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Discharge summary
|
report
|
Admission Date: [**2180-8-17**] Discharge Date: [**2180-8-23**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Abdominal pain and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 97527**] is an 85 year old male with renal cell carcinoma,
end stage renal disease on HD, atrial fibrillation not on
coumadin [**12-27**] fall risk, mild dementia who presented from home
with abdominal pain and fatigue. The abdominal pain was diffuse
and associated with abdominal distention. It was not associated
with fevers, chills, nausea, vomiting, hematochezia or melena.
He does not make urine at baseline. In the emergency room he
had a CTA which showed no pulmonary embolism or aortic pathology
but did show a large right pleural effusion and large ascites
(baseline). His blood pressure at baseline is 90/60 but he
dropped transiently to the 70s and he was given 3.8 L IVF. He
had a diagnostic paracentesis which was negative for SBP. His
lactate was mildly elevated at 2.8. On transfer to the ICU his
vitals were T: 99.8 BP:99/75 HR: 90 O2: 96% on 2L. In the ICU
he did not receive additional IVF. He was monitored overnight
and was noted to be stable but with a persistent oxygen
requirement as high as 5L. He received dialysis according to
his normal schedule and was transferred to the floor for further
management.
Currently, patient reported coming to hospital for nodule on his
left rib. He reported falling 2 weeks ago and having that lesion
on his rib after that. He reports tripping on a step but not
hitting his head. According to his wife, he has a poor
ambulatory baseline and uses a walker. He denied other
complaints. He seemed quite somnolent but was arousable to have
an appropriate conversation although he was not completely sure
of his medical history. He did not endorse cough but
occasionally had a wet cough but was not bringing up any sputum.
Review of systems: 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:
- Diabetes
- Dyslipidemia
- Hypertension
- Atrial Fibrillation
- ESRD on HD MWF
- h/o renal cell carcinoma, s/p R radical nephrectomy [**2173-10-11**]
- 1.2 cm enhancing lesion in the upper pole of the left kidney
noted in [**2179-1-23**]
- Gout
- Left foot cellulitis
- Pulmonary hypertension
- Ascites related to right heart failure and pulmonary
hypertension
- C. Diff Colitis on long term PO vancomycin
Social History:
The patient currently lives with his wife in their house. He has
a health aide who sleeps at the house each night. He worked as a
wholesale produce salesperson. He denies smoking, ethanol or
drug use.
Family History:
Negative for kidney disease, hypertension, diabetes.
Physical Exam:
Admission Physical Exam:
Vitals: 96.7 HR: 99 BP: 102/61 RR: 16 O2: 99% on 3L
Tmax: 35.9 ??????C (96.7 ??????F) Tcurrent: 35.8 ??????C (96.4 ??????F)
General Appearance: Well nourished, No acute distress
HEENT: PERRL, EOMI, mucous membranes moist, oropharynx clear,
poor dentition
Neck: No lymphadenopathy, soft mobile mass on right jaw,
non-tender, non-erythematous.
Cardiovascular: Irregularly irregular, s1 and s2, [**12-31**] murmur at
LLSB without rubs or gallops
Pulmonary: Decreased breath sounds at R base, crackles at L
base, apices clear, no wheezes, ronchi
Abdomen: soft, distended, non-tender, present bowel sounds, no
organomegaly appreciated. Hard calcific appearing mass on left
lower rib border, no erythema or tenderness.
Extremities: cool, 1+ DP pulses, no clubbing or cyanosis
Skin: multiple healing scrapes on L shoulder/upper arm
Neuro: CN II-XII grossly intact, 5/5 strength in upper and lower
extremities b/l, sensation intact and symmetric b/l
Discharge Exam:
Vitals: Breathing comfortably on room air with saturations
90-95%, blood pressure in 90s systolic
Pertinent Results:
Chemistries:
[**2180-8-17**] 10:59AM GLUCOSE-135* UREA N-26* CREAT-4.1*
SODIUM-148* POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-36* ANION
GAP-16
[**2180-8-17**] 10:59AM ALT(SGPT)-15 AST(SGOT)-17 CK(CPK)-50 ALK
PHOS-76 TOT BILI-0.9
[**2180-8-17**] 10:59AM LIPASE-18
[**2180-8-17**] 10:59AM ALBUMIN-4.0
[**2180-8-17**] 10:59AM BLOOD CK-MB-4
[**2180-8-17**] 10:59AM BLOOD cTropnT-0.38*
[**2180-8-17**] 09:59PM BLOOD CK-MB-NotDone cTropnT-0.34*
[**2180-8-17**] 09:59PM BLOOD CK(CPK)-45
[**2180-8-23**] 07:00AM GLUCOSE-150* UREA N-38* CREAT-5.0* SODIUM-145*
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-33* ANION GAP-15
Hematology:
[**2180-8-17**] 10:59AM BLOOD PT-15.3* PTT-27.9 INR(PT)-1.3*
[**2180-8-17**] 10:59AM BLOOD WBC-5.7 RBC-4.26* Hgb-12.2* Hct-39.1*
MCV-92# MCH-28.7 MCHC-31.2 RDW-16.8* Plt Ct-164
[**2180-8-17**] 10:59AM BLOOD Neuts-75.9* Lymphs-15.2* Monos-6.8
Eos-1.0 Baso-1.0
[**2180-8-23**] 07:00AM BLOOD WBC-4.4 RBC-4.04* Hgb-12.0* Hct-37.7*
MCV-93# MCH-29.6 MCHC-31.8 RDW-16.7* Plt Ct-144
Other Laboratories;
[**2180-8-17**] 07:49PM BLOOD Type-ART Temp-36.7 O2 Flow-5 pO2-71*
pCO2-53* pH-7.41 calTCO2-35* Base XS-6 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2180-8-17**] 10:57AM BLOOD Glucose-129* Lactate-2.8*
[**2180-8-17**] 07:49PM BLOOD freeCa-1.16
[**2180-8-17**] 01:00PM ASCITES WBC-35* RBC-[**Numeric Identifier 78448**]* Polys-13* Lymphs-30*
Monos-46* Macroph-11*
[**2180-8-17**] 01:00PM ASCITES TotPro-4.0 LD(LDH)-76 Albumin-2.4
Microbiology:
Blood cultures x 2 [**2180-8-17**] - no growth to date
Clostridium Difficle - negative on [**2180-8-22**] and [**2180-8-23**]
EKG: Afib rate 108 now in 90s. LAD and TWF in inf and lateral
leads which is old.
CXR [**2180-8-17**]:
IMPRESSION: Interval increase in size of a right-sided pleural
effusion which is large. Haziness of the right sided pulmonary
vasculature suggests
asymmetric pulmonary edema. Probable small left pleural
effusion.
CT Chest/Abdomen/Pelvis:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Unchanged large right-sided pleural effusion. Findings
suggestive of asymmetric pulmonary edema involving the right
lung.
3. Unchanged large amount of ascites. No acute intra-abdominal
or
intra-pelvic pathology.
4. Unchanged enhancing left renal mass which is most likely a
renal cell
carcinoma.
Echocardiogram [**2180-8-17**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
There is mild global left ventricular hypokinesis (LVEF = 40-50
%). The right ventricular free wall is hypertrophied. The right
ventricular cavity is markedly dilated with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The supporting structures
of the tricuspid valve are thickened/fibrotic. Moderate to
severe [3+] tricuspid regurgitation is seen. 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.
Brief Hospital Course:
Mr. [**Known lastname 97527**] is an 85 year old male with renal cell carcinoma,
end stage renal disease on HD, atrial fibrillation not on
coumadin [**12-27**] fall risk, mild dementia who presented from home
with abdominal pain and fatigue.
Abdominal Pain: Unclear etiology. Pain was diffuse and not
associated with other symptoms with the exception of worsening
abdominal distention and ascites. Paracentesis was negative for
SBP with a SAAG > 1.1. Abdominal and pelvis CT scan was
negative for acute pathology. Pain resolved spontaneously. No
further workup was pursued.
Hypotension: Patient's blood pressure transiently decreased to
the high 70s in the emergency room but he was asymptomatic. His
baseline blood pressures run in the low 90s and s/p
resuscitation he remained within his baseline. He had no signs
or symptoms of infection. He had no signs of cardiac ischemia.
He had a mildly elevated lactate which resolved with hydration.
He had an echocardiogram which showed a mildly depressed EF
compared to priors but was otherwise not significantly changed.
No further workup was performed. His blood pressures for the
remainder of his hospitalization ranged in the low 90s to low
100s systolic. He did have one transient episode of blood
pressures in the 70s systolic during hemodialysis during which
time he was asymptomatic and his hypotension resolved with a
small fluid bolus.
NSVT: Patient was noted to have short, asymptomatic runs of
NSVT on telemetry. He was hemodynamically stable. His
metoprolol was restarted at his home dose and he tolerated this
well.
Acute on Chronic Right Sided Heart Failure: Patient was noted
to have gross ascites, right sided pleural effusion, and
worsening hypoxia in the setting of getting IVF. His oxygen
requirement improved with dialysis. His fluid status will need
to be managed by his dialysis facility with consideration of
running him at a lower dry weight.
Ascites: Patient had a diagnostic paracentesis in the emergency
room with a SAAG of > 1.1 and no evidence of SBP. Cytology was
pending at the time of dischage. The etiology has been
attributed in the past to his right sided heart failure.
Echocardiogram during this hospitalization showed mildly
decreased LVEF compared to priors with severe tricuspid
regurgitation and moderate pulmonary hypertension. His fluid
status will need to be managed by dialysis.
History of Clostridium Difficile: No recent diarrhea but has
had multiple recurrences and is on chronic PO vancomycin which
was continued. During this hospitalization he had between [**12-29**]
bowel movements per day. He had two stool samples which were
negative for clostridium difficle. Tapering his vancomycin
should be considered as an outpatient.
End Stage Renal Disease on dialysis: He received dialysis
according to his usual scheduled. As above, he has significant
ascites and right sided pleural effusions which are chronic
which will be managed with dialysis as an outpatient.
Atrial Fibrillation: Rate controlled. Not anticoagulated
secondary to fall risk. He was started on aspirin 325 mg daily
and continued on metoprolol for rate control.
Renal Cell Carcinoma: Patient is s/p resection of renal cell
carcinoma in [**2172**], now with new lesion on CT scan followed by
urology. He will need to see urology as an outpatient for
further management.
Left Chest Lesion: During this hospitalization he noted that he
had a hard protrusion from his left lower rib cage. Initially
he noted that this finding was new, but later reported that it
has been present for many years. The lesion was noted on CT
scan and was felt to be related to the chostochondral junction.
No further workup was pursued.
Code: DNR/DNI (discussed with patient)
Communication: Wife [**Name (NI) **] [**Telephone/Fax (1) 97528**]
Medications on Admission:
Alendronate 70 mg weekly
Nephrocaps daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Vancomycin 125 mg PO Q8H
Vitamin D 1,000 units PO daily
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] park
Discharge Diagnosis:
Primary:
Ascites
Hypotension
End stage renal disease
NSVT
Discharge Condition:
Stable. Breathing comfortably on room air. Ambulating with a
walker.
Discharge Instructions:
You were seen and evaluated for your abdominal pain and fatigue.
You had a diagnostic paracentesis which was negative for SBP
and a CT scan which showed fluid in your abdomen but otherwise
no acute abnormalities.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take aspirin 325 mg daily
Please keep all your followup appointments as scheduled.
Please seek immediate medical attention if you experience any
fevers, chills, lightheadedness, dizzines, chest pain,
difficulty breathing, worsening abdominal pain or distension,
unexplained weight gain or any other concerning symptoms.
Followup Instructions:
You have the following appointments scheduled here at [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1675**]:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2180-9-5**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2180-12-12**] 11:30
Please call and schedule an appointment with your urologist Dr.
[**Last Name (STitle) **] within the next 2-4 weeks. His office phone number is
[**Telephone/Fax (1) 4276**].
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"707.03",
"799.02",
"250.00",
"V45.73",
"403.91",
"V45.11",
"799.4",
"272.4",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12312, 12364
|
7768, 11599
|
243, 249
|
12466, 12539
|
4096, 7745
|
13243, 13819
|
2922, 2977
|
11791, 12289
|
12385, 12445
|
11625, 11768
|
12563, 13220
|
3017, 3960
|
3976, 4077
|
2007, 2255
|
177, 205
|
277, 1988
|
2277, 2686
|
2702, 2906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 196,721
|
14863
|
Discharge summary
|
report
|
Admission Date: [**2142-7-12**] Discharge Date: [**2142-7-23**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Dyspnea, hypertension
Major Surgical or Invasive Procedure:
1. Ultrasound Guided Tap
2. Venogram
History of Present Illness:
Ms. [**Known lastname **] is a 24 year old female with a history of SLE, ESRD on
HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with
frequent admission for hypertensive urgency/emergency, with
chronic abdominal pain that presented to the ED [**7-12**] with
critically high blood pressure and dyspnea. She was recently
discharged on [**7-8**] for hypertensive urgency and dyspnea. She
was treated with labetolol gtt, [**Month/Year (2) 2286**], and her home
medications with improvement of her BP. She was discharged home
in stable condition on [**7-8**]. She had been doing well at home,
but missed her HD session on [**7-10**] due to transportation issues.
She has been taking her medications without any difficulty. On
the morning of admission, she noted increase dyspnea, and had a
dry cough, although this is not particularly new. She presented
to the ER for dyspnea. She continues to have the chronic
abdominal pain which is unchanged, and is controlled right now.
In the emergency department, VS= 98.1, 240/140, 128, 30, 96%RA.
On initial evaluation, she was noted to have SBP 70s on the
right arm, 240s on the left arm. She did not complain of any
pain. She underwent CTA torso to eval for dissection which was
negative for dissection or PE. The imaging showed persistent SVC
thrombus. There was also note of bilateral ground glass and
nodularities therefore was given levofloxacin 750 mg IV x 1. She
was given labetalol IV, then started on a labetalol gtt. Her BP
remained elevated, therefore she was transferred to the ICU for
BP control and then [**Month/Year (2) 2286**]. She was also given dilaudid 1 mg
IV x 1 as well.
Ms. [**Known lastname **] was taken to the MICU and treated for malignant
hypertension. She was given hemodialysis and her blood pressure
stabilized. She was transferred to the medical floor. She
continued to receive [**Known lastname 2286**] Tuesday, Thursday, and Saturday.
On [**7-16**], she had a paracentesis of her abdomen. She is
complaining of focal tenderness around the point of insertion.
On [**7-17**], she was transferred back to the MICU because of stridor
that was treated with Heliox. She was stabilized, and came back
to the floor on [**7-19**]. On [**7-19**], Ms. [**Known lastname **] had a venogram. On
[**7-23**], an angiography intervention for an occlusion of her left
brachiocephalic vein was discontinued because her occlusion was
not as drastic as prior imaging indicated when tested with a 22
gauge needle. Ms. [**Known lastname **] was discharged on [**7-23**] with stable
blood pressures and abdominal pain controlled.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD 3. Malignant hypertension with baseline SBP's
180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Denies tobacco, alcohol or illicit drug use. Lives with mother
and is on disability for multiple medical problems.
Family History:
No known autoimmune disease.
Physical Exam:
General: A&Ox3. NAD, oriented x3.
HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear,
Neck: supple, no LAD
Lungs: CTA B, with few crackles at bases.
CV: RRR, S1, S2
Abdomen: soft, minimally distended, diffuse mild tenderness to
palpation
Ext: palpable DP/PT pulses, no clubbing, cyanosis or edema.
Neuro: CN 2-12 intact. moving all four extremities
spontaneously.
Pertinent Results:
[**2142-7-22**] 07:50AM BLOOD WBC-2.8* RBC-2.51* Hgb-7.3* Hct-23.1*
MCV-92 MCH-29.1 MCHC-31.8 RDW-21.1* Plt Ct-134*
[**2142-7-21**] 10:30AM BLOOD WBC-3.5* RBC-2.36* Hgb-6.8* Hct-21.6*
MCV-92 MCH-28.9 MCHC-31.6 RDW-20.5* Plt Ct-121*
[**2142-7-22**] 07:50AM BLOOD PT-14.7* PTT-35.0 INR(PT)-1.3*
[**2142-7-22**] 07:50AM BLOOD Glucose-154* UreaN-20 Creat-4.4* Na-138
K-4.0 Cl-103 HCO3-23 AnGap-16
[**2142-7-21**] 10:30AM BLOOD Vanco-17.8
[**2142-7-20**] 09:35AM BLOOD WBC-3.8* RBC-2.39* Hgb-7.0* Hct-21.6*
MCV-90 MCH-29.2 MCHC-32.4 RDW-19.8* Plt Ct-120*
[**2142-7-19**] 12:30PM BLOOD WBC-3.6* RBC-2.49* Hgb-7.0* Hct-22.5*
MCV-90 MCH-28.3 MCHC-31.3 RDW-18.8* Plt Ct-121*
[**2142-7-20**] 09:35AM BLOOD Plt Ct-120*
[**2142-7-20**] 09:35AM BLOOD PT-19.7* PTT-38.4* INR(PT)-1.8*
[**2142-7-19**] 12:30PM BLOOD Plt Ct-121*
[**2142-7-19**] 12:30PM BLOOD PT-29.5* PTT-43.9* INR(PT)-2.9*
[**2142-7-20**] 09:35AM BLOOD Glucose-90 UreaN-19 Creat-4.2*# Na-138
K-4.2 Cl-102 HCO3-25 AnGap-15
[**2142-7-19**] 12:30PM BLOOD Glucose-72 UreaN-34* Creat-6.0*# Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2142-7-19**] 12:30PM BLOOD Calcium-8.2* Phos-4.6* Mg-1.6
[**2142-7-18**] 05:44AM BLOOD Calcium-8.9 Phos-5.1* Mg-1.7
[**2142-7-12**] 12:27PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**Last Name (un) **]
[**2142-7-12**] 12:27PM BLOOD C3-69* C4-17
[**2142-7-19**] 12:30PM BLOOD Vanco-16.7
[**2142-7-17**] 08:57AM BLOOD Vanco-15.9
[**2142-7-14**] 04:16AM BLOOD Vanco-19.2
[**2142-7-17**] 07:27AM BLOOD Type-ART pO2-66* pCO2-52* pH-7.30*
calTCO2-27 Base XS--1
[**2142-7-12**] 02:06PM BLOOD Lactate-1.0
Brief Hospital Course:
24 y/o female with h/o SLE, ESRD on HD, malignant HTN, h/o SVC
syndrome, PRES, prior ICH, and recent SBO, presented to ED on
[**7-12**] for dyspnea and hypertensive urgency.
1. hypertensive urgency - pt presented to ER with SBP in 240s
and c/o dyspnea. Her blood pressures were reported as unequal
and CTA in ER was done. This study showed no signs of
dissection. Pt's blood pressure was controlled with labetalol
gtt. At time of transfer, she denied CP and SOB. CE's were
flat. She was started on her home BP regimen of oral labetalol
on [**2142-7-15**], and nifedipine/hydralazine/aliskerin soon after
admission. Pt was also continued on her HD regimen for ESRD,
for volume control.
.
2. angioedema - pt developed facial swelling and shortness of
breath while on medical floor. She was taken to ICU and
responded favorably to Heliox. Patient returned to floor and
has been comfortably breathing since. Given history of SVC,
venogram was ordered that did not indicate a complete occlusion
of the left brachiocephalic vein, as previously thought, with
help of 22 gauge needle.
3. cough: pt presented with chronic cough/dyspnea without
fevers. Chest CT revealed bilateral infiltrates and
nodularities, noted possibly infectious vs edema. Pt was started
on vanc/zosyn given recent hospitalization, brief temp spike,
and pulm infiltrates. Abx were stopped after cultures were neg.
At time of transfer, pt's dyspnea was largely resolved and these
findings were felt to be more consistent with edema given
hypertensive urgency.
.
4. chronic abdominal pain - pt has had chronic abdominal pain,
which was well controlled at time of transfer. She was continued
on her current outpt pain regimen of po dilaudid, fentanyl
patch, lidoacine patch. Her LFTs and lipase were wnl. She had no
signs of SBO.
.
5. bacteremia - GPC in pairs and clusters; started on vanco on
[**2142-7-12**].
.
6. Ascites - unclear etiology and new findings for her. Pt is
to get workup with liver team as outpatient. Her [**Date Range 2286**] seems
to have slightly improved this finding. Her coags were
unremarkable. She was seen by Hepatology in house who did not
have any specific recommendations at this time but asked to see
her in follow up as an outpatient.
.
7. ESRD on HD - HD SaTuTh,. Pt was continued on her HD regimen
while in house. Sevelamer was continued as well.
.
8. anemia/pancytopenia - chronic anemia, baseline pancytopenia,
likely [**2-12**] CKD and SLE, currently above baseline, though has h/o
GIB. Pt's pancytopenia remained stable; C3 and C4 studies were
performed and it was felt that her SLE was not active at this
time. Guiac stools were neg. EPO was continued at HD.
.
9. h/o gastric ulcer - PPI was continued throughout
hospitalization.
.
10. SLE - pt was continued on home regimen of prednisone 4mg po
qdaily.
.
11. h/o SVC thrombosis - patient's warfarin was discontinued
after discussion with Dr. [**Last Name (STitle) 4883**]. She frequently is outside
of therapeutic range on this medication and given the suspected
problems with medication compliance, it was felt it was safer to
discontinue it altogether.
.
12. seizure disorder - pt was continued on home regimen keppra
1000 mg PO 3X/WEEK (TU,TH,SA).
.
13. depression - pt was continued on her home celexa.
.
Medications on Admission:
1.Nifedipine 90 mg PO DAILY (Daily).
2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime).
3.Lidocaine 5 % PATCH Q24HR.
4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H
7.Prednisone 4 mg PO DAILY (Daily).
8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday).
9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday).
10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD
12.Labetalol 1000 mg Tablet Tablet PO TID
13.Hydralazine 100 mg Tablet PO Q8H
14.Warfarin 3 mg Tablet PO Once Daily at 4 PM.
15.Pantoprazole 40 mg PO Q12H (every 12 hours).
16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA).
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
4. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO QAM (once a day (in the morning)).
5. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
10. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal every Thursday.
11. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day): Please hold if systolic blood pressure < 100 or HR < 55.
14. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(TU,TH,SA).
16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
17. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous HD PROTOCOL (HD Protochol).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*2*
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain: do not drive or operate heavy machinery with
this medication as it can cause drowsiness.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Malignant Hypertension
Angioedema
Ascites
End Stage Renal Disease
Secondary:
Chronic Abdominal Pain
Anemia/Pancytopenia
Lupus
Gastric Ulcer
SVC Thrombosis
Seizure Disorder
Depression
Discharge Condition:
Hemodynamically stable with blood pressures 130-140 / 60-90
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2142-7-12**] because of critically high
blood pressure. While here, you were given IV antihypertensive
medications, and then you were switched to antihypertnsive
medications by mouth. You received multiple sessions of
hemodialysis. You had a distended, tender belly, and you
underwent a ultrasound guided tap to remove the fluid in your
abdomen. On [**2142-7-17**], you developed throat and facial swelling,
and you were transferred from the medical floor to the ICU. You
were given medication to help open your airway; you were
stabilized and went to hemodialysis several times. You were
transferred back to the medical floor. You had a venogram on
[**2142-7-20**], and the results at this time are still pending.
You had blood cultures drawn that were positive for bacteria.
You received IV antibiotics while at hemodialysis. You will
continue to receive these antibiotics at your appointments.
Please keep all of your medical appointments.
Please go to the nearest emergency room if you experience any of
the following:
1. Chest Pain
2. Headaches
3. Lightheadedness
4. Changes in vision
5. Nausea and Vomiting
Followup Instructions:
Please continue your regular hemodialysis schedule.
You have the following appointments scheduled. Please call if
you need to cancel or change your appointments.
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-7-21**]
12:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-7-30**] 2:00
Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2142-8-8**] 3:15
Completed by:[**2142-7-24**]
|
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"790.7",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
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icd9pcs
|
[
[
[]
]
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12857, 12863
|
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|
314, 355
|
13100, 13162
|
5059, 6648
|
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|
4615, 4645
|
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4660, 5040
|
253, 276
|
383, 2985
|
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|
4483, 4599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,191
| 194,622
|
50856
|
Discharge summary
|
report
|
Admission Date: [**2128-7-19**] Discharge Date: [**2128-7-24**]
Date of Birth: [**2049-6-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Hypotension, SOB
Major Surgical or Invasive Procedure:
Femoral line placement
Midline placement
History of Present Illness:
78 y/o woman with a history significant for severe dementia, a
recent hospitalization for hematuria with question of bladder
CA, and chronic UTI on abx as outpatient, who was sent to [**Hospital1 18**]
ED from her nursing home for hypotension and SOB. History was
gathered from patient's daughters [**Name (NI) 33964**] and [**Name (NI) **], and
extrapolated from nursing-home records.
Ms. [**Known lastname **] [**Last Name (Titles) 4351**] complained of SOB on the evening PTA. She
was placed on 2L O2 NC, and satted 96-98% with relief of her
dyspnea. She was later noted to be hypotensive to 78/50 with HR
62, at which point the decision was made to transfer her to the
[**Hospital1 18**] ED.
On arrival to the [**Hospital1 18**] ED, BP was initially 71/28, HR 61, RR 25
, satting 100% on 100% NRB. BP fell to 60/palp and she was
bolused 1L NS and started on norepinephrine gtt initially at
0.03mcg/kg/min, which was eventually increased to 0.3mcg/kg/min
with BP increasing to 119/54 systolic. UA, Ucx and Bcx were
sent, and she was given 1g ceftriaxone, 500mg metronidazole, and
750mg levofloxacin, out of concern for aspiration PNA.
In the ICU Ms. [**Known lastname **] appears comfortable with VS T98 HR69
BP96/37 RR 20-25 satting 100% on 3LNC with norepinephrine at
0.2mcg/kg/minute.
Past Medical History:
- Patient with severe dementia, MS-like syndrome with
progressive lower extremity weakness since her 40s now unable to
weight bear at all.
- Depression
- HTN
- HL
- CKD
- DM 2
Social History:
Lives at [**Hospital1 599**] NH. 50-60 pack year smoker, stopped 6 months ago.
Daughters live near by. Per patient - quit smoking "years ago"
Family History:
No history colon, breast, prostate, ovarian cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98 BP:96/37 P:69 RR:20-25 SpO2: 100% on 3L NC
General: Obese, NAD
HEENT: PERRL. Dry mucus membranes, no oropharyngeal erythema or
exudate.
Neck: No LAD or elevated JVD
Lungs: Mild expiratory wheezes throughout. Mild bibasilar
crackles.
CV: Faint heart sounds. RRR, no m/r/g
Abdomen: Obese, soft, NT/ND. Active BS
Ext: Warm and well-perfused. 2+ pitting edema to mid-calf
bilaterally.
Skin: No palmar erythema, Duputreyn's contractures, spider
angiomata, or stigmata of endocarditis.
Neuro: Alert to person and "[**Country **]", unsure of date, season or
year. No photophobia or neck stiffness.
Discharge Physical Exam:
VS T 98.7, BP 140/60, P 86, RR 24, O2 96% on 2L (93% on RA)
Pt conversant, but only oriented to self and "hospital." No
acute distress. Unlabored breathing. Diffusely ronchorous breath
sounds. Bilateral pitting edema to the knees. Midline and foley
in place.
Pertinent Results:
===================
LABORATORY RESULTS
===================
Admission Labs:
WBC-25.1*# RBC-4.20 HGB-12.7 HCT-37.7 MCV-90 MCH-30.3 MCHC-33.7
RDW-16.3*
--NEUTS-86* BANDS-3 LYMPHS-7* MONOS-4
--HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL
[**Name (NI) 60958**] [**Name (NI) 60959**]
PT-13.0 PTT-24.3 INR(PT)-1.1
GLUCOSE-219* UREA N-56* CREAT-3.0*# SODIUM-144 POTASSIUM-5.2*
CHLORIDE-106 TOTAL CO2-20*
LACTATE-4.4*
Discharge Labs:
WBC-9.2 RBC-3.33* Hgb-10.1* Hct-30.6* MCV-92 RDW-15.8* Plt
Ct-273
Glucose-143* UreaN-16 Creat-0.7 Na-146* K-3.9 Cl-109* HCO3-31
AnGap-10
CK Trend:
[**2128-7-19**] 01:20PM CK(CPK)-56 CK-MB- 2 TropnT 0.14*
[**2128-7-19**] 09:48PM CK(CPK)-57 CK-MB- 2 TropnT 0.07*
[**2128-7-20**] 04:11AM TropnT-0.06*
Microbiology:
blood cultures ([**7-19**]): pending
URINE CULTURE ([**7-19**]) (Final [**2128-7-23**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
===============
OTHER RESULTS
===============
Renal ultrasound ([**7-19**]):
IMPRESSION:
1. No hydronephrosis.
2. Moderate volume of urine within the urinary bladder. A Foley
catheter
balloon is not visualized. Given this, and the clinical
complaint of absent urine output, would recommend Foley
catheter repositioning/replacement.
CXR ([**2128-7-19**]): Limited examination shows mild progression of
bilateral lower lobe opacities which could represent sequelae of
aspiration or atelectasis.
ECG ([**2128-7-19**]): Sinus rhythm. Overall, tracing is within normal
limits. Compared to the previous tracing of [**2128-2-5**] no
significant change.
Brief Hospital Course:
79 year old female with a history of dementia, hypertension,
diabetes mellitus, and CKD, & chronic urinary obstruction who
was sent to the ED from her nursing home for hypotension
attributable to a urinary tract infection complicated by sepsis.
She had a transient pressor requirement and presented in ARF
which resolved prior to discharge. She will complete a 14 day
course of antibiotics for a proteus UTI.
# Sepsis/Acute Bacterial cystitis: She presented with new
hypoxia and hypotension from a presumed aspiration pneumonia or
urinary tract infection. CXR in the ED showed bibasilar
atelectasis without definite focal consolidation. She has a
history of recurrent UTIs, including in [**2128-1-20**] with Proteus
mirabilis. She initially had a pressor requirement in the MICU.
Vancomycin and cefepime were started. As her hypoxia resolved
fairly rapidly and her urine cultures grew P mirabilis
(sensitivities attached), UTI seemed the more likely culprit.
Vancomycin was discontinued and she was afebrile with
down-trending leukocytosis on cefepime alone for 3 days prior to
discharge. With final sensitivities she was switched from
cefepime to ceftriaxone with plan for total 14 day course.
Midline was placed so she could complete a 14 day course of
parenteral therapy (with day1= [**7-19**]). She will need surveillance
labs (cbc,chem7,lfts) drawn at rehab in the midst of outpatient
course while on IV antibiotics.
# Acute Kidney Injury: Her creatinine was elevated to 3.0 on
admission from a baseline of ~1.0 on her prior admission.
Ultrasound showed no sign of obstruction and her UOP was
generally quite good. Suspect pre-renal physiology in setting of
hypoperfusion secondary to sepsis. Given the prompt recovery to
her baseline, do not suspect ATN. Cr 0.7 on day of discharge.
# Positive Troponin, Demand-mediated NSTEMI: Her Troponin was
elevated to 0.14 on admission and trended down to 0.07 when
rechecked later, this was in the setting of an acutely decreased
GFR and then down to 0.06. EKG on admission showed no acute
ischemic changes, and she denied any anginal symptoms. This
most likely represented demand ischemia in the setting of her
sepsis, tachycardia, and initial hypotension. She was started on
ASA 325 during the admission and discharged on ASA 81mg daily.
# Chronic urinary obstruction: Foley wasa changed in MICU given
UTI. From what the family has conveyed to us, she was
previously on straight cath [**Hospital1 **] and did not tolerate/like this,
so is now with chronic foley in place. If pt is ammenable,
intermittent straight cath would lower the chance of recurrent
UTI in the future.
# Bladder Mass: Confirmed with the patient and her daughter that
they are aware of this mass & the strong possibility of
maligancy. The have seen outpt urology at [**Hospital1 112**] and decided not
to pursue further evaluation/treatment for this given the
patient's dementia and other co-morbidities.
# HTN: Her home anti-hypertensives were held throughout the
admission given the above. These include metoprolol, HCTZ, and
ramipril. They should be restarted in a step-wise fashion as
needed after discharge.
# Lung Disease: She has a long prior smoking history but quit
about one year ago. She does not have a known history of COPD
per medical records, but receives occasional nebulizer
treatments at home. These were continued during her stay.
# Diabetes Mellitus Type 2: Glyburide was held and she was on
SSI during this admission. Glyburide to be restarted (at lower
dose given aspirin) on return to rehab.
# Dementia / Depression: Continued celexa, memantine, and
donepezil.
.
# Prophylaxis: Heparin 5000 units SC TID
# Code: DNR/DNI (confirmed with HCP) during this admission
# Disposition: transferred back to [**Hospital1 **] of [**Location (un) 55**]
# Follow-up: Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] is on staff at [**Hospital1 **]
Medications on Admission:
Simvastatin 40 mg PO QHS
Metoprolol tartrate 50 mg PO Q6H
Hydrochlorothiazide 25 mg PO DAILY
Ramipril 20 mg PO DAILY
Albuterol 90 mcg inhaler 2 puffs Q6H PRN SOB or wheeze
Ipratropium-Albuterol neb IH Q4H PRN SOB
Ipratropium 0.03% nasal 2 sprays each nostril TID PRN
Glyburide 2.5 mg PO DAILY
Docusate 200 mg PO QHS
Bisacodyl 10 mg PR DAILY PRN constipation
Milk of Magnesia 30 ml PO daily PRN constipation
Citalopram 30 mg PO DAILY
Memantine 10 mg PO QAM
Donepezil 10 mg PO QHS
Acetaminophen 1000 mg PO TID standing
Discharge Medications:
1. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. memantine 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
3. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB or wheeze.
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB or wheeze.
7. ipratropium bromide 0.03 % Spray, Non-Aerosol Sig: Two (2)
Nasal three times a day.
8. docusate sodium 100 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. Milk of Magnesia Oral
11. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
13. ceftriaxone 1 gram Piggyback Sig: One (1) gm Intravenous
once a day for 8 days: last day of course is [**8-1**].
Disp:*8 doses* Refills:*0*
14. glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
15. Outpatient Lab Work
Please draw CBC, Chem 7, and LFTs *1 on [**2128-7-28**] and fax to MD
on call for monitoring of IV antibiotic course
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Septic shock
Urinary tract infection, complicated
Acute Renal Failure
Dementia
Bladder mass NOS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were transferred from your nursing home to [**Hospital1 18**] with
shortness of breath and very low blood pressure. We discovered
an infection in your bladder. You improved promptly with
antibiotics.
A midline catheter was placed so that you can continue to
receive antibiotics for a few more days at the time of
discharge.
Several medications are on hold: metoprolol, HCTZ, and ramipril
will have to be re-started by your outpataient doctors.
Your glyburide dose was descreased as you were started on
aspirin. Your regular providers can modify this dose based on
your blood glucose levels.
You have been started on aspirin 81mg per day to protect your
heart.
Followup Instructions:
-You should follow-up with your primary care doctor, Dr.
[**Last Name (STitle) **], at [**Hospital1 **] of [**Location (un) 55**].
-You and your family have decided to not pursue further
evaluation of the mass in your bladder. Should you wish to
follow-up with a urologist, you should schedule an appointment
with the urologist you saw previously at [**Hospital6 **].
|
[
"403.90",
"276.0",
"595.0",
"250.00",
"038.9",
"041.9",
"785.52",
"584.9",
"294.8",
"585.9",
"276.7",
"995.92",
"596.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10931, 11021
|
5028, 8948
|
323, 366
|
11161, 11161
|
3069, 3128
|
12067, 12440
|
2065, 2118
|
9516, 10908
|
11042, 11140
|
8974, 9493
|
11339, 12044
|
3512, 5005
|
2158, 2764
|
266, 285
|
394, 1690
|
3144, 3496
|
11176, 11315
|
1712, 1889
|
1905, 2049
|
2789, 3050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,438
| 177,482
|
32993
|
Discharge summary
|
report
|
Admission Date: [**2156-1-22**] Discharge Date: [**2156-2-12**]
Date of Birth: [**2104-9-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
s/p redo AVR/CABG x1 (19mm St. [**Male First Name (un) 923**] mechanical valve/LIMA to
LAD)
History of Present Illness:
51 yo M with prior endocarditis, AVR in [**2145**]. Followed for DOE
and recent back pain resulting in hospitalization in [**11-21**]. Echo
showed severe AI. Blood cultures showed coag negative staph
bacteremia. PICC placed for IV antibiotics. Diskitis but no
abcsess. Referred for surgery.
Past Medical History:
PMH thrombocytopenia, COPD, HepC, endocarditis/diskitis,
depression, anxiety, AVR '[**45**]
Social History:
+ tobacco 20 pack years
denies etoh
unemployed
Family History:
NC
Physical Exam:
Slightly SOB at rest, pale
Stasis changes BLE
Right eye strabismus
Lungs CTA left, right base crackles
Healed sternotomy
RRR 6/6 diastolic murmur, [**1-21**] sytolic murmur
Abdomen ventral hernia
Extrem warm, 2+ edema BLE
Neur grossly intact
Pertinent Results:
[**2156-2-12**] 06:15AM BLOOD WBC-6.3 RBC-3.79* Hgb-11.5* Hct-33.5*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.2 Plt Ct-211
[**2156-2-12**] 06:15AM BLOOD Plt Ct-211
[**2156-2-12**] 06:15AM BLOOD PT-19.5* PTT-28.4 INR(PT)-1.8*
[**2156-2-11**] 03:19AM BLOOD PT-18.0* INR(PT)-1.6*
[**2156-2-10**] 05:57AM BLOOD PT-19.0* PTT-28.5 INR(PT)-1.8*
[**2156-2-9**] 05:13AM BLOOD PT-18.1* PTT-26.9 INR(PT)-1.7*
[**2156-2-8**] 05:49AM BLOOD PT-16.3* INR(PT)-1.5*
[**2156-2-12**] 06:15AM BLOOD Glucose-93 UreaN-16 Creat-0.7 Na-138
K-3.6 Cl-100 HCO3-32 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76735**]Portable TTE
(Focused views) Done [**2156-2-11**] at 10:10:42 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: [**2104-9-3**]
Age (years): 51 M Hgt (in): 72
BP (mm Hg): 110/70 Wgt (lb): 151
HR (bpm): 60 BSA (m2): 1.89 m2
Indication: s/p AVR redo with 19mm St. [**Male First Name (un) 923**] mechanical valve.
CABG with subsequent tamponade and pleural evacuation. Assess
for residual effusion,
ICD-9 Codes: 423.9
Test Information
Date/Time: [**2156-2-11**] at 10:10 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**]
[**Last Name (NamePattern1) 4135**], RDCS
Doppler: Limited Doppler and color Doppler Test Location: West
Inpatient Floor
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *29 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *1.4 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.33
Mitral Valve - E Wave deceleration time: 212 ms 140-250 ms
TR Gradient (+ RA = PASP): 22 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2156-2-5**].
LEFT VENTRICLE: Mild global LV hypokinesis. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well
seated, normal leaflet/disc motion and transvalvular gradients.
[The amount of AR is normal for this AVR.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic signs of tamponade. No RA or RV diastolic
collapse.
Conclusions
There is mild global left ventricular hypokinesis (LVEF = 45-50
%). Right ventricular chamber size and free wall motion are
normal. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] Moderate [2+] tricuspid regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. No right atrial or right
ventricular diastolic collapse is seen.
IMPRESSION: Tiny residual echo lucent area anterior to the right
ventricle. No evidence of tamponade. Normally functioning aortic
bioprosthesis. Mild global LV hypokinesis.
Compared with the prior study (images reviewed) of [**2156-2-5**],
there is now no evidence of cardiac tamponade.
CHEST (PA & LAT) [**2156-2-10**] 11:06 AM
CHEST (PA & LAT)
Reason: evaluate rt ptx
[**Hospital 93**] MEDICAL CONDITION:
51 year old man with s/p avr
REASON FOR THIS EXAMINATION:
evaluate rt ptx
HISTORY: AVR repair.
FINDINGS: In comparison with the study of [**2-9**], there is no
change. Again there is a tiny right apical pneumothorax.
Moderate cardiomegaly persists with relatively small bilateral
pleural effusions, more marked on the right. No evidence of
acute pneumonia.
Brief Hospital Course:
He was admitted to cardiac surgery. He was seen by hepatology.
He was cleared for surgery by dental. He was seen and followed
by ID. MRI showed diskitis with ? of osteo of the spine. He was
taken to the operating room on [**1-27**] where he underwent a redo
sternotomy, AVR, and CABG x 1. He was transferred to the ICU in
stable condition on epi, neo and propofol. He was extubated on
POD #1. He was given 48 hours of vanocmycin since he was in the
hospital > 24 hours preoperatively. He continued on nafcillin,
and rifampin, and caspofungin for yeast from a blood culture
drawn from a PICC line. He was started on coumadin for his
mechanical valve. He was started on a heparin gtt until his INR
was therapeutic. He was seen by opthamology and fungal eye
infection was ruled out. He developed a small pneumothorax after
his chest tubes were pulled, which was stable on subsequent
chest x rays. He awaited therapeutic INR.
He developed cardiac tamponade and was taken emergently back to
the operating room on [**2-5**]. He was extubated later that same
day. He was transferred back to the floor on POD #1. He was
restarted on coumadin for his mechanical valve. He continued to
have a stable apical pneumothorax. He awaited increasing INR,
and was ready for discharge home on POD #16/7.
He will require completion of a 10 week course of IV nafcillin
and PO rifampin, and has completed a 2 week course of
caspofungin.
[**Doctor First Name **] at Dr. [**Last Name (STitle) 76736**] office has agreed to manage coumadin,
goal INR [**1-18**] for mechanical aortic valve.
Medications on Admission:
naficillin 2gm q4h (staph), ASA, Lasix 40', KCL, Methadone 15"',
Roxicodone 15 prn, rifampin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8
Hours) for 10 weeks: 10 weeks from [**12-16**], dosing until [**2-24**].
Disp:*126 Capsule(s)* Refills:*0*
4. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours) for 10 weeks: 10 weeks from [**12-16**].
dosing until [**2-24**].
Disp:*504 grams* Refills:*0*
5. Outpatient Lab Work
weekly CBC, LFTs, Chem 7 to Dr. [**Last Name (STitle) 76737**], phone number
[**Telephone/Fax (1) 76738**]
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*30 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: Check INR [**1-/2077**] with results to Dr. [**Last Name (STitle) 39975**].
Disp:*60 Tablet(s)* Refills:*1*
9. PICC Line Care
Saline 5-10 cc SASH and PRN;
Heparin Flush (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.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*qs 1 month* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
1 weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
14. Methadone 10 mg Tablet Sig: 1.5 Tablets PO three times a
day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
s/p redo AVR/CABG x1 (19mm St. [**Male First Name (un) 923**] mechanical valve/LIMA to
LAD)[**2156-1-27**]
endocarditis
tamponade s/p mediatinal reexploration [**2-5**]
acute diastolic CHF
endocarditis [**2145**]
bacteremia [**11-21**]
diskitis
prior Bentall with homograft [**2145**]
Hep C
chronic pain
thrombocytopenia
depression/anxiety
Discharge Condition:
good
Discharge Instructions:
SHOWER daily and pat incisions dry
no lotions, creams, or powders on any incision
no driving for one month
no lfting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness or drainage
IV abx to continue to complete 10 weeks course from [**12-16**].
TARGET INR 2.0-3 for mechanical aortic valve - dosing per Dr.
[**Last Name (STitle) 76736**] office.
Followup Instructions:
see Dr. [**Last Name (STitle) 39975**] in 4 weeks
see Dr. [**Last Name (STitle) **] in 6 weeks
see Dr. [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) 76737**] Thursday [**2-19**] @ 4:30
Completed by:[**2156-2-12**]
|
[
"496",
"424.1",
"428.33",
"423.3",
"996.71",
"070.54",
"512.1",
"E878.1",
"722.90",
"428.0",
"414.01",
"997.1",
"998.11",
"300.4",
"287.4",
"571.5",
"420.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"34.1",
"37.0",
"50.11",
"39.61",
"36.15",
"34.03",
"88.72",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
9605, 9660
|
5882, 7450
|
323, 417
|
10044, 10051
|
1214, 5462
|
10474, 10743
|
933, 937
|
7593, 9582
|
5499, 5528
|
9681, 10023
|
7476, 7570
|
10075, 10451
|
952, 1195
|
280, 285
|
5557, 5859
|
445, 737
|
759, 853
|
869, 917
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,599
| 172,617
|
386
|
Discharge summary
|
report
|
Admission Date: [**2139-1-14**] Discharge Date: [**2139-1-22**]
Date of Birth: [**2059-5-5**] Sex: M
Service: SURGERY
Allergies:
Lisinopril / Aspirin Enteric Coated
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Abdominal Distention
Nausea and Vomiting
Major Surgical or Invasive Procedure:
[**1-14**]:
1. Lysis of single strand adhesion with derotation of a
volvulus
2. Placement of a nasogastric tube
[**1-15**]: Second look laparotomy
History of Present Illness:
79M s/p repair of AAA [**1-31**] presents with abdominal distention,
nausea and vomiting.
Past Medical History:
CAD (s/p CABG),
HTN,
^lipid,
MGUS,
DJD,
Orthostatic syncope,
L4-5 disc herniation.
Social History:
+Tobacco; +ETOH
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam- [**2139-1-14**]
97.5 68 162/72 18 94%
comfortable
no icterus/jaundice
neck supple
CTAB
CV regular
abdomen distended, NT, easily reducible (R)inguinal hernia
ext palpable DP (B), no edema
Pertinent Results:
CTA ABD W&W/O C & RECONS [**2139-1-14**] 3:43 AM
FINDINGS: Abdomen, the evaluation of upper abdomen is somewhat
limited due to motion artifact. The oral contrast seen mostly in
stomach and duodenum, and duodenum is dilated, measuring 4.3 cm.
There is ascites anterior to the liver, overall unchanged since
prior study. In this study, no focal liver lesion is seen.
Gallbladder, spleen, pancreas, adrenal glands and kidneys are
unchanged with renal cyst with perinephritic fat stranding. The
patient is status post aortic aneurysm repair with surgical
clips. There is no evidence of leak or hematoma. There is small
amount of soft tissue surrounding the abdominal aorta at the
level of surgery at just below the renal arteries, however, the
soft tissue has markedly decreased since prior study.
There is markedly dilated loops of small bowel, mostly in mid
lower pelvis, measuring up to 3.2 cm associated with moderate
amount of ascites, new cyst prior study. The distal small bowel
is collapsed, and oral contrast has not reached the small bowel.
There are two possible transitional point, one in left lower
quadrant and the other one in right lower quadrant. The finding
is representing small-bowel obstruction, and its also worrisome
for closed loop obstruction or ischemia given the presence of
ascites. However, SMA and its branches opacified. There is no
significant lymphadenopathy. The visualized portion of the large
bowel is within normal limits. There is no evidence of free air.
In the visualized portion of the lung bases, note is made of
basilar atelectasis with left pleural effusion. Aspiration or
aspiration pneumonia in this area cannot be totally excluded.
There is marked degeneration of lumbar spine with vacuum
phenomena. There is no suspicious lytic or blastic lesion in
skeletal structures.
IMPRESSION:
1. Markedly dilated loops of small bowel in mid lower pelvis
associated with moderate amount of ascites, with collapsed
distal small bowel, representing high grade mechanical
small-bowel obstruction, worrisome for closed loop. SMA and its
branches opacified, however, given the presence of ascites,
presence of ischemia cannot be excluded. Urgent clinical
attention is needed.
2. Dilated and fluid-filled duodenum as described above.
3. Persistent ascites anterior to the liver.
4. Status post AAA repair, without evidence of leak.
5. Renal cyst.
Operative Note [**2139-1-14**]
PREOPERATIVE DIAGNOSIS: Acute small-bowel obstruction.
POSTOPERATIVE DIAGNOSIS: Acute small-bowel obstruction with
volvulus and an internal hernia.
PROCEDURES:
1. Lysis of single strand adhesion with derotation of a
volvulus.
2. Placement of a nasogastric tube.
ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**], RES and [**Name6 (MD) 3447**] [**Name8 (MD) 3448**], MD.
ANESTHESIA: General.
SURGICAL FINDINGS: This elderly male, status post aortic
aneurysmectomy some months ago, presented with a 2 day
history of vomiting. He denied abdominal pain and had no
acute abdominal findings, however, his white blood cell count
was elevated to 11,000. He was brought to surgery.
Unfortunately, without an NG tube, as we were totally unable
to pass it through his nares, it was elected to go ahead and
protect his airway, intubate him, and then have ENT assist
with placement if we could not do it with him asleep.
He was, therefore, brought to surgery, anesthetized and an OG
was put into place and approximately 2 liters of feculent
material were recovered from the stomach. The airway was
protected throughout the entire time. Having accomplished
this he had usual prep and draping and had a midline
incision. The bowel was very compromised, appeared to be
necrotic through approximately 60% of the bowel. He
additionally had some some telangiectasias noted on the
mesenteric surface and the jejunum and the LAO areas. He had
a single banjo string adhesion across the base of the
mesentery creating an internal hernia through which he had
volvulized a significant component of his bowel. After this
was taken down with electrocautery to control bleeding the
bowel was derotated. The patient did not manifest any unusual
acid reperfusion syndrome at that point, however, the bowel
over the next ensuing 20 minutes did pink up significantly
but still had a significant hemorrhagic aspect to it. There
was also a lot of hemorrhage into the mesentery. Based on
this it was decided that we should do a second look
laparotomy the following day for bowel viability. Since the
bowel looked so much better we did not want to resect a large
component that was effected.
Prior to completion of the procedure the patient had the OG
removed and we still could not place an NG tube with the
patient anesthetized so the ENT service came to the room,
visualized the nares with a scope and placed mucosal
vasoconstrictors and ultimately was able to thread an NG tube
through the nose. During the course of the operation we had
given considerations to doing a gastrostomy, however, prior
to the operation I had been advised by the patient's
cardiologist that he was quite noncompliant and that could be
a problem in the postoperative management. Therefore, in an
effort to avoid someone pulling out a tube we decided not to
place it if we could get the NG tube.
OPERATION: Under adequate general endotracheal anesthesia
the patient was prepped and draped in the usual fashion. The
midline incision was opened and the above noted findings were
observed. He had significant adhesions of the omentum to the
anterior abdominal wall which were taken down but once we
entered the post omental aspect he was fairly free of
adhesions. The necrotic bowel and feculent smell immediately
met us. We were able to identify the banjo string adhesion
very promptly and lyse that, first with electrocautery to
control any bleeding and then sharply with the Metzenbaum
scissors to actually divide the strand. Once this occurred we
were able to derotate the bowel and as noted above it, over
the ensuing several minutes, pinked up fairly well. The bowel
was run along its entire course on 2 different runs to make
sure there was no perforation and to assess for viability.
The remainder of the abdomen was explored and there was found
to be no issues. The retroperitoneum was intact without
hemorrhage in or around the aortic graft and there appeared
to be [**Last Name **] problem associated with that. After a significant
amount of time in the operating room we re-visualized the
bowel and the bowel actually had gotten much better in
appearance but was still quite dusky looking. Because of my
lack of confidence that this was going to be recovered bowel
we decided to not leave him on the table longer but to just
simply bring him back to surgery the next day for a 2nd look.
Based on this and having an, otherwise, negative exploration
of his abdomen the patient had closure with running #1 double
looped PDS. The skin was closed with skin staples. Sterile
dressing was applied and the patient was reversed from
anesthesia and returned to the ICU for further ongoing
resuscitation. ENT service had been able to successfully
place the NG tube and it was elected not to place a
gastrostomy tube unless it was necessary on re-evaluation the
next day. Sponge, needle and instrument count were correct
x2.
Please note this is a re-dictation of an OP note which was
apparently not able to be found.
Operative Note- [**2139-1-15**]
PREOPERATIVE DIAGNOSES: Small bowel ischemia.
POSTOPERATIVE DIAGNOSES: Bowel in recovery.
OPERATION: Second look laparotomy.
ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**], RES
[**Name6 (MD) 3449**] [**Name8 (MD) 3450**], M.D.
ANESTHESIA: General
FINDINGS: This 79-year-old male presenting acutely with a
small bowel obstruction 24 hours ago had exploratory
laparotomy. He had a single band adhesion around the base of
the mesentery with a large component of the small bowel,
approximately 60%, quite compromised with venous congestion
and ischemia. He was derotated and his mesenteric obstruction
was relieved, however, in an effort to preserve bowel he was
closed, resuscitated overnight and brought back to surgery
today for a second look laparotomy. At surgery today he had
recovering bowel identified. There were no areas of frank
necrosis. There were areas of obvious suspected mucosal
sloughing and there was blood in the right colon which would
be consistent with a mucosal slough. The mesenteric hematomas
and congestion had cleared out almost entirely and a
subserosal lesion which was questioned on the first operation
had totally disappeared. Therefore, it represented a
lymphangiectasia which was dilated secondary to mesenteric
compromise.
The patient had an abdominal wash out. All of the entire
abdomen was inspected. The NG tube was confirmed to be a good
location and we reclosed.
PROCEDURE: Under adequate general anesthesia, the patient
was prepped and draped in the usual fashion. The midline
incision was reopened and the abdomen was explored. There was
a fair amount of blood and even feculent smelling exudate in
the abdomen. This was all washed out with gentle warm lavage.
Having accomplished that, the bowel was run in its entirety
including the colon. The stomach and the duodenum were noted
to be normal in appearance. The NG tube was in good position.
The small bowel was run from the ligament of Treitz to the
ileocecal valve twice to make sure there were no areas of
necrosis or pinpoint perforation, primarily because of the
odor that was present in the abdomen. After we had totally
irrigated the resident fluid out of the abdomen, it was much
better and there was no unusual odor. There was no
demonstrable fecal leaks and there was no demonstrable small-
bowel necrosis. Based on this, the patient had a second
lavage. The omentum was pulled down over the small bowel and
closure was effected using double looped PDS to the fascial
layers. The skin was closed with staples. Sterile dressing
was reapplied. The patient was partially reversed from
anesthesia but kept on the ventilator and returned the ICU
for ongoing resuscitation. During the course of the
operation, because of his blood loss overnight, he was given
1 unit of blood and 350 cc of crystalloid.
Brief Hospital Course:
[**Known firstname 3451**] [**Known lastname 3452**] was evaluated in the emergency department at [**Hospital1 18**] on
[**2139-1-13**]. Initial WBC count was 9.2. KUB showed dilated loops
of small bowel with air-fluid level, worrisome for small bowel
obstruction. He was made NPO and IV fluids were started. An NGT
was attempted several times without success. He was admitted to
the surgery department under the care of Dr. [**Last Name (STitle) **]. There was
reattempt at NGT placement without success. Repeat WBC count
was 12.6. Urinalysis was negative for infection. CTA of the
abdomen/pelvis was completed which showed markedly dilated loops
of small bowel in mid lower pelvis associated with moderate
amount of ascites, with collapsed distal small bowel,
representing high grade mechanical small-bowel obstruction,
worrisome for closed loop. There was no evidence of AAA leak.
Given these findings he was taken to the operating room where he
underwent lysis of a single strand adhesion with derotation of a
volvulus; and placement of a nasogastric tube. He tolerated the
procedure well and was taken to the ICU. At POD 1 he was taken
back to the opertating room, as planned, in order to reevaluate
the condition of the bowel after resuscitation overnight.
Recovering bowel was identified with no areas of necrosis. The
small bowel was run from the ligament of Treitz to the
ileocecal valve twice to make sure there were no areas of
necrosis or pinpoint perforation and his abdomen copiously
irrigated. He tolerated the procedure well and was returned to
the ICU for continued care. At POD 1 he was extubated. WBC
count was 6.9; HCT was 28.5. Urine output was adequate.
Ciprofloxacin/Flagyl/Ampicillin were continued for empiric
coverage. At POD [**3-27**] he was transferred to the floor. The NG
tube had been accidentally removed. He remained NPO. At POD
[**5-29**] he was afebrile and doing well. He was +flatus and his diet
was advanced to clears. The urinary catheter was removed. At
POD [**6-30**] he was tolerating clear liquids. His WBC count was 6.1.
He was OOB and ambulating.
On [**2139-1-22**] he was discharged home in good condition. He was to
follow up with Dr. [**Last Name (STitle) **] in clinic in [**1-27**] weeks.
Medications on Admission:
Atenolol
ASA
Lovastatin
Relafen
Senna
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation: Please hold for loose stools.
.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute small-bowel obstruction with
volvulus and an internal hernia
Discharge Condition:
Good
Discharge Instructions:
Please return or contact for:
* Fever (>101 F) or chills
* Abdominal Pain
* Nausea or vomiting
* Inability to pass gas or stool
* Redness, drainage or bleeding from incision site
* Chest pain
* Shortness of breath
* Any other concerns
You may shower; gently wash incision and pat dry. No tub baths
or swimming for two weeks. The staples will be removed at your
next clinic visit.
Please resume your home medications as prescribed. Please do not
drive while taking pain medications.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in clinic in [**1-27**] weeks. Please
call for an appointment. The number is [**Telephone/Fax (1) 2359**]. You may
also call this number for any questions or concerns.
Completed by:[**2139-1-22**]
|
[
"V45.81",
"560.81",
"557.0",
"272.4",
"560.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.12",
"46.81",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
14036, 14042
|
11363, 13618
|
334, 490
|
14152, 14158
|
1036, 11340
|
14691, 14943
|
765, 782
|
13706, 14013
|
14063, 14131
|
13644, 13683
|
14182, 14668
|
797, 1017
|
254, 296
|
518, 609
|
631, 715
|
731, 749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,568
| 142,064
|
28660
|
Discharge summary
|
report
|
Admission Date: [**2125-6-7**] Discharge Date: [**2125-7-8**]
Date of Birth: [**2059-6-20**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
fevers and relapsed AML
Major Surgical or Invasive Procedure:
You were admitted to the intensive care unit during this
hospitalization, but had no major surgical or invasive
procedures.
History of Present Illness:
65 yo M with h/o AML D+119 s/p allo-SCT presents with febrile
neutropenia and fatigue. He was seen in clinic on [**2125-6-1**] and was
feeling well, his performace status was 100%. His peripheral
blood showed 19% atypicals which later were read by pathology as
blasts. There was concern for relapse. He was brought back to
clinic on [**2125-6-5**] for a lab check and had 54% blasts. He reports
that 5 days prior to admission he had a temp of 100.6 which
quickly resolved. Then two days prior to admission he began to
feel weak and have chills. This morning his daughter took his
temperature and it was 101.2. He still complains of fatigue and
weakness. He felt some lightheadedness, but no fainting or LOC.
He denies CP, SOB, cough, diarrhea, dysuria, hematuria, no
rectal pain.
.
In the clinic, he appeared weak and fatigued and given his
temperature at home, it was decided that he should be admitted
to the hospital. Blood cultures and urine cultures were taken.
He was given cefepime and vancomycin.
Past Medical History:
AML s/p allo SCT
BPH
renal stone
Social History:
Patient lives with wife and daughter. [**Name (NI) **] has 2 sons and 2
daughters. [**Name (NI) **] is a retired car salesman. He denies ever smoking
and only occasionally drank etoh prior to his diagnosis.
Family History:
Sister had breast Ca. Mother died at 89 and had alzheimers.
Father died at 79 of CVA.
Physical Exam:
VS: T 99.9, BP 128/92, HR 80, RR 18
General: fatigued appearing male lying in bed; right chest port
site is clean without erythema or edema
HEENT: NCAT, anicteric, mildly injected conjunctiva, MMM, oral
pharynx clear without erythema or exudate. No ulcers or lesions.
CV: RRR, nl S1 S2, no m/r/g
Lungs: CTAB no w/r/r
Abd: +BS, soft, NTND
Extremities: + 1 pitting edema bilaterally lower extremities
with R slightly greater than left. No calf tenderness. No
clubbing or cyanosis. 2+ DP pulses bilaterally.
Neuro- A/O x3, bilateral hands with tremor (chronic), CN II-XII
intact
Skin: very warm skin. hyperpigmented LE.
Pertinent Results:
Studies:
[**2125-6-7**] CXR:
IMPRESSION: No significant interval change compared to
radiograph from [**2125-4-6**]. No acute cardiopulmonary process.
[**2125-6-10**] CT chest:
IMPRESSION:
1. Small peripheral basilar consolidation of the left lower lobe
which is nonspecific and may represent atelectasis versus early
pneumonia.
2. Three-mm nodule in the right lower lobe and a 4-mm nodule in
the right upper lobe for which attention should be paid on
followup examinations.
3. Sub-cm exophytic hyperdense lesion within the upper pole of
the right kidney which is nonspecific and may represent a
hemorrhagic cyst, however MRI is indicated on a non-emergent
basis for further characterization.
Brief Hospital Course:
1. Leukemia Relapse.
Mr. [**Known lastname 22571**] was found on admission to have 90% circulating
blasts, consistent with a relapse of his leukemia. He was
treated with a cycle of decitabine and ultimately started on
hydrea for cytoreduction. Discussion regarding donor lymphocyte
infusion was started and the patient will follow up with his
[**State 792**]Oncologist and Dr. [**First Name (STitle) 1557**] for further therapy.
.
2. Febrile Neutropenia
On admission, Mr. [**Known lastname 22571**] had fever and neutropenia. There was
no obvious source for infection given lack of localizing signs
or symptoms initially. He did have a portacath which looked
clean and intact. He was initially started on cefepime and
vancomycin but continued to spike to 102 with occasional rigors.
His initially set of blood cultures had [**3-28**] bottle of coag
negative staph that subsequently cleared after a 14 day course
of antibiotics. For possibility of fungal infection, he was
treated with caspofungin, and this was later broadened to
voriconazole. The patient had recurrent bouts of
fever/hypothermia and hypotension requiring MICU treatment, but
was able to be stabilized with fluids and never required
pressors. On [**2125-6-29**], the patient cultured out Gram Negative
Rods, that speciated to stenotrophomonas maltophilia. His
antibiotic regimen was changed to high dose bactrim IV for a
planned 2 week course followed by chronic treatment with PO
bactrim.
.
3. rash- He developed maculopapular rash on legs on [**2125-6-13**]-
nickel size erythematous raised lesions, which were initially
non pruritic but became pruritic. There was concern over sweet's
syndrome vs. leukemia cutis. A dermatology consult was obtained
and biopsies were taken. The biopsy showed superficial to
mid-dermal perivascular mixed lymphocytic and eosinophilic
infiltrate with atypical mononuclear cells consistent with
blasts and red blood cell extravasation. No vasculitis or
neutrophilic infiltrate is seen. A hypersensitivity reaction
with infiltration by circulating leukemic cells is favored,
however if the eruption becomes more prominent, re-biopsy to
exclude the development of leukemia cutis should be considered,
as clinically appropriate. Over the course of the
hospitalization, the rash become less prominent and improved.
.
4. Disposition: After a prolonged hospitalization, the patient
was discharged home to complete the IV bactrim course. He will
follow up with his hematologist in [**Doctor Last Name 792**]for further
decitabine and will follow up with Dr. [**First Name (STitle) 1557**] for further
discussion regarding donor lymphocyte infusion.
Medications on Admission:
Terazosin HCl 5 mg PO HS
PredniSONE 20 mg PO daily
Acyclovir 400 mg PO Q8H
Zolpidem Tartrate 5 mg PO HS:PRN
Fluconazole 200 mg PO Q24H
FoLIC Acid 1 mg PO DAILY
Prilosec 20 mg Oral [**Hospital1 **]
Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR
Ursodiol 600 mg PO QPM
Ursodiol 300 mg PO QAM
Mycophenolate Mofetil 250 mg PO BID
CycloSPORINE Modified (Neoral) 100 mg PO Q12H
GlyBURIDE 2.5 mg PO BID
Metoprolol 50 mg PO BID
lorazepam 1mg qhs prn
prednisolone eye gtts
hydrea 500mg daily (started on [**2125-6-5**])
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
2. Portcath Care
Portcath care per protocol
3. Bactrim 80-400 mg/5 mL Solution Sig: Six Hundred (600) mg
Intravenous every twelve (12) hours for 7 days.
Disp:*qs * Refills:*0*
4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*90 Tablet(s)* Refills:*2*
5. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a
day: Start after IV antibiotics are completed.
Disp:*30 Tablet(s)* Refills:*2*
14. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary diagnosis:
Acute Myelogenous Leukemia relapsed after stem cell transplant
febrile neutropenia
hypotension
rash
Secondary diagnosis:
Diabetes Mellitus
Benign Prostatic Hypertrophy
Discharge Condition:
Fair, with stable vital signs.
Discharge Instructions:
You were admitted with fatigue, fevers and rigors, while having
a low immune system (febrile neutropenia). You were found to
have a relapse of your leukemia and had a bacteria growing in
your blood. You were treated with chemotherapy, decitabine, and
hydroxyurea, as well as antibiotics.
You will need to complete another week of IV antibiotics,
followed by oral antibiotics on an ongoing basis. The antibiotic
is called Bactrim, and you will take 600mg every twelve hours
for seven days by the IV, and then take one double-strength
tablet daily from then on.
Given the nature of your long hospitalization, several
medications were changed. In particular, your cyclosporin,
cellcept (MMF) were stopped because of your relapse.
Additionally, your metoprolol was discontinued because your
blood pressures have not been elevated.
You will find an updated medication list with your discharge
paperwork. It is important that you only take your new medicines
as prescribed.
If you have any fevers (temp>100.4), chills, chest pain,
shortness of breath, or any other symptoms of concern to you
please call our [**Date Range 1978**]/oncology clinic or go to the
emergency room.
Followup Instructions:
You will also follow up with Dr. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 51764**]. A follow-up
appointment is scheduled at the [**State 792**]Hospital at 11:00am
on [**2124-7-9**]. The office phone number is [**Telephone/Fax (1) 69338**].
You will need to make a follow-up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1557**] for in two weeks time. His phone number is: [**Telephone/Fax (1) **].
|
[
"486",
"799.02",
"255.4",
"250.00",
"205.00",
"V58.67",
"287.4",
"600.00",
"401.9",
"782.1",
"518.0",
"288.00",
"782.3",
"995.91",
"V58.65",
"780.99",
"996.62",
"038.0",
"996.89",
"458.9",
"V13.01",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"99.04",
"99.25",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
7911, 7963
|
3207, 5853
|
291, 417
|
8195, 8228
|
2487, 3184
|
9448, 9944
|
1748, 1835
|
6410, 7888
|
7984, 7984
|
5879, 6387
|
8252, 9425
|
1850, 2468
|
228, 253
|
445, 1451
|
8125, 8174
|
8003, 8104
|
1473, 1507
|
1523, 1732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,249
| 197,117
|
38041
|
Discharge summary
|
report
|
Admission Date: [**2134-9-17**] Discharge Date: [**2134-9-20**]
Date of Birth: [**2074-1-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 60 year old male with a history of alcohol abuse
and alcohol withdrawal with delerium tremens who presents from
home after having a witnessed seizure. Per report he had been
sober for 8 months but started drinking 4 days prior to
presentation. He drank 30 beers per day. His last drink was at
6 AM. Per the patient he was sitting on his bed at 7 AM on the
morning of admission when his building manager noted him to have
a generalized seizure where he fell back on the bed, his eyes
rolled into the back of his head and he was shaking. Unclear if
bowel or bladder incontinence. His neigbor called 911 and had
him brought to the emergency room. Per EMS reports he actually
told his neighbor that he had a seizure and that he was going to
have a few beers so that it wouldn't happen again and the
neighbor called 911 but did not actually witness a seizure.
.
In the ED, initial vs were: T: 99.1 P: 95 BP: 147/81 R: 16 O2
sat 95% on RA. Alcohol level on arrival was 322. He received
two liters of normal saline, 5 doses of 10 mg IV valium CIWA >
10. He had a CT of the head which showed a prominent extraaxial
space in the right posterior fossa which could represent a
subdural hematoma versus CSF hydroma. He was seen by
neurosurgery who did not feel that this required neurosurgical
intervention. He was admitted to the [**Hospital Unit Name 153**] for further
management.
.
On arrival he continues to endorse visual hallucinations. He is
tremulous. He denies fevers, chills, chest pain, shortness of
breath, nausea, vomiting, abdominal pain, diarrhea,
constipation, dysuria, hematuria, leg pain or swelling. He has
no numbness but does feel weak. He has not been eating since he
started drinking again. He reports that his most recent
admission for alcohol withdrawal was one year ago when he had
delerium tremens. He has had alcohol withdrawal related
seizures in the past, most recently two years ago.
Past Medical History:
Past Medical History:
Alcohol Abuse - previously was sober for 8 months but has a 40
year history of drinking. Drinks up to 30 beers per day. Has
had multiple admissions for alcohol withdrawal, most recently 1
year ago when he had delerium tremens. Reports last seizure
related to alcohol was two years ago.
Hepatitis C - followed at [**Hospital6 **]
Depression
Scoliosis
Social History:
Alcohol abuse as above. Drinks 30 beers per day. Per patient
quit for 8 months and started drinking again four days ago.
Last drink at 6 AM this morning. 40 pack year smoking history,
quit 2 years ago. Denies a history of IV drug use. Has one
tattoo from age 16 done at home. No blood transfusions.
Family History:
Father was an alcoholic
Physical Exam:
Physical Exam on admission [**2134-9-17**]:
Vitals: T: 96.5 BP: 146/73 P: 79 R: 18 O2: 96% on RA
General: Alert, oriented to person, [**Month (only) 216**], [**Hospital1 18**]
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neurologic: CN II-XII tested and intact, strength 5/5,
sensation intact, gross tremor and dysmetria on finger to nose,
gait not tested.
.
Physical exam on transfer from [**Hospital Unit Name 153**] to floor [**2134-9-19**]:
T96.8 HR 61 BP 128/74 RR 17 SpO2 95% RA.
General: Alert, oriented to person, [**Month (only) 216**], [**Hospital1 18**]
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neurologic: CN II-XII tested and intact, strength 5/5,
sensation intact, gross tremor and dysmetria on finger to nose,
gait not tested.
Pertinent Results:
[**2134-9-20**] 06:00AM BLOOD WBC-5.3 RBC-4.10* Hgb-12.7* Hct-38.3*
MCV-93 MCH-31.1 MCHC-33.3 RDW-13.0 Plt Ct-208
[**2134-9-19**] 05:47AM BLOOD WBC-5.0 RBC-4.01* Hgb-12.8* Hct-36.9*
MCV-92 MCH-32.0 MCHC-34.8 RDW-13.3 Plt Ct-204
[**2134-9-18**] 03:20AM BLOOD WBC-6.4 RBC-3.86* Hgb-12.5* Hct-35.9*
MCV-93 MCH-32.4* MCHC-34.8 RDW-13.0 Plt Ct-208
[**2134-9-17**] 02:30PM BLOOD WBC-7.9 RBC-4.34* Hgb-13.9* Hct-39.6*
MCV-91 MCH-32.0 MCHC-35.1* RDW-13.3 Plt Ct-254
[**2134-9-17**] 02:30PM BLOOD Neuts-69.2 Lymphs-25.2 Monos-4.7 Eos-0.3
Baso-0.7
[**2134-9-20**] 06:00AM BLOOD Plt Ct-208
[**2134-9-19**] 05:47AM BLOOD Plt Ct-204
[**2134-9-19**] 05:47AM BLOOD PT-12.8 PTT-48.1* INR(PT)-1.1
[**2134-9-20**] 06:00AM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-140
K-3.4 Cl-102 HCO3-28 AnGap-13
[**2134-9-19**] 05:47AM BLOOD Glucose-97 UreaN-6 Creat-0.7 Na-137 K-3.8
Cl-101 HCO3-25 AnGap-15
[**2134-9-18**] 12:13PM BLOOD Glucose-137* UreaN-10 Creat-0.7 Na-137
K-3.8 Cl-100 HCO3-27 AnGap-14
[**2134-9-17**] 02:30PM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-133
K-5.4* Cl-89* HCO3-22 AnGap-27*
[**2134-9-20**] 06:00AM BLOOD ALT-207* AST-229* AlkPhos-53
[**2134-9-19**] 05:47AM BLOOD ALT-215* AST-257* AlkPhos-54 TotBili-1.4
[**2134-9-18**] 03:20AM BLOOD ALT-229* AST-265* AlkPhos-55 TotBili-0.8
[**2134-9-17**] 02:30PM BLOOD ALT-267* AST-294* AlkPhos-59 TotBili-0.7
[**2134-9-20**] 06:00AM BLOOD calTIBC-246* Ferritn-1100* TRF-189*
[**2134-9-19**] 05:47AM BLOOD TSH-3.7
[**2134-9-17**] 02:30PM BLOOD TSH-2.6
[**2134-9-17**] 02:30PM BLOOD ASA-NEG Ethanol-338* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2134-9-18**] 04:08AM BLOOD Lactate-3.7*
.
Images:
.
[**9-17**] CT Head: 1. Prominent extra-axial space in the right
posterior fossa, which may reflect a chronic subdural hematoma
versus CSF hygroma. 2. Mucosal thickening involving the
bilateral ethmoid sinuses and secretions
within the left maxillary sinus. 3. Opacification of the mastoid
air cells right greater than left s/p partial resection of the
right mastoid air cells.
.
[**9-18**] CXR: no acute cardiopulmonary disease
.
EKG: Atrial fibrillation with rapid ventricular response
interspersed with sinus beats. Normal axis, normal intervals,
no acute ST segment changes, no priors for comparison.
.
[**2134-9-20**] TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). 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.
Mild (1+) aortic regurgitation is seen. The aortic regurgitation
jet is eccentric. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
60 year old male with a history of alcoholism and depression who
presents with seizures and visual hallucinations with a serum
alcohol level of 338 on presentation.
.
# Alcohol Withdrawal: Patient remained hemodynamically stable
but endorsed visual hallucinations and with a reported history
of seizure on admission (although very elevated serum alcohol on
presentation). Presentation concerning for alcohol withdrawal
and delerium tremens, although benzodiazepine intoxication can
also appear similarly. Time course is not appropriate for
delerium tremens as last drink was less than 24 hours ago. Pt
put on CIWA scale with close attention to signs of intoxication.
He required a total of 110mg valium during ICU course (including
30mg on day of transfer). Pt was started on thiamine, folate,
MVI. IVF were given for anion gap acidosis. Of note: Pt is very
anxious at baseline so this was taken into account when doing
CIWA. Upon arrival to the floor, he required 2 doses of 10mg of
valium at midnight, and at noon on [**9-20**].
.
At 4PM pt was found dressing himself to leave, stating he wanted
to leave against medical advice. When asked why, he stated that
he needed to get out of the hospital. He denied pain, feeling
neglected, and when asked if he was leaving to get another
drink, he did not answer. After discussion regarding the risk
of leaving (results of TTE had not returned, risk of ongoing
withdrawl), he was able to restate this risks, and was felt
alert, oriented, and competent to leave. Before he could be
given his discharge paper work and AMA form, he was found to
have eloped. Security was called, and a description was
provided.
.
# s/p seizure: Patient with reported seizure this morning 1
hour after last drink. Per patient it was witnessed, per ED
record it was not. Time course unlikely for alcohol withdrawal
seizure but given his history of alcohol abuse. CT head with ?
small subdural but neurosurgery has evaluated him and did not
think likely this was a seizure focus. No history of epilepsy.
Electrolytes within normal limits. Serum toxicology otherwise
negative. Pt placed on seizure precautions and valium per CIWA
scale.
.
After discussion with neurosurgery, pt was felt to have chronic
hygroma, which does not require anti-seizure medications,
intervention, or further follow-up.
.
# Atrial fibrillation: New onset, in ICU. TSH normal in ER at
2.6. No known history of arrhythmia. EKG with results above. Pt
started on metoprolol 25mg PO TID. HR 50s-70s during ICU course,
and his metoprolol dose was decreased to 12.5mg po BID. At
discharge, plan was to discharge pt home with instructions to
take metoprolol, aspirin (CHADs=0), and seek treatment for
alcohol abuse as above. TTE revealed slighltly depressed EF
50%, 1+AR.
.
# Anion gap acidosis: Bicarbonate slightly decreased with an
anion gap of 22 upon admission, closed with hydration. Most
likely etiology was felt starvation ketosis. Lactate decreased
from 3.7 to 1.4.
.
# Hepatitis C: Followed at [**Hospital1 2177**]. Transaminases elevated in the
200s, which may be related to combination of alcohol and viral
illness. Pt instructed to have outpatient followup.
.
# DISPOSITION: As above, pt found to have eloped prior to being
given discharge paperwork, and AMA form. Security was made
aware.
Medications on Admission:
none
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
alcohol withdrawl
paroxysmal atrial fibrillation
right side hygroma on CT HEAD
Discharge Condition:
vital signs stable, receivd 10mg PO valium 4 hours prior to
discharge on day of discharge, understands risks of leaving AMA
given results of echocardiogram pending.
Discharge Instructions:
you were admitted to the hospital with alcohol withdrawl after a
seizure. YOU ARE LEAVING AGAINST MEDICAL ADVICE, as the results
of your echocardiogram have not been completed. you eloped
before you could be provided with dischargepaper work.
.
your CT scan revealed a right side hygroma, you were seen by the
neurosurgical service. this does not require further
intervention or follow-up.
.
you were found to have an abnormal heart rythym, called atrial
fibrillation, and were started on a medication called
metoprolol, and aspirin to prevent risk of stroke.
.
You were offered social work consultation regarding your alcohol
abuse, but declined.
.
The following changes were made to your medication regimen:
1. you were started on aspirin 81mg po qdaily.
2. you were started on toprol xl 25mg po qdaiy.
.
If you develop symptoms of headache, reccurent seizures, chest
pain, shortness of breath, or other worrisome symptoms please
contact your emergency department or primary care physician.
Followup Instructions:
you should follow-up with your primary care physician [**Name Initial (PRE) 176**] [**3-2**]
weeks of your discharge.
|
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20,656
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46411
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Discharge summary
|
report
|
Admission Date: [**2206-3-24**] Discharge Date: [**2206-3-28**]
Date of Birth: [**2131-12-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Compazine / Protamine / Ampicillin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Ultrafiltration/Hemodialysis
History of Present Illness:
74 yo F with ESRD on HD (TThSat), T2DM, sCHF, and other medical
issues presented with SOB from [**Hospital1 100**] Senior Life. Shortness of
breath started Sunday with non-productive cough. She reported
mild nasal congestion and subjective fevers. Had mild nausea on
Sunday and on the day of her presentation. Denied sore throat,
chills, chest pain, palpitation, V/D, abdominal pain, diarrhea,
constipation. She stated that her weight is usually around 98
lb. She denied any LE swelling, orthopnea, PND. She denies
drinking excessive fluid but endorses having very salty soup at
[**Hospital1 2286**] on Saturday. Reports from daughter also confirm patient
takes salty chips due to dislike with food at rehab and being a
picky eater. Patient states that she makes urine but very small
amounts and only intermittently
In the ED, initial VS were: 98.6 63 145/66 20 97% 2L. However,
O2 sat dropped to the 70%, requiring titration to 4L. Labs were
notable for WBC 5.6, Hgb 8.6, Hct 27.4, Plt 161, Crt 4.1, blood
cultures x 2 pending. ECG showed sinus, ~70, axis is normal but
decreased amplitude for QRS in I/aVL, sub-mm STD in III and III,
TWI in aVL, and V2, poor R wave progression, flattened T wave in
V3. CXR showed increased right sided pleural effusion, hazy
opacity in the RML c/w pulmonary edema. Patient was given
levofloxacin 750 mg IV x1 for concern of possible pneumonia.
Nephrology was informed about patient for possible need of
[**Hospital1 2286**]. Patient is DNR. Upon transfer, VS were BP 144/55 HR
63 RR 25 pOx 88 % on 5 L NC, A&Ox3.
On arrival to the MICU, patient reports breathing is better. She
was further diuresed and sent to the floor on 2L of O2
Past Medical History:
- CKD stage V on HD
- ACCESS HISTORY AND COMPLICATIONS: Has right UE AVF, c/b
aneursyms, s/p interpositional graft, s/p ballooning [**2205-7-8**].
- T2DM c/b retinopathy, nephropathy, neuropathy, gastroparesis
(Currently does not require medications for diabetes management)
- secondary hyperparathyroidism
- HTN
- HLD
- sCHF
- non-ischemic cardiomyopathy
- sickle cell trait
- anemia of chronic disease
- PVD with celiac artery stenosis
- Depression
- Cataract
Social History:
Lives at [**Hospital 98599**] rehab
No alcohol, tobacco, or illicits.
Has 3 daughters
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: 97.9, 67, 123/72, 97%, RR 16, 2L.
General: Alert, oriented, no acute distress
HEENT: nasal canula in place, sclera anicteric, MMM, oropharynx
clear, EOMI, PERRL
Neck: supple, JVP difficult to assess (dressing and IV access in
place)
CV: Regular rate and rhythm, [**12-23**] holosystolic and diastolic
murmur, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Phycial exam on discharge
VS Tm 98.6 Tc 97.6 HR 66 (66-140) BP 110-146/60-70 RR 18
O2 sat 100% on 2L
General: No acute distress,orientedx3,
HEENT: sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD not distended.
CV: Regular rate and rhythm, [**1-21**] holosystolic murmur loudest at
right and left upper sternum likely due to right arm fistula, no
rubs, gallops
Lungs: Bronchial breath sounds at the right lung bases. Improved
aeration in both lungs. Unable to appreciate previous dullness
to percussion on right lung.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
Labs on Admission:
[**2206-3-24**] 01:50PM BLOOD WBC-5.6 RBC-3.14* Hgb-8.6* Hct-27.4*
MCV-87 MCH-27.4 MCHC-31.5 RDW-18.3* Plt Ct-161
[**2206-3-24**] 01:50PM BLOOD Neuts-71.3* Lymphs-19.7 Monos-5.8 Eos-2.6
Baso-0.5
[**2206-3-24**] 01:50PM BLOOD Glucose-90 UreaN-26* Creat-4.1* Na-142
K-4.7 Cl-101 HCO3-30 AnGap-16
[**2206-3-24**] 01:50PM BLOOD cTropnT-0.07*
Microbiology:
[**2206-3-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2206-3-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
Imaging:
[**2206-3-24**]
CXR lateral: A single lateral view of the chest was provided.
Layering effusions are seen, right greater than left. Further
evaluation is not possible on this single lateral view.
CXR portable: FINDINGS: Portable AP upright chest radiograph
obtained. A right subclavian venous stent is again noted. There
are pleural effusions, right greater than left. There is hazy
opacity obscuring the majority of the right mid-lower lung which
is most compatible with pulmonary edema, though a component of
the layering effusion is also possible. Pulmonary edema is less
evident in the left lung. The heart size is difficult to assess
but appears grossly stable. Atherosclerotic calcification along
the thoracic aorta noted. Tracheobronchial tree calcification
is also noted. Bony structures are intact. Clips in the upper
abdomen noted.
IMPRESSION: Possible pulmonary edema with bilateral pleural
effusions, right greater than left.
[**2206-3-25**]
CXR Number 1:
COMPARISON: [**2206-3-24**].
SINGLE AP PORTABLE VIEW OF THE CHEST: In comparison to prior
radiograph,
there is little relevant change. Right subclavian venous stent
is in
unchanged position. Bilateral pleural effusions, right greater
than left are again present, unchanged. No focal opacities
concerning for a developing infectious process. Atherosclerotic
calcifications throughout the thoracic aorta as well as the
tracheobronchial tree are noted. No pneumothora
CXR Number 2:
Comparison is made with prior study performed the same day
earlier in the
morning.
Right pleural effusion has decreased in amount, now small. It is
associated with a large atelectasis in the right lower lobe.
Mild cardiomegaly is stable. There is no pneumothorax. The aorta
is tortuous. A stent in the right subclavian vein is again
noted. Multiple surgical clips are present in the upper abdomen.
Left pleural effusion has resolved. The main pulmonary arteries
are enlarged as before.
[**2206-3-26**]
CXR Number 3 - Lateral decub
FINDINGS: In comparison with study of [**3-25**], there has been
removal of some
pleural fluid from the right chest. The fluid collection in the
minor fissure has essentially been eliminated. However, right
lateral decubitus view shows a substantial amount of free
pleural fluid layering out along the right chest wall
[**2203-3-27**]
FINDINGS: There is a severely enlarged heart, unchanged in size
from [**2203**]. A left sided subclavian stent is in place. There are
also significant vascular calcifications throughout the aortic
arch, great vessels and descending aorta. A metalic structure is
seen within the caudal segments of the heart (2:40) which was
present since at least [**2201**], but not prior to this. Surgical
history in OMR reveals no clear correlation.
Calcifications are also seen in the tracheobronchial tree, as
well as subdiaphragmatically throughout all the branches of the
aorta. Severe coronary artery calcifications of the LAD, left
circumflex artery as well as the aortic annulus are also
present. There is no substantial appreciable mediastinal
lymphadenopathy; however, without IV contrast, it is difficult
to ascertain.
There is a simple-measuring, layering, nonhemorrhagic small
right-sided
pleural effusion with compressive atelectasis adjacent to it. No
definitive masses or nodules are identified in either lung.
There is no left-sided effusion. Minimal areas of atelectasis
are present at the left lower lobe.
Subdiaphragmatically, extensive vascular calcifications are
again noted as well as several hypodensities within the
partially imaged right kidney, consistent with the patient's
history of ESRD and [**Year (4 digits) 2286**].
No suspicious bony lesions for malignancy.
IMPRESSION:
1. Small right-sided simple-appearing pleural effusion with
adjacent atelectasis.
2. Extensive vascular calcifications as detailed above
ECHO
[**2206-3-25**]
There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. There is moderate to severe
global left ventricular hypokinesis (LVEF = 35%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. There is abnormal
systolic septal motion/position consistent with right
ventricular pressure overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate to severe
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate global left ventricular systolic
dysfunction. Mild right ventricular systolic dysfunction. Mild
mitral regurgitation. Elevated left-sided filling pressures and
moderate to severe pulmonary hypertension.
Compared with the prior study (images reviewed) of
[**2200-9-15**], biventricular systolic function has substantially
improved. Pulmonary pressures have increased. There has been
impressive further calcification of the intracardiac structures,
particularly - of the mitral valve apparatus
Labs on discharge
[**2206-3-27**] 07:47AM BLOOD WBC-5.0 RBC-3.72* Hgb-9.9* Hct-31.9*
MCV-86 MCH-26.7* MCHC-31.1 RDW-17.9* Plt Ct-180
[**2206-3-27**] 07:47AM BLOOD Glucose-108* UreaN-30* Creat-4.0* Na-136
K-5.1 Cl-93* HCO3-35* AnGap-13
[**2206-3-27**] 07:47AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.7
Pending results:
[**2206-3-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2206-3-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
Brief Hospital Course:
74 yo F with CKD stage V on HD (T/Th/Sat), T2DM, sCHF, and other
medical issues presents today with SOB from HSL.
# Dyspnea. Patient presented to the ED on 2L of oxygen with
O2sat dropping up to 70% and being switched to 4L of Oxygen and
was sent to the MICU. ECG showed sinus, ~70, axis is normal but
decreased amplitude for QRS in I/aVL, sub-mm STD in II and III,
TWI in aVL, and V2, poor R wave progression, flattened T wave in
V3. CXR showed increased right sided pleural effusion, hazy
opacity in the RML c/w pulmonary edema. Patient was given
levofloxacin 750 mg IV x1 for concern of possible pneumonia
while in ED but this was stopped once she was in the MICU due to
little suspicion for pneumonia. Nephrology was informed about
patient for possible need of [**Numeric Identifier 2286**] and she was dialysed on
Tuesday at the MICU.
Patient was transferred to the floor on 2L of O2. She was stable
though she could not be weaned off O2 without her saturations
falling to 89%. Etiology was thought to be due to fluid overload
in the form of pleural effusion and pulmonary edema. This was
possibly in the setting of cardiac decompensation due to viral
infection. Patient was afebrile and had an intermittent non
productive cough and there was was little suspicion for
pneumonia.
Patient dry weight which was communicated as 95-98 pounds from
HSL staff was higher than her weight while fluid overloaded on
the floor. Her dry weight was estimated at 84 pounds while she
was inpatient.
Subsequent cxray showed resolving pleural effusion after each
[**Numeric Identifier 2286**]. There was concern for malignancy with possible fluid
reaccumulation but patient refused a thoracentesis. However a CT
was done which still showed pleural effusion in the right lung
but no evidence of consolidation or mass.
Patients's O2 sat improved on roomair after her last [**Numeric Identifier 2286**] on
[**2206-3-27**]. Of note O2 sat was 91-92% when measured on her
fingers and 100% when measured on her toes. Possibly due to nail
polish or AV fistula steal syndrome. However patient denies
cramping in her arms or hands or pain or stiffness.
# ESRD. HD on T/Th/Sat. Essentially anuric at baseline.
Hemodialysis was performed on set days and she was continued on
nephrocaps and cinacalcet.
# T2DM. Last HgbA1C is < 4.9 in 1/[**2205**]. Patient had 2 episodes
of hypoglycemia for which she was given [**Location (un) 2452**] juice and
repleted and was on insulin sliding scale according to her
preadmission medication list. She received no insulin while
inpatient and her finger sticks were all <170. With no
hyperglycemic results and no hypoglyemic events on finger stick
checks.
It was concluded patient does not require to be on insulin and
this was taken off her discharge meds.
# HTN. Stable while inpatient. The discussion of why patient is
not Ace-Inhibitor came up. According to records Ace-Inhibitor
was stopped due to episode of hyperkalemia 10 years ago. However
in the setting of HD, it should be reevaluated, as patient would
benefit from being on an Ace-Inhbitor for her systolic CHF. Home
medications, amlodipine and metoprolol were continued
# sCHF/non-ischemic cardiomyopathy, last EF back in [**2199**] was <
30%.Echo showed cardiac function had improved with a systolic
function of 35%. However pulmonary pressures had increased with
increase calcification of mitral valves. MI was ruled out and
patient was contined on metoprolol, isosobide dinitrate, Aspirin
81mg.
# Tremors:
Patient apparently had tremors on admission to rehab years ago
and was started on carbidopa/levodopa which minimized her
symptoms. Concern for side effect of medications. Patient could
probably do with a nonselective beta blocker instead of Sinemet.
# Anemia of chronic disease. Stable Hct compared to baseline
(28-30). Epo given per renal
# Depression- continued on home citalopram and mirtazepine
# Hyperparathyrodism - Related to her h/o renal failure was her
elevated PTH in the setting of secondary hyperparathyroidism as
expected.
# Transitional issues
- f/u on starting Ace Inhibitor on patient which could provide
further long term benefit. (Prior history of becoming
hyperkalemic on Ace-Inhibitor was probably prior to begining HD)
- f/u on use of Carbidopa/Levodopa for tremors. Patient could
also benefit from a nonselective beta blocker rather than
carbidopa/levodopa due to possible side effects. Decision
deferred to PCP.
[**Name Initial (NameIs) **] Diabetes medications were stopped. Patient had normal glucose
while in patient. Previous HbA1C was 4.9 in [**2205**] and due to
concern for increase mortality in elderly patients with such low
HbA1c and concern for hypoglycemia episodes - Insulin was
stopped. f/u with outpatient to ensure patient does not require
insulin in the far future.
Medications on Admission:
- insulin humulin R- sliding scale only
- metoprolol tartrate 25 mg [**Hospital1 **]
- metoprolol tartrate 12.5 mg [**Hospital1 **]
- ASA 81 mg daily
- citalopram 20 mg qPM
- mirtazapine 7.5 mg qHS
- Tylenol 650 q6h prn
- camph/menth/phenol 1 application TID topically
- omeprazole 40 mg daily
- zofran 4 mg q8h prn
- dextrose prn
- isosorbide dinitrate 10 mg TID
- cinacacalcet 60 qPM 1700
- vitamin B complex daily
- amlodipine 10 mg daily
- gabapentin 100 mg T/Th/Sat
- loperamide 2 mg q12hr prn
- loperamide 2 mg Tues/Sat
- carbidopa/levodopa 25/100 1 tab QID
** patient was d/c with pravastatin 40 mg at last discharge but
it is no longer on her medication list.
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold if SBP < 100
2. Aspirin 81 mg PO DAILY
3. Carbidopa-Levodopa (25-100) 1 TAB PO QID
4. Cinacalcet 60 mg PO QPM
5. Citalopram 20 mg PO QPM
6. Gabapentin 100 mg PO QHD
on [**Hospital1 2286**] days
7. Isosorbide Dinitrate 10 mg PO TID
hold if SBP < 100
8. Loperamide 2 mg PO BID:PRN PRN
9. Metoprolol Tartrate 37.5 mg PO BID
hold if SBP < 100 or HR < 60
10. Mirtazapine 7.5 mg PO HS
11. Omeprazole 40 mg PO DAILY
12. Vitamin B Complex 1 CAP PO DAILY
13. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
no more than 4 grams a day
14. camphor-menthol *NF* 0.5-0.5 % Topical TID PRN
One appl Topical three times a day as needed for pruritus. This
is a medication you were taking prior to admission. Please
continue taking it.
15. Docusate Sodium 100 mg PO BID PRN
This is a medication you were taking prior to admission. Please
continue taking it.
16. Senna 1 TAB PO BID:PRN Constipation
Twice a day as needed for constipation
17. Ondansetron 4 mg PO Q8H:PRN Nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary diagnosis:
acute on chronic systolic CHF
pleural effusions R>L
Secondary diagnosis:
CKD stage V on HD
DM type II, now diet-controlled
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 5749**],
You were admitted to [**Hospital1 69**] for
difficulty breathing.
Your breathing got better with extra fluid taken out from
[**Hospital1 2286**]. Your chest X-ray shows that there is extra fluid that
accumulated in your lungs. Your labs did not show signs of
heart attack. Your overall symptoms also do not seem to be from
pneumonia. It will be important for you to stay away from salty
food.
The kidney doctors think that your dry weight is now
38.5kilograms or 84 pounds . Weigh yourself every morning, let
your doctor know if your weight goes up more than 3 lbs.
If you experience any shortness of breath, difficulty breathing,
dizziness, chest pain, fevers or chills, cough, consult your
doctor
Please note the following changes in your medications:
Medications stopped:
Insulin- you had episodes of hypoglycemia and your glucose
levels were normal without insulin. Your HbA1c was also found to
be low.
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2206-3-29**]
12:00
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2206-5-13**]
2:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"447.4",
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"276.69",
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"311",
"282.5",
"250.50",
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"403.91",
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"428.22",
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
17141, 17206
|
10595, 15403
|
317, 348
|
17404, 17404
|
4298, 4303
|
18531, 18872
|
2667, 2684
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16121, 17118
|
17227, 17227
|
15429, 16098
|
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|
2699, 2713
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270, 279
|
376, 2063
|
17320, 17383
|
17246, 17299
|
4317, 10572
|
17419, 17531
|
2085, 2548
|
2564, 2651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,002
| 157,680
|
52992
|
Discharge summary
|
report
|
Admission Date: [**2190-6-12**] Discharge Date: [**2190-6-21**]
Service: NEUROLOGY
HISTORY OF THE PRESENT ILLNESS: The patient is a 79-year-old
man with a history of hypertension and lung cancer being
admitted to the Neurology Service with multiple complaints.
It is not clear which of these complaints is the most
important. I will recount them in chronological order.
Mr. [**Known lastname 109238**] first had headaches in about [**Month (only) 956**]. He
stated that the headaches would start in the back of his neck
and then spread to the front of his head. These headaches
became so bothersome that he visited the Emergency Department
twice and had detailed workups including CAT scans and lumbar
punctures which were negative. About ten days ago, he had an
episode where he said that he was trying to walk over a lip
in front of his front door and he could not lift his right
foot. He said that it was inverted and he could not control
it in order to move properly. This episode went away in a
few minutes.
One week prior to admission, his headache symptoms changed in
character. He noted that his headache would start in his
right shoulder, progress up across the back of his neck and
through his forehead bilaterally. These headaches would last
for hours at a time and did not really respond to medication.
Yesterday, when driving to the doctor's office, he noticed a
change in his vision as he came into and out of a tunnel. He
had a kaleidoscopic sensation in his left eye that lasted for
eight to ten minutes and it resolved when he got out of the
tunnel. This morning, he had several events that were
worrisome to him. He reports that he had increased to dose
of his medication Flexeril last night and was also taking a
larger dose this morning. He made himself a bowl of oatmeal.
When he was walking towards the kitchen after breakfast, he
almost fell. Several minutes later, he had slurring of his
speech. He did not describe it as an inability to find words
or inability to understand but actually slurring of speech.
His legs gave out shortly after his speech was slurred. He
said that they felt rubbery and that he was about to flop to
the ground. He was brought to the Emergency Room by the
ambulance at that time for evaluation of this problem.
While in the Emergency Room, the patient had another episode
of kaleidoscopic vision in his left eye for about five to ten
minutes. It resolved spontaneously. The patient reports no
double vision, neck, or backache, weakness in his arms, or
new sensory changes in his arms or legs. He has not had any
impairment in consciousness and his bowel and bladder have
been unaffected.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Lung cancer.
3. Peptic ulcer disease.
4. Peripheral neuropathy.
5. Prostate nodule.
ADMISSION MEDICATIONS:
1. Zocor 20 mg p.o. q.d.
2. Neurontin 200 mg p.o. t.i.d.
3. Protonix 40 mg p.o. q.d.
4. Multivitamin.
5. Fosinopril 20 mg p.o. q.d.
6. Flomax 0.4 mg p.o. q.h.s.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Parents both died at 86 of old age.
Hypertension runs in the family.
SOCIAL HISTORY: Smoked 40 pack years, quit 30 years ago.
Occasional scotch and soda years ago. Prisoner of war during
World War II, was a D17 gunner, policeman, and state
legislature, retired in mid 70s.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: He was
afebrile. His heart rate was 73, blood pressure 165/52,
pulse 18, 02 saturation 97% on room air. General: He was a
well-nourished, well-developed, elderly man lying in the
Emergency Department bed in no distress. HEENT: Tender to
palpation over the scalp on the right. No trauma. The
mucous membranes were moist. Pulmonary: Clear to
auscultation bilaterally. Cardiovascular: Regular, no
murmurs. Abdomen: Soft, nontender. Extremities: There
were 2+ pulses, cut over the medial foot on the right side.
Neurologic: Mental status: He was awake, alert, and
oriented. Language was fluent. No anomia. Months of the
year backwards are accurate. Cranial nerves: Visual fields
are full. Bilateral cataracts. Left fundus showed
hypertensive changes. Could not visualize the right fundus.
The extraocular muscles were intact without diplopia or
nystagmus. Facial strength and sensation were normal.
Hearing was intact. Tongue and palate was symmetric. Motor
examination: Increased tone in the lower extremities
bilaterally. Normal bulk throughout. Slight weakness in
finger extension in finger extension on the left sensory,
decreased joint position sense in all four extremities,
previous losses of the right foot, patchy left pinprick in
the lower extremities. The reflexes were decreased
throughout. Could not elicit an ankle. Toes were equivocal.
Coordination: Finger-to-nose was intact, heel-to-shin was
sloppy bilaterally. Gait was narrow based, hesitant, stride
length was short, reports shrapnel in right leg is
responsible for some of his gait difficulties.
LABORATORY/RADIOLOGIC DATA: White count 7.5, hematocrit 35,
platelets 359,000. Sodium 128, potassium 4.4, chloride 96,
bicarbonate 22, BUN 16, creatinine 0.9, glucose 88.
PT/PTT/INR were 12.5, 1.0, and 26.2. Troponin 1.5, 1.4. ESR
69.
MRI of the head showed diffuse periventricular white matter
disease, and multiple foci not adjacent to the ventricles.
There did not appear to be a right vertebral artery.
HOSPITAL COURSE: The patient was admitted to the Neurology
Service and initially started on aspirin for stroke
prophylaxis. As the diagnosis of temporal arteritis was
quite likely, he was given steroids, 1 gram IV q.d.
On hospital day number three, unfortunately, the patient
developed complete loss of vision in his left eye. He was
given 60 mg or prednisone emergently and seen by
Ophthalmology consult who diagnosed a left central retinal
artery occlusion. His vision improved after he was started
on heparin and also Brimonidine eyedrops and Diamox. At this
point, his visual loss in the left eye is a central cecal
scatoma.
The patient had an echocardiogram of the carotids which were
normal and did not disclose an embolic source. He had an EEG
which was also normal.
DISPOSITION: The patient was discharged on [**2190-6-21**].
DISCHARGE DIAGNOSIS: Temporal arteritis.
DISCHARGE MEDICATIONS:
1. Zocor 20 mg p.o. q.d.
2. Multivitamins one cap p.o. q.d.
3. Protonix 40 mg p.o. q.d.
4. Diamox 500 mg p.o. b.i.d.
5. Brimonidine eyedrops 0.2% one drop q. eight hours in each
eye.
6. Aspirin 325 mg p.o. q.d.
7. Coumadin 5 mg p.o. q.d.
8. Prednisone 60 mg p.o. q.d.
The patient will have INRs checked on [**2190-6-23**], [**2190-6-30**], and [**2190-7-7**]. He will follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1206**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as an outpatient. He will
also follow-up with his primary care physician and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
The patient is being discharged in stable condition. His
visual fields have improved to a left central cecal scatoma.
His ESR is now one. He will be tapered from steroids as an
outpatient and will continue on Coumadin.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. [**MD Number(1) 11772**]
Dictated By:[**MD Number(1) 109239**]
MEDQUIST36
D: [**2190-6-21**] 03:02
T: [**2190-6-25**] 19:54
JOB#: [**Job Number 109240**]
|
[
"401.9",
"362.31",
"V12.71",
"446.5",
"721.0",
"368.41",
"162.9",
"355.8",
"784.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3072, 3142
|
6322, 7506
|
6278, 6299
|
5430, 6256
|
2832, 3054
|
4082, 5412
|
3385, 3935
|
3951, 4065
|
2699, 2809
|
3159, 3370
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,517
| 180,733
|
5424
|
Discharge summary
|
report
|
Admission Date: [**2196-10-31**] Discharge Date: [**2196-11-2**]
Date of Birth: [**2129-2-5**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Lasix
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
67-year-old female with past medical history of severe TBM
s/p Y-stent in [**7-9**], severe COPD (on home O2), CAD s/p MI, CHF,
hypertension, and severe anxiety, now transferred from [**Hospital 1562**]
Hospital with COPD exacerbation and aspergillus in her sputum.
Major Surgical or Invasive Procedure:
flexible and rigid bronchoscopy
History of Present Illness:
67-year-old female with past medical history of severe TBM
s/p Y-stent in [**7-9**], severe COPD (on home O2), CAD s/p MI, CHF,
hypertension, and severe anxiety, now transferred from [**Hospital 1562**]
Hospital with COPD exacerbation and aspergillus in her sputum.
She has had frequent hospitalizations in the past few months for
dyspnea and COPD exacerbations. During these episodes, she
reports copious, thin secretions with an inability to cough. She
most recently was admitted to [**Hospital 1562**] Hospital on [**2196-10-15**] for
COPD exacerbation and underwent bronchoscopy to remove
secretions. Initial bacterial studies revealed colonization
w/aspergillus and [**Female First Name (un) **], no infection, no atypical cells, no
evidence of HSV or AFB. CXR had revealed severe COPD with no
infiltrates. At this time, she was continued on her regimen of
aerosol treatment, started on Solu-Medrol, and placed on
levaquin
for possible infectious etiology of acute bronchitis. She was
discharged on [**2196-10-20**]. On [**2196-10-31**] she was readmitted to
[**Hospital 1562**] Hospital for shortness of breath, fever (temp=101.2 F),
and chills. She was started on voriconazole for positive
aspergillus culture from sputum, and subsequently transferred to
[**Hospital1 18**] for further evaluation and management, including rigid
bronchoscopy and removal of Y-stent.
Past Medical History:
Past Medical History:
COPD w/exacerbation
tracheal bronchomalacia
severe anxiety
anemia of chronic disease and iron deficiency
HTN
CAD s/p MI
CHF
GERD
osteoporosis
compression fractures, asymptomatic
hyperlipidemia
Past Surgical History:
[**2196-6-22**]- Flexible bronchoscopy
[**2196-7-20**]- Rigid and flexible bronchoscopy with Y-stent placement
[**2196-8-15**]- Flexible bronchoscopy
Social History:
lives in [**Hospital1 **] w/ husband
Family History:
non-contributory
Physical Exam:
Physical Exam:
T HR 91 BP 123/72 RR 23 O2 sat 92% 3L Nc
Gen: NAD, awake, alert
HEENT: PERRL, EOMI, mucous membranes moist
Neck: No JVD, no masses or bruits.
Heart: Regular rate and rhythm. S1 and S2. No murmurs.
Lungs: Decreased breath sounds with basilar crackles and
occasional expiratory wheezes.
Abdomen: soft, nontender, nondistended, no organomegaly.
Extremities: warm, well-perfused, 1+ edema.
Pertinent Results:
chest CT:
IMPRESSION:
1. Marked consolidation in the left lower and right lower lobes
with more mild consolidation in the lingula and right upper lobe
could be consistent with aspergillosis. Followup chest CT is
recommended after treatment to ensure resolution.
2. Severe apical predominant emphysema, right greater than left.
3. Severe coronary artery atherosclerotic calcifications.
4. Moderate aortic valve calcifications.
5. Tracheobronchial tree is patent; per report the tracheal
stent was removed prior to this examination.
6. 10-mm low-density rounded focus in the spleen is incompletely
characterized but likely represents a cyst. If clinically
warranted, an ultrasound examination could provide definitive
characterization.
7. Multiple mid-thoracic wedge compression fractures, difficult
to compare. Multiple healing posterior rib fractures.
Brief Hospital Course:
pt was admitted from [**Hospital **] hosp to the SICU for severe TBM w/
Y stent and aspergillus PNA. taken to the OR on [**11-1**] and y
stent was removed w/o complication. Infectious disease was
consulted re: aspergillus treatement. pt was maintained on
voriconazole ( several month vs. life long course) and one week
of levoflox. Pt was d/c'd to home w/ VNA services and follow up
with Dr. [**Last Name (STitle) **] (IP) and Dr. [**First Name (STitle) 1075**] (ID) on [**12-2**].
Medications on Admission:
Medications:
[**Doctor First Name **] D 1tab po bid
Ambien 5mg po qhs insomnia
Aspirin 81mg po daily
Atrovent 0.5mg via neb q4h
Cardizem CD 180mg po daily
Cozaar 25mg po daily
Dulcolax prn constipation
Iron 325mg po tid
Klonopin 1mg po bid and 2mg po qhs
MiraLax 17g in 8oz water daily
Oxandrin 2.5mg [**Hospital1 **]
Oxygen 3L via Nc
Plavix 75mg po daily
Prilosec 20mg po qhs
Robinul 2mg po bid
Multivitamin 1 tab po daily
Zocor 80mg po daily
Foradil 12mcg [**Hospital1 **]
Spiriva 18mcg daily
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Lactobacillus Acidophilus Tablet Sig: One (1) Tablet PO
bid ().
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Oxandrolone 2.5 mg Tablet Sig: One (1) Tablet PO bid ().
11. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO daily ().
12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
16. PredniSONE 10 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily)
for 2 days: [**11-3**], [**11-4**].
Disp:*12 Tablet(s)* Refills:*0*
17. PredniSONE 50 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily) for 3 days: [**11-5**], 4, 5.
Disp:*15 Tablet(s)* Refills:*0*
18. PredniSONE 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily) for 3 days: [**11-8**], 7, 8.
Disp:*12 Tablet(s)* Refills:*0*
19. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: [**11-11**], 10, 11.
Disp:*9 Tablet(s)* Refills:*0*
20. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: [**11-14**], 13, 14.
Disp:*6 Tablet(s)* Refills:*0*
21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: 11/15,16, 17.
Disp:*3 Tablet(s)* Refills:*0*
22. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
Disp:*60 Disk with Device(s)* Refills:*2*
23. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: 1.26 mg
Inhalation every six (6) hours as needed.
24. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
25. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
26. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
27. Outpatient Lab Work
have your blood drawn on [**11-27**]
CBC, BUN, Creat, LFT's
fax results to Dr. [**First Name (STitle) 1075**] [**Name (STitle) 21994**] disease at [**Telephone/Fax (1) 432**]
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
tracheobronchial malacia with y stent removal
Discharge Condition:
good
Discharge Instructions:
call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 10084**] if you develop worsening
shortness of breath, fever, chills, chest pain, or difficulty
breathing, nausea, or vomitting.
If you have any visual changes, STOP the voriconale and call
infectious disease for an URGENT appointment [**Telephone/Fax (1) 457**].
Have your blood drawn ( CBC, BUN/Creat, LFT's) on [**11-27**] and
the results faxed to Dr. [**First Name (STitle) 1075**] at [**Telephone/Fax (1) 432**]
Followup Instructions:
You have follow up appointment with Infectious Disease Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1075**] on [**12-2**] at 10:30am in the [**Hospital **] medical building
basement.
You have a follow up appointment with Dr.[**Name (NI) 5070**] office
[**Telephone/Fax (1) 10084**] on friday [**12-2**] at 12:30pm. Please arrive in
Daycare [**Hospital1 **] [**Location (un) 453**] at 11:30am for check in. Do not eat
or drink anything after midnight on [**12-1**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2196-11-9**]
|
[
"401.9",
"496",
"428.0",
"484.6",
"250.00",
"519.19",
"117.3",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.56",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
7565, 7626
|
3808, 4292
|
541, 575
|
7716, 7723
|
2925, 3785
|
8245, 8875
|
2461, 2479
|
4838, 7542
|
7647, 7695
|
4318, 4815
|
7747, 8222
|
2239, 2391
|
2509, 2906
|
235, 503
|
603, 1978
|
2022, 2216
|
2407, 2445
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,613
| 138,542
|
50512
|
Discharge summary
|
report
|
Admission Date: [**2141-8-1**] Discharge Date: [**2141-8-8**]
Date of Birth: [**2064-11-4**] Sex: M
Service: MEDICINE
Allergies:
Lovenox
Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
Chest pain, tachypnea, hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76M with h/o CKD on dialysis MWF, anoxic brain injury, TIIDM
brought in from nursing home for respiratory distress and chest
pain. Morning of [**2141-8-1**], patient found by nurse at 5:10 with
chest pain and tachypnic to 40 with a O2 saturation of 75% and
hypertensive to 200 in the context of being dialyzed yesterday
and the intention of being redialyzed today for fluid overload.
EMS was called immediately and he was put on BIPAP and
transferred to the ED. Upon arrivival he was found to be
breathing 25x/min and satting 94% on BIPAP. SBPs continued in
the 200s and he was given 325mg ASA and started on a nitro drip.
The chest pain resolved. VBG demonstrated pH 7.39 pCO2
46 pO2 155 and a lactate of 1.0. Troponin was 0.37 (previously
.41 on [**10-10**]). An EKG was obtained, NSR at 92. CXR appeared
grossly volume overloaded. Patient was not given antibiotics
and dialysis is aware.
Vitals on transfer afebrile, HR 80s, 160/70, 100% on positive
pressure ventilation.
Past Medical History:
Anoxic brain injury s/p likely VF arrest in the setting of
hyperkalemia
CKD stage V, on HD MWF at [**Hospital **] hospital
HTN
DM II
Severe peripheral neuropathy
Glaucoma
Depression
Social History:
Lives at [**Hospital3 537**] in JP.
niece/HCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (3) 105203**] 043
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
No history of cardiac disease, diabetes.
Physical Exam:
Physical Exam on Arrival to MICU
Vitals: T: 97.5 BP: 192/105 P: 82 R: 20 O2: 100% on FiO2 of 40%,
4 PEEP/ 8 pressure support.
General: Alert, oriented to place, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP of 10-12cc H20, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
murmur, no rubs, gallops
Lungs: ? crackles on bases, patient is with positive pressure
ventilation
Abdomen: well healed midline scare, soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities on
right, 4-/5 on left, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred, finger-to-nose could not cooperate
with
Discharge exam:
VITALS: T 97.6 - 125/64 - 18 - 57 - 100 on 2L - BG 75 (range
81-215)
General: Arousable, but keeps eyes closed. Oriented to place, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP prominent, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
murmur, no rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Healed midline scar, soft, non-tender, non-distended,
bowel sounds present, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Patent L radial HD access site intact, well-perfused
Neuro: 4/5 strength upper/lower extremities on bilaterally, gait
deferred
Pertinent Results:
[**2141-8-1**] 06:10AM WBC-4.8 RBC-5.57 HGB-12.5* HCT-42.5 MCV-76*
MCH-22.5* MCHC-29.5* RDW-18.6*
[**2141-8-1**] 06:10AM GLUCOSE-225* UREA N-45* CREAT-5.3* SODIUM-136
POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-27 ANION GAP-21*
[**2141-8-1**] 06:19AM LACTATE-1.0
[**2141-8-1**] 06:19AM TYPE-[**Last Name (un) **] PO2-155* PCO2-46* PH-7.39 TOTAL
CO2-29
CXR: Interstitial and alveolar opacities consistent with
moderate pulmonary edema.
EKG: NSR at 92, LAD, PRWP, no new ST t wave changes
[**2141-8-8**] 08:05AM BLOOD WBC-4.3 RBC-4.94 Hgb-11.1* Hct-38.2*
MCV-77* MCH-22.5* MCHC-29.1* RDW-18.2* Plt Ct-210
[**2141-8-8**] 08:05AM BLOOD Plt Ct-210
[**2141-8-8**] 08:05AM BLOOD Glucose-65* UreaN-30* Creat-5.1*# Na-135
K-4.7 Cl-93* HCO3-32 AnGap-15
[**2141-8-8**] 08:05AM BLOOD Calcium-9.0 Phos-6.4* Mg-2.4
[**2141-8-5**] 07:35PM BLOOD %HbA1c-7.4* eAG-166*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The PA systolic pressure could not be
quantified. There is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
preserved regional and low normal global left ventricular
systolic function. No pericardial effusion.
Final Report
STUDY: PA and lateral chest: FINDINGS: There is again seen
cardiomegaly which is stable. It is difficult to comment on
pericardial effusion versus baseline cardiomegaly on
radiographs. If there is high concern, recommend ultrasound or
CT scan. The lungs are grossly clear. There has been
resolution of the pulmonary edema since the previous study.
There are no pneumothoraces or large pleural effusions.
Surgical clips are seen projecting over the GE junction.
Brief Hospital Course:
76M with h/o CKD on dialysis MWF, anoxic brain injury, TIIDM
brought in from nursing home for respiratory distress and chest
pain.
Active Diagnoses
# Respiratory distress: Pt was volume overloaded given elevated
JVP, diastolic hypertension and history of concern for
insufficient fluid off at last HD. Pt underwent ultrafiltration
and BIPAP. He was weaned off BIPAP and nitro drip without
issues. Rec'd dialysis in house. Respiratory status returned to
baseline at discharge.
# Chest pressure: He experienced chest pressure most likely
attributed to demand ischemia in setting of volume overload.
Resolved with nitrodrip and bipap. EKG without changes from
previous. Troponin unchanged from his baseline. Chest pressure
resolved with dialysis.
# Hypertension: Pt was hypertensive to SBP 200s on admission.
He appeared clinically volume overloaded with evidence on CXR.
He was placed on nitroglycerin drip x5hrs and weaned off,
tolerating this well. His outpt meds were continued:
isosorbide, lisinopril, amlodipine, carvedilol. SBP thereafter
110-160s.
#Hypoglycemia: Pt dropped to the 20s for glucose and was given
in total 4 amps of dextrose, glucagon shot, and D10 drip and was
transferred back to the icu for monitoring. Cleared with
dialysis and patient titrated off D5W and was tolerating POs.
The etiology of the hypoglycemia may have been related to a
non-optimized insuling dosing schedule (previously on NPH).
After consultation with [**Last Name (un) **], Mr. [**Known lastname **] NPH was stopped,
and he was managed on Lantus with a Humalog sliding scale.
Etiology also seemed to be related to Mr. [**Known lastname 1058**] not eating
breakfast on hemodialysis days, as he often returned with
hypoglycemia. Per recommendations from [**Last Name (un) **], he is to be
covered by the night-time insulin sliding scale on mornings of
hemodialysis that he does not eat breakfast to avoid post-HD
hypoglycemia. Please see attached Humalog ISS.
Chronic Diagnoses
# End stage renal disease: MWF dialysis at [**Hospital1 882**].
- Nephrocaps 1mg qd
- calcium acetate 667mg TID
- Pilocarpine 1% 1 drop to right eye QID
- Held ergocalciferol [**Numeric Identifier 1871**] units weekly and Procrit 0.6mL at HD
while in house
# DM: To stop NPH, [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Glucose
well-controlled on 5 units Lantus QHS, with an updated humalog
sliding scale. Of note, he should be covered by the night-time
humalog scale on mornings that he has hemodialysis and does not
eat breakfast, in order to avoid post-HD hypoglycemia.
# Glaucoma: Remained stable. Continued outpatient eyedrops.
# Chronic pain: Remained stable. Continued outpt meds:
Gabapentin & Tylenol.
# Depression: Not currently treated. Recommend follow-up of this
issue by PCP.
# GERD: Stable. Continued outpatient meds: omeprazole.
# BPH: Continued outpatient finasteride.
Transitional Issues
- Insulin regimen has been changed. Please follow up with [**Last Name (un) **]
Diabetes Center for follow-up of diabetes care.
-He does tolerate SC heparin despite lovenox allergy.
-Communication: Patient, niece/HCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], cell [**Telephone/Fax (5) 105206**],
-Code Status: Full (confirmed with [**Hospital3 537**])
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Hospital3 **] list, correct
except for Insulin, which I am unable to enter properly.
1. Amlodipine 10 mg PO DAILY
Hold for SBP<100
2. Omeprazole 20 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Levobunolol 0.25% 1 DROP BOTH EYES [**Hospital1 **]
6. brimonidine *NF* 0.2 % OU [**Hospital1 **]
7. Senna 1 TAB PO BID
8. Docusate Sodium 100 mg PO BID
9. Calcium Acetate 667 mg PO TID W/MEALS
10. Pilocarpine 1% 1 DROP RIGHT EYE QID
11. Acetaminophen 500 mg PO QOD HS
12. Gabapentin 400 mg PO HS
13. Carvedilol 12.5 mg PO BID
Hold for SBP<100, HR<60
14. Lisinopril 40 mg PO DAILY
Hold for SBP<100
15. Guaifenesin 20 mL PO TID cough
16. Loperamide 2 mg PO QID:PRN diarrhea
17. Polyethylene Glycol 17 g PO BID:PRN constipation
18. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
19. Epoetin Alfa 0.6 mL SC M,W,F AT HD Start: HS
20. Lidocaine 5% Patch 1 PTCH TD DAILY
21. Isosorbide Mononitrate 30 mg PO QAM
Hold for SBP<120
22. 70/30 18 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Hold for SBP<100
2. Omeprazole 20 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. brimonidine *NF* 0.2 % OU [**Hospital1 **]
6. Senna 1 TAB PO BID
7. Levobunolol 0.25% 1 DROP BOTH EYES [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Calcium Acetate 667 mg PO TID W/MEALS
10. Pilocarpine 1% 1 DROP RIGHT EYE QID
11. Acetaminophen 500 mg PO QOD HS
12. Gabapentin 400 mg PO HS
13. Carvedilol 12.5 mg PO BID
Hold for SBP<100, HR<60
14. Lisinopril 40 mg PO DAILY
Hold for SBP<100
15. Guaifenesin 20 mL PO TID cough
16. Loperamide 2 mg PO QID:PRN diarrhea
17. Polyethylene Glycol 17 g PO BID:PRN constipation
18. Epoetin Alfa 0.6 mL SC M,W,F AT HD
19. Lidocaine 5% Patch 1 PTCH TD DAILY
20. Isosorbide Mononitrate 30 mg PO QAM
Hold for SBP<120
21. Loratadine *NF* 10 mg Oral qd itching, allergic rash
22. Vitamin D 50,000 UNIT PO 1X/WEEK (TU)
23. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary: Hypoglycemia
Secondary: Chronic kidney disease
Discharge Condition:
Mental Status: Confused - always to year.
Level of Consciousness: Interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 1058**],
It was a pleasure caring for you while you were hospitalized at
the [**Hospital1 **]. As you know, you were admitted to the
intensive care unit for difficulty breathing. After that problem
resolved, you were sent to the general medical floor.
Unfortunately you suffered low blood sugar which was very
difficult to treat and required us to send you back to the
intensive care unit. You did well and were able to be sent back
to the general medical floor where you had no further
complications and were safely discharged.
There were some changes in medication that we started at the
hospital.
1. START Glargine 5 units in the evening.
2. START Humalog sliding scale four times a day except on the
mornings of hemodialysis.
3. DISCONTINUE Novolin 20 units and Novolin 18 units
PLEASE NOTE that when you are NOT EATING breakfast on the
mornings that you have HEMODIALYSIS, you should follow the
NIGHT-TIME insulin sliding scale. This means you will only get
insulin if your blood sugar is over 201 on the mornings that you
get hemodialysis to avoid having very low blood sugar.
Please also follow up with the future appointments listed below.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2141-9-28**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11307**], MD [**Telephone/Fax (1) 3752**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: THURSDAY [**2141-11-16**] at 1:45 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMODIALYSIS
When: WEDNESDAY [**2141-8-9**] at 12:00 PM
Please call [**Telephone/Fax (1) 3402**] to schedule an appointment with Dr. [**Last Name (STitle) **]
at the [**Last Name (un) **] Diabetes Center.
Description: [**Last Name (un) **] Diabetes Center
Department: [**Last Name (un) **] Diabetes Center
[**Last Name (un) **] Phone: ([**Telephone/Fax (1) 3258**]
Completed by:[**2141-8-26**]
|
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"285.9",
"585.6",
"276.69",
"600.00",
"530.81",
"V15.52",
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"356.9",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"93.90"
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icd9pcs
|
[
[
[]
]
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11066, 11137
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5619, 8924
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303, 309
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11237, 11237
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3332, 5596
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,186
| 137,092
|
30265
|
Discharge summary
|
report
|
Admission Date: [**2182-4-3**] Discharge Date: [**2182-4-15**]
Date of Birth: [**2154-9-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ativan
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2182-4-8**] - AVR (#23 On-X mechanical), and ascending aorta repair
w/gelweave graft
History of Present Illness:
This 27-year-old patient who has had a previous aortic
valvuloplasty as a child presented with recurrent severe aortic
stenosis with a dilated ascending
aorta. The coronary angiogram demonstrated no major abnormality
in the coronary circulation and confirmed the severe aortic
stenosis. He was electively admitted for aortic valve
replacement and replacement of the ascending aorta.
Past Medical History:
Bicuspid aortic valve
s/p Aortic Valvuloplasty
AS
ADD
Hyperlipidemia
GERD
Migraines
Left Retinal Vein thrombosis
Panic attacks
Social History:
Lives with grandmother. Smokes 3 cigs per day with apast smoking
h/o 1.5 ppd for several years. He drinks 6-8 beers weekely.
Family History:
There is CAD, Diabetes and HTN disease in his family but none
premature.
Physical Exam:
58 SR 18 102/58 69" 85.8 KG
GEN: WDWN in NAD
HEENT: NCAT, PERRL, EOMI, OP Benign
NECK: Supple, FROM, Radiating murmur to bilateral carotids
LUNGS: CTA
HEART: RRR, IV/VI SEM
ABD: Benign
EXT: 2+ Pulses. no c/c/e
NEURO: Left LQ visual field cut. Nonfocal otherwise
Pertinent Results:
[**2182-4-3**] 10:08PM PT-12.6 PTT-26.1 INR(PT)-1.1
[**2182-4-3**] 10:08PM PLT COUNT-143*
[**2182-4-3**] 10:08PM WBC-8.4 RBC-4.67 HGB-14.4 HCT-40.3 MCV-86
MCH-30.9 MCHC-35.8* RDW-13.1
[**2182-4-3**] 10:08PM ALBUMIN-4.6 CALCIUM-9.4 PHOSPHATE-3.8
MAGNESIUM-2.2
[**2182-4-3**] 10:08PM ALT(SGPT)-24 AST(SGOT)-18 LD(LDH)-210 ALK
PHOS-68 TOT BILI-0.3
[**2182-4-3**] 10:08PM GLUCOSE-124* UREA N-21* CREAT-1.6* SODIUM-142
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-31 ANION GAP-12
[**2182-4-5**] Cardiac Cath
1. Selective coronary angiography in this right dominant system
revealed no flow limiting coronary artery disease. The LMCA was
normal.
The LAD had mild proximal ectasia. The LCx had a 20% proximal
stenosis.
The RCA had mild proximal ectasia.
2. Supravalvular aortography demonstrated demonstrated 4+ AI
and
dilated aortic root.
3. Resting hemodynamics demonstrated a normal RVEDP of 12 mmHg.
There
was an elevated LVEDP of 15 mmHg. Pulmonary artery pressure was
27/12
mmHg. Central aortic pressure was 108/53 mmHg. There was a
mean
gradient of 54 mmHg across the aortic valve. Cardiac index was
perserved at 2.7 l/min/m2. Calculated aortic valve area was .84
cm2
(moderate to severe aortic stenosis).
[**2182-4-8**] ECHO
PRE-CPB: 1. No atrial septal defect or patent foramen ovale is
seen by 2D,
color Doppler or saline contrast with maneuvers.
2. here is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal.Overall left ventricular systolic function
is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There is a saccular
dilitation of
the ascending aorta from above the ST junction to 5 cm above the
valve but
below the PA bifircation. The widest diameter is 3.9 cm. There
is no dissection flap seen.
5. The aortic valve is bicuspid. The aortic valve leaflets are
severely
thickened/deformed. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild to moderate ([**1-29**]+) aortic regurgitation is
seen.
6. The mitral valve appears structurally normal with trivial
mitral
regurgitation.
POST-CPB:
1. The aortic valve prosthesis (#23 Onyx) appears to be well
seated,and there appear to be two small areas of aortic
insufficiency contained within the valve apparatus.
2. The Biventricular systolic function is well preserved.
3. There is a normal aortic contour.
[**2182-4-4**] Carotid Ultrasound:
Normal carotid study.
[**2182-4-15**] 06:35AM BLOOD WBC-9.3 RBC-3.56* Hgb-10.9* Hct-30.3*
MCV-85 MCH-30.7 MCHC-36.1* RDW-14.4 Plt Ct-305#
[**2182-4-15**] 06:35AM BLOOD Plt Ct-305#
[**2182-4-15**] 06:35AM BLOOD PT-22.7* PTT-107.3* INR(PT)-2.2*
[**2182-4-15**] 06:35AM BLOOD Glucose-104 UreaN-20 Creat-1.2 Na-136
K-4.6 Cl-96 HCO3-31 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 72052**] was admitted to the [**Hospital1 18**] on [**2182-4-3**] via transfer for
further management of his aortic stenosis and dilated ascending
aorta. A cardiac catheterization was performed which showed a
20% stenosis of his circumflex artery with otherwise normal
coronaries. He was worked-up in the usual preoperative manner
including a carotid ultrasound which was normal. An echo was
performed which showed a bicuspid aortic valve with mild
stenosis and moderate-to-severe regurgitation. A dilated left
ventricle with preserved global and regional systolic function
was also noted. Given Mr. [**Known lastname 72053**] history of non-sustained
ventricular tachycardia, an electrophysiology consult was
obtained. Amiodarone was discontinued with the plan to observe
him on beta blockers alone. A genetics consult was obtained for
evaluation of a possible connective tissue disorder however he
did not have any findings consitent with marfan's or other
connective tissue disorders. On [**2182-4-8**], Mr. [**Known lastname 72052**] was taken to
the operating room where he underwent an aortic valve
replacement with a 23mm onyx valve and an ascending aorta
replacement with a 24mm gelweave graft. Postoperatively he was
taken to the cardiac intensive care unit for monitoring. He had
some postoperative bleeding which was corrected with
transfusions of red blood cells, fresh frozen plasma, platelets
and cryoprecipitate. By postoperative day one, Mr. [**Known lastname 72052**] had
awoke neurologically intact and was extubated. Beta blockade was
resumed and coumadin was started for anticoagulation. He was
transferred to the floor on POD #1. He was diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. As
he was unable to void following removal of his foley catheter,
it was reinserted for his retention. Ciprofloxacin was given for
coverage. His urinary retention resolved. He was seen by
neurology for grey dots in ihs visual field and upper visual
field cut. Recommendations include Fioricet for migraine
headache, anticoagulation given the question of history of
embolis to the eye and mechanical valve. He remained on IV
heparin and coumadin until his INR was therapeutic and he was
ready for discharge to home on POD # 7.
Medications on Admission:
asa
Discharge Medications:
1. 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*
2. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
INR [**4-17**], and every Monday and Thursday with results to Dr. ***
Discharge Disposition:
Home with Service
Discharge Diagnosis:
AS
asc. aortic aneurysm
NSVT
ADD
migraines
GERD
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12070**] in [**3-31**] weeks. ([**Telephone/Fax (1) 72054**]
Follow- up with Dr. [**Last Name (Prefixes) **] in [**5-2**] weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with Cardiologist Dr. [**Last Name (STitle) 72055**] in [**1-29**] weeks.
Please call all providers for appointments.
Completed by:[**2182-4-15**]
|
[
"346.90",
"314.00",
"424.1",
"272.4",
"441.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
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icd9pcs
|
[
[
[]
]
] |
7852, 7871
|
4328, 6682
|
285, 375
|
7963, 7970
|
1472, 4305
|
1097, 1171
|
6736, 7829
|
7892, 7942
|
6708, 6713
|
7994, 8458
|
8509, 8901
|
1186, 1453
|
233, 247
|
403, 788
|
810, 939
|
955, 1081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,060
| 174,823
|
24307
|
Discharge summary
|
report
|
Admission Date: [**2182-4-4**] Discharge Date: [**2182-4-7**]
Date of Birth: [**2144-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
Alcohol intoxication
Altered mental status
Major Surgical or Invasive Procedure:
Intubation [**2182-4-4**]
Extubation [**2182-4-5**]
History of Present Illness:
Initial history and physical is as per ICU team.
.Mr. [**Known lastname 24927**] is a 37M with a history of severe alcoholism with
regular admissions to [**Hospital1 18**] for management of withdrawl,
complicated by DT's in the past, HBV, and HCV. Today at 2PM he
was found unresponsive by EMS at the T station, and brought to
the emergency department.
.
In the ED vitals were T=98.6, BP=111-134/79-96, HR=78-112,
RR=[**12-21**], O2sat=97%RA, FSBS 173. He was initially alert and
communicative, however, upon falling asleep, he became hypoxic
to 54% RA with an absent gag reflex, and was then intubated.
Sedated on a propofol drip, given 2mg Ativan given at 1442, 5mg
haldol, 2mg of narcan, and 1LNS. Right femoral CVL placed.
Labs were notable for an ETOH level of 280, and a leukocytosis
to 12,000. Otherwise tox screen was notable only for
benzodiazepines (patient was discharged on [**3-31**] for alcohol
intoxication, managed with BZDs). A head CT CT Cspine and CXR
were negative.
Past Medical History:
1. polysubstance abuse: ETOH, listerine, heroin, IVDU,
benzodiazepines
2. hepatitis C
3. hepatitis B
4. compartment syndrome RLE, [**2171**]
5. OCD and anxiety
6. depression with hx suicidal ideations and attempts
7. ethanol abuse, hx DTs and withdrawal seizures, intubated in
past
8. chronic bilateral hand swelling
9. Severe peripheral neuropathy
Social History:
The patient has previously reported he is homeless and lives in
front of [**Location (un) 7073**] train station. He drinks regularly, often a
liter of listerine and a fifth of vodka and additional beer
every day. He has a history of IV heroin and smoking cocaine but
has insisted he quit both of those activities >10 years ago. He
also smoked cigarettes in the past but claims he stopped in
[**2167**].
Family History:
Father with depression and alcoholism. Mother died of DM
complications.
Physical Exam:
Admission PE:
Vitals: T: 96.6, HR 86, BP: 104/76 HR:75
GEN: Sedated intubated
HEENT: Pupils pinpoint, equal and reactive bilaterally
NECK: No JVD, lymphadenopathy, trachea midline
CV: RRR, no M/R/G; 2+ radial, DP, and PT pulses bilaterally
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Upon weaning propofol, opens eyes to voice, sits up,
moves all four extremities to command, babinskis downgoing, no
clonus.
SKIN: Lacerations at the left brow and cheek.
Pertinent Results:
Admission labs:
[**2182-4-4**] 01:57PM BLOOD WBC-11.3*# RBC-4.55* Hgb-12.9* Hct-39.3*
MCV-86 MCH-28.3 MCHC-32.8 RDW-17.3* Plt Ct-426#
[**2182-4-4**] 01:57PM BLOOD Neuts-35.7* Bands-0 Lymphs-56.8*
Monos-3.2 Eos-3.5 Baso-0.9
[**2182-4-4**] 01:57PM BLOOD Plt Ct-426#
[**2182-4-5**] 04:21AM BLOOD PT-13.0 PTT-28.5 INR(PT)-1.1
[**2182-4-4**] 01:57PM BLOOD Glucose-129* UreaN-11 Creat-1.0 Na-142
K-4.9 Cl-101 HCO3-32 AnGap-14
[**2182-4-4**] 01:57PM BLOOD ALT-132* AST-110* AlkPhos-87 TotBili-0.2
[**2182-4-4**] 01:57PM BLOOD Lipase-61*
[**2182-4-4**] 01:57PM BLOOD Calcium-9.1 Phos-4.4# Mg-2.2
[**2182-4-4**] 01:57PM BLOOD ASA-NEG Ethanol-280* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2182-4-4**] 06:55PM BLOOD Type-ART pO2-545* pCO2-44 pH-7.40
calTCO2-28 Base XS-2 Intubat-INTUBATED
[**2182-4-4**] 06:55PM BLOOD Lactate-1.7
[**2182-4-4**] CT head: 1. No intracranial hemorrhage or edema.
2. Unchanged depressed left nasal bone fracture.
[**2182-4-5**] CT C spine: IMPRESSION:
No acute fracture.
NG tube appears to be looped within the pharynx.
.
CXR:
FINDINGS: In comparison with the study of [**4-4**], there is little
overall
change. Specifically, no evidence of acute pneumonia. Monitoring
and support
devices remain in place.
Brief Hospital Course:
Mr. [**Known lastname 24927**] is a 37M with a PMH s/f severe alcoholism with
multiple ICU admissions for management of airway
protection/withdrawl in the past, HCV, and HBV, found
unresponsive in the setting of alcohol intoxication, intubated
for airway protection and hypoxia prior to recieving benzos in
ED, with incidentally diagnosed leukocytosis on routine labs.
.
#. Altered mental status: DDX includes ETOH intoxication with
level of 280, other toxic ingestion, intracranial bleed from his
fall, seizure from ETOH withdrawl vs. trauma. Head CT negative
for a bleed, CT Cspine was negative, and no clear
toxic-metabolic abnormalities on initial labs. His mental
status improved.
.
#. Hypoxia: In the setting of alcohol intoxication, likely
secondary to an aspiration event. CXR was negative for
pneumonia. Pt was extubated in the ICU. His O2 sasts remained
stable after that.
.
#. ETOH intoxication: Patient has a history of withdrawl
seizures. Also has severe anxiety at baseline, and is difficult
to monitor with a CIWA scale, as his subjective symptoms have
been unreliable. We used vital signs (hyperthermia, HTN,
Tachycardia)to monitor ETOH withdrawl, and wrote for diazepam as
needed. He was given MVI, thiamine, and folic acid. The
patient was often very agitated and anxious and demanded valium
despite not showing any vital sign evidence of withdrawal. SW
was consulted but the patient eloped before he could be seen.
As previously documented in previous OMR notes, this patient
should be section 35ed for his safety if he continues to come to
the hospital intoxicated.
.
# HCV/HBV: previous hx transaminitis, at baseline
.
# FEN: Diet was advanced to Regular s/p extubation.
.
# PPX: heparin SC
.
# Access: hx of difficulty with pIV and pt combative, femoral
CVL placed in ED upon arrival. Removed before discharge.
.
# Code: Full code
.
# Dispo: On [**2182-4-7**], the [**Name8 (MD) 228**] RN went to check on him and he
was found to have eloped from the hospital.
.
This discharge summary is signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as Dr. [**Name (STitle) 61607**] is no longer working at [**Hospital1 18**].
Medications on Admission:
None
Discharge Medications:
Pt eloped
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH intoxication
Discharge Condition:
Fair.
Discharge Instructions:
Pt eloped
Followup Instructions:
Pt eloped
|
[
"311",
"305.60",
"291.81",
"070.32",
"518.81",
"577.0",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6354, 6360
|
4089, 4471
|
313, 366
|
6422, 6429
|
2823, 2823
|
6487, 6499
|
2195, 2268
|
6320, 6331
|
6381, 6401
|
6291, 6297
|
6453, 6464
|
2283, 2804
|
231, 275
|
394, 1386
|
3678, 4066
|
2840, 3669
|
4486, 6265
|
1408, 1759
|
1775, 2179
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,957
| 175,511
|
33052
|
Discharge summary
|
report
|
Admission Date: [**2164-7-26**] Discharge Date: [**2164-8-1**]
Service: MEDICINE
Allergies:
Carbamazepine / Fosamax / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
HTN
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] F with history of mechanial fall in [**6-/2164**] resulting in
prolonged rehabilitation that is ongoing, though patient with
increasing hypertension, dyspnea, constipation, and confusion in
last several days. Presented to the ED early on [**7-26**] (0300) with
hypertension and dyspnea. Patient reports that she awoke from
sleep with a strange feeling in her head. She and daughter agree
that she dyspnea has been persistent over entire rehab course.
Has had decreased PO intake in last week.
.
Upon presentation to the ED, vitals were: T 98, HR 68, BP
206/98, RR 14, O2Sat 98%. CXR was performed. Patient was felt to
have CHF exacerbation and was given nitro paste and furosemide
IV. KUB showed a dialted bowel loop. CT abdomen and pelvis
performed and confirmed dilated bowel loop; however, without any
additional pathology. Stool guaiac was negative. CT head was
negative. 10 hours into ED course patient's BP was still 200
systolic. Patient had been given PO HTN meds, though vomited
twice and couldn't keep meds down. Labetalol drip was started
with good effect and ICU bed request was made. EKG in ED was
sinus without acute changes and two sets of troponin were drawn
10 hours apart and were negative.
In the MICU, labetalol gtt was stopped since SBP<160. She
continued to have SBP 140-170s.Took home PO meds this morning
and vomitted up MVI but took BP meds ok. She was sleepy but
arousable. today tried po narcan to see if fentanyl patch could
be making her sleepy and fentanyl patch was decreased to
50mcg/hr TP Q72h. Cr was seen to increase slightly.
Prior to transfer to the floor, patients vitals were: T
afebrile, HR 70, BP 174 systolic, RR 97% on 2L NC.
Past Medical History:
- Diastolic CHF
- LE edema
- Iron Deficiency Anemia
- Mild/moderate dementia
- Hypercholesterolemia
- Hypertension
- Osteoporosis
- Status post CVA
- Gastroesophageal reflux disease
- Presbyesophagus
- Constipation
- Trigeminal neuralgia
- Compression fractures - T7 through 11 and T12
- Basal cell carcinoma
- Restless legs syndrome
- Parkinsonian symptoms
Social History:
She is married, and her spouse is still alive. They both reside
in an assisted care facility. She denies alcohol or tobacco
use. She has one son and one daughter.
Family History:
Non-Contributory
Physical Exam:
Physical Exam:
VS: T afebrile, HR 76, BP 161/74, RR 22, O2Sat 100% 3L NC
GEN: NAD
HEENT: PERRL, oral mucosa extremely dry
NECK: JVP elevated at approximately 10 cm
PULM: Kyphosis, diffuse crackles along posterior lung fields
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, thin, soft, NT, ND
RECTAL: Normal rectal tone with soft stool mixed with solid
pellets in rectal vault
EXT: bilateral 1+ pitting edema
NEURO: Hypophonia and hoarse voice, oriented to self and
clinical situation, confused about dates and chronology of
events in last week
Pertinent Results:
Labs at Admission:______________
[**2164-7-26**] 03:00AM PT-13.1 PTT-27.4 INR(PT)-1.1
[**2164-7-26**] 03:00AM WBC-9.6 RBC-4.10* HGB-11.4* HCT-34.8* MCV-85
MCH-27.9 MCHC-32.9 RDW-14.9
[**2164-7-26**] 03:00AM GLUCOSE-119* UREA N-36* CREAT-1.6* SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2164-7-26**] 04:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2164-7-26**] 03:00AM CK-MB-4 cTropnT-0.05* proBNP-4947*
[**2164-7-26**] 12:50PM cTropnT-0.04*
----Imaging:-----
***CT-Head***
FINDINGS: There is no evidence of acute hemorrhage, edema, mass
effect, or
acute large vacular territory infarction. Prominence of the
ventricles and
sulci reflects generalized atrophy and appears similar to the
prior
examination. Confluent areas of periventricular and subcortical
white matter
hypodensities most likely reflects sequela of chronic small
vessel ischemic
disease. There are calcifications of the bilateral carotid
siphons. The
visualized paranasal sinuses are clear.
IMPRESSION: No evidence of acute intracranial process.
***CT-Abdomen***
IMPRESSION:
1. Dilatation of a segment of small bowel up to 3.5 cm without
evidence of
abrupt transition point and oral contrast is seen beyond this
loop of bowel in
decompressed loops. Findings are consistewnt with partial
obstruction.
2. Small bilateral pleural effusions, left greater than right,
with simple
fluid attenuation.
3. Evidence of prior granulomatous disease in the liver and
spleen.
4. Extensive atherosclerotic calcification of the aorta.
5. Left renal cysts.
6. Multiple compression deformities, age indeterminate.
_________________________
Labs at discharge:
[**2164-7-30**] 06:10AM BLOOD WBC-7.9 RBC-3.57* Hgb-9.8* Hct-29.9*
MCV-84 MCH-27.5 MCHC-32.9 RDW-15.1 Plt Ct-265
[**2164-7-30**] 06:10AM BLOOD Glucose-89 UreaN-49* Creat-1.9* Na-139
K-4.4 Cl-104 HCO3-27 AnGap-12
[**2164-7-27**] 03:23AM BLOOD ALT-16 AST-25 LD(LDH)-365* AlkPhos-83
Amylase-84 TotBili-0.4
Brief Hospital Course:
[**Age over 90 **] yo female with hypertensive crisis likely secondary to
missing anti-hypertensive doses because of N/V. Pt was found to
have SBP>200 and had concurrent complaints of mental fuzziness
(however, baseline AD). Was started on labetalol drip because
of inability to tolerate PO. In the ICU, pt was maintained on
labetalol drip until could tolerate PO medications, and was then
restarted on home carvedilol and losartan, and because it was
thought that her nausea might be in part due to very high dose
of fentanyl, fentanyl patch dose was decreased to 50mcg. SBPs
on HD1 occasionally spiked despite home antihypertensives, so
patient was additionally started on 2.5mg amlodipine daily.
Transferred to floor with stable VS. Overnight, pt vitals
remained stable with a BP of 146-150/66-67. Her SOB improved and
cognitive functioning returned closer to baseline. She was
deemed stable for discharge to rehabilitation. She did have
diarrhea after having an aggressive bowel regimen in the ICU.
She was repleted with gentle fluids and her creatinine and dry
mouth improved. We were gentle because of her known heart
failure with an EF of about 35%. She was doing well and at her
baseline and happy to be with her husband.
Medications on Admission:
1) Aspirin 81 mg PO/NG DAILY
2) Losartan Potassium 100 mg PO/NG DAILY
3) Fentanyl Patch 75 mcg/hr TP Q72H
4) Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5) Pramipexole 0.5 mg Oral [**Hospital1 **]
6) Multivitamins 1 TAB PO/NG DAILY
7) Lidocaine 5% Patch 1 PTCH TD DAILY
8) Carvedilol 25 mg PO/NG [**Hospital1 **]
9) Simvastatin 10 mg PO/NG DAILY
10) Omeprazole 40 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
-HTN
Secondary:
-Constipation
-CHF
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the [**Hospital1 **] for very high
blood pressure, difficulty breathing and overall confusion. We
treated your high blood pressure successfully and your breathing
improved as a result of these treatments. We were also
originally concerned about your constipation and evaluated you
for an obstruction but you were not obstructed based on imaging
studies and physical exam. Overnight your clinical situation
improved such that we feel comfortable sending you to a
rehabilitation facility for further monitoring and physical
therapy.
While you were here, some of your home medications were changed.
We DECREASED your Fentanyl patch to 50mcg TP Q72h. We STARTED
Amlodipine 2.5mg Daily. Please continue to take these
medications.
Please continue to take all other medications as prescribed by
your doctor.
Please attend all follow-up appointments
Followup Instructions:
Please follow up with the Physicians at the rehabilitation
facility. Tell your doctor if you have headache, nausea or feel
short of breath.
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
|
[
"292.81",
"294.8",
"332.0",
"428.0",
"564.00",
"280.9",
"276.51",
"401.0",
"733.00",
"333.94",
"530.81",
"E935.2",
"584.9",
"428.33",
"272.0",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7910, 8032
|
5213, 6452
|
258, 264
|
8121, 8121
|
3162, 4866
|
9189, 9445
|
2569, 2588
|
6877, 7887
|
8053, 8100
|
6478, 6854
|
8299, 9166
|
2618, 3143
|
215, 220
|
4886, 5190
|
292, 1987
|
8136, 8275
|
2009, 2369
|
2385, 2553
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,303
| 168,535
|
2767
|
Discharge summary
|
report
|
Admission Date: [**2138-11-3**] Discharge Date: [**2138-11-8**]
Date of Birth: [**2083-8-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 55 year old woman with insulin dependent diabetes
with poor control who presents to the ED with DKA. Patient has
had diabetes since [**2131**]. She has been seen at [**Company 191**] by Sister
[**Name (NI) 1743**] [**Name (NI) **] since [**2131**]. Per OMR notes she often gets her
care at the [**Hospital1 2177**] ED. She has never been admitted to this hospital
with DKA. On the day of admission she was found to be lethargic
by her boyfriend. [**Name (NI) **] called EMS. Blood sugar was 660 when they
arrived. She was lethargic but arousable, responsive and
oriented x three but could not explain why she was in the
hospital or give her past medical history. She denied chest
pain, sob and abdominal pain.
.
In the ED blood sugar was 725. Sodium was 160 and bicarbonate
was 17 with and anion gap of 36. She was given ten units of
insulin and started on an insulin drip. She also received five
liters of normal saline. Initial vitals were 98.6, 109, 160/63,
18 and 97% on 2L. Four hours later her blood sugar was 328 and
her gap was 24.
.
[**Hospital Unit Name 153**] course:
** DKA-Given her hx of poorly controlled DM, likely type I, she
was thought to develop DKA in setting of med non-compliance.
There is no obvious source of infection or other ppt factor. gap
was closed at 12 on [**11-4**]. [**Last Name (un) **] consulted. Started on 50u qAm
on 70/30 and 30 u qPM.
.
** ARF also resolved w/ significant fluid resucitation. creat
1.7 on admission to 0.7 on [**11-4**].
.
** Hypernatremia-This was thought to be in setting of
dehydration FENa<1%. Free water deficit is 6L. Her Na improved
from 165 on admission to 145 on [**11-5**].
.
.
.
.
.
.
.
.
.
.
.
.
.
.
................................................................
When pt was transferred to the floor, she was feeling much
better. She denies N/V and diarrhea. She is eating well. She
denies HA, CP, SOB or abdominal pain. She states that she has
some trouble taking her insulin twice a day and was not taking
it twice a day prior to this admission. She reports that checks
her fingersticks once or twice a day. She knows that she is
supposed to check her fingersticks before she goes to work as a
schoolbus driver but it is not clear if she does so.
Past Medical History:
1. Insulin dependent diabetes x 6 years (HgbA1c [**5-18**] 10.3%).
2. Learning disability
3. HTN
4. low back pain
Social History:
Pt lives with her sister. She has worked as as a [**Doctor Last Name **] driver for
disabled children for over 20 years. She states that she checks
her blood sugar once a day, but it is not clear that she
actually does this. Her sister is concerned that she does not
take very good care of herself and says that she sometimes skips
her insulin. Pt says that sometimes she gets very tired and
doesn't take it.
Family History:
Mother had diabetes.
Physical Exam:
VS: T 98.1 HR 101 BP 129/58 RR 12 O2 sat 97% 2L
Gen: Lying in bed in NAD. Oriented to person and place.
Lethargic.
HEENT: PERRL, EOMI, sclera anicteric, MM very dry.
Neck: No LAD, JVD or thyromegly.
CV: RRR with no m/r/g
Lungs: CTA bilaterally
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: No clubbing, cyanosis or edema.
Pertinent Results:
[**2138-11-3**] 09:45PM GLUCOSE-533* UREA N-23* CREAT-0.8 SODIUM-141
POTASSIUM-2.9* CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2138-11-3**] 02:00PM SODIUM-166*
[**2138-11-3**] 02:00PM CK(CPK)-102
[**2138-11-3**] 02:00PM CK-MB-1 cTropnT-<0.01
[**2138-11-3**] 10:20AM GLUCOSE-125* UREA N-29* CREAT-0.9 SODIUM-166*
POTASSIUM-3.6 CHLORIDE-126* TOTAL CO2-31 ANION GAP-13
[**2138-11-3**] 03:40AM GLUCOSE-142* UREA N-31* CREAT-1.0 SODIUM-164*
POTASSIUM-4.1 CHLORIDE-125* TOTAL CO2-28 ANION GAP-15
[**2138-11-3**] 03:38AM WBC-10.0 RBC-4.57 HGB-13.0 HCT-40.7 MCV-89
MCH-28.3 MCHC-31.9 RDW-14.2
[**2138-11-3**] 03:38AM PLT COUNT-318
[**2138-11-3**] 03:38AM PT-14.3* PTT-20.6* INR(PT)-1.4
[**2138-11-3**] 03:41AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
.
.
Portable AP view of the chest dated [**2138-11-2**] shows the heart,
hilar, and mediastinal contours are unremarkable. The pulmonary
vasculature is normal. There are no pleural effusions. There is
no pneumothorax. The lung fields are clear. The surrounding
osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
1) DKA: Unclear cause. Patient reports viral like illness prior
to admission with several episodes of vomiting and diarrhea. No
hx of fevers. Reports taking her meds despite her illness,
however, may not be completely compliant. Given her severe
hyperglycemia, patient was started on an insulin drip until her
anion gap closed. She was then continued on the drip because she
was receiving D5W to correct her hypernatremia. [**Last Name (un) **] consulted
- pt started on standing insulin and weaned off the drip. [**First Name8 (NamePattern2) **]
[**Last Name (un) **], started on new regimen of 70/30 (60 units in am, 35
units before dinner)the evening of [**11-5**]. Insulin dose titrated
up for better glycemic control. Patient will need out-patient
teaching at [**Last Name (un) **] given her history of a learning disability.
.
2) Hypernatremia: Serum Na 166 on admission. Osmotic diuresis
from glucosuria. FENa < 1% (0.59%)consistent with hypovolemic
hypernatremia. Resolved with D5W, which was then stopped. Serum
Na WNL on discharge.
.
3) ARF: Likely due to hypovolemia given FENa of 0.59%. Improved
with hydration and ultimately resolved. Lisinopril was held and
should consider being restarted as an out-patient. Unclear if pt
has any baseline renal insufficiency, however, on discharge Cr
was 0.8.
.
4) Change in mental status: likely due to hypernatremia and
hyperglycemia. Mental status improved with correction of her
glucose and sodium. Patient appears to have baseline cognitive
delay; her sister confirmed that she was at her baseline upon
discharge.
.
5) Cardiac: No history of chest pain. Patient ruled out for MI
with three sets of cardiac enzymes. Will need further evaluation
with stress as outpatient given complaints of chest pain in past
per clinic notes. Started on aspirin and atorvastatin while
in-patient.
.
Medications on Admission:
Glucophage 500 daily
Insulin 70/30 70 q am and 40 q pm
Lisinopril 2.5 mg
Robaxin 500 mg [**Hospital1 **]
ASA 81 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig:
Eighty (80) units Subcutaneous every morning.
Disp:*2400 units* Refills:*2*
4. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig:
Forty Five (45) units Subcutaneous with dinner.
Disp:*1350 units* Refills:*2*
5. Syringe Syringe Sig: 100 cc Miscell. twice a day:
please dispense 60 disposable 100 cc syringes.
Disp:*60 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnoses
1. hyperglycemia
2. hypernatremia
.
Secondary diagnoses
1. Insulin dependent diabetes x 6 years (HgbA1c [**5-18**] 10.3%)
2. Learning disability
3. HTN
4. low back pain
Discharge Condition:
good
Discharge Instructions:
Please take all of your medications as prescribed.
*
Please check your finger sticks twice a day.
*
Please call your doctor or come to the emergency department if
you develop fevers/chills, nausea/vomiting, diarrhea, are
haviing trouble eating and drinking, if you develop urinary
frequency, increased thirst, if you pass out, if your blood
sugar is very high or very low, or if you develop any other
symptoms that are concerning to you.
Followup Instructions:
Please follow up with your regular doctor at the [**Hospital **] clinic
in [**4-19**] days.
*
Please follow-up at the [**Hospital **] clinic --> # [**Telephone/Fax (1) 2378**]. You
can call for an appointment on Monday [**2138-11-10**].
|
[
"724.2",
"276.2",
"276.0",
"250.12",
"584.9",
"401.9",
"315.9",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7511, 7569
|
4789, 6116
|
323, 330
|
7800, 7807
|
3574, 4766
|
8293, 8534
|
3183, 3205
|
6804, 7488
|
7590, 7779
|
6658, 6781
|
7831, 8270
|
3220, 3555
|
274, 285
|
358, 2599
|
6131, 6632
|
2621, 2737
|
2753, 3167
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,310
| 169,068
|
45497
|
Discharge summary
|
report
|
Admission Date: [**2170-4-28**] Discharge Date: [**2170-5-1**]
Date of Birth: [**2096-6-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Abdominal Pain, Nausea, Vomiting
Major Surgical or Invasive Procedure:
[**2170-4-29**]: EGD
History of Present Illness:
Monitoring after bowel obstruction in setting of elevated INR
and recent Stent ([**4-17**]) requiring pt to remain on ASA/plavix
.
History of Present Illness:
73M w/ CAD s/p CABG with recent SVG-PDA BMS placed on [**4-17**], sCHF
(EF 30% with ICD since [**2165**]), restrictive lung disease with
history of asbestos exposoure, p/w chest pain, nausea, vomiting,
abdominal pain.
Pt stated that his pain started yesterday (Fri) evening. The
pain was [**6-19**], pressure over left sternum, associated with
abdominal pain, nausea and vomiting - lasted all night. Had seen
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**], earlier that day and was okay, although feeling
slightly off all day. Pt also had three grey loose stool last
night. Didn't have any nausaea or abdominal pain until it
developed suddenly at night. Threy up evening meds (which
according to his wife include his ASA/plavix).
At baseline, pt has chronic SOB with limited ambulation capacity
within the room. He also c/o 3-4 days cough before this
presentation. On ROS, Denies diarrhea or constipation. Denies
history of prior bowel surgeries. No HA, lightheadedness,
dizziness.
Of note, pt had recent PCI by Dr. [**Last Name (STitle) **] on [**4-17**], with BMS placed in
SVG-RPDA. Pt had patent LIMA-CAD, SVD-D, and occluded SVG-OM.
In the ED, initial VS were: 98.6 64 135/68 16 97%. In the [**Name (NI) **], pt
c/t have [**2168-5-16**] chest pain, not responding to nitro sl (1 tab)
and morphine (5mg IV) and dilaudid 1mg IV. Cards saw in ED and
in setting of no EKG changes, neg trops x 2, evidence of bowel
obstruction thought said no concern ACS. Rec continuing
ASA/Plavix due to recent BMS. Dr. [**Last Name (STitle) **] informed. Significant
improvement in abd pain after NG placement with nasty NGT output
after placement. CT abdomen showed strange duodenal volvulus in
part that cannot volvulize -> [**Doctor First Name **] atd more likely obstructive
mass -> need EGD with possible bipsies (GI happy to do once
coagulopathy corrected - want INR < 2, prefer < 1.7). Would only
go to OR for surgery in emergency without diagnosis. Got 2 units
FFP and 10mg IV Vit K. Since was somewhat confused in the ED and
had high INR, head CT done to r/o bleed - no acute changes.
Evidence of vascular disease. VS okay, mid 90s on RA
On arrival to the MICU, feels much better after NGT placement.
No longer nauseated and no abdominal pain. Doesn't feel
confused. No chest pain. Breathing fine.
Past Medical History:
- CAD s/p anterior and inferior MIs s/p CABG [**2153**]
- Ischemic Cardiomyopathy and CHF ([**4-/2168**] EF 28%) s/p ICD in
[**2165**]
- Afib on warfarin
- PACING/ICD: dual chamber ICD [**5-/2166**]
- s/p bilateral carotid endarterectomy
- Diabetes
- Dyslipidemia
- Hypertension
- h/o Frontal lobe CVA
- Restrictive lung disease (asbestos exposure)
- Obstructive sleep apnea on CPAP
- h/o PUD
- Benign abdominal tumor s/p resection
- Restless leg syndrome
- Depression on lamotrigine
- Prostate cancer, s/p radiation, c/b radiation proctitis
- Gout
- Arthritis
Social History:
Born in [**Country 4754**] but moved to US at age 16. Retired radio and
television announcer. Lives with wife. [**Name (NI) **] 4 adult children and
7 grandchildren, including 3 daughters who live within 20
minutes of his house and one son who is a professional dancer in
[**Location (un) 7349**]. Denies ever smoking. Rare alcohol use and no drug use.
Family History:
Maternal aunt may have had [**Name (NI) 2481**] disease. Father died of
complications related to a football injury at a young age.
Mother lived to be 93 and died following a rapidly progressive
course of pancreatic cancer. One sister died in early teens
possibly related to malnutrition. 4 adult siblings are all in
good health. Brother HTN.
Physical Exam:
Admission exam:
General: Alert and oriented x 3 with no distress
HEENT: Sclera anicteric, dry MM, OP clear, NGT in place
Neck: supple
CV: IRIR, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no focal deficits, some odd comments during interview but
seemed to generally understand what is going on and why in
hospital
Discharge Exam:
General: AAOx3, in NAD
HEENT: MMM, neck supple
CV: Irregularly irregular, no MRG
Lungs: CTAB
Abd: Soft, nontender, nondistended normoacive bowel sounds, no
rebound or guarding
Ext: Warm well perfused. 2+ pulses bilaterally
Pertinent Results:
Admission labs:
[**2170-4-28**] 09:50AM BLOOD WBC-8.7 RBC-4.00* Hgb-9.6* Hct-33.2*
MCV-83 MCH-24.1* MCHC-29.0* RDW-22.2* Plt Ct-325
[**2170-4-28**] 09:50AM BLOOD Neuts-80.7* Lymphs-10.7* Monos-8.3
Eos-0.3 Baso-0.1
[**2170-4-28**] 09:50AM BLOOD PT-69.2* PTT-60.3* INR(PT)-7.0*
[**2170-4-28**] 09:50AM BLOOD Glucose-212* UreaN-23* Creat-0.9 Na-139
K-3.3 Cl-104 HCO3-24 AnGap-14
[**2170-4-28**] 09:50AM BLOOD ALT-46* AST-27 CK(CPK)-49 AlkPhos-89
TotBili-0.4
[**2170-4-29**] 11:58AM BLOOD Lactate-1.9
Discharge labs:
[**2170-5-1**] 08:00AM BLOOD WBC-8.1 RBC-3.58* Hgb-8.6* Hct-30.1*
MCV-84 MCH-24.0* MCHC-28.6* RDW-22.2* Plt Ct-269
[**2170-5-1**] 08:00AM BLOOD PT-13.9* PTT-29.7 INR(PT)-1.3*
[**2170-5-1**] 08:00AM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-140
K-3.7 Cl-101 HCO3-28 AnGap-15
[**2170-5-1**] 08:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3
CT Head W/O Contrast -- Preliminary Result+ Dictated ([**1-/8741**])
No ICH. CHronic bifrontal encephalomalcia and microvasc dz.
CT Abd & Pelvis With Contrast -- Preliminary Result:
Marked stomach distension with twisting of the duodenal bulb,
concerning for early developing midgut volvulus (possibly [**1-11**]
surgical adhesions). Distal bowel is fluid filled with areas of
wall edema and hyperenhancement-could be reactive vs. unerlying
GI infection/inflammation. Markedly distended GB and new mild
diffuse bil dil- ?related to partial CBD obstruction at site of
volvulus. No specific signs for acute cholecystitis, correlate
clinically.
Chest (Pa & Lat)
Preliminary Report: Mild interstitial edema with small bilateral
effusions.
EKG: Afib, rate controlled, abnormal conduction with some PCVs,
no significant change from prior, no ST changes.
Brief Hospital Course:
73yo M w/ PMH significant for A.fib (on Coumadin), presumed ILD,
severe CAD (s/p 4V CABG), ischemic cardiomyopathy with an LVEF
of 25% presenting with bowel obstruction due to duodenal
volvulus due to hematoma, inflammatory cause, stricture, or
mass, also w/ supratherapeutic INR.
# Bowel Obstruction: Symptoms initially of N/V/Abd pain. Pt had
area of duodenal inflammation on CT scan and surgery was
originally consulted who did not think he required a surgical
intervention. an NG tube was placed and he had a large amount of
nonbloody noncoffee ground gastric contents were suctioned out.
He was made NPO and watched overnight. GI was consulted who
performed an EGD which showed 2 duodenal ulcers but with some
edema around the ampula. While ther was edema near the pylorius
the EGD socope was easily passed through and therefore not an
obstruction. The patient had decreased output from his NGT and
it was pulled on HD #3. His diet was slowly advanced and he was
tolerating a normal diet at the time of discharge. He denied
any further abodminal pain.
-Started omeprazole 40mg po BID
-Pt will require repeat EGD in 6-8weeks (to be scheduled by the
patient)
-Patient should avoid NSAIDs and alcohol
# CAD with recent Stents: Patient with significant CAD with
situation further complicated by new BMS on [**2170-4-17**]. High risk
for occlusion of stents if misses meds. He had one episode of
chest pain that resolved without intervention within 5 minutes
and had no EKG changes. He was maintained on his outpatient
plavix and aspirin even when he had his NGT in place for concern
about restenosis of his recent stent.
-No changes made to regimen
# Ischemic Cardiomyopathy and CHF ([**4-/2168**] EF 28%) s/p ICD in
[**2165**]:
Currently appears to be euvolemic without respiratory
symptoms.Patient was restarted on all of his home medications
prior to discharge.
-No changes made
# Afib on warfarin: Patient came in with supratherapeutic with
INR in 7s. Only on warfarin for Afib, and although his CHADS2
score is 5, it was felt that with his ulcers on admission eh was
at higher risk of bleeding than of a stroke so he was not
bridged with heparin. He was restarted on coumadin on HD #3.
-WIll require close f/u of his INR and make adjustments for goal
of [**1-12**]
# Hypertension: BP in 110-140s on presentation.Patient was
transiently on IV metoprolol while he was NPO with the NGT in
place, and was placed back on all of his home meds prior to
discharge.
-
# Diabetes: Recent A1C was 7.4. Continued his home ISS during
hospitalization.
# Psych - Depression with risk of delerium. He was given
seroquel with good response while inpatient. He had no acute
episodes of altered mental status and while he did pull out
multiple NGT, he was not trying to leave. ALl home meds were
restarted prior to discharge.
You will need to follow up with general surgery as an
outpatient within 5-6 weeks.
Tranistional Issues:
Pending labs/studies: None
Medications started:
Omeprazole 40mg by mouth twice a day (this is to help the ulcers
heal and prevent new ones)
Medications changed: None
Medications stopped: None
Follow-up needed for:
1. Abdominal pain
2. Will need repeat EGD in 6-8weeks
3.Needs surgery follow-up in 5-6weeks
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Medications on Admission:
1. citalopram 20 mg daily
2. insulin lispro ISS
3. docusate sodium 100 [**Hospital1 **]
4. nitroglycerin 0.4 mg Tablet SL PRN
5. warfarin 2 mg Tablet daily
6. acetaminophen 500-1000mg TID PRN pain
7. lamotrigine 400mg daily
8. simvastatin 20 mg daily
9. ranolazine 1,000 mg Tablet Extended Release [**Hospital1 **]
10. aspirin 325 mg Tablet daily
11. isosorbide mononitrate 90 mg Tablet Extended Release 24 hr
12. simethicone 80 mg Tablet, QID PRN gas/bloating
13. clopidogrel 75 mg Tablet daily
14. metoprolol tartrate 100 mg Tablet [**Hospital1 **]
15. furosemide 40 mg Tablet daily
16. Flomax 0.4 mg Capsule, Ext Release 24 hr
17. Seroquel 25 mg Tablet Qhs
18. Seroquel 25 mg Tablet Qhs PRN agitation
19. lisinopril 2.5 mg Tablet daily
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
5. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
6. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: do not exceed 3 g in 24 hour period.
7. lamotrigine 200 mg Tablet Sig: Two (2) Tablet PO once a day.
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Outpatient Lab Work
Please check INR on [**2170-5-3**] and have results faxed to Dr. [**Name (NI) 29823**] office (or discussed over the phone).
12. 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*
13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
14. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for indigestion.
15. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
16. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
19. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for agitation.
20. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Duodenal Ulcer
Secondary: CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 3265**],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**].
You were admitted to the hospital because you were having
abdominal pain, nausea and vomiting and found to have a large
amount of fluid not passing out of your stomach. You were in
the intensive care unit for a night so that they could monitor
you closely and performed an endoscopy (looked in your stomach
with a small camera) and they saw two ulcers in your duodenum
(part of your small intestines) and some inflammation that may
have caused the blockage of fluid out. They did not need to do
anything for these except give medicines. You had a tube in
your nose for part of your stay to give your stomach a rest.
After we pulled out this tube you started to drink fluids and
eat solids without problems.
You will need to follow up with general surgery as an outpatient
within 5-6 weeks.
Tranistional Issues:
Pending labs/studies: HPylori (your PCP will [**Name9 (PRE) 702**] this
result)
Medications started:
Omeprazole 40mg by mouth twice a day (this is to help the ulcers
heal and prevent new ones)
Medications changed: None
Medications stopped: None
Follow-up needed for:
1. Abdominal pain
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] of general surgery on [**2170-5-24**]
at 2PM. [**Hospital Unit Name **], [**Location (un) 470**].
Phone: [**Telephone/Fax (1) 600**]
Please also see Dr. [**Last Name (STitle) 1007**] within 2 weeks after discharge.
Phone: [**Telephone/Fax (1) 10492**]. He will arrange follow up appointment with
GI as an outpatient.
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2170-5-4**] at 9:15 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2170-5-24**] at 11:00 AM
With: L. KAPUST,LICSW/[**Location (un) **] [**Telephone/Fax (1) 1047**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2170-5-24**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 26**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], OT [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
"V12.54",
"414.8",
"412",
"786.59",
"V58.67",
"300.00",
"V45.82",
"V15.3",
"V15.84",
"427.31",
"414.00",
"V45.02",
"428.0",
"428.22",
"V10.46",
"250.00",
"518.89",
"V58.61",
"311",
"535.40",
"V45.81",
"272.4",
"530.10",
"327.23",
"333.94",
"790.92",
"531.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
12651, 12709
|
6703, 10029
|
338, 360
|
12783, 12783
|
4984, 4984
|
14265, 15819
|
3839, 4182
|
10820, 12628
|
12730, 12762
|
10055, 10797
|
12934, 14242
|
5498, 6680
|
4197, 4723
|
4739, 4965
|
265, 300
|
547, 2868
|
5000, 5482
|
12798, 12910
|
2890, 3453
|
3469, 3823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,222
| 156,340
|
34918+57955
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-9-23**] Discharge Date: [**2167-10-11**]
Date of Birth: [**2115-11-18**] Sex: F
Service: SURGERY
Allergies:
Ibuprofen / Oxycodone / Remicade
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
partial SBO
Major Surgical or Invasive Procedure:
[**2167-9-27**] exlap, ventral hernai repair, ostomy resiting
History of Present Illness:
51F w/ h/o DM2, Crohn's s/p TI resection & subtotal colectomy
w/ileostomy & ileostomy revision, bilateral ventral hernias, who
presented to an OSH with 1 day of abdominal pain. The pain was
sharp and constant, diffusely throughout the abdomen. She denies
associated nausea or vomiting. Her last ostomy BM was noted last
night, as well as flatus. At the OSH, her WBC was 9.5, Cr 1.48,
glucose 225. Her lactate was 1.5. CT scan there showed dilated
loops of bowel in R ventral hernia, concerning for early small
bowel obstruction. She was transferred to [**Hospital1 18**] for further
management. She had one episode of emesis in the ED, she states
due to the contrast. She denies fevers, chills, changes in
urination, bloody bowel movements.
Here at [**Hospital1 18**], she was initially volume resuscitated and managed
conservatively. On HD4 it was noted that the pateint was
[**Last Name (LF) 79904**], [**First Name3 (LF) **] she was taken to the OR for an ex lap for
high-grade SBO on [**9-27**] which revealed a right-sided incarcerated
hernia w/strangulated bowel that was resected, as well as a
left-sided hernia that was not incarcerated. The hernia was
closed w/sutures on fascia and a new ostomy was created. Her
intraoperative course was c/b O2 desaturation of unclear
etiology. EBL was 100cc; she got 2L crystalloid, no PRBC, and
200g albumin, was on neo intra op briefly.
On arrival to the MICU, patient's VS 98.1, 136/67, HR 98,
satting 100% w/FiO2 1, rate 12, TV 500. She is intubated and
sedated, and minimally responsive.
Past Medical History:
- Crohn's disease s/p TI resection & subtotal colectomy
w/ileostomy & ileostomy revision [**2164**]
- parastomal hernia repair [**2165**]
- DM2
- SBOs
- HTN
- pancreatitis
- Nonischemic cardiomyopathy (EF 20%)
- Bilateral ventral hernia
- s/p vaginal hysterectomy [**2151**], with revision [**2152**]
- s/p bilateral axillary I+D for furunculosis [**2161**]
Social History:
The patient is widowed, smokes 5 cigarettes a day, does not
drink any alcohol, denies drugs. Lives with dtr son in law and
two cousins. Primary language is Portuguese but she is fluent in
English. She is interested in cigarette cessation. She works as
a seamstress from home. She last worked 2 weeks ago. She
emigrated to this country 22 years ago. She is independent of
ADLs and IADLs. She does express concern about her finances
since she is now in the hospital.
Family History:
Her mother is deceased, had complications of myocardial
infarction and heart failure. Her father died of complications
of cirrhosis. He was a heavy drinker. She has multiple siblings.
They all still live in [**Country 4194**] and details are unknown.
Physical Exam:
99 98.6 84 118/67 8 99 ra
GEN: Alert and oriented x 3
CVS: RRR
CTAB
Soft abdomen with midline and former ostomy site closed with
staple, c/d/i/ Ostomy with semiformed output + Gas
Ext: Trace LE edema
Pertinent Results:
RUE U/S [**10-3**]:
FINDINGS: Normal compression of the right internal jugular
vein. The
subclavian and axillary veins were not visualized. There is
normal
compression and augmentation of the right basilic and brachial
veins. The
PICC line was seen in the cephalic vein extending to the
axillary vein which
showed a trace amount of flow. The most distal portion of the
PICC was
obscured by overlying bandage.
IMPRESSION: Technically limited study without evidence for a
right upper
extremity DVT. The subclavian and axillary veins were not
visualized.
CXR [**10-3**]
FINDINGS: In comparison with the study of [**9-30**], there are
continued low lung
volumes. Nasogastric tube has been removed and right PICC line
extends to the
mid portion of the SVC.
There is increased opacification at the right base with poor
definition of the
heart border. Although this could represent crowding of
vessels, in the
appropriate clinical setting, supervening pneumonia would have
to be seriously
considered. Some atelectatic changes are seen in the
retrocardiac region at
the left base.
CT Abdomen [**10-1**]
There are bilateral pleural effusions which are new from
comparison.
Ground-glass opacities in the lingula and left lower lobe likely
also
represent focal atelectasis; however, infection or other
inflammatory process
is not excluded. No suspicious nodule. No pericardial
effusion. A
nasogastric tube extends into the stomach. Normal appearance of
the
gastroesophageal junction.
Lack of IV contrast limits evaluation of the solid organs of the
abdomen. The
liver is diffusely hypodense, suggesting fatty infiltration. No
focal liver
lesions identified. There is high-density material within the
gallbladder
which may represent sludge versus vicarious excretion of
previously
administered contrast. Normal non-contrast appearance of the
pancreas, spleen,
adrenals, kidneys, ureters and bladder appears decompressed by a
Foley
catheter.
There is diffuse and extensive mesenteric edema and free fluid
as well as
diffuse small-bowel wall thickening suggesting acute
inflammation, ischemia or
enteritis. Contrast is not seen to reach distally to the
ileostomy. The small
bowel loops immediately proximal to the ostomy are collapsed.
However, no
area of frank transition point can be identified to suggest a
mechanical bowel
obstruction. Lack of IV contrast and diffuse mesenteric edema
limit
assessment of portions of the bowel for this purpose. There is
no evidence of
pneumatosis. Patient is status post subtotal colectomy with
unremarkable
appearance of the residual sigmoid colon.
There are two large fluid collections in the abdominal wall,
which correlate
with the site of previous hernia and stoma, the largest is on
the right
measuring 14 x 5 cm with a smaller collection on the left
measuring 8 x 3 cm.
Both of these contain gas and are suspected to be infected.
There is also
diffuse soft tissue edema.
Normal caliber of the aorta and its major branches with mild
atherosclerotic
calcification. No acute or suspicious osseous findings.
IMPRESSION:
1. Two subcutaneous abdominal wall fluid collections containing
gas are
suspicious for abscesses. These would be amenable to
percutaneous drainage.
2. Diffuse, severe mesenteric edema with diffuse small-bowel
wall thickening
may represent enteritis, active inflammation or bowel ischemia.
Distal small
bowel is collapsed and partial small bowel obstruction cannot be
entirely
excluded, though no transition point is identified. If
clinically indicated
repeat scanning could be performed with a delay to allow further
passage of
enteric contrast.
3. Fatty liver.
4. New bilateral pleural effusions.
5. Focal ground-glass opacities in the lingula and left lower
lobe likely
represent atelectasis; however, infection or inflammation is not
excluded.
[**9-28**] ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the basal inferior septum, inferior wall and
inferolateral wall and of the mid inferior and inferolateral
walls. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. The
effusion appears circumferential. There is no echo evidence of
tamponade physiology.
IMPRESSION: Suboptimal image quality. There is mild focal left
ventricular systolic dysfunction as described above. The right
ventricle is not well seen but is probably mildly dilated with
borderline function. At least mild to moderate tricuspid
regurgitation with mild pulmonary hypertension. Circumferential
pericardial effusion without evidence of tamponade physiology.
Compared with the prior study (images reviewed) of [**2164-1-4**],
above named wall motion abnormalities are new. The right
ventricle is probably dilated/hypokinetic on current study. The
amount of pericardial fluid cannot be compared due to suboptimal
image quality.
[**9-27**] Tissue Pathology
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 79905**],[**Known firstname **] [**2115-11-18**] 51 Female [**-1/3678**]
[**Numeric Identifier 79906**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. WHITE/dif
SPECIMEN SUBMITTED: small bowel, omentum, ileostomy.
Procedure date Tissue received Report Date Diagnosed
by
[**2167-9-27**] [**2167-9-28**] [**2167-9-30**] DR. [**Last Name (STitle) **]. BROWN/vf
Previous biopsies: [**-1/5024**] GI BIOPSY (1 JAR)
[**-1/4319**] R. UPPER BACK & GROIN (2 JARS)
[**-1/2634**] GI BIOPSY (1 JAR)
[**Numeric Identifier 79907**] GI BIOPSY (2 JARS).
(and more)
DIAGNOSIS:
1. Omentum, omentectomy (A-C):
Mature adipose tissue with vascular congestion.
2. Small bowel, resection (D-I):
Ischemic necrosis, focally transmural, extending to one margin.
3. Ileostomy (J-Q):
Ischemic necrosis, focally transmural, extending to the proximal
margin.
Clinical: Ventral hernia, small bowel obstruction.
Gross: The specimen is received fresh in three containers,
each labeled with the patient's name, "[**Known lastname 12330**], [**Known firstname **]" and the
medical record number.
Part 1 is additionally labeled "omentum." It consists of a
fragment of yellow fatty omentum that measures 19 x 10.5 x 1.0
cm. The specimen is hemorrhagic, but otherwise grossly
unremarkable. Serial sectioning reveals yellow fatty cut
surfaces. The specimen is represented in cassettes A-C.
Part 2 is additionally labeled "small bowel." It consists of a
short and dilated segment of small bowel with scant attached
mesentery that measures 1.7 cm in length and up to 4.0 cm in
diameter. The serosa of the small bowel is diffusely
erythematous. The mesentery is diffusely firm. Both ends of
the small bowel are open. One end is normal appearing, while
the other end is [**Doctor Last Name 352**]/tan and grossly necrotic. The specimen is
opened to reveal an empty lumen. The mucosa is tan with normal
folds, except leading up to grossly necrotic margin. No lesions,
masses or polyps are identified within the small bowel segment.
The bowel wall is thick and measures up to 0.4 cm in greatest
thickness. Within the mesentery, no lymph nodes are identified.
The specimen is represented as follows: D-E = potentially
necrotic margin with firm mesentery, F-G = opposite margin with
firm mesentery, H = representative small bowel, I = mesentery
entirely submitted for potential lymph nodes.
Part 3 is additionally labeled "ileostomy." It consists of an
ileostomy specimen that measures 15 x 5.5 x 3.0 cm. An attached
portion of mesentery is present that measures 5 x 3.6 x 1.5 cm.
The small bowel segment alone measures 15 x 3.5 cm. The serosa
of the small bowel is diffusely erythematous. The small bowel
is opened on both ends. One end appears to be the stoma site.
A potential rim of tan white skin is present around the stoma
site. The small bowel is opened along the antimesenteric surface
to reveal an empty lumen. Within the center of the segment, a
circumferential strictured area is identified which measures 3.5
x 2.0 cm. The margin opposite the stoma site contains tan to
focally green mucosa which extends from that margin to the
stricture, 7.0 cm in length. The mesentery is firm, but
otherwise grossly unremarkable. No lymph nodes are identified.
The specimen is represented as follows: J = stoma margin, K =
opposite margin, L = representative small bowel from stoma to
stricture, M = representative small bowel within stricture, N =
representative small bowel from stricture site to margin
opposite stoma (?pseudomembranous), O-Q = representative
sections of mesentery.
[**9-27**] CXR:
FINDINGS: In comparison with the study of [**9-26**], there are lower
lung volumes which may account for much of the prominence of the
transverse diameter of the heart. Endotracheal tube tip lies
approximately 2.5 cm above the level of the carina. Nasogastric
tube extends well into the stomach.
Opacification at the bases is consistent with small effusions
and compressive atelectasis at the bases.
[**9-30**] CXR:
Cardiac size is top normal accentuated by low lung volumes and
projection. There is mild pulmonary edema. Bibasilar opacities
larger on the right side are consistent with atelectasis. There
is no pneumothorax. Bilateral pleural effusions are larger on
the right side. NG tube tip is in the stomach.
Brief Hospital Course:
MICU COURSE:
# SBO: Patient was s/p resection of strangulated bowel from R
incarcerated hernia. closed hernia w/suture on fascia with new
ostomy. Patient was maintained on vanco/cipro/flagyl (D1 [**9-27**])
in the MICU. IV PPI was started. Patient was kept NPO. Blood,
urine cx were sent. Pain control was maintained with dilaudid
PCA.
# Mechanical ventilation: Patient was intubated for the surgery
and kept intubated given need for fluid resuscitation and
uncertainty of cardiac function. In addition, she had a
desaturation in the OR, but recovered. Patient was extubated
without event and did well from a respiratory standpoint.
# ?Non-Ischemic Cardiomyopathy: Patient with potential hx of
non-ischemic CM with poor EF. EKG performed with no ischemic
changes seen. Given intraoperative desaturation and need for
ventilation, repeat ECHO was conducted, which was un revealing,
LVEF 40-45%.
# Crohn's disease: Patient takes prednisone 5mg PO daily at
home. In MICU, was maintained on equivalent dose of IV
methylprednisolone while in-house (4mg daily).
# [**Last Name (un) **]/ATN: Patient with elevated creatinine. Not unsurprising
given s/p procedure. Nephrology involved to [**First Name9 (NamePattern2) **] [**Last Name (un) **]. Urine
sediment with muddy brown casts.
[**2167-9-29**]: transferred out of ICU to regular floor. [**2167-10-1**],
ultrasound-guided bilateral abdominal abscess drainage of
serous, non-purulent fluid, low abdominal JP drains placed x 2.
[**2167-10-2**]: Transferred to ICU for insulin drip secondary to
uncontrolled blood sugars (300s-400s) on floor. [**Last Name (un) **] consult
obtained. ISS titrated and drip was stopped.
[**2167-10-3**]: Patient's blood glucose back to 100s-200s by [**2167-10-3**].
WBC remained elevated to 21.6 despite antibiotics
(Vancomycin/flagyl) - CXR obtained showed no evidence of
pneumonia. In addition, RUE U/S obtained because of asymmetric
arm swelling s/p PICC placement, which did not show evidence of
DVT (although was a limited study). Antibiotics discontinued.
[**2167-10-5**]: Reduced to half TPN and advanced diet to regular as
tolerated.Initially she had decrease appetite which improved
over the next couple of days and the TPN was subsequently
discontinued.
[**2167-10-6**]: Pt was evaluated by psych for depressed mood an
suicidal ideation regarding the size of her new ileostomy stoma.
Surgical team had several lengthy conversations with pt
regarding her surgery and swollen bowel. Pt was reassured that
she can expect some shrinkage of the stoma as the fluid comes
off. She continued to be diuresed with Lasix IV for fluid volume
overload. She was transfused with 2 units of RBC for anemia
related to her surgery. Her hematocrit level improved
appropriately. She had no further signs of acute blood loss and
her vital signs remained stable. [**2167-10-6**] Pt was started on
Zoloft as recommended by psych. Her mood overall had improved
and she reported coping better with her ostomy.
In regards to her nutrition pt reported appetite to be
suboptimal with poor oral intake. She was started on glucerna
per nutrition recomendation.Her diabetic diet remains
appropriate given poorly controlled blood glucose values
(ranging from 188-317 mg/dl on [**2167-10-6**]). [**Last Name (un) **] diabetes
continued to follow pt and her insulin was just appropriately
per their reccommendations. She continued on her IV
methylprednisolone and was transition to prednisone.
Medications on Admission:
omeprazole, prednisone 5', novolog SSI, lantus 34 units qhs
Discharge Medications:
1. HYDROmorphone (Dilaudid) 1-3 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 0.5-1.5 tablet(s) by mouth q
4hr Disp #*40 Tablet Refills:*0
2. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Pantoprazole 40 mg PO Q24H
4. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Strangulated recurrent incisional hernia
Hpergylcemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
- 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, increase
ostomy output or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
-Your pain is not improving within 8-12 hours or not gone within
24 hours. Call or return immediately if your pain is getting
worse or is changing location or moving to your chest or back.
-Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
-Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
-Please resume all regular home medications and take any new
meds
as ordered.
-Continue to ambulate several times per day.
Incision Care:
-Your staples will be removed at your follow-up appoinment.
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
Call and schedule follow-up appointment with Dr. [**Last Name (STitle) **] in
2 weeks [**Telephone/Fax (1) 9**].
Call and schedule follow-up appointment with your
gastroenterologist in 2 weeks.
Call and schedule appointment with your primary care provider [**Last Name (NamePattern4) **]
1 week.
Completed by:[**2167-10-9**] Name: [**Known lastname 10227**],[**Known firstname 12832**] Unit No: [**Numeric Identifier 12833**]
Admission Date: [**2167-9-23**] Discharge Date: [**2167-10-11**]
Date of Birth: [**2115-11-18**] Sex: F
Service: SURGERY
Allergies:
Ibuprofen / Oxycodone / Remicade
Attending:[**First Name3 (LF) 4**]
Addendum:
Patient remained in the hospital on [**10-10**] to continue to monitor
her high ostomy output of 2800+ ml. Her immodium was increased
to QID and she took [**2-9**] psyllium wafer [**Hospital1 **] on [**10-10**]. On [**10-11**], her
ostomy output had slowed down to an acceptable range. The
patient was counceled about titrating her immodium to an
apporpriate output. Her staples were removed and replaced with
steri-strips prior to discharge.
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16**] MD [**MD Number(1) 17**]
Completed by:[**2167-10-11**]
|
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"305.1",
"E878.8",
"569.83",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
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"99.15",
"46.41",
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] |
icd9pcs
|
[
[
[]
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] |
20435, 20637
|
13212, 16671
|
304, 367
|
17230, 17230
|
3308, 13189
|
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|
2819, 3071
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|
17153, 17209
|
16697, 16759
|
17381, 18451
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18466, 19249
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|
252, 266
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395, 1937
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17245, 17357
|
1959, 2320
|
2336, 2803
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,909
| 125,433
|
20244
|
Discharge summary
|
report
|
Admission Date: [**2148-3-9**] Discharge Date: [**2148-3-12**]
Date of Birth: [**2102-10-18**] Sex: M
Service: MEDICINE
Allergies:
Gabapentin / Lipitor / Zyprexa / Seroquel
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 year old male w ESRD on M/W/F HD, CHF, COPD on home O2 and
OSA on nocturnal biPAP and right sided pleural effusion
presenting [**Location (un) 54358**]with shortness of breath and
hypoxia. The patient is a poor historian but reports recently
being in the hospital and being transferred [**Location (un) 54359**]to live approximately 2-3 days ago. Although he has requires
daytime oxygen at baseline, he reports not being given O2 while
[**Location (un) 54360**]. He felt short of breath earlier on the day
of admission so he called EMS. Per report, when EMS arrived, his
sat was in the 60s so he was placed on supplemental O2 and
transferred to the [**Hospital1 18**] ED.
.
In the ED, initial vs were: 99.1 74 152/92 20 98% 4L NC --> 80s
on 6L NC. Exam was notable for an uncomfortable male, expiratory
wheezing with bilateral decrease in basilar breath sounds. Labs
revealed Hct 29.5, K 4.9, creatinine 11.3, lactate 1.2, ABG
7.32/57/74 on 8L NC CoOx 6%. Blood cultures were drawn. Patient
was given vanc, cefepime, levofloxacin, methylpred 125mg IV and
nebs *3. CXR showed right pleural effusion. VS prior to transfer
were: 71 144/69 14 95% on 8L.
.
Upon arrival to the ICU, the patient is very agitated and
combative. He is not interested in providing further history. He
reports wanting to die.
Past Medical History:
CHF (further history unknown)
COPD on home O2
ESRD on HD M/W/F
OSA on nocturnal biPap
Paranoid psychotic disorder
Substance abuse
Social History:
- Tobacco: Ongoing
- etOH: Admits to drinking, unclear how much or how recently
- [**Name (NI) 3264**]: Endorses active use
- Lives at [**Location **] House [**Telephone/Fax (1) 54361**]
Family History:
Mother - cancer, type unknown. Father was on dialysis.
Physical Exam:
Vitals: 98.1 156/67 19 94% on 40% high flow
General: Alert, oriented, agitated, yelling; poor hygeine
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: diminished BS throughout, scattered crackles
CV: Regular rate and rhythm
Abdomen: obese
GU: no foley (reportedly anuric)
Ext: warm, no edema
Pertinent Results:
Admission Labs:
[**2148-3-9**] 10:40AM BLOOD WBC-4.6 RBC-3.03* Hgb-10.0* Hct-29.5*
MCV-97 MCH-32.9* MCHC-33.8 RDW-20.3* Plt Ct-154
[**2148-3-9**] 10:40AM BLOOD Neuts-69.4 Lymphs-20.5 Monos-8.5 Eos-1.2
Baso-0.3
[**2148-3-9**] 10:40AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Stipple-OCCASIONAL
[**2148-3-9**] 10:40AM BLOOD PT-13.7* PTT-26.0 INR(PT)-1.2*
[**2148-3-9**] 10:40AM BLOOD Glucose-78 UreaN-64* Creat-11.3* Na-144
K-4.9 Cl-101 HCO3-28 AnGap-20
[**2148-3-9**] 10:40AM BLOOD ALT-19 AST-28 LD(LDH)-254* CK(CPK)-59
AlkPhos-268* TotBili-0.3
[**2148-3-9**] 10:40AM BLOOD Lipase-44
[**2148-3-9**] 10:40AM BLOOD proBNP-[**Numeric Identifier 54362**]*
[**2148-3-9**] 10:40AM BLOOD cTropnT-0.06*
[**2148-3-10**] 12:40AM BLOOD CK-MB-3 cTropnT-0.04*
[**2148-3-10**] 05:43AM BLOOD CK-MB-3 cTropnT-0.03* proBNP-[**Numeric Identifier **]*
[**2148-3-9**] 10:40AM BLOOD Calcium-8.8 Phos-4.4# Mg-2.4
[**2148-3-9**] 10:40AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2148-3-9**] 11:52AM BLOOD pO2-74* pCO2-57* pH-7.32* calTCO2-31*
Base XS-0
[**2148-3-10**] 11:23AM BLOOD Type-ART Temp-36.1 pO2-62* pCO2-64*
pH-7.26* calTCO2-30 Base XS-0 Intubat-NOT INTUBA
[**2148-3-9**] 11:06AM BLOOD Lactate-1.2
.
PCXR:
1. Opacification of the right lower lung presumably combination
of moderate
right pleural effusion and RLL atelectasis; however, cannot
exclude pneumonia.
2. Improved aeration of the left lung base with residual
atelectasis.
3. Persistent prominent hila, as seen on CT could be reactive
lymphadenopathy.
4. Mild edema..
.
ECHO:
Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Right ventricular hypertrophy with mild cavity
enlargement with free wall hypokinesis. Moderate pulmonary
artery systolic hypertension. Mild symmetric left ventricular
hypertrophy with preserved global and regional left ventricular
systolic function.
This constellation of findings is suggestive of a chronic or
acute on chronic primary pulmonary process (e.g., primary
pulmonary hypertension, pulmlonary embolism, bronchospasm, sleep
apnea, etc.).
.
Brief Hospital Course:
45M with what appears to be paranoid schizophrenia, ESRD on HD,
COPD on 3L NC O2 at home, OSA on CPAP, and substance abuse who
was admitted to the ICU for hypoxic respiratory distress from
volume overload and due to lack of access to his home oxygen per
the patient.
.
In the MICU, empiric antibiotics and steroids were started.
However, his hypoxia was much improved after a single session of
HD. His behavioral issues were an impediment to optimal medical
care, and due to threatening behavior and suicidal expressions
he was placed on a 1:1 security sitter and made Section 12.
.
# Hypoxia: Given rapidity of response to HD, it seem likely that
he was volume overloaded. Given this, antibiotics and steroids
were stopped. Continued HD Q MWF for volume control. Received
standing Albuterol 0.083% Neb Soln 1 NEB IH Q6H and Ipratropium
Bromide Neb 1 NEB IH Q6H. His oxygen requirement decreased back
to baseline over the course of his hospitalization to his
baseline requirement of 3L NC O2. The patient has a pleural
effusion that is of unclear etiology. Pulmonary recommended
repeat thoracentesis and/or consideration of a thoracotomy was
suggested for further work up but the patient adamently refused.
One barrier for the patient is that he reports that he was not
allowed to use his portable oxygen outside of his room at his
group home. We explained to the patient that there was a danger
to have oxygen around when he was smoking and he understands the
risks of combustion. However, he does need to wear his oxygen
at all other times. He reported having a functional CPAP
machine at home to use for his OSA.
-outpatient pulmonary or interventional pulmonary follow up for
further evaluation of his pleural effusion is suggested if the
patient is agreeable in the future patient is agreeable
.
# Psychotic disorder: After being aggitated in the MICU, the
patient remained non-aggressive on the floor (though he had
paranoia, did raise his voice and did try to leave the floor to
smoke on multiple occasions). We believe his increased
aggression was likelely due to hypoxia and hypercarbia. Has
paranoid features, which were felt consistent with schizophrenic
v schizoaffective v bipolar disorder. Psych and SW consulted on
the patient this admission. After talking to outpatient
providers, and doing an evaluation, psychiatry felt the patient
was at his baseline and section 12 was removed. He was
continued Divalproex (DELayed Release) 375 mg PO BID for mood
stablization.
.
# COPD: Active smoker. Baseline oxygen requirement is 3L NC O2.
Received standing nebs as above and supplemental oxygen.
Encouraged smoking cessation.
-Started Albuterol Inhaler
- [**Month (only) 116**] benefit from a long acting anticholinergic such as
tiotropium and an inhaled steroid such as fluticasone given his
smoking history and hypoxia. Outpatient pulmonary follow up
recommended as above.
.
# OSA: Patient required CPAP at night with settings 20/10. At
first patient [**Month (only) 15797**] that he had a CPAP machine at home, however
his group home confirmed that he did and the patient later
agreed that he did. It is very important that the patient
continued to wear CPAP at night or while taking naps.
.
# ESRD on HD: HD Q MWF. Continued home Calcium Acetate 1334 mg
PO/NG TID W/MEALS.
.
# Pulmonary Hypertension: Patient had an ECHO suggestive of
pulmonary hypertension most likely [**1-10**] to COPD and OSA with
normal EF of 55%. Patient was continued on his home Aspirin 81
mg PO/NG DAILY, home ACEi and Bblocker. Consider starting a
statin as an outpatient. Pulm follow up recommended as above.
.
# HTN: Patient was continued on home Amlodipine 10 mg PO/NG
DAILY, Lisinopril 40 mg PO/NG, DAILY and was treated with
Metoprolol Tartrate 37.5 mg PO/NG TID. On discharge his
Metoprolol was switched back to home Toprol XL 100mg po daily.
Medications on Admission:
(per recent DC summary)
- Aspirin 81 mg PO daily
- Calcium acetate 1334 mg PO TID w meals
- Hydroxyzine 25 mg PO Q6H
- Divalproex 375 mg PO BID
- Acetaminophen 650 mg PO Q6H
- Metoprolol succinate 100 mg PO daily
- Amlodipine 10 mg PO daily
- Lisinopril 40 mg PO daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*1 unit* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- COPD
- ESRD
- Psychosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with dangerously low oxygen
levels. This was due to a combination of lung disease from
smoking, missing your oxygen, and fluid retention. Smoking is
extremely unhealthy. If you do not use your oxygen you will
also have inadequate oxygen levels.
.
We offered you a further work up for the fluid in your lung but
you refused further management. We counselled you about
stopping smoking, but you refused nicotine patches and lozenges.
.
Please continue to take your medications as directed.
You require oxygen 3L continuous flow to maintain your
oxygenation. However, it is VERY dangerous for you to smoke and
have the oxygen tank near you as it could explode.
.
Please follow up with your primary care doctor. They will call
you with an appointment.
.
We made the following changes to your medications:
STARTED Albuterol inhaler. You can use this up to every 4 hours
as needed for shortness of breath or wheezing.
Followup Instructions:
We are working on a follow up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 45392**] within 1-3 days. The office will
contact you at home with an appointment. If you havent heard
please call the office at [**Telephone/Fax (1) 54363**].
|
[
"285.29",
"491.21",
"518.84",
"327.23",
"428.42",
"285.9",
"585.6",
"403.91",
"799.02",
"305.1",
"305.60",
"295.30",
"428.0",
"V62.0",
"V62.84",
"511.9",
"416.8",
"303.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10272, 10278
|
5344, 9198
|
310, 317
|
10357, 10357
|
2442, 2442
|
11485, 11799
|
2022, 2079
|
9519, 10249
|
10299, 10336
|
9225, 9496
|
10510, 11320
|
2094, 2423
|
11349, 11462
|
263, 272
|
345, 1649
|
2458, 5321
|
10372, 10486
|
1671, 1802
|
1818, 2006
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,734
| 148,224
|
19366
|
Discharge summary
|
report
|
Admission Date: [**2116-1-3**] Discharge Date: [**2116-1-14**]
Date of Birth: [**2067-10-16**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Right thigh redness and pus under cast.
Major Surgical or Invasive Procedure:
Open reduction internal fixation right tibial plateau fracture
with tibial rod placement on [**1-7**]
History of Present Illness:
Mr. [**Known lastname 4223**] is a 48 year-old male with long-standing IDDM,
Addison's disease, hypothyroidism, HTN, CAD, and a history of
right medial tibial plateau fracture in [**7-/2115**] treated
conservatively and recently diagnosed right proximal
metadiaphysis fracture of the right tibia treated with a full
leg cast and NWB ([**2115-12-24**]), now presenting from home after his
VNA nurse noticed some pus coming from under the cast with
erythema of the toes. His severe neuropathy precludes him from
having pain. He denies fever, chills, nausea, vomiting, or
abdominal pain.
In the ED, he was seen by Ortho who removed his cast, and he was
placed in a splint with no weight bearing precautions.
Past Medical History:
1. IDDM diagnosed at age 29 with triopathy and Charcot joints
2. ESRD on HD Tues/Thurs/Sat, awaiting transplant from sister
3. CAD s/p NSTEMI in [**6-/2114**], recent MIBI without perfusion
defects. Preserved EF per echo [**6-/2115**], LVH.
4. Poorly controlled hypertension
5. Hypercholesterolemia
6. Hypothyroidism
7. Addison??????s disease diagnosed at age 29
8. Anemia of chronic disease
9. Chronic LE edema
10. s/p recent medial tibial plateau/proximal fibula fracture in
[**7-/2115**] treated conservatively
11. s/p recently diagnosed right tibial proximal metadiaphysis
fracture treated with a full leg cast and NWB ([**2115-12-24**])
12. History of C. difficile colitis
Social History:
No tob, EtOH, illicits, from [**Location (un) 3146**], living at home. He was a
former clerk/supervisor but is currently on disability. Has
familiy that lives nearby.
Family History:
Father died age 50 due to cancer
Mother died age 60 due to breast cancer
4 brothers, 3 sisters: 2 siblings w/ DM
Physical Exam:
Physical Exam:
VS: T: 98.1; BP: 138/72; P: 72; RR: 18; O2: 97 RA
Gen: sleeping on stretcher; easily arousable; NAD;
HEENT: PERRLA; EOMI; sclera anicteric; OP clear
Neck: No LAD. supple
CV: RRR S1S2. No M/R/G
Lungs: CTA b/l
Abd: +BS. soft, NT, ND.
Ext: RLE in recently placed cast up to mid-thigh and toes
exposed; in posterolateral R thigh, an oval area of erythema
measuring 3cm by 6cm, with central ulceration; no skin
compromise; erythematous 2nd and 3rd toes; L ankle swollen,
warm;
Neuro: AOx3, normal mental status; CN II-XII intact
Pertinent Results:
Relevant laboratory data on admission:
WBC-11.2* RBC-3.38* HGB-11.1* HCT-33.0* MCV-98 MCH-RDW-14.9
NEUTS-82.8* LYMPHS-9.6* MONOS-2.6 EOS-4.8* BASOS-0.2
PLT COUNT-534*#
GLUCOSE-570* UREA N-30* CREAT-4.4* SODIUM-128* POTASSIUM-4.7
CHLORIDE-87* TOTAL CO2-25 ANION GAP-21
LACTATE-0.9
[**2116-1-3**] Knee X-ray: There is a depressed healed fracture
involving the medial right tibial plateau. unchanged from the
prior study. There is a more recent partially healed transverse
fracture involving the proximal diaphysis of the right tibia
with increased anterior angulation compared from the prior
study.
Brief Hospital Course:
48 year-old man with long-standing complicated IDDM, Addison's
disease, hypothyroidism, poorly controlled HTN, CAD, and recent
tibial fracture treated with a full leg cast, admitted with RLE
cellulitis and displaced tibial fracture. His hospital course
will be reviewed by problems.
1) RLE cellulitis: As noted above, his physical examination on
admission was remarkable for a cellulitic area on his
posterolateral right thigh. His full leg cast was removed, and
his RLE was placed in a splint. He was afebrile on admission,
with normal WBC. Vancomycin was started in the ED, dosed by
level in the hospital (1gm IV for level <15). Blood cultures
sent prior to the initiation of antibiotics returned negative.
He remained afebrile throughout his hospital stay, and will
complete a 14-day course of Vancomycin. He will receive his
doses at hemodialysis q 48 hours, with last dose on [**2116-1-16**]
(last dose given in hospital on [**1-13**]).
2) Right tibial fracture: A right knee X-ray obtained on the day
of admission revealed increased anterior angulation of his
partially healed transverse fracture involving the proximal
diaphysis of the right tibia. Given the displaced fracture, he
was taken to the OR on [**1-7**] for ORIF and tibial rod placement,
without immediate complications. Post-operatively, he was
started on Coumadin for DVT prophylaxis (not a candidate for
Lovenox given ESRD) with a goal INR 2.0, to be continued for 4
weeks (until [**2116-2-4**]). Of note, his Coumadin was transiently
held in hospital given a supratherapeutic INR. Please follow INR
daily until therapeutic and stable, adjust the dose of Coumadin
accordingly. Goal INR 2.0. (First dose of Coumadin given on
[**2116-1-9**]). He will also need arrangements for follow-up of his
INR as an out-patient.
He needs to remain non-weight bearing on his RLE for 6 weeks. Of
note, he will need close monitoring of his leg given severe
neuropathy and limited sensation.
3) IDDM: Complicated IDDM, followed at [**Last Name (un) **] as an out-patient.
He was followed by the [**Last Name (un) **] service while in hospital.
Peri-operatively, he was placed on stress dose steroids given
his history of Addison's disease. While on high dose steroids,
he was transferred to the MICU for critically elevated sugars
(U/A negative for ketones, normal gap) requiring insulin drip
([**Date range (1) 52680**]). Lantus was titrated down to 18 units QHS as
steroids were weaned, and he was switched back to a Humalog
sliding scale on [**1-8**], with fair glycemic control. Of note, his
current Hydrocortisone regimen with varying daily doses likey
further exacerbates his glycemic control. He has a scheduled
follow-up appointment with [**Last Name (un) **] as noted in the discharge
plan.
4. ESRD on HD: He was followed by Renal while in hospital, with
HD as needed (required additional sessions for fluid removal).
He is now back to his usual schedule Tu/Th/Sat. PTH 112. On
Nephrocaps.
5. Hypertension: Poorly controlled BP. His medication regimen
was modified in the hospital, with Labetalol increased to 600 mg
PO TID. He was continued on Clonidine 0.2 mg PO TID, Hydralazine
75 mg PO QID. Diltiazem was discontinued, and he was placed on
Nifedipine CR 60 mg PO QD for a short period of time. On [**1-10**],
his blood pressure dropped to 100 systolic, with symptoms of
weakness. Nifedipine was discontinued, blood cultures were sent,
and he was given an extra dose of Hydrocortisone 5 mg PO to
cover for possible adrenal insufficiency. His blood pressure
normalized, and he was restarted on Diltiazem, titrated up to
120 mg PO QID.
Of note, volume overload has been a major contributor to his HTN
in the past. He is non-compliant with dietary restrictions at
home, and will need emphasis on dietary and medication
compliance.
6. Hypothyroidism: He was continued on his out-patient dose of
Synthroid 50 mcg PO QD. Last TSH 2.0 on [**2115-12-22**].
7. Addison??????s disease: Pre-admission, it looks as though he was
on Hydrocortisone 20 mg PO QAM, plus either 5 mg, 10mg or 15 mg
in PM depending on the day of the week. However, his morning
dose of hydrocortisone was not reordered on admission (?
omission), and he was maintained on 5 or 10 or 15 mg daily in
alternating doses in the hospital (see medications below), with
stable labs and blood pressure. As noted above, he was placed on
stress dose steroids peri-operatively with HC 50 mg IV q8 hours
X 2 doses, followed by HC 25 mg IV X 1 dose, followed by HC 20
mg PO, then back to his pre-op regimen. The patient's primary
endocrinologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) was [**Name (NI) 653**], and
records from his multiple recent admissions were reviewed to
clarify the rationale behind his hydrocortisone regimen, without
a clear explanation found. ? Related to dialysis. These varying
doses likely further complicate his glycemic control. However,
given his stability in hospital, decision was made to continue
this regimen at the time of discharge. He was continued on
Fludrocortisone throughout. He is scheduled to see Dr. [**Last Name (STitle) **]
at the [**Last Name (un) **], at which time these issues can be readdressed.
8. Code: Full code.
Medications on Admission:
Levothyroxine 50 mcg qday
Fludrocortisone 0.05 mg q12 hour
Hydrocortisone 10 mg qwed, sat
Hydrocortisone 5 mg qMon, Thurs, Sun
Hydrocortisone 15 mg qTues, Fri
Protonix 40 mg qday
Renagel 800 mg tid
Fosrenal 500 mg tid with meals
Vitamin B 1 po qday
ASA 325 mg po qday
Neurontin 300 mg tid
Folic acid 1 mg qday
Diltiazem 120 mg po QID
Hydralazine 50 mg q6 hour
Clonidine 0.2 mg tid
Labetalol 400 mg tid
Metoclopramide 5 mg QID
Lantus 20 units sc qhs
HISS starting at 150 by 2 units
Doxercalciferol 2.5 mg qo
Discharge Medications:
1. Vancomycin in Dextrose 1 g/250 mL Solution Sig: One (1) gm
Intravenous Q hemodialysis as needed: Last dose on [**2116-1-16**].
2. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO four times
a day: Hold for SBP<110.
3. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
4. Humalog sliding scale as directed
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fludrocortisone 0.1 mg Tablet Sig: 0.5 Tablet PO Q 12H (Every
12 Hours).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: with meals.
10. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO 5X/DAY ():
Patient may refuse night dose.
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
18. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours): Hold for SBP<110.
19. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Hold for SBP<110.
20. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day): Hold for SBP<110.
21. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK:
Monday, Thursday, Saturday.
22. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO 2X/WEEK:
Wednesday and Sunday.
23. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO 2X/WEEK:
Tuesday, Friday.
24. Coumadin 1 mg Tablet Sig: ASDIR Tablet PO ASDIR: Check daily
INR, restart Coumadin when INR<2.5, goal INR 2.0. Adjust dose of
Coumadin accordingly. Until [**2116-2-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right lower extremity cellulitis
Displaced right tibial plateau fracture status post open
reduction internal fixation on [**2116-1-7**]
Poorly controlled hypertension
Poorly controlled insulin-dependent diabetes mellitus
Addison's disease
Hypothyroidism
Peripheral neuropathy
Discharge Condition:
Patient discharged to a rehab facility in stable condition.
Discharge Instructions:
Please note that we have made some changes to your medications.
Please take all medications as prescribed.
You will continue to receive Vancomycin at dialysis until
[**2116-1-16**].
You also need to remain on Coumadin for the prevention of clot
until [**2116-2-4**].
You have scheduled follow-up appointments with Drs. [**Last Name (STitle) **] and
[**Name5 (PTitle) 1005**]. Please see below for dates and times.
Followup Instructions:
1. You have a scheduled appointment with Dr. [**Last Name (STitle) 1005**] on [**1-28**]. You will need to have a CXR prior to this appointment.
- Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2116-1-28**] 8:40
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2116-1-28**] 9:00
2. You also have a scheduled appointment with Dr. [**Last Name (STitle) **] at
the [**Last Name (un) **] on Thursday [**2116-1-16**] at 11:30. It is important
that you go to this appointment.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2116-1-14**]
|
[
"707.09",
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] |
icd9cm
|
[
[
[]
]
] |
[
"97.14",
"97.88",
"79.36",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11379, 11458
|
3363, 8591
|
310, 413
|
11777, 11839
|
2740, 2765
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12304, 13039
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2050, 2165
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11863, 12281
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2195, 2721
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231, 272
|
441, 1148
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2779, 3340
|
1170, 1849
|
1865, 2034
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,828
| 193,425
|
52982
|
Discharge summary
|
report
|
Admission Date: [**2128-6-12**] Discharge Date: [**2128-6-25**]
Date of Birth: [**2056-12-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Estolate / Xylocaine / Adhesive Tape
Attending:[**First Name3 (LF) 16983**]
Chief Complaint:
CC: hip pain
Major Surgical or Invasive Procedure:
Gamma Nailing of Left Femur under GA on [**2128-6-16**]
History of Present Illness:
71 year old woman with metastatic breast cancer to brain, spine,
pelvis and femurs, recent NSTEMI, HTN, presents with L hip pain.
She developed acute onset of severe left hip pain [**8-30**] the night
prior to admission. She suffers chronic bone pain from bone
metastases but this was significantly worse. She was unable to
weight bear without significant pain. She had no history of
trauma or falls.
Patient taken to OR on [**2128-6-16**] for L ORIF. Intra-op course was
complicated by 750 cc blood loss and hypotension requiring 1L
NS, 2 units of PRBCs. Patient received 2 more units of PRBCs
upon arrival to the floor. Her Hct never responded
appropriately and on [**6-18**] it dropped from 29 to 23 with
increasing tension on her L thigh. Patient subsequently
hypotensive with SBP in the 80s despite receiving 2L IVFs. She
was transfused another 1 u PRBCs and 1 L NS and her SBP
recovered to 120s. She was taken back to OR for I& D and had
200 cc drained. Upon return from OR her SBP remained stable in
110s. Patient also had her lovenox restarted.
.
Past Medical History:
PMH:
1. Onc history: Left breast cancer diagnosed in [**2124-6-20**] with
three positive nodes and underwent lumpectomy followed by
Cytoxan and Adriamycin. In [**2126-3-22**] she was diagnosed with a
vetebral metastatic lesion and at the same time was also
diagnosed with colorectal cancer for which she underwent
excision. Has also been on gemtricitabine. Right pathologic
proximal femur fracture s/p ORIF [**2128-4-8**], s/p XRT
2. Goiter with hypothyroidism
3. Hypertension
4. Anxiety disorder
5. Lymphedema left arm
6. Rectal cancer
7. Admission to [**Hospital Unit Name 153**] [**5-27**] for hyertensive emergency after
presented with dyspnea, course complicated by NSTEMI
8. S/P L hip ORIF on [**6-16**] complicated by hypotension and
hemorrhage on lovenox requiring 4 units of PRBCs in 24 hours.
.
Social History:
SH: The patient lives alone in [**Location (un) **] with a caregiver during
day. She has 2 grown daughters. She reports prior tobacco and
EtOH, but none currently.
Family History:
FH:
Fa died at 73 of CAD
Mo died at 97
Physical Exam:
sentences
HEENT - anicteric, MMM
Neck - JVD @ 8 cm, no cervical lymphadenopathy
Chest - no crackles at bases appreciated
CV - Normal S1/S2, RRR, [**1-27**] HSM at apex
Abd - + BS, SNT/ND, no hsm appreciated
Extr -
Neuro - Alert and oriented x 3 no focal deficits appreciated
Skin - No rashes
.
Pertinent Results:
[**2128-6-13**]. MRI of left hip.
1. Limited examination for detection of subtle fracturs due to
diffuse
extensive metastatic disease. Given this limitation, there is no
evidence for acute femoral neck fracture.
2. Subacute fracture through the left greater trochanter and
left iliac
crest, better evaluated on the CT of [**2128-6-12**].
3. The right hip is status post gamma nail and intramedullary
rod placement. Surrounding right hip joint fluid is most likely
postoperative in nature.
4. Extensive subcutaneous edema.
5. Fibroid uterus.
.
[**2128-6-22**]. CT head.
No acute abnormality is detected including no hemorrhage or
hydrocephalus or herniation. There has been interval decrease in
the size of midline shift.
Multiple metastatic foci within the both occipital lobes and
both frontal
lobes appear unchanged.
Multiple bony lytic lesions within the left frontal bone, right
temporal bone and right side of C1 appear unchanged.
.
[**2128-6-23**]. CXR.
There is a left retrocardiac opacity and underlying infiltrate
cannot be
excluded in this location. The cardiac silhouette is mildly
prominent. The patient has a right-sided Port-A-Cath. There is
no signs for overt pulmonary edema. There is increased density
to the bony structures, (particularly the ribs and the proximal
right humerus) consistent with known blastic metastases.
.
Brief Hospital Course:
In summary, Ms. [**Known lastname 1007**] is a 71 Year old female with metastatic
breast cancer to the brain, spine, pelvis and femur admitted
with left hip pain. Sheound to have an impending pathologic
fracture and went to the OR on [**6-16**]. Surgery was complicated by
hypotension requiring pressors and dropping hematocrit. She was
felt to be bleeding into hip so she was taken back to the OR on
[**6-17**] to cauterize small arterial bleed in mid-thigh. She
developed delerium during the hospital stay thought to be due to
polypharmacy (opioids, klonipin, steroids) and possible
pneumonia.
.
1. Impending hip fracture, s/p ORIF. Ms. [**Known lastname **] has extensive
bony metastases to left femur. Left hip MRI showed an avulsion
fracture of the greater trochanter and an iliac [**Doctor First Name 362**] fracture,
both of which were subacute. Patient went the OR on [**6-16**] with
Dr. [**First Name (STitle) 4223**] to stabilize femur. Following surgery, she was
hypotensive requiring pressors, had decreased urine output,
falling hematocrit and increased tension in her left hip. She
was thought to be bleeding at surgical site in her left hip so
was taken back to the OR on [**6-17**] for caterization of small
arterial bleed. She was hemodynamically stable for the rest of
the hospital stay.
.
Pt. was also seen by radiation oncology. She was scheduled to
get simulation on [**6-25**] and will begin XRT the following week.
.
2. Delerium. Patient became delerious on [**6-16**]. Delerium was
thought to be due to benzos, opioids, and anxiety of surgery. He
mental status continued to wax and wane.
.
On [**6-26**], she became even more severely delerious. She was no
longer oriented to herself, she would perseverate on topics, she
was unable to name basic objects or follow commands. Otherwise
exam is nonfocal and unchanged from the past. Delerium is
likely multifactorial. Delerium may be due to use Klonapin,
high doses of opioids, and steroids (for WBRT)in a patient with
brain metastases. Furthermore, the patient developed a rising
[**Known lastname **] count and CXR could not rule out a retrocardiac opacity,
suggesting that PNA could be contributing to delerium. UA was
negative. Patient also has hyponatremia due to SIADH. A head
CT did not show an acute cause of mental status changes.
Delerium resolved after stopping Klonapin and beginning
antibiotics for pneumonia.
.
3. Pain. Pt.'s pain was controlled with Oxycontin and
oxycodone PRNs.
.
4. Hypothyroidism. Pt has known hypothyroidism, however a TSH
was rechecked and found to be elevated (11), with low T4.
Synthroid was increased to 50mg qday.
.
5. Left foot weakness/numbness. Patient reports left foot
numbness and has [**2-23**] strengh on dorsiflexion and plantarflexion
of left foot that is unchanged from previous Rad Onc note. MRI
of the lumbar spine confirmed there was no change from previous
MRI of the spine and showed NO cord compression.
.
6. HTN. Patient is on metoprolol and lisinopril for
hypertension. Hypertension was well controlled with the
exception of hypotension following surgery.
.
7. Breast cancer. Ms. [**Known lastname 1007**] has metastatic breast cancer with
metastases to the brain and bones. She recently underwent WBRT
and continued dexamethasone taper throughout hospital stay.
Patient got a dose of Velban on [**2128-6-15**]. It is not clear if she
will continue to get treatment with Velban, but the original
plan was to get weekly Velban.
.
8. CAD. Ms. [**Known lastname **] had recent NSTEMI (one month ago). Her
cardiac enzymes were mildly elevated following surgery and her
post-op EKG showed ST depressions in the setting of hypotension.
Small troponin leak is likely due to demand ischemia.
.
9. Anasarca. Patient became edematous following surgery because
she was given a significant amount of fluids to keep her blood
pressure and urine output stable. Diuresis began on [**6-22**] with
lasix. Patient responded very well to lasix.
.
10. A.Fib. Patient developed Atrial fibrillation with rapid
ventricular response on [**2128-6-23**]. She was rate controlled with
metoprolol. She will not be fully anticoagulated at present
because of recent hip surgery, but is getting prophylactic
lovenox and baby aspirin. At a future date, her primary care
physician should evaluate as to whether or not she should be
anticoagulated.
.
10. Anxiety. Due to delerium, ativan dose was lowered.
.
11. PPx. Continue Lovenox.
.
12. Communication: [**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/ HCP [**Telephone/Fax (1) 109222**]
(work), [**Telephone/Fax (1) 109224**] (cell).
.
13. FULL CODE
.
Medications on Admission:
Medications at home:
1. Bisacodyl 5 mg Tablet PO DAILY as needed for constipation.
2. Oxycodone 40 mg Tablet Sustained Release 12 Q8H
3. Oxycodone 5 mg Tablet PO Q3H (every 3 hours) as needed for
pain.
4. Docusate Sodium 100 mg PO BID as needed for constipation.
5. Senna 8.6 mg Tablet PO BID as needed for constipation.
6. Lorazepam 0.5 mg [**12-23**] PO Q6H as needed for anxiety or
insomnia.
7. Ibuprofen 600 mg Tablet PO Q8H as needed for pain.
8. Sertraline 50 mg PO DAILY
9. Metoprolol Succinate 25 mg PO DAILY
10. Omeprazole 20 mg PO once a day.
11. Levothyroxine 25 mcg PO DAILY
12. Aspirin 325 mg PO DAILY
13. Calcium Carbonate 500 mg QID as needed for heartburn.
14. Lisinopril 5 mg 0.5 Tablet PO DAILY
15. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): through [**6-9**], then 1 tab 3 times per day through [**6-16**],
then 1 tab 2 times per day through [**6-24**] then per Dr. [**Last Name (STitle) 724**].
Disp:*100 Tablet(s)* Refills:*0*
16. Albuterol-Ipratropium 6 hours as needed for shortness of
breath or wheezing.
17. Lidoderm 5 %(700 mg/patch) Adhesive Patch 12hours. Wait 12
hours before placing the next patch.
.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heart
burn.
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-23**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Place
for 12 hours and then wait 12 hours before placing a new patch.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain,, fever.
11. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Seven
(7) Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: Please take last dose on [**7-2**].
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous Q 24H (Every 24 Hours).
18. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
19. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Pathologic fracture of neck of left femur
Metastatic breast cancer
.
Secondary diagnosis:
hypothyroidism
hypertension
anxiety
rectal cancer
Discharge Condition:
fair. not ambulating.
Discharge Instructions:
You were admitted to the hospital for repair of left hip
fracture. Please keep incision clean and dry. You can leave it
open to the air once it stops oozing and is dry. Please pat dry
the inscision after showering.
.
Your dose of Synthroid for your hypothyroidism was increased to
50 mcg daily. Please continue to take this medication at this
increased dose. Please have your doctor check your thyroid
function blood tests in three weeks.
.
You were started on Lovenox to prevent blood clots (deep vein
thrombosis). Please continue to take this medication every day.
.
You were started on an antibiotic, Levofloxacin, for pneumonia.
Please continue to take this for 7 more days. Your last dose
will be due on [**7-2**].
.
Your dose of dexamethasone was lowered to 4 mg two times a day.
Please continue at this dose. Please discuss with Dr. [**Last Name (STitle) **]
about when your steroid dose should be reduced.
Followup Instructions:
Please call Dr. [**First Name (STitle) 4223**] to set up an appointment for the week
of [**7-5**]. Ph. [**Telephone/Fax (1) 1228**].
.
Please see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3260**], NP on [**2128-7-2**] at 9:30 AM.
Phone:[**Telephone/Fax (1) 22**].
.
Please see Dr. [**Last Name (STitle) **] on [**2128-9-23**] at 11 AM.
Phone:[**Telephone/Fax (1) 127**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**]
|
[
"253.6",
"V10.05",
"486",
"410.72",
"998.11",
"244.9",
"V10.3",
"198.5",
"733.14",
"E878.8",
"424.0",
"427.31",
"198.3",
"401.9",
"292.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.98",
"79.35",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12158, 12228
|
4268, 8970
|
338, 396
|
12431, 12456
|
2890, 4245
|
13427, 13952
|
2520, 2560
|
10182, 12135
|
12249, 12249
|
8996, 8996
|
12480, 13404
|
9017, 10159
|
2575, 2871
|
286, 300
|
424, 1494
|
12358, 12410
|
12268, 12337
|
1516, 2322
|
2338, 2504
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,649
| 121,732
|
11366
|
Discharge summary
|
report
|
Admission Date: [**2141-8-14**] Discharge Date: [**2141-8-18**]
Date of Birth: [**2084-9-16**] Sex: M
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
bronchoscopy x3
Y stent placement
History of Present Illness:
56 yo M h/o renal cell carcinoma with mets to lung initially
presenting today for rigid bronch/eval of prior Y-stent
placement, transferred to MICU for respiratory distress. Pt has
had multiple rigid bronchs since [**5-13**] with local tumor
ablation/excision. Most recently pt had bronch in [**7-13**] with
Y-stent placement. Pt has been doing well since that time. 2
days PTA pt was becoming increasingly dyspneic, significantly
worsening one day PTA. Wife [**Name (NI) 653**] hospital. Pt scheduled to
come in today for elective bronch/further evaluation of tumor.
.
On bronch pt was noted to have a 100% occluded RMS and patent
stent on the left. During the procedure, pt appeared agitated/
uncomfortable, and was given atomized lidocaine as well as
propofol and sats dropped to 80s. Code was called. Pt electively
intubated with bronch. L mainstem demonstrated increased
secretions. On suctioning, sats recovered. Transferred to MICU
for further management.
Past Medical History:
metastatic RCC (onc hx below)
MI
hyperlipidemia
GERD
anxiety
.
Onc hx:
1. Radical nephrectomy on [**2132-9-24**].
2. Resection of local recurrence in the renal bed in 08/[**2135**].
3. High-dose interleukin-2 for mediastinal lymphadenopathy.
4. Pfizer AG-[**Numeric Identifier 36405**] trial begun on 02/[**2138**]. He was taken off
study in [**5-/2140**] because of an MI.
5. Started on sorafenib in [**6-/2140**], discontinued in [**11/2140**]
because of abdominal side effects.
6. CyberKnife to an enlarging right adrenal mass in 10/[**2140**].
7. Sutent
Social History:
lives with wife, distant history of tob
Family History:
non-contributory
Physical Exam:
Temp 101
BP 111/63
Pulse 121
Resp 20
O2 sat 98% on vent
AC 400X 14 fi02 1 peep 5
Gen - intubated, sedated
HEENT - PERRL, anicteric, mucous membranes moist
Neck - no JVD
Chest - diminished breath sounds on R
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - sedated
Skin - No rash
Pertinent Results:
[**2141-8-14**] 05:28PM TYPE-ART PO2-56* PCO2-47* PH-7.39 TOTAL
CO2-30 BASE XS-2
[**2141-8-14**] 05:28PM LACTATE-1.1
[**2141-8-14**] 04:32PM GLUCOSE-111* UREA N-17 CREAT-0.9 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-27 ANION GAP-14
[**2141-8-14**] 04:32PM CK(CPK)-36*
[**2141-8-14**] 04:32PM CK-MB-NotDone cTropnT-0.02*
[**2141-8-14**] 04:32PM WBC-14.4* RBC-3.35* HGB-10.1* HCT-30.7*
MCV-92 MCH-30.0 MCHC-32.7 RDW-16.3*
[**2141-8-14**] 04:32PM NEUTS-85.6* LYMPHS-6.1* MONOS-6.6 EOS-1.1
BASOS-0.5
[**2141-8-14**] 04:32PM PLT COUNT-392
[**2141-8-14**] 03:30PM TYPE-ART PO2-63* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-0
[**2141-8-14**] 03:30PM LACTATE-1.7
[**2141-8-14**] 12:28PM GLUCOSE-113* UREA N-15 CREAT-0.8 SODIUM-134
POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-28 ANION GAP-16
[**2141-8-14**] 12:28PM estGFR-Using this
[**2141-8-14**] 12:28PM CK(CPK)-14*
[**2141-8-14**] 12:28PM CK-MB-NotDone cTropnT-<0.01
[**2141-8-14**] 12:28PM CALCIUM-9.7 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2141-8-14**] 12:28PM WBC-12.2* RBC-3.73* HGB-11.0* HCT-34.0*
MCV-91 MCH-29.5 MCHC-32.4 RDW-16.3*
[**2141-8-14**] 12:28PM PLT COUNT-441*#
[**2141-8-14**] 12:28PM PT-13.2* PTT-38.6* INR(PT)-1.2*
.
EKG [**8-14**]: Sinus tachycardia. Compared to tracing on [**2141-6-28**] the
tachycardia is new and the T wave is now flat in lead III and
upright in lead aVF.
Brief Hospital Course:
A/P: 56 yo M h/o RCC with mets to lung initially presented with
SOB and respiratory decompensation, now s/p Y-stent replacement
of the carina for occluded RMS bronchus.
.
# Respiratory distress: Initial presentation likley [**3-10**] mets
causing collapse of bronchus, and complicated by mucous plug and
possibly aspiration. Pt is now s/p extubation and replacement of
Y-stent to carina, with airway patency and resolution of
subjective dyspnea. Patient was weened off of oxygen, ambulating
at 92% on discharge. Patient will receive help from visiting
nurse at home and has been prescribed home suction unit. He
will finish 7-day course of cefpodoxime and clindamycin for
possible aspiration PNA. He will f/u with inteventional
pulmonology in 2 weeks and has scheduled radiation therapy to
start [**8-21**] with outpt rad onc.
.
#. H/o tumor bleed: Patient received total of 2 units blood
during this admission, hematocrit stablized at 30 on discharge.
Patient will follow-up with pulmonology.
.
# CAD s/p MI in [**5-12**]: Currently CP free. Patient will continue
beta blocker, statin, but holding aspirin at this time in
setting of bleeding risk. Pt will f/u with pulmonologist
regarding restarting his aspirin.
.
# Hyperlididemia: Continue Statin
.
# GERD: Stable, patient to continue PPI.
.
# Renal Cell Carcinoma: Management per outpatient oncologist,
scheduled for radiation therapy as outpatient.
.
Medications on Admission:
Fentanyl patch 75 mcg q72 h
Zocor ? dose
Prilosec 20 mg daily
Ativan 1 mg qhs
Zoloft 50 mg daily
Toprol 25 daily
aspirin 325 mg daily
Tylenol prn
Colace
Compazine as needed
oxycodone as needed for
knee and back pain
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
3. Cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H (every
12 hours) for 3 days.
Disp:*24 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Respiratory suction unit
Please order respiratory suction unit/cannister with suction
mechanism for use at home for increased pulmonary secretions in
a gentleman with bronchial metastases.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Primary:
Metastatic Renal Cell Carcinoma
Occluded right main stem bronchus status post Y-stent placement
Secondary:
History of myocardial infarction
Anxiety
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for acute respiratory distress during a
bronchoscopy. You were found to have a completely occluded
right main stem bronchus from your tumor. You were admitted to
the intensive care unit. Your Y stent was replaced and your
oxygenation improved. You received 2 units of blood for a low
hematocrit secondary to tumor bleeding. It was stable on
admission and you are oxygenation well.
.
Please note, you were started on antibiotics for possible
aspiration pneumonia, you will finish your antibiotics on [**8-20**],
please finish all medications. We are holding your aspirin for
now, as you have had bleeding. Please consult your
pulmonologist about restarting this medication as it is
important for your heart.
.
If you develop any concerning symptoms, in particular difficulty
breathing, light-headedness, prolonged fevers, or increased
blood in your sputum, please call your doctor or present to the
emergency room.
.
Please remember to take all medications as indicated.
.
Please follow up with all medical appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2141-8-31**]
11:00
Provider: [**Name10 (NameIs) **],ROOM ONE IP ROOMS Date/Time:[**2141-8-31**] 11:00
Provider: [**Name10 (NameIs) 454**],NINE [**Name10 (NameIs) 454**] Date/Time:[**2141-8-31**] 10:00
.
Please call Interventional Pulmonology to set up an appointment
for f/u withing 2 weeks after your discharge from the hospital.
([**Telephone/Fax (1) 17398**]
.
Please follow-up with your Oncologist as arranged
.
|
[
"519.19",
"272.4",
"197.0",
"285.9",
"300.00",
"530.81",
"786.3",
"V45.73",
"412",
"V10.52",
"V45.82",
"V15.82",
"414.01",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"98.15",
"99.04",
"32.01",
"96.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6619, 6666
|
3857, 5269
|
308, 344
|
6867, 6876
|
2464, 3834
|
7967, 8489
|
1992, 2010
|
5536, 6596
|
6687, 6846
|
5295, 5513
|
6900, 7944
|
2025, 2445
|
248, 270
|
372, 1337
|
1359, 1919
|
1935, 1976
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,581
| 198,570
|
25725+57464
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-8-18**] Discharge Date: [**2116-8-26**]
Date of Birth: [**2039-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
relatively asymptomatic
Major Surgical or Invasive Procedure:
OPCABG x1 (LIMA to LAD) [**2116-8-18**]
History of Present Illness:
77 yo male with prior MI in [**2110**] inCX territory. Had DES to LAD
and CX at that time. Recent cardiolite scan showed infero-apical
ischemia with EF 58%. Cath revealed LAD/diag dz. Referred for
CABG.
Past Medical History:
CAD
HTN
elev. lipids
NIDDM
MI [**2110**] (Cypher stents LAD and CX)
PVD
bil. carotid dz s/p right CEA [**2112**]
hypothyroidism
Social History:
retired
lives with girlfriend
75 pack/year hx; quit [**2085**]
quit ETOH 45 years ago
Family History:
NC
Physical Exam:
5'[**17**]" 160#
HR 68 reg RR14 right 184/82 left 184/82
NAD
psoriaticplaques bil. knees
HEENT unremarkable
neck supple, full ROM, no carotid bruits
CTAB
RRR, no murmur
soft, NT, ND, + BS; midline scar well-healed
warm, well-perfused
no varicosities or edema noted
neuro grossly intact
2+ bil. fems/DP/PT/radials/carotids
Pertinent Results:
Conclusions
Pregraft
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.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The right ventricular cavity is moderately dilated
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
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 no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known firstname **]
[**Known lastname 8273**] at 1330hours.
Postgraft:
Preserved biventricular systolic function.
LVEF 55%.
Mild to moderate TR.
NO regional wall motional abnormalities.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2116-8-20**] 16:08
?????? [**2110**] CareGroup IS. All rights reserved.
[**2116-8-21**] 07:34PM BLOOD WBC-13.2* RBC-3.34* Hgb-10.7* Hct-31.0*
MCV-93 MCH-31.9 MCHC-34.4 RDW-13.1 Plt Ct-204
[**2116-8-18**] 03:43PM BLOOD WBC-17.0*# RBC-4.19* Hgb-13.4* Hct-36.8*
MCV-88 MCH-32.0 MCHC-36.4* RDW-13.5 Plt Ct-255
[**2116-8-20**] 03:14AM BLOOD PT-14.6* PTT-30.7 INR(PT)-1.3*
[**2116-8-18**] 03:43PM BLOOD PT-14.6* PTT-26.8 INR(PT)-1.3*
[**2116-8-21**] 07:34PM BLOOD Glucose-135* UreaN-23* Creat-1.2 Na-138
K-4.4 Cl-106 HCO3-22 AnGap-14
[**2116-8-19**] 02:00AM BLOOD Glucose-114* UreaN-12 Creat-1.0 Na-139
K-4.7 Cl-113* HCO3-20* AnGap-11
[**Known lastname **],[**Known firstname **] [**Medical Record Number 64112**] M 77 [**2039-3-2**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2116-8-20**] 9:42
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2116-8-20**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 64113**]
Reason: s/p CABG w/hypoxia-r/o PTX/effusion
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with
REASON FOR THIS EXAMINATION:
s/p CABG w/hypoxia-r/o PTX/effusion
Provisional Findings Impression: PSS FRI [**2116-8-21**] 1:11 PM
PFI: Mild bibasilar atelectasis and small left pleural effusion
unchanged
since earlier on [**8-20**]. Heart size is top normal. No
pneumothorax.
Final Report
AP CHEST, 09:55 P.M. [**8-20**]
HISTORY: CABG. Hypoxia.
IMPRESSION: AP chest compared to [**8-18**] and [**2120-8-20**]:23
p.m.
Relatively mild bibasilar atelectasis unchanged since earlier in
the day or
[**8-18**]. Pleural effusion, if any, is minimal, on the left
following
removal of left pleural tube. Heart is top normal size, though
increased
since [**8-18**]. Right lung clear.
*
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2116-8-21**] 1:57 PM
Imaging Lab
Brief Hospital Course:
Admitted [**8-18**] and underwent surgery with Dr. [**Last Name (STitle) **].
transferred tothe CVICU in stable condition on phenylephrine and
propofol drips. Extubated on the morning of POD #1. Chest tubes
and pacing wires removed on POD #2. Went into A fib and coumadin
started. Amio was bolused and and a drip was started. Several
hours later his heart rate blocked down to the upper 40s, BP
stable. Amio was discontinued and over the next several days the
beta-blocker was optimized as HR and BP would tolerate. He was
transferred to the floor on POD #3 to begin increasing his
activity level. The remainder of his postoperative course was
essentially uneventful. On POD #7 it was felt that he was ready
for discharge to home with VNA. Dr[**Last Name (STitle) 64114**] office was contact[**Name (NI) **]
and [**Name2 (NI) 64115**] to follow Mr.[**Known lastname 64116**] INR and Coumadin dosing for 1
month, INR goal 2.0 for in/out of AFib postoperatively. All
necessary follow up appointments were instructed.
Medications on Admission:
ASA 325 mg daily
levoxyl 125 mcg daily
lipitor daily
lopressor every third day
metformin 500 mg [**Hospital1 **]
diovan 160 mg daily
plavix 75 mg daily
Discharge Medications:
1. Aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO HS (at
bedtime).
Disp:*30 [**Hospital1 8426**](s)* Refills:*0*
3. Levothyroxine 125 mcg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*0*
4. Metformin 500 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a
day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*0*
5. Metoprolol Tartrate 25 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO BID (2
times a day).
Disp:*30 [**Hospital1 8426**](s)* Refills:*0*
6. Furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO once a day for
3 days.
Disp:*3 [**Hospital1 8426**](s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. Ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*0*
9. Ibuprofen 400 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Q6H (every 6
hours) as needed.
Disp:*120 [**Hospital1 8426**](s)* Refills:*0*
10. Propoxyphene N-Acetaminophen 100-650 mg [**Hospital1 8426**] Sig: [**12-25**]
Tablets PO Q4H (every 4 hours) as needed.
Disp:*45 [**Month/Day (2) 8426**](s)* Refills:*0*
11. Warfarin 1 mg [**Month/Day (2) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM: **As [**Name8 (MD) **] MD orders.
Disp:*60 [**Name8 (MD) 8426**](s)* Refills:*0*
12. Warfarin 2 mg [**Name8 (MD) 8426**] Sig: One (1) [**Name8 (MD) 8426**] PO ONCE (Once) for
1 days: tonight [**2116-8-25**].
Disp:*30 [**Month/Day/Year 8426**](s)* Refills:*0*
13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed: for wheezing.
Disp:*1 * Refills:*0*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 3
days.
Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
15. Plavix 75 mg [**Month/Day/Year 8426**] Sig: One (1) [**Month/Day/Year 8426**] PO once a day.
Disp:*30 [**Month/Day/Year 8426**](s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD s/p OPCABG x1
HTN
elev. lipids
NIDDM
MI [**2110**] (Cypher stents LAD and CX)
PVD
bil. carotid dz s/p right CEA [**2112**]
hypothyroidism
postop A fib
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
SHOWER daily and pat incision dry
call for fever greater than 100.5, redness or drainage
no lifting greater than 10 pounds for 10 weeks
no driving for one month and until off all narcotics
Followup Instructions:
see Dr. [**Last Name (STitle) 7389**] in [**12-25**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2116-8-25**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 11368**]
Admission Date: [**2116-8-18**] Discharge Date: [**2116-8-26**]
Date of Birth: [**2039-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Discharge postponed until [**2116-8-26**] due to elevated INR on
[**2116-8-25**]. Coumadin was discontinued and Vitamin K 10mg SC was
administered. A repeat INR on day of discharge was down from 4.9
to 2.0. Dr.[**Last Name (STitle) **] cleared Mr.[**Known lastname **] for discharge to home
without Coumadin.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 413**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2116-8-26**]
|
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"285.9",
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"794.39",
"412",
"799.02",
"250.00",
"V15.82",
"V45.82",
"244.9",
"411.1",
"401.9",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9488, 9665
|
4425, 5441
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344, 387
|
8313, 8320
|
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281, 306
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3581, 4402
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|
641, 770
|
786, 873
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,649
| 167,237
|
32466
|
Discharge summary
|
report
|
Admission Date: [**2111-9-10**] Discharge Date: [**2111-9-30**]
Date of Birth: [**2067-9-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
fevers/malaise
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Left parietal embolectomy
History of Present Illness:
43 year old male, with history of IV drug abuse
(cocaine/oxycontin) and hepatitis C, presents from OSH after
experiencing fevers, abdominal pain, shortness of breath, and
malaise.
Hx is somewhat limited secondary to patient's lethargy. Per
patient and girldriend, he has been having fevers at night for a
little less than a week, with night sweats. His girlfriend took
his temperature 2 nights prior to admission and was found to be
103.2. Over the last few days he has felt "tired" but continued
to use IV drugs and drink ETOH. Patient drinks 1-2 liters of rum
daily and shoots cocaine and oxycontin. Last drank alcohol 3
days prior to admission. Last used cocaine 3 days prior to
admission and last used oxycontin 1 day ago. Patient was trying
to self detox and describes becoming very ill last time he
attempted detox. He also complains of abdominal pain, with one
episode of non-bloody emesis today. Patient also endorses
feeling shortness of breath, worse in the evenings when at rest
over the past three days. He denies any chest pain. There was
some concern of assymetric swelling of right calf but this has
since improved per girlfriend. Otherwise he denies changes in
vision, weakness.
He went to OSH and VS were Tm 103.3, HR 143, BP 126/86, 93% on
RA. His ECG showed sinus tachycardia, an echocardiogram showed
mitral valve vegetation and MR (no report), and CT
chest/abd/pelvis showed splenic, renal and hepatic infarction.
An RLE US was done, no official report, but reportedly negative
for DVT. Patient was started on Vancomycin and Zosyn, and also
got toradol, zofran and 2mg ativan. He was transferred to [**Hospital1 18**]
for further work up.
At [**Hospital1 18**], patient arrived in ED with VS: 98.4 108/72 104 20s 80s
on RA. He improved on a NRB to the mid 90s. Exam notable for a
murmur. Labs notable for WBC 40s, 89% polys, neg serum
alcohol/benzos, lactate 1.6, ABG: 7.45/38/128/27. He received
one dose of gentamicin. A head CT was done and prelim showed:
with 8mm hypodense area in right frontal periventricular region.
While on the floor, patient complained of shortness of breath,
restlessness, and abdominal pain. He denied chest pain, fevers
since the AM.
Past Medical History:
CARDIAC HISTORY: Questioned distant history of MI associated
with drug use per girlfriend
[**Name (NI) **] abuse/IVDA/alcoholism --IVDU x 22 yrs (cocaine,
oxycodone)- last use 40mg oxycodone injected a few hours prior
to presentation at OSH ([**2111-9-9**])
Hepatitis C dx 6 years ago -->HCV Ab + [**2108**] but VL ndetectable
Social History:
-Owns tree clipping business
-Tobacco history: 2-3ppd for unclear number of years
-ETOH: 1-2 liters of rum daily
-Illicit drugs: IV admin of cocaine and oxycontin, IVDA since
[**22**] years old
Physical Exam:
ADMISSION EXAM:
VS: T=36.4 HR=112 RR=33 O2 sat=97% on 15L with NRB
GENERAL: Arousable, closing eyes in middle of question. Oriented
x3. Cooperative. Using respiratory accessory muscles
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with no elevation in JVP
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4;however, difficult to accurately assess with lung sounds
LUNGS: Appeared in respiratory distress using accessory muscles.
Late expiratory wheeze throughout, poor air movement throughout,
decreased breath sounds at bases with occsional crackles. No
chest wall deformities, scoliosis or kyphosis.
ABDOMEN: Mildly distended, diffusely tender with voluntary
guarding, worse in RUQ, hepatomegaly to 4cm below lateral costal
border. Abd aorta not enlarged by palpation. No evidence of
caput medusa.
EXTREMITIES: No peripheral edema. Right calf measured 1/2inch
greater than left, no edema or erythema.
SKIN: No evidence of [**Last Name (un) 1003**] lesions, osler nodes, or splinter
hemorrhages. Lesion on right index finger patient states is an
old cut. No stasis dermatitis, ulcers, scars, or xanthomas. No
evident spider angiomas.
Neuro: CNII-XII intact, strenght [**5-27**] bilaterally, sensation
grossly intact, no evidence of tremor or asterixis.
.
Discharge Exam:
Tmax: 98.4 T current: 97.1 BP: 116-131/73-83 HR 120-128 97% RA
last 24 hours: I= 960 O= 1775 and incontinent
last 8 hours: I= 680 O= 400 + incontinent
.
GENERAL: Alert. Oriented x2. Cooperative, calm.
HEENT: Sclera anicteric.
NECK: Supple with no elevation in JVP, no LAD
CARDIAC: Tachy, RRR, normal S1, S2. 3/6 systolic murmur at apex,
now non radiating to right and carotids.
LUNGS: clear to auscultation anteriorly and posteriorly
ABDOMEN: soft, NT, ND, +BS
EXTREMITIES: No peripheral edema. Left arm PICC line c/d/i
SKIN: No evidence of [**Last Name (un) 1003**] lesions, osler nodes, or splinter
hemorrhages.
Neuro: CN2-12 intact. Left sided extremities 5/5 strength. [**3-27**]
weakness on right upper and lower extremeties (starting to lift
right arm to gravity for 1-3 seconds), can move fingers, hip and
toes. follows all commands. Markedly improved since [**9-25**].
Pertinent Results:
Labs on discharge:
XXXX
[**2111-9-10**] 10:05AM BLOOD WBC-46.8*# RBC-4.16* Hgb-11.9*# Hct-35.8*
MCV-86 MCH-28.6 MCHC-33.3 RDW-13.8 Plt Ct-251
[**2111-9-11**] 05:00AM BLOOD WBC-28.0* RBC-3.88* Hgb-11.1* Hct-33.3*
MCV-86 MCH-28.6 MCHC-33.3 RDW-13.8 Plt Ct-268
[**2111-9-12**] 04:30AM BLOOD WBC-23.5* RBC-3.61* Hgb-10.5* Hct-30.6*
MCV-85 MCH-29.1 MCHC-34.4 RDW-13.8 Plt Ct-294
[**2111-9-18**] 05:16AM BLOOD WBC-20.1* RBC-3.75* Hgb-10.9* Hct-31.1*
MCV-83 MCH-29.1 MCHC-35.2* RDW-13.6 Plt Ct-510*
[**2111-9-19**] 05:04AM BLOOD WBC-21.9* RBC-4.03* Hgb-11.3* Hct-32.9*
MCV-82 MCH-28.1 MCHC-34.5 RDW-13.7 Plt Ct-591*
[**2111-9-20**] 06:00AM BLOOD WBC-23.0* RBC-4.04* Hgb-11.6* Hct-33.9*
MCV-84 MCH-28.7 MCHC-34.2 RDW-13.7 Plt Ct-667*
[**2111-9-24**] 07:30AM BLOOD WBC-17.7* RBC-4.30* Hgb-12.1* Hct-34.8*
MCV-81* MCH-28.1 MCHC-34.6 RDW-14.4 Plt Ct-720*
[**2111-9-25**] 04:58AM BLOOD WBC-18.2* RBC-4.57* Hgb-12.6* Hct-38.1*
MCV-83 MCH-27.6 MCHC-33.1 RDW-14.7 Plt Ct-768*
[**2111-9-20**] 06:00AM BLOOD Neuts-80* Bands-0 Lymphs-13* Monos-5
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2111-9-24**] 07:30AM BLOOD Neuts-79.6* Lymphs-12.8* Monos-5.7
Eos-1.2 Baso-0.7
[**2111-9-10**] 10:05AM BLOOD PT-12.8 PTT-29.9 INR(PT)-1.1
[**2111-9-10**] 10:05AM BLOOD Plt Smr-NORMAL Plt Ct-251
[**2111-9-11**] 05:00AM BLOOD PT-14.3* PTT-28.7 INR(PT)-1.2*
[**2111-9-11**] 05:00AM BLOOD Plt Ct-268
[**2111-9-16**] 03:38AM BLOOD PT-13.6* PTT-26.6 INR(PT)-1.2*
[**2111-9-16**] 03:38AM BLOOD Plt Ct-519*
[**2111-9-17**] 03:13AM BLOOD Plt Ct-584*
[**2111-9-18**] 05:16AM BLOOD PT-13.7* PTT-27.1 INR(PT)-1.2*
[**2111-9-18**] 05:16AM BLOOD Plt Ct-510*
[**2111-9-22**] 02:31AM BLOOD Plt Ct-650*
[**2111-9-23**] 02:22AM BLOOD Plt Ct-627*
[**2111-9-24**] 07:30AM BLOOD Plt Ct-720*
[**2111-9-10**] 10:05AM BLOOD Glucose-116* UreaN-12 Creat-0.6 Na-133
K-4.7 Cl-97 HCO3-27 AnGap-14
[**2111-9-10**] 10:25PM BLOOD Glucose-105* UreaN-13 Creat-0.4* Na-132*
K-4.4 Cl-100 HCO3-27 AnGap-9
[**2111-9-11**] 05:00AM BLOOD Glucose-118* UreaN-15 Creat-0.4* Na-134
K-4.6 Cl-99 HCO3-27 AnGap-13
[**2111-9-15**] 04:50PM BLOOD UreaN-14 Creat-0.4* Na-134 K-4.3 Cl-96
[**2111-9-16**] 03:38AM BLOOD Glucose-126* UreaN-15 Creat-0.4* Na-129*
K-4.1 Cl-93* HCO3-30 AnGap-10
[**2111-9-17**] 03:13AM BLOOD Glucose-123* UreaN-20 Creat-0.5 Na-135
K-4.6 Cl-98 HCO3-31 AnGap-11
[**2111-9-19**] 05:04AM BLOOD Glucose-95 UreaN-15 Creat-0.4* Na-139
K-3.8 Cl-101 HCO3-29 AnGap-13
[**2111-9-20**] 06:00AM BLOOD Glucose-79 UreaN-12 Creat-0.3* Na-134
K-4.1 Cl-96 HCO3-28 AnGap-14
[**2111-9-22**] 02:31AM BLOOD Glucose-99 UreaN-11 Creat-0.4* Na-134
K-4.0 Cl-100 HCO3-25 AnGap-13
[**2111-9-23**] 02:22AM BLOOD Glucose-105* UreaN-12 Creat-0.5 Na-134
K-4.1 Cl-98 HCO3-28 AnGap-12
[**2111-9-25**] 04:58AM BLOOD Glucose-103* UreaN-13 Creat-0.6 Na-134
K-4.2 Cl-97 HCO3-26 AnGap-15
[**2111-9-13**] 05:39AM BLOOD ALT-14 AST-18 LD(LDH)-213 AlkPhos-71
TotBili-0.3
[**2111-9-24**] 07:30AM BLOOD ALT-20 AST-20 LD(LDH)-230 AlkPhos-65
TotBili-0.3
[**2111-9-25**] 04:58AM BLOOD ALT-21 AST-20 LD(LDH)-235 AlkPhos-72
TotBili-0.3
[**2111-9-10**] 02:33PM BLOOD CK-MB-23* MB Indx-16.0* cTropnT-0.19*
[**2111-9-11**] 05:00AM BLOOD CK-MB-17* MB Indx-21.5* cTropnT-0.22*
[**2111-9-11**] 11:06AM BLOOD CK-MB-14* MB Indx-11.3* cTropnT-0.18*
[**2111-9-10**] 10:05AM BLOOD Lipase-9
[**2111-9-12**] 04:30AM BLOOD Lipase-11
[**2111-9-10**] 10:05AM BLOOD Albumin-2.9* Calcium-8.1* Phos-4.2 Mg-2.2
[**2111-9-10**] 10:25PM BLOOD Calcium-7.7* Phos-5.0* Mg-2.1
[**2111-9-11**] 05:00AM BLOOD Calcium-8.0* Phos-4.5 Mg-2.1
[**2111-9-18**] 05:16AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.3
[**2111-9-19**] 05:04AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
[**2111-9-21**] 06:25AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.3
[**2111-9-23**] 02:22AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.2
[**2111-9-25**] 04:58AM BLOOD Calcium-9.7 Phos-4.8* Mg-2.3
[**2111-9-12**] 04:30AM BLOOD Triglyc-147
[**2111-9-13**] 05:39AM BLOOD Triglyc-144
[**2111-9-16**] 03:38AM BLOOD Triglyc-93
[**2111-9-14**] 02:49PM BLOOD Osmolal-283
[**2111-9-14**] 07:44PM BLOOD Osmolal-282
[**2111-9-15**] 03:41AM BLOOD Osmolal-281
[**2111-9-13**] 05:39AM BLOOD RheuFac-11 CRP-70.4*
[**2111-9-12**] 04:30AM BLOOD Genta-1.0* Vanco-5.2*
[**2111-9-13**] 05:39AM BLOOD Genta-0.4*
[**2111-9-10**] 10:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2111-9-10**] 10:18AM BLOOD pO2-128* pCO2-38 pH-7.45 calTCO2-27 Base
XS-3 Comment-NO CLINICA
[**2111-9-10**] 01:30PM BLOOD Type-[**Last Name (un) **] pO2-104 pCO2-39 pH-7.45
calTCO2-28 Base XS-2
[**2111-9-10**] 06:43PM BLOOD Type-ART pO2-44* pCO2-40 pH-7.46*
calTCO2-29 Base XS-4
[**2111-9-16**] 06:22AM BLOOD Type-ART Temp-37.7 pO2-120* pCO2-49*
pH-7.45 calTCO2-35* Base XS-9
[**2111-9-16**] 08:36AM BLOOD Type-ART Rates-/33 Tidal V-464 PEEP-5
FiO2-50 pO2-80* pCO2-43 pH-7.48* calTCO2-33* Base XS-7
Intubat-INTUBATED Vent-SPONTANEOU
[**2111-9-16**] 05:01PM BLOOD Type-ART PEEP-5 pO2-86 pCO2-43 pH-7.50*
calTCO2-35* Base XS-8 Intubat-INTUBATED
[**2111-9-17**] 03:26AM BLOOD Type-ART Temp-37.9 Rates-/23 Tidal V-570
PEEP-5 FiO2-50 pO2-83* pCO2-44 pH-7.49* calTCO2-34* Base XS-9
Intubat-INTUBATED Vent-SPONTANEOU
[**2111-9-18**] 05:26AM BLOOD Type-ART Temp-37.8 PEEP-5 FiO2-50 pO2-77*
pCO2-47* pH-7.46* calTCO2-34* Base XS-8 Intubat-INTUBATED
Vent-SPONTANEOU
[**2111-9-18**] 12:40PM BLOOD Type-ART pO2-109* pCO2-37 pH-7.47*
calTCO2-28 Base XS-3
[**2111-9-16**] 11:29PM BLOOD Lactate-1.0 K-4.2
[**2111-9-17**] 03:26AM BLOOD Lactate-0.9
[**2111-9-16**] 11:29PM BLOOD O2 Sat-98
[**2111-9-17**] 03:26AM BLOOD O2 Sat-95
[**2111-9-10**] 11:35AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2111-9-17**] 10:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.037*
[**2111-9-20**] 03:51PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2111-9-20**] 03:51PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
Blood Culture, Routine (Final [**2111-9-24**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2111-9-19**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5143**] @ [**2014**] ON [**9-19**] - FA6B.
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
.
ECG Study Date of [**2111-9-10**] 10:21:58 AM
Sinus tachycardia. Cannot exclude prior septal myocardial
infarction.
No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
105 138 80 322/400 68 44 48
.
TTE (Complete) Done [**2111-9-10**]
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-15mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size is normal. with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No vegetations
seen on the aortic valve. No aortic regurgitation is seen. The
mitral anterior valve leaflet is moderately thickened and does
not coapt well with the posterior leaflet. No vegetations seen
on the mitral valve. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is severe pulmonary artery systolic
hypertension. There is a very small pericardial effusion.
IMPRESSION: Very abnormally thickened anterior mitral leaflet
with moderate to severe mitral regurgitation. No clear
vegetations. If clinically indicated, a transesophageal
echocardiographic examination is recommended to further evaluate
mitral leaflets and mitral regurgitation.
.
CT HEAD W/O CONTRAST Study Date of [**2111-9-10**]
IMPRESSION: 8 mm right frontal white matter hypodensity,
nonspecific, and
without mass effect. Finding may represent a small focus of
chronic small
vessel ischemic change, however given patient age, lack of
additional evidence of small vessel ischemic change and his
history of endocarditis with evidence of emboli elsewhere in the
body, septic embolus can not be excluded. Recommend MRI for
further evaluation. No acute intracranial hemorrhage.
.
TEE (Complete) Done [**2111-9-11**]
Conclusions
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. A patent foramen ovale is
present. 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
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. 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. There is a 12 x 5-mm broad-based,
sheet-like vegetation on the anterior leaflet of the mitral
valve. A highly-eccentric, posteriorly-directed jet of severe
(4+) mitral regurgitation is seen.
IMPRESSION: Mitral valve vegetation with severe regurgitation.
No annular abscess or infectious involvement of other valves
seen at this time. Patent foramen ovale.
.
MR HEAD W & W/O CONTRAST Study Date of [**2111-9-11**]
IMPRESSION:
1. New area of left parietal hemorrhage measuring approximately
4 cm with
surrounding edema without midline shift. No enhancement seen in
this region.
2. Acute infarcts in the right temporal lobe and right parietal
lobe in the region of posterior cerebral artery.
3. Small areas of blood product near the left sylvian fissure,
which given
patient's clinical history of septic emboli needs further
evaluation with CT angiography to exclude a mycotic aneurysm.
Other findings as described above.
4. At the present time, infarcts do not demonstrate any
enhancement but
underlying septic emboli cannot be excluded.
5. The findings were discussed with Dr. [**Last Name (STitle) **] at the time of
interpretation of this study on [**2111-9-12**] at 11:00 a.m.
.
CT HEAD W/O CONTRAST Study Date of [**2111-9-13**]
IMPRESSION:
1. No significant change in size of left parietal
intraparenchymal hemorrhage compared to MRI [**2111-9-11**],
with extension into the subarachnoid space, with diffuse
subarachnoid hemorrhage within the left cerebral hemisphere.
2. Evolving infarct within the right PCA territory.
3. Mild mass effect on the left lateral ventricle, with mild
rightward shift of midline, and slight increase in dilation of
the left temporal [**Doctor Last Name 534**].
.
CT HEAD W/O CONTRAST Study Date of [**2111-9-15**]
IMPRESSION:
1. Stable left parietal intraparenchymal hemorrhage with
persistent stable
mass effect and rightward shift of normally midline structures.
2. Evolving right temporal lobe infarction.
3. Stable left subarachnoid hemorrhage.
4. Orogastric tube remains coiled in the nasopharynx.
.
FOOT AP,LAT & OBL LEFT Study Date of [**2111-9-15**]
IMPRESSION: No radiographic evidence of osteomyelitis. If there
is continued concern for a bone infection, recommend further
evaluation with MRI.
.
CT HEAD W/O CONTRAST Study Date of [**2111-9-17**]
IMPRESSION:
1. Stable appearance of left parietal intraparenchymal
hemorrhage with mild mass effect.
2. Evolving right PCA infarct.
.
CT PELVIS W/CONTRAST Study Date of [**2111-9-20**]
IMPRESSION:
1. Expected evolution of the infarcts in the left kidney and
spleen. Small
new infarct in the right kidney.
2. No new intra-abdominal fluid collections or abscesses are
detected.
3. Small pericardial effusion.
4. Trace pleural effusions with subsegmental left lower lobe
atelectasis.
.
CAROTID/CERVICAL BILAT Study Date of [**2111-9-21**]
IMPRESSION:
Diagnostic cerebral angiogram demonstrates a sidewall, likely
infective
microbial (mycotic) aneurysm arising from the posterior parietal
branch of the left M3 MCA segment. The aneurysm and the
supplying posterior parietal branch was successfully embolized
by Onyx. No immediate post-procedure
complications.
.
ECG Study Date of [**2111-9-23**] 6:17:34 PM
Sinus tachycardia. There is variation in precordial lead
placement as compared with previous tracing of [**2111-9-20**]. The rate
has increased. Otherwise, no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
112 130 78 316/407 60 10 40
.
Brief Hospital Course:
Mr. [**Known lastname 75772**] is a 43 year old male with hx of HCV and
[**Known lastname 7344**] abuse who presented with fevers, malaise x 5 days,
transferred from OSH and found to have mitral valve vegetation
and evidence of septic emboli concerning for infective
endocarditis.
# Endocarditis:
The patient was admitted with complaints of fatigue, malaise,
abd pain, sob, and fever for past week. He had been actively
using IV drugs (shooting crushed oxycontin and cocaine) prior to
admission and drinking 2 liters of EtOH daily. CT abd showed
septic embolic and TTE; subsequent TEE showed mitral valve
vegetation and leukocytosis. He was started on vancomycin and
zosyn at OSH; here, he was started on vancomycin and ceftriaxone
with gentamicin for synergy. On presentation, CT did show
evidence of septic emboli to the abdomen and brain. Blood
cultures at OSH were positive for Strep salivarius; blood
cultures here on [**9-18**] were positive for staph epi, thought to be
a contaminant. His course was complicated by finding of large
intraparenchymal brain hemorrhage on MRI attributed to his
endocarditis. He was started on LeVETiracetam 1000 mg PO/NG [**Hospital1 **]
for seizure prophylaxis. Picc line was placed for long term IV
antibiotic administration. Gentamicin was administered for
total of 14 days. Vancomycin (day #1 [**9-12**]) should continue for
a total of 6 weeks, last dose on [**2111-10-24**]. Patient has followup
set up with Infectious Disease team after discharge.
Patient will require outpatient evaluation by Cardiothoracic
Surgery to evaluate for mitral valve repair after finishing his
course of antibiotics. He should follow up in Cardiology clinic
after the CT Surgery evaluation.
# Cerebral hemorrhage:
On presentation, neurological exam was normal, though head CT
showed 8 mm right frontal white matter hypodensity, nonspecific,
and
without mass effect. Follow up study using head MRI showed
large brain hemorrhage in region of R PCA territory with a L
parietal intraparenchymal hemorrhage. Neurosurgery and neurology
were consulted and pt was started on Keppra for seizure
prophylaxis. Follow up studies suggested midline shift in the
evolving R PCA lesion and he was started on mannitol briefly.
Patient was followed with serial neuro exams on the ventilator
however after extubation he continued to be unable to move right
side of body. Has been informed of this, but patient unable to
remember or process this information completely at this time. He
was kept on fall precautions and low boy bed. Cerebral angiogram
on Monday [**9-22**] showed mycotic aneurysm in the left middle
cerebral artery; the aneurysm was embolized with some sacrifice
of a small distal branch of the left MCA. Patient had some mild
cerebral edema post procedure and was monitored for two nights
in the Neuro ICU, then transferred to the floor. On the floor,
he showed some mild improvement in being able to just slightly
move his right hand and foot. Of note, patient does appear to
show some signs of frontal lobe dysfunction, including
impulsivity. Patient was seen by physical and occupational
therapy. He will require extensive post-stroke physical therapy
to attempt to regain as much function as possible of his right
upper and lower extremities.
Patient will need CT-A of head and follow up with Neurosurgery
team in 1 month as outpatient, already scheduled.
# Respiratory Status:
He was intubated for respiratory distress likely [**2-24**] to alcohol
withdrawal. He was extubated [**9-18**] w/o complication and kept on
oxygen via NC. Oxygen was weaned as tolerated.
# Alcohol Withdrawal:
Patient describes very difficult prior detox attempts. He
admitted to drinking >2 liters of alcohol during his recent
substance abuse binges. Intubated in CCU for respiratory
distress. Valium per CIWA scale was unable to alleviate his
diaphoresis, anxiety, and tachypnea. He was started on thiamine
and MVI and midazolam sedation while intubated. Post-extubation
he was continued on lorazepam 2-4 mg IV Q2H:PRN CIWA>10 for a
few days. CIWA scale was discontinued upon transfer to floor,
as patient no longer showed any signs of withdrawal.
# Abdominal pain:
Pt complained of abdominal pain early during hospitalization,
likely secondary to septic emboli to kidney, liver, and spleen.
Abdominal pain self-resolved. Patient was treated for
endocarditis to prevent further septic emboli.
# [**Month/Year (2) **] abuse:
Patient has recent history of IV drug abuse with injection of
cocaine and oxycontin. Social work was consulted to follow along
with patient. Withdrawal symptoms managed as stated above.
Patient was kept on nicotine patch.
# Hepatitis C:
Patient was diagnosed with HCV 6 years ago, unclear if he had
started any treatment. ALT, AST, and total bili were not
elevated with normal INR. No stigmata of chronic liver disease
were noted on exam. Recommend follow up with hepatologist as
outpatient.
.
# Agitation:
Pt had several episodes of agitation and delerium at night time.
Pt was otherwise calm during the day. Agitation was felt to
likely be a sundowning effect or possible residual withdrawal
symptoms. On several occasions pt attempted to stand up and walk
which resulted in him falling out of bed given his limited
mobility. Pt did not injure himself or hit his head but there
was concern regarding his agitation leading to possible injury.
Veil bed and low bed were tried; veil bed made the pt more
agitated and angry while the low bed did not fully keep pt
within the bed but prevented falls from any height. Zyprexa was
tried as an alternative but there was some concern about whether
this contributed to further agitation on one occasion. Pt was
given low dose of ativan in the evenings with good effect,
allowing him to sleep through all or most of the night without
incident.
#Discharge:
Pt was discharged to [**Hospital3 **] in stable condition for
further rehabilitation care during his recover and completion of
IV antibiotics.
Medications on Admission:
Tylenol - up to 4 tabs [**Hospital1 **]
MVI
Ibuprofen ? amount
Discharge Medications:
1. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) bag Intravenous Q24H (every 24 hours) for 4 weeks: Last
day on [**2111-10-24**].
2. Outpatient Lab Work
Please send weekly LFT's, CBC with differential and chem -7
while pt on IV antibiotics to [**Telephone/Fax (1) 1419**] fax ([**Hospital1 18**] ID outpt
safety lab)
[**First Name9 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 3 weeks.
6. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 2 weeks: then d/c.
7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 2 weeks.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
9. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day) as needed for itching: on arm and wrist.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO 12:00AM.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
15. 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.
16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for arm rash.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Endocarditis
Hemorrhagic stroke
Alcohol withdrawal
Substance Abuse
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 75772**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital with symptoms of fever, abdominal pain,
shortness of breath and low energy. You were found to have an
infection in your heart on your mitral valve called endocarditis
likely secondary to your IV drug use. You were started on IV
antibiotics to treat this infection.
While you were hospitalized, your breathing became more labored
and you had difficulty protecting your airway in the setting of
withdrawal from the recent drugs and alcohol you had been using.
You were intubated and kept on a ventilator to help you breath.
You were extubated after a few days on the ventilator without
complication.
You also had a stroke that was attributed to your heart
infection. It was a bleed detected which is the reason for your
right sided arm and leg weakness. You were transferred to the
general floor after being stabilized in the ICU. You were
continued on IV antibiotics for the infection. Neurology
followed your case in the hospital to make recommendations
regarding your stroke. You were also seen by the Neurosurgery
team who embolized the aneurysm they found in the left side of
your brain so that it would not bleed again.
The following changes have been made to your medications:
1. Started Ceftriaxone to treat the infection in your heart
valve
2. Take folic acid, thaimine and a multivitamin to treat
nutritional deficiencies.
3. Take nicotine patch to treat your nicotine addiction.
4. Take Levetiracetam to prevent a seizure after your stroke.
5. Take cortisone or Sarna lotion as needed for your rash
6. Take colace and senna if you get constipated
7. Take Tylenol for pain
8. Take Ativan 1-2mg at midnight to help you sleep or for
anxiety
9. Take Heparin injections to prevent more blood clots
10. Stop taking Ibuprofen
Please follow up with your doctors at the [**Name5 (PTitle) 4314**] below.
It is important that you follow up with the Neurosurgery team
and get a repeat CT-Angiogram of your head in 1 month.
You will also follow up with the infectious disease doctors.
After finishing all of your antibiotics, you will need to see
the Cardiothoracic Surgeons in clinic so that they can decide
whether or not you would benefit from surgery to fix your heart
valve that has been damaged from your infection.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2111-10-16**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: RADIOLOGY
When: THURSDAY [**2111-11-5**] at 1:30 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2111-11-5**] at 2:15 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SURGERY
When: THURSDAY [**2111-10-29**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2111-11-12**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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60,436
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Discharge summary
|
report
|
Admission Date: [**2132-2-11**] Discharge Date: [**2132-2-15**]
Date of Birth: [**2080-8-15**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Numbness of bilateral lower extremities right greater than left,
increasing claudication pain
Major Surgical or Invasive Procedure:
OPERATIONS PERFORMED:
1. Right common femoral profunda femoral artery
endarterectomy and patch angioplasty with superficial
femoral artery.
2. Stenting of right external iliac artery and right common
iliac artery.
3. Right iliac angiogram.
4. Placement of catheter into aorta.
History of Present Illness:
Patient a 51-year-old male with a history of coronary artery
disease, status post coronary artery bypass grafting (3
vessels)and aortic valve replacement on [**2131-12-29**] and severe
disabling claudication of bilateral extremities status post
bilateral lower
extremity arteriogram on [**2132-1-30**], found to have near-occlusive
lesions in distal superficial femoral artery and popliteal
arteries originally scheduled for bilateral femoral
endarterctomy
on [**2132-2-27**], now presenting with one week new onset numbness in
the lower extremities worse on the right than left. The numbness
has been especially prominent at night, in both legs to the
level
of the ankles. Patient is now forced to get out of bed into the
chair in order to improve the numbness and the leg pain. He
reports decreased ability to walk, used to be able to walk about
5 minutes, now about 3 minutes. He denies any SOB, chest pain,
palpitations, fevers, nausea, vomiting, diarrhea or
constipation.
Of note: He saw his PCP 5 days ago. He was started on cephalexin
500mg qid for the non-healing wound on the left extremity on the
medial surface right above the knee, the site of the incision
made during the bypass operation. Patient also noticed "cracked
skin" on the heals bilaterally and between 3rd and 4th toe on
the
right foot.
Past Medical History:
tobacco abuse
MVA in [**2130**]
Social History:
Currently smokes half a pack daily. Smoked over a pack daily for
about 20 years. Drinks several days for week. Only beer. The
most he will drink is 6 when watching a game, but usually just
2. Works in property management. Lives by himself. Divorced 10
years ago.
Family History:
Hyperlipidemia
Says his father had "blockage" and a stent in his 60s
Physical Exam:
PE:
VS: 97.2 88 134/76 16 98RA
gen: WA/ WD, NAD
CV: RRR
pulm: CTA b/l
abdomen: +BS, NT/ND
extremities: minimal asymmetry edema on the right foot, right
and
left heal skin cracks, no signs of infection, space between 3rd
and 4th toe on right foot posteriorly cut non-infected, right
medial leg on right above the knee level - non-healing wound -
about 1 cm with yellow dry base, surrounding redness of about 1
cm
pulse exam:
fem [**Doctor Last Name **] PT DP
right palp palp Dop -
left palp palp Dop Dop
Pertinent Results:
[**2132-2-14**] 03:12AM BLOOD
WBC-6.3 RBC-3.63* Hgb-10.3* Hct-31.3* MCV-86 MCH-28.5 MCHC-33.0
RDW-16.4* Plt Ct-203
[**2132-2-14**] 03:12AM BLOOD
Plt Ct-203
[**2132-2-14**] 03:12AM BLOOD
Glucose-94 UreaN-10 Creat-0.7 Na-135 K-4.3 Cl-103 HCO3-25
AnGap-11
[**2132-2-13**] 05:36AM
BLOOD Calcium-8.6 Phos-4.9* Mg-2.3
[**2132-2-12**] 07:21AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.004
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
Mr.[**Known lastname 41687**], [**Known firstname **] was admitted on [**2-11**] with numbness of
bilateral lower extremities right greater than left,increasing
claudication pain . He agreed to have an elective surgery.
Pre-operatively, he was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
It was decided that she would undergo a:
1. Right common femoral profunda femoral artery
endarterectomy and patch angioplasty with superficial
femoral artery.
2. Stenting of right external iliac artery and right common
iliac artery.
3. Right iliac angiogram.
4. Placement of catheter into aorta.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
He was then transferred to the VICU for further recovery. While
in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home in stable
condition.
To note he did recieve IV vanco for harvest vein site infection.
He will be DC'd on Keflex.
Medications on Admission:
Carvedilol 12.5 [**Hospital1 **], Lisinopril 40, Simvastatin 20, Aspirin 81,
Multivitamin
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*6*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: prn for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Multiple Vitamins Daily Tablet Sig: One (1) Tablet PO
once a day.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
8. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower extremity ischemia with rest pain.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Division of [**Name8 (MD) **] and Endovascular Surgery
Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-13**]
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
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? 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:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2132-4-1**] 12:00
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2132-4-15**] 3:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2132-7-16**] 3:20
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2132-3-3**] 9:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2132-3-3**] 7:45
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2132-3-3**] 8:15
Completed by:[**2132-2-15**]
|
[
"V45.81",
"440.22",
"414.00",
"998.83",
"V43.3",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.42",
"00.46",
"39.90",
"38.18",
"00.42"
] |
icd9pcs
|
[
[
[]
]
] |
6041, 6047
|
3540, 5159
|
362, 653
|
6138, 6138
|
3004, 3517
|
9180, 10243
|
2347, 2417
|
5299, 6018
|
6068, 6117
|
5185, 5276
|
6283, 8747
|
8773, 9157
|
2432, 2985
|
229, 324
|
681, 1995
|
6152, 6259
|
2017, 2050
|
2066, 2331
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,925
| 192,151
|
40880
|
Discharge summary
|
report
|
Admission Date: [**2152-4-6**] Discharge Date: [**2152-4-15**]
Date of Birth: [**2101-2-27**] Sex: M
Service: SURGERY
Allergies:
Nafcillin / Zosyn / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
confusion, low grade fevers
Major Surgical or Invasive Procedure:
[**2152-4-8**]: CT Guided placement of 10 Fr Drain
[**2152-4-10**]: Upsizing of existing drain to 12 Fr drain via existing
approach
[**2152-4-13**]: Picc line
History of Present Illness:
Mr. [**Known lastname **] is a 51yo gentleman with history of R
colectomy/end ileostomy for ?necrotic R colon, and subsequently
ABO incompatible OLT on [**2152-1-15**]. He also has hepatic artery
stenosis and is on coumadin. He was readmitted [**3-1**] for fevers
and found to have a perihepatic fluid collection that was
drained. These drains were recently removed. He also had wound
debridement with vac placement that has also been removed.
He came to clinic today from rehab confused. His temperature at
rehab last night was 100.5. He has been having epistaxis
intermittantly at rehab. He is still on tube feeds, but his
weight and PO intake have been stable. In clinic today he was
confused and generally looks unwell. Pt states he has abdominal
pain that has been there since OLT. He reports nausea in the
mornings but no emesis. He states he has a good appetite. He
denies fevers or chills. He reports multiple loose bowel
movements daily in his ostomy. Per rehab report ostomy output
has
been less watery lately. He denies SOB or chest pain. He denies
headache, lightheadedness or dizziness.
Past Medical History:
HCV/EtOH Cirrhosis c/b Jaundice, Ascites
3 cords of grade I varices were seen starting at 30 cm ([**2151-6-3**])
ABO incompatible OLT on [**2152-1-15**]
postop abdominal abscesses, Ecoli
Heterozygous for H63D MUTATION
Hyponatremia
MSSA osteomyelitis of the L foot s/p debridement [**5-24**]
GERD
HTN
Gout
CAD - pt does not recall h/o MI or stents
Cervical laminectomy
Social History:
Lives w/ wife, walks w/ a cane and is independent w/ ADLs. He
quit ETOH in [**2151-5-14**]. He quit smoking for three months but
has started again and is smoking 1 cig per day (last 3 days
PTA).
Family History:
No h/o liver disease
Physical Exam:
T 98.3, 74, 133/79, 18, 98% on RA
Gen: Garbled speech, but coherent. Restless, tremulous. A&Ox3.
HEENT: Anicteric. Dry blood around dobhoff.
Neck: No JVD. No LAD. No TM.
CV: RRR.
Pulm: CTAB.
Abd: Soft, non distened, non tender, subxyphoid wound has
minimal
drainage, no hernias/masses. Ostomy appliance in place with gas
and stool output.
Ext: warm and well perfused, no C/C/E
Neuro: Motor and sensation grossly intact.
Labs:
11.8>----<186
34.1
chem: pend
PT: 39.2 PTT: 62.2 INR: 3.8
LFT:pend
U/A neg
FK; pend
Pertinent Results:
[**2152-4-14**] 04:46AM BLOOD WBC-6.1 RBC-3.55* Hgb-9.8* Hct-30.9*
MCV-87 MCH-27.6 MCHC-31.7 RDW-19.3* Plt Ct-127*
[**2152-4-14**] 04:46AM BLOOD PT-16.6* PTT-46.0* INR(PT)-1.6*
[**2152-4-14**] 04:46AM BLOOD Glucose-156* UreaN-25* Creat-0.9 Na-137
K-4.2 Cl-106 HCO3-22 AnGap-13
[**2152-4-14**] 04:46AM BLOOD ALT-14 AST-49* AlkPhos-172* TotBili-1.4
[**2152-4-13**] 05:30AM BLOOD Calcium-9.6 Phos-2.4* Mg-1.6
[**2152-4-14**] 04:46AM BLOOD tacroFK-11.1
[**2152-4-15**] 03:27AM BLOOD PT-17.2* PTT-44.8* INR(PT)-1.6*
[**2152-4-15**] 03:27AM BLOOD WBC-6.2 RBC-3.50* Hgb-9.9* Hct-29.2*
MCV-84 MCH-28.1 MCHC-33.7 RDW-19.6* Plt Ct-128*
[**2152-4-15**] 03:27AM BLOOD Glucose-166* UreaN-28* Creat-1.0 Na-135
K-4.7 Cl-104 HCO3-22 AnGap-14
[**2152-4-15**] 03:27AM BLOOD ALT-14 AST-49* AlkPhos-178* TotBili-1.3
[**2152-4-15**] 03:27AM BLOOD tacroFK-PND
Brief Hospital Course:
He was admitted to the Transplant service and pan-cultured. IV
Meropenem and Vancomycin were started. ABD CT was done
demonstrating increase in size of a communicating perihepatic
and pelvic fluid collection with interval removal of the
percutaneous drainage catheters. There was slight interval
decrease in size of splenic bed enhancing fluid collection. INR
was 3.7 on admission. Coumadin was held and FFP give to reverse
coumadin for CT drainage of collection.
On [**4-8**],a 10 French drainage catheter was placed under CT
guidance into the intra-abdominal connected fluid collections.
Fluid sample was sent for gram stain and culture. This isolated
E. coli sensitive to Meropenem and VRE. Vancomycin was switched
to Daptomycin on [**4-11**]. He remained afebrile and blood and urine
cultures were negative. Picc line was placed in R arm on [**4-13**].
On [**4-9**], he was transferred to the SICU for respiratory
distress/hypoxia from blood from oropharynx. He was emergently
intubated. ENT was consulted for epistaxis/oropharyngeal
bleeding. No evidence of epistaxis or obvious source of
bleeding aside from mucosal erosion and oozing of hard and soft
palate was noted. Bleeding stopped.
CXR demonstrated prominence of the cardiomediastinal silhouette,
CHF, left lower lobe collapse and/or consolidation, small left
effusion and more patchy opacity in the right cardiophrenic
angle are all unchanged compared with earlier the same day.
Repeat CXR on [**4-10**] showed opacification in both lungs suspicious
for pneumonia. CXR on [**4-11**] showed bilateral pleural effusions
(R>L). Given note of borderline size of the cardiac silhouette,
a TTE was done noting moderately dilated RA. Moderate symmetric
LVH. LVEF >55%. 1+ AR. Possibly diastolic dysfunction, but
findings were inconclusive.
He was extubated. Mental status improved. Speech and Swallow
evaluated noting
On [**4-10**], abscess drainage decreased. Drain was upsized from 10
Fr to 12 Fr while under CT, 250cc drained during procedure.
Outputs averaged 25cc per day of brown purulent fluid.
Confusion was evaluated by Head CT which was negative. Confusion
was multifactorial and was attributed to supra therapeutic
Prograf level which was high at 19.1. Prograf was held for 5
days then resumed at 0.5mg [**Hospital1 **] for trough level of 9.7. Prograf
dose was decreased to 0.5mg daily for an elevated trough and
will be monitored Monday and Thursdays. Confusion was also felt
to be related to abdominal abscess. He was kept NPO initially
due to altered mental status and episode of nasopharyngeal
bleeding. Once mental status improved and oral pharyngeal
bleeding stopped, diet was up graded. Speech therapist
re-evaluated him and declared him safe for thin liquids and soft
solids.
Coumadin (for splenic vein thromus)was held until [**3-/2069**] when it
was resumed. Coumadin 1mg was given [**3-/2069**] then increased to 2mg
on [**4-13**]. Other medication changes included discontinuation of
Valcyte and Prednisone (completed taper). Prograf doses were
adjusted per trough. Of note, Fluconazole was to continue
indefinately. Propranolol (previously started for tremors from
SSRI)was decreased to 20mg qd.
PT recommended rehab. The plan was to transfer to [**Hospital1 **] in
[**Hospital1 8**].
Will have coumadin and prograf doses adjusted by the transplant
institute based on biweekly labs.
Medications on Admission:
Humalog SS, mag gluconate 1000mg tid, saline spray nu prn,
vancomycin 125mg qid (started [**4-4**]),cellcept 500mg [**Hospital1 **], prograf
0.5mg [**Hospital1 **](changed from [**2-13**] on [**4-5**]), prednisone 7.5mg qd
(started
[**3-15**]), ASA 81mg qd, Lido patch qd to L foot, immodium 2mg [**Hospital1 **], TF
Nepro 65cc/h x 8 h, glucerna tid, sertraline 75mg qd, valcyte
900mg qd, prilosec [**Hospital1 **], levothyroxine 50mg (incr'd [**3-17**]),
florinef
0.1mg 3x/wk (T-Th-Sat), propranolol 20mg [**Hospital1 **], colace 100 [**Hospital1 **],
mvi
qd, fluconazole 200mg qd, pentamidine 300mg inh qmo-due [**4-8**],
lido patch to R flank
Discharge Medications:
1. sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution
Sig: One (1) PO BID (2 times a day).
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. propranolol 10 mg Tablet Sig: Two (2) Tablet PO once a day.
7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a
day: 0.5 mg daily until dose adjusted by the transplant center.
12. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours): duration 1 month.
13. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
14. daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 12887**]y (470)
mg Intravenous Q24H (every 24 hours): duration 1 month.
15. 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.
16. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.125 mg Injection
Q3H (every 3 hours) as needed for breakthrough pain.
17. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day.
18. Outpatient [**Name (NI) **] Work
PT/INR [**4-17**] then 2-3x/week
goal inr [**3-17**]
19. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: goal INR 2-2.3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Perihepatic fluid collection: Abscess; E coli, Enterococcus
Respiratory failure; resolved
Prograf toxicity
Mental status changes related to Prograf toxicity
h/o splenic vein thrombus
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:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, confusion, nausea, vomiting, inability to tolerate food,
fluids or medications, increased stool/ostomy output, lack of
stool/ostomy output, increased drain output, drainage becomes
bloody or develops a foul odor, or any other concerning
symptoms.
Continue blood draw for [**Telephone/Fax (1) **] monitoring every Monday and
Thursday, with results faxed to the transplant clinic at
[**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk Phos, T bili, trough
prograf, PT/INR.
Please do not make any medication adjustments without consulting
the transplant clinic.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2152-4-20**] 3:00 [**Hospital1 18**] [**Hospital Ward Name 517**], [**Last Name (NamePattern1) 439**]
[**Location (un) **], [**Location (un) 86**]
|
[
"997.49",
"041.49",
"401.9",
"276.69",
"V44.2",
"518.81",
"V42.7",
"781.0",
"V58.61",
"041.04",
"572.0",
"796.0",
"998.59",
"530.81",
"572.2",
"E878.0",
"447.1",
"584.9",
"V12.09",
"787.91",
"V12.51",
"289.59",
"274.9",
"459.0",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.97",
"54.91",
"29.11",
"21.21",
"97.29",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9694, 9737
|
3694, 7071
|
338, 499
|
9963, 9963
|
2832, 3671
|
10819, 11102
|
2253, 2275
|
7769, 9671
|
9758, 9942
|
7097, 7746
|
10146, 10796
|
2291, 2813
|
270, 300
|
527, 1630
|
9978, 10122
|
1652, 2024
|
2040, 2237
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,712
| 176,913
|
21011
|
Discharge summary
|
report
|
Admission Date: [**2149-1-17**] Discharge Date: [**2149-1-19**]
Date of Birth: [**2091-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57 yo M with history of metastatic hepatocellular is admitted to
the ICU under the sepsis protocol. He last recieved chemotherapy
last Monday. He presented to the ED with fever to 102.4 and
hypotensive. No source of infection identified so far.According
to him, his baseline BP is 120/80. After 3 L IVF, his blood
pressure was still in low 90s and he was thus enrolled in sepsis
protocol and had RIJ placed. He recieved 4L before transferring
to ICU. He recieved one dose of cefipime initially.He denies
any sick contact. According to him, he had recieved 6 weeks of
adriamycin and had not developed fever after any of those. He
claims that appetite has been good and he has satisfactory oral
intake.
He also complained of right sided pleurtic chest pain that had
been occuring intermittenly for about 2 months. According to
him, it's not a severe pain and it does not radiates. CTA done
in the ED ruled out DVT. He denies leg swelling/recent
travel/recent trauma to the leg.
Past Medical History:
1. hepatitis B(Hep C negative)
2. metastatic hepatocellular carcinoma on weekly adriamycin;
primary oncologist is Dr.[**First Name (STitle) **]
3. hypercholesterolemia
*PCP:[**Last Name (NamePattern4) **]. [**First Name (STitle) **] from [**Hospital3 **] comm health
Social History:
He came here from [**Country 651**] six years ago. Does not
speak English. He is married with two children, age 21 to 24.
He has worked in the restaurant business. He quit smoking
cigarettes seven years ago and does not drink any alcohol
Family History:
no family history of cancer
Physical Exam:
T 96.3 P76 BP100/57 R16 SpO2 100% CVP 6
Gen-NAD, very pleasant
HEENT-anicteric, oral mucosa dry, neck supple, no JVD
CV-RRR, no r/m/g, chest pain reproducible by palpation
resp-CTAB
[**Last Name (un) 103**]-active BS, soft, NT/ND, no HSM
neuro-A+OX3, PERL, CN II-XII intact, move all 4 limbs
skin-unremarkable
extremities-no peripheral edema, DP 1+ b/L, no leg swelling/no
palpable cord
Pertinent Results:
CTA [**2149-1-16**]: No pulmonary embolism. Stable mediastinal
lymphadenopathy.There are no focal consolidations or
pleural effusions. No pericardial effusion.Limited views of the
upper abdomen show multiple large
heterogeneous liver masses. The pancreas and spleen are grossly
unremarkable
RUQ U/S [**2149-1-18**]: The gallbladder is decompressed and there is no
evidence of cholelithiasis or acute cholecystitis. The common
bile duct is not dilated at 4 mm. Limited views of the liver
again show multiple, large heterogeneously echoic liver masses
consistent with the patient's known history of metastatic
disease. No biliary dilatation is seen.
Brief Hospital Course:
57yo with history of hepatocellular carcinoma admitted under
sepsis protocol with ED presentation of fever, hypotension and
pleuritic chest pain
1. Hypotension: He was admitted to the [**Hospital Unit Name 153**] on [**1-17**] under the
sepsis protocol. He last received chemotherapy last Monday. He
presented to the ED with fever to 102.4 and hypotensive with SBP
in the 70's. According to him, his baseline BP is 120/80. After
3 L IVF, his blood pressure was still in low 90s and he was thus
enrolled in the sepsis protocol and had a RIJ placed. He
received 4L before transfer to the [**Hospital Unit Name 153**]. He received one dose of
emperic cefipime initially. He denies any sick contact. On
admission, the pt also complained of right sided pleurtic chest
pain that had been occuring intermittenly for about 2 months.
According to him, it's not a severe pain and it does not
radiates. CTA done in the ED ruled out PE. On transfer to the
[**Hospital Unit Name 153**], the pt continued to receive IV fluids for a total of 5 L.
However, no pressors were ever needed. The pt became afebrile.
No source of infection was ever found. The antibiotics was
initially switched to ceftaz but was later changed to oral
ciprofloxacin but was discontinued since he remained afebrile
and pt is not neutropenic. He got a RUQ ultrasound which was
negative for cholecystitis or cholangitis as there was no ductal
dilation. He had an episode of T 101.2 on transfer to the floor
but remained afebrile without antibiotics for 24 hrs. All of
the cutlures were negative at the time of discharge. Patient
appeared well and wanted to go home. He was discharged with no
antibiotics. His right IJ was removed at the time of discharge.
2. Hepatocellular CA: Patient is getting weekly adriamycin and
will be followed by Dr. [**First Name (STitle) **].
Discharge Medications:
1. Epivir Oral
2. Ativan Oral
3. Compazine 10 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
hypotension
hepatocellular carcinom
Discharge Condition:
Afebrile, hemodynamically stable, asymptomatic
Discharge Instructions:
Please take all medications as prescribed. Please keep all of
your follow-up appointments including your appointment this
Tuesday [**1-21**] at 9:30am with [**First Name5 (NamePattern1) 14552**] [**Last Name (NamePattern1) **].
Please contact Dr. [**First Name (STitle) **] or a covering physician immediately if
you have fever, nausea/ vomiting pain or other worrisome
symptoms or report directly to the emergency department.
Followup Instructions:
Please keep your appoitment with [**First Name5 (NamePattern1) 14552**] [**Last Name (NamePattern1) **] of [**Last Name (NamePattern1) **]/Onc at
9:30am on [**2149-1-21**].
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] Date/Time:[**2149-1-21**] 9:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2149-1-21**] 9:30
Provider: [**Name Initial (NameIs) **]/Onc Date/Time:[**2149-1-27**] 10:30
Completed by:[**2149-1-20**]
|
[
"038.9",
"070.30",
"196.2",
"995.93",
"196.0",
"272.0",
"155.0",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5044, 5050
|
3023, 4865
|
322, 328
|
5136, 5184
|
2349, 3000
|
5661, 6226
|
1898, 1927
|
4888, 5021
|
5071, 5115
|
5208, 5638
|
1942, 2330
|
276, 284
|
356, 1335
|
1357, 1626
|
1642, 1882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,040
| 111,377
|
40537
|
Discharge summary
|
report
|
Admission Date: [**2114-7-30**] Discharge Date: [**2114-8-4**]
Date of Birth: [**2033-1-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2114-7-31**]
Coronary bypass grafting x4: Left internal mammary artery to
the left anterior descending artery; and reverse saphenous vein
graft to the distal right coronary artery, obtuse marginal
artery, and diagonal artery.
History of Present Illness:
81 year old female with a history of hypertension and GERD
presented to OSH [**7-29**] with epigastric pain described as [**10-22**]
without radiation. She reports this pain began while sitting on
the beach, at rest, with associated slight
dyspnea. She denies other associated symptoms. Paramedics were
called and she was taken to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. Cardiac cath was
performed and revealed severe multivessel coronary disease. She
was transferred to [**Hospital1 18**] for evaluation of coronary
revascularization.
Past Medical History:
Coronary Artery Disease
PMH:
Hypertension
Gastroesophageal Reflux Disease
PSH:
Right knee replacement x 2
Cholecystectomy ~[**2108**] c/b pancreatitis
Social History:
Lives with: son-[**Name (NI) **]
Contact: [**Name (NI) **] Phone # [**Telephone/Fax (1) 88762**]
Occupation:
Cigarettes: Smoked no [x]
ETOH: denies
Illicit drug use
Family History:
mother with breast cancer otherwise noncontributory
Physical Exam:
Pulse:66 Resp:20 O2 sat: R/A=99%
B/P 159/82
Height: 5'2" Weight:178 LBs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] 1+(R)LE
_____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none Right: 2+ Left:2+
Pertinent Results:
[**2114-7-31**] Intra-op TEE
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2114-7-31**]
at 1100 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation present. Aorta is intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2114-8-1**] 13:05
Pre-op labs:
[**2114-7-30**] 08:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-7-30**] 09:25PM PT-12.7 PTT-40.0* INR(PT)-1.1
[**2114-7-30**] 09:25PM PLT COUNT-275
[**2114-7-30**] 09:25PM WBC-7.1 RBC-4.08* HGB-11.6* HCT-35.2* MCV-87
MCH-28.4 MCHC-32.9 RDW-14.4
[**2114-7-30**] 09:25PM %HbA1c-5.9 eAG-123
[**2114-7-30**] 09:25PM ALBUMIN-4.2
[**2114-7-30**] 09:25PM LIPASE-31
[**2114-7-30**] 09:25PM ALT(SGPT)-14 AST(SGOT)-17 LD(LDH)-152 ALK
PHOS-50 AMYLASE-28 TOT BILI-0.4
[**2114-7-30**] 09:25PM GLUCOSE-136* UREA N-21* CREAT-1.2* SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-26 ANION GAP-12
Discharge labs:
[**2114-8-3**] 05:49AM BLOOD WBC-10.5 RBC-3.65* Hgb-10.5* Hct-30.6*
MCV-84 MCH-28.8 MCHC-34.3 RDW-14.1 Plt Ct-173
[**2114-7-31**] 03:58PM BLOOD PT-13.7* PTT-29.5 INR(PT)-1.2*
[**2114-8-4**] 05:19AM BLOOD Glucose-99 UreaN-29* Creat-1.3* Na-135
K-4.8 Cl-98 HCO3-31 AnGap-11
[**Known lastname 88763**],[**Known firstname 4092**] [**Medical Record Number 88764**] F 81 [**2033-1-20**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2114-8-2**] 2:55
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2114-8-2**] 2:55 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 88765**]
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman s/p cabg and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
Final Report
CHEST RADIOGRAPH
INDICATION: Post CABG with removal of chest tube drains, to look
for
pneumothorax.
FINDINGS: Comparison was made with prior radiograph with the
recent from [**8-1**], [**2114**]. There is no demonstrable pneumothorax. Right PICC line
is seen with
the tip in the mid SVC. The findings in the bilateral lung
including bibasal
atelectasis and the right mid lung atelectasis are relatively
unchanged. No
new consolidation. Patient is status post CABG with a stable
cardiomediastinal
outline.
Brief Hospital Course:
The patient was admitted to cardiac surgery service with 3
vessel coronary artery disease for surgical evaluation. After
the usual preoperative workup she was brought to the Operating
Room on [**2114-7-31**] where the patient underwent CABG x4 with Dr.
[**Last Name (STitle) **].
Please see the operative report for details, in summary she had:
Coronary bypass grafting x4: Left internal mammary artery to
the left anterior descending artery; and reverse saphenous vein
graft to the distal right coronary
artery, obtuse marginal artery, and diagonal artery. His bypass
time was 90 minutes.
with a crossclamp time of 75 minutes. She tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition on Propofol an Neosynephrine infusions, for
recovery and invasive monitoring. She remained hemodynamically
stable in the immediate post-op period, woke neurologically
intact and was extubated on the day of surgery. She remained
hemodynamically stable, and weaned from vasopressor support
following extubation. On POD 1 beta blocker was initiated and
the patient was begun on diuretic therapy. She was transferred
to the telemetry floor for further recovery.
The remainder of her hospital course was uneventful, all tubes,
lines and epicardial pacing wires were discontinued per cardiac
surgery protocol and without complication. The patient worked
with physical therapy service for assistance with strength and
mobility. She continued to make progress and was discharged to
[**Hospital 88766**] Rehab at [**Location (un) 22287**] on POD 4.
She is to followup with Dr [**Last Name (STitle) **] on [**2114-8-29**] at 1:15PM.
Medications on Admission:
Lisinopril 10(1),Omeprazole 20(2),HCTZ 25(1)
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. potassium chloride 20 mEq Packet Sig: One (1) PO Q12H (every
12 hours) for 7 days.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 30191**] Rehabilitation & Nursing Center - [**Location (un) 22287**]
Discharge Diagnosis:
Coronary Artery Disease s/p cabg
PMH:
Hypertension
Gastroesophageal Reflux Disease
PSH:
Right knee replacement x 2
Cholecystectomy ~[**2108**] c/b pancreatitis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Tramadol
Sternal Incision: healing well, no erythema or drainage
Left Leg incision: healing well, no erythema or drainage
Edema ****
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 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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
[**Telephone/Fax (1) 409**] Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2114-8-8**]
10:00AM
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**Hospital Ward Name **] BLDG [**Hospital Unit Name **] [**2114-8-29**] at
1:15PM
Cardiologist Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] pls call for appt in 4
weeks.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 26717**] in [**4-17**] 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**
Provider: [**Name10 (NameIs) **] CARE NURSE #Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2114-8-8**] at 10Am
Completed by:[**2114-8-4**]
|
[
"401.9",
"530.81",
"V43.65",
"V17.3",
"411.1",
"414.01",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7936, 8044
|
5303, 6961
|
320, 552
|
8248, 8464
|
2251, 3919
|
9299, 10174
|
1536, 1589
|
7057, 7913
|
4669, 4711
|
8065, 8227
|
6987, 7034
|
8488, 9276
|
3935, 4629
|
1604, 2232
|
270, 282
|
4743, 5280
|
580, 1147
|
1169, 1322
|
1338, 1520
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,979
| 126,329
|
21365
|
Discharge summary
|
report
|
Admission Date: [**2185-6-7**] Discharge Date: [**2185-6-14**]
Date of Birth: [**2134-4-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increasing dyspnea
Major Surgical or Invasive Procedure:
[**2185-6-7**] Minimally Invasive Mitral Valve Replacement utilizing a
[**Street Address(2) 56457**]. [**Male First Name (un) 923**] mechanical valve
History of Present Illness:
51 yo female with severe MR and increasing dyspnea referred
pre-op for cath prior to valve surgery. Followed with serial
echos, and most recent in [**4-23**] showed worsening MR since [**2180**],
as well as severe pulm. HTN. She also has had intermittent chest
pain with exertion. Cath in [**Month (only) 116**] showed normal coronaries, 4+ MR,
and EF >55%.Referred to Dr. [**Last Name (STitle) 1290**] for surgical
repair/replacement.
Past Medical History:
MVP/MR
[**First Name (Titles) **] [**Last Name (Titles) 2182**]
right benign breast lumpectomy
osteopenia
s/p ectopic pregnancy 20 yrs. ago
thrombosed left femoral pseudoaneurysm
Social History:
30 pack yea history- quit 3 1/2 years ago
lives with her 2 children
divorced
[**1-21**] glasses wine/week
Family History:
? CAD (unclear)
Physical Exam:
NAD, WD,WN
NC/AT, PERRLA, EOMI, OP benign
complete dentures
neck supple, full ROM, no lymphadenopathy or thyromegaly
carotids 2+ Bilat. without bruits
CTAB
RRR 3/6 holosystolic murmur
+ BS, soft, NT, ND, no masses or HSM
no c/c/e, 2+ bilat. peripheral pulses
non-focal neuro exam
Pertinent Results:
[**2185-6-13**] 06:00AM BLOOD WBC-8.1 RBC-3.46* Hgb-11.1* Hct-32.4*
MCV-94 MCH-32.0 MCHC-34.2 RDW-13.6 Plt Ct-292#
[**2185-6-14**] 07:00AM BLOOD PT-23.6* INR(PT)-2.4*
[**2185-6-13**] 06:00AM BLOOD Plt Ct-292#
[**2185-6-13**] 06:00AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-139
K-4.3 Cl-101 HCO3-31 AnGap-11
[**2185-6-13**] 06:00AM BLOOD Calcium-9.1 Phos-4.2# Mg-1.7
REPORT
INDICATION: 51-year-old post-mitral valve replacement with right
leg
weakness.
TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain
without IV
contrast including axial FLAIR, gradient echo, and
diffusion-weighted
sequences. MR angiogram of the brain with 3D time-of-flight and
multiplanar
reformatted images.
No prior studies.
MRI OF THE BRAIN WITHOUT IV CONTRAST: Numerous areas of focal
increased T2
and FLAIR signal intensity are seen within the white matter of
both cerebral
hemispheres as well as in the periventricular white matter
surrounding both
lateral ventricles. Numerous focal rounded areas of
susceptibility artifact
are also seen within the cortex and subcortical white matter of
both cerebral
hemispheres. Some of these may represent flow-related artifact.
There is no
restricted diffusion. No structural brain abnormality is seen on
T1-weighted
images. Ventricles and sulci are normal in appearance.
MR ANGIOGRAM: Normal signal intensity is seen within both
vertebral, both
internal carotid, the basilar, and circle of [**Location (un) 431**] arteries and
branch
vessels. There is a dominant left anteroinferior cerebellar
artery. No flow-
limiting stenosis or area of aneurysmal dilation is seen.
IMPRESSION:
1. MRI [**Location (un) 4059**] small vessel ischemic changes.
2. Areas of susceptibility on gradient echo images may represent
early
amyloid angiopathy or sequela from prior small emboli.
3. MR [**First Name (Titles) 20827**] [**Last Name (Titles) 4059**] no flow-limiting stenosis or
aneurysmal
dilation.
Findings were communicated with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20286**] on the morning of [**6-14**], [**2184**].
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 23303**] [**Doctor Last Name **]
Approved: WED [**2185-6-15**] 5:23 PM
Procedure Date:[**2185-6-14**]
FINAL REPORT
HISTORY: Effusion.
PA and lateral radiographs of the chest demonstrate interval
removal of the
two right jugular central venous catheters seen on [**2185-6-8**].
Prosthetic
cardiac valve is unchanged. There is widening of the
acromioclavicular joint
and probable resection of distal right clavicle. There is no
pneumothorax.
The lungs are clear. Trachea is midline. There is a small
right-sided
pleural effusion.
IMPRESSION:
Interval removal of right jugular central venous catheters. No
pneumothorax.
Resolution of previously described congestive heart failure.
Small persistent
right pleural effusion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: [**Doctor First Name **] [**2185-6-23**] 8:02 AM
Procedure Date:[**2185-6-11**]
FINAL REPORT
INDICATION: Status post mitral valve replacement, evaluate for
right groin
hematoma.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the right groin
were performed.
Common femoral vein and artery appear unremarkable without
evidence of fistula
or pseudoaneurysm. No fluid collections are identified.
Ultrasound over
the patient's area of pain in the right thigh area [**Name (NI) 4059**]
patent vessels
without evidence of abnormal fluid collection.
IMPRESSION: No evidence of right groin hematoma, fistula or
pseudoaneurysm.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2185-6-11**] 11:13 AM
Procedure Date:[**2185-6-10**]
Conclusions
PRE-BYPASS:
1) No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%).
2) Right ventricular chamber size and free wall motion are
normal. The ascending, transverse and descending thoracic aorta
are normal in diameter and free of atherosclerotic plaque.
3) The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
4) there is a long anterior mitral leaflet with a probable
myxomatous appearance. The posterior leaflet is small or
retracted. There is an eccentric regurgitant jet with reversal
in pumonary veins c/w severe mitral regurgitation.
C-[**Month (only) **] distance is 3.0cm. Mitral annulus is 3.7cm.
Post-Bypass (1):
A prosthetic ring is seen in mitral annulus stable in position.
Preserved biventricular systolic function. Aortic contour is
well preserved. There is a mitral regurgitant jet, eccentric
seen well in MVLAX view c/w a moderate or atleast a mild to
moderate regurgitation.
Post-Bypass (2):
A mechanical prosthetic valve is seen in the mitral position,
stable inpositon and both the leaflets are opening and closing
well. Peak transmital gradient is 5mm of Hg and a mean of 3mm of
Hg (immediate post-bypass).
Preserved biventricular systolic function. Aortic contour is
well preserved. Trivial MR and no AI.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
Brief Hospital Course:
Admitted on [**6-7**] and underwent minimally invasive mitral valve
replacement with a mechanical valve. Transferred to the CSRU in
stable condition on titrated phenylephrine and propofol drips.
On nipride and insulin drips on POD #1, and did not extubate
until later in the day. Chest tubes removed that evening and pt.
c/o pain and paresthesia of right inner thigh. Coumadin started
that evening,all drips off, and transferred to the floor on POD
#2 to begin to increase her activity level. Gentle diuresis and
beta blockade started and heparin continued until INR
therapeutic. Neurology consult obtained for right thigh pain on
POD #3. Vascular service also consulted and CT scanning /US
completed for the femoral neuropathy. All exams negative for
hematoma or fluid collection.Neurontin started per neurology and
follow up encouraged with neurology clinic post-discharge.Right
leg pain improved on discharge day with dilaudid. Coumadin
dosing and INR follow up to be done by Dr. [**Last Name (STitle) 30197**]. First blood
draw to be done [**6-16**].
Medications on Admission:
prozac 20 mg daily
trazadone 50 mg daily
albuterol MDI prn
fosamax 70 mg q Monday
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. 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:*0*
3. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) for 10 days.
Disp:*42 Tablet(s)* Refills:*0*
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-24**]
hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): Increase to 100-100-200 in 5 days.
Disp:*90 Capsule(s)* Refills:*2*
9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1
doses: Check INR [**2185-6-16**] with results faxed to Dr. [**Last Name (STitle) 56458**]
office.
Disp:*60 Tablet(s)* Refills:*0*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral Regurgitation - s/p Minimally Invasive Mitral Valve
Replacement([**Street Address(2) 56457**]. [**Male First Name (un) 923**] mechanical valve), Postop
Right Leg Neuropathic Pain, Chronic Obstructive Pulmonary
Disease, Left Femoral Pseudoaneurysm with Thrombosis, Prior
Right Breast Lumpectomy, Osteopenia
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. Call with fever, redness or drainage from incision or
weigh gain more than 2 pounds in one day or five in one week.
No driving until follow up woth surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**3-23**] weeks - call for appt
Dr. [**Last Name (STitle) **] in [**1-21**] weeks - call for appt
Dr. [**Last Name (STitle) 30197**] in [**1-21**] weeks - call for appt
Dr. [**First Name (STitle) **] (Neurology) [**Telephone/Fax (1) 541**]
Dr. [**Last Name (STitle) 30197**] will adjust Warfarin as outpatient. VNA should fax
results to [**Telephone/Fax (1) 19981**]. Please check INR [**2185-6-16**]. Patient will
eventually will have blood drawn at [**Hospital1 **] [**Location (un) 620**] lab when VNA
services have expired.
Completed by:[**2185-7-4**]
|
[
"997.2",
"424.0",
"496",
"E878.1",
"444.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9803, 9861
|
7298, 8354
|
303, 455
|
10218, 10225
|
1595, 7275
|
10507, 11103
|
1261, 1278
|
8486, 9780
|
9882, 10197
|
8380, 8463
|
10249, 10484
|
1293, 1576
|
245, 265
|
483, 920
|
942, 1122
|
1138, 1245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,667
| 149,534
|
51390
|
Discharge summary
|
report
|
Admission Date: [**2122-2-3**] Discharge Date: [**2122-2-21**]
Date of Birth: [**2064-11-7**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides) / Atorvastatin / Nsaids
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Type 1 DM
Major Surgical or Invasive Procedure:
1. pancreas after kidney transplant ([**2122-2-3**])
2. transplant pancreatectomy, SMV & portal vein thrombectomy
([**2122-2-9**])
History of Present Illness:
56-year-old, Caucasian lady with a long history of Type I
diabetes. She underwent a living related donor kidney transplant
in [**2107**] and has had excellent kidney function. She now presents
for pancreas after kidney transplantation.
Past Medical History:
1. DM type 1
2. ESRD
3. s/p living related renal transplant, [**2107**]
4. HTN
5. DM retinopathy
6. s/p vitrectomy
7. depression
8. anterior tibia fx [**2115**]
Social History:
She works as an APRN and is married. She does not smoke or
drink. There is no history of IV drug use. She has a black belt
in karate.
Family History:
Mother with depression, son with hx of alcohol and marijuana
abuse, paternal cousin and his two sons completed suicide.
Physical Exam:
AVSS.
Gen: A&O x3
Chest: CTA B, RRR
Abdomen: S, NT, ND, mild superficial wound dehiscence
Ext: mild pedal edema
Pertinent Results:
[**2122-2-20**] 06:20AM BLOOD WBC-3.4* RBC-2.72* Hgb-8.8* Hct-26.9*
MCV-99* MCH-32.6* MCHC-32.9 RDW-17.7* Plt Ct-246
[**2122-2-20**] 06:20AM BLOOD Glucose-140* UreaN-25* Creat-1.3* Na-139
K-4.2 Cl-107 HCO3-25 AnGap-11
[**2122-2-20**] 06:20AM BLOOD Amylase-31
[**2122-2-20**] 06:20AM BLOOD Lipase-31
[**2122-2-21**] 05:31AM BLOOD Cyclspr-152
Brief Hospital Course:
Patient was brought to the operating room on [**2122-2-3**] for
pancreas after kidney transplant, for details see operative
report. Post-operatively, the patient was monitored in the PACU
and transferred to the floor without insulin drip. She
continued to do well.
On POD #7, she was noted to have a blood sugar of 476 and was
taken emergently to the OR for exploration. For details, see
operative note. In summary, the patient had a thrombosed,
necrotic pancreas and transplant pancreatectomy as well as SMV &
portal vein thrombectomy was performed. The patient was kept
intubated and transferred to the ICU, and experienced some
problems with agitation and delirium. She was ultimately
diuresed, extubated and mental status was improved. CT of the
head on ([**2122-2-11**]) showed no anatomical cause of mental status
change.
The patient was then monitored on the floor and maintained on
TPN until bowel function returned. Psychiatry was consulted and
made medication adjustments for her delirium, which improved and
also for psychosocial counseling. Her wound did have a small
skin dehiscence, but no fascial dehiscence and it was packed
with wet-to-dry dressings. [**Last Name (un) **] diabetes service was
consulted and restarted her insulin pump for glycemic managment.
Ultimately, the patient was discharged to home on PODs #18/10
tolerating a regular diet, in adequate pain control, and alert
and oriented.
Medications on Admission:
1. Neoral 75 mg [**Hospital1 **]
2. Imuran 100 mg QD
3. prednisone 3 mg QOD
4. captopril 50 mg [**Hospital1 **]
5. methyldopa 1 mg [**Hospital1 **]
6. bupropion SR 100 mg [**Hospital1 **]
7. Effexor 75 mg [**Hospital1 **]
8. clonazepam 0.5 mg TID
9. Pepcid 20 mg [**Hospital1 **]
10. Oscal [**Hospital1 **]
11. vitamin C
12. FeSO4
13. MVI
14. insulin pump
15. Humalog
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO QOD ().
3. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
1. DM I
2. s/p renal tranplant [**2107**]
3. depression/anxiety
4. wound infection, superficial wound dehiscence
5. failed pancreas transplant, s/p transplant pancreatectomy
Discharge Condition:
Stable. Glucose controlled by insulin pump. Wound without
cellulitis, packed with wet-to-dry dressing.
Discharge Instructions:
Call Transplant Office [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, inability to take medications, increased redness of
incision or drainage from incision, or any questions. Resume
regular lab schedule. No heavy lifting. [**Month (only) 116**] shower.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Date/Time:[**2122-3-12**] 11:30
Call tranplant office [**Telephone/Fax (1) 673**] to schedule follow up in am
Completed by:[**0-0-0**]
|
[
"V53.91",
"518.5",
"293.0",
"682.2",
"287.5",
"452",
"V42.0",
"280.9",
"996.86",
"250.83",
"401.9",
"781.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"00.93",
"38.06",
"52.6",
"99.15",
"96.71",
"52.82",
"96.04",
"38.93",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
4055, 4061
|
1708, 3139
|
326, 458
|
4279, 4385
|
1343, 1685
|
4708, 4935
|
1075, 1196
|
3557, 4032
|
4082, 4258
|
3165, 3534
|
4409, 4685
|
1211, 1324
|
277, 288
|
486, 724
|
746, 908
|
924, 1059
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,582
| 112,961
|
54064
|
Discharge summary
|
report
|
Admission Date: [**2197-3-8**] Discharge Date: [**2197-3-9**]
Date of Birth: [**2118-11-7**] Sex: F
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
woman initially transferred from [**Hospital6 4620**] to
the Emergency Department at [**Hospital1 188**] for management of pneumonia and respiratory failure.
The patient has multiple medical problems to include
schizophrenia, dementia, Parkinson's Disease, and atrial
fibrillation. The patient was status post right above the
knee amputation on [**2-17**], at [**First Name8 (NamePattern2) 1495**] [**Hospital **]
Hospital. Following this procedure, she was transferred to
[**Hospital 110826**] Health and Rehabilitation Center.
While at the rehabilitation center, the patient was noted to
be febrile to 103.2 F., diaphoretic and short of breath.
She was then transferred to [**Hospital6 4620**] for
further work-up. At that hospital, she was noted to be
hypertensive, tachycardic, tachypneic, with a decreased
oxygen saturation. Chest x-ray disclosed evidence for right
upper lobe, left lower lobe infiltrates. Therefore, the
patient was intubated and pan cultured; given a dose of
Zosyn. Her labs were notable for an elevated white blood
cell count at 23.8. Chemistries were notable for
hypernatremia with a sodium of 155, an elevated BUN and
creatinine 48, 1.0.
The patient was transferred to [**Hospital1 188**] for further management of her respiratory failure. On
presentation to the Emergency Department at [**Hospital1 346**], the patient's temperature was 101.2
F.
PAST MEDICAL HISTORY:
1. Schizophrenia.
2. Parkinson's Disease.
3. Atrial fibrillation.
4. PEG tube placed [**2197-2-8**], at [**First Name8 (NamePattern2) 1495**] [**Hospital **]
Hospital.
5. Status post cerebrovascular accident.
6. Status post right above the knee amputation for dry
gangrene. The procedure was done on [**2-17**], at [**First Name8 (NamePattern2) 1495**]
[**Hospital **] Hospital.
7. Status post cerebrovascular accident.
8. Status post right above the knee amputation for dry
gangrene. The procedure was done on [**2-17**], at [**First Name8 (NamePattern2) 1495**]
[**Hospital **] Hospital.
9. Status post third degree burns sustained in the [**2153**]
during an accident.
10. Status post pacer placement.
11. Gastroesophageal reflux disease.
12. Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Hydrochlorothiazide 12.5 mg p.o. q. day.
2. Digoxin 0.125 mg p.o. q. day.
3. Catapres 0.1 microgram patch q. week.
4. Colace 100 twice a day.
5. Senna two q. day.
6. Restoril 15 q. h.s.
7. Ativan 0.25 q. h.s.
8. Metoprolol 150 twice a day.
9. Lisinopril 40 q. day.
10. Norvasc 10 q. day.
11. Albuterol and Atrovent nebulizers p.r.n.
12. Prazosin 4 q. day.
13. Jevity tube feeds, 60 cc per hour.
14. Multivitamin, one q. day.
15. Artificial tears.
16. Zyprexa 20 q. h.s.
17. Abilify 10 q. h.s.
SOCIAL HISTORY: The patient resides in a rehabilitation.
Per son, the patient has an extensive smoking history. The
patient's family contact is her son, [**Name (NI) 1193**] [**Name (NI) 1557**],
[**Telephone/Fax (1) 110827**].
FAMILY HISTORY: Not known.
PHYSICAL EXAMINATION: In general, a chronically ill
appearing female lying in bed, intubated. Vital signs were
temperature of 101.0 F.; blood pressure 140/80; heart rate
92; respiratory status - the patient on assist control
ventilation, total volume 400, respiratory rate 12, FIO2
100%, PEEP 5, O2 saturation 96%. HEENT: The pupils are
sluggish, Periorbital burn scar. Endotracheal tube in
place. Mucous membranes were dry. Neck with left IJ line in
place. Heart is irregularly irregular, S1, S2, no murmurs,
rubs or gallops. Lungs with coarse breath sounds anteriorly.
Abdomen is soft, nontender, nondistended, positive bowel
sounds. G-tube in place. Extremities with right stump,
black ulceration, left heel; left pretibial ulcer.
Contractures of upper extremities. Neurologic: The patient
is intubated and sedated, unable to cooperate with
neurological examination. Skin with burn scars present on
face, torso and upper extremities.
LABORATORY: On presentation, white blood cell count 24.9,
hemoglobin 8.7, hematocrit 29.6. Differential 84%
neutrophils, 12% bands, 3% lymphs, platelet count 610. PT
13.8, PTT 19.9, INR 1.3.
Chemistries with sodium 154, potassium 3.0, chloride 115,
bicarbonate 27, BUN 43, creatinine 0.9 with a glucose of 106.
Initial CK MB 2, troponin T 0.07, magnesium 1.7, digoxin
level 1.0. Initial blood gas 7.40, pCO2 44, pO2 68, lactate
2.7.
EKG: Atrial fibrillation at 80 beats per minute, QT 362, QT
corrected 391, downsloping ST segments in II, III, AVF, V3
through V6. Normal axis. Consider anteroseptal infarction.
RADIOLOGY: Chest x-ray with aspiration versus multifocal
pneumonia with consolidations in the left lower lobe and
right lower lobe, endotracheal tube in place. Left internal
jugular venous catheter tip within the left brachiocephalic
vein.
IMPRESSION: This is a 78 year old woman with multiple
medical problems including atrial fibrillation, dementia, and
schizophrenia, transferred from [**Hospital3 1196**] to
[**Hospital1 69**] for management of
respiratory failure. Chest x-ray notable for right lower
lobe and left lower lobe infiltrates.
Labs significant for hypernatremia and elevated white count.
PLAN:
1. RESPIRATORY FAILURE: The patient initially was admitted
to the Medical Intensive Care Unit for management of her
respiratory failure thought to be secondary to aspiration
pneumonia. The patient remained on assist control mechanical
ventilation. Sputum culture was obtained. She was continued
on Zosyn for broad spectrum coverage. She continued on
Albuterol, Atrovent nebulizer treatments. Her sputum culture
grew Methicillin resistant Staphylococcus aureus; therefore,
on the subsequent day, Vancomycin was added to the patient's
regimen.
The patient was also noted to have a Klebsiella urinary tract
infection. The Klebsiella was initially thought to be beta
lactamase resistant, so the patient was changed to meropenem
and Vancomycin. The patient self extubated on [**3-4**],
her respiratory status improved. She was weaned off
supplemental oxygen. The patient was transferred to the
Medical Floor on [**3-4**].
2. INFECTIOUS DISEASE: As noted above, the patient was
noted to have a Methicillin resistant Staphylococcus aureus
pneumonia and a klebsiella urinary tract infection. There
was also concern about possible postoperative infection of
the patient's right stump.
The Infectious Disease Service was involved in managing the
patient's antibiotic regimen. As noted above, the patient
remained on Vancomycin for her Methicillin resistant
Staphylococcus aureus pneumonia. The patient is to complete
a three week course of treatment for this pneumonia.
Regarding the patient's Klebsiella urinary tract infection,
initially it was thought that the Klebsiella was beta
lactamase resistant; however, further sensitivities revealed
that this organism was sensitive to Ceftriaxone.
On [**3-4**], however, the patient developed a peripheral
eosinophilia. The Infectious Disease Service thought that
this reaction might be due to beta lactin antibiotics;
therefore, the patient was changed from ceftriaxone to
Aztreonam. The patient to complete a two week course of
Aztreonam for her Klebsiella urinary tract infection.
Given persistently elevated white count, the patient
underwent a CT scan of her right stump to rule out the
presence of a fluid collection. No focal fluid collection
was identified within the right lower extremity.
Finally, on [**3-5**], the patient was noted to have
Candiduria. The patient's Foley catheter was changed. She
was started on a seven day course of fluconazole.
3. FLUIDS, ELECTROLYTES AND NUTRITION: On admission, the
patient was noted to be hypernatremic with a sodium of 155.
The patient was thought to be volume depleted. She was
hydrated and given free water boluses for her PEG tube. The
patient was also maintained on her tube feeds and a nutrition
consultation was obtained for assistance with tube feeds.
The patient started Probalan, 50 cc per hour. The patient
was maintained on aspiration precautions during her hospital
stay.
4. CARDIOVASCULAR: Pump - On admission the patient's
anti-hypertensive medications were initially held; then they
were reintroduced and then required further titration during
her hospital stay. The patient is currently on Metoprolol
100 three times a day, Lisinopril 40 twice a day,
Hydrochlorothiazide 25 q. day; Norvasc 10 q. day; and
Clonidine patch 0.2 mg patch weekly. The patient also
remains on her digoxin 125 micrograms q. day. Digoxin level
was within normal limits during this hospital admission.
Coronary artery disease: The patient was noted to have
elevated troponin on admission. CK remained flat. It was
thought that this elevated troponin was secondary to demand
ischemia.
Rhythm: The patient has a history of atrial fibrillation
with pacer. The patient's heart rate was stable during this
admission. She remains on her digoxin and beta blocker.
The patient is not on anti-coagulation given history of
cerebrovascular hemorrhage.
5. VASCULAR: As noted above, there was concern for a
possible postoperative wound infection in the patient's right
stump. Vascular Surgery was consulted for evaluation of this
area as well as a left pretibial ulcer. Vascular surgery
recommended multi-Podis boots to decrease skin breakdown.
They also provided recommendations regarding dressing
changes. On [**3-7**], Vascular Surgery took the patient
to the Operating Room for revision of the right above the
knee amputation stump. The area was debrided and revised.
6. GASTROINTESTINAL: The patient was maintained on a proton
pump inhibitor and bowel regimen during her hospital stay.
At one point, she was noted to have elevated liver function
tests including alkaline phosphatase. These elevated liver
enzymes were thought to be secondary to medication or sepsis.
Liver function tests have trended down during her hospital
stay.
7. PSYCHIATRIC: The patient has a history of schizophrenia.
She was maintained on her psychiatric medications during her
hospital stay to include Zyprexa, Abilify and Ativan as
needed.
8. HEMATOLOGIC: The patient was noted to be anemic during
her hospital stay. Iron studies were sent off and it was
felt that it was an anemia secondary to chronic disease. Of
note, the patient underwent an esophagogastroduodenoscopy at
the outside hospital recently. Esophagogastroduodenoscopy
disclosed erosive gastritis.
9. PROPHYLAXIS: The patient was maintained on subcutaneous
heparin during her hospital stay. She was also maintained on
proton pump inhibitor and bowel regimen.
10. ACCESS: The patient had a left internal jugular vein
catheter during her hospital stay. A PICC line was placed in
the right basilic vein on [**3-8**].
11. CODE STATUS: The patient remains full code.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Klebsiella urinary tract infection.
2. Methicillin resistant Staphylococcus aureus pneumonia.
3. Candiduria.
4. Possible beta lactate allergy.
5. Hypertension.
6. Atrial fibrillation.
7. Peripheral vascular disease, status post revision of
right above the knee amputation stump.
8. Hypertension.
9. Schizophrenia.
10. Dementia.
DISCHARGE MEDICATIONS:
1. Albuterol one to two puffs inhaled q. six hours as
needed.
2. Atrovent two puffs four times a day.
3. Multivitamin one tablet p.o. q. day.
4. Albuterol one nebulizer q. six hours.
5. Lopressor 100 mg three times a day.
6. Atrovent nebulizer q. six hours p.r.n.
7. Lisinopril 40 twice a day.
8. Hydrochlorothiazide 25 q. day.
9. Norvasc 10 q. day.
10. Clonidine 0.2 patch weekly.
11. Digoxin 0.125 micrograms q. day.
12. Aspirin 325 q. day.
13. Colace 15 ml twice a day.
14. Senna one twice a day.
15. Abilify 10 q. day.
16. Olanzapine 20 q. day.
17. Ativan 0.5 to 1 mg q. four hours p.r.n.
18. Vancomycin 1 gram q. 18 hours times eleven days.
19. Aztreonam 1 gram q. eight hours times four days.
20. Fluconazole 100 mg p.o. times five days.
21. Lansoprazole 30 q. day.
22. Subcutaneous heparin 5000 units twice a day while
hospitalized.
DISCHARGE INSTRUCTIONS:
1. The patient's son will arrange follow-up with a physician
within one week after discharge.
2. Dressings changes right above the knee amputation, gauze
dry dressings should be changed daily.
3. For patient's left tibial ulcer, wet-to-dry dressing
changes q. day.
4. Tube feeds, Probalan full strength, 50 cc per hour.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2197-3-8**] 16:47
T: [**2197-3-8**] 17:03
JOB#: [**Job Number 110828**]
|
[
"707.14",
"295.90",
"482.41",
"V09.0",
"427.31",
"997.62",
"276.0",
"599.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.72",
"84.3"
] |
icd9pcs
|
[
[
[]
]
] |
3198, 3210
|
11114, 11455
|
11478, 12328
|
12352, 12956
|
3233, 11068
|
11084, 11093
|
183, 1598
|
1620, 2950
|
2967, 3181
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
252
| 193,470
|
23645
|
Discharge summary
|
report
|
Admission Date: [**2133-8-15**] Discharge Date: [**2133-8-19**]
Date of Birth: [**2078-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
vomiting blood
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy with banding of varices
History of Present Illness:
55 y/o M w/hx of alcoholic cirrhosis and grade II esophageal
varices, w/recent MICU admission [**3-28**] for UGIB, who presented to
OSH with hematemesis. He reports that he was in his USOH and
feeling well until this evening. He was drinking iced coffee
with his daughter and began to feel vaguely nauseous. He was at
his daughter's house, and so he went home. When he stood up, he
felt very "hot", and then he vomited approximately [**1-25**] cup of
bright red blood. He called EMS and was taken to [**Hospital3 18201**]. For other review of systems, he occasionally
has a mild increase in his abdominal girth with some associated
tenderness, but none recently. He denies any fevers or chills.
He has some occasional lower extremity edema in the RLE
*
At [**Location (un) **], he was afebrile, tachycardic to 123, bp 95/49. His
labs there were significant for a Hct of 19.4 (from 29 2 days
ago in liver clinic), platelets 150, WBC 14. His creatinine was
1.4 (1.0 on recent check in Liver clinic). His INR was 2.1. He
also had a lipase of 243. He received Vit K 10 mg SQ, protonix
40 mg IV, octreotide bolus and gtt, 3.5 L NS. He was transfused
2 U PRBCs. He had several episodes of vomiting black emesis
with clots and was subsequently medflighted to [**Hospital1 18**].
*
In our ED, he remained tachycardic but has a stable bp in the
120s. Labs were drawn and revealed a Hct of 25, INR 1.5, Plt
117. Creatinine was 1.0. He had an NG lavage which did not
clear after 2L. He was admitted to the MICU.
.
MICU course:
UGIB - EGD done [**8-15**] showing non bleeding varices, 3 bands
placed. Resuscitated with fluid but still tachycardic; TSH
checked, .77, 2.5. Received 4 units RBC in [**Hospital1 18**] (+2 at
[**Location (un) **]) c HCT on txf (28.2-30.9), 1 unit FFP. Tx c PPI IV,
octreotide drip, levofloxacin for sepsis prophylaxis in
cirrhotics with variceal bleed
.
Cirrhosis - Nadolol, lactulose held in setting of low BP and
acute bleed. Lactulose started once hct stable. RUQ u/s c
dopplers done to assess portal flow. Pt. creatinine stable
0.9-1.0; not likely hepatorenal in MICU.
.
On questioning, pt. denies any abdominal pain, nausea, vomiting,
hematemesis, only has had 1 BM since arrival to hospital. Has
appetite, drinking clear fluids currently.
Past Medical History:
Past Med Hx:
1. Alcoholic cirrhosis: had 3 week hospital stay here in [**Month (only) 958**]
[**2133**], where he presented with hematemesis. Was intubated in
MICU, had EGD x3 which showed grade II esophageal varices (not
bleeding, had scarring in [**3-27**] cm of distal esophagus which were
felt consistent with prior endoscopic therapy), and portal
gastropathy. Actual source of bleeding never found, pt never
had endoscopic intervention here. Had abd u/s at that time
which showed patent portal vein. Also had a Swan at the time
which per report did not reveal a cardiac cause of his
hypotension. TTE normal.
2. left Femoral DVT, rx w/IVC filter (clot was felt to be due to
femoral cordis)
3. VRE UTI during [**3-28**] hosp
Social History:
Soc Hx: Was a heavy drinker until prior hospitalization in
[**2133-3-24**]. Smoked 2 ppd x 20 yrs, now smokes 10 cigs/day.
Lives at home alone, daughter lives one mile away.
Family History:
no history of liver disease
Physical Exam:
T: 98.4 BP: 129/72 P: 104 R: 12 O2 sat: 98% RA
Gen: awake, alert and oriented male in no acute distress
HEENT: NC, AT. NGT in place. Sclerae mildly icteric. PERRL.
MMM.
Neck: supple, no LAD.
Lungs: Mild inspiratory crackles at R base, o/w CTA
bilaterally.
CV: tachycardic, regular, no m/r/g.
Abd: mildly distended, nontender, no fluid wave. + bs.
Ext: trace R ankle edema, o/w no peripheral edema, good distal
pulses bilaterally
Skin: warm and dry. Erythema over superior chest, no palmar
erythema.
Neuro: moving all extremities well. No asterixis.
PE on txf from MICU:
VS - 98.8, 82, 119/52, 17, 98% RA
HEENT - sclerae anicteric, conjunc. pink, EOMI
Lungs - CTA at apices, bases
Abd - soft, NT, + hepatmegaly (8-9 cm in length by percussion),
+ spider angiomas over sternum, spleen not palpable
Heart - RRR, S1, S2
Ext - +palmar erythema, trace edema to ankles b/l, pneumoboots
on
Neuro - A* O * 3, no asterixis
Pertinent Results:
Labs at [**Location (un) **]:
WBC 14 (67 polys/2 bands), Hct 19 (MCV 100), Plt 150
Na 142, K 5.1, Cl 108, Bicarb 25, BUN 28, Creat 1.4, Glc 104
Calcium 8.2, albumin 2.1, total protein 5.4
Tot bili 0.8, alk phos 134, ALT 26, AST 25, amylase 29, lipase
243
.
[**2133-8-15**] 02:25AM BLOOD WBC-15.1*# RBC-2.80* Hgb-8.9* Hct-25.9*
MCV-93 MCH-31.8 MCHC-34.4 RDW-17.4* Plt Ct-117*
[**2133-8-15**] 06:00AM BLOOD WBC-13.0* RBC-2.50* Hgb-8.0* Hct-23.8*
MCV-95 MCH-31.9 MCHC-33.6 RDW-18.0* Plt Ct-105*
[**2133-8-18**] 05:53AM BLOOD WBC-9.7 RBC-3.31* Hgb-10.4* Hct-30.2*
MCV-91 MCH-31.3 MCHC-34.4 RDW-17.0* Plt Ct-91*
[**2133-8-18**] 08:00PM BLOOD Hct-32.2*
[**2133-8-19**] 06:00AM BLOOD WBC-7.9 RBC-3.36* Hgb-10.8* Hct-30.4*
MCV-90 MCH-32.0 MCHC-35.4* RDW-16.7* Plt Ct-96*
.
[**2133-8-15**] 02:25AM BLOOD PT-15.0* PTT-29.4 INR(PT)-1.5
[**2133-8-15**] 02:25AM BLOOD Plt Ct-117*
[**2133-8-19**] 06:00AM BLOOD PT-13.6* PTT-28.8 INR(PT)-1.2
[**2133-8-19**] 06:00AM BLOOD Plt Ct-96*
.
[**2133-8-15**] 02:25AM BLOOD Glucose-98 UreaN-29* Creat-1.0 Na-143
K-5.6* Cl-114* HCO3-22 AnGap-13
[**2133-8-15**] 06:00AM BLOOD Glucose-109* UreaN-30* Creat-1.0 Na-144
K-4.6 Cl-113* HCO3-24 AnGap-12
[**2133-8-19**] 06:00AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-138
K-3.7 Cl-108 HCO3-23 AnGap-11
.
[**2133-8-15**] 02:25AM BLOOD Albumin-2.6*
[**2133-8-15**] 06:00AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.6
.
[**2133-8-18**] 05:53AM BLOOD Free T4-0.7*
[**2133-8-15**] 06:00AM BLOOD TSH-0.77
.
RUQ U/S c Doppler:
The liver has a heterogenous echotexture and nodular surface
contour suggestive of underlying cirrhotic change. No focal mass
lesion demonstrated.
Doppler assessment of the hepatic vasculature shows patent left,
right and main portal veins with normal directional flow. The
left middle and right hepatic veins and inferior vena cava are
patent with normal spectral waveform on Doppler. Right, left,
and main hepatic arteries are demonstrated with a good systolic
upstroke.
There is a moderate amount of intra-abdominal ascites, which
appears simple on [**Month/Day/Year 950**]. The common bile duct is prominent
in diameter at 7 mm but there is no intrahepatic biliary
dilatation. A number of small echogenic gallstones are noted in
the dependent portion of the gallbladder, which is nondistended
and non-thickened.
The splenic and superior mesenteric veins are patent on color
Doppler flow.
Brief Hospital Course:
UGIB - this was thought likely [**2-25**] to portal
gastropathy/esophageal varices. He has not been banded in the
past. Since his NG lavage did not clear after 2 L, persistent
coffee grounds, dark brown liquids, he was transferred to the
MICU. He received IVF, 4 units of pRBCs and he remained HD
stable. He underwent EGD in the morning after admission to the
MICU as described above under HPI. He was transferred to the
floor after he had been HD stable c no further episodes
hematemesis, BRBPR, and c a stable hematocrit. On the floor, he
had one episode of BRBPR but remained HD stable c a stable crit.
He was continued on his levaquin regimen started in the MICU
for a 7 day course (day [**7-30**], [**8-21**]). He was taken off the
octreotide drip and switched to PO protonix. He was discharged
with a plan for EGD with banding on Monday, [**2133-8-24**], c Dr.
[**Last Name (STitle) **].
.
Cirrhosis: According to discharge summary from [**2133-3-24**], pt
was supposed to be on Nadolol, lactulose, protonix but pt
reported that he is only taking nortriptyline. He was started
on nadolol on transfer to the floor. He was maintained on
lactulose. An abdominal U/S c Dopplers was done (see above).
He did not become hepatorenal. He was discharged with
prescriptions for lactulose and nadolol.
.
TCA use: The pt. came in using nortryp.; this was d/w his PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 28583**]. He was started on this for peripheral neuropathy
[**2-25**] Etoh use. He reported minimal paresthesias in his feet and
no recent Etoh use; it was thought better to stop this
medication in this context.
.
Thyroid studies: In the MICU, the question was raised that he
may be hyperthyroid given his elevated HR despite fluid
resuscitation. A TSH and free T4 were checked. One TSH level
was low, another normal. A free T4 level was low. His HR came
down on transfer to the floor and we did not pursue further
workup for hyperthyroidism given his low T4.
.
IVC filter: A discussion was had c the IR resident who was
involved in the placement of his IVC filter; a trapease filter
as he has is usually a permanant filter.
Medications on Admission:
Nortriptyline
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Upper Gastrointestinal Bleed
2. Alcoholic Cirrhosis
Discharge Condition:
Good
Discharge Instructions:
You should contact your PCP or go to the Emergency Room if you
continue to have any more episodes of bloody vomiting, bloody
stools, bright red blood in the stool, light headedness,
dizziness, chest pain, shortness of breath. You should take all
your medications as prescribed and keep all your appointments
with health care providers.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on Monday, [**2133-8-24**] at
10:00 AM for an EGD with banding. You should not eat anything
after midnight the night before the procedure. You will need to
arrange for a ride home after the procedure on [**2133-8-24**]. The
appointment is listed below:
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2133-8-24**]
10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2133-8-24**] 10:00
You also have the following other appointments listed below:
Provider: [**Name10 (NameIs) **] Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2133-10-12**] 8:30
|
[
"789.5",
"571.2",
"285.1",
"456.20",
"357.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9916, 9922
|
7055, 9221
|
328, 381
|
10029, 10035
|
4658, 7032
|
10420, 11401
|
3662, 3691
|
9285, 9893
|
9943, 10008
|
9247, 9262
|
10059, 10397
|
3706, 4639
|
274, 290
|
409, 2694
|
2716, 3453
|
3469, 3646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,181
| 192,529
|
53099
|
Discharge summary
|
report
|
Admission Date: [**2145-12-13**] Discharge Date: [**2145-12-20**]
Date of Birth: [**2073-11-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Abdominal aortic aneurysm, status post a failed endovascular
repair.
Major Surgical or Invasive Procedure:
1. Removal of aortic Endograft.
2. Resection of infrarenal abdominal aortic aneurysm
History of Present Illness:
This is a 72-year-old male who
presented in [**2136**] with an abdominal aortic aneurysm that was
repaired with an endovascular graft. Postoperatively, he had
a persistent endoleak despite coiling of his [**Female First Name (un) 899**]. As the
aneurysm sac continues to enlarge, he was consented for
removal of the Endograft and resection of the aneurysm.
Past Medical History:
PMH: AAA, Afib, MVP, HTN, COPD, DM2
PSH: EVAR 01, endoleak repair 09, MVR (tissue valve)
Social History:
not known
Family History:
not known
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:
[**2145-12-20**] 06:00AM BLOOD
WBC-15.0* RBC-2.71* Hgb-8.7* Hct-25.0* MCV-92 MCH-32.0 MCHC-34.6
RDW-15.8* Plt Ct-198
[**2145-12-20**] 06:00AM BLOOD
PT-21.6* PTT-28.4 INR(PT)-2.0*
[**2145-12-20**] 06:00AM BLOOD
Glucose-139* UreaN-24* Creat-1.0 Na-137 K-3.8 Cl-101 HCO3-27
AnGap-13
[**2145-12-20**] 06:00AM BLOOD
Calcium-8.2* Phos-2.9 Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname **],[**Known firstname **] J. was admitted on [**12-13**] with failed
endograft. He agreed to have an elective surgery.
Pre-operatively, he was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preparations were
made.
It was decided that she would undergo a:
OPERATIONS:
1. Removal of aortic Endograft.
2. Resection of infrarenal abdominal aortic aneurysm.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
He was then transferred to the VICU for further recovery. While
in the VICU he received monitored care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabilized from the acute setting of post operative care,
he was transferred to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home in stable
condition.
To note pt febrile with increase WBC. Pan Cx'd., found to have a
UTI. On Cipro x 5 days.
Medications on Admission:
Coumadin 5', Atenolol 50', amlodipine 5', quinapril 40', HCTZ
12.5', Lipitor 20', Actos 30', fluoxetine 20", ambien prn
Discharge Medications:
1. 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*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 1 doses.
Disp:*30 Tablet(s)* Refills:*1*
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever/pain.
11. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
failed endograft repair
Discharge Condition:
afebrile, vital stable signs, stable on his feet but needs
additional physical therapy at home, alert and oriented
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-31**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**1-26**]
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
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? 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:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
****Resume your normal routine for checking your INR levels and
having the dose adjusted by your PCP************
Followup Instructions:
please call Dr.[**Name (NI) 1392**] office to schedule a follow up appt
in [**12-25**] weeks.
-Please call your PCP to make sure they are back to following
your INR levels and adjusting your coumadin dose
Completed by:[**2145-12-20**]
|
[
"427.31",
"V58.61",
"E878.2",
"401.9",
"996.1",
"424.0",
"599.0",
"285.9",
"496",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"39.52"
] |
icd9pcs
|
[
[
[]
]
] |
4609, 4670
|
1895, 3265
|
387, 474
|
4738, 4855
|
1524, 1872
|
7709, 7946
|
1017, 1028
|
3435, 4586
|
4691, 4717
|
3291, 3412
|
4879, 7143
|
7169, 7686
|
1043, 1505
|
278, 349
|
502, 861
|
883, 974
|
990, 1001
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,370
| 151,490
|
49827
|
Discharge summary
|
report
|
Admission Date: [**2103-3-3**] Discharge Date: [**2103-3-10**]
Date of Birth: [**2028-10-30**] Sex: M
Service: MEDICINE
Allergies:
Remeron
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line placement
History of Present Illness:
73 yo M with h/o lung cancer (carcinoid)in [**2100**], s/p right
thoracotomy with RUL, RML labectomy,w/ resulting restrictive
lung disease, Colon CA s/p resection with neg colonoscopy 2
years ago), CAD s/p CABG '[**86**], recently discharged 3 days ago
from [**Hospital1 18**] (CCU--> floor for CHF exacerbation) who was doing
well at home for 1 day but over the last day has had increasing
dyspnea with 02 requirement (SP)2 of mid 80's on 2-4L NC which
improved w/ nebs). o/n, given valium for sleep and then this AM
had decreased 02 sats to 70's and EMS called. Arrived in ED w/
02 sats 80's on NRB and was intubated. Given additional 80iv
lasix by EMS (+ daily 60qd in AM). Started on propofol drip and
subsequently had drop in BPs to SBP of 60'2 and dopamine was
started at 7.5. Denies fever, chills, nausea, vomiting,
abdominal pain, chest pain, dysuria. Able to take in po's.
Past Medical History:
Carcinoid tumor of the lung s/p RML/RLL resection
Melanoma
Congestive Heart Failure
Restrictive lung disease by PFTs
CAD
Colon CA
History of hepatitis/ascites after antidepressant use(?)
Social History:
Lives in [**Location 745**] with wife. Was a business man by trade. Has
three daughters actively involved in his healthcare. No alcohol
or tobacco use.
Family History:
non contributory
Physical Exam:
Deceased.
Apneic, pulseless.
Pertinent Results:
[**2103-3-3**] 10:26PM TYPE-ART TEMP-37.6 PO2-245* PCO2-63* PH-7.48*
TOTAL CO2-48* BASE XS-20
[**2103-3-3**] 10:26PM LACTATE-1.1
[**2103-3-3**] 09:18PM TYPE-ART TEMP-38.0 PO2-450* PCO2-51* PH-7.60*
TOTAL CO2-52* BASE XS-24
[**2103-3-3**] 09:18PM LACTATE-1.3
[**2103-3-3**] 09:18PM freeCa-1.05*
[**2103-3-3**] 05:51PM TYPE-ART TEMP-38.9 PO2-376* PCO2-57* PH-7.55*
TOTAL CO2-51* BASE XS-23
[**2103-3-3**] 05:51PM GLUCOSE-83 LACTATE-1.2
[**2103-3-3**] 05:51PM freeCa-0.98*
[**2103-3-3**] 05:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2103-3-3**] 05:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-NEG
[**2103-3-3**] 05:40PM URINE RBC-[**4-7**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2103-3-3**] 05:33PM GLUCOSE-74 UREA N-40* CREAT-0.8 SODIUM-135
POTASSIUM-3.4 CHLORIDE-84* TOTAL CO2-50* ANION GAP-4*
[**2103-3-3**] 05:33PM ALT(SGPT)-160* AST(SGOT)-153* LD(LDH)-333*
CK(CPK)-53 ALK PHOS-68 TOT BILI-1.3
[**2103-3-3**] 05:33PM CK-MB-NotDone cTropnT-0.11*
[**2103-3-3**] 05:33PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-2.9
MAGNESIUM-1.7
[**2103-3-3**] 05:33PM HAPTOGLOB-225*
[**2103-3-3**] 05:33PM OSMOLAL-281
[**2103-3-3**] 05:33PM WBC-12.3* RBC-2.68* HGB-8.5* HCT-24.7*
MCV-92# MCH-31.8 MCHC-34.5 RDW-16.1*
[**2103-3-3**] 05:33PM PLT COUNT-409
[**2103-3-3**] 05:33PM PT-35.2* PTT-41.6* INR(PT)-7.8
[**2103-3-3**] 04:47PM TYPE-ART O2-70 PO2-282* PCO2-52* PH-7.59*
TOTAL CO2-51* BASE XS-25 -ASSIST/CON INTUBATED-INTUBATED
[**2103-3-3**] 01:36PM TYPE-ART PEEP-5 O2-70 PO2-229* PCO2-44
PH-7.57* TOTAL CO2-42* BASE XS-16 INTUBATED-INTUBATED
[**2103-3-3**] 12:48PM TYPE-ART RATES-/16 TIDAL VOL-600 O2-97
PO2-306* PCO2-72* PH-7.38 TOTAL CO2-44* BASE XS-14 AADO2-328 REQ
O2-59 INTUBATED-INTUBATED VENT-CONTROLLED
[**2103-3-3**] 12:25PM LACTATE-3.1*
[**2103-3-3**] 12:00PM GLUCOSE-208* UREA N-47* CREAT-1.0 SODIUM-126*
POTASSIUM-5.0 CHLORIDE-78* TOTAL CO2-40* ANION GAP-13
[**2103-3-3**] 12:00PM CK(CPK)-55
[**2103-3-3**] 12:00PM cTropnT-0.14*
[**2103-3-3**] 12:00PM CK-MB-NotDone
[**2103-3-3**] 12:00PM WBC-14.8* RBC-2.99* HGB-9.9* HCT-29.7*
MCV-99* MCH-33.0* MCHC-33.3 RDW-15.8*
[**2103-3-3**] 12:00PM NEUTS-92.9* BANDS-0 LYMPHS-3.8* MONOS-3.2
EOS-0.1 BASOS-0
[**2103-3-3**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+
TARGET-OCCASIONAL
[**2103-3-3**] 12:00PM PLT SMR-HIGH PLT COUNT-541*#
[**2103-3-3**] 12:00PM PT-35.3* PTT-43.3* INR(PT)-7.8
ECG Study Date of [**2103-3-9**] 6:29:28 AM
Sinus rhythm
Possible inferior infarct - age undetermined
Nonspecific inferolateral T wave flattening
Since previous tracing, T wave flattening and faster heart rate
seen
CHEST (PORTABLE AP) [**2103-3-9**] 5:45 PM
Endotracheal tube is at the thoracic inlet. The cuff appears
slightly overinflated. Internal jugular central venous line is
new and contains a Swan- Ganz catheter, the tip of which is
within the right pulmonary artery. The patient is status post
CABG. The left-sided PICC is in stable position. Again, noted
are patchy bilateral parenchymal opacities, overall unchanged
allowing for differences in technique. There is a moderate sized
right effusion and a small left effusion. There is no
pneumothorax.
Brief Hospital Course:
1. Respiratory failure: Hypoxic resp failure thought most likely
secondary to multifocal/ ? aspiration PNA (given valium). Recent
CCU admission so may be nosocomial, and patient was started on
levofloxacin/Flagyl/CTX/vancomycin. Over hospital course,
patient was in addition thought to be in volume overload with a
component of CHF given h/o CAD, and diuresis was attempted with
success, however limited by hypotension as below.
Further, patient continued throughout MICU course to fail any
attempts to wean ventilation, and tracheostomy was offered.
Patient declined tracheostomy and requested extubation and
withdrawal of care.
2. Hypotension: Likely [**3-7**] combination of hypovolemia and sepsis
and patient was treated with Dopamine infusion. Also thought to
be exacerbated by afib and lack of atrial kick.
3. Atrial Fibrillation: Patient was continued on amiodarone,
which was not felt to contribute to patient's pulmonary issues.
However, patient was noted to be hypotensive when in atrial
fibrillation.
4. CAD: Cont. Statin. Hold ASA given increased INR. Currently in
SR. Will cont. amio change to 200 qd as long QTc. cycle enzymes
(trending down Tnt 0.16).
5. CHF: total body volume overloaded but intravascularly dry.
CVP was elevated following line placement and objective numbers
attained (~[**12-15**]), and patient responded to diuresis, however,
pressures also fell accordingly as above.
On hospital day 7, patient indicated to MICU team and family
that he wished to have care withdrawn and to be extubated. On
hospital day 8, patient was extubated and given comfort measures
only. He expired shortly following extubation with family at
bedside.
Medications on Admission:
amiodarone
lasix
moexipril
metoprolol
aldactone
warfarin
atorvastatin
atrovent
ambien
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxic respiratory failure
Bacterial Pneumonia
Coronary artery disease
Congestive heart failure
Hypotension
Sepsis
Atrial fibrillation
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"V10.05",
"428.0",
"V45.81",
"518.81",
"414.00",
"276.1",
"482.41",
"285.9",
"414.8",
"V10.11",
"995.92",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"99.04",
"96.6",
"38.91",
"96.04",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
6901, 6910
|
5063, 6737
|
295, 343
|
7090, 7100
|
1734, 5040
|
7152, 7158
|
1652, 1670
|
6873, 6878
|
6931, 7069
|
6763, 6850
|
7124, 7129
|
1685, 1715
|
228, 257
|
371, 1254
|
1276, 1464
|
1480, 1636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,700
| 182,174
|
53859
|
Discharge summary
|
report
|
Admission Date: [**2128-9-24**] Discharge Date: [**2128-10-3**]
Date of Birth: [**2055-12-2**] Sex: M
Service: MEDICINE
Allergies:
Oyster Shell / Cardizem
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization x 2
History of Present Illness:
72 yo M c history of CAD s/p mid LAD [**Last Name (LF) **], [**First Name3 (LF) **] 20%, DM2, CRI
baseline cr 2.1, cardiogenic shock.
found to have ST depressions V4-V6, taken to emergent cath.
Found to have 3v-d, wutg
developed pulmonary edema, intubated, became hypotensive after
propofol, transferred to CCU, started dopa gtt
Pt had a resp acidosis 7.0/79/61
.
Echo [**2128-1-7**]:
LV EF 20% mod dilated LV, global dysfxn. E:A 0.92
TR gradient 40 RV nl size/fxn
3+MR, trace AR, [**1-4**]+TR.
.
Cath [**2128-9-24**]:
R dominant system
LMCA: 70% diffuse
LAD: diffuse dz patent [**Month/Day/Year **]. 80% diag.
LCX: total occlusion ostial, R-->L collaterals
Past Medical History:
1. CAD status post multiple interventions. [**2124**]-RCA [**Year (4 digits) **]. [**5-4**]
Cypher [**Month/Year (2) **] to prox. LAD. [**1-6**] NSTEMI s/p PTCA of LAD ISR.
2. CHF, EF 20% 1/04
3. Diabetes mellitus.
4. Status post ICD placement secondary to syncope and V-tach
in setting of an MI.
5. Hypertension.
6. Gallstones.
7. Gout.
8. Chronic renal insufficiency with a baseline creatinine of
1.5-2.4.
Social History:
SOCIAL HISTORY: He is an ex-smoker, quit 30-35 years ago,
and before then had a 2-pack per day history x 15-20 years.
Occasional alcohol, approximately 1 drink a day. Lives with
wife.
Family History:
Both parents died of CAD.
.
ALLERGIES:
Cardizem rash
Oyster
Brief Hospital Course:
.
72 yo M c history of CAD s/p mid LAD [**Last Name (LF) **], [**First Name3 (LF) **] 20%, DM2, CRI
baseline cr 2.1, presented to ED with unstable angina, found to
have ST depressions V4-V6, taken to emergent cath without
intervention, developed pulmonary edema, intubated, became
hypotensive after propofol, transferred to CCU, still with
pressor requirements.
.
Echo [**2128-1-7**]:
LV EF 20% mod dilated LV, global dysfxn. E:A 0.92
TR gradient 40 RV nl size/fxn
3+MR, trace AR, [**1-4**]+TR.
.
Cath [**2128-9-24**]:
R dominant system
LMCA: 70% diffuse
LAD: diffuse dz patent [**Month/Day/Year **]. 80% diag.
LCX: total occlusion ostial, R-->L collaterals
.
. Cardiovascular
PUMP: Cardiogenic Shock.CHF. Initially low CI and high SVR out
of cath [**Month/Day/Year **], Alternately on milrinone +/- dobuta but SVR low,
continued VT, weaned off [**9-30**] PM for SVR in 500s w/ CI [**3-5**]. ?
Numbers today looked worse with increasing SVR and lower C0/CI
(1.35). Sepsis vs med effect, holding MAPs 50s-60s now on
levophed alone. Levophed was attempted to wean, thought
contributory to ar's, started vasopressin. Still on lidocaine.
MAPs still low, sometimes down to 40s, levophed turned back up,
now at 0.183. Last TTE EF 20%, mod-severe MR. [**Name13 (STitle) **] family, LVAD
is no longer an option. IABP is not an option either. CVVHD
currenlty on, patient is still net positive due to all the IV
drips. CO/CI was dropping overnight prior to withdrawal of
care--discussed starting another pressor/ionotrope. During the
last 2 days before withdrawal of care, the MAPs and CI/CO were
dropping despite the max doses of levophed and continious CVVHD
removing fluid every day. Patient's family and HCP decided that
he is not going to be going for LVAD and decided to withdraw
care in agreement with Dr. [**Last Name (STitle) **], patient's cardiologist.
.
ISCHEMIA: s/p NSTEMI, 3v-d on cath. Not a candiadate for CABG as
he has poor targets. Cath [**9-30**] for mid RCA x 3 BMS, LMCA x
Cypher DES . Pt's CKs leveling off depsite the continued shocks
that he is receiving. However, persistent v-fib may be still
related to ischemia. Ultimately, the multiple shocks were
thought to be due to multiple scar foci within the heart, the
territory that was not possible to re-vascularize with multiple
coronary interventions.
.
RHYTHM: Persistent VT/VF while ischemic, and post-cath
reperfusion VT/VF vs ongoing ischemia/demand. EP switched DDI =>
DDD, but PMTs induced => back to DDI. VT controlled with amio
gtt (increased for 1200 mg/d); lido loaded, now, on maintenance
drip. On milrinone right after cath [**Month/Year (2) **], but that was
subsequently stopped since it was thought to be more ar-genic.
2 days prior to CMO, had a series of at least 20 shocks for
going into v-fib. Was re-bolused with amio and lidocaine. Upon
withdrawal of care was on amio and lidocaine drips. Some
ectopy, no runs of vfib/vtack overnight prior to CMO.
.
2. Pulm: Hypoxia. day 7 of intubation, on levo/flagyl for HAP in
RML. gr stain grew out psedomonas, sensies pending. Hemoptysis
from ETT [**10-1**] AM, resolved now, likely high PA pressures/CHF in
setting of suctioning; differential includes PE, evolving
PNA/tracheobronchitis. Patient dropping sats with bloody
suctioning from ETT, PEEP and FiO2 increased, latest gas shows
good oxygenation, satting 97%. During the day continued to
desat, PaO2 75, PEEP and FiO2 increased. Oxygenation
dramatically improved, and CO went up to 4 with higher PEEP.
Since then, PEEP and FiO2 decreased to 10/0.4--however CO/CI has
decreased with the PEEP decreasing. Patient was oxygenating well
when care was withdrawn.
.
3. Renal/FEN: AoCRF on CVVHD. Cr up, UOP down. Likely
maintenance ATN. CVVH now via R fem line. ? CHF vs dye
nephropathy, Cr currenlty dropping with CVVHD. Unable to keep
negative every hour, some hours negative, patient is off CVVHD
with more insult due to recent dye load for cath. decreasing
urine output. goal neg 1-2L/day. There is an issue with CVVH
line clotting/ started on heparin drip to keep line open.
heparin--HIT ab negative. Patient was on CVVHD when care was
removed.
.
4. ID: Hosp aquired PNA (post-intubation aspiration), on
Vanc/Zosyn x 2 days, was on Levo/Flagyl (day 3 on [**10-1**] x 10 day
course). WBC falling, afebrile. Only + U/Cx on [**9-24**] w/ levo-S
enterococcus. Sputum/Cx with PsA, + PMNs. On Zosyn, afebrile [**Doctor First Name **]
care was removed.
.
13. Communication: with wife and family. Care was withdrawn on
Friday, [**2128-10-1**]. Family decline an autopsy.
Medications on Admission:
Meds:
Metoprolol Tartrate 50 mg daily
Isosorbide Dinitrate 20 mg [**Hospital1 **]
Aspirin 325 mg daily
Clopidogrel 75 mg daily
Simvastatin 60mg daily???
Insulin
Furosemide 40 mg QAM
Furosemide 20 mg QPM
Digoxin 125 mcg??? half tab???
Allopurinol 300 mg daily
Folic Acid 1 mg daily
Lisinopril 5 mg daily
SL nitro prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiopulmonary arrest
Discharge Condition:
expired
Completed by:[**2128-10-5**]
|
[
"427.89",
"585.6",
"585.9",
"276.1",
"276.2",
"414.01",
"274.9",
"995.91",
"599.0",
"584.5",
"996.74",
"E879.8",
"507.0",
"E849.8",
"427.41",
"482.1",
"038.9",
"996.04",
"250.00",
"458.29",
"414.8",
"E849.7",
"410.71",
"518.81",
"E879.1",
"785.51",
"428.0",
"424.0",
"427.1",
"041.04",
"790.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"36.06",
"00.13",
"37.23",
"00.40",
"96.72",
"00.45",
"99.15",
"89.64",
"96.04",
"99.04",
"00.66",
"37.22",
"99.20",
"38.93",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6711, 6720
|
1753, 6315
|
303, 332
|
6786, 6824
|
1669, 1730
|
6682, 6688
|
6741, 6765
|
6341, 6659
|
253, 265
|
360, 1020
|
1042, 1451
|
1483, 1653
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,955
| 117,177
|
46484
|
Discharge summary
|
report
|
Admission Date: [**2129-1-19**] Discharge Date: [**2129-2-16**]
Date of Birth: [**2073-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Iodine; Iodine Containing / Amlodipine / Metoprolol
Succinate / Latex
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
valve replacement surgery
History of Present Illness:
55 yo F w/ hx Hodgkin's s/p XRT in [**2094**] p/w severe abd pain x 3
weeks, worse over past week. She reports she woke up the day
after [**Holiday 1451**] (~ 3 weeks ago) w/ LBP. She also had
associated RLQ and LLQ pain. The pain is sharp, non-radiating,
intermittent, no relationship to food, worse when she sits up
and when she walks. She received flexeril and ibuprophen from
her PCP w/out significant relief. She reports "lifelong"
constipation w/ BM [**2-6**]/week, last BM was [**2129-1-18**], (small,
non-diarrheal, non-bloody, non-mucoid). No fevers, chills,
n/v/d, melena, hematochezia, knee, or other joint pain. + 4lb
wt loss/2 weeks. She also reports neck pain x 3 days, no fevers,
no rash, no HA, no photophobia, that is relieved by ibuprofen.
Past Medical History:
1. Hodgkin's Lymphoma in the [**2094**], s/p XRT to mediastinum and
splenectomy (no chemo)
2. PE on anticoagulation but d/c'ed [**3-9**] alveolar hemorrhage, s/p
IVC filter [**2118**]
3. XRT-induced fibrosis and bronchiectasis, no baseline O2
requirement
4. CHF, admitted [**5-9**] with CHF exacerbation
4. s/p MVR, porcine. [**2118**]
5. hypothyroidism
6. s/p CCY
7. GERD
8. EtOH abuse (last drink reportedly mid-[**Month (only) **])
9. Chronic fatigue syndrome
10. abd pain in [**2124**] s/p colonoscopy and CT abd negative
11. s/p E.Coli pyelonephritis [**2111**]
12. constrictive pericarditis s/p pericardial stripping [**2118**]
13. OSA
14. hx ARF
15. Gout
Social History:
unprotected sex over past 7 months after 10 yrs of abstinence.
Has hx of ETOH abuse, but reports no EtOH since "mid [**Month (only) **]."
Family History:
No history of CAD, no hx of clotting disorders
Physical Exam:
Tm: 98.9 Tc: 98.7 BP: 106/48 P: 98 RR: 18 O2sat: 95% on 3L
I/O: [**Telephone/Fax (1) 98754**] Wt: 65.7 kg (no prior weight documented since
arrival on [**Hospital Ward Name 517**])
GEN: thin female in no acute distress, breathing more
comfortably
HEENT: no photophobia, PERRL, OP clear, MMM
Lungs: decreased breath sounds [**2-6**] way up bilaterally, dull to
percussion [**2-6**] way bilaterally, worse than yesterday morning but
improved from last night
CV: RRR, S1/S2, no m/r/g
ABD: BS+, ND, no masses, nontender
EXT: no edema, + palmar erythema, no splinter hemorrhages, no
osler nodes or [**Last Name (un) **] lesions
Pertinent Results:
CBC trend:
[**2129-1-30**] 05:44AM BLOOD WBC-17.1* RBC-3.32* Hgb-9.8* Hct-30.5*
MCV-92 MCH-29.6 MCHC-32.2 RDW-16.4* Plt Ct-457*
[**2129-1-29**] 05:45AM BLOOD WBC-18.6* RBC-3.28* Hgb-9.9* Hct-30.0*
MCV-92 MCH-30.3 MCHC-33.1 RDW-16.3* Plt Ct-402
[**2129-1-28**] 05:32AM BLOOD WBC-18.1* RBC-3.28* Hgb-9.8* Hct-29.9*
MCV-91 MCH-30.0 MCHC-32.9 RDW-16.1* Plt Ct-355
[**2129-1-27**] 04:11AM BLOOD WBC-16.1* RBC-3.39* Hgb-10.1* Hct-30.5*
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.8* Plt Ct-291
[**2129-1-26**] 03:52AM BLOOD WBC-15.4* RBC-3.54* Hgb-10.8* Hct-32.4*
MCV-91 MCH-30.4 MCHC-33.2 RDW-15.6* Plt Ct-261
[**2129-1-25**] 07:30AM BLOOD WBC-21.7* RBC-3.80* Hgb-11.8* Hct-34.8*
MCV-92 MCH-31.0 MCHC-33.9 RDW-15.4 Plt Ct-268
[**2129-1-24**] 06:35AM BLOOD WBC-20.7* RBC-3.92* Hgb-11.5* Hct-34.3*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.4 Plt Ct-258
[**2129-1-23**] 08:15AM BLOOD WBC-24.6* RBC-3.84* Hgb-11.7* Hct-34.1*
MCV-89 MCH-30.6 MCHC-34.4 RDW-15.1 Plt Ct-187
[**2129-1-22**] 09:35AM BLOOD WBC-17.8* RBC-4.15* Hgb-12.4 Hct-36.4
MCV-88 MCH-29.9 MCHC-34.1 RDW-14.4 Plt Ct-161
[**2129-1-21**] 07:00AM BLOOD WBC-15.9* RBC-4.23 Hgb-12.8 Hct-37.1
MCV-88 MCH-30.2 MCHC-34.4 RDW-14.1 Plt Ct-168
[**2129-1-20**] 06:55AM BLOOD WBC-18.0* RBC-3.89* Hgb-11.9* Hct-35.9*
MCV-92 MCH-30.6 MCHC-33.1 RDW-14.7 Plt Ct-179
[**2129-1-19**] 03:20PM BLOOD WBC-15.6*# RBC-4.26 Hgb-13.2 Hct-38.0
MCV-89 MCH-31.0 MCHC-34.7 RDW-14.8 Plt Ct-215#
Chem 10 trend:
[**2129-1-31**] 06:10AM BLOOD Glucose-79 UreaN-17 Creat-1.1 Na-137
K-4.6 Cl-100 HCO3-28 AnGap-14
[**2129-1-30**] 05:44AM BLOOD Glucose-83 UreaN-17 Creat-1.1 Na-138
K-4.9 Cl-99 HCO3-27 AnGap-17
[**2129-1-29**] 05:45AM BLOOD Glucose-95 UreaN-20 Creat-1.3* Na-133
K-4.7 Cl-96 HCO3-26 AnGap-16
[**2129-1-28**] 07:30PM BLOOD UreaN-21* Creat-1.5*
[**2129-1-28**] 05:32AM BLOOD Glucose-94 UreaN-19 Creat-1.4* Na-135
K-4.9 Cl-99 HCO3-26 AnGap-15
[**2129-1-27**] 04:11AM BLOOD Glucose-102 UreaN-13 Creat-1.0 Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
[**2129-1-26**] 03:52AM BLOOD Glucose-112* UreaN-11 Creat-0.9 Na-133
K-3.8 Cl-98 HCO3-25 AnGap-14
[**2129-1-25**] 07:30AM BLOOD Glucose-122* UreaN-11 Creat-0.8 Na-134
K-4.1 Cl-100 HCO3-20* AnGap-18
[**2129-1-24**] 06:35AM BLOOD Glucose-88 UreaN-11 Creat-0.9 Na-131*
K-3.5 Cl-96 HCO3-20* AnGap-19
[**2129-1-23**] 08:15AM BLOOD Glucose-103 UreaN-13 Creat-0.9 Na-131*
K-3.0* Cl-97 HCO3-20* AnGap-17
[**2129-1-22**] 09:35AM BLOOD Glucose-100 UreaN-16 Creat-1.1 Na-128*
K-3.6 Cl-92* HCO3-20* AnGap-20
[**2129-1-21**] 07:00AM BLOOD Glucose-76 UreaN-14 Creat-1.0 Na-135
K-4.1 Cl-101 HCO3-20* AnGap-18
[**2129-1-20**] 06:55AM BLOOD Glucose-79 UreaN-14 Creat-1.0 Na-132*
K-3.2* Cl-99 HCO3-21* AnGap-15
[**2129-1-31**] 06:10AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9
[**2129-1-30**] 05:44AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0
[**2129-1-29**] 05:45AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.5
[**2129-1-28**] 05:32AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.6
[**2129-1-27**] 04:11AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.7
[**2129-1-26**] 03:52AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.3
[**2129-1-25**] 07:30AM BLOOD Phos-4.5 Mg-1.5*
[**2129-1-24**] 06:35AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.2*
[**2129-1-23**] 08:15AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.2*
[**2129-1-22**] 09:35AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.5*
[**2129-1-21**] 07:00AM BLOOD Albumin-3.3* Calcium-9.1 Phos-4.1
[**2129-1-20**] 06:55AM BLOOD Calcium-8.5 Phos-5.0* Mg-1.9
[**2129-1-19**] 05:35PM BLOOD Calcium-8.9 Phos-4.2 Mg-1.2*
Cardiac enzymes:
[**2129-1-30**] 09:49AM BLOOD CK(CPK)-16*
[**2129-1-29**] 06:22PM BLOOD CK(CPK)-23*
[**2129-1-30**] 09:49AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2129-1-30**] 01:43AM BLOOD CK-MB-2 cTropnT-0.02*
[**2129-1-29**] 06:22PM BLOOD CK-MB-NotDone cTropnT-0.02*
Liver function tests:
[**2129-1-26**] 03:52AM BLOOD ALT-25 AST-36 AlkPhos-331* TotBili-0.6
[**2129-1-23**] 08:15AM BLOOD ALT-30 AST-44* TotBili-0.7
[**2129-1-22**] 09:35AM BLOOD ALT-34 AST-57* AlkPhos-315*
[**2129-1-21**] 07:00AM BLOOD ALT-44* AST-72* LD(LDH)-396* AlkPhos-306*
TotBili-0.9
[**2129-1-20**] 06:55AM BLOOD ALT-41* AST-64* AlkPhos-262*
[**2129-1-19**] 05:35PM BLOOD ALT-43* AST-61* AlkPhos-263* Amylase-50
TotBili-0.8
[**2129-1-26**] 03:52AM BLOOD GGT-228*
[**2129-1-21**] 07:00AM BLOOD GGT-192*
[**2129-1-19**] 05:35PM BLOOD Lipase-24
Thyroid function tests:
[**2129-1-26**] 03:52AM BLOOD TSH-13*
[**2129-1-26**] 03:52AM BLOOD T4-9.9 T3-70* Free T4-1.4
Gent levels: (relatively unreliable in relation to actual timing
of dosing)
[**2129-1-30**] 06:00PM BLOOD Genta-1.0*
[**2129-1-30**] 01:43AM BLOOD Genta-6.6
[**2129-1-30**] 12:47AM BLOOD Genta-1.6*
[**2129-1-29**] 12:11PM BLOOD Genta-1.2*
[**2129-1-29**] 05:45AM BLOOD Genta-1.8*
[**2129-1-28**] 02:29PM BLOOD Genta-6.9
[**2129-1-28**] 05:32AM BLOOD Genta-4.8*
[**2129-1-25**] 02:08PM BLOOD Genta-4.4*
[**2129-1-25**] 07:30AM BLOOD Genta-2.4*
ABG:
[**2129-1-25**] 09:22AM BLOOD Type-ART pO2-85 pCO2-33* pH-7.39
calHCO3-21 Base XS--3
Micro:
Had 2/2 bottles [**1-20**] with strep viridans, and 6/6 bottles [**1-22**]
with strep viridans. sensitivities below:
Blood cx from [**1-20**]: ANAEROBIC BOTTLE (Final [**2129-1-24**]):
VIRIDANS STREPTOCOCCI.
SENT TO [**Hospital3 **] FOR SPECIATION PER DR. [**Last Name (STitle) 5645**]
[**2129-1-27**].
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 4 R
PENICILLIN------------ 0.25 I
VANCOMYCIN------------ <=0.5 S
Admission CXR/KUB, [**1-19**]:
1. Non-specific bowel gas pattern with a single dilated loop in
the left abdomen.
2. Mild CHF with bilateral effusions, left greater than right.
Superimposed left base infection is not excluded.
3. Calcified left upper mediastinal mass, likely related to
history of treated lymphoma.
Abd CT, [**1-19**]:
1. No CT evidence for appendicitis.
2. Bilateral pleural effusions, moderate on the left and small
on the right. Associated bilateral dependent atelectasis is also
appreciated.
3. No evidence for bowel pathology or obstruction.
CXR [**1-22**]:
Bilateral pleural effusions, left greater than right. Note that
pneumonia at one or both lung bases cannot be excluded.
CXR, left lateral decub, [**1-24**]:
Bilateral moderate sized layering pleural effusions. CHF cannot
be excluded.
TEE, [**1-24**]:
1. The left atrium is dilated. The right atrium is dilated.
2. The left ventricle is normal in size. LV systolic function
appears
depressed.
3. There is a small vegetation on the non-coronary cusp of the
aortic valve.
Mild (1+) aortic regurgitation is seen.
4. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral
valve leaflets are markedly thickened. The gradients are higher
than expected
for this type of prosthesis. There is a large mobile vegetation
on the mitral
valve. It is approximately 1 cm in diameter at its base and a
large mobile
portion which is 2 cm in length
Chest CTA, [**1-25**]:
No pulmonary embolus. Multifocal pneumonia with near complete
collapse of the left lower lobe. Pneumonia in this area is not
excluded.
CXR, [**1-25**]:
1. Right PICC line at SVC/right braciocephalic junction.
Recommend advancement by several centimeters to ensure placement
over the SVC.
2. Interval worsening of bilateral pleural effusion with
collapse/consolidation of the lower lungs and bilateral patchy
airspace opacities. Differential diagnosis includes multifocal
pneumonia.
Panorex, [**1-26**]:
Probable lytic lesion in the right maxilla to the right of
midline surrounding a tooth. Suboptimal examination. Abscess not
excluded.
CXR, [**1-27**]:
1) Interval decrease in size of right pleural effusion, possible
slight interval increase in size of left pleural effusion.
2) Vague, patchy multifocal bilateral parenchymal opacities,
unchanged.
.
Echo: [**2129-2-15**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Mitral Valve - Mean Gradient: 25 mm Hg
TR Gradient (+ RA = PASP): *50 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2129-2-1**].
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild
global LV
hypokinesis.
RIGHT VENTRICLE: Dilated RV cavity. RV function depressed.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Small
vegetation on aortic valve. Mild to moderate ([**2-6**]+) AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Increased MVR
gradient. Large vegetation on mitral valve. No MR. [Due to
acoustic shadowing,
the severity of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate
PA systolic hypertension.
GENERAL COMMENTS: Based on [**2121**] AHA endocarditis prophylaxis
recommendations,
the echo findings indicate a high risk (prophylaxis strongly
recommended).
Clinical decisions regarding the need for prophylaxis should be
based on
clinical and echocardiographic data. Results were personally
reviewed with the
MD caring for the patient. Results were reviewed with the
Cardiology Fellow
involved with the patient's care. Ascites.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is mild global left ventricular
hypokinesis with
abnormal septal motion. The right ventricular cavity is dilated
with free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic
stenosis is not present. There is a small ~4mm highly mobile
echodensity on
the outflow tract side of the valve c/w a vegetation. At least
mild (1+)
aortic regurgitation is seen (mitral inflow is coincident with
aortic
regurgitation, making quantification difficult). A bioprosthetic
mitral valve
prosthesis is present. The prosthesis is well seated. The
gradients are higher
than expected for this type of prosthesis and c/w severe mitral
stenosis.
There is a large (>1.5cm mobile echodensity c/w a vegetation
involving the
mitral leaflets. No mitral regurgitation is seen. [Due to
acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.]
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary
artery systolic hypertension.
Compared with the prior study (tape reviewed) of [**2129-2-1**], a
small mobile
vegetation is now seen on the aortic valve and at least mild
aortic
regurgitation is identified. The mobile component of the mitral
valve
vegetation is somewhat smaller (is there a history of
embolization?). The
right ventricular cavity is now larger, the transmitral gradient
has
increased, and estimated pulmonary artery systolic pressure is
higher.
Brief Hospital Course:
1. Endocarditis: The pt was afebrile on admission, but had a
persistent leukocytosis, and blood cultures grew strep viridans
in [**9-12**] bottles. She was initially treated with levo/flagyl on
[**1-21**], changed to vancomycin and ceftriaxone, and on [**1-24**] was
changed to penicillin and gentamicin. She had a TEE which
revealed a 1.2 cm vegetation on her (porcine) mitral valve, as
well as a smaller vegetation on her (native) aortic valve.
Daily EKG's were checked to evaluate her P-R interval, which
progressively lenghtened, from 170s to >200 on [**1-29**]. It then
returned to the 180s the next day. However, on the evening of
[**1-30**], as she was talking on the phone, she developed a
wide-complex tachycardia. She remained stable, was mentating,
had no chest pain or shortness of breath. An EKG demonstrated
A-V dissociation with tachycardia originating from her left
anterior fascicle. (She has a LBBB at baseline.) She was
placed on lopressor 12.5 [**Hospital1 **]. She was transferred to the
Cardiology service at this point. She was evaluated by CT
surgery who preferred for her to receive 4 weeks of IV
antibiotics before proceeding with a valve replacement, and
would re-evaluate. Was taken to cath lab on [**2129-2-1**] for
pacemaker placement. Post procedure developed
hypotension+hypoxia, CXR showed pulmonary edema, patient was
emergently intubated, ABG: 7.14/65/55, transferred to the CCU.
After developing ARF on AIN on gentamycin and penicillin, and
these were d/c'd and started Anceph and Vancomycin at suggestion
on ID consultants. In discussion with surgery, the surgeons
felt that surgery had too high of a risk to benefit ratio.
However, when on follow-up echo, her mitral stenosis showed to
have worsened dramatically, she was taken emergently to surgery
for valve replacement. She was unable to come off of the pump
after surgery, seemingly from right heart failure; per surgical
note revascularization of the right heart was accomplished but
in spite of this the patient died.
2. CHF: Pt became volume overloaded in light of fluid
resuscitation during sepsis. Her volume was managed in the ICU
by CVVH [**3-9**] renal failure.
.
3. Dental abscess: Her initial presentation began with mouth
pain, and a panorex was done which demonstrated a possible
dental abscess. This was likely the source of her endocarditis.
It was removed in the ICU by OMFS.
.
4. Acute Renal Failure: Likely in the setting of severely
hypotensive episode on [**1-31**] and AIN from penicillin and
gentamycin. Pr became oliguric and eventually required CVVH
dialysis for volume management.
Medications on Admission:
flexeril, now d/c'ed
lasix 10mg po q24h
motrin now d/c'ed
norvasc 5mg po q24h
protonix 40mg po q24h
ASA 325mg po q24h
synthroid 100mcg po q24h
acyclovir prn herpes
mvit
lotrimin cream
Discharge Medications:
Current meds:
Lasix 10 mg iv prn
Protonix 40 mg po daily
ASA 325 mg po daily
Synthroid 100 mcg po daily
Penicillin G 3 MU IV q4h, day #7
[HOLDING] --> Gentamicin, day #7
Reglan, anzemet, bisacodyl prn
Cyanocobalamin
Folate
Thiamine
MVT
[HOLDING] --> Metoprolol 25 mg po bid
[HOLDING] --> Lisinopril 2.5 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2129-3-17**]
|
[
"041.09",
"522.5",
"785.51",
"427.31",
"785.52",
"421.0",
"584.9",
"285.9",
"303.91",
"564.09",
"V10.79",
"428.0",
"996.61",
"785.0",
"995.91",
"244.9",
"038.11",
"038.0",
"V10.72",
"427.1",
"E878.1",
"486",
"518.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"36.15",
"23.09",
"96.04",
"38.93",
"37.61",
"38.91",
"37.78",
"96.72",
"35.21",
"39.61",
"35.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
16722, 16731
|
13534, 16152
|
362, 389
|
16777, 16781
|
2746, 6146
|
16832, 16865
|
2037, 2085
|
16386, 16699
|
16752, 16756
|
16178, 16363
|
16805, 16809
|
2100, 2727
|
6163, 13511
|
308, 324
|
417, 1179
|
1201, 1865
|
1881, 2021
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,109
| 155,286
|
49857
|
Discharge summary
|
report
|
Admission Date: [**2156-5-4**] Discharge Date: [**2156-5-11**]
Date of Birth: [**2084-2-4**] Sex: M
Service: MEDICINE
Allergies:
Nitrate / Niacin
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
R-sided chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 y.o. M with h/o CAD, s/p CABG x 3 '[**37**], h/o adenoma s/p
surgical resection in [**4-2**], who presented with R sided chest
pain upon inspiration on [**2156-5-4**].
.
History from the [**Hospital Unit Name 153**] admit note:
"Patient was in his usual state of health when he noticed a
sudden R sided CP 3 days ago in the evening while he was
watching TV. Prior to that day he was mowing his grass
exercising more than usual and attributed his pain to muscle
pull and his arthritis pain which he experiences usually in his
shoulders. Patient states his pain lasted a few seconds, right
sided, nonradiating. It was brought on by taking deep breath,
nonexertional. He denied any SOB, no DOE. Patient at baseline is
able to walk up 3 flights of stairs with groceries and easily
walk a mile. He denies any cp, no nausea/vominting, no
diaphoresis, no lightheadedness, no recurrence of his anginal
equivalent."
.
The patient was dx with a PE in the ED. He was admitted to the
[**Hospital Unit Name 153**] on [**5-4**]. He was HD stable the entire time. Started on
heparin and coumadin.
.
Currently he c/o of the R sided chest pain which he said is
worse with movement. he feels more fatigued than normal. Mild
SOB when O2 is off. + pleurtic pain on right with deep insp. no
leg pains.
Past Medical History:
CABG x 3 in [**2137**]
HTN
Dyslipidemia
Arthritis
right hepatic flexure adenoma
Social History:
lives with family in a 3rd story of a multi family house, lives
with wife, has 8 children, quit smoking in '[**39**] after 50 years;
no etoh, no ivdu; retired in [**2139**] as [**Company 2318**] bus driver; active,
bowls weekly.
Family History:
no history of hematologic disorders in family including
children, no history of clots, no h/o stroke, mother with [**Name2 (NI) **],
DM in grandmother; brothers had cancers (?)
Physical Exam:
100.0, 136/78, 72, 20, 98% 4L (same as in the [**Hospital Unit Name 153**] from
transfer), 87% RA. 184 lbs.
Gen: NAD, speaking full sentences, no resp distress
HEENT: NC, AT, anicteric, clear OP, + JVP elevated, no bruits
CV: RRR, nl s1, soft S2. little variation of split with
inspiration. 2/6 SEM over RUSB. no R parasternal heave. Pain on
palpation of the R chest wall. non-displaced PMI
Pulm: scan rhonchi over bases b/l. Dull to percussion and
decreased BS at the R base. no wheezes
Abd: + BS, SNT, ND
Ext: no edema, no cyanosis, no palpable cords
Pertinent Results:
[**2156-5-4**] 04:55AM PLT COUNT-167
[**2156-5-4**] 04:55AM NEUTS-68.8 LYMPHS-20.7 MONOS-8.6 EOS-1.7
BASOS-0.3
[**2156-5-4**] 04:55AM WBC-5.4# RBC-4.39* HGB-13.6* HCT-38.5* MCV-88
MCH-31.0 MCHC-35.3* RDW-14.7
[**2156-5-4**] 04:55AM CK-MB-4
[**2156-5-4**] 04:55AM cTropnT-<0.01
[**2156-5-4**] 04:55AM CK(CPK)-393*
[**2156-5-4**] 04:55AM estGFR-Using this
[**2156-5-4**] 04:55AM GLUCOSE-106* UREA N-18 CREAT-1.3* SODIUM-138
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
[**2156-5-4**] 03:21PM PTT-150*
[**2156-5-4**] 10:50PM PTT-127.1*
[**2156-5-4**] 10:50PM CK-MB-3 cTropnT-<0.01 proBNP-527*
[**2156-5-4**] 10:50PM CK(CPK)-249*
.
CTA chest: IMPRESSION:
1. Large extensive bilateral pulmonary emboli, with a saddle
embolus straddling the left and right main pulmonary arteries.
The greatest clot burden in the right main and lower lobe
interlobar arteries, correlating with early infarcts in the
right middle and lower lobes.
2. Distention of the azygos vein may suggest a degree of right
heart strain, but the right ventricle is normal in size, with no
leftward deviation of the intraventricular septum.
3. Possible thrombosis in the azygos vein, which is not
opacified.
.
Bilat lower extremity ultrasounds: IMPRESSION: Right popliteal
deep venous thrombosis, with venous collateral formation around
clot. No evidence of DVT in the left lower extremity.
.
TTE: Conclusions:
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%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventircle may be dilated.
Right ventricular free wall motion appears preserved. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion
Brief Hospital Course:
1) Pulmonary embolism: No known risk factors. Patient started
on heparin gtt and coumadin. Remained hemodynamically stable
here, not significant strain on right side of heart. Sating
wellon room air. Patient required coumadin 10mg daily to become
therapeutic. Will need follow up of INR as outpatient. Follow
up with PCP for further work up re: coagulopathy and malignancy
risk factors (especially colonoscopy). Also consider repeat TTE
and follow up with pulmonary clinic in [**3-2**] months to evaluate R
heart strain.
.
2) HTN: Normotensive during this admission. Patient more
bradycardic as well and EKG obtained and reviewed with
cardiology who did not feel there were acute new changes. All
BP meds still held at time of discharge and should follow up as
outpatient.
Medications on Admission:
HCTZ 25 QD
Isordil 40 mg QD
Nifedipine 30 mg CR QD
Lipitor 10 mg QD
ASA 325 mg QD
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
This dose may be adjusted by coumadin clinic or your primary
care doctor in the future.
Disp:*60 Tablet(s)* Refills:*2*
4. Outpatient Lab Work
Please draw PT/PTT/INR and have results sent to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 4844**] (Phone: [**Telephone/Fax (1) 250**], Fax: [**Telephone/Fax (1) 30662**]) on Thursday, [**5-13**],[**2155**].
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral pulmonary emboli with saddle embolus
Right lower extremity DVT
Mod PA systolic hypertension
Discharge Condition:
Good
Discharge Instructions:
You were found to have a large pulmonary embolism and deep vein
thrombosis (DVT) in your right leg. We are still uncertain why
you developed these and recommend once you have them further
treated to get further evaluation by your primary care doctor.
If you develop chest pain, shortness of breath please return to
the hospital or call your doctor.
.
Your blood pressure has remained in the normal range during your
hospital stay. For that reason do not restart your blood
pressure medications until you next see your primary care doctor
and cardiologist and they can make the decision whether to
restart them.
.
Please come back to the outpatient lab here at [**Hospital1 18**] and have
your blood drawn to check your INR on [**2156-5-13**]. The results will
be sent to Dr. [**Last Name (STitle) 4844**] and his clinic will contact you if you
need to change your coumadin dose.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. (cardiology clinic)
Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2156-5-20**] 10:00
2. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2156-6-10**] 10:10
3. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2156-9-14**] 11:00
4. Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2156-5-26**] 2:50
|
[
"401.9",
"415.19",
"414.01",
"V45.81",
"416.8",
"272.4",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6452, 6458
|
4895, 5678
|
294, 301
|
6604, 6611
|
2749, 4872
|
7541, 8129
|
1982, 2160
|
5811, 6429
|
6479, 6583
|
5704, 5788
|
6635, 7518
|
2175, 2730
|
236, 256
|
329, 1615
|
1637, 1718
|
1734, 1966
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,225
| 118,713
|
28296
|
Discharge summary
|
report
|
Admission Date: [**2146-12-12**] Discharge Date: [**2146-12-21**]
Date of Birth: [**2068-4-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
L IJ CVL placement
History of Present Illness:
This 78 year old gentleman is s/p CABG in early [**Month (only) 1096**] at [**Hospital 7302**] was transferred to nursing home for rehab
on [**11-30**] after several falls out of bed. He was then readmitted
to [**Hospital6 3105**] on [**2146-12-3**] after developing acute
pulmonary edema/CHF/unresponsiveness?. There was a question
whether he had a small MI; he reportedly had a small NQWMI. He
improved with diuresis and was not intubated. Since admission
has had an altered mental status and there is concern for
possible hypoxic encephalopathy. The patient was going to be
recathed, but this has been on hold pending mental status
clearing. CT scan of the head was reportedly negative. Patient
is reportedly non-verbal and agitated at baseline. Prior to this
CABG, the patient was apparently a active gentlemen doing ADLs.
Patient was apparently given ativan prior to transfer. His wife
is present and states that he is slightly more somnolent after
ativan; but has had waxing and [**Doctor Last Name 688**] mental status.
.
Pt is now referred for further management at [**Hospital1 18**]. Case
discussed with Dr. [**Last Name (STitle) **] who agreed to take pt on [**Hospital Unit Name **].
.
Past Medical History:
CABG x [**Hospital3 68704**] (LIMA to LAD, vein grafts to OMI and PDA)
ischemic cardiomyopathy.
Hyperlipidemia
DM type II
Obesity
Partial colectomy for diverticulitis
Social History:
Smoking X 40 yrs but quit 20 years ago. There is no history of
alcohol abuse.
Family History:
NC
Physical Exam:
VS - T 95 BP 131/71 P 96 R 12 O2sat 93% ra.
Gen: somnolent. arousable to voice. not following commands.
HEENT: NCAT. Sclera anicteric. PERRL Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6 cm.
CV: well healed sternotomy scar. 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 not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. right medial leg incision
healing well.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: limited by somnolence. clonus x4.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
CT head [**12-13**]:
There is no acute intracranial hemorrhage, edema, or mass
effect.
There is moderate cerebral atrophy with associated prominence of
the sulci and ventricles. Few foci of low density in the
periventricular white matter adjacent to the frontal horns of
the lateral ventricles likely represent mild chronic small
vessel ischemic disease in a patient of this age. Calcifications
are noted in the internal carotid arteries bilaterally.
The imaged bones appear unremarkable. There is opacification of
a left
posterior ethmoid air cell.
.
CXR [**2146-12-12**]:
No previous images. Intact midline sternal sutures are seen
related to previous CABG procedure. Cardiac silhouette is
somewhat prominent, as is the tortuosity of the descending
aorta. However, no evidence of vascular congestion or acute
focal pneumonia.
.
[**2146-12-14**] TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. The mitral valve
leaflets are mildly thickened (?MVP?). An eccentric, posteriorly
directed jet of at least mild to moderate ([**12-9**]+) mitral
regurgitation is seen. No mitral valve vegetation is seen but
the images are suboptimal. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.
If clinically indicated, a TEE would be better to exclude a
valvular vegetation and to better assess the basis and severity
of mitral regurgitation.
.
[**2146-12-16**] TEE:
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild prolapse of the anterior mitral
leaflet. There is small (3 x 5 mm) vegetation on the tip of the
anterior mitral leaflet. An associated posteriorly-directed jet
of moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Small mitral valve vegetation. Moderate mitral
regurgitation.
.
CT torso [**2146-12-16**]:
1. No nidus of infection found to explain patient's
endocarditis.
2. Partially thrombosed right superficial femoral artery
pseudoaneurysm
measuring 2.5 cm.
3. 7-mm pulmonary nodule. If the patient is at high risk for
lung cancer,
followup CT at 6-12 months is recommended. (If the patient is
considered low risk, followup CT at 12 months is recommended).
.
P-mibi [**2146-12-19**]: no ischemic symptoms or ECG changes.
MIBI:
1. Fixed, large, mild intensity inferior wall perfusion defect.
2. Normal LV cavity size, post-CABG septal hypokinesis, and
probably slightly reduced systolic function (qualitatively EF
appears to be 40-45%).
.
colonoscopy [**2146-12-15**]:
Diverticulosis of the sigmoid colon and descending colon
Blood in the colon
Ulceration and erythema in the rectum compatible with ischemic
colitis
Otherwise normal colonoscopy to cecum
.
[**2146-12-15**] EGD:
Erythema and erosion in the stomach body and antrum compatible
with erosive gastritis
Ulcer in the duodenal bulb (injection, endoclip)
Erythema in the second part of the duodenum and duodenal bulb
compatible with duodenitis
Otherwise normal EGD to second part of the duodenum
.
[**2146-12-12**] 11:00PM GLUCOSE-117* UREA N-30* CREAT-0.9 SODIUM-140
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
[**2146-12-12**] 11:00PM estGFR-Using this
[**2146-12-12**] 11:00PM ALT(SGPT)-26 AST(SGOT)-31 LD(LDH)-288*
CK(CPK)-42 ALK PHOS-75 TOT BILI-1.2
[**2146-12-12**] 11:00PM CK-MB-NotDone cTropnT-0.05*
[**2146-12-12**] 11:00PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-4.0
MAGNESIUM-2.2
[**2146-12-12**] 11:00PM TSH-2.0
[**2146-12-12**] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2146-12-12**] 11:00PM WBC-7.6 RBC-4.35* HGB-12.6* HCT-36.1* MCV-83
MCH-29.0 MCHC-34.9 RDW-16.4*
[**2146-12-12**] 11:00PM NEUTS-65.9 LYMPHS-24.2 MONOS-5.5 EOS-3.4
BASOS-1.0
[**2146-12-12**] 11:00PM PLT COUNT-256
[**2146-12-12**] 10:20PM TYPE-ART PO2-98 PCO2-28* PH-7.50* TOTAL
CO2-23 BASE XS-0
[**2146-12-12**] 10:20PM LACTATE-1.3
Brief Hospital Course:
78 year old male with a history of CAD s/p CABG, DM2, CHF,
admitted with altered mental status and GI bleed found to have
duodenal ulcer, ischemic rectal colitis, and vancomycin
sensitive enteroccocal and staph mitral valve endocarditis.
.
Patient was initially admitted to the Cardiology service for an
NSTEMI for possible cath. However, cardiac enzymes on admission
were negative. He then began to have GI bleeding and was found
to have positive blood cultures, eventually attributed to
endocarditis. See below for problem specific hospital course.
.
# endocarditis: high grade bacteremia with enterococcus and coag
negative staph, both sensitive to vancomycin. Enteroccocus was
sensitive to ampicillin but given resistence pattern of staph,
he needed to be maintained on vancomycin with gentamicin
synergy. Blood cultures were positive on [**12-13**] and [**12-14**] and he had
no further positive blood cultures on surveillance from
[**Date range (1) 68705**]. Possible sources of endocaritis include CABG,
post-CABG CVL, gut translocation from GIB. He had a CT torso
performed which showed no clear source of infection. ID was
consulted and recommended a 2 wk course of vancomycin with
gentamicin to treat the staph. As an outpatient, he will then be
changed to ampicillin and gentamicin for 4 additional weeks to
treat the enterococcus. Vancomycin and gentamicin peaks and
troughs were monitored to ensure therapeutic dosing and avoid
toxic levels. After blood cultures cleared, patient had a PICC
line placed at bedside for outpatient antibiotics. CVL was
discontinued and tip sent for culture which had no growth at the
time of discharge. He will receive 2 weeks of vancomycin 750 mg
Q12H and gent 100 mg Q12H to treat staph line associated
bacteremia. He will then change vanco to ampillin 2 grams Q4H to
complete 4 additional weeks of amp/gent for enterococcus
[**Date range (1) 68706**]. CBC/diff, renal function, electrolytes, LFTs, gent
peak/trough, and vanco trough will need to be checked every 5
days and results should be faxed to the [**Hospital **] clinic as instructed.
Patient will likely need suppressive antibiotics after
completing his 6 wk course of vancomycin and gentamicin given
sternal wires in place. He will follow up with ID as an
outpatient.
.
# acute on chronic systolic heart failure: according to OSH
reports, patient in pulmonary edema on presentation and ECHO
showed EF 30%. After reviewing OSH records, it appears that
patient had significantly elevated MBI (CK 329, MB 80) at OSH
with anterolatateral TWI in the setting of pulmonary edema. Here
cardiac enzymes were negative and ECHO showed EF>55%. He had no
hemodynamic compromise in the setting of endocarditis. He
maintained euvolemia throughout his hospitalization. After his
GI bleed resolved, his beta blocker was restarted. Ace inhibitor
was held due to low normal blood pressures. He had coronary
evaluation as below. If possible, patient would likely benefit
from initiation of low dose ace-inhibitor if blood pressures
tolerate.
.
# CAD: s/p recent CABG. Recent NSTEMI at OSH raises question of
whether a graft went down acutely as he was recently
revascularized. Cardiac enzymes here were negative and patient
had no symptoms of chest pain or shortness of breath. As above,
ECHO showed preserved EF. LDL was at goal at <50. He was
continued on aspirin and statin. Beta blocker was held in the
setting of GI bleed and then restarted. He underwent P-MIBI
which showed a large fixed mild intensity perfusion defect in
the inferior wall. He had no ischemic symptoms or ECG changes
with infusion. He will follow up with his CT surgeon as an
outpt and was set up for a new visit in [**Hospital1 1388**] cardiology
department for follow up.
.
# Delerium: Patient had prolonged delerium following recent
CABG. His mental status rapidly improved once antibiotics were
started suggesting his delerium was most likely due to his
endocarditis. Hypnotic and sedating meds were held and patient
was at his mental status baseline for the remainder of his
hospitalization.
.
# GI bleed: likely combination of upper and lower GIB with
duodenal ulcer, diverticulosis, and rectal colitis. Duodenal
ulcer treated with injection and clipping. He was treated with
PPI [**Hospital1 **]. He received 2 units of PRBCs during admission. He had
no further bleeding following intervention. Hct remained stable
after transfusion. Aspirin was initially held but was then
restarted without incident. He was started on niferex for
presumed iron deficiency anemia. H pylori Ab was sent which was
positive so he was set up to receive triple therapy for
treatment. The plan was to continue PPI [**Hospital1 **], change to
ampicillin after 2 weeks of vancomycin (which would take the
place of amoxicillin), and then add clarithromycin at that time
x 7 days. He was scheduled for outpatient GI follow up in [**3-13**]
weeks for repeat sigmoidiscopy.
.
# DM: type 2: well controlled on insulin sliding scale and
lantus. HbA1C was checked and was 5.6. Home medications were
eventually reconciled and found that patient had been taking
metformin SR 1000 mg qpm. This medication was restarted and his
lantus was discontinued. He was continued on insulin sliding
scale. He was continued on a baby aspirin throughout.
.
# htn: normotensive on low dose beta blocker. Home valsartan was
held and was not restarted due to low blood pressures.
.
# hyperlipidemia: LDL<50. His gemfibrozil was discontinued. He
was started on a statin which continued throughout
hospitalization.
.
# OSA: no prior history of OSA. Diagnosed at OSH. Had nighttime
O2 desaturations. He was treated with CPAP nasal pillow, autoset
5-12 mmHg during hospitalization. ABG showed no respiratory
acidosis or CO2 retention. He will need an outpatient sleep
study set up by his primary care provider.
.
# pulmonary nodule: found on CT scan [**12-16**]. 7 mm. He will need a
repeat CT scan in 6 months for surveillance
.
# glaucoma: after home medication reconciliation, patient was
restarted on his outpatient eye drops for glaucoma.
Medications on Admission:
gemfibrozil 600mg [**Hospital1 **]
metoprolol 50 mg [**Hospital1 **]
valsartan 40 mg daily
metformin SR 1000 mg qhs
asa 325mg daily
brimonidine 0.2% opth 1 drop each eye TID
dorzolamide/timolol 0.5% oph 1 drop each eye [**Hospital1 **]
travatan 0.004% oph qhs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. Outpatient Lab Work
Please have the following blood tests checked every 5 days:
CBC with diff, Chem-7, LFTs, ESR, CRP, vancomycin trough,
gentamicin peak/trough.
Have the results faxed to the infectious disease nurses at [**Hospital 61**] Medical Center. fax: [**Telephone/Fax (1) 432**].
7. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: Please start this medication in 2 weeks on the
same day that you change your vancomycin to ampicillin.
Disp:*14 Tablet(s)* Refills:*0*
8. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 10 days: 2 week course
[**Date range (1) 68707**].
Disp:*[**Numeric Identifier 3301**] mg* Refills:*0*
9. Gentamicin 40 mg/mL Solution Sig: One Hundred (100) mg
Injection every twelve (12) hours for 5 weeks: 6 wk course
[**Date range (1) 68708**].
Disp:*7000 mg* Refills:*0*
10. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) grams
Injection every four (4) hours for 4 weeks: 4 wk course
[**Date range (1) 68706**]
Give via infusion pump. TO BE STARTED AFTER COMPLETING 2 WEEKS
OF VANCOMYCIN [**12-29**].
Disp:*336 grams* Refills:*0*
11. Metformin 1,000 mg Tab,Sust Rel Osmotic Push 24hr Sig: One
(1) Tab,Sust Rel Osmotic Push 24hr PO QPM (once a day (in the
evening)).
12. Brimonidine 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours): each eye.
13. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): each eye.
14. Travatan 0.004 % Drops Sig: One (1) drop Ophthalmic Qday ():
each eye.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary:
- Mitral valve endocarditis (Amp sensitive Enterococcus, CNSE)
- NSTEMI
- Systolic heart failure
- UGIB secondary to duodenal ulcer; H.pylori positive
- Rectal ischemic colitis
- Blood loss anemia
- Delirium
- Right femoral pseudoaneurysm
- 7 mm pulmonary nodule
Secondary:
- CAD s/p CABG x 4. coronary artery disease
- Diabetes mellitus type II
- Hypertension
- Hyperlipidemia
- Obstructive sleep apnea
Discharge Condition:
Ambulating with walker and assist. Afebrile. Hemodynamically
stable. All surveillance blood cultures negative.
Discharge Instructions:
You were admitted to the hospital for altered mental status and
you were found to have an infection of your heart valve. You
will need to remain on antibiotics for 6 weeks and will follow
up with infectious disease. You were also found to have a
bacteria in your stomach which can cause ulcers. You will
receive antibiotics for tis.
.
During your hospitalization you were also found to have bleeding
in your GI tract. You will need to have a sigmoidoscopy repeated
in [**3-13**] weeks as an outpatient.
.
A CT scan performed during your hospital stay showed a small
nodule in your lungs. This is most likely benign but you will
need a repeat CT scan in 6 months for surveillance.
.
You were diagnosed with obstructive sleep apnea during your
hospitalization. You should ask your primary doctor to refer you
to a sleep study once discharged from the hospital. You can
continue to use nasal CPAP at night until your study is
performed.
.
Please continue to take all medications as prescribed. Please
note the following changes to your medications:
1. your metoprolol dose has been decreased
2. your gemfibrozil has been stopped
3. you have been started on simastatin for cholesterol
4. your valsartan has been stopped
5. you will need to take the antibiotics vancoymcin and
gentamicin for 2 weeks. After 2 weeks, the vancomycin will be
changed to ampicillin and you will continue ampicillin and
gentamicin for 4 additional weeks.
6. You have been started on protonix which you should take twice
a day.
7. After you change your vancomycin to ampicillin, you will also
need to start the antibiotic clarithromycin to treat H pylori
infection in your stomach which may have caused the ulcer which
was found during your hospitalization. You will take
clarithromycin for 7 days.
.
You will need to have blood work performed every 5 days for
monitoring while on antibiotics as prescribed. These results
should be faxed to the [**Hospital1 18**] infectious disease clinic as
prescribed.
.
For any questions regarding your antibiotics, please call the
infectious disease nurses of [**Hospital1 **] at [**Telephone/Fax (1) 14774**] or call doctor on call when clinic is
closed.
Please keep all follow up appointments as listed below.
.
Please call your doctor or return to the hospital if you
experience any fevers, chills, chest pain, shortness of breath,
nausea, vomiting, abdominal pain, problems with your PICC line
or any other concerns.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4402**] on [**2146-12-29**] at 1:30
pm. Phone [**Telephone/Fax (1) 68709**].
.
Please follow up in the infectious disease clinic:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2147-1-13**] 9:30
.
Please follow up with your cardiothoracic surgeon Dr. [**Last Name (STitle) 68710**]
on [**2146-12-28**] at 2 pm. Phone: [**Telephone/Fax (1) 68711**].
.
Please follow up with your new Cardiologist Dr. [**Last Name (STitle) **] on [**2147-1-10**]
at 4pm. Phone: [**Telephone/Fax (1) 62**].
.
Please follow up with Gastroenterology on [**2146-1-24**] at 12:30 pm to
have a repeat sigmoidoscopy performed. Phone: ([**Telephone/Fax (1) 463**]
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878
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3132
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Discharge summary
|
report
|
Admission Date: [**2131-5-16**] Discharge Date: [**2131-5-30**]
Date of Birth: [**2061-8-17**] Sex: F
Service: MEDICINE
Allergies:
Lasix / Diuril
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
nasal packing
History of Present Illness:
69yo with hx of MVR (mechanical), anemia of chronic disease
(transfusion-dependent), COPD/emphysema and IPF with trans trach
on home O2 presented 5 days ago with epistaxis that had been
intermitent over last 3 weeks prior to admission which has been
chronic issue while on coumadin with negative work up. In ED
was packed by ENT with bilateral packings which required
continuous O2 monitoring and stay in the MICU, she was monitored
and IR guided emolization was considered, but pt declined the
required general anesthesia for an elective procedure with risk
of stroke as well from emolization. Now bleeding has slowed
down with minimal packing and she feels better, but still with
right sided facial pain/pressure from the packing and possible
nerve injury. Also stay complicated by conjunctivitios stable on
e-mycin eye drops. No other shortness of breath or pain or
other symptoms except constipation with pain meds. She is
anxious to be about transfer to floor and increased ambulation
so she can go home.
Past Medical History:
1. Chronic obstructive pulmonary disease. The patient uses
4 liters of oxygen at home. Pulmonary function tests on [**2131-3-13**]
showing FEV1 of 1.39L (80%), FEV1/FVC 75%, DLCO of 17.34 (25%
decrease since [**8-30**])
2.Idiopathic pulmonary fibrosis.
3. Frequent Nose bleeds--no etiology other than coumadin despite
extensive work ups
4. Placement of transtracheal oxygen cath due to O2 contrib. to
epistaxis. Has needed recanulation x1
5. Anemia due to MVR, CRI-- baseline 30
6. MVR (metal) replaced in [**2125**] due to acute MR
7. Hypertension.
9. Hypercholesterolemia.
9. Hypothyroidism.
10. MRSA/VRE colonization (negative swabs for both in [**8-30**])
11. Sinus node dysfunction s/p DDD [**Date Range 4448**] in [**2125**]
12. Congestive heart failure with echocardiogram [**Month (only) 956**]
[**2130**] with an EF of 40%, mild global hypokinesis, mitral valve
regurgitation with trivial mitral regurgitation, 3+ tricuspid
regurgitation, mild pulmonary artery systolic hypertension.
13. Meniere's disease, tinnitus, diminished hearing bilaterally.
14. Breast cancer treated with radical mastectomy of right
breast. No chemotherapy. No radiation therapy.
15. Spinal arthritis.
16. Myopia, corrected with glasses.
17. Cataracts.
Social History:
The patient lives in [**Location 2624**] with her husband. The patient works
in human resources for the State of [**State 350**] promoting
diversity. The patient has a 36 pack year history of smoking,
having smoked 1 ppd from the ages of 14 to 50. Quit with the
help of acupuncture. The patient uses alcohol occasionally. no
IVDU.
Family History:
There is no known history of bleeding or clotting disorders.
There is a family history of muscle cramps. Her father had
polymyositis and her mother had [**Name2 (NI) 500**] cancer.
Physical Exam:
VS: HR 53 BP 131/52 Sat 100% on 4L transtracheal O2
GEN aao, nad
HEENT PERRL, MMM, ecchymosis right peri-nasal area, bilateral
packing in place without blood, transtracheal cath in place for
O2
CHEST CTAB with occasional bibasilar crackles R>L, and
occasional end exp wheezes bilaterally, +right sided scar
CV RRR, mechanical S1, nl S2
ABD soft NT, slightly distended, +BS
EXT no edema, 2+DP pulses bilaterally
Neuro CN II-XII intact sensation, but with mildly decreased
right motor muscle strength
Pertinent Results:
[**2131-5-16**] 04:15PM GLUCOSE-108* UREA N-26* CREAT-1.4*
SODIUM-149* POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-33* ANION
GAP-8
[**2131-5-16**] 04:15PM IRON-55
[**2131-5-16**] 04:15PM calTIBC-312 VIT B12-1587* FOLATE-GREATER TH
FERRITIN-633* TRF-240
[**2131-5-16**] 04:15PM WBC-4.2 RBC-2.89* HGB-9.1* HCT-28.3* MCV-98
MCH-31.6 MCHC-32.3 RDW-15.1
[**2131-5-16**] 04:15PM NEUTS-74.8* LYMPHS-15.2* MONOS-4.9 EOS-4.9*
BASOS-0.1
[**2131-5-16**] 04:15PM PLT COUNT-114*
[**2131-5-16**] 04:15PM PT-20.2* PTT-50.0* INR(PT)-2.6
[**2131-5-15**] 11:45PM HCT-27.1*
[**2131-5-15**] 11:45PM PT-18.4* INR(PT)-2.1
Brief Hospital Course:
69F with COPD, IPF, HTN, on coumadin for MVR here with epistaxis
s/p packing and control of bleeding.
1)Epistaxis: initially required nasal packing by ENT which
required continuous O2 monitoring, but remained stable and
although embolization was considered, it was not done because
patient did not want elective intubation which would have been
required for the procedre and with the risk of stroke with
embolization this procedure was deferred. The packing was
eventually removed and an absorbable intranasal packing was
placed and nares kept moist with ocean spray and vaseline. She
did have occasional episodes of minimal epistaxis which was
managed with courses of afrin and supportive measures and her
hematocrit remained stable after 3 total units of blood
transfusions. She was continued on ancef while packing remained
in place. She did have some pressure headaches from the packing
which was stable on percocet and dilaudid as needed.
2)s/p MVR: for severe mitral regurgitation 6 yrs ago-- stable
for now-- initially coumadin held and reversed with vitamin K
and 2units of FFP and eventually she was restarted on coumadin
with goal INR around 2.5-3.0 as her risk of bleeding is
significant. During her stay she was bridged with heparin until
INR was therapeutic.
3)Anemia: acute on chronic with blood loss anemia on top of
anemia of chronic disease with baseline hematocrit around 30.
She was transfused total of 3units of PRBC and her hematcrit
remained stable above 30 during the rest of her stay, she was
also restarted on her home epogen regemin.
4)COPD/IPF: stable at baseline home O2 via trans-tracheal
catheter. Drainage from trans-tracheal catheter was managed by
interventional pulmonary team with periodic strippings and
bronchoscopies as above. Otherwise she was continued on her
home doses of albuterol, combivent and inhaled steroids.
5)CHF: 40% EF, but stable and euvolemic-- continued on home
bumex and [**Last Name (un) **]
6)Hypothyroid: stable on home thyroid meds
Medications on Admission:
Coumadin 7 x6 days and 12mg x1 day
bumex 1mg qd
levoxyl 112mcg qd
lipitor 20mg qd
cozaar 50mg qd
quinine 260BID
tums [**Hospital1 **]
Flovent
Combivent
Mucinex DM 600BID
Discharge Medications:
1. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BIDWM (2 times a day (with meals)).
7. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-28**]
Puffs Inhalation Q6H (every 6 hours) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
12. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every
4 hours).
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day).
Disp:*1 bottle* Refills:*2*
14. Warfarin Sodium 1 mg Tablet Sig: Seven (7) Tablet PO at
bedtime.
15. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
16. Outpatient Physical Therapy
Please continue to follow up with your pulmonary and respiratory
therapists for care of your trans-tracheal catheter and
stripping as you need to for diagnosis of COPD and interstitial
lung disease
17. Erythromycin 5 mg/g Ointment Sig: 0.5 inch Ophthalmic four
times a day for 4 days.
Disp:*qs tube* Refills:*0*
18. Oxymetazoline HCl 0.05 % Aerosol, Spray Sig: One (1) Spray
Nasal [**Hospital1 **] (2 times a day) for 3 days.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
epistaxis
blood loss anemia
anemia of chronic disease
chronic anticoagulation for mitral mechanical valve
chornic pulmonary obstructive disease
interstitial pulmonary fibrosis
Discharge Condition:
good, ambulating without difficulty and breathing comfortably on
2L of oxygen via tran-tracheal catheter
Discharge Instructions:
Please call your PCP or return if you have any increase in
bleeding from your nose, shortness of breath or pain. Please
continue all your medications as prescribed.
Followup Instructions:
Please see your PCP [**Last Name (NamePattern4) **] [**8-5**] days.
Please have your INR checked in the next 2 days and get your
trans-tracheal catheter followed by IP as you have been prior to
admission.
Please follow up with your ENT Dr [**Last Name (STitle) 1837**] within the next
month.
Provider: [**Name10 (NameIs) **] CALL Where: NONE CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-6-5**] 9:00
Provider: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS Where: [**Hospital6 29**]
REHAB SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2131-6-13**]
10:15
Provider: [**Name10 (NameIs) **] CALL Where: NONE CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-7-3**] 9:00
Completed by:[**2131-5-30**]
|
[
"244.9",
"424.0",
"518.81",
"V44.0",
"285.1",
"428.0",
"V10.3",
"V58.61",
"515",
"784.7",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.01"
] |
icd9pcs
|
[
[
[]
]
] |
8425, 8431
|
4326, 6334
|
284, 299
|
8651, 8757
|
3690, 4303
|
8972, 9739
|
2969, 3153
|
6554, 8402
|
8452, 8630
|
6360, 6531
|
8781, 8949
|
3168, 3671
|
235, 246
|
327, 1342
|
1364, 2604
|
2620, 2953
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,226
| 138,378
|
48944
|
Discharge summary
|
report
|
Admission Date: [**2135-3-23**] Discharge Date: [**2135-3-27**]
Date of Birth: [**2082-9-12**] Sex: F
Service: CT SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Briefly, this is a 52-year-old
female with a history of heart murmur who was found to have
mild aortic stenosis in [**2125**], followed by serial
echocardiograms and it was found that the aortic valve area
was fully getting worse. She also had decreased exercise
tolerance. The patient presented to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office
for evaluation of aortic valve replacement.
PAST MEDICAL HISTORY: Significant for:
1. Aortic stenosis.
2. Anxiety.
3. Chronic anemia.
4. Left frozen shoulder.
PAST SURGICAL HISTORY: Significant for:
1. Dilatation and curettage times two.
2. Rhinoplasty.
3. Cardiac catheterization.
MEDICATIONS ON ADMISSION:
1. Celebrex 200 mg p.o. twice a day.
2. Ativan 0.25 mg p.o. p.r.n.
3. Aciphex 20 mg p.o. twice a day.
4. Multivitamin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: She was afebrile with stable vital
signs. She was in no apparent distress and sitting
comfortably. Her lungs were clear. Her heart was regular
with holosystolic murmur. Her abdomen was soft, nontender,
nondistended, bowel sounds were present. Extremities were
warm and well perfused.
LABORATORY DATA: Her laboratories were all within normal
limits.
HO[**Last Name (STitle) **] COURSE: The patient was evaluated by Dr. [**Last Name (Prefixes) 411**] and it was decided that she would go to the operating
room. She was taken to the operating room on [**2135-3-23**], for
an aortic valve replacement through a mini sternotomy.
Please see operative report for further details. The patient
was transferred to the CSRU postoperatively and had an
uneventful course. She was fully weaned from the ventilator
and extubated. She was kept on some blood pressure
supporting medications and was able to be weaned off those
medications. She was began on Lasix diuresis. On
postoperative day number two, she was transferred out to the
floor. She continued to improve. Her Foley catheter was
removed and she continued to do well and was able to void.
The patient was extubated. Physical therapy was consulted in
order to assess her ambulation and her deconditioning. It
was decided prior to discharge that the patient was doing
well, was able to match her previous function and the patient
was safe to be discharged home. The patient's chest tube was
removed on postoperative day number three. She continued to
do well. Her diet was advanced and she was tolerating
regular diet and her pain was well controlled using Naprosyn
and Ibuprofen. The patient was discharged to home on
postoperative day number four tolerating a regular diet and
doing well.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was instructed to
follow-up with Dr. [**Last Name (Prefixes) **] in three to four weeks and
follow-up with her primary care physician in one to two
weeks. She was also instructed to do no heavy lifting of her
upper extremities and protect her sternum. She had no other
restrictions.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once daily.
2. Lasix 20 mg p.o. twice a day.
3. Colace 100 mg p.o. twice a day.
4. Protonix 40 mg p.o. once daily.
5. Lopressor 12.5 mg p.o. twice a day.
6. Naprosyn one to two tablets p.o. q4hours p.r.n. for pain.
7. Compazine 10 mg p.o. q6hours p.r.n. for nausea.
8. Motrin 600 mg p.o. q6hours p.r.n.
FOLLOW-UP: The patient was instructed to follow-up with her
primary care physician for adjustment of these medications,
specifically, the stopping of her Lasix diuresis.
DISCHARGE DIAGNOSES:
1. Aortic stenosis, now status post aortic valve replacement
through a mini sternotomy.
2. Anxiety.
3. Chronic anemia.
4. Left frozen shoulder.
5. Status post dilatation and curettage times two.
6. Status post rhinoplasty.
7. Status post cardiac catheterization.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2135-3-27**] 11:14
T: [**2135-3-27**] 11:24
JOB#: [**Job Number 102779**]
|
[
"424.1",
"997.3",
"300.00",
"998.11",
"E878.1",
"511.9",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"39.61",
"89.68",
"34.09",
"35.21",
"99.05",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
3727, 3998
|
3199, 3706
|
885, 1047
|
755, 859
|
1070, 3173
|
633, 731
|
4023, 4333
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,097
| 140,501
|
17466+56858
|
Discharge summary
|
report+addendum
|
Admission Date: [**2105-6-8**] Discharge Date: [**2105-6-15**]
Date of Birth: [**2068-6-20**] Sex: F
Service: SURGERY
Allergies:
Metamucil
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2105-6-10**] Epidural catheter placement
[**2105-6-10**] ORIF right tibia fracture
[**2105-6-10**] IVC filter placement
History of Present Illness:
36-year-old female restrained driver, s/p motor vehicle crash.
She was transported to [**Hospital1 18**] via EMS for further care.
Past Medical History:
Asthma
Breast reduction
Abdominoplasty
Family History:
Noncontributory
Physical Exam:
Upon admission:
BP 72/palp HR 87 RR 23 O2 Sat 94% GCS 15
HEENT: PEARRLA clear TM
Neck: cervical collar in place
Chest: left chest wall tenderness
Abd: FAST neg
Pelvis: Stable
Rectum: nl tone
Extr: TTP RLE; + palp pulses RLE
Pertinent Results:
[**2105-6-8**] 06:45PM HCT-32.3*
[**2105-6-8**] 01:55PM GLUCOSE-123* UREA N-9 CREAT-0.6 SODIUM-137
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
[**2105-6-8**] 07:55AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2105-6-8**] 07:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2105-6-8**] 07:25AM WBC-9.9 RBC-3.79* HGB-12.0 HCT-33.9* MCV-89
MCH-31.7 MCHC-35.5* RDW-12.7
[**2105-6-8**] 07:25AM PT-12.5 PTT-22.7 INR(PT)-1.1
[**2105-6-8**] 07:25AM PLT COUNT-376
[**2105-6-8**] 07:25AM FIBRINOGE-396
CT HEAD W/O CONTRAST [**2105-6-8**] 7:33 AM
FINDINGS: Non-contrast head CT. There is no intra-axial or
extra-axial hemorrhage, edema, mass effect, shift of normally
midline structures, or evidence of hydrocephalus. Surrounding
osseous and soft tissue structures are normal. Visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are well aerated.
IMPRESSION:
No acute intracranial hemorrhage.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2105-6-10**] 12:04 PM
Current examination does reveal a thrombus within multiple
segmental and subsegmental branches predominantly affecting the
right lower lobe but also seen affecting the right upper lobe.
Evaluation of the lung parenchyma reveals significant bibasilar
atelectasis, left greater than right. Also, small bilateral
pleural effusions are seen. Patchy areas of peripheral air space
opacity are seen within the lungs bilaterally, predominantly
within the upper lobes. This is a non-specific finding.
Differential considerations would include infectious and
inflammatory etiologies. Clinical correlation is recommended.
Areas of atelectasis are also seen to involve the right middle
lobe.
No significant hilar or mediastinal lymphadenopathy is
identified.
The liver, adrenal glands, pancreas, gallbladder, and kidneys
appear grossly unremarkable. The spleen appears normal. There is
no evidence of splenic trauma. Visualized bowel is grossly
unremarkable. There is no evidence of free fluid within the
abdomen.
No suspicious lytic or blastic bony lesions are seen. The
patient's known left-sided rib fractures are again incidentally
noted.
IMPRESSION:
1. Pulmonary embolism is identified as noted above. This finding
is discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at approximately 12:30
p.m. on [**2105-6-10**].
2. Patchy areas of air space opacity and bibasilar consolidation
as noted above.
3. Bilateral small pleural effusions are seen.
4. No evidence of splenic injury.
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST
CLINICAL INDICATION: Status post MVC with decreased oxygen
saturation and prior suggestion of splenic injury.
TECHNIQUE: MDCT images are acquired through the thorax with
intravenous contrast with CT pulmonary angiogram. Also,
unenhanced images of the abdomen are acquired for
interpretation. Multiplanar reconstructions are provided for
interpretation.
FINDINGS: Direct comparison is made to prior CT dated [**2105-6-8**].
Current examination does reveal a thrombus within multiple
segmental and subsegmental branches predominantly affecting the
right lower lobe but also seen affecting the right upper lobe.
Evaluation of the lung parenchyma reveals significant bibasilar
atelectasis, left greater than right. Also, small bilateral
pleural effusions are seen. Patchy areas of peripheral air space
opacity are seen within the lungs bilaterally, predominantly
within the upper lobes. This is a non-specific finding.
Differential considerations would include infectious and
inflammatory etiologies. Clinical correlation is recommended.
Areas of atelectasis are also seen to involve the right middle
lobe.
No significant hilar or mediastinal lymphadenopathy is
identified.
The liver, adrenal glands, pancreas, gallbladder, and kidneys
appear grossly unremarkable. The spleen appears normal. There is
no evidence of splenic trauma. Visualized bowel is grossly
unremarkable. There is no evidence of free fluid within the
abdomen.
No suspicious lytic or blastic bony lesions are seen. The
patient's known left-sided rib fractures are again incidentally
noted.
IMPRESSION:
1. Pulmonary embolism is identified as noted above. This finding
is discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at approximately 12:30
p.m. on [**2105-6-10**].
2. Patchy areas of air space opacity and bibasilar consolidation
as noted above.
3. Bilateral small pleural effusions are seen.
4. No evidence of splenic injury.
Brief Hospital Course:
She was admitted to the Trauma Service; Orthopedics was
consulted because of her fractured right tibia. she was taken to
the operating room for ORIF of this. There were no
intraoperative complications; postoperatively later during the
night she was noted to have increased heart rate and drop in her
oxygen saturations. She was transferred to the Trauma ICU; a CTA
of her torso was performed and revealed a pulmonary embolus.
Because of her recent trauma with hemoperitoneum and splenic
injury she was a poor candidate for immediate full
heparinization. She was therefore consented and prepped for an
IVC filter placement; this procedure was without any
complications. Postoperatively she underwent tight
heparinization followed by treatment with Coumadin. She
responded rather quickly with a rise in her INR after only a few
doses; she will be discharged on 2 mg Coumadin with instructions
to follow up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 31258**] of her
dose as an outpatient. "Mini-coumadin" is considered quite
adequate because she has an IVC filter and no evidence of
symptomatic DVT. Her primary care doctor was notified of this.
Acute Pain service was also consulted for placement of epidural
catheter given her rib fractures; she would later be changed to
oral narcotics for pain control.
She was evaluated by Physical therapy and it is being
recommended that she go home with PT services.
Medications on Admission:
Albuterol MDI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Outpatient [**Name (NI) **] Work
PT/INR every Tuesday and Friday with results to PCP
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Motor vehicle crash
Pulmonary embolus
Rib fractures (left [**8-12**])
Right tibial plateau fracture
Discharge Condition:
Good
Discharge Instructions:
DO NOT put full weight on your right leg because of your
fracture. Wear the brace as instructed.
Return to the Emergency room if you develop any fevers, chills,
headache, dizziness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea and/or any other symptoms that
are concerning to you.
You have been prescribed a blood thinner called Coumadin because
of the blood clot in your lung. It is important that you have
your blood levels checked weekly so that your dose can be
adjusted.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 2 weeks. Call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in 2 weeks. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up with your primary care doctor tomorrow ([**6-16**]) for
checking your INR blood level.
Completed by:[**2105-6-15**] Name: [**Known lastname 9033**],[**Known firstname 9034**] Unit No: [**Numeric Identifier 9035**]
Admission Date: [**2105-6-8**] Discharge Date: [**2105-6-15**]
Date of Birth: [**2068-6-20**] Sex: F
Service: SURGERY
Allergies:
Metamucil
Attending:[**First Name3 (LF) 9036**]
Addendum:
See upadated discharge medication list.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Outpatient [**Name (NI) **] Work
PT/INR every Tuesday and Friday with results called to Dr.
[**Last Name (STitle) 9037**] [**Telephone/Fax (1) 9038**]
Goal INR [**3-8**]
7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO QPM as DIR: Dose
will be based on PT/INR.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**]
Completed by:[**2105-6-15**]
|
[
"823.00",
"415.11",
"493.90",
"807.03",
"868.03",
"E878.8",
"E816.0",
"865.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"38.7",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
10317, 10536
|
5541, 6984
|
292, 417
|
8005, 8012
|
936, 5518
|
8569, 9337
|
657, 674
|
9360, 10294
|
7878, 7984
|
7010, 7025
|
8036, 8546
|
689, 691
|
229, 254
|
445, 578
|
705, 917
|
600, 641
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,539
| 130,161
|
8727
|
Discharge summary
|
report
|
Admission Date: [**2165-3-29**] Discharge Date: [**2165-4-8**]
Date of Birth: [**2102-1-23**] Sex: F
Service:
ADMTTING DIAGNSOIS:
Trauma.
HISTORY OF PRESENT ILLNESS: This is a 75 year-old female who
was transferred to the [**Hospital1 69**]
after falling approximately 13 steps down stairs. She was
found unconscious and unresponsive at the scene by EMS at
which time she was intubated. Her [**Location (un) 2611**] Coma Scale at the
scene was 3. She was transferred to the [**Hospital1 346**] by Med-Flight and upon arrival was
intubated and sedated.
Her examination was significant for 1 mm pupils bilaterally.
Her trachea was midline. Her chest was clear to auscultation
bilaterally. Her examination was regular rate and rhythm.
Her abdomen was soft, nontender, nondistended, with multiple
surgical scars. Extremities: she had a right foot
transmetatarsal amputation. Emergency Room rectal
examination showed normal tone. Heme negative. She
underwent a chest x-ray that demonstrated no pneumothorax or
rib fractures. She underwent a plain film of the pelvis
which showed no evidence of fractures. Her CT scan of the
head demonstrated a large traumatic subarachnoid bleed with
mild midline shift. Her abdomen and pelvis CT was negative
for any gross traumatic abnormalities as was the CT of the
chest. She had laboratory values sent at the time which
were significant for a white count of 5.6, hematocrit of 32
and platelets of 214. Her coagulation studies were normal
with an INR of 1.0 and a PTT of 26.7. Her blood gas was
significant for the following values - a pH of 7.36, pCO2 of
35, pO2 of 282, bicarbonate of 21 and a base excess of -4.
Upon speaking with the family her past medical history was
significant for a total abdominal hysterectomy. She had
colon cancer, status post resection. She had a right
transmetatarsal amputation. She had an allergy to Compazine.
Her medications at home included Effexor, Diovan,
hydrochlorothiazide, trazodone.
She was transferred to the Trauma Intensive Care Unit after a
neurosurgical consult was obtained and a right
ventriculostomy drain was placed at the bedside under sterile
conditions. Her ICPs were found to be in the 10 to 20 range.
At this point she was treated aggressively with labetalol to
maintain a cerebral perfusion pressure of greater than 70 and
she was treated with a ventriculostomy drain to main an ICP
of less than 20. Despite aggressive management over the next
several days her neurological status did not improve. She
would be taken off sedation at least once a day for sedation
holiday and demonstrated no purposeful movement. She had
extensor posturing of the upper extremities and repeat head
CT confirmed traumatic subarachnoid hemorrhage and MRI of the
head was obtained which demonstrated no evidence for acute
infarction. The patient was transferred to the neurosurgical
service and after over a week of aggressive treatment her
family felt that she would not make a meaningful recovery and
after meeting with the Intensive Care Unit team they withdrew
support on [**2165-4-8**]. The patient expired on [**4-8**].
[**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2165-5-17**] 08:31
T: [**2165-5-17**] 08:53
JOB#: [**Job Number 30539**]
|
[
"805.06",
"860.0",
"401.9",
"V10.05",
"276.2",
"E880.9",
"852.05",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.72",
"02.2",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
188, 3389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,226
| 141,153
|
17271
|
Discharge summary
|
report
|
Admission Date: [**2121-10-28**] Discharge Date: [**2121-11-14**]
Date of Birth: [**2068-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
metal Tracheal stent fracture
Major Surgical or Invasive Procedure:
1. Rigid bronchoscopy with yellow Dumon tracheoscope, Flexible
bronchoscopy, PolyFlex stent removal x 3, Fiberoptic intubation.
2. Rigid bronchoscopy with a black Dumon tracheoscop, Flexible
bronchoscopy, Tumor debridement (metal stent), Argon plasma
coagulation to granulation tissue
3. Flexible bronchoscopy with therapeutic aspiration.
4. Flexible bronchoscopy through ETT, Therapeutic aspiration of
secretions, BAL of the left lower lobe.
5. Rigid bronchoscopy with black [**Last Name (un) 48377**] tracheoscope, Flexible
bronchoscopy.
6. Flexible bronchoscopy via tracheostomy, placement of
tracheostomy tube (8.0 adjustable [**Last Name (un) 295**]).
History of Present Illness:
A 53-year-old gentleman sent from [**Location (un) 11177**] for evaluation of
tracheobronchomalacia/ d/t tracheobronchialmegally, status post
multiple metal stents, now with stent fracture. Currently with 3
Polyflex stentsoverlying the frcatured metal stents, trachea and
bilateral main stem. Walked in for elective procedure, on 3 L O2
baseline at home. Pt taken to bronch by IP for plan to remove
old stents and place Y stent. There was multiple fractured
pieces noted, the old plastic stents were removed. Airway
collapse noted, and plan is to keep intubated for repeat
procedures for removal of remaining metal stent fragments.
Past Medical History:
DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,
tracheobroncheomalacia c/b multiple pneumonias and s/p stents
both metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly),
spinal fusion L3-4 w/ chronic lower back pain
SURGICAL Hx: multiple pulm stents, s/p tracheostomy in setting
of stroke 8 yrs prio, cholecystectomy/appy, hernia repair, TENS
L side abd, lumbar fusion
Social History:
lives in [**Country **], (past pulm procedures in SD), married lives
w/ family, past underground miner, +EtOH, past smoker quite 10
years ago
Family History:
Non-contributory
Physical Exam:
General: Looks well, breathing comforatbly w/ trach in place.
VS: 98.6, 97.4, 56, 146/60, 20, 100% on 40% trach mask.
HEENT: #8 [**First Name9 (NamePattern2) 48378**] [**Last Name (un) **] in place.
Chest: breath sounds course bilat. Able to clewar secretions
effectively.
COR: RRR S1, S2
abd: soft, NT
Extrem: no edema
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2121-11-11**] 11:16PM 18.7* 3.79* 11.3* 32.6* 86 29.9 34.8 14.9
330
Source: Line-portacath
[**2121-11-11**] 01:26PM 19.7* 4.05* 11.8* 34.9* 86 29.1 33.8 14.9
320
Source: Line-portacath
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2121-11-11**] 01:26PM 91.0* 5.2* 2.5 1.0 0.3
[**2121-11-3**] 1:10 pm BRONCHOALVEOLAR LAVAGE FINAL REPORT
[**2121-11-8**]**
GRAM STAIN (Final [**2121-11-3**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2121-11-7**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
MORAXELLA CATARRHALIS. >100,000 ORGANISMS/ML..
SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
2ND TYPE.
_________________________________________________________
SERRATIA MARCESCENS
| PSEUDOMONAS AERUGINOSA
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- <=1 S 8 S 4 S
CEFTAZIDIME----------- <=1 S 16 I 2 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S 2 I =>4 R
GENTAMICIN------------ <=1 S 8 I 8 I
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S 1 S
PIPERACILLIN---------- <=4 S 32 S <=4 S
PIPERACILLIN/TAZO----- <=4 S 32 S <=4 S
TOBRAMYCIN------------ <=1 S 2 S 2 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2121-11-11**] 2:59 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2121-11-11**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Brief Hospital Course:
The patient was admitted on [**2121-10-28**] for elective bronchoscopy
and stent removal. He was taken to the OR and tolerated the
procedure well. He was intubated in the OR, and remained
intubated in the TSICU d/t tracheal swelling from manipulation
and for planned further bronchoscopy for additional stent
removal. While in the TSICU, he was taken back to the OR for
multiple bronchoscopies and stent fragment retrievals on [**12-17**], [**11-3**], and [**11-6**]. On [**11-6**], a tracheostomy was placed by
Dr. [**Last Name (STitle) **] as a temporizing measure for the tracheobroncial
malacia d/t tracheobronchomegally. The patient had a sputum
culture that grew serratia, moraxella and psuedomonas and he was
started on vanco and Zosyn. He remained afebrile while in the
TSICU.
He was transferred to the floor on [**11-7**].
On [**11-10**] he had an episode of desaturation into the low 80s.
His saturation returned to [**Location 213**] after suctioning of his trach,
and he was considered stable at that time. Placed on RTC
mucolytics w/ no further episodes.
Fever: on [**11-10**] he spiked a fever to 102.2, WBC ^ 23.8. Blood,
urine, and sputum cultures were sent at that time. ID was
consulted and zosyn was changed to meropenum based on
sensitivity data. vanco was continued.
[**11-11**] WBC 19.7
[**11-12**] WBC 18.7, temp 101.
[**11-14**] WBC 10.2, afebrile. vamco d/c'd [**11-13**]. On meropemum for
total of 14 days- course to be completed on [**2121-11-25**].
Medications on Admission:
Acetaminophen, Clonidine, Famotidine, Furosemide, Dilaudid,
Heparin, Insulin, Lorazepam, Methadone, Piperacillin-Tazobactam,
Prednisone, Simvastatin, lexapro
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for fever or pain.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours).
14. Methadone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for chronic pain.
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush: Heparin
Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen. .
16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ML Inhalation Q6H (every 6 hours).
18. Meropenem 500 mg Recon Soln Sig: 500 MG Recon Solns
Intravenous Q6H (every 6 hours) for 11 days: end date thru
[**2121-11-25**].
19. Insulin
NPH 15 Units QAM NPH 15 Units QPM
Insulin SC Sliding Scale: Regular Insulin
Breakfast Lunch Dinner Bedtime
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 2 Units 2 Units 2 Units 2 Units
141-160 mg/dL 4 Units 4 Units 4 Units 4 Units
161-180 mg/dL 6 Units 6 Units 6 Units 6 Units
181-200 mg/dL 8 Units 8 Units 8 Units 8 Units
201-220 mg/dL 10 Units 10 Units 10 Units 10 Units
221-240 mg/dL 12 Units 12 Units 12 Units 12 Units
241-260 mg/dL 14 Units 14 Units 14 Units 14 Units
261-280 mg/dL 16 Units 16 Units 16 Units 16 Units
281-300 mg/dL 18 Units 18 Units 18 Units 18 Units
301-320 mg/dL 20 Units 20 Units 20 Units 20 Units
321-340 mg/dL 22 Units 22 Units 22 Units 22 Units
341-360 mg/dL 24 Units 24 Units 24 Units 24 Units
361-380 mg/dL 26 Units 26 Units 26 Units 26 Units
381-400 mg/dL 28 Units 28 Units 28 Units 28 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Diabetes Mellitus Type 2
Coronary Artery Disease
Obstructive Sleep Apnea (no CPAP)
Pneumonia (x4 with intubation, trach for failure to wean 5 yrs
ago + 3 liters of 02 x 10 years)
Asthma/Emphysema
Multiple Tracheal Bronchial stents
Obesity
PSH: lumbar fusion [**2096**], cholecystectomy, appendectomy, hernia
repair, TENS (left side abdomen) pt reports not working
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 48379**] office [**Telephone/Fax (1) 48380**] if experience: fever,
chills, increased cough, or sputum production or if you have any
problems with your trach tube- #8 adjustable [**Last Name (un) **].
continue antibiotic merpenum thru [**2121-11-25**].
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] prior to return home to [**Country **] as
directed [**Telephone/Fax (1) 48380**]. They will call you for an appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2121-11-18**]
|
[
"041.7",
"519.02",
"327.23",
"518.81",
"E878.8",
"278.00",
"E849.7",
"996.69",
"250.00",
"493.20",
"519.19",
"518.0",
"E879.8",
"E849.8",
"996.59",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"32.01",
"31.1",
"33.24",
"33.78",
"33.22",
"31.42",
"96.72",
"31.74",
"33.23",
"96.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9565, 9608
|
4977, 6460
|
306, 965
|
10016, 10032
|
2580, 4917
|
10354, 10642
|
2206, 2224
|
6668, 9542
|
9629, 9995
|
6486, 6645
|
10056, 10331
|
2239, 2561
|
4954, 4954
|
237, 268
|
993, 1626
|
1648, 2030
|
2046, 2190
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,836
| 199,740
|
12974
|
Discharge summary
|
report
|
Admission Date: [**2165-3-12**] Discharge Date: [**2165-4-15**]
Date of Birth: [**2095-9-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
Aortic valve replacement(25mm St. [**Male First Name (un) 923**] mechanical), aortic root
enlargement, coronary artery bypass grafts x 4(LIMA-LAD,
SVG-Dg,SVG-OM,SVG-AM) [**2165-3-26**]
right and left heart catheterization, coronary angiogram, left
ventriculogram [**2165-3-12**]
Sternal exploration, evacuation tamponade, ligation vein graft
bleeder [**2165-3-29**]
History of Present Illness:
Mr. [**Known lastname 916**] is a 69 y/o gentleman with multiple risk factors who
was seen for stress testing. He was recently admitted
[**Date range (1) 39783**] to the [**Hospital Unit Name 196**] service for shortness of breath and
found to have a new cardiomyopathy with EF 30% and global
hypokinesis with some akinesis of the inferior wall. He was seen
by Dr.[**Last Name (STitle) **] in clinic on [**2165-3-1**] where he reported worsening
shortness of breath and symptoms of advanced heart failure.
Stress testing with additional vascular imaging was planned.
The patient underwent pharmacologic stress testing this morning
with development of ischemic ECG changes (worsening global ST
depression) along with hypotension. He was brought to nuclear
medicine for imaging, and then directly admitted to the
cardiology service.
Since his discharge in [**Month (only) 1096**] he has not been as active, but
notes his breathing is much better. He is able to ambulate about
50ft before becoming short of breath.
He has noted increasing swelling in both legs since discharge
and a slight worsening in the wound on the back of his left
lower leg. He is not able to go shopping on his own anymore as
he gets tired. He denies any pain or cramping in his legs with
ambulation; it is mainly his shortness of breath that limits his
activities.
Cardiac catheterization was performed. Dr.[**Last Name (STitle) **] was
consulted for coronary revascularization as well as Aortic root
enlargement and Aortic valve replacement.
Past Medical History:
morbid obesity
noninsulin dependent diabetes mellitus
hyperlipidemia
post thyroidectomy hypothroidism
hypertension
venous stasis
sleep apnea
Social History:
-Tobacco history: remote Quit smoking: 30+ yrs ago
-ETOH: history of alcohol abuse, quit 7 years ago
-Illicit drugs: None
Family History:
non-contributory.
Physical Exam:
Admission:
VS - T HR 110 BP 99/60 RR 18 O2 96%RA
Gen: Obese, pleasant gentleman in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. Poor dentition
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, MCL
Irreg irreg S1S2 2/6 SEM at apex and MCL, non-radiating.
No thrills, lifts. No S3 or S4. No carotid bruits.
Chest: Well-demarcated, erythematous plaques in bilateral breast
folds.
Resp were unlabored, no accessory muscle use.
CTAB, no crackles, wheezes or rhonchi.
Abd: Obese, non-tender, +BS.
Ext: Chronic venous statis changes, lymphedema bilaterally to
knees, L>R. Healing longitudinal wound w/dirt around it on left
calf, no exhudate, erythema, necrosis. No femoral bruits
appreciated.
Neuro: CN II-XII Grossly intact, UE/LE strength 5/5 & symmetric.
Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+
Pertinent Results:
[**2165-3-30**] 04:23AM BLOOD WBC-29.2* RBC-3.27*# Hgb-9.7* Hct-28.5*
MCV-87 MCH-29.8 MCHC-34.1 RDW-16.5* Plt Ct-153
[**2165-4-1**] 01:40AM BLOOD WBC-18.4* RBC-2.80* Hgb-8.4* Hct-24.9*
MCV-89 MCH-29.9 MCHC-33.6 RDW-17.1* Plt Ct-203
[**2165-3-31**] 01:48AM BLOOD Glucose-89 UreaN-31* Creat-1.2 Na-136
K-4.1 Cl-103 HCO3-24 AnGap-13
[**2165-4-1**] 01:40AM BLOOD Glucose-62* UreaN-33* Creat-1.2 Na-137
K-4.1 Cl-104 HCO3-27 AnGap-10
[**2165-3-31**] 03:22PM BLOOD Type-ART pO2-98 pCO2-39 pH-7.46*
calTCO2-29 Base XS-3
[**2165-4-10**] 03:18AM BLOOD WBC-12.4* RBC-3.28* Hgb-9.6* Hct-30.3*
MCV-92 MCH-29.2 MCHC-31.6 RDW-16.6* Plt Ct-516*
[**2165-4-9**] 02:24AM BLOOD WBC-12.1* RBC-3.28* Hgb-9.7* Hct-30.6*
MCV-93 MCH-29.5 MCHC-31.6 RDW-17.2* Plt Ct-520*
[**2165-4-10**] 03:18AM BLOOD PT-17.2* PTT-57.9* INR(PT)-1.6*
[**2165-4-9**] 02:24AM BLOOD PT-17.0* PTT-31.7 INR(PT)-1.5*
[**2165-4-8**] 02:37AM BLOOD PT-20.2* PTT-31.4 INR(PT)-1.9*
[**2165-4-7**] 03:42AM BLOOD PT-21.9* PTT-33.7 INR(PT)-2.1*
[**2165-4-6**] 02:47AM BLOOD PT-21.9* PTT-34.7 INR(PT)-2.1*
[**2165-4-5**] 01:48AM BLOOD PT-24.6* PTT-39.3* INR(PT)-2.4*
[**2165-4-10**] 03:18AM BLOOD Glucose-104 UreaN-23* Creat-0.8 Na-139
K-3.8 Cl-92* HCO3-43* AnGap-8
[**2165-4-9**] 08:41PM BLOOD K-3.5
[**2165-4-8**] 09:47PM BLOOD K-3.4
[**2165-4-15**] 03:04AM BLOOD WBC-10.4 RBC-3.34* Hgb-9.7* Hct-30.7*
MCV-92 MCH-29.0 MCHC-31.6 RDW-16.1* Plt Ct-502*
[**2165-4-15**] 03:04AM BLOOD PT-28.7* PTT-33.2 INR(PT)-2.9*
[**2165-4-15**] 03:04AM BLOOD Glucose-79 UreaN-25* Creat-0.9 Na-138
K-4.6 Cl-92* HCO3-43* AnGap-8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 39784**]Portable TTE
(Complete) Done [**2165-4-3**] at 2:44:01 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2095-9-25**]
Age (years): 69 M Hgt (in): 69
BP (mm Hg): 92/53 Wgt (lb): 382
HR (bpm): 72 BSA (m2): 2.72 m2
Indication: s/p CABG/AVR. ?pericardial effusion. ?Left
ventricular function.
ICD-9 Codes: 786.05, 423.9, V43.3, 424.2
Test Information
Date/Time: [**2165-4-3**] at 14:44 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7749**]
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: Definity Tech Quality: Suboptimal
Tape #: 2009W020-0:50 Machine: Vivid [**6-11**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 17 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - E Wave deceleration time: 234 ms 140-250 ms
TR Gradient (+ RA = PASP): *30 to 40 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2165-3-29**].
Intravenous administration of echo contrast was used due to poor
native endocardial border definition.
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. The IVC
was not visualized. The RA pressure could not be estimated.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. No LV
mass/thrombus. Severely depressed LVEF. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). Normal
AVR gradient. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Significant PR.
PERICARDIUM: Small pericardial effusion. Effusion echo dense,
c/w blood, inflammation or other cellular elements. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal with moderate global hypokinesis (LVEF= 25-30
%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. A
mechanical aortic valve prosthesis is present. The transaortic
gradient is normal for this prosthesis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a small,
circumferential, echo dense pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Suboptimal image quality. Severe global left
ventricular hypokinesis. Mild pulmonary artery systolic
hypertension. Small echo-dense pericardial effusion with no
echocardiographic signs of tamponade. Significant pulmonary
regurgitation.
Compared with the prior study (images reviewed) of [**2165-3-29**],
the pericardial effusion is slightly smaller and the heart rate
is slower. The other findings are similar.
CLINICAL IMPLICATIONS:
Based on [**2162**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.
[**Name10 (NameIs) 39785**] signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2165-4-3**] 16:02
[**Known lastname **],[**Known firstname **] [**Medical Record Number 39786**] M 69 [**2095-9-25**]
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2165-4-12**] 10:05 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2165-4-12**] 10:05 AM
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 39787**]
Reason: r dl picc 55cm
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with picc
REASON FOR THIS EXAMINATION:
r dl picc 55cm
Final Report
HISTORY: PICC line placement.
FINDINGS: In comparison with the previous study, the tip of the
PICC line
lies in the mid-to-lower portion of the SVC. Continued
enlargement of the
cardiac silhouette with vascular congestion and bilateral
pleural effusions,
more marked on the right.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: FRI [**2165-4-12**] 12:20 PM
Imaging Lab
Brief Hospital Course:
This patient is a 69 year old white male with multiple risk
factors including diabetes, hypertension, hyperlipidemia,
cardiomyopathy who was admitted for a positive stress test.
Nuclear imaging showed areas of reversibility concerning for
Left main disease. He also was in new atrial fibrillation.
His medical regimen was adjusted after admission and he remained
pain free. He remained in atrial fibrillation with a controlled
ventricular response. He underwent catheterization which
revealed triple vessel disease, severe aortic stenosis and both
systolic and diastolic dysfunction with a left ventricular
ejection fraction of 30-35%.
Cardiac surgical evaluation was undertaken and surgery was
scheduled. A urinary infection delayed surgery and was treated
with a course of antibiotics.
On [**3-26**] he underwent cardiac surgery with an Aortic valve
replacement (#25mm St.[**Male First Name (un) 923**] Mechanical)/coronary artyery bypass
grafting (left internal mammary artery grafted to left anterior
descending artery/saphenous vein grafted to Diagnal/obtuse
marginal/AM, Aortic root enlargement with pericardial patch).
Cross clamp time= 162 minutes, Cardiopulmonary bypass time = 208
minutes. Please refer to Dr[**Doctor Last Name **] operative report for
further details. He remained stable from a cardiac standpoint.
He self-extubated and was able to remain off the ventilator.
On [**3-29**] he developed acute hypotension. A surface echo was
negative preliminarily, however, a TEE demonstrated a
significant pericardial effusion with tamponade. He suffered
cardiac arrest as preparations for evacuation were underway and
the chest was opened at the bedside, with stabilization quickly.
There was a bleeding source from a vein graft found as the
source for the effusion. The chest was closed, multiple
pressors were necessary. He remained stable and by the next
morning was extubated. Epinephrine and Levophed were weaned off
over 48 hours. He remained in atrial fibrillation postop and
Amiodarone was continued for rate control. Zosyn, Cipro and
vancomycin were give for 5 days after the reoperation.
He required extensive pulmonary toilet and continued with a
poor, ineffective cough. He spent nights on BiPap and
occassionally daytime hours as well. He was very difficult to
induce a diuresis and required resumption of phenylephrine until
[**4-4**] when he became hypercarbic to 60 and acidotic. He was
electively reintubated and aggressive diuresis attempted. He
became nonoliguric and a Lasix infusion was continued. After
aggressive diuresis of multiple liters he was awakened and
ventilatory support weaned. A prolong trial of 0 PEEP was well
tolerated and he was again extubated on [**4-9**]. He continued to
diurese well, and hemodynamics remained stable, off pressors.
His metabolic alkalosis was treated with hydrochloric acid
replacement and Diamox. He remained stable with an effective
cough and arrangements were made for a rehabilitation facility.
Mr.[**Known lastname 916**] continued to progress and on POD#20/17 he was
transferred to the rehabilitation center for further increase in
strength, endurance , and improvement in activities of daily
living. All follow up appointments were advised.
Medications on Admission:
levothyroxine 225mcg/D
Simvastatin 40mg/D
Glyburide 2.5 mg/D
ASA 325 mg/D
Lasix 80mg/D
Discharge Medications:
1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
2. Simvastatin 40 mg [**Known lastname 8426**] Sig: Two (2) [**Known lastname 8426**] PO DAILY
(Daily).
3. Aspirin 325 mg [**Known lastname 8426**], Delayed Release (E.C.) Sig: One (1)
[**Known lastname 8426**], Delayed Release (E.C.) PO DAILY (Daily).
4. Furosemide 40 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO BID (2 times a
day).
5. Glyburide 2.5 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO DAILY (Daily).
6. Ranitidine HCl 150 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO BID (2
times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Hydrocortisone 1 % Ointment Sig: One (1) Appl Topical QID (4
times a day).
10. Levothyroxine 125 mcg [**Known lastname 8426**] Sig: Two (2) [**Known lastname 8426**] PO DAILY
(Daily).
11. Amiodarone 200 mg [**Known lastname 8426**] Sig: Two (2) [**Known lastname 8426**] PO DAILY
(Daily).
12. Warfarin 1 mg [**Known lastname 8426**] Sig: MD [**First Name (Titles) 39788**] [**Last Name (Titles) 8426**] PO DAILY
(Daily) as needed for mech AVR.
13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze.
15. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed) as needed for K<4.4 and CR<2.0.
16. Acetaminophen 500 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO Q6H
(every 6 hours) as needed for pain or temp > 101.
17. Warfarin 2 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO today for 1
doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Aortic stenosis
Coronary Artery Disease
pericardial tamponade
s/p aortic valve replacement, root enlargement,coronary artery
bypass grafting
chronic venous stasis legs
s/p evacuation pericardial tamponade
chronic Atrial Fibrillation
systolic and diastolic Heart Failure
morbid obesity
noninsulin dependent Diabetes Mellitus
urinary tract infection
obstructive sleep apnea
post thyroidectomy hypothyroidism
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-8**] weeks ([**Telephone/Fax (1) 10548**])
Dr. [**First Name4 (NamePattern1) 1370**] [**Last Name (NamePattern1) **] [**Last Name (un) 28949**] in [**12-7**] weeks ([**Telephone/Fax (1) **])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2165-4-15**]
|
[
"250.00",
"428.33",
"041.00",
"272.4",
"285.9",
"459.81",
"427.5",
"401.9",
"244.9",
"427.1",
"996.79",
"276.8",
"278.01",
"782.1",
"E879.9",
"427.31",
"518.81",
"523.10",
"458.29",
"423.3",
"997.1",
"707.8",
"041.10",
"599.0",
"411.1",
"424.1",
"425.4",
"707.12",
"423.9",
"276.3",
"327.23",
"414.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"93.90",
"99.04",
"99.07",
"96.04",
"36.15",
"39.61",
"39.98",
"35.22",
"88.56",
"88.53",
"38.93",
"77.31",
"96.6",
"96.72",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
16410, 16471
|
11065, 14312
|
298, 667
|
16920, 16927
|
3563, 9531
|
17331, 17878
|
2532, 2551
|
14449, 16387
|
10500, 10526
|
16492, 16899
|
14338, 14426
|
16951, 17308
|
2566, 3544
|
9554, 10460
|
243, 260
|
10558, 11042
|
695, 2212
|
2234, 2376
|
2392, 2516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,944
| 154,128
|
14030
|
Discharge summary
|
report
|
Admission Date: [**2126-7-3**] Discharge Date: [**2126-7-5**]
Date of Birth: [**2057-5-3**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male who is here for a left internal carotid artery
angioplasty. He is admitted on [**2126-7-3**]. Attending
physician was Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1132**].
PAST MEDICAL HISTORY: History of hypertension, coronary
artery disease, status post right ICA stent in [**2124-3-22**],
carotid stenosis, renal calculi, glaucoma, status post
clipping MCA aneurysm [**2126-6-21**], and subarachnoid
hemorrhage.
PAST SURGICAL HISTORY: Right internal carotid artery stent
[**2124-3-22**] and clipping MCA aneurysm [**2126-6-21**].
ALLERGIES: The patient has no known drug allergies.
HOSPITAL COURSE: The patient was admitted on [**2126-7-3**] in
stable condition. On [**2126-7-4**], the patient was taken to
the OR for left internal carotid artery angioplasty
procedure, carried out without complications. The patient
was sent to PACU in stable condition. Postoperative check of
the patient, the patient was alert and oriented x 3. There
was no drift. His speech was intact, fluent, and
comprehensive. He was out of bed ambulating. His groin and
insertion site was clean, dry, and intact without hematoma.
His distal pulses are present.
ASSESSMENT/PLAN: Status post left internal carotid artery
angioplasty. Condition is stable and the patient is to be
discharged to home on this date.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg tablet, delayed release, one tablet p.o.
daily.
2. Plavix 75 mg tablet one tablet p.o. daily.
3. Metoprolol tartrate 25 mg tablet one tablet p.o. b.i.d.
4. Dilantin extended 100 mg capsule 1 capsule p.o. three
times a day.
5. Amiodarone hydrochloride 200 mg tablet one tablet p.o.
daily.
6. Tylenol With Codeine No. 3 300-30 mg tablet 1-2 tablets
p.o. q.4-6h. p.r.n. for pain, dispensed 60 with 2 refills.
DISCHARGE INSTRUCTIONS: The patient is to be discharged
home. The patient to watch the insertion site for signs of
infection, i.e, redness, swelling, or discharge. He is to
call the office if fever or any of the above occur. Keep
incision dry. He may shower in 2 days but no bath for one
week.
FINAL DIAGNOSIS: Status post left internal carotid
angioplasty.
RECOMMENDATIONS: He was recommended follow up. He is to
follow up with Dr. [**Last Name (STitle) 1132**] in [**11-23**] days. His major surgical
procedure was left ICA angioplasty.
DISCHARGE CONDITION: He is neurologically stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2126-7-5**] 07:48:49
T: [**2126-7-5**] 08:13:34
Job#: [**Job Number 41880**]
|
[
"433.10",
"401.9",
"414.01",
"V13.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
2584, 2865
|
1573, 2011
|
853, 1550
|
2329, 2562
|
2036, 2311
|
685, 835
|
162, 416
|
439, 661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,507
| 196,852
|
48033
|
Discharge summary
|
report
|
Admission Date: [**2126-7-23**] Discharge Date: [**2126-8-3**]
Date of Birth: [**2049-1-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lasix
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
headache, hypertension
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
77F former smoker with HTN, thyroid nodule, and anxiety presents
with headache. She came to the emergency room because she had a
headache and thought her BP must be elevated. She does not have
a h/o headaches and the last time she had a headache, her BP was
elevated so she felt it must be the case this time. Denies
vision changes, lightheadedness or chest pain. No
numbness/tingling except for some stiff/tingling left fingers
this afternoon after waking from a nap, but it quickly resolved.
.
In the ED, initial vitals were remarkable for SaO2 of 90% RA. Pt
denies SOB. HA resolved with sublingual nitroglycerin given by
EMS. HTN treated in ED with total of 15mg lopressor IV.
Ambulatory SaO2 was 90% RA. CXR (done b/c low O2 sat) showed new
large R pleural effusion, with possible air bronchograms (see
read below). Pt given levofloxacin and admitted for w/u of new
pleural effusion. Vitals on transfer vs temp 98 HR 67 BP 184/80
RR 22 O2sat 96%RA.
.
On the floor, pt's headache had resolved. She states she has
never been aware of SOB. She states she is unable to do as much
as she could about a year ago but is still able to perform many
of her household chores by herself. She lives on the [**Location (un) 17879**] and is able to climb the steps (approx 20) in [**12-25**] min,
only getting SOB if she climbs too fast or walks too quickly to
the bathroom. She does not know if she has dyspnea with exertion
as she does not exercise much. For the past week, she has noted
that she has some orthopnea and needs to sleep with 2-3 pillows
which helps. Mild exertional dyspnea was noted by her PCP in
[**2125-6-22**].
.
Of note, pt has had significant anxiety for the past year due to
loss of her husband and workup of her thyroid nodule. She
becomes SOB and has palpitations when anxious and is unable to
provide clear history about her breathing when she feels calm.
Also, Pt states her weight [**2125-7-23**] was 163 lbs. She cut out
sugar and salt from her diet due to DM and CRI and weight
decreased to 121 lbs(not exactly intentional, but did decrease
with diet). Weights not recorded in OMR to correlate.
.
BP on the floor was 210/114, possibly due to anxiety. Pt given
lorazepam 0.5mg x1 and BP rechecked in both arms 30 min later.
Still 190/92 R arm and 240/100 L arm. Pt remained asymptomatic
although she was very uncomfortable when cuff inflated.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denied cough. Denied
chest pain or tightness. Denied nausea, vomiting, diarrhea.
Occassional constipation, chronic for her. Last BM was yesterday
and appeared normal. No recent change in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Thyroid nodule (most recent FNA [**2126-7-3**] - insufficient
material)
-Anxiety
-Type 2 diabetes - used to be on metformin and actos, but DM
improved when she lost weight
-Hyperlipidemia - h/o rhabdomyolysis with statin (hospitalized
in ICU)
-Hypertension - metoprolol most recently increased to 75mg daily
on [**2126-7-15**];
-Right subclavian stenosis with 52 mm systolic blood pressure
gradient.
-Chronic kidney disease, last Cr 2.8 on [**2126-7-15**] - seen by
nephrology, attributed to hypertension and diabetes
-Bilateral less than 40% ICA stenosis.
Social History:
Widowed, Lives alone, daughter and son-in-law live downstairs
and help her carry things upstairs. Pt able to do her own
laundry, dishes, some other household chores but does get more
tired than before. Quit smoking 40y ago, no EtOH, no drugs, no
current sexual relationship.
.
Note: Daughter with Asperger's syndrome; Per pt's son: Pt feels
her daughter and son-in-law can take care of her but daughter
sometimes has difficulty taking care of herself.
Family History:
non-contributory
Physical Exam:
Physical Exam on admission [**2126-7-23**]:
Afebrile BP: 190/92 (R arm), 240/100 (L arm) P:72 R:20-24 O2:
94% 2L (90% RA)
General: Pleasant, alert, oriented, appears anxious
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: visible and palpable L nodule at L base of thyroid,
supple, no LAD
Lungs: Bronchial breath sounds on R, Basilar rales on L,
dullness to percussion approx [**11-24**] way up on R, dullness [**11-25**] way
up on L.
CV: RRR, normal S1 + S2, 1/6 systolic murmur at RUSB and LUSB,
no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: warm, well perfused, 2+ DP pulses, trace nonpitting edema
of L leg (chronic per pt); no edema of R leg
.
Physical exam on discharge [**2126-8-3**]:
Vitals: 97.2 BP: 179/73 P:68 O2: 97% RA
General: Pleasant, AOx3
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: visible and palpable L nodule at L base of thyroid,
supple, no LAD
Lungs: bibasilar crackles, no wheezes or ronchi
CV: RRR, normal S1 + S2, 2/6 systolic murmur at RUSB and LUSB
radiating to carotids and L axilla, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: warm, well perfused, 2+ DP pulses, trace nonpitting edema
of L leg (chronic per pt); no edema of R leg
Skin: large erythematous patch on lower abdomen and thighs, no
increased warmth, swelling or tenderness, dry skin
Neuro: CN II-XII intact, [**3-26**] strenth UE and LE b/l, able to
follow simple commands, no dysarthria
Pertinent Results:
Labs on admission [**2126-7-23**]:
BLOOD WBC-9.1 RBC-4.51 Hgb-12.5 Hct-38.7 MCV-86 MCH-27.7
MCHC-32.3 RDW-13.2 Plt Ct-344
Neuts-79.8* Lymphs-12.7* Monos-5.2 Eos-1.9 Baso-0.4
BLOOD PT-11.6 PTT-28.9 INR(PT)-1.0
.
Labs on discharge [**2126-8-3**]:
WBC-12.5* RBC-3.62* Hgb-10.2* Hct-31.6* MCV-87 MCH-28.3
MCHC-32.4 RDW-13.3 Plt Ct-361
Glucose-130* UreaN-48* Creat-2.2* Na-140 K-3.8 Cl-107 HCO3-23
AnGap-14
Calcium-8.8 Phos-2.7 Mg-2.1
.
Iron studies: calTIBC-156* Ferritn-265* TRF-120*
.
Lipids: Triglyc-692* HDL-25 CHOL/HD-7.2 LDLmeas-101
.
Lipase: 10, 14
.
Images:
[**2126-7-23**] CXR: Bilateral moderate-sized pleural effusion, right
more than left, with atelectasis of right lower lobe, right
middle lobe and left lower lobe.
.
EKG [**2126-7-23**]: NSR 66, nl PR, QRS, nl axis, Q in III, TWI in AVL,
T-wave flattening in aVR and V5, J-point elevations in V2 and V3
- all unchanged from [**2125-9-30**].
.
[**2126-7-24**] CT Head: No evidence of acute process, and no change
since [**2125-7-23**].
.
[**2126-7-24**] Head CT IMPRESSION: No evidence of acute process, and no
change since [**2125-7-23**].
.
[**2126-7-25**]: MRI head prelim: Multifocal regions of acute embolic
infarcts, predominantly within posterior circulation on the
right and also involving the anterior circulation suggesting a
proximal source.
.
[**2126-8-2**] L-spine: No previous images. Mild scoliosis convex to
the left, most likely positional. Narrowing with spurring and
sclerosis involving multiple intervertebral disc spaces,
consistent with widespread degenerative change. Of incidental
note is calcification in the aorta.
.
[**2126-8-2**] Bilateral hip: Three views of each hip show no evidence
of fracture or dislocation. No substantial degenerative change
is appreciated.
.
[**2126-8-3**] CXR Portable: Currently, the patient is in improved, but
still present pulmonary edema with bibasilar consolidations and
bilateral pleural effusions. The consolidation may represent
areas infection as was previously suggested, but also may be a
combination of infection and atelectasis.
Brief Hospital Course:
77F with HTN, thyroid nodule, and anxiety presents with headache
now resolved and hypertensive urgency, found to have new embolic
posterior strokes, oxygen requirement and bilateral pleural
effusions.
.
# Acute mental status changes/posterior stroke - On the morning
after admission, pt was noted to have acute mental status
changes c SBPs in 210s. CT Head done and was unremarkable. Pt
was transferred to the MICU. DDx initially included ativan
induced-delerium, infection, metabolic derangement, acute
stroke, hypertensive emergency. Pt was combative in the MICU and
required haldol which was then switched to geodon prn per psych
recommendations. Pt was not found to have any metabolic
derangement. She was pan-cultured and completed course of
levofloxacin for community acquired pna. By cxr she was noted to
have pulmonary edema significantly worsened as compared to the
day before. Pt also had an MRI which showed evidence of acute
stroke in posterior circulation. Per neurology attending, this
is more likely watershed stroke than embolic stroke. They
recommended aspirin 325mg daily and no statin. Etiology of
altered mental status was felt to be [**12-24**] stroke, perhaps
exacerbated by pulmonary edema and anxiety [**12-24**] difficulty
breathing. Pt was AOx3 at time of discharge.
.
# Hypoxic respiratory failure - Pt admitted with decreased
oxygen saturation on RA with CXR demonstrating bilateral pleural
effusions. Pt not aware of SOB at baseline but does have dyspnea
when anxious. PCP noted mild DOE in [**2125-6-22**] note. In the
setting of elevated SBP > 200 pt had flash pulmonary edema. Pt
was intubated for hypoxic respiratory failure and diuresed
gently c lasix. Given h/o thyroid nodule and weight loss (which
may be due to dietary changes), there was also concern for
malignant effusion. Pt had thoracentesis c drainage of 1.3L from
R lung which showed a transudative effusion. Cytology was
negative for malignant cells. Pt was extubated on HD7. She was
oxygenating 96% RA at discharge.
.
# Hypertension - Pt with persistent hypertension, followed by
nephrology, attributed to b/l RAS, admitted c hypertensive
urgency. Bilateral artery stenosis was not able to be confirmed
due to inability to do imaging with contrast given pt's poor
renal funciton. She was maintained on multiple blood pressure
medicines throughout her ICU stay. BP goal immediately after her
stroke was 160-180 which was then switched to 140-160. This was
accomplished with metoprolol, amlodipine and imdur (her home
meds) plus clonidine patch. Labetolol drip, nitro patch and
hydralazine IV were occasionally used on a prn basis in the ICU.
Renal was consulted and followed patient in-house. They
recommended continuing to hold her ACE inhibitor or [**Last Name (un) **] at this
time. Despite goal SBP 140-160, the patient continued to have
episodes of lability up to SBP 200. At time of discharge pt was
on Clonidine 0.2mg patch, Amlodipine 10mg daily, Metoprolol 75mg
[**Hospital1 **], Isosorbide 60mg [**Hospital1 **].
.
Of note, pt has R subclavian stenosis with 50mm Hg pressure
difference. Blood pressures were taken from her leg, rather than
either arm.
.
#[**Last Name (un) 13160**] Pt developed rising creatinine while in the MICU in the
setting of early diuresis with a Cr of 4.2. Pt also developed a
rash and low grade temps. This was felt to perhaps be c/w AIN,
though it is also possible that pt was prerenal while being
diuresed. Pt had small increase in peripheral eos and rare eos
in urine which could be c/w either process. Multiple meds were
stopped out of concern for AIN versus drug rash. Cr continued to
trend downwards during her hospitalization and was 2.2 at
discharge, close to her baseline.
.
# Chronic renal insufficiency - Cr [**2126-7-15**] was 2.8 (improved
from end of [**2124**]). Per nephrology, most likely due to HTN and
diabetes. Goal BP <130/80. Avapro ([**Last Name (un) **]) stopped due to elevated
Cr 3.7. Nephrology's plan was to continue to hold avapro given
suspected renal artery stenosis. Meds were renally dosed. Cr at
discharge was 2.2. Pt will follow up with nephrology as an
outpatient for medication management.
.
# [**Name (NI) 20972**] Pt developed macular blanching rash over her abdomen and
back associated c low grade temperatures. This was felt to be
c/w drug rash versus AIN. Multiple meds were stopped including
the following: famotidine was switched to lansoprazole,
hydralazine was discontinued, lasix was discontinued (though pt
has gotten lasix as outpatient), levoquin and vancomycin were
intially continued but these were also discontinued on the day
after the rash appeared. Rash significantly improved over course
of hospitalization.
.
# Large Thyroid nodule displacing trachea (not compressing)-
most recent FNA [**2126-7-3**] inconclusive due to insufficient sample.
Nodule appeared benign [**2124-12-22**]. Pt to have outpatient follow
up.
.
# Type 2 diabetes - used to be on metformin and actos, but DM
improved when she lost weight. Not currently on medications.
HbA1c [**2126-5-9**] was 5.8%. Pt's FSBS was monitored in house and
remained 100-150 and it was determined that pt has no insulin
needs at this time.
.
# Hyperlipidemia - h/o rhabdomyolysis with acute renal failure
on statin. Cholesterol checked [**2126-5-9**] by PCP. [**Name10 (NameIs) **] an acute
concern during this hospitalization. Pt will follow up as outpt.
.
# Right subclavian stenosis with 52 mm systolic blood pressure
gradient. Pt currently asymptomatic. BP was measured in both
arms or in the leg given pressure gradient. No intervention
during this hospitalization.
.
# FEN: Low salt cardiac diet
.
# Disposition: to rehab.
Medications on Admission:
Medications - Prescription (confirmed with patient's home list)
AMLODIPINE - 10 mg daily
ISOSORBIDE MONONITRATE ER - 30mg daily
LORAZEPAM - 0.5 mg daily
METOPROLOL SUCCINATE - 75 mg Tablet Sustained Release daily
ONDANSETRON HCL - 4 mg q8h: PRN nausea
SERTRALINE - 50mg daily (pt takes in evening)
ASPIRIN - 325mg daily
CALCIUM CARBONATE 500 mg- 2 tabs [**Hospital1 **] (Pt taking Ca but does not
have dose with her)
Vitamin D - 1600 IU daily (400mg QID)
FERROUS SULFATE - 65mg daily (elemental) - ordered as Ferrous
Sulfate 325mg daily on admission
MULTIVITAMINS
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID: PRN as needed for pruiritis.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID:
PRN as needed for constipation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID: PRN as
needed for constipation.
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a
day).
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO twice a day:
hold for SBP <100, HR <50.
13. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
1. hypertension
.
2. mental status changes/posterior stroke
.
3. acute kidney injury on chronic kidney disease
Discharge Condition:
Stable, SaO2 97% RA, SBP 160s-190s (labile)
Discharge Instructions:
You were admitted to [**Hospital1 18**] with headache and high blood
pressure. You developed mental status changes and were sent to
the ICU. In the ICU, you were intubated for difficulty to
breathe. Imaging of your head showed that you had a small stroke
in the back of your brain. It does not seem that you have any
neurological effects of the stroke. Your blood pressure
medications were changed to better control your hypertension.
Your blood pressure will remain labile due to the narrowing of
your renal arteries. The doctors also removed [**Name5 (PTitle) **] from around
your lung. You also had acute kidney injury on top of your
chronic kidney disease. This is thought to be due to narrowing
of the arteries going to your kidneys. The renal doctors saw [**Name5 (PTitle) **]
and made recommendations to control your blood pressure.
You blood pressure medications were titrated up and may require
furthur titration at rehab. At discharge your blood pressure was
still elevated sometimes up to 200/100, but you were
asymptomatic and this seems to be improving with more
medications.
Please call Dr [**Last Name (STitle) 131**] or return to the hospital if you develop
fevers, chills, chest pain, difficulty breathing, weakness,
confusion or any other concerning symptoms.
It was a pleasure taking care of you, we wish you the best!
Followup Instructions:
1. Please make an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] (phone
[**Telephone/Fax (1) 133**]) within 2 weeks of being discharged from rehab for
hospital follow up.
.
2. MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
Specialty: Nephrology (kidney)
Date and time: [**2126-8-8**] 3:00pm
Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) **]
Phone number: [**Telephone/Fax (1) 721**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
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66,011
| 179,563
|
50781
|
Discharge summary
|
report
|
Admission Date: [**2152-5-3**] Discharge Date: [**2152-5-25**]
Date of Birth: [**2086-8-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin / Iodine-Iodine Containing / Coreg /
Rosuvastatin / metronidazole / alendronate sodium / simvastatin
/ Ezetimibe / risedronate sodium / Vitamin D
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Anticoagulation with heparin for colonoscopy
Major Surgical or Invasive Procedure:
Elective colonoscopy on [**2152-5-5**] (with MAC)
Colonoscopy on [**2152-5-9**]
Colonoscopy on [**2152-5-12**]
History of Present Illness:
65 yo F pt with hx of rheumatic heart disease s/p mitral valve
replacement ([**Doctor Last Name 1395**]-[**Doctor Last Name **] metallic prosthesis) [**2104**],
complicated by diastolic dysfunction, mild stenosis,paravalvular
leak prone to occasional heart failure and mild hypotension
admitted for an elective colonoscopy with need for MAC
anestheisa and heparin bridging. Pt has never had a colonoscopy.
She recently had a (+) blood test for colon cancer last week,
done by Quest (Colovantage). Patient denies any recent weight
loss, night sweats, fevers, chills, melena, BRBPR, diarrhea,
constipation. Patient has mild SOB at baseline. GI are planning
to perform colonscopy on [**Year (4 digits) 2974**]. Pt's last dose of coumadin was
Sunday. She will also need SBE prophylaxis as per her primary
cardiologst (although guidelines don't say it is necessary, he
recognizes this and would like to err on the side of caution).
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, chest pain or tightness, palpitations. Denied
nausea, vomiting, or abdominal pain. No recent change in bowel
or bladder habits. No dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
1. Rheumatic heart disease status post mitral valve replacement
with a [**Doctor Last Name 1395**]-[**Doctor Last Name **] metallic prosthesis in [**2104**].
2. Congestive heart failure - ECHO in [**6-28**] EF 50-55% mitral
insuffiency
3. Chronic atrial fibrillation.
4. Hypertension
4. HLD
5. Carotid stenosis
6. Vitamin D deficiency
7. Borderline diabetes, not on medications.
8. Anemia, on iron supplements.
9. Spontaneous hemarthroses in right knee in [**2150-7-21**], [**2150-8-19**],
[**10-27**]
10. Osteoarthritis of the knees
11. Migraine headaches
12. Allergic rhinitis
.
Past Surgical History:
1. Mitral valve replacement [**2104**]
2. CCY for gallstones [**2108**]
3. Tubal ligation in [**2110**]
Social History:
The patient lives with her husband. She is a nonsmoker (she
quit
smoking in [**2114**]). She does not drink alcohol. Denies IVDU.
Family History:
FHx negative for premature coronary artery disease or sudden
cardiac death. She does mention that one of her uncles had a
heart condition at an older age as well as her mother who had a
valve problem in her 50s, but she eventually passed away at the
age of 96.
Physical Exam:
Physical Exam:
Vitals: T: 96.3 BP: 119/62 P: 80 irreg irreg; R: 22 O2: 96 RA
General: Alert, oriented, no acute distress. Pleasant woman.
HEENT: Sclera anicteric, MMM, oropharynx clear skin warm smooth
and dry.
Neck: supple, JVP elevated with prominent V wave height 12.5 cm.
Carotids 2+ equal without bruit.
Chest: Clear to auscultation bilaterally, no wheezes, fine dry
atelectatic rales at both bases about 1/4 up.Left parascapular
thoracotomy scar.
CV: Irregularly irregular rate and rhythm, normal S1 + S2, Gr
[**1-23**] hololsystolic murmur loudest in midaxillary line 5th ICS, Gr
2/6 SEM at RUSB, no rubs or gallops, prominent parasternal RV
lift.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, 13 cm liver, 3 FB's below the
costal margin, pulsatile. Cholecystectomy scar.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
pedal medial malleolar and some pretibial edema.
Neuro: Normal muscle tone, moves all extremities bilaterally,
reflexes 2+ UE and LE bilaterally, toes downgoing bilaterally.
CNI: not tested, CNII: PERRLA 4mm to 2mm bilaterally. CNIII, IV,
VI: EOMI. CN VII: Facial muscles intact. CN VIII: Intact
bilaterally CNIX,X: Palate elevates symmetrically. CNXI: Intact
CNXII: Tongue protrudes midline. Gait: normal.
Pertinent Results:
Admission labs:
[**2152-5-3**] 09:45PM WBC-3.2* RBC-4.03* HGB-11.6* HCT-34.8* MCV-87
MCH-28.9 MCHC-33.4 RDW-14.4
[**2152-5-3**] 09:45PM PT-21.1* PTT-150* INR(PT)-1.9*
[**2152-5-4**] 05:15AM BLOOD Glucose-86 UreaN-38* Creat-1.2* Na-142
K-4.3 Cl-106 HCO3-26 AnGap-14
[**2152-5-4**] 05:15AM BLOOD ALT-31 AST-52* LD(LDH)-340* AlkPhos-117*
TotBili-1.0
[**2152-5-4**] 02:55AM BLOOD proBNP-2791*
[**2152-5-4**] 05:15AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9 Iron-112
[**2152-5-4**] 05:15AM BLOOD calTIBC-295 VitB12-1741* Folate-GREATER
TH Hapto-<5* Ferritn-117 TRF-227
.
Imaging:
ECHO [**2152-5-4**]:
IMPRESSION: Normal left ventricular function. Ball and cage
mitral prosthesis with normal gradient and at least mild mitral
regurgitation. Dilated and hypokinetic right ventricle with
severe tricuspid regurgitation and moderate pulmonary
hypertension. Mild aortic regurgitation. Biatrial dilatation
with the right atrium being markedly dilated.
.
Splenic US [**2152-5-5**]:
FINDINGS: Transverse and sagittal images were obtained of the
spleen. The
spleen is enlarged measuring 16.2 cm. The splenic appearance is
unremarkable. No ascites is seen in the left upper quadrant.
IMPRESSION: Splenomegaly.
.
Colonoscopy [**2152-5-5**]:
Impression: Polyp in the proximal ascending colon (polypectomy)
Otherwise normal colonoscopy to cecum.
.
Colonoscopy [**2152-5-9**]:
Impression: There was blood throughout the colon making
visualization difficult. The mucosa was not examined.
There was a large blood clot in the proximal ascending colon at
the site of prior polypectomy. There was a clip buried within
the clot. The area was washed extensively but the clot could not
be removed. Biopsy forceps were used to try to remove the clot
but this was not successful. There was erythema and active
oozing seen at the superior aspect of the clot. (endoclip,
injection)
.
Colonoscopy [**2152-5-12**]:
Impression:Blood in the colon
The polypectomy site was identified by presence of clips. An
adherent clot was noted adjacent to the clips. Fresh bleeding
was noted from the base. The clot was removed by wash and
suction. A small visible vessel was noted. Three clips were
applied with successful hemostasis. 5 cc of epinephrine was
injected into the mucosa for hemostasis.
The rest of the colon was not fully examined.
Otherwise normal colonoscopy to cecum.
Polyp described as serrated adenoma requiring repeat colonoscopy
in 5 years given increased risk of finding of serrated polyp.
Discharge Labs:
Brief Hospital Course:
65 yo F pt with hx of rheumatic heart disease at age 7, s/p
mitral valve replacement ([**Doctor Last Name 1395**]-[**Doctor Last Name **] mechanical prosthesis)
[**2104**], complicated by mitral insufficiency, ? ball variance/and
or paravalvular leak, pulmonary hypertension and RV
failure,tricuspid insufficiency and normal LV function, admitted
for an elective colonoscopy with need for MAC anesthesia and
heparin bridging.
.
# Positive Colovantage test: Patient has not undergone routine
screening colonoscopy however she underwent the Colovantage
testing which came back as positive on [**2152-4-12**], indicating that
she has increased likelihood of colorectal cancer. She was
admitted for IV heparin bridge due to her mechanical valve (pt
must be anticoagulated; at high risk for thrombus) starting [**12-23**]
days after discontinuing her coumadin (stopped on [**4-30**]).
Colonoscopy performed on [**5-5**] under MAC anesthesia with removal
of a single sessile polyp in the ascending colon. Post procedure
her stay was complicated by bleeding, see below.
.
#Loose bloody stools: On [**5-7**], patient experienced loose stools
mixed with blood. Her coumadin was held, heparin initially
continued. Hct started to fall on [**5-8**] to 25 and she was given 2
units RBCs. Heparin was stopped and she was reprepped for a
colonscopy (#2). She remained hemodynamically stable. On [**5-9**], a
large clot was visualized at the polypectomy site which could
not be evacuated, so additional clips were placed along with
epinephrine. Heparin was restarted after procedure. However, on
[**2152-5-11**], patient's hct dropped to 28 and patient experienced
increased bloody stools. Patient received one more unit RBCs and
heparin was dc'd for 6 hrs. She was repreped for a repeat scope
that was done on [**2152-5-12**]. The clot was removed and more clips
were placed and epi injected. Post procedure her hct remained
stable.
.
# Mechanical Mitral Valve: Patient is s/p mitral valve
replacement ([**Doctor Last Name 1395**] [**Doctor Last Name **] valve) for mitral stenosis/atrial
fibrillation in [**2104**]. Patient was admitted for heparin bridge
for her procedure. She was given SBE prophylaxis (clindamycin
600mg IV) with her procedures. Her home coumadin was initially
restarted on [**5-5**], but it was dc'd on [**5-7**] due to bloody bowel
movements. For her bleeding episodes as stated above her heparin
was stopped at given intervals. Her coumadin was restarted on
[**2152-5-15**]. She had increasing warfarin requirement from her usual
dose of 5.5 mg with slow rise in INR until therapeutic plateau
(2.3) was reached with 8 mg of warfarin Q PM likely related to
increase in PO nutrients supplemented with Boost.
She may need less warfarin as she returns to her usual home
diet. She was bridged with heparin until [**2152-5-25**].
.
# CHF: Patient had an ECHO in [**2151-6-20**] with a EF of 50-55%
and moderate to severe tricuspid regurgitation and pulm artery
htn noted. CXR on [**2152-4-12**] performed by her cardiologist revealed
probable small left pleural effusion, no evidence of CHF; BNP
was 218 on [**2152-4-12**]. Patient presents volume overloaded with
systolic ejection murmur; repeat ECHO essentially unchanged from
[**6-/2151**], worsening pulm htn. Pro-BNP elevated to 2791 on [**5-4**].
Her home medications, including nebivolol, valsartan, and
diltiazem were discontinued in setting of bleed so that symptoms
of blood loss would not be masked. Transfusions were performed
slowly over 4 hours in order to not fluid overload. Patient was
without an oxygen requirement and clear lungs throughout the
hospitalization. In the ICU, home diltiazem was restarted and
tolerated well.
.
#Splenomegaly/pancytopenia: Patient presented with
thrombocytopenia on admission labs (plts 79); unclear etiology
(heme had low suspicion for HIT). Per outpt cardiology records,
patient's platelets were 129 on [**2152-4-12**]. Patient's anemia [**12-22**]
hemolysis from mechanical valve (LDH elevated, low haptoglobin).
Splenic ultrasound shows splenomegaly; heme will likely perform
outpt BM bx. Valsartan can be associated with leukopenia;
further investigation revealed that pt had a cough with
ace-inhibitor. No ACE or [**Last Name (un) **] was rx'd pending consultation i f/u
with Dr. [**Last Name (STitle) **]. Will also follow up with heme-onc as outpatient.
.
#Atrial fibrillation: Patient is rate controlled with diltiazem,
nebivolol; anticoagulated with heparin (was on coumadin) while
in house. During colonoscopy, pt had episode of AFib with RVR,
and required a dose of esmolol. She was transferred to the ICU
for overnight monitoring. In the ICU, home regimen of diltiazem
was restarted. On a dose of Dilt ER without beta blocker her
ambulatory HR was 120-130. Dilt ER was increased to 180 PO daily
with excellent rate control, never greater than 90. While
febrile to 99.6 on the day of discharge peak rate over 12 hrs
was 114. Patient was successfully bridged back to coumadin with
discharge INR of 2.3.
.
#Fever: the day prior to discharge, [**2152-5-24**], the patient had a
low-grade temperature to 100.4. She felt well, without cough,
diarrhea, abdominal pain or dysuria. A urinalysis was negative.
Abdomen was benign on exam and she was eating and drinking
normally. The day of disharge she had a temperature of 99.6 at
12pm. She was counseled to continue monitoring her temperature
at home and call her primary care doctor with any new symptoms.
No antibiotics were started. She has close follow-up with Dr.
[**Last Name (STitle) **].
.
#Difficult to crossmatch blood: Patient required several
transfusions and was difficult to crossmatch. Further
investigation by the blood bank revealed a new clinically
significant alloantibody, anti-E. The patient was notified of
this new finding and is to carry this information with her. A
card describing this finding will be issued by pathology.
.
# HTN: Patient is stable on her home medications. No
hypertension was recorded.
.
#Transition of care: She will need close monitoring of her INR
after discharge and follow up for blood loss. She should have a
hematocrit checked after discharge. She should also have heart
failure medications re-evaluated and restarted. Unclear why she
is on nebivolol rather than carvedilol. Some concern as to
whether Valsartan is causing pancytopenia and may want to
consider restarting ACE inhibitor instead of Valsartan. She has
a hematology/oncology appointment to evaluate her pancytopenia.
Medications on Admission:
Home Medications (reconciled with Dr. [**Last Name (STitle) **]:
Valsartan 160 mg once daily
Diltiazem 120mg once daily
Furosemide 20mg once daily
Coumadin 5.5mg daily
Nebivolol 10mg 1 tablet once daily
Iron 325 mg 1 tablet twice a day
Calcium citrate 600mg +400 iu 1 tablet twice a day
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
5. warfarin 8 mg PO once a day: Dose to be adjusted per Dr. [**Last Name (STitle) **].
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Elective colonoscopy
Secondary Diagnosis:
s/p mitral valve replacement [**Doctor Last Name 1395**] [**Doctor Last Name **] mechanical prosthesis
diastolic CHF
RV failure secondary to Pulmonary Hypertension
Mitral insufficiency
Atrial fibrillation,chronic
Transfusion reaction alloantibody Anti E.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a planned colonoscopy to follow up a
positive Colovantage colon cancer screen. You required heparin
while you were not taking Coumadin because of your mechanical
mitral valve. During your colonoscopy on [**2152-5-5**] a polyp was
removed and you started to bleed from your colon. This required
two additional colonoscopies [**2152-5-9**] and [**2152-5-12**] to stop the
bleeding. After the bleeding stopped, you were able to start
your Coumadin again [**2152-5-15**] to get you back close to your goal
INR 2.5-3.5. You were very patient and we were able to get you
close to you goal INR 2.3 with your Coumadin before leaving the
hospital. You will need to have you INR closely followed. You
should have your INR checked [**2152-5-26**] at 1pm with Dr. [**Last Name (STitle) **] and
continue follow up with him.
Your temperature was slightly elevated at 100.4 on [**2152-5-25**], but
you had no symptoms of feeling unwell. It will be important for
you to continue to check your temperature. If you begin to feel
unwell please follow up with your primary care doctor or nearest
emergency department.
.
Please go to all your follow up appointments. If you see any
evidence of bleeding please contact your primary care physician
immediately or go to your nearest ED.
Also you have congestive heart failure that causes you to hold
on to water in your legs. If you notice increased swelling in
your legs or an increase in your weight please contact your
primary care doctor or cardiologist. You nebivolol and valsartan
were stopped. Please discuss with your cardiologist what
medications you should resume for your congestive heart failure.
Please follow-up with hematology for follow-up of your low blood
counts and possible bone marrow biopsy.
.
Changes were made to your medications. Please:
- STOP Bystolic (nebivolol)
- increase diltiazem to 180mg daily
- increase warfarin (Coumadin) to 8mg daily (4 x 2mg tablets)
- STOP valsartan for now. Dr. [**Last Name (STitle) **] may want to restart this
medication in the future.
Followup Instructions:
Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A.
Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 7728**]
Appt: [**Last Name (LF) 2974**], [**4-26**] at 1pm
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2152-6-7**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2152-5-25**]
|
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18,456
| 109,933
|
20332+57142
|
Discharge summary
|
report+addendum
|
Admission Date: [**2163-7-25**] Discharge Date: [**2163-8-25**]
Date of Birth: [**2102-6-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
61 year-old female diagnosed with primary amyloidosis in [**Month (only) 958**]
[**2163**], recently harvested after Cytoxan chemotherapy, being
admitted for melphalan therapy followed by auto-BMT as a
palliative measure.
Major Surgical or Invasive Procedure:
Triple lumen catheter placement ([**2163-7-25**])
Esophagogastroduodenoscopy ([**2163-7-26**] and [**2163-8-13**])
Right femoral line cordis placement ([**2163-8-4**])
Endotracheal intubation ([**2163-8-4**] to [**2163-8-5**])
History of Present Illness:
Ms. [**Known lastname **] is a 61 year-old woman diagnosed with primary
amyloidosis in [**2162-3-6**]. At that time, she presented with
progressive lower extremity edema. Work-up revealed significant
proteinuria. A renal biopsy was then performed and showed lambda
light chain deposits. She was also found to have lambda light
chain in her urine. A diagnosis of primary [**Doctor Last Name **] amyloidosis was
subsequently made. She was recently harvested after Cytoxan
therapy and is now being admitted for melphalan chemotherapy
followed by autologous stem cell transplant. Her screening
evaluation revealed normal pulmonary function and no significant
cardiac dysfunction. Except for the proteinuria, her renal
function is normal.
Other than her leg edema, Ms. [**Known lastname **] complains of increasing
weakness and fatigue. She denies SOB, cough, headache, syncope,
chest pain or palpitation, abdominal pain or dysuria. She also
denies any recent febrile illness.
Past Medical History:
1) Primary amyloidosis diagnosed in [**3-10**] following clinical
proteinuria. Renal biopsy demonstrated a predominance of lambda
light chains. Bone marrow biopsy in [**5-10**] showed low level (5-10%
of the cellularity) monoclonal lambda plasmacytosis.
2) Multiple bilateral breast cysts: Biopsies negative for
cancer.
3) History of premature ventricular complexes
4) History of duodenal ulcer
5) Surgery to right leg ligamentin [**2139**]'s
Social History:
She currently lives with her husband and has three children. Her
younger son had [**Name (NI) 1932**] disease approximately 3-4 years ago.
She has a 20 pack-year smoking history and reports occasional
alcohol consumption, no drugs.
Family History:
Significant for [**Name (NI) 1932**] disease in her son. She ahd a brother
with renal cell carcinoma. Her mother is alive at the age of 93.
Her father died at the age of 84 of "old age".
Physical Exam:
GENERAL: Pleasant woman in NAD.
VITAL SIGNS: Temp 97, HR 104, BP 110/64, RR 20, oxygen
saturation 96% on RA
HEENT: PERRL, EOMI. no sinus tenderness. Clear oropharynx.
NECK: No JVD. No carotid bruit.
RESP: Clear to auscultation bilaterally
CVS: Normal S1, S2. No murmur/rub or gallop. Left subclavian
triple lumen in place.
GI: Normal BS. Soft and non-tender. No hepatosplenomegaly.
EXt: 3+ pitting edema to thighs. No clubbing, no cyanosis.
NEURO: AAO X3. CN II-XII intact. Strenght [**5-11**] thoughout.
Pertinent Results:
Pertinent laboratory results on admission include WBC-12.5*
(NEUTS-82.6* LYMPHS-11.5* MONOS-4.0 EOS-0.7 BASOS-1.2),
HGB-12.0, HCT-34.5*, PLT 588*. Chemistry reveals GLUCOSE-153*,
UREA N-21*, CREAT-0.6, SODIUM-141, POTASSIUM-3.8, CHLORIDE-106,
HCO3-25, CALCIUM-8.5, PHOSPHATE-3.8, MAGNESIUM-1.6, URIC
ACID-9.5*, ALBUMIN-2.8*. Liver enzymes show ALT-16, AST-18,
ALP-115 with normal bilirubin profile. LDH 276.
Imaging:
CXR ([**2163-6-3**]): Normal
Skeletal survey ([**2163-5-26**]): Normal
Echo ([**2163-6-14**]): LVH with low normal LVEF (50-55%), 1+ MR.
Brief Hospital Course:
Her hospital course will be reviewed by problems:
1) Primary amyloidosis: Ms [**Known lastname **] was treated with 2 days of high
dose Melphalan, followed by one rest day. Stem cells were
reinfused on [**2163-7-29**]. Her ANC reached a nadir on [**2163-8-3**],
then was above 500 on [**2163-8-9**]. She was given Neupogen from
[**2163-8-2**] until [**2163-8-11**]. She tolerated the chemo well.
2) CNS: On [**2163-7-30**] (day +1), the patient developed a transient
right visual field defect which resolved spontaneously after one
hour with no recurrence. Neurology was consulted. MRI head on
[**7-30**] revealed a hyperintense region in the left temporal lobe
consistent with acute infarction. Work-up for an embolic focus
was initiated and was negative. EKG revealed NSR. Echo (TTE)
showed no evidence of a thrombus, moderate symmetric LVH and
LVEF low-normal 50-55%. TEE was not performed given low ANC and
low platelets. Carotid doppler ([**2163-8-2**]) showed no stenosing
lesion. She was also placed on telemetry for evaluation of
arrhythmia (see CVS). Decision was taken not to administer ASA
given thrombocytopenia post reinfusion. Heparin was also not
indicated in her case, given negative embolic work-up and high
risk of heparinization. She was IV hydrated to maintain her BP
at a higher level, and continued on Lipitor. Her CVA was
subsequently felt to be possibly related to hypercoagulability
secondary to her nephrotic syndrome.
During her hospital stay, Ms [**Known lastname **] was also found to have a
fluctuating mental status, mostly at night, starting around day
+18. Infectious and metabolic work-ups were negative, including
TSH, B12, and RPR. Psychiatry was consulted, with an impression
of delirium. All BDZ, anticholinergics and cognitive depressant
medications were held. Patient's mental status subsequently
improved. She will follow-up with psychiatry as an out-patient
to evaluate for underlying depression in setting of her medical
condition.
3) GI: On day 6 post BMT, patient developped some hematuria,
followed by a small volume of hematemesis. This was followed by
massive hematochezia and hematemesis ~450cc total. Platelets
were 37. With each episode, she became more fatigued and
hypotensive, with SBP decreasing to 70's (baseline 100's) and
decreased mentation. Agressive IVF and blood product support
were initiated. She was transferred to the [**Hospital Unit Name 153**] for hemodynamic
instability. GI was consulted emergently. The patient was
electively intubated for endoscopy. EGD revealed a smooth,
non-bleeding, 12 cm mass in the mid-body of the greater
curvature, but no evidence of active bleeding. She was started
on Protonix IV. She overall received 2L NS, 1L LR, 4U PRBC's, 2U
FFP, 6hr pressor support with levophed over initial
stabilization. HCT initially dropped from 25-->16, then
increased to 29 after 4U PRBC's. A repeat CT head showed no
bleed. She returned to the floor on [**2163-8-7**].
On [**2163-8-13**], a repeat EGD was performed to assess
prognostication prior to anticoagulation for a subclavian
catheter-related thrombosis. It revealed Grade 2 esophagitis in
the lower third of the esophagus and a segment suspicious for
Barrett's esophagus. More importantly, it showed a 10 cm X 1,5
cm cratered ulcer in the stomach body. Given high-risk of
rebleeding, decision was taken not to anticoagulate. The line
was pulled out with no complications. High dose Protonix was
started along with Carafate. Her hematocrit remained stable
while on the floor. She was last transfused on [**2163-8-11**].
Helicobacter pylori serology negative. She will follow-up with
GI as an out-patient and will need a repeat EGD.
4) Respiratory: After extubation, Ms. [**Known lastname **] required supplemental
oxygen up to 4L via NP to maintain her oxygen saturation above
92 %. She was gradually weaned off oxygen on the floor and
supplemental oxygen was discontinued on [**2163-8-24**]. At discharge,
her oxygen saturation is 92-94 % on room air. Serial CXRs
revealed fairly stable bilateral pleural effusions and vascular
congestion consistent with pulmonary edema. No evidence of
pneumonia or pulmonary infiltrate.
5) CVS: As mentionned, patient was placed on telemetry following
CVA/TIA. She had a few asymptomatic episodes of NSVT, up to 12
beats, without hemodynamic instability. Her primary cardiologist
was contact[**Name (NI) **] (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**]) and an EP consult was obtained.
As per EP, she was started on Metoprolol 12.5 mg PO BID. We were
unable to increase the dose to a target of 25 mg PO BID given
patient's borderline low BP (SBP in 90s-100s). A repeat cardiac
echo on [**2163-8-15**] showed mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mild symmetric LVH
with low normal LVEF (55%) and a small pericardial effusion was
seen.
EKGs revealed sinus tachycardia, probable prior anterior and
inferior MI and non-specific lateral ST-T changes were noted. Of
note, her QTc is slightly prolonged and should be followed. She
will follow-up with her primary cardiologist at D/C.
6) GU: Patient's volume status remained a major issue during her
hospital stay. She has anasarca secondary to her primary
condition, proteinuria and hypoalbuminemia. She was gently
diuresed with Lasix with good results. Her creatinine remained
normal throughout. Her electrolytes were repleted as needed. A
24-hour urine collection revealed a total protein of 232 mg/dL,
Ucreat of 25. Her albumin remains low at 2.3 at discharge. She
will be discharged on Lasix 20 mg PO BID and should have
biweekly Chem 10 with electrolyte repletion as necessary.
She experienced multiple episodes of incontinence while on the
floor, both of urine and feces, felt secondary to reduced
mobility and access. She reports a history consistent with
stress incontinence prior to her admission. On the floor, a
foley was inserted for a short period of time. U/A and urine
cultures were negative. She also complained of bladder spasms,
controlled with Ditropan. No further incontinence at D/C. Off
Ditropan.
Nutrition: She was started on TPN upon return from the [**Hospital Unit Name 153**]
status post massive UGI bleed. diet was advanced slowly and TPN
was D/C'd on [**2163-8-13**].
7) ID: Patient had some diarrhea while in hospital. Flagyl was
started on [**8-8**] and D/C'd on [**8-9**] given C.diff negative on 3
occasions. Her diarrhea was felt to be most likely secondary to
erythromycin, started post UGI bleed to increase GI motiliy. She
also had a low-grade temperature starting on [**2163-8-10**] (100.1).
She was continued on her prophylactic Levoquin (started on day
-2). Vancomycin was added. Levo switched to Cefepime. All
antibiotics were D/C'd on [**8-15**] given no longer neutropenic and
negative work-up.
8) Skin: While in hospital, Ms. [**Known lastname **] had a severe candidal rash
involving her groins, genitalia and buttocks. Fluconazole and
Miconazole powder were prescribed. The rash improved on the
above regimen and with a foley catheter which kept the area dry
(patient incontinent at times). She also has 2 groin lesions
from previous femoral sticks/cordis in the ICU. Plastic Surgery
was consulted, who felt that the lesions were superficial and
required no antibiotics. Wound care with wet-to-dry dressings
were recommended.
She was followed by OT and PT in hospital and will benefit from
continued services at D?C. She will be discharged to a skilled
nursing facility. COndition stable at discharge.
Medications on Admission:
ASA 81 mg PO once daily
Ranitidine 150 mg PO once daily
Lipitor 20 mg PO once daily
Toprol 20 mg PO once daily
Discharge Medications:
1. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Carafate 1 g Tablet Sig: One (1) Tablet PO every six (6)
hours: Please take on an empty stomach.
Disp:*120 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: Half Tablet PO twice a
day: Take 12.5 mg PO twice daily.
Disp:*30 Tablet(s)* Refills:*2*
4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. 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*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Life Care Facilities
Discharge Diagnosis:
1) Primary amyloidosis
2) Gastric ulcer
Discharge Condition:
Patient discharged to skilled nursing facility in stable
condition.
Discharge Instructions:
Please call your primary oncologist or return to the clinic if
you develop fever or chills, or if you experience worsening
shortness of breath or increased leg swelling.
Please follow-up with Dr [**Last Name (STitle) 11493**], Dr [**Last Name (STitle) 410**], Dr [**Last Name (STitle) 2161**]
(gastroenterology) and psychiatry as indicated below.
Followup Instructions:
1) Please follow-up with Dr [**Last Name (STitle) 410**] in the next 3 weeks. Please
call his office at [**Telephone/Fax (1) 3760**] to schedule an appointment in
early [**Month (only) **].
2) Please follow-up with gastroenterology for your stomach
ulcer. Your appointment is scheduled for [**2163-9-16**] at
0900 with Dr [**Last Name (STitle) 2161**] as indicated below:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2163-9-16**] 9:00
3) Please call your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] and schedule an
appointment to see him in the next 1 month.
4) You may call the psychiatry [**Hospital 6669**] clinic to schedule an
appointment at [**Telephone/Fax (1) 1387**].
Completed by:[**2163-8-25**] Name: [**Known lastname 10161**],[**Known firstname 3989**] A Unit No: [**Numeric Identifier 10162**]
Admission Date: [**2163-7-25**] Discharge Date: [**2163-8-25**]
Date of Birth: [**2102-6-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6234**]
Chief Complaint:
61 year-old female diagnosed with primary amyloidosis in [**Month (only) 880**]
[**2163**], recently harvested after Cytoxan chemotherapy, being
admitted for melphalan therapy followed by auto-BMT as a
palliative measure.
Major Surgical or Invasive Procedure:
Triple lumen catheter placement ([**2163-7-25**])
Esophagogastroduodenoscopy ([**2163-7-26**] and [**2163-8-13**])
Right femoral line cordis placement ([**2163-8-4**])
Endotracheal intubation ([**2163-8-4**] to [**2163-8-5**])
Brief Hospital Course:
Prior to D/C, Ms. [**Known lastname **] had a repeat CXR to better characterize
RUL and RLL opacities visualized on CXR on [**2163-8-24**] initially
done after she complained of a self-limited episode of
right-sided chest pain. Repeat CXR revealed a RUL opacity
concerning for possible pneumonia. Patient clinically stable and
afebrile, off oxygen with saturation of 93% on room air, but
noted to have an elevated WBC count (18.1 on [**2163-8-24**] down to
14.0 today). Given high WBC and CXR picture, will cover with
Levofloxacin for 1 week. She will be reevaluated in 1 week on
[**Hospital Ward Name 1836**] 7, with repeat CBC and CXR.
Discharge Medications:
1. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Carafate 1 g Tablet Sig: One (1) Tablet PO every six (6)
hours: Please take on an empty stomach.
Disp:*120 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: Half Tablet PO twice a
day: Take 12.5 mg PO twice daily.
Disp:*30 Tablet(s)* Refills:*2*
4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. 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*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Life Care Facilities
Discharge Diagnosis:
1) Primary amyloidosis
2) Gastric ulcer
Discharge Condition:
Patient discharged to skilled nursing facility Life Care
Facility in stable condition.
Discharge Instructions:
Please call your primary oncologist or return to the clinic if
you develop fever or chills, or if you experience worsening
shortness of breath or increased leg swelling.
Please follow-up with Dr [**Last Name (STitle) 1653**], Dr [**Last Name (STitle) 223**], Dr [**Last Name (STitle) 8818**]
(gastroenterology) and psychiatry as indicated below.
Followup Instructions:
1) PLease come back to [**Hospital Ward Name 1836**] 7 next Wednesday for follow-up
cell counts and CXR.
2) Please follow-up with Dr [**Last Name (STitle) 223**] on [**2163-9-7**] at
13:30. His office # is [**Telephone/Fax (1) 10163**].
3) Please follow-up with gastroenterology for your stomach
ulcer. Your appointment is scheduled for [**2163-9-16**] at
0900 with Dr [**Last Name (STitle) 8818**] as indicated below:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 10164**], MD Where: [**Hospital6 189**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1368**] Date/Time:[**2163-9-16**] 9:00
4) Please call your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1653**] and schedule an
appointment to see him in the next 1 month.
5) You may call the psychiatry [**Hospital 10165**] clinic to schedule an
appointment at [**Telephone/Fax (1) 10166**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6235**] MD [**MD Number(1) 6236**]
Completed by:[**2163-8-25**]
|
[
"277.3",
"997.1",
"996.74",
"427.1",
"599.7",
"434.91",
"280.0",
"531.40",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"45.13",
"96.71",
"99.15",
"96.04",
"99.04",
"99.25",
"41.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16140, 16187
|
14634, 15275
|
14382, 14611
|
16271, 16359
|
3227, 3784
|
16754, 17809
|
2499, 2687
|
15298, 16117
|
16208, 16250
|
11375, 11488
|
16383, 16731
|
2702, 3208
|
14121, 14344
|
794, 1768
|
1790, 2234
|
2250, 2483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,286
| 191,993
|
40153
|
Discharge summary
|
report
|
Admission Date: [**2176-12-14**] Discharge Date: [**2176-12-30**]
Date of Birth: [**2112-2-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Lactose
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 64f who was in her usual state until this evening
when she was in her bathroom and her family heard her fall. When
they arrived she was reportedly minimally responsive and 911 was
called. Upon EMS arrival she was awake and verbal though she had
left sided hemi-paresis. She was hypertensive during transport
and EMS had difficulty controlling it. She was reported to be as
high as systolic in the 220's. Head CT at OSH showed large right
basal ganglia hemorrhage measuring 7cm x 3.3cm with extension
into the ventricles and approximately 10mm midline shift. She
was
intubated at OSH when she became less responsive and transferred
to [**Hospital1 18**] for further evaluation.
Past Medical History:
Reported as none from OSH
Social History:
Lives with family at home
Family History:
NC
Physical Exam:
BP: 189/ 92 HR: 87 R O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 1.5mm sluggishly reactive EOMs Unable to
evaluate
Neck: Supple. C Collar in place
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated. Not following commands. No eye
opening.
Motor: Localizes with RUE, brisk withdrawl to noxious of RLE.
Extensor posturing LUE. Weak withdrawl LLE
On discharge: Neurologically she has minimal eye opening,
follows commands intermitently on the right and moves the right
side spont/antigravity.
Pertinent Results:
CT HEAD W/O CONTRAST [**2176-12-14**]
Redemonstration of a 6.7 x 2.9 cm right intra-axial hemorrhage
centered within the basal ganglia with intraventricular
extension, likely
hypertensive hemorrhage. Stable 7-mm leftward shift with slight
interval
increase in contralateral occipital [**Doctor Last Name 534**] entrapment and diffuse
sulcal
effacement, right greater than left. No new focus of hemorrhage.
No evidence of subfalcine or transtentorial or tonsillar
herniation.
[**2176-12-30**] 06:00AM BLOOD WBC-9.0 RBC-2.89* Hgb-9.0* Hct-25.3*
MCV-87 MCH-31.0 MCHC-35.5* RDW-15.0 Plt Ct-416
[**2176-12-28**] 06:27AM BLOOD Neuts-73.4* Lymphs-17.3* Monos-5.1
Eos-3.8 Baso-0.4
[**2176-12-30**] 06:00AM BLOOD Plt Ct-416
[**2176-12-30**] 06:00AM BLOOD Glucose-106* UreaN-20 Creat-0.6 Na-142
K-3.7 Cl-106 HCO3-30 AnGap-10
[**2176-12-14**] 04:40PM BLOOD CK(CPK)-114
[**2176-12-13**] 11:11PM BLOOD Lipase-49
[**2176-12-30**] 06:00AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.4
[**2176-12-26**] 06:33AM BLOOD CRP-51.0*
[**2176-12-29**] 05:18AM BLOOD Vanco-12.6
Brief Hospital Course:
64 y/o F who was found in her bathroom after family heard a
fall. Patient was seen to be minimally responsive and family
called 911. Was L side hemiparetic when seen by EMS, but awake
and verbal. Patient was seen to be hypertensive on route to
hospital with SBP into the 220s. Head CT revealed a R sided
basal ganglia hemorrhage with IVH extension. She was intubated
and transferred to [**Hospital1 18**] for further neurosurgical work up. On
examination, patient is following commands with R side and L
hemiparesis, pupils PERRL. Patient was extubated. On [**12-15**] pt
exam remained stable and continued to follow commands on her
right side but with no eye opening. Her mannitol was weaned to
25G q6 which was weaned over two days. Stroke neurology was
consulted to aid in family discussions regarding prognosis. They
felt that compression of the lateral hypothalamus and mass
effect on structures of the anterior cranial fossa have resulted
in a depressed level of consciousness. They would recommend a
drain if needed. The family stated that Mrs. [**Known lastname 88193**] clearly
did not want to be severely disabled if anything untoward were
to happen,
per her family. She was made a DNR/DNI. The family are refused
surgical intervention the family including EVD placement at this
time. Dr [**First Name (STitle) **] had further discussions with the family on [**12-17**]
with the outcome of continued medical management. Her cervical
spine was cleared and her collar was removed on [**12-18**]. On [**12-20**]
she had a PEG placed.
As off [**12-19**] patient was cleared to transfer to the SDU,
however, there was no bed availability thus patient remained in
ICU.
Ms [**Known lastname 88193**] remained neurologically with left arm plegia. On
[**12-25**] she was noted to develop fevers, her Dilantin was dc'd,
Lenis were negative for DCT. An echo was done which showed no
vegitation and a EF of 70%. ID was reconsulted, they recommended
changing her VAP antibiotics (which she was already on) to
Vanco, Cipro and Zosyn.
She has removed afebrile since [**12-28**] though she developed
diahrea which has been negative for C-Diff.
Neurologically she has minimal eye opening, follows commands
intermitently on the right and moves the right side
spont/antigravity.
Medications on Admission:
None per report
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection four times a day.
9. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
11. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
12. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 10 days: stop
date [**1-10**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
R basal Ganglia hemorrhage with IVH extension
Discharge Condition:
Mental Status: Nonverbal
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
PLEASE OBTAIN A CXR PRIOR TO LEAVING REHAB TO FOLLOW UP ON YOUR
PNEUMONIA
Completed by:[**2176-12-30**]
|
[
"431",
"780.09",
"518.82",
"348.5",
"427.89",
"787.20",
"784.3",
"342.90",
"507.0",
"V49.86",
"V64.2",
"378.55",
"787.91",
"401.9",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"96.71",
"38.93",
"45.13",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
6229, 6303
|
2763, 5038
|
300, 307
|
6393, 6393
|
1696, 2740
|
7507, 7944
|
1132, 1136
|
5104, 6206
|
6324, 6372
|
5064, 5081
|
6561, 7484
|
1151, 1356
|
1543, 1677
|
232, 262
|
335, 1022
|
6408, 6537
|
1044, 1072
|
1088, 1116
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,895
| 183,901
|
38850
|
Discharge summary
|
report
|
Admission Date: [**2106-6-23**] Discharge Date: [**2106-7-2**]
Date of Birth: [**2022-12-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Atrial Fibrillation
Major Surgical or Invasive Procedure:
[**2106-6-24**] Right axillary subclavian embolectomy and right radial
artery embolectomy via brachial artery approach.
History of Present Illness:
83 year old male with a known history of aortic stenosis, renal
insufficiency, diabetes mellitus, and HTN who underwent an
aortic valve replacement with a [**Street Address(2) 6158**]. [**Hospital 923**] Medical Biocor
tissue valve on [**2106-6-10**]. He was found to be in atrial
fibrillation by son (cardiologist) on night prior to admit.
[**Name (NI) **] wife reported [**Name (NI) 269**] stated that his heart rate was
"irregular" yesterday morning, as well. Patient denied
palpitations, SOB or chest pain. He had been on a 5 day course
of Prednisone for LE edema (20 mg/day) with elevated BS. He was
admitted for anticoagulation and management of atrial
fibrillation.
Past Medical History:
aortic stenosis
hypertension
Diabetes mellitus
Aortic stenosis
Renal insufficiency
Duodenal ulcers/GI bleeding (rectal and esophageal)
Gout
deep vein thrombosis 3 years ago
benign prostatic hyperplasia
Social History:
Lives with: : Moved from [**Country **] to the US in [**2080**]; currently
retired and lives in [**Hospital3 28354**] in [**Location (un) 86**] with his wife. [**Name (NI) **]
two
sons, both of whom are in medicine.
Occupation:Ran a factory in [**Location (un) **] that produced electrical
pumps.
Tobacco:denies
ETOH: occasional
Family History:
Father died of MI at age 77, sister had aortic
valve replacement.
Physical Exam:
Physical Exam
Pulse: Resp:18 O2 sat:100% RA
B/P Right:107/55 Left:
Height:5'5" Weight:79.8 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 2+ LE edema
Varicosities: None []
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2106-6-23**] 12:45PM GLUCOSE-177* UREA N-56* CREAT-2.1* SODIUM-136
POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-27 ANION GAP-17
[**2106-6-23**] 12:45PM ALT(SGPT)-53* AST(SGOT)-29 LD(LDH)-254* ALK
PHOS-320* AMYLASE-83 TOT BILI-0.9
[**2106-6-23**] 12:45PM LIPASE-66*
[**2106-6-23**] 12:45PM WBC-14.7*# RBC-4.44* HGB-10.5* HCT-35.0*
MCV-79* MCH-23.5* MCHC-29.9* RDW-17.1*
[**2106-7-1**] 05:30AM BLOOD WBC-8.9 RBC-3.77* Hgb-9.3* Hct-28.4*
MCV-75* MCH-24.6* MCHC-32.7 RDW-17.1* Plt Ct-366
[**2106-7-1**] 05:30AM BLOOD PT-28.1* INR(PT)-2.8*
[**Known lastname **],[**Known firstname **] [**Medical Record Number 86241**] M 83 [**2022-12-19**]
Radiology Report BILAT UP EXT VEINS US Study Date of [**2106-6-25**]
10:17 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2106-6-25**] 10:17 AM
BILAT UP EXT VEINS US Clip # [**Clip Number (Radiology) 86242**]
Reason: SWELLING LT ARM PAIN RT ARM
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with as above
REASON FOR THIS EXAMINATION:
s/p AVR w/post op AF now s/p RUE embolectomy for ischemic arm
r/o DVT
Final Report
MEDICAL HISTORY: 83-year-old man status post AVR, with postop
AF, now status
post right upper extremity embolectomy for ischemic arm, rule
out DVT.
FINDINGS: On the left, the internal jugular vein compresses
completely and
demonstrates a normal venous waveform within it, with
respiratory variation.
The left subclavian vein, axillary vein, both brachial veins
compress
completely and augment well. The left cephalic vein demonstrates
flow within
it. The left basilic vein compresses completely and demonstrates
flow within
it on color Doppler imaging. Left cephalic vein compresses
completely.
On the right, the internal jugular vein compresses completely,
and
demonstrates normal venous waveform within it. The right
subclavian vein,
axillary vein, and both brachial veins compress completely and
augment well.
The right basilic vein does not compress completely and contains
echogenic
thrombus within it. It is, however, not completely occluded as
some blood
flow is detected within it. The right cephalic vein compresses
completely and
demonstrates blood flow within it on color Doppler imaging. At
the site of
the surgical wound in the mid right upper extremity, a rounded
hypoechoic
lesion is seen to lie anterior to the brachial artery, which
measures 0.9 x
1.1 x 1 cm in diameter. This does not display flow within it,
and likely
represents a small pseudoaneurysm; however, a small hematoma is
also in the
differential. This hematoma is compressing one of the brachial
veins on the
right; however, this brachial vein remains patent with no
thrombus seen within
it currently.
CONCLUSION:
1. Partially thrombosed right basilic vein.
2. Likely small pseudoaneurysm or hematoma arising from the
brachial artery
at the site of the surgical wound. No blood flow is detected
within this.
This pseudoaneurysm or hematoma is compressing one of the
brachial veins on
the right; however, this vein is currently patent with no
thrombus within it.
This report was discussed with [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) **] on [**2106-6-25**] at
5:30.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 60223**] [**Name (STitle) 23303**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2106-6-26**] 8:12 AM
Imaging Lab
Brief Hospital Course:
Admitted [**2106-6-23**] to evaluate for atrial fibrillation. On
admission, patient already converted back to a normal sinus
rhythm. Cardiology was consulted with recommendations to start
Coumadin and Amiodarone. In addition, patient was hyperkalemic
and hyperglyemic and treated appropriately with diuretics and
regular insulin. On hospital day two, patient developed new
right arm pain with diminished pulses. [**Month/Day/Year **] surgery was
consulted and patient was emergently brought to the operating
room for right axillary subclavian embolectomy and right radial
artery embolectomy. For surgical details, please see operative
note. Following surgery, he was brought to the CVICU in stable
condition. He was maintained on intravenous Heparin and
transesophogeal echocardiogram was performed which showed no
evidence of thrombus in the left atrial appendage.
**Echocardiogram was notable for severe mobile aortic
atheroma.** He maintained stable hemodynamics and transferred to
the SDU on postoperative day one. Warfarin was resumed and
intravenous Heparin was continued until his INR became
therapeutic. Warfarin was dosed for a goal INR between 2.0 -
3.0. Rheumatology was also consulted during his stay for an
acute gout flare of his left knee. He concomitantly experienced
low grade fevers for which pan cultures were obtained.
Aspiration of his left knee was also performed along with
intraarticular injection of steroids. Patient tolerated the
procedure and there were no complications. Knee aspiration
confirmed gout and pan cultures remained negative. Over several
days, medical therapy was optimized and he was eventually
cleared for discharge to home with [**Month/Day/Year 269**] on POD# 8.
First blood draw on [**7-3**] with INR/K+/BUN/creat. Results to be
called to pt's son, Dr. [**Known lastname 32668**].
Medications on Admission:
1. Aspirin 81 mg [**Known lastname 8426**], Delayed Release (E.C.) Sig: One (1)
[**Known lastname 8426**], Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 10 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO EVERY OTHER
DAY (Every Other Day).
3. Carvedilol 12.5 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO BID (2 times
a day).
4. Furosemide 40 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO BID
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID
6. Glipizide 5 mg [**Known lastname 8426**] Extended Rel 24 hr Sig: One (1) [**Known lastname 8426**]
TID
7. Allopurinol 100 mg [**Known lastname 8426**] PO DAILY
8. Rabeprazole 20 mg [**Known lastname 8426**], Delayed Release (E.C.) Sig: One
(1) [**Known lastname 8426**], Delayed Release (E.C.) PO once a day.
9. Folic Acid 1 mg [**Known lastname 8426**] Sig: One (1) [**Known lastname 8426**] PO once a day.
10. Acetaminophen 500 mg [**Known lastname 8426**] Sig: Two (2) [**Known lastname 8426**] PO Q6hrs prn
pain.
11. Predisone 20 mg po daily (completed 5 day course [**6-22**])
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks: do not take if loose stools.
Disp:*28 Capsule(s)* Refills:*0*
2. Aspirin 81 mg [**Month/Year (2) 8426**], Chewable Sig: One (1) [**Month/Year (2) 8426**], Chewable
PO DAILY (Daily).
Disp:*30 [**Month/Year (2) 8426**], Chewable(s)* Refills:*1*
3. Atorvastatin 10 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO every other
day.
Disp:*30 [**Month/Year (2) 8426**](s)* Refills:*1*
4. Tramadol 50 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO Q6H (every 6
hours) as needed for pain.
Disp:*20 [**Month/Year (2) 8426**](s)* Refills:*0*
5. Allopurinol 100 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY
(Daily).
Disp:*30 [**Month/Year (2) 8426**](s)* Refills:*1*
6. Folic Acid 1 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY (Daily).
Disp:*30 [**Month/Year (2) 8426**](s)* Refills:*1*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
8. Amiodarone 200 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO once a day:
until Cardiologist directs otherwise.
Disp:*30 [**Month/Year (2) 8426**](s)* Refills:*1*
9. Furosemide 40 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID (2 times a
day).
Disp:*60 [**Month/Year (2) 8426**](s)* Refills:*1*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Aspirin 81 mg [**Month/Year (2) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Month/Year (2) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Month/Year (2) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
12. Carvedilol 12.5 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID (2
times a day).
Disp:*60 [**Month/Year (2) 8426**](s)* Refills:*2*
13. Warfarin 1 mg [**Month/Year (2) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily):
INR goal 2-2.5 for 6 months for embolectomy, or as directed by
Cardiologist for PAF.
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2*
14. Glipizide 5 mg [**Last Name (Titles) 8426**] Extended Rel 24 hr Sig: Two (2) [**Last Name (Titles) 8426**]
Extended Rel 24 hr PO BID (2 times a day).
Disp:*120 [**Last Name (Titles) 8426**] Extended Rel 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
-Right Upper Extremity Ischemia, s/p Right axillary subclavian
embolectomy and right radial artery embolectomy on [**6-24**]
-Postop Atrial Fibrillation, s/p Aortic Valve Replacement-[**6-10**]
-Hyperkalemia
-Hyperglycemia
-Chronic Renal Insufficiency
-Acute Gout
-Hypertension
-Postop Fevers
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2106-7-15**] 1:45
Please call to schedule appointments
Primary Care Dr. [**Known lastname **],VARTAN [**Telephone/Fax (1) 12551**] in [**2-13**] weeks
Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 10548**] in [**2-13**] weeks
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2106-7-27**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2106-7-27**] 11:15
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation and
arterial embolectomy (x 6 months as recommended by Hematology)
Goal INR 2.0-2.5
First draw Saturday ->[**7-4**]
** please also draw K+/BUN/creat. with results to Dr.
[**Known lastname 32668**]
Results to :
Vartan [**Known lastname 32668**]
phone [**Telephone/Fax (1) 12551**] fax
**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:[**2106-7-2**]
|
[
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"274.01",
"428.0",
"427.31",
"600.00",
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"444.21",
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] |
icd9cm
|
[
[
[]
]
] |
[
"81.92",
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"99.23",
"88.72",
"38.03"
] |
icd9pcs
|
[
[
[]
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312, 434
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11958, 12116
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2472, 3389
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3491, 5951
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,283
| 170,113
|
50944
|
Discharge summary
|
report
|
Admission Date: [**2198-2-16**] Discharge Date: [**2198-2-21**]
Date of Birth: [**2115-12-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic Mass
Gas and Fluid filled collection near right lobe of liver
Major Surgical or Invasive Procedure:
CT guided drainage
History of Present Illness:
This is a 82 year old female, previously healthy, recently
discharged from OSH ([**2-12**]) after work-up of obstructive jaundice
s/p ERCP complicated by submucosal air injection. She is now
admitted with a hepatic gas and fluid collection.
She first noticed jaundice, [**Male First Name (un) 1658**]-colored floating stools, dark
urine, and achylower abdominal pain radiating to back 1 week
ago. She denies weight loss, no N/V. She went to PCP and was
[**Name9 (PRE) 105874**] to [**Hospital3 **] hospital. A MRCP there showed
cholelithiasis and severe dilation of CBD (2-cm) due to presumed
distal CBD stricture. She had an ERCP on [**2-9**] c/b submucosal air
injection leading to retroperitoneal air, PTX, and
pneumopericardium. She was placed on Unasyn and did not have a
fever. She then had a PTC on [**2198-2-12**] to relieve the strictured
CBD. She was discharged without ABX and received Percocet for
pain control, and her PTC was capped.
Past Medical History:
PSH:
ERCP and PTC
Right shoulder repair with titanium rods
Social History:
Retired. family runs Bed&Breakfast. 1 son
[**Name (NI) 1139**] - 3 ppd x 25 years, quit 40 years ago
EtOH - wine each night
Family History:
grandmother - pancreatic CA
father-melanoma
Aunt - gallstones
Physical Exam:
VS: Tm 99.7 126/58 80 14 96%3L
sitting in chair, alert, comfortable, conversant. Mild Jaundice
nc/at, eomi, op clear
supple
crackles left base, [**Month (only) **] air movement
s1s2 nl, rrr, no m/r/g
soft, obese, nt/nd, PTC capped and in place. no guarding or
rebound tenderness.
+foley
warm, no warm, good distal pulses, no tremor, nl tone
oriented to self, date, place, why she's here. registration and
delayed recall [**4-2**] with prompting. able to count days of week
and months of year backwards correctly.
Pertinent Results:
[**2198-2-17**] 06:00AM BLOOD WBC-26.6* RBC-3.60* Hgb-11.3* Hct-33.4*
MCV-93 MCH-31.5 MCHC-33.9 RDW-13.4 Plt Ct-320
[**2198-2-19**] 04:50AM BLOOD WBC-12.2* RBC-3.37* Hgb-10.7* Hct-31.8*
MCV-95 MCH-31.8 MCHC-33.7 RDW-13.3 Plt Ct-335
[**2198-2-19**] 04:50AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-139
K-3.7 Cl-103 HCO3-27 AnGap-13
[**2198-2-16**] 08:50PM BLOOD ALT-147* AST-37 AlkPhos-212* Amylase-29
TotBili-2.3* DirBili-1.4* IndBili-0.9
[**2198-2-19**] 04:50AM BLOOD ALT-67* AST-47* AlkPhos-155* TotBili-1.3
[**2198-2-16**] 08:50PM BLOOD Lipase-35
[**2198-2-17**] 11:48PM BLOOD Lipase-38
[**2198-2-16**] 08:50PM BLOOD Albumin-3.3* Calcium-8.8 Phos-2.9 Mg-2.0
[**2198-2-17**] 11:48PM BLOOD Albumin-2.9* Calcium-8.4 Phos-2.5* Mg-2.1
.
CTA ABD W&W/O C & RECONS [**2198-2-16**] 10:54 AM
IMPRESSION:
1. Subcapsular collection about the right lobe of the liver
containing gas and fluid. This may relate to the PTC catheter in
place, although infection cannot be excluded. Finding was
discussed with Dr. [**Last Name (STitle) **] and a drainage procedure is planned.
2. Gas and fluid-containing collection posterior to the
duodenum, small right psoas abscess, and retroperitoneal gas are
consistent with duodenal perforation.
3. Ill-defined mass in the head of the pancreas with pancreatic
ductal dilation is worrisome for carcinoma.
4. Multiple hypodense hepatic lesions including a cyst at the
dome of the liver and additional lesions too small to accurately
characterize.
5. Bilateral hypodense renal lesions are too small to
characterize.
6. Bilateral pleural effusions and atelectasis.
7. Intraperitoneal air, in the setting of extensive
extraperitoneal air, may relate to the patient's recent
procedures and/or duodenal perforation.
8. Diverticulosis without evidence of diverticulitis.
.
CT HEPATIC DRAINAGE [**2198-2-17**] 3:06 PM
IMPRESSION:
1. Successful placement of an 8 French locking pigtail catheter
within a subhepatic fluid collection without complication.
2. CT cholangiogram demonstrating opacification of the biliary
tree, free flow of contrast into the duodenum and into the
gallbladder. No evidence of contrast tracking retrograde via the
PTC catheter contributing to or causing this subhepatic fluid
collection.
3. No change in small amount of intraperitoneal and
retroperitoneal air, slight increase in atelectasis and
bilateral pleural effusions compared to the study done one day
earlier.
Brief Hospital Course:
This is a 82 year old female with a pancreatic mass, s/p ERCP
and stent placement at an OSH on [**2198-2-9**], now with a gas and
fluid filled collection posterior to the duodenum.
Mental status change: On HD 2, she had an acute mental status
change, was tachycardic, and had an increased O2 requirement.
She was transferred to the ICU for further care.
Neuro: Her mental status improved, although was still forgetful
at times. Likely related to infection, medications, environment
change, pain. She was back to her baseline at time of discharge.
Fluid collection: Later that day she went for successful
placement of an 8 French locking pigtail catheter within a
subhepatic fluid collection without complication. A CT
cholangiogram demonstrating opacification of the biliary tree,
free flow of contrast into the duodenum and into the
gallbladder. No evidence of contrast tracking retrograde via the
PTC catheter contributing to or causing this subhepatic fluid
collection.
The PTC was capped and the new pigtail drain was draining. The
drain put out ~100cc of clear, yellow fluid initially, and at
time of discharge was only putting out a scant amount.
Her diet was advanced over the next few days as she had return
of bowel function.
Resp: A CXR revealed pleural effusion and atelectasis. She was
requiring O2 by NC and still had labored breathing. This was
likely due to atelectasis, inability to take full breaths
secondary to pain. Once back on the floor, she was weaned off
her O2 as she increased her activity and continued to improve.
Hypovolemia: She received IV fluid bolus for low urine output
with good response.
Medications on Admission:
None
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
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. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abscess in the right upper quadrant above the liver
Biliary and pancreatic duct dilation
Ill-defined pancreatic head mass
Discharge Condition:
Good
Tolerating a diet
Pain well controlled
Drain in place
PTC drain capped
Discharge Instructions:
-Avoid swimming and baths until your follow-up appointment, it
is OK to shower.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
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 skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily and work towards daily
ambulation.
* No heavy lifting (>[**11-14**] lbs) until your follow up
appointment.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2198-3-2**] at 11:45am.
Call [**Telephone/Fax (1) 1231**] with questions or concerns.
Completed by:[**2198-2-22**]
|
[
"276.52",
"576.2",
"293.0",
"157.0",
"572.0",
"518.0",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"87.54",
"50.91"
] |
icd9pcs
|
[
[
[]
]
] |
6744, 6750
|
4675, 6307
|
387, 408
|
6916, 6994
|
2238, 4652
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8697, 8872
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6362, 6721
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6333, 6339
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7018, 8674
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1703, 2219
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274, 349
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436, 1385
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1407, 1467
|
1483, 1609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,808
| 133,400
|
54709
|
Discharge summary
|
report
|
Admission Date: [**2115-6-5**] Discharge Date: [**2115-6-21**]
Date of Birth: [**2045-11-21**] Sex: F
Service: NEUROLOGY
Allergies:
Iodine
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Global Aphasia, Right Sided Weakness
Major Surgical or Invasive Procedure:
Intra-arterial tPA administration
PEG tube placement
History of Present Illness:
Ms. [**Known lastname 111870**] is a 69 year-old right handed woman with past
medical history of hypertension, chronic back pain and a left
shoulder fracture one month prior who presented as an OSH
transfer Code Stroke for reported sudden onset aphasia and right
sided weakness. She was last reported without symptoms (as
noted by husband) at 1700hrs on [**2115-6-5**]. After finding her at
1730hrs on the floor not speaking, he called EMS who on arrival
noted right sided weakness and a left gaze deviation. Her GCS
per EMS was 3, and on evaluating her, witnessed a systolic blood
pressure drop to 89 with respiratory rate decrease. EMS
intubated the patient in the field and brought her to [**Hospital1 5979**]. A CT scan obtained at [**Hospital3 **] was negative
for hemorrhage or acute process (comfirmed upon [**Hospital1 18**] review),
but because she was intubated [**Hospital1 487**] reported inability to
obtain a clear exam to warrant tPA administration.
Therefore, the patient was transferred to [**Hospital1 18**] for possible tPA
and/or intervention. She arrived intubated and sedated at [**Hospital1 18**]
ED, with right-sided weakness when weaned off of sedation.
However, given the shortcomings inherent with an intubated
examination and her difficulty arousing from sedation, she went
to CT/CTA/CTP, which showed a left MCA clot at the bifurcation
and left MCA stroke with perfusion mismatch on imaging. She was
started on tPA and taken to the neurointerventional suite where
intraarterial tPA was administered.
Past Medical History:
- HTN
- chronic back pain
- tripped down stairs 1 month ago resulting in L shoulder fx
- Thyroid cancer s/p lobectomy
- COPD
- chronic leukocytosis
Social History:
lives with husband, independent
quit smoking 1 year ago
Family History:
no history of neurologic diseases
Physical Exam:
Vitals: T: 98.0 P: 68 R: 20 BP: 110/62 SaO2: 98% on ETT
General: somnolent, intubated, even off sedation, slow to arouse
to sternal rub
HEENT: NC/AT, no scleral icterus noted, ETT in place
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted, old surgiucal scar notes in RLQ
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
NIH Stroke Scale score was 11 or greater:
1a. Level of Consciousness: 1
1b. LOC Question: 1
1c. LOC Commands: 1
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: (unable to test, intubated)
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 2
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: (unable to test, intubated)
10. Dysarthria: 0
11. Extinction and Neglect: 0
-Mental Status: Alert, intubated, sedated initially and
unarousable. With propofol held was slow to respond to sternal
rub, grimaced to pain. Was able to briefly follow commands to
squeeze and let go on her L hand and to wiggle her L toes. Was
able to wiggle her R toes minimally to command, and could not
move her RUE to command.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Decreased
corneal reflex response on the R. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: pt with midline gaze, able to overcome midline in
both directions when head was moved.
V: unable to test
VII: unable to test.
VIII: Hