain.
You were evaluated and treated by the medicine service. You were
found to have a severe kidney infection with bacteria growing in
your blood. You were started on intravenous antibiotics. You
also required the placement a tube into your kidney to help
drain your kidney. You were also found to be in kidney failure
and your breathing became difficult. You were transfered to the
intensive care unit where you received emergent hemodialysis
that significantly improved your breathing. You continued to
improve both in the intensive care unit and on the general
medicine floor. You kidney function also improved enough to no
longer require in hospital hemodialysis. You should follow
closely with the many specialty services that participated in
your care. Please see these follow up appointments below.
The following changes have been made to your outpatient
medications:
1. You have been STARTED on 500mg of Meropenem IV every twelve
hours, you will continue this medication for 2 weeks total, Day
1 = [**12-20**] Expected completion date is [**2102-1-17**] you will follow
with the [**Hospital **] clinic for this medication.
2. You have been STARTED on 250mg of Cirpofloxacin by mouth
every 12 hours, you will continue this medication for 4 week
total, Day 1 = [**12-20**] Expected completion date is [**2102-2-14**] you
will follow with the [**Hospital **] clinic for this medication.
3. Your Azathioprine has been DECREASED to 37.5 mg daily.
4. Your Aspirin has been STOPPED. Please discuss restarting with
your vascular surgeon.
No other changes have been made to your medications.
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
Name: [**Doctor First Name **]-[**Last Name (LF) **], [**First Name3 (LF) **]
Address: [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 41397**]
Phone: [**Telephone/Fax (1) 9146**]
When: Thursday, [**12-29**], 4:30
*Dr. [**Last Name (un) 88910**] is another physician on Dr. [**Last Name (STitle) 75239**] team.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2102-1-4**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2102-1-13**] at 3:00 PM
With: URODYNAMICS STUDY [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2102-1-20**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
**We are working on a follow up appointment with Interventional
Radiology. You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call [**Telephone/Fax (1) 8243**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]
|
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67,050
| 118,850
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40212
|
Discharge summary
|
report
|
Admission Date: [**2200-1-20**] Discharge Date: [**2200-1-31**]
Date of Birth: [**2143-8-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Placement of a temporary R internal jugular catheter
Placement of a tunneled hemodialysis catheter
Paracentesis x 3
History of Present Illness:
56M with history of HCV and ETOH cirrhosis complicated by SBP
and multiple therapeutic paracentesis and recent ex lap for bile
leak presenting from nursing home s/p unwitness fall. Patient
was reportedly attempting to get OOB with his walker when he
slipped and fell. Does not believe he hit his head, but patient
appears confused. Was at PT later this afternoon and complained
of HA. Was sent to ED for further eval. On arrival, called from
nursing home regarding abnormal lab values including CR 6.1, BUN
113, and K 6.4.
.
On arrival to the ED labs were significant for Na 125, K 7.2,
Bicarb of 20 Gap of 13 BUN/Cr of 118/6.4 from baseline Cr of 2.3
from last admission. T bili 5.4 up from 2.0. No EKG changes
reported.
.
Patient had diagnostic paracentesis completed in ED. Results
pending.
.
.
In the ED her received 10U insulin amp D50 1 amp calcium
gluconate with K normalizing to 6.4.
.
Renal was consulted, and hepatology and transplant surgery are
aware of the admission. He is being admitted to MICU for
managment of [**Last Name (un) **].
.
On arrival to the MICU, he is awake and answering questions.
Knows he is [**Location (un) **] but is otherwise confused.
.
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:
- HCV/EtOH cirrosis (dx >10 yrs ago): Complicated by portal HTN,
recurrent ascites, pancytopenia, and hepatic encephalopathy
(MELD 18, Child's Class C)
- s/p R reverse total shoulder arthroplasty followed by removal
for recurrent MRSA infections
- SBP
- CRF (baseline Cr 1.5)
- HTN
- DM2: Insulin Dependent
- PVD
- Cholecystitis
- h/o C. diff colitis
- chronic lower back pain s/p L2 kyphoplasty
- Left inguinal hernia incarceration s/p repair with mesh [**4-2**]
- s/p left 5th toe amputation
- multiple mechanical falls
- I&D of R shoulder [**11/2199**]
Social History:
Pt is from [**Male First Name (un) 1056**] and moved here 1 yr ago for tx of his
liver dx. He has been going to [**Hospital6 3105**] since
then. All of his family is in [**Male First Name (un) 1056**].
- Last drink was [**8-/2199**]
- Denies smoking.
Family History:
denies any FH of liver problems
Physical Exam:
ADMISSION EXAM
General: Alert oriented x1
HEENT: Sclera icteric.
Neck: supple. JVP elevated to 5cm
CV: Regular rate and rhythm, doitant heart sounds
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Distended marked ascites.
GU: Foley in place
Ext: Warm/well perfused with 1+ edema to the shins.
Neuor: + Astrixes
.
DISCHARGE EXAM
Pertinent Results:
LABORATORY DATA
CBC
[**2200-1-20**] 07:59PM BLOOD WBC-9.2# RBC-3.68* Hgb-11.1* Hct-31.5*
MCV-86 MCH-30.0 MCHC-35.1* RDW-17.0* Plt Ct-68*
[**2200-1-20**] 07:59PM BLOOD Neuts-83.4* Lymphs-7.9* Monos-7.1 Eos-1.1
Baso-0.6
[**2200-1-28**] 05:40AM BLOOD WBC-1.9* RBC-2.32* Hgb-6.9* Hct-21.0*
MCV-91 MCH-29.9 MCHC-33.0 RDW-17.0* Plt Ct-24*
.
COAGULATION STUDIES
[**2200-1-20**] 05:35PM BLOOD PT-13.8* PTT-24.2* INR(PT)-1.3*
[**2200-1-28**] 05:40AM BLOOD PT-21.7* PTT-45.3* INR(PT)-2.1*
.
CHEMISTRY
[**2200-1-20**] 05:35PM BLOOD Glucose-63* UreaN-118* Creat-6.4*#
Na-125* K-7.2* Cl-92* HCO3-20* AnGap-20
[**2200-1-28**] 05:40AM BLOOD Glucose-51* UreaN-17 Creat-2.9*# Na-132*
K-3.6 Cl-96 HCO3-31 AnGap-9
.
LFTS
[**2200-1-20**] 05:35PM BLOOD ALT-35 AST-37 LD(LDH)-262* AlkPhos-114
TotBili-5.4*
[**2200-1-28**] 05:40AM BLOOD ALT-24 AST-35 AlkPhos-65 TotBili-4.0*
.
MISC
[**2200-1-21**] 11:13AM BLOOD Cryoglb-NO CRYOGLO
[**2200-1-20**] 05:35PM BLOOD Ammonia-52
[**2200-1-21**] 02:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2200-1-21**] 02:30PM BLOOD HCV Ab-POSITIVE*
[**2200-1-21**] 11:13AM BLOOD PEP-POLYCLONAL IgG-2788* IgA-508* IgM-200
[**2200-1-21**] 11:13AM BLOOD C3-35* C4-16
[**2200-1-21**] 09:09PM BLOOD Lactate-1.7
[**2200-1-25**] 01:08AM BLOOD Lactate-2.5*
[**2200-1-25**] 05:49AM BLOOD Lactate-2.2*
.
URINE STUDIES
[**2200-1-20**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2200-1-20**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2200-1-20**] 08:00PM URINE RBC-5* WBC-7* Bacteri-FEW Yeast-NONE
Epi-0
[**2200-1-20**] 08:00PM URINE Mucous-RARE
[**2200-1-20**] 10:19PM URINE Hours-RANDOM UreaN-358 Creat-69 Na-<10
K-64 Cl-<10
[**2200-1-20**] 10:19PM URINE Osmolal-319
.
ASCITES FLUID
[**2200-1-20**] 09:24PM ASCITES WBC-150* RBC-900* Polys-36* Lymphs-25*
Monos-31* Mesothe-2* Macroph-6*
[**2200-1-22**] 05:41PM ASCITES TotPro-1.7 Glucose-118 LD(LDH)-79
TotBili-1.2 Albumin-LESS THAN
[**2200-1-22**] 05:41PM ASCITES WBC-370* RBC-465* Polys-26* Lymphs-8*
Monos-1* Mesothe-1* Macroph-64*
.
MICROBIOLOGY
URINE CULTURE (Final [**2200-1-21**]): NO GROWTH.
Blood Culture, Routine (Final [**2200-1-26**]): NO GROWTH.
GRAM STAIN (Final [**2200-1-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2200-1-23**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2200-1-26**]): NO GROWTH.
.
GRAM STAIN (Final [**2200-1-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2200-1-25**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2200-1-28**]): NO GROWTH.
.
EKG- Baseline artifact. Underlying rhythm is probably sinus
rhythm. Low QRS voltage in the limb leads. Consider left
anterior fascicular block. Compared to the previous tracing of
[**2200-1-20**] no interim diagnostic change.
.
HEAD CT
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect, or acute territorial infarction. There are mild centrum
semiovale and periventricular hypodensities consistent with
sequela of chronic small vessel disease. The ventricles and
sulci are mildly prominent given patient age. The paranasal
sinuses and mastoids are clear. No acute fracture is seen. There
is no large subgaleal hematoma.
IMPRESSION: No acute intracranial process. Chronic changes, as
above
.
ABDOMINAL ULTRASOUND
IMPRESSION:
1. No hydronephrosis.
2. Shrunken nodular hepatic architecture, consistent with
cirrhosis, with no focal liver lesion identified.
3. Splenomegaly and a large amount of ascites.
4. Sludge filling the lumen of the gallbladder.
5. Patent hepatic vasculature.
.
CHEST XRAY
FINDINGS: This is an AP portable upright film and therefore has
less sensitivity for free air than standing upright film. No
free air is identified. The lungs are clear. Right IJ line is
unchanged.
.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
56 YOM with history of HCV and ETOH cirrhosis complicated by SBP
and multiple therapeutic paracentesis and recent ex lap for bile
leak presenting from nursing home s/p unwitness fall with labs
consistent with [**Last Name (un) **].
.
ACTIVE ISSUES
.
# [**Last Name (un) **]: On admission patient was noted to have a creatinine of
6.4 from a baseline of 1.5 and potassium of 7.2. There were no
EKG changes In the ED he was given calcium gluconate, insulin,
D50, and 30 grams kayexalate. Potassium remained elevated. The
patient was seen by Nephrology who felt his renal failure was
consistent with hepatorenal syndrome (UNa <10, FeUrea 28%, bland
sediment). Post renal etiology was also considered but felt to
be unlikely as creatinine has remained elevated despite
placement of a foley. Renal/hepatic ultrasound showed no signs
of obstruction, only large ascites and cirrhotic liver. He
ultimately required placement of a temporary dialysis line and
dialysis for correction of electrolyte abnormalities. He was
also started on octreotide and midodrine. The patient remained
oliguric without appreciable improvement in his creatinine. When
patient's mental status improved dialysis was discussed in depth
and the patient expressed an interest in continuation of
dialysis on a long term basis. Therefore a tunneled dialysis
line was placed and he was started on dialysis. Octreotide was
discontinued as it did not seem to be helping but midodrine was
continued to help improve blood pressure.He will be on a
Tuesday, Thursday, Saturday schedule at the nursing facility. Of
note dialysis was complicated by low blood pressures making
volume removal challenging.
.
# AMS: Patient was noted to be confused on admission. This was
attributed to hepatic encephalopathy vs. uremia. Paracentesis in
the ED was negative for SBP. Infectious work-up including urine
cultures, blood cultures and chest xray were negative. The
patient had a head CT that was unrevealing. The patient was
treated with lactulose and rifaximin with improvement in mental
status. Mental status was at baseline at the time of discharge.
.
# Ascites- Patient noted to have a large amount of ascites. As
above paracentesis was negative for spontaneous bacterial
peritonitis. Patient underwent therapeutic paracentesis with
removal of 5 L of ascitic fluid.
.
# Abnormal UA: UA was suggestive of a possible UTI. Cultures
were negative and therefore the patient was not given antibiotic
therapy.
.
# HCV/EtOH Cirrhosis: Patient with poor prognosis as he is not a
transplant candidate and he now has what is likely hepatorenal
syndrome. He was continued lactulose, and rifaxamin. Peritoneal
studies were negative for infection so patient was continued on
prophylactic ciprofloxacin. Nadolol was held given hypotension
during dialysis.
.
# Hyperkalemia: as above potassium was noted to be elevated at
7.2 on admission. He was not noted to have EKG changes.
Hyperkalemia was attributed to acute renal failure. He
underwent dialysis as above with normalization of her
electrolytes. His Potassium was 3.9 on discharge.
.
# Hyponatremia: Patient was noted to have a sodium of 125 on
admission. This was felt to be due to hypervolemic hyponatremia
secondary to cirrhosis. Sodium improved with dialysis.
.
# Type II Diabetes- Patient is on insulin therapy at home. He
was maintained on an insulin sliding scale while admitted.
.
TRANSITIONAL ISSUES
- Patient was full code throughout this admission
- Patient will follow-up at the Liver center
.
Hemodialyis:
First session: Saturday, [**2200-2-1**] at 10:45am
The address and phone number of the treatment facility is:
.
FMC - [**Location (un) 7661**] Dialysis Center
[**Location (un) **]
[**Location (un) 7661**] [**Numeric Identifier 88288**]
Phone: [**Telephone/Fax (1) 21116**]
Nephrologist: Dr. [**Last Name (STitle) 62780**] [**Name (STitle) 88289**]
.
His outpt HD schedule will be every Tues, Thurs and Sat at
11:15am
.
Medications on Admission:
albuterol q4h prn
vit C 500 mg po daily
colace 100 mg po bid
ensavet 240 ml po bid
iron 325 mg po bid
folic acid 1 mg po daily
neurontin 300 mg po bid
glucerna shakes
lactobacillis 4 tabs po bid
lactulose 30 mg po tid
nadolol 40 mg po daily
oxycodone 10 mg q4h prn
omeprazole 20 mg po daily
rifaximin 550 mg po bid
sevelamer 800 mg po tid
thiamine 100 mg po daily
trazadone 25 mg po prn
determir 12 units qhs
SSI
nephrocaps daily
zinc sulfate 220 mg po daily
ambien 5 mg po prn
zofran 4 mg po q6h prn nausea
(lasix and aldactone on hold, cipro SBP ppx not being given)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] Colonial Heights
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hepatorenal syndrome
Hepatic encephalopathy
Secondary Diagnosis
Hepatitis C
Cirrhosis
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr [**Known lastname 88290**] [**Known lastname 7203**],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were confused. This was felt to
be due to toxins that your liver was able to clear. We also
found that your kidneys were not working well. You required
dialysis which you will need to continue. You were given a
special IV so that you can continue to have dialysis.
We made the following changes to your medications
1. STOP nadolol
2. STOP lasix
3. STOP spironolactone
4. START midodrine
5. STOP vitamin C and zinc
You should continue to take all other medications as instructed.
Please call with any questions or concerns.
|
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75,509
| 107,340
|
50736
|
Discharge summary
|
report
|
Admission Date: [**2194-4-25**] Discharge Date: [**2194-5-7**]
Date of Birth: [**2122-7-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
[**2194-4-29**] 1. Ultrasound-guided left common femoral access for
sheath
placement.
2. Right lower extremity angiogram.
3. Angioplasty of tibioperoneal trunk and posterior tibial
artery, right leg.
4. Right superficial femoral artery stent, [**6-/2163**] Zilver
postdilated with 680 Submarine.
5. Right transmetatarsal amputation.
History of Present Illness:
71M with a history of venous stasis ulcers and bilateral lower
extremity ischemia had a recent right lower angio w/ AT stent
[**2194-4-11**]. On the same admission the patient had a Right 4th toe
open ray amputation [**4-13**] complicated by sepsis that resolved
with a VAC dressing. The patient was discharged home on PO
augmentin for unspeciated mixed wound flora. The plan was for
the patient to return to the hospital for a repeat
angio/possible Right TMA. He then returned to [**Location **] from his rehab
facility on [**2194-4-25**] with slurred speech and a non-productive
cough. A CXR demonstrated volume overload associated
with decreased oxygen sats.
Past Medical History:
PAD
CHF Ef 50%([**2193**])
ESRD, dialysis dependent T/Th/Sat schedule
COPD
atrial fibrillation
s/p pacemaker for bradycardia
s/p AV fistula left wrist (clotted off)
s/p AV fistula ([**2194-1-26**]) in LUE
Social History:
From [**Location (un) 686**], lives in [**Location (un) **] with wife, 2 daughters.
Retired social worker (21 years). 60-80 pack year history quit
25 years ago. No alcohol or recreational drugs. We recently
discharged to Rehab on [**2194-4-23**].
Family History:
Non-contributory
Physical Exam:
VS: 98.2 HR: 70 BP: 90/42 RR: 14 SPo2: 95%
NAD, alert and oriented x 3
VC: RRR, no mrg
Resp: CTA bilaterally
Abd- soft, NT, ND
Wound: right TMA site CDI, dry dressing intact
Trace edema
Pulse exam: Fem DP PT
Left palp dop dop
Right palp dop dop
Pertinent Results:
[**2194-5-6**] 08:45AM BLOOD WBC-12.4* RBC-2.55* Hgb-8.4* Hct-27.6*
MCV-108* MCH-32.9* MCHC-30.4* RDW-17.1* Plt Ct-188
[**2194-5-3**] 01:50AM BLOOD WBC-10.5 RBC-2.45* Hgb-8.2* Hct-26.4*
MCV-108* MCH-33.5* MCHC-31.1 RDW-18.6* Plt Ct-208
[**2194-5-2**] 12:55AM BLOOD WBC-11.2* RBC-2.46* Hgb-8.2* Hct-25.6*
MCV-104* MCH-33.5* MCHC-32.2 RDW-18.7* Plt Ct-191
[**2194-5-1**] 02:52AM BLOOD WBC-11.9* RBC-2.62* Hgb-8.7* Hct-27.1*
MCV-104* MCH-33.3* MCHC-32.1 RDW-19.2* Plt Ct-180
[**2194-5-6**] 08:45AM BLOOD Plt Ct-188
[**2194-5-6**] 04:34AM BLOOD PT-22.5* PTT-37.7* INR(PT)-2.1*
[**2194-5-5**] 04:29AM BLOOD PT-19.7* PTT-34.8 INR(PT)-1.8*
[**2194-5-4**] 04:45AM BLOOD PT-18.8* INR(PT)-1.7*
[**2194-5-6**] 08:45AM BLOOD Glucose-114* UreaN-49* Creat-5.1* Na-135
K-4.3 Cl-98 HCO3-26 AnGap-15
[**2194-5-5**] 04:29AM BLOOD Glucose-123* UreaN-37* Creat-4.3* Na-134
K-4.2 Cl-98 HCO3-28 AnGap-12
[**2194-5-4**] 04:45AM BLOOD Glucose-145* UreaN-26* Creat-3.5* Na-136
K-4.2 Cl-99 HCO3-32 AnGap-9
[**2194-5-3**] 01:50AM BLOOD Glucose-80 UreaN-18 Creat-2.5* Na-136
K-4.2 Cl-102 HCO3-30 AnGap-8
[**2194-5-2**] 12:55AM BLOOD Glucose-83 UreaN-26* Creat-3.0* Na-135
K-4.4 Cl-100 HCO3-27 AnGap-12
[**2194-5-1**] 02:52AM BLOOD Glucose-89 UreaN-19 Creat-2.4* Na-134
K-4.0 Cl-99 HCO3-30 AnGap-9
[**2194-4-30**] 04:45PM BLOOD CK(CPK)-64
[**2194-4-30**] 07:57AM BLOOD CK(CPK)-32*
[**2194-4-30**] 12:56AM BLOOD CK(CPK)-20*
[**2194-4-27**] 02:49PM BLOOD CK(CPK)-30*
[**2194-4-27**] 09:01AM BLOOD ALT-15 AST-35 LD(LDH)-184 AlkPhos-97
Amylase-61 TotBili-0.6
[**2194-4-25**] 11:15AM BLOOD ALT-11 AST-36 AlkPhos-101 TotBili-0.4
[**2194-4-30**] 04:45PM BLOOD CK-MB-4 cTropnT-0.39*
[**2194-4-30**] 07:57AM BLOOD CK-MB-4 cTropnT-0.31*
[**2194-4-30**] 12:56AM BLOOD CK-MB-4 cTropnT-0.25*
[**2194-4-27**] 02:49PM BLOOD CK-MB-5 cTropnT-0.29*
[**2194-5-6**] 08:45AM BLOOD Calcium-7.7* Phos-5.3* Mg-2.2
[**2194-5-5**] 04:29AM BLOOD Calcium-7.9* Phos-4.6* Mg-2.1
[**2194-5-4**] 04:45AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.1
[**2194-5-3**] 01:50AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
[**2194-5-2**] 12:55AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
[**2194-5-6**] 08:45AM BLOOD Vanco-16.3
[**2194-5-2**] 12:55AM BLOOD Vanco-13.7
[**2194-5-3**] 01:54AM BLOOD Type-ART pO2-129* pCO2-56* pH-7.34*
calTCO2-32* Base XS-3
[**2194-5-2**] 04:45PM BLOOD Type-ART pO2-104 pCO2-64* pH-7.31*
calTCO2-34* Base XS-2
[**2194-5-2**] 04:32AM BLOOD Type-ART Temp-37.7 pO2-133* pCO2-58*
pH-7.29* calTCO2-29 Base XS-0 Intubat-NOT INTUBA
[**2194-5-5**]
INDICATION: 71-year-old male with end-stage renal disease,
admitted [**2194-4-25**]
with mental status changes and dysarthria. Evaluate for evidence
of evolving
infarct.
COMPARISON: [**2194-4-25**] and [**2194-1-26**].
NON-CONTRAST HEAD CT:
There is little change compared to prior studies. There is no CT
evidence of
acute or evolving subacute territorial infarct. Periventricular
and
subcortical white matter hypodensities are again seen,
compatible with chronic
small vessel infarcts, most discrete in the in the right
thalamus and left
corona radiata/centrum semiovale. There is no acute intracranial
hemorrhage
or mass effect, including no shift of midline structures or
effacement of the
basal cisterns. Mild prominence of the ventricles and sulci
suggests global
volume loss. The bones remain unremarkable. There is a small
mucus retention
cyst in the imaged portion of the left maxillary sinus,
incompletely
visualized. There are extensive arterial calcifications.
IMPRESSION: No evidence of an acute intracranial process,
including no CT
evidence for an evolving acute or subacute infarct. Grossly
unchanged chronic
small vessel infarcts.
The study and the report were reviewed by the staff radiologist.
[**2194-4-26**]
[**2194-4-26**] 5:05 am SWAB Source: R 4th toe amp site.
**FINAL REPORT [**2194-5-2**]**
GRAM STAIN (Final [**2194-4-26**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2194-5-2**]):
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..
ANAEROBIC CULTURE (Final [**2194-4-30**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
NEURO/PAIN: Upon admission, Neurology was initially consulted
regarding concern for sepsis and infectious encephalopathy. They
recommended a head CT on [**4-25**] which showed no evidence of acute
intracranial process. The patient was closely monitored with
stable neurologic exams. A repeat head CT was obtained for
follow-up, after transfer from the ICU, which was deemed stable
and without intracranial process. The patient was maintained on
IV pain medication in the immediate post-operative period and
transitioned to PO narcotic medication with adequate pain
control on POD#[**1-30**]. The patient remained neurologically intact
and without change from baseline during their stay. The patient
remained alert and oriented to person, location and place.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. Their
vitals signs were closely monitored with telemetry. The
patient's home statin medication was continued. Patient had a
previous right 4th toe amputation on [**4-13**] and on this admission,
presented with concern for sepsis requiring ICU admission and
minimal pressor support transiently during dialysis sessions. On
[**2194-4-29**] he was taken for right lower extremity angiography and
eventually a TMA amputation.
The patient did well following their vascular procedures. The
patient was closely monitored with serial pulse exams in the
post-op period. If appropriate, doppler signaling was frequently
assessed in the involved extremity. Their post-op pulse exam
demonstrated dopplerable signals in his DP/PT bilaterally. The
patient's cardioprotective dose of Aspirin was continued
post-op. The patient was placed on a heparin gtt for
anticoagulation and was bridged to oral Coumadin without issues
upon transfer from the ICU -- with a regimen of Coumadin 1 mg PO
every other day, with close monitoring of his INR (goal [**1-30**]).
Their PTT was assessed every 6 hours until therapeutic levels
were achieved (PTT goal 60 - 80). The patient was continued on
Plavix 75 mg PO daily in the post-op period, for their Rigth AT
stent.
Of note, his pacemaker failed to fire with a significant pause
in the ICU on [**2194-4-26**], EP interrogated the pacer and it was
deemed stable.
RESPIRATORY: The patient was initially intubated and required
ICU admission, but was successfully extubated in the unit once
his initial volume overload was controlled with dialysis. Serial
CXRs were obtained to monitor his pulmonary fluid status. The
patient had no episodes of desaturation or pulmonary concerns
following extubation. He was transitioned to on/off biPAP
assistance (mainly in the evenings), until weaning to nasal
cannula, and fianlly weaned of oxygen. The patient denied cough
or respiratory symptoms. Pulse oximetry was monitored closely
and the patient maintained adequate oxygenation.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#[**1-30**]
following his TMA. The patient experienced no nausea or
vomiting. The patient was transitioned to a
regular/cardiac/diabetic healthy diet on POD#3 and IV fluids
were discontinued once adequate PO intake was established.
GENITOURINARY: The patient's hemodialysis was continued on
admission to the ICU. His urine output was minimal. The
patient's intake and output was closely monitored. The patient's
creatinine was stable following dialysis and volume was removed
during his dialysis sessions.
HEME: The patient's post-op hematocrit was stable and trended
closely. The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
closely monitored with adjustment of his Coumadin dosing, with
an INR of [**1-30**]. The patient had no evidence of bleeding from
their incision.
ID: The patient was admitted and maintained on Vancomycin,
Ciprofloxacin and Flagyl IV for his right toe infection.
Cultures were obtained which showed a mixed bacteria specimen,
and upon discharge PO Augmentin was continued for 2-weeks. Their
white count was monitored closely post-operatively and their
incision was closely monitored for any evidence of infection or
erythema.
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale. His home Lantus/glargine was continued with close
blood glucose monitoring.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op once cleared by physical therapy. The
patient also had sequential compression boot devices in place
during immobilization to promote circulation. GI prophylaxis was
sustained with Protonix/Famotidine when necessary. The patient
was encouraged to utilize incentive spirometry, get out of bed
early and was discharged to rehab in stable condition.
Medications on Admission:
1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-29**]
Puffs Inhalation Q6H (every 6 hours).
2. sevelamer HCl 400 mg Tablet Sig: Eight (8) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. ascorbic acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
14. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
15. 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.
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
17. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for dry skin.
18. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): give after HD on HD days. cont through
TMA operation.
19. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
check pt/inr frequently.
20. Lantus 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous once a day: at breakfast.
21. insulin regular human 100 unit/mL Solution Sig: sliding
scale Injection four times a day: please see below
.
22. sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose
0-70mg/dL ----Proceed with hypoglycemia protocol----
71-150mg/dL 0Units 0Units 0Units 0Units
151-200mg/dL 2Units 2Units 2Units 2Units
201-250mg/dL 4Units 4Units 4Units 4Units
251-300mg/dL 6Units 6Units 6Units 6Units
301-350mg/dL 8Units 8Units 8Units 8Units
351-400mg/dL 10Units 10Units 10Units 10Units
Instructons for NPO Patients: Evening Prior to
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 100% usual dose. Morning of
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 50% of usual dose; If on premix insulin
(e.g. 70/30, 75/25): take total number of AM units ordered,
divide by 3, and give that many units as NPH; If on sliding
scale of short acting insulin: administer according to HS
schedule. Hold all oral antidiabetic medications, and consider
sliding scale coverage; If appropriate, give IVF with dextrose
to prevent hypoglycemia.
23. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
24. Outpatient Lab Work
please check PT/INR at least two - three times per week
Goal INR: 2.0-3.0
Dx: Afib
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. heparin (porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day): please titrate for goal INR [**1-30**].
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours): total of 2 weeks. Please give
after HD.
17. Insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-109 mg/dL 0 Units 0 Units 0 Units 0 Units
110-140 mg/dL 2 Units 2 Units 2 Units 0 Units
141-180 mg/dL 4 Units 4 Units 4 Units 1 Units
181-210 mg/dL 6 Units 6 Units 6 Units 3 Units
211-240 mg/dL 8 Units 8 Units 8 Units 5 Units
> 240 mg/dL Notify M.D.
18. warfarin 1 mg Tablet Sig: One (1) Tablet PO every other day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**]
Discharge Diagnosis:
Gangrene and infection, right foot
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, 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 to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-30**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**2-28**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2194-5-30**] 10:00
|
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"496",
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"440.24",
"682.7",
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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17448, 17553
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317, 664
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17632, 17632
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1869, 1887
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15372, 17425
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11903, 15349
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17817, 19807
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19833, 20470
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1902, 2270
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263, 279
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692, 1359
|
5009, 6876
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17647, 17793
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1381, 1588
|
1604, 1853
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,415
| 132,513
|
36100
|
Discharge summary
|
report
|
Admission Date: [**2149-3-19**] Discharge Date: [**2149-3-26**]
Date of Birth: [**2090-10-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Oral Bleeding
Confusion
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Laryngoscopy
Blood Transfusion
History of Present Illness:
Mr. [**Known lastname 81893**] is a 58 year old man with history of EtOH
cirrhosis, diagnosed [**9-/2147**], c/b encephalopathy, ascites and
hepatic hydronephrosis, s/p TIPS [**1-/2148**], no known varices,
hepatoma on recent MRI, who was admitted from clinic with
confusion.
.
The patient was in his USOH until last night when his wife
noticed that he was somewhat wobbly while walking. This morning,
he started having word finding difficulties and confusion on his
way to the transplant clinic. His wife notes that this is a
typical presentation of his encephalopathy. No recent fall or
head trauma. He has had a mild productive cough over the last
few days, light and dark sputum, no blood. No fevers, chills,
SOB, CP, N/V, abdominal pain, dysuria, headache, sore throat,
runny nose. He notes that he has been having [**3-28**] loose BM/day
and that he has been adherent to his medications. His wife notes
that he's been managing his own medications recently.
.
On the floor, initial VS: T 98.2 BP 128/62 P 73 RR 18 O2sat
97%RA. The patient currently feels well and has no complaints at
this time. He notes a leg cramp in his left leg this AM and
prior shoulder pain, which has resolved.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- EtOH cirrhosis diagnosed [**9-/2147**], c/b encephalopathy, ascites
and hepatic hydronephrosis, s/p TIPS [**1-/2148**], no known varices
- hepatoma on recent MRI liver
- left trapped lung and recurrent pleural effusion s/p left
VATS, total pulmonary decortication, mechanical and chemical
pleurodesis [**2148-5-1**]
- type 2 diabetes mellitus, diet-controlled
- chronic obstructive pulmonary disease
- gastroesophageal reflux disease
- depression
- hypothyroidism
Social History:
He lives in [**Hospital1 392**] with his wife [**Doctor First Name **] and together they owned
a flower shop which they just sold. Used to work for the federal
government. EtOH: 12 drinks/day for many years, now abstinent
since [**2147-10-2**]. Smoking: since age 15. IVDU: denies
Family History:
Mother died of MI. Father died of cancer, unknown type. He has a
brother with type 2 diabetes.
Physical Exam:
Vitals - T 98.2 BP 128/62 P 73 RR 18 O2sat 97%RA
GENERAL: well appearing man, NAD, AOx2
HEENT: NC/AT, EOMI, MMM, OP clear
CARDIAC: RRR, S1S2, no m/r/g appreciated
LUNG: mild wheezing RUL, otherwise clear
ABDOMEN: soft, nt, nd, +bs, no rebound/guarding
EXT: nonpitting edema b/l LE, +dp pulses
NEURO: AOx2, unaware of date, some word finding difficulty, CN
II-XII intact, strength/sensation intact throughout, mild tremor
and +asterixis
PSYCH: pt is currently sad, no SI or HI at this time
Pertinent Results:
Laboratory Data
.
[**2149-3-19**] 03:30PM BLOOD WBC-6.9 RBC-3.30* Hgb-9.8* Hct-29.2*
MCV-89# MCH-29.9 MCHC-33.7 RDW-15.3 Plt Ct-131*
[**2149-3-20**] 03:00AM BLOOD WBC-8.2 RBC-3.13* Hgb-9.5* Hct-27.7*
MCV-89 MCH-30.5 MCHC-34.4 RDW-15.2 Plt Ct-138*
[**2149-3-21**] 04:25AM BLOOD WBC-5.9 RBC-3.28* Hgb-9.9* Hct-29.6*
MCV-90 MCH-30.3 MCHC-33.6 RDW-15.6* Plt Ct-108*
[**2149-3-21**] 02:54PM BLOOD WBC-7.4 RBC-3.39* Hgb-10.5* Hct-30.9*
MCV-91 MCH-31.0 MCHC-34.0 RDW-15.6* Plt Ct-113*
[**2149-3-22**] 05:50AM BLOOD WBC-7.2 RBC-3.55* Hgb-10.3* Hct-31.7*
MCV-90 MCH-29.1 MCHC-32.5 RDW-15.4 Plt Ct-104*
[**2149-3-23**] 02:43AM BLOOD WBC-7.5 RBC-3.26* Hgb-9.7* Hct-29.2*
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.3 Plt Ct-100*
[**2149-3-24**] 03:51AM BLOOD WBC-7.1 RBC-3.27* Hgb-10.1* Hct-30.1*
MCV-92 MCH-30.9 MCHC-33.5 RDW-15.3 Plt Ct-107*
[**2149-3-25**] 05:20AM BLOOD WBC-6.5 RBC-3.21* Hgb-9.5* Hct-29.0*
MCV-90 MCH-29.5 MCHC-32.6 RDW-15.3 Plt Ct-102*
[**2149-3-26**] 07:10AM BLOOD WBC-7.0 RBC-3.05* Hgb-9.4* Hct-28.4*
MCV-93 MCH-30.6 MCHC-32.9 RDW-15.5 Plt Ct-115*
[**2149-3-19**] 03:30PM BLOOD PT-13.6* PTT-33.5 INR(PT)-1.2*
[**2149-3-25**] 05:20AM BLOOD PT-13.5* PTT-33.4 INR(PT)-1.2*
[**2149-3-19**] 03:30PM BLOOD Glucose-120* UreaN-51* Creat-2.2* Na-137
K-4.0 Cl-100 HCO3-27 AnGap-14
[**2149-3-20**] 03:00AM BLOOD Glucose-115* UreaN-54* Creat-2.3* Na-137
K-3.9 Cl-100 HCO3-28 AnGap-13
[**2149-3-21**] 04:25AM BLOOD Glucose-106* UreaN-47* Creat-1.7* Na-144
K-4.0 Cl-112* HCO3-23 AnGap-13
[**2149-3-22**] 05:50AM BLOOD Glucose-124* UreaN-35* Creat-1.5* Na-152*
K-3.6 Cl-121* HCO3-24 AnGap-11
[**2149-3-23**] 02:43AM BLOOD Glucose-145* UreaN-28* Creat-1.4* Na-149*
K-3.2* Cl-121* HCO3-21* AnGap-10
[**2149-3-24**] 03:51AM BLOOD Glucose-107* UreaN-30* Creat-1.5* Na-139
K-3.8 Cl-113* HCO3-21* AnGap-9
[**2149-3-25**] 05:20AM BLOOD Glucose-106* UreaN-35* Creat-1.6* Na-134
K-4.8 Cl-107 HCO3-23 AnGap-9
[**2149-3-26**] 07:10AM BLOOD Glucose-106* UreaN-43* Creat-1.6* Na-134
K-4.8 Cl-104 HCO3-22 AnGap-13
[**2149-3-19**] 03:30PM BLOOD ALT-35 AST-64* AlkPhos-115 TotBili-1.4
[**2149-3-22**] 05:50AM BLOOD ALT-33 AST-64* AlkPhos-97 TotBili-1.2
[**2149-3-23**] 02:43AM BLOOD ALT-39 AST-84* LD(LDH)-298* AlkPhos-99
TotBili-0.9
[**2149-3-25**] 05:20AM BLOOD ALT-49* AST-89* LD(LDH)-311* AlkPhos-135*
TotBili-0.8
[**2149-3-26**] 07:10AM BLOOD ALT-46* AST-79* LD(LDH)-314* AlkPhos-169*
TotBili-0.5
[**2149-3-25**] 05:20AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.0 Mg-2.2
[**2149-3-19**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-3-20**] 11:53PM BLOOD freeCa-1.06*
.
[**3-19**] Urine Culture <10,000 organisms
[**3-19**] Blood Cultures Negative
.
Imaging
[**2149-3-19**] Chest Xray
PA and lateral upright chest radiographs were compared to
[**2149-1-24**]. Mild cardiomegaly is stable. Mediastinum is
unremarkable. Bilateral linear basal opacities are present and
might be consistent with areas of atelectasis. Small bilateral
pleural effusion is seen. There is no evidence of pneumothorax.
No focal abnormalities worrisome for infectious process are
demonstrated.
.
[**2149-3-20**] Abdominal Ultrasound
IMPRESSION:
1. Small-to-moderate amount of ascites, without significant
interval change.
2. Patent flow within TIPS.
.
[**2149-3-21**] Chest Xray
FINDINGS: In comparison with the study of [**3-20**], the endotracheal
tube and
nasogastric tube remain in place. Continued prominence of the
cardiac
silhouette with left ventricular configuration. Some
indistinctness of the pulmonary vessels suggests increased
pulmonary venous pressure. There is increased opacification in
the retrocardiac region, consistent with some atelectasis.
.
[**2149-3-22**] CT Head
IMPRESSION: No acute intracranial process. Unchanged bifrontal
extra-axial CSF space.
.
[**2149-3-22**] CT Spine
IMPRESSION:
1. No abnormal neck mass noted within the limits of non-contrast
CT.
2. No acute malalignment of the cervical spine
.
[**2149-3-20**] EGD
Erosions in the gastroesophageal junction
Blood in the fundus
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname 81893**] is a 58 year old man with a history of alcoholic
cirrhosis diagnosed in 9/[**2147**]. He is s/p TIPS in [**1-/2148**] with no
known varices. He presented with confusion and developed an oral
bleed.
.
#Hematemesis: On the evening of admission Mr. [**Known lastname 81893**]
developed bleeding from his mouth. His hematocrit significantly
decreased. He was transfused a total of four units. He underwent
an EGD and laryngoscopy. There was a small ulcer visible on the
hard palate. No active sources of bleeding were visualized. A
tagged red blood cell scan did not show any areas of bleeding.
CT scan of the head and neck did not show any masses. His
hematocrit remained stable during the rest of the admission. He
had no further episodes of bleeding.
.
# Alcoholic Cirrhosis: He was diagnosed in 9/[**2147**]. He is s/p
TIPS in 1/[**2148**]. He was placed on home regimen of lactulose and
rifaximin. His confusion improved and he returned to his
baseline. His spironolactone and lasix were temporarily held
while in the MICU. These were eventually restarted at a lower
dose on the floor. He was scheduled for follow up with the liver
center.
.
# COPD: He was placed on fluticasone-salmeterol and nebulizers.
He was discharged on his home medications.
.
# Community Acquired Pneumonia: An early chest xray seemed to
have a retrocardiac opacity. He was started on ceftriaxone and
azithromycin. He completed the course prior to discharge.
.
# Hypernatremia: He developed hypernatremia while in the ICU. He
was given free water. His sodium normalized.
.
# DM2: He is normally diet controlled at home. He was placed on
an insulin sliding scale at discharge.
.
# Hypothyroidism: Continued levothyroxine.
.
# GERD: Continued PPI.
.
# Depression: Continued home medications for depression.
Venlafaxine was switched to a formulary medication during the
admission. Social work assisted him during the admission.
Medications on Admission:
- Albuterol nebs q6h prn wheezing
- Bupropion 75mg PO BID
- Calcium Carbonate 500mg PO QID
- Cyanocobalamin 500mcg PO daily
- Desvenlafaxine 50mg PO daily
- Fluticasone-Salmeterol 250-50mcg inh [**Hospital1 **]
- Folate 1mg PO daily
- Lactulose 15-30mL QID
- Levothyroxine 100mcg PO daily
- Pantoprazole 40mg PO daily
- Rifaximin 400mg PO TID
- Thiamine 100mg PO daily
- Lasix 80mg PO daily
- Spironolactone 200mg PO daily
- Combivent 2puffs q6h
- Methylphenidate 10mg PO BID
- Oxycodone 5mg PO q8h prn
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
3. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): Please titrate to have at least 3 bowel movements
daily.
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Desvenlafaxine 50 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
11. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
12. Calcium 500 mg Tablet Sig: One (1) Tablet PO four times a
day.
13. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours.
14. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hepatic Encephalopathy
Oral Ulcer
Cirrhosis
Community Acquired Pneumonia
Secondary Diagnosis:
Anemia
Chronic Obstructive Pulmonary Disease
Diabetes Mellitus Type II
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with confusion. You were also found to
have bleeding from your mouth. While you were in the hospital,
you had several procedures and studies to determine where the
bleeding was coming from. Eventually, your bleeding stopped. We
will have you follow up with your physician after you are
discharged from the hospital.
It is very important for you to continue to take your lactulose.
You need to take it everyday. This is very important.
We have changed the following medications:
Please decrease the amount of furosemide (lasix) that you take
to 40 mg.
Please decrease the amount of spironolactone you take to 100 mg.
Please weigh yourself everyday. If your weight increases by more
than 3 pounds, please call Dr.[**Name (NI) 6670**] office. You may need to
increase the dose of your medications.
Followup Instructions:
We have scheduled the following appointments for you:
Please follow up with your primary care provider. [**Name Initial (NameIs) **] message was
left at your primary care physician's office requesting an
appointment in the next ten days. They should call you tomorrow
with the exact date and time. If you have any questions or do
not hear from them, please call [**Telephone/Fax (1) 81894**].
We have also scheduled an appointment for you with the liver
center c/o Dr. [**Last Name (STitle) **].
This is on [**4-3**] at 10 AM. Please call ([**Telephone/Fax (1) 1582**] if
you have any questions.
We have also scheduled an appointment for you with psychiatry.
This is with Dr. [**Last Name (STitle) 12879**] on [**3-31**] at 2 PM. The office is
located at [**Street Address(2) 81895**] in [**Hospital1 392**]. Please call
[**Telephone/Fax (1) 81896**] with questions.
|
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48,056
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40765
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Discharge summary
|
report
|
Admission Date: [**2179-5-11**] Discharge Date: [**2179-5-25**]
Date of Birth: [**2113-8-11**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Severe neck pain and headache, s/p cardiac stenting, found to
have diffuse SAH
Major Surgical or Invasive Procedure:
[**2179-5-10**] CORONARY STENT PLACEMENT X 2 (done at [**Hospital **] Hospital
prior to transfer)
[**2179-5-11**] CEREBRAL ANGIOGRAM (diagnostic)
[**2179-5-18**] Cerebral Angiogram- (diagnostic)
History of Present Illness:
65 yo M notes sudden onset of severe neck pain yesterday
morning with subsequent emesis. He was brought to [**Hospital **]
hospital where his EKG revealed mild ST elevations and was taken
for cardiac catheterization (stent x2 RCA). His symptoms did
not
resolve post-procedure and he was then sent for a CTH which
revealed SAH around the basal cisterns. He was then transferred
for neurosurgical intervention. He complains of neck pain, mild
headache, no current nausea. He notes diplopia, no
weakness/numbness.
Past Medical History:
DM, Hyperlipidemia, HTN
Social History:
Lives alone
Denies Tobacco use
Occasional ETOH
has children but lists sister [**Name (NI) **] for emergency contact
Family History:
no family history of aneurysms per pts sister
his mother had a history of MI and stroke
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 2 [**Doctor Last Name **]: 3 GCS E: 4 V: 5 Motor: 6
O: T: 98 BP: 146/65 HR: 64 R 20 O2Sats 98
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4->3 bilat
EOMs: R lateral rectus palsy, otherwise EOM intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, 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, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-20**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On the day of discharge: [**2179-5-25**] the patient is alert and
oriented to person, place, and time. The upper extremities are
full strength. The patient is able to ambulate with a walker
with assist. He has continues to have diplopia secondary to the
VI cranial nerve palsy, slight left pronator drift intermittent.
The patient is conversive and looking forward to discharge to
rehab.
Pertinent Results:
HEAD CTA [**2179-5-11**]:
IMPRESSION:
1. Compared with OSH CT head [**5-10**]: Stable subarachnoid
hemorrhage within the basal cisterns and the
prepontine/premedullary cistern as well as intraventricular
hemorrhage layering within the occipital horns. There are also
stable scattered foci of left hemispheric subarachnoid
hemorrhage as well as subarachnoid hemorrhage layering on the
tentorium cerebelli.
2. The ventricles are prominent similar to the prior study.
3. The CTA is negative for aneurysm, AVM or AVF.
[**2179-5-11**]: CEREBRAL ANGIOGRAMRichard [**Known lastname 78337**] underwent cerebral
angiography for subarachnoid hemorrhage. The study was normal.
ECG Study Date of [**2179-5-11**] 8:18:04 AM
Sinus rhythm with A-V conduction delay. Left atrial abnormality.
Inferior wall myocardial infarction of indeterminate age. Cannot
exclude myocardial ischemia. Clinical correlation is suggested.
No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 230 110 414/426 32 69 131
NECK CTA [**2179-5-12**]:
IMPRESSION: Normal MRA of the neck without evidence of vascular
abnormality. Residual hyperdense blood products remain in the
prepontine and premedullary cystern less conspicuous compared
with the prior study.
HEAD CT [**2179-5-14**]:
IMPRESSION:
1. Evolving subarachnoid hemorrhage within the basal cisterns
and
prepontine/premedullary cisterns. Stable foci of left
hemispheric subarachnoid hemorrhage and hemorrhage layering at
the tentorium cerebelli.
2. Unchanged intraventricular hemorrhage layering within the
occipital horns with stable appearance of the ventricles. No
evidence of hydrocephalus.
3. No new focus of hemorrhage.
Chest Xray [**2179-5-16**]:
FINDINGS: In comparison with the study of [**5-11**], there is
continued low lung volumes with top normal size cardiac
silhouette and probable mild elevation of pulmonary venous
pressure. Atelectatic changes are again seen at the right base
and in the retrocardiac region. In the appropriate clinical
setting, one of these could be a manifestation of developing
consolidation.
MRI Brain [**2179-5-16**]:
IMPRESSION:
Acute infarcts in the right anterior mid-brain and right pons
and further
punctate infarcts in the right cerebellum and right post-central
gyrus.
Evolution of blood in the subarachnoid space, prepontine and
premedullary
cisterns. Intraventricular hemorrhage layering the posterior
horns of both
lateral ventricles is stable.
ECHO [**2179-5-17**]:
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. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. 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.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Dilated aortic root. No definite structural cardiac source of
embolism identified.
Chest Xray [**2179-5-17**]:
IMPRESSION: AP chest compared to [**5-10**] through [**5-16**]:
Mild pulmonary edema has cleared since [**5-16**]. There is still
substantial
consolidation or atelectasis at the right lung base. Moderate
cardiomegaly
has probably improved. Pleural effusions are presumed but not
appreciable in size.
LENIS [**2179-5-17**]:
IMPRESSION:
No evidence of DVT.
[**2179-5-18**]:
[**Known firstname **] [**Known lastname 78337**] underwent cerebral angiography which failed to
reveal a source of his subarachnoid hemorrhage. This was his
second
angiogram.
CHEST (PORTABLE AP) Study Date of [**2179-5-19**] 2:24 PM IMPRESSION:
1. Resolved pulmonary vascular congestion.
2. Improved bibasilar atelectasis.
3. Unchanged low lung volumes.
ABDOMEN (SUPINE & ERECT) PORT Study Date of [**2179-5-20**] 4:10 PM
IMPRESSION: No evidence of ileus or obstruction.
ECG Study Date of [**2179-5-21**] 1:32:04 AM
Baseline artifact. Sinus rhythm with atrial premature beats. Q
waves
with T wave flattening in leads II, III and aVF. Consider
inferior myocardial infarction, age undetermined. Since the
previous tracing of [**2179-5-14**] the axis is less vertical and ST-T
wave abnormalities are less prominent. Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**]
A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 184 92 372/410 41 53 27
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2179-5-25**] 06:35 12.5* 4.15* 13.4* 38.3* 92 32.2* 34.9 13.6
414
[**2179-5-21**] 06:00 16.2* 4.06* 12.9* 39.0* 96 31.8 33.1 13.5
316
[**2179-5-20**] 02:05 15.6* 3.62* 11.5* 34.1* 94 31.7 33.6 13.8
271
Source: Line-aline
[**2179-5-19**] 02:03 14.7* 3.91* 12.4* 36.5* 93 31.7 34.0 13.8
278
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2179-5-25**] 06:35 219*1 20 0.9 135 4.3 98 26 15
[**2179-5-21**] 06:00 169*1 16 0.8 136 4.1 100 26 14
[**2179-5-21**] 02:30 159*1 17 0.9 136 3.6 99 26 15
[**2179-5-20**] 02:05 213*1 19 1.1 140 3.5 103 27 14
Source: Line-aline
[**2179-5-19**] 02:03 167*1 22* 1.0 142 3.1* 104 30 11
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2179-5-25**] 06:35 8.8 3.0 2.3
Brief Hospital Course:
Mr. [**Known lastname 78337**] was admitted to the Neurosurgical ICU where an
Arterial line was placed and patient was monitored closely with
Q1h Neuro checks.
He underwent a cerebral angiogram on the morning of [**5-11**] which
was negative for aneurysm / avm or dural avf. He was placed on a
Insulin drip for managment of his diabetes as he was NPO. On
[**5-12**] he was transitioned to Insulin sliding scale as he was
tolerating a regular diet. He underwent a CTA neck to assess for
further anomalies, but was negative. On [**5-13**], he was more
lethargic and a Head CT was performed and it demonstrated no
acute hemorrhage or increasing edema.
On [**5-16**] In AM the patient was more lethargic, there was new lower
extremitiy weakness on exam noted, MRI brain was consistent with
Acute infarcts in the right anterior mid-brain and right pons
and further punctate infarcts in the right cerebellum and right
post-central gyrus. Evolution of blood in the subarachnoid
space, prepontine and premedullary cisterns. Intraventricular
hemorrhage layering the posterior horns of both lateral
ventricles is stable. Neurology recommended to continue with ASA
and Plavix to prevent stent thrombosis of his cardiac stents but
also for secondary stroke prophylaxis. In addition, he is an
simvastatin for his hyperlipidemia.
BLOOD and URINE cultures were negative.
On [**2179-5-17**], patient was febrile to 103.7F. A CXR and LENIs were
done. His dilantin was discontinued and as he is day 7, no
further AEDs were added. He underwent an ECHO to r/o vegetation
which was consistent with Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Dilated aortic root. No definite structural
cardiac source of embolism identified.LENIS were consistent with
No evidence of DVT.The chest xray was consistent with Mild
pulmonary edema has cleared since [**5-16**]. There is still
substantial consolidation or atelectasis at the right lung base.
Moderate cardiomegaly has probably improved. Pleural effusions
are presumed but not appreciable in size.
On [**5-18**], he underwent a angiogram to re-assess for aneurysm,
which was negative. Post-angio he was transferred back to the
Neuro ICU so that his blood pressure could be managed down to
less than 160 (he had been autoregulating previously to
180-200). He was transferred to the SDU on [**5-20**] for further
management. He continued to be hypertensive and worked with PT
and OT.
On [**5-21**] medicine was consulted to assist in developing a
treatment regimen for his Blood Pressure control as an
outpatient given the fact he was on many oral agents. They
recommended changing norvasc to 10mg daily, Lisinopril to 40mg
daily, and changing Zocor to Lipitor.
The patient remained stable on [**5-22**] and [**5-23**] while awaiting rehab
placement and his blood pressure was much improved on the new
regimen.
On [**5-24**], The patient had one episode of elevated blood sugar to
419 which was treated with which was treated with 10 units
regular insulin. This was rechecked at approximately 330 pm and
was 330, this was after the patient had lunch. On trend it was
noted that his sugars were not so well controlled. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Diabetes consult was called and their recs followed. He may
need further titration at rehab. Follow up is outlined in his
discharge summary.
Medications on Admission:
Medications prior to admission: simvastatin, lantus, ASA 81mg,
Novolog ISS
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML PO BID (2
times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 7 days.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
DO NOT STOP TAKING THIS UNLESS CLEARED BY CARDIOLOGY AND
NEUROLOGY.
7. acetaminophen 650 mg/20.3 mL Solution Sig: [**1-17**] PO Q6H (every
6 hours) as needed for pain, t>38.5.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): DO NOT STOP TAKING THIS UNLESS CLEARED TO DO SO BY
CARDIOLOGY AND NEUROLOGY .
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for neck/head pain.
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
11. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-17**]
Drops Ophthalmic PRN (as needed) as needed for irritation.
12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for Constipation.
13. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
15. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for HTN.
17. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
21. Ondansetron 4 mg IV Q8H:PRN nausea
22. HydrALAzine 10 mg IV Q6H prn sbp> 180
23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
24. 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.
25. insulin glargine 100 unit/mL Solution Sig: Forty Six (46)
UNITS Subcutaneous HS.
26. Humulin R 100 unit/mL Solution Sig: One (1) Injection AC
AND HS : SEE SLIDING SCALE COVERAGE .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
SUBARACHNOID HEMORRHAGE
VENTRICULOMEGALY
INTRAVENTRICULAR HEMORRHAGE
RIGHT 6TH NERVE PALSY with diplopia
FEVER
RIGHT PONS INFARCT
RIGHT MIDBRAIN INFARCT
RIGHT CEREBELLAR INFARCT
CARDIAC INFARCTION / OLD
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.
?????? AS directed by your doctor, take anti-inflammatory
medications: Aspirin 325 mg qd and Plavix 75 mg qd for recent
Right carotid artery stents x2 at [**Hospital **] Hospital [**2179-5-10**] and
non acute embolic strokes.
?????? You have been prescribed Nimodipine 60 mg PO Q4H a calcium
channel blocker to assist in decreasing your vulnerability to
Vasospasm. You will need to be on this medication a total of 21
days. The last day that you will take this is on [**2179-6-1**].
Followup Instructions:
PLEASE FOLLOW-UP WITH DR [**First Name (STitle) **] IN 4 WEEKS WITH MRI/MRA. The
office number is [**Numeric Identifier 89108**]
[**2179-6-24**] 02:30p [**Last Name (LF) **],[**First Name3 (LF) **] J.
LM [**Hospital Unit Name **], [**Location (un) **]
NEUROSURGERY WEST
[**2179-6-24**] 01:20p MRI DEPARTMENT [**Hospital Ward Name **]
[**Location (un) **], BASEMENT
RADIOLOGY
FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN REGARDING YOUR HIGH
BLOOD PRESSURE, STROKES AND SUGAR CONTROL(DIABETES)
YOU WERE SEEN BY THE [**Last Name (un) **] CENTER WHILE HERE AT [**Hospital1 18**] / THEY
MADE SOME CHANGES TO YOUR INSULIN REGIME / YOU CAN FOLLOW UP
WITH THE [**Last Name (un) **] DIABETES CENTER AT [**Telephone/Fax (1) **] / YOU WERE SEEN
BY DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] / YOU [**Month (only) **] ALSO FOLLOW UP WITH YOUR
ENDOCRINOLGIST IN [**Location (un) **].
You have an apointment with neuro-opthomology for possible prism
lenses to minimize the double vision you have been experiencing.
The appointment has been made with the Eye Clinic Dr
[**Last Name (STitle) **],[**First Name3 (LF) 6131**] (at [**Telephone/Fax (1) 253**]).[**2179-6-22**] 2:30 pm [**Hospital Ward Name 23**]
Buliding [**Location (un) 442**].
Please follow up with Dr [**First Name (STitle) **] [**Name (STitle) **] of Neurology in 4
weeks. Please call their office to arrange an appoitment:([**Telephone/Fax (1) 19129**]
Completed by:[**2179-5-25**]
|
[
"V45.82",
"564.09",
"412",
"351.8",
"272.4",
"403.90",
"274.9",
"V58.67",
"250.02",
"414.8",
"585.9",
"780.60",
"430",
"E936.1",
"518.0",
"378.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
15098, 15195
|
9077, 12503
|
385, 584
|
15442, 15442
|
3311, 9054
|
16523, 18013
|
1327, 1416
|
12629, 15075
|
15216, 15421
|
12529, 12529
|
15625, 16500
|
1446, 1839
|
12561, 12606
|
267, 347
|
612, 1130
|
2091, 3292
|
15457, 15601
|
1152, 1177
|
1193, 1311
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,878
| 129,759
|
49030
|
Discharge summary
|
report
|
Admission Date: [**2177-4-24**] Discharge Date: [**2177-4-25**]
Date of Birth: [**2122-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
status-post cardiac arrest
Major Surgical or Invasive Procedure:
Intubation, central line placement
History of Present Illness:
50M transferred from LGH s/p cardiac arrest. Pt was at home in
bed, snoring, wife left room, later heard no sounds so went to
check on pt and found him unresponsive and cynotic, EMS arrived,
no shock advised on AED, intubated, CPR, epi/atropine x 4,
developed VF, defib x 1, then asystole, then WCT, started
lidocaine. At OSH, L SC CVL placed. K 7.1, treated for hyperK.
In ED here, initial BP 60-70, HR 80s, BP improved once maxed out
on dopa/levophed. R fem a-line and L fem CVL placed. TTE
performed. CTA torso.
Review of sytems: Recently has felt well. No f/c, abd pain,
n/v/d, cough.
Past Medical History:
- Hep C
- Mild sleep apnea
Social History:
No T/E/D. Hx EtOh 10 years ago.
Family History:
Non-contributory
Physical Exam:
Admission Exam
Vitals: T: 29C (84F) BP: 104/58 P: 89 R: 20 set O2: 96% on 100%
FIO2
Vent: 700 x 20 x 10 x 100%
General: Unresponsive
HEENT: Sclera anicteric, NC/AT, Pupils 7mm and fixed, OGT,
+edema
Neck: Supple
Lungs: Coarse bilaterally
CV: s1s2 RRR
Abdomen: soft, mildly distended, bowel sounds present
Ext: Cool ext, not moving,
Neuro: Absent corneals, no withdrawal to pain,
Pertinent Results:
[**2177-4-24**] 11:37PM TYPE-ART TEMP-36.6 PO2-53* PCO2-62* PH-7.17*
TOTAL CO2-24 BASE XS--6 INTUBATED-INTUBATED
[**2177-4-24**] 10:34PM TYPE-ART TEMP-35.4 PO2-44* PCO2-63* PH-7.14*
TOTAL CO2-23 BASE XS--8 INTUBATED-INTUBATED
[**2177-4-24**] 09:30PM TYPE-ART TEMP-35.3 PO2-45* PCO2-72* PH-7.12*
TOTAL CO2-25 BASE XS--7
[**2177-4-24**] 09:30PM LACTATE-11.3* K+-2.9*
[**2177-4-24**] 09:30PM freeCa-1.04*
[**2177-4-24**] 09:05PM GLUCOSE-623* UREA N-26* CREAT-2.7* SODIUM-134
POTASSIUM-2.9* CHLORIDE-87* TOTAL CO2-21* ANION GAP-29*
[**2177-4-24**] 09:05PM CALCIUM-7.4* PHOSPHATE-4.5 MAGNESIUM-2.3
[**2177-4-24**] 09:05PM WBC-0.7* RBC-3.57* HGB-11.9* HCT-36.1*
MCV-101* MCH-33.3* MCHC-32.9 RDW-15.7*
[**2177-4-24**] 09:05PM PLT COUNT-193
[**2177-4-24**] 09:05PM PT-33.8* PTT-62.1* INR(PT)-3.5*
[**2177-4-24**] 09:05PM FIBRINOGE-110*
[**2177-4-24**] 05:52PM TYPE-ART TEMP-34.1 RATES-22/ PEEP-12 O2-100
PO2-52* PCO2-56* PH-7.20* TOTAL CO2-23 BASE XS--6 AADO2-624 REQ
O2-99 INTUBATED-INTUBATED VENT-CONTROLLED
[**2177-4-24**] 05:52PM LACTATE-11.4*
[**2177-4-24**] 05:16PM HGB-11.1* calcHCT-33
[**2177-4-24**] 05:14PM GLUCOSE-547* UREA N-25* CREAT-2.4* SODIUM-138
POTASSIUM-2.9* CHLORIDE-92* TOTAL CO2-21* ANION GAP-28*
[**2177-4-24**] 05:14PM ALT(SGPT)-4294* AST(SGOT)-5186* CK(CPK)-7330*
TOT BILI-1.2
[**2177-4-24**] 05:14PM CK-MB-127* MB INDX-1.7 cTropnT-1.29*
[**2177-4-24**] 05:14PM CALCIUM-7.3* PHOSPHATE-5.1*# MAGNESIUM-2.3
[**2177-4-24**] 05:14PM WBC-0.9*# RBC-3.22* HGB-10.7* HCT-32.0*
MCV-99* MCH-33.3* MCHC-33.6 RDW-15.5
[**2177-4-24**] 05:14PM NEUTS-11* BANDS-1 LYMPHS-86* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2177-4-24**] 05:14PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ BURR-1+
STIPPLED-1+ TEARDROP-OCCASIONAL
[**2177-4-24**] 05:14PM PLT SMR-NORMAL PLT COUNT-158
[**2177-4-24**] 05:14PM PT-33.4* PTT-74.0* INR(PT)-3.5*
[**2177-4-24**] 05:14PM FIBRINOGE-122*
[**2177-4-24**] 05:14PM FIBRINOGE-122*
[**2177-4-24**] 04:30PM TYPE-ART PO2-52* PCO2-75* PH-7.20* TOTAL
CO2-31* BASE XS-0
[**2177-4-24**] 04:30PM LACTATE-11.2* K+-3.4*
[**2177-4-24**] 04:30PM O2 SAT-80
[**2177-4-24**] 04:30PM freeCa-1.09*
[**2177-4-24**] 03:26PM TYPE-ART PO2-61* PCO2-57* PH-7.12* TOTAL
CO2-20* BASE XS--11
[**2177-4-24**] 03:26PM LACTATE-8.8* K+-3.6
[**2177-4-24**] 03:26PM freeCa-0.92*
[**2177-4-24**] 02:31PM TYPE-ART PO2-78* PCO2-46* PH-7.15* TOTAL
CO2-17* BASE XS--12
[**2177-4-24**] 02:31PM LACTATE-8.1*
[**2177-4-24**] 02:31PM freeCa-0.85*
[**2177-4-24**] 02:31PM freeCa-0.85*
[**2177-4-24**] 02:17PM VoidSpec-REECTED, N
[**2177-4-24**] 01:33PM TYPE-ART TEMP-31 O2-100 PO2-46* PCO2-33*
PH-7.31* TOTAL CO2-17* BASE XS--8 AADO2-653 REQ O2-100
INTUBATED-INTUBATED
[**2177-4-24**] 01:33PM LACTATE-8.3*
[**2177-4-24**] 01:33PM freeCa-0.93*
[**2177-4-24**] 12:57PM TYPE-ART TEMP-30.9 O2-100 PO2-45* PCO2-34*
PH-7.18* TOTAL CO2-13* BASE XS--14 AADO2-653 REQ O2-100
[**2177-4-24**] 12:57PM LACTATE-8.3*
[**2177-4-24**] 11:17AM TYPE-ART PO2-83* PCO2-50* PH-7.07* TOTAL
CO2-15* BASE XS--15
[**2177-4-24**] 11:17AM GLUCOSE-143* LACTATE-11.2* NA+-134* K+-5.6*
CL--101
[**2177-4-24**] 11:17AM freeCa-0.97*
[**2177-4-24**] 10:59AM GLUCOSE-156* UREA N-21* CREAT-1.9* SODIUM-138
POTASSIUM-5.7* CHLORIDE-100 TOTAL CO2-14* ANION GAP-30*
[**2177-4-24**] 10:59AM ALT(SGPT)-5860* AST(SGOT)-4647* CK(CPK)-2522*
ALK PHOS-100 AMYLASE-586* TOT BILI-1.1
[**2177-4-24**] 10:59AM LIPASE-43
[**2177-4-24**] 10:59AM CK-MB-60* MB INDX-2.4 cTropnT-0.54*
[**2177-4-24**] 10:59AM ALBUMIN-3.0* CALCIUM-7.1* PHOSPHATE-12.4*
MAGNESIUM-3.1*
[**2177-4-24**] 10:59AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2177-4-24**] 10:59AM NEUTS-64.0 BANDS-0 LYMPHS-32.7 MONOS-1.9*
EOS-0.5 BASOS-0.9
[**2177-4-24**] 10:59AM PT-37.8* PTT-131.4* INR(PT)-4.1*
[**2177-4-24**] 09:11AM TYPE-ART PO2-78* PCO2-63* PH-7.06* TOTAL
CO2-19* BASE XS--13 INTUBATED-INTUBATED
[**2177-4-24**] 08:55AM UREA N-21* CREAT-2.0*
[**2177-4-24**] 08:55AM estGFR-Using this
[**2177-4-24**] 08:55AM CK(CPK)-1167*
[**2177-4-24**] 08:55AM CK-MB-27* MB INDX-2.3 cTropnT-0.26*
[**2177-4-24**] 08:55AM CK-MB-27* MB INDX-2.3 cTropnT-0.26*
[**2177-4-24**] 08:55AM PT-32.3* PTT-93.5* INR(PT)-3.4*
[**2177-4-24**] 08:55AM PT-32.3* PTT-93.5* INR(PT)-3.4*
[**2177-4-24**] 08:55AM FIBRINOGE-95*
[**2177-4-24**] 08:42AM GLUCOSE-122* LACTATE-10.9* NA+-134* K+-7.3*
CL--99* TCO2-14*
[**2177-4-24**] 08:31AM WBC-14.0* RBC-3.08* HGB-10.4* HCT-31.6*
MCV-103* MCH-33.8* MCHC-32.9 RDW-15.1
[**2177-4-24**] 08:31AM WBC-14.0* RBC-3.08* HGB-10.4* HCT-31.6*
MCV-103* MCH-33.8* MCHC-32.9 RDW-15.1
[**2177-4-24**] 08:31AM PLT COUNT-274
[**2177-4-24**] 08:21AM PO2-67* PCO2-67* PH-7.00* TOTAL CO2-18* BASE
XS--16
[**2177-4-24**] 08:21AM GLUCOSE-126* LACTATE-12.7* NA+-133* K+-7.1*
CL--97*
[**2177-4-24**] 08:21AM GLUCOSE-126* LACTATE-12.7* NA+-133* K+-7.1*
CL--97*
Brief Hospital Course:
The patient was admitted to the MICU from the ED after CT scans
of the head and torso were performed. The CT head demonstrated
diffuse cerebral edema. The CT torso demonstrated bilateral
dependent consolidations concerning for aspiration; no pulmonary
embolism. There was severe acidosis requiring bicarbonate
infusions. The patient was hypotensive, requiring ultimately 4
pressors to keep the MAP above 60. He eventually became
difficult to oxygenate, despite maximum support on the
ventilator, including trials of repositioning and inhaled nitric
oxide. Antibiotics were given. There was evidence of dense renal
failure as well as liver failure, with coagulopathy. The patient
received transfusions of FFP and pRBCs. The patient was noted
to be 29C on arrival to the MICU; the patient was slowly
rewarmed to a goal of 35C given the concern about
neuroprotection post-arrest but in the setting of coagulopathy
the usual goal of 33-34C was modified to 35C. The Neurology
service was consulted on hospital day 2 and confirmed the very
poor prognosis. The family decided to change the code status to
DNR. The patient's hemodynamics worsened and he expired with his
family present at 13:30. The Medical Examiner was notified and
declined the case. The family elected for a post-mortem
examination and this was arranged. A call was placed to his
PCP's office.
Medications on Admission:
Ambien
Citalopram
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Aspiration pneumonia
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"570",
"572.8",
"507.0",
"584.9",
"070.70",
"286.9",
"518.81",
"348.5",
"276.7",
"785.50",
"276.2",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"38.91",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8029, 8038
|
6574, 7932
|
344, 380
|
8117, 8126
|
1548, 6551
|
8182, 8192
|
1115, 1133
|
8000, 8006
|
8059, 8096
|
7958, 7977
|
8150, 8159
|
1148, 1529
|
278, 306
|
943, 1000
|
408, 925
|
1022, 1050
|
1066, 1099
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,298
| 156,084
|
36140
|
Discharge summary
|
report
|
Admission Date: [**2159-1-20**] Discharge Date: [**2159-2-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Right ankle fracture.
Major Surgical or Invasive Procedure:
[**2159-1-21**]: ORIF Right ankle fracture.
History of Present Illness:
Mr. [**Known lastname 10602**] is an 89 yo male with prostate cancer who presents
with a right ankle fracture sustained during a mechanical fall
yesterday. He states that he was bending over in the bathroom to
pick up something from the floor and fell onto his right side.
He denies hitting his head or loss of consciousness. He
initially refused transport to the hospital but was then
transferred to [**Hospital3 **] this morning after noting that
his ankle was more swollen with worsening pain. He states that
he was unable to ambulate. On arrival at [**Hospital3 **], he was
diagnosed with a bimalleolar fracture of the right ankle. His
labs at [**Hospital3 **] were significant only for troponinI of
0.07. He was transferred to [**Hospital1 18**] for surgical evaluation.
On arrival to our ED, T 97.9, HR 83, BP 100/40, RR 18 , SpO2 96%
on RA. At the time of this interview he reports pain is 4 out of
10 in severity and he complains only of hunger. He states that
he ambulates at baseline with a walker and can walk for 30
minutes in duration with his walker and routinely walks in the
corridor of the apartment building where he lives. He reports
occasional falls and states that his wife has always been able
to help him up. He has never had any chest pain and denies any
shortness of breath, orthopnea, ankle edema, palpitations,
syncope or presyncope.
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. There is no recent fevers, chills or
rigors. There is no exertional buttock or calf pain. All of the
other review of systems were negative. He reports that he is
continent of urine and that his last BM was yesterday.
Past Medical History:
Prostate cancer, s/p TURP in ~[**2151**], treated intermittently with
hormonal therapy, no treatment for past several years, staging
unknown.
Urinary incontinence
Chronic constipation
Coronary artery disease, ? previous MI per PCP, [**Name10 (NameIs) **] no
supporting evidence and patient denies
COPD
Compression fracture of L-spine
Social History:
Ambulates with walker past 8 years
Family History:
NC
Physical Exam:
On discharge:
VS: T 97.4, BP 102/66, HR 76, RR 20, SpO2 95% on RA
Tm 97.4, 92-136/60-69, 74-100, 16-29, 94-97% on RA
Gen: NAD. Oriented x3. Russian-speaking only.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no
exudates or ulceration.
Neck: Supple, JVP not elevated.
CV: regular, normal S1, S2. 1/6 SEM.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
rales, wheezes or rhonchi.
Abd: Soft, NTND.
Ext: Right ankle in air cast. No c/c/edema. 2+ DP pulses
bilaterally, 2+ radial pulses.
Skin: No stasis dermatitis, ulcers, scars.
Pertinent Results:
Labs on admission:
[**2159-1-20**] 12:00PM BLOOD WBC-8.2 RBC-3.97* Hgb-13.5* Hct-37.6*
MCV-95 MCH-34.0* MCHC-35.9* RDW-13.8 Plt Ct-199
[**2159-1-20**] 12:00PM BLOOD Neuts-84.8* Lymphs-10.6* Monos-3.8
Eos-0.7 Baso-0.1
[**2159-1-20**] 12:00PM BLOOD PT-13.1 PTT-30.9 INR(PT)-1.1
[**2159-1-20**] 12:00PM BLOOD Glucose-119* UreaN-17 Creat-1.1 Na-135
K-6.1* Cl-100 HCO3-26 AnGap-15
[**2159-1-20**] 12:00PM BLOOD CK(CPK)-108
[**2159-1-20**] 12:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2159-1-21**] 05:15AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7
Labs on discharge:
[**2159-2-6**] 06:09AM BLOOD WBC-6.6 RBC-2.95* Hgb-9.7* Hct-28.1*
MCV-95 MCH-32.8* MCHC-34.3 RDW-14.6 Plt Ct-432
[**2159-2-5**] 05:02AM BLOOD PT-14.2* PTT-33.8 INR(PT)-1.2*
[**2159-2-6**] 06:09AM BLOOD Glucose-101 UreaN-19 Creat-1.0 Na-138
K-4.1 Cl-106 HCO3-24 AnGap-12
[**2159-2-6**] 06:09AM BLOOD Mg-1.9
Knee/Ankle X-ray [**2159-1-20**]:
Limited examination secondary to overlying cast material.
Bimalleolar fractures involving the right ankle as described.
Overall, the alignment appears near anatomic. If further
assessment of fracture extent is required, a CT of the ankle is
advised. Unremarkable right knee.
Abdominal x-ray [**2159-1-23**]:
Dilated loops of colon, with air also seen in the rectum, which
can be seen in an early obstruction or pseudo-obstruction.
CT abd/pelvis [**2159-1-25**]:
1. Extensive emphysema within the gastric wall, with foci of
free air along the GE junction and medial aspect of the stomach.
Given the patient's reported lack of acute abdominal findings or
risk factors for infarction or signs of infection, these
findings are likely due to traumatic dissection by repeated NG
tube placement or intramural dissection of air from massive
gastric distention as seen on prior abdominal radiograph from
[**2159-1-24**]. These findings were discussed urgently with Dr.
[**First Name8 (NamePattern2) 5320**] [**Last Name (NamePattern1) 73438**] at 6:30 p.m. on [**2159-1-25**].
2. Decreased colonic distention without evidence of obstruction,
likely resolving ileus.
3. Non-obstructive 5-mm left renal calculus and additional tiny
left renal stones vs. excreted (previously administered)
contrast.
4. Small left and tiny right pleural effusions.
5. Incompletely evaluated lesions of the left kidney, for which
ultrasound is recommended for further evaluation.
CT abd [**2159-1-27**]:
1. Interval decrease in the gastroesophageal pneumatosis and
tiny pneumomediastinum.
2. Stable small left pleural effusion and adjacent atelectasis.
3. Small cystic-appearing lesion in the uncinate process of the
pancreas. This could represent a side-branch IPMN or sequela of
prior pancreatitis. Further evaluation with MRCP would be
helpful when the clinical situation permits.
4. Stable severe L2 compression fracture.
5. Tiny volume ascites.
Brief Hospital Course:
Mr. [**Known lastname 10602**] presented to the [**Hospital1 18**] on [**2159-1-20**] via transfer from
[**Hospital3 **] Medical Center with a right ankle fracture. He
was evaluated, prepped, consented, and cleared for surgery by
medicine. On [**2158-1-20**] he was taken to the operating room and
underwent an ORIF of his right ankle. He tolerated the
procedure well, was extubated, transferred to the recovery room,
and then to the floor. On the floor he was seen by physical
therapy to improve his strength and mobility.
On [**2159-1-23**], a KUB film showed dilated bowel 11.5 cm, stool in
rectum, and he was given mag citrate. The following day, a KUB
obtained after the patient vomited showed very large gastric
bubble with no definite ileus. An NG tube was placed with a
large amount of fluid draining. His WBC increased to 20 (up from
13) though the patient remained afebrile. Cipro IV was started
while the patient was NPO. On [**2159-1-25**], his NGT put out 600cc
brown flacky out-put within 3 hrs. The patient appeared to
improve and WBC went down to 19.5 from 23. Again, he remained
afebrile, with stable VS, soft abdomen, and decreased
distention.
A subsequent abdominal CT showed emphysema within the gastric
wall, Heme Occult +, Gastric Occult +, and IV Protonix was
started. The CT findings may be related to extensive gastric
distention from recent ileus, or traumatic dissection from NG
tube, with focal perforation.
A General Surgery Assessment concluded it was a contained
perforation. The NGT was continued and broad spectrum
antibiotics were started (Vanc, Cipro, Flagyl, Fluconazole). GI
was consulted and felt an EGD would be contraindicated.
After after stay in the ICU for precautionary reasons, a repeat
CT scan showed resolving emphysema. The patient did receive two
days of TPN in the interim. This was discontinued as the patient
began to tolerate PO intake. He was started on Vitamin D and
calcium supplement. He was restarted on Lovenox for an
additional two weeks post-discharge and is to remain non-weight
bearing on his right lower extremity until further follow up in
ortho clinic in two weeks.
Medications on Admission:
HCTZ 25 mg daily
Senna
Tylenol prn pain
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Tablet Sig: 1-2 Tablets 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. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
twice a day for 2 weeks.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Status post mechanical fall.
Right ankle fracture.
Discharge Condition:
Stable. afebrile, able to tolerate PO.
Discharge Instructions:
You were admitted for a right ankle fracture which is healing
well. While you were here, you had a tube placed in your stomach
to decompress you GI tract and you did not eat for several days.
It important for you to continue to eat regularly to stimulate
your GI tract to function.
Your HCTZ was discontinued. You are being given Pantoprazole 40
mg daily, as well as the bowel medications, Bisacodyl, Docusate
Sodium, and Senna for constipation as needed. You should also
take Vitamin D and calcium supplements as written for help with
osteoporosis and bone healing.
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Continue to be non-weight bearing on your right leg.
Continue your lovenox injections as instructed for a total of 4
weeks after surgery
If you have any increased pain, swelling not relieved with rest
and elevation or if you have a temperature greater than 101.5
please call the office or come to the emergency department
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in
two weeks, please call [**Telephone/Fax (1) 1228**] to schedule that
appointment.
Completed by:[**2159-2-19**]
|
[
"E885.9",
"584.9",
"V10.46",
"285.1",
"998.2",
"293.0",
"564.09",
"786.8",
"577.2",
"578.9",
"276.51",
"496",
"560.1",
"997.4",
"263.0",
"998.81",
"733.00",
"E878.8",
"824.4",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"79.36",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8999, 9069
|
6001, 8141
|
282, 329
|
9164, 9205
|
3165, 3170
|
10491, 10715
|
2576, 2580
|
8231, 8976
|
9090, 9143
|
8167, 8208
|
9229, 10468
|
2595, 2595
|
2609, 3146
|
221, 244
|
3713, 5978
|
357, 2151
|
3184, 3694
|
2173, 2508
|
2524, 2560
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,439
| 184,523
|
32920
|
Discharge summary
|
report
|
Admission Date: [**2158-3-17**] Discharge Date: [**2158-3-26**]
Date of Birth: [**2079-11-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Penicillins / Percocet / Codeine /
Aspirin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
murmur noted on physical exam, echo revealed AI
Major Surgical or Invasive Procedure:
AVR (21mm tissue), Replacecment of ascending aorta, total arch
replacement w/reimplantation of great vessels.
History of Present Illness:
pre-op eval. for breast lesion revealed heart murmur. Echo
found AI, and thoracoabdominal aneurysm.
Past Medical History:
IBS, back pain, former smoker, breast ca
Social History:
smokes 1/2ppd, no ETOH
retired, lives alone
Family History:
twin sister s/p valve replacement
Physical Exam:
unremarkable pre-op
Pertinent Results:
[**2158-3-25**] 07:10AM BLOOD WBC-11.6* RBC-3.67* Hgb-11.0* Hct-33.1*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.3 Plt Ct-232#
[**2158-3-22**] 02:03AM BLOOD PT-12.5 PTT-32.5 INR(PT)-1.1
[**2158-3-25**] 07:10AM BLOOD Glucose-118* UreaN-18 Creat-1.1 Na-137
K-3.7 Cl-92* HCO3-34* AnGap-15
[**2158-3-23**] 02:54AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76611**]Portable
TTE (Focused views) Done [**2158-3-18**] at 8:57:16 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2079-11-24**]
Age (years): 78 F Hgt (in): 63
BP (mm Hg): 160/90 Wgt (lb): 130
HR (bpm): 90 BSA (m2): 1.61 m2
Indication: Tamponade/pericardial effusion.
ICD-9 Codes: 423.3
Test Information
Date/Time: [**2158-3-18**] at 08:57 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**]
[**Last Name (NamePattern1) **], RDCS
Doppler: Limited Doppler and no color Doppler Test Location:
West SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid [**8-7**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.4 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic function (LVEF>55%). Suboptimal technical quality, a
focal LV wall motion abnormality cannot be fully excluded.
RIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free
wall hypokinesis.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
GENERAL COMMENTS: Echocardiographic results were reviewed by
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Right
ventricular chamber size is normal with moderately depressed
free wall contractility. A well-seated bioprosthetic aortic
valve prosthesis is present. There is a 1.5-2.0cm echogenic
filled space anterior to the right ventricle and left ventricle
which appears similar to the pre-operative images of [**2158-2-28**] and
likely represents epicardial fat.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2158-3-18**] 09:29
Brief Hospital Course:
Admitted the day of surgery, taken to the OR for AVR (tissue)
and raplacement of ascending aorta & total arch (please see
operative note for details of procedure). Post-op, she was taken
to the ICU on neosynephrine drip for BP support. Initially,
she required some blood products & IV fluids for labile BP, she
was placed on inotropes for cardiac index. She was duiresed
over the next few days, and ultimately extubated on POD # 5.
Her pressors & inotropes were also weaned off during those days.
On POD # 6, a speech/swallow evalutaion was obtained due to
some apparent difficulty swallowing. She was diagnosed w/mild
to moderate dysphagia, and a diet of ground solids and thin
liquids was ordered. She was transferred from the ICU to the
telemetry floor later on POD # 6. Her beta blockers were started
and increased, continues with diuresis, and has remained
hemodynamically stable. She remains slow to progress from a
physical therapy standpoint. She is now ready to be transferred
to a rehab facility to continue with physical therapy &
speech/swallowing therapy.
Medications on Admission:
Glycolax
tylenol prn
Lopressor
Lipitor
ASA
SC heparin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 5502**]Nursing Home - [**Location (un) 5503**]
Discharge Diagnosis:
Thoraco-abdominal Aortic aneurysm
Aortic valve insuficiency
Breast Cancer
IBS
chronic bronchitis
Discharge Condition:
good
Discharge Instructions:
Diet: Ground solids and thin liquids
[**Month (only) 116**] shower, pat incisions dry, no lotions or powders to any
incisions
vital sign monitoring, tight BP control (SBP should remain <
140's)
No lifting > 10# in 10 weeks
no driving for 1 month
Followup Instructions:
with Dr. [**Last Name (STitle) 15170**] in [**3-5**] weeks
with Dr. [**Last Name (STitle) 914**] in [**5-6**] weeks
Completed by:[**2158-3-25**]
|
[
"458.29",
"441.7",
"424.1",
"491.8",
"112.0",
"564.1",
"276.6",
"401.9",
"174.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"35.21",
"39.61",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5983, 6074
|
3819, 4896
|
380, 492
|
6215, 6222
|
853, 3796
|
6517, 6664
|
763, 798
|
5000, 5960
|
6095, 6194
|
4922, 4977
|
6246, 6494
|
813, 834
|
293, 342
|
520, 622
|
644, 686
|
702, 747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,445
| 100,659
|
32773
|
Discharge summary
|
report
|
Admission Date: [**2132-4-23**] Discharge Date: [**2132-5-7**]
Date of Birth: [**2057-12-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
GI bleed. MRSA bacteremia.
Major Surgical or Invasive Procedure:
-Esophagogastroduodenoscopy (EGD), [**2132-4-24**]
-PICC line, [**2132-5-2**]
History of Present Illness:
Mrs. [**Known lastname 76318**] is a 74 year old woman with past medical
history significant for rheumatoid arthritis (on chronic
prednisone), asthma, hypertension, hyperthyroidism, presenting
from rehab facilty after being found to have altered mental
status and bright red blood per rectum.
Per transfer notes, patient was intially taken to [**Hospital 1474**]
hospital where she was evaluated for abdominal pain. Vitals on
arrival 94/52, 83, 14, 98 F. Given her altered mental status, CT
head was performed with preliminary read raising the question of
a basal ganglia hemorrhage. Labs there revealed AST 103 / ALT
112, Ap 451, T bili 3.0 and D bili 2.1. Patient was transferred
for further management of suspected intracraneal hemorrhage.
In our ED, 98.2, 110/63, 85, 22 100% 4L NC. Patient underwent
repeat head CT which did not reveal any acute intracraneal
process. Patient was also noted to have two bowel movements with
bright red blood. Labs repeated and given OSH elevation in liver
enzymes and congestive pattern, CT abdomen was performed.
Surgery, GI and ERCP services were [**Name (NI) 653**], and decision was
made to admit patient to ICU for further management.
At this time, patient denies any pain or discomfort. She is not
accompanied by family and she reports feeling slightly confused.
She is unable to relate why she was brought to the hospital and
believes she was home earlier today. Denies any chest pain, but
reports some difficulty breathing. Also reports single episode
of vomiting earlier in the week with gastric contents and clear
liquid. She denied any light headedness or palipiations.
Past Medical History:
-Asthma
-Rheumatoid Arthritis, on Prednisone since [**2097**] per patient
-Hypertension
-Hyperthyroidism, on methimazole
-Anxiety
-Transient Ischemic Attack (9 years ago)
-Glaucoma
-Status-post bilateral knee replacements
-Status-post bilateral hip replacements
Social History:
Does not smoke, drink alcohol or take other drugs. Lives with
husband and has visiting home health aid. Last walked two weeks
ago, however prior to that did require a walker and assistance.
Family History:
Sister with pancreatic cancer.
Physical Exam:
On admission:
Tmax: 37.4 ??????C (99.4 ??????F)
Tcurrent: 37.4 ??????C (99.4 ??????F)
HR: 90 (86 - 90) bpm
BP: 128/65(65) {84/45(55) - 128/65(65)} mmHg
RR: 24 (24 - 29) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic), II/VI at left base
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: , Rhonchorous: )
Abdominal: Soft, Bowel sounds present, Tender: Right upper and
lower quadrants, Obese
GU: Anus with tender external hemorrhoid and small fissure at
the 6 o??????clock position,
Extremities: Right: Trace, Left: Trace, (+) Ecchymoses
Musculoskeletal: Muscle wasting
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): Self, place, Movement: Not assessed,
Tone: Not assessed
On discharge:
Vitals: T 98.0, BP 120/66, HR 76, RR 24, O2 sat 93% on room air.
Tm 100.1, 120-131/59-81, 70-101, 22-24, 91-93% on room air
I/O [**Telephone/Fax (1) 76319**], 0/450 since midnight.
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition,
evidence of thrush
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: normal S1/S2, +systolic murmur
Peripheral Vascular: normal radial and pedal pulses
Respiratory/Chest: good air movement with upper airway coarse
breath sounds present on anterior exam, no crackles noted on
posterior exam
Abdominal: Soft, Bowel sounds present, diffuse tenderness, no
guarding
Extremities: severe joint disruption due to RA, s/p bilateral
hip and knee replacements, large amount of anasarca noted with
3+ edema in right lower extremity, 2+ in left lower, 1+ in left
upper, and significant improvement in right upper back to
baseline; overall improving slowly
Skin: Warm, + multiple ecchymoses
Neurologic: Attentive, Follows commands, alert and oriented.
Pertinent Results:
Labs on admission:
[**2132-4-24**] 09:41AM BLOOD WBC-16.7* RBC-3.04* Hgb-9.0* Hct-27.7*
MCV-91 MCH-29.5 MCHC-32.4 RDW-17.0* Plt Ct-326
[**2132-4-23**] 05:10PM BLOOD WBC-18.2* RBC-3.67* Hgb-10.8* Hct-33.3*
MCV-91 MCH-29.3 MCHC-32.3 RDW-17.9* Plt Ct-318
[**2132-4-23**] 10:02PM BLOOD Neuts-96.3* Lymphs-2.6* Monos-1.1* Eos-0
Baso-0
[**2132-4-23**] 05:10PM BLOOD PT-11.7 PTT-23.5 INR(PT)-1.0
[**2132-4-23**] 10:02PM BLOOD PT-14.0* PTT-23.9 INR(PT)-1.2*
[**2132-4-23**] 05:10PM BLOOD Glucose-163* UreaN-44* Creat-1.0 Na-131*
K-5.3* Cl-89* HCO3-29 AnGap-18
[**2132-4-24**] 09:41AM BLOOD Glucose-150* UreaN-30* Creat-0.8 Na-133
K-4.5 Cl-98 HCO3-27 AnGap-13
[**2132-4-23**] 05:10PM BLOOD ALT-82* AST-60* CK(CPK)-107 AlkPhos-463*
TotBili-4.7* DirBili-3.5* IndBili-1.2
[**2132-4-24**] 03:06AM BLOOD ALT-65* AST-48* AlkPhos-392* TotBili-4.3*
[**2132-4-23**] 05:10PM BLOOD cTropnT-0.02*
[**2132-4-24**] 09:41AM BLOOD Calcium-7.4* Phos-1.7* Mg-2.4
[**2132-4-23**] 05:10PM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.2
Mg-2.8*
[**2132-4-23**] 05:28PM BLOOD Lactate-1.6
Labs on discharge:
[**2132-5-5**] 05:33AM BLOOD WBC-11.9* RBC-2.52* Hgb-7.3* Hct-23.3*
MCV-93 MCH-29.0 MCHC-31.3 RDW-19.5* Plt Ct-353
[**2132-5-3**] 05:23AM BLOOD Neuts-87.6* Lymphs-8.6* Monos-2.4 Eos-1.1
Baso-0.3
[**2132-5-3**] 05:23AM BLOOD PT-13.7* PTT-32.1 INR(PT)-1.2*
[**2132-5-5**] 05:33AM BLOOD Glucose-111* UreaN-14 Creat-0.8 Na-133
K-4.6 Cl-99 HCO3-30 AnGap-9
[**2132-5-4**] 05:58AM BLOOD ALT-36 AST-43* LD(LDH)-304* AlkPhos-487*
TotBili-1.9*
[**2132-5-5**] 05:33AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9
Additional labs:
[**2132-4-25**] 06:40AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
[**2132-4-25**] 06:40AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2132-4-25**] 06:40AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2132-4-26**] 06:18AM BLOOD PEP-HYPOGAMMAG IgG-545* IgA-204 IgM-465*
IFE-NO MONOCLO
[**2132-4-24**]:
EGD: esophageal candidiasis
[**2132-4-28**]:
CT ABD/PELV:
1. Small amount of new perihepatic free fluid.
2. No evidence of obstruction.
3. Small bilateral pleural effusions with associated atelectasis
and/or consolidation of the adjacent lung.
4. Calcified rounded lesion within the uterus, c/w calcified
fibroid.
5. Bilateral renal hypodensities, too small to characterize, may
reflect renal cysts.
[**2132-4-28**]:
ECHO: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thicknesses and cavity size are
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). Diastolic function could not
be assessed. There is an abnormal systolic flow contour at rest,
but no left ventricular outflow obstruction. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Hyperdynamic LV systolic dysfunction with an
abnormal systolic flow contour without LVOT gradient. Mild
mitral regurgitation. Mild pulmonary artery systolic
hypertension.
PICC Line placement [**2132-5-2**]: Uncomplicated ultrasound and
fluoroscopically guided single-lumen PICC line placement via the
right basilic venous approach. Final internal length is 36 cm
with the tip positioned in the SVC. The line is ready to use.
Brief Hospital Course:
Mrs [**Known lastname 76318**] is a 74 year old woman with rheumatoid
arthritis, asthma, hypertension, presenting from [**Hospital1 **] with
question of basal gangia ICH, found not to have any intracraneal
process but having abdominal pain, leukocytosis, bright red
blood per rectum.
# MRSA Sepsis - Patient was initially admitted to the ICU with
GI bleed and was quickly transitioned to the floor once her Hct
was stable. On the floor, GI planned for a colonoscopy, but
during the prep, she triggered for hypotension, tachypnia with
anxiety and altered mental status. She was transfered to the
ICU, started on levaphed and her vitals were T: 100.8 BP: 116/50
on 0.3 of levo P: 90 R: 18 O2: 100% on 3L NC. A Left IJ was
placed and her Right IJ, which was placed in the ED for access
due to GIB, was pulled. She was given 6 liters of IV fluid and
was off of pressors by the next morning. She was started on
Vanc/Zosyn. Blood cultures grew out 4/4 bottles of MRSA
(presumed from initial CVL) with GNR in [**11-25**] bottles. A TTE
showed mildly thickened mitral valve, but no evidence of
valvular vegitation. She defervesed and was tranfered from the
ICU on Vanc/Zosyn. Zosyn was discontinued and the patient was
continued on Vancomycin for a planned six week total course for
line infection. Her surveillance blood cultures remained
negative at the time of discharge. The decision was made to
treat for six weeks (a full course for endocarditis) as the
patient did not want to undergo further invasive procedures
including TEE. The patient will follow up with Infectious
Disease Clinic after her course of Vancomycin to monitor for
recurrence of infection. In addition to endocarditis, there
remains a concern for potential seeding of her artifical joints
(knees and hips). Her white count was trending down throught the
day of discharge.
# New Atrial fibrillation with RVR: During fluid resuscitation
in the ICU, the patient developed a-fib with RVR in the setting
of pressors. Amiodarone bolus and drip were started and on day
2, metoprolol was started. This was titrated up to 25 mg TID
and the patient converted back into sinus rhythm briefly. Over
the course of her 3rd night in the ICU, her rhythm continued to
flip back and forth between sinus and a-fib, but primarily in
sinus with rates of 80s. She was discharged with heart rate in
the 70's on 12.5mg twice daily of Metoprolol, which may titrated
up if needed.
# GI bleeding: She was initially sent to the ICU for a
questionable history of melena, she had no melena during a
period of observation and no significant HCT drop to suggest an
upper GI bleed. She did have bright red blood per rectum and on
exam a rectal fissure and hemorrhoids. In the ICU she underwent
an EGD which revealed esophageal candidiasis. She was then
transferred to the floor where she underwent a prep for a
colonoscopy, but decompensated as above. She had possible
proctitis on CT scan and treated with cipro flagyl. GI followed
and did not want to do colonoscopy in setting of sepsis. She
expressed a desire to limit invasive testing and due to the fact
that she had a recent (2 years ago) colonoscopy which did not
show any masses, it was felt that colonoscopy could be deferred
at this time. Her HCT remained stable throughout the remainder
of the admission. On [**2132-5-6**] she received one unit of pRBC's for
a HCT of 22.7 for symptommatic relief. There was no evidence of
continued bleeding at the time of discharge. It recommended for
her to have weekly CBC checked for HCT monitoring.
# Hyperbilirubinemia / elevated transaminases: The patient is
status-post cholecystectomy, however this does not exclude
intrabiliary obstruction. Gastroenterology was consulted and
LFTs were trended. At discharge, her LFTs were slowly improving.
She is negative Ab for autoimmune hepatitis, PSC, and viral
hepatitis. The differential includes drug induced liver disease
(methimazole and AZT ?????? recently discontinued, chronic prednisone
?????? recently lowered) or possibly congestive hepatitis. Her
methimazole was held on this admission. If her TSH, T3 and T4
remain within normal limits, this will not be restarted.
# [**Female First Name (un) 564**] Esophagitis: Seen on intial EGD - likely due to
chronic prednisone. She was treated with fluconazole, and
completed a 10 day course starting from [**2132-4-24**].
# Arthritis, rheumatoid (RA): On prednisone 10mg daily at
baseline. Initially she presented on 40mg PO prednisone for
question of COPD flare, and this was tapered in the setting of
GI bleed. Her steriods were transiently increased to stress
doses in the ICU for possible adrenal insufficiency in the face
of long standing steriod use, but once septic picture presented
itself, prednisone was restarted at 5mg [**Hospital1 **].
# Hypertension: Initially on telemetry the patient had short
bursts of a long PR narrow complex tachycardia, likely causes
are atrial tachycardia, AVRT or uncommon AVNRT. Lisinopril was
held, and initially metoprolol was held as well during
hypotension, but restarted in the face of A-fib with RVR.
Metoprolol was titrated up to acheive rate control and at
discharge was titrated back down to 12.5mg [**Hospital1 **]. This may be
titrated as needed.
# Anasarca: The patient received +7L while in ICU. She is
clearly edematous and has been diruesed approximately 3L since
arriving to floor. The plan is to continue gentle diruesis as
this is helping with her anasarca and her assoiciated pain. It
should be noted that she is incontinent, making monitoring of
urine output difficult. She should be regularly bladder scanned
and straight cath performed if needed. Please avoid foley as
this would be an additional source of potential infection.
# Leg pain: Likely due to anasarca and patient states it is new
pain and not in ankle (ie- not due to RA). She is asking for
pain control and clearly bothered by the pain. Low dose opiate
has been started though she is worried about somnolence with
these medications. Please use low doses as needed.
Medications on Admission:
Xanax 0.5mg QHS, .375 Daily
Albuterol
atrovent
Nystatin
Alphagan
Ferrous sulfate
Calcitriol
Gabapentin 300mg qhs, 100mg AM
Naproxen
Docusate
Alendronate 70mg
Azathioprine 75mg [**Hospital1 **]
Protonix 40mg daily
Lisinopril 20mg
Methimazole 10mg daily
Xalatal
Metoprolol 50mg [**Hospital1 **]
Vitamin D
Tums
Aspirin
Amlodipine
Prednisone 40mg daily
Singulair
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB.
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO q8am.
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q2PM ().
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane DAILY (Daily) as needed for mouth pain.
16. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale.
Subcutaneous ASDIR (AS DIRECTED).
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO
Q4H (every 4 hours) as needed for pain: Hold for oversedation or
RR<12.
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5 Tablet PO
BID (2 times a day) as needed for pain: Hold for oversedation or
RR<12.
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
20. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day).
21. 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.
22. Vancomycin 500 mg IV Q 24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8971**] Rehab
Discharge Diagnosis:
Primary:
-Gastrointestinal (GI) bleed
-MRSA Bacteremia
-Septic shock
Secondary:
-Rheumatoid arthritis
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted for gastrointestinal (GI) bleed. While you
were here, you developed a blood infection with MRSA bacteria.
You were treated briefly in the ICU for this and received fluids
and antibiotics. You had a PICC line placed which you will use
to complete a six week course of vancomycin which will be
completed on [**2132-6-9**].
Your Lisinopril and your Methimazole were discontinued. Your
Metoprolol was reduced to 12.5mg twice a day. Your Prednisone
was resumed at your long-term dose of 5mg twice a day. You are
to continue Vancomycin through [**2132-6-9**]. Your Azathioprine was
also held and this may be resumed at follow up with your PCP.
You are being given low dose Percocet to help manage your pain.
Please be careful when taking these medications as they can make
you drowsy and increase your risk for falls. You should not
attempt to operate any kind of machinery (incuding driving)
while on this medication.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
You have a follow up appoitment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2132-5-19**]
at 1:45pm. The office can be reached [**Telephone/Fax (1) 3183**]. Please
discuss resumption of Azathioprine, Methimazole and Lisinopril
at this visit.
You also have a follow up appointment with Infectious Disease
Clinic to monitor your progress in treating your infeciton:
-Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2132-6-11**]
1:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2132-5-8**]
|
[
"782.4",
"300.00",
"573.8",
"565.0",
"995.92",
"112.84",
"455.6",
"038.12",
"V58.65",
"999.31",
"782.3",
"427.31",
"242.90",
"714.0",
"493.90",
"569.3",
"E879.8",
"576.8",
"785.52",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17022, 17074
|
8468, 14513
|
341, 421
|
17221, 17241
|
4882, 4887
|
18464, 19138
|
2582, 2614
|
14922, 16999
|
17095, 17200
|
14539, 14899
|
17265, 18441
|
2629, 2629
|
3792, 4863
|
275, 303
|
5953, 8445
|
449, 2074
|
4901, 5934
|
2096, 2359
|
2375, 2566
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,721
| 150,594
|
29685
|
Discharge summary
|
report
|
Admission Date: [**2160-12-24**] Discharge Date: [**2161-1-4**]
Date of Birth: [**2096-11-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Anacin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2160-12-29**] Mitral Valve Replacement(27mm [**Company 1543**] Mosaic Tissue
Valve) via right Thoracotomy
History of Present Illness:
64 year old male with progressive exertional shortness of breath
over the last month. He was undergoing cardiac workup and
presented at OSH for Stress test in Atrial flutter, he was
admitted and underwent cardiac catherization and echocardiogram
that revealed CAD and mod-severe mitral regurgitation.
Transferred for cardiac surgery
Past Medical History:
Coronary Artery disease s/p CABG [**2150**]
Mitral regurgitation
Atrial Flutter
Hypertrophic cardiomyopathy
Chronic ischemic heart disease
Hypertension
Myxomatous Mitral valve disease
Anxiety disorder (panic attacks)
Elevated cholesterol
Social History:
Married, lives with spouse
[**Name (NI) 1403**] full time as meat salesman
Tobacco 40 pack year history quit in [**2150**]
ETOH denies
Family History:
Father and Grandfather both with coronary artery disease dx in
their 60's
Physical Exam:
General no acute distress, well nourished
Skin intact, old sternal, right calf and left ankle incisions
healed. Right groin s/p Cath soft no hematoma, no bruit
HEENT Perrla, EOMI
Neck: supple, full ROM, no lymphadenopathy
Chest CTA bilat ant/post
Heart RRR, [**1-27**] sys murmur no rub/gallop
Abd soft, NT, ND +BS, no palpable masses
Ext warm no edema no varicosities
Pulses +2 DP/PT/Rad/Fem, Carotids -?murmur
Neuro nonfocal A/Ox3 MAE 5/5 strength
Pertinent Results:
[**2160-12-24**] 12:50PM PT-12.5 PTT-27.3 INR(PT)-1.1
[**2160-12-24**] 12:50PM PLT COUNT-289
[**2160-12-24**] 12:50PM WBC-5.5 RBC-4.43* HGB-11.6* HCT-33.1* MCV-75*
MCH-26.3* MCHC-35.2* RDW-14.7
[**2160-12-24**] 12:50PM ALT(SGPT)-29 AST(SGOT)-34 LD(LDH)-184 ALK
PHOS-189* TOT BILI-0.7
[**2160-12-24**] 12:50PM GLUCOSE-120* UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
[**2160-12-24**] 03:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2160-12-29**] ECHO
PreBypass: No spontaneous echo contrast is seen in the left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild global right ventricular hypokinesis. LV
apical hypokinesis is noted- the remaining left ventricular
segments contract normally.The ascending thoracic aorta is
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. The mitral regurgitation jet is eccentric
and anteriorly directed.. Moderate [2+] tricuspid regurgitation
is seen. There is no pericardial effusion.
Post Bypass: Global RV and LV apical function improved. MVR
investigated - no MR noted, appropriate valve seating with
struts in good postion. Peak valve gradient 12. Descending and
ascending aorta without defect or flap dissection, aortic valve
without AI.
[**2161-1-2**] CXR
PA and lateral chest views obtained with patient in upright
position demonstrate status post sternotomy and the presence of
multiple surgical clips in the anterior mediastinum consistent
with previous bypass surgery. In addition 3 small ring-shaped
metallic structures indicate the presence of a mitral valve
prosthesis in appropriate position. Comparison is made with the
previous chest examination of [**2160-12-31**] at that time
described persistent elevation of the right-sided hemidiaphragm
and evidence of pleural thickening mostly on the right side
remains rather unchanged. When comparison is made with the
preoperative chest examination dated [**2160-12-24**], i.e.
prior to mitral valve replacement evidence of sternotomy and
bypass surgery existed already. The now persisting elevation of
the diaphragmatic contour and adhesions surrounding the right
lower lobe area are new. Further follow up is recommended.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname **] was transferred to the floor from [**Hospital3 10494**]. He was seen in consultation by dental medicine and was
cleared for surgery. He was started on heparin for his atrial
fibrillation. He underwent PFTs. He was taken to the operating
room on [**2160-12-29**] where he underwent an MVR with a 27 mm
[**Company **] mosaic tissue valve via a right thoracotomy.
Postoperatively he was taken to the SICU in stable condition. He
awoke and was extubated later that same day. He was weaned from
his vasoactive drips and transferred to the floor on POD #1. He
did well post operatively. On POD #2, he was found to have a
prolonged PR interval to .4, for which he was seen by
electrophysiology. His beta blocker was subsequently
discontinued. He developed atrial fibrillation and flutter and
coumadin was subsequently started. His electrolytes were
repleted and he converted back to normal sinus rhythm.The
physical therapy service worked with him daily to increase his
postoperative strength and mobility. He was gently diuresed
towards his preoperative weight. Mr. [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
six. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist
and his primary care physician as an outpatient. His coumadin
will be followed by [**Hospital1 **] Heart Center's coumadin clinic for
an INR goal of 2.0-3.0.
Medications on Admission:
Toprol XL 50mg daily
Folic Acid 1mg daily
ECASA 325mg daily
Xanax 0.25mg prn panic attacks (3-4x/wk)
Ultram prn pain
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 tabs* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*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. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Take
one tablet daily.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Mitral regurgitation - s/p Mitral Valve Replacement
Atrial Flutter
Coronary Artery Disease - CABG [**2150**]
Hypertropic cardiomyopathy
Chronic ischemic heart disease
Hypertension
Anxiety disorder
Elevated Cholesterol
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**2-26**] weeks.
Dr. [**Last Name (STitle) **] in [**12-27**] weeks.
Dr. [**Last Name (STitle) 1655**] in [**12-27**] weeks.
[**Hospital 197**] Clinic at [**Hospital1 **] Heart Center on Tuesday [**1-6**] for
INR check
Completed by:[**2161-1-16**]
|
[
"272.0",
"414.8",
"V45.81",
"401.9",
"427.32",
"425.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6886, 6945
|
294, 405
|
7207, 7214
|
1759, 4321
|
7533, 7838
|
1198, 1273
|
5964, 6863
|
6966, 7186
|
5823, 5941
|
7238, 7510
|
1288, 1740
|
4372, 5797
|
235, 256
|
433, 768
|
790, 1029
|
1045, 1182
|
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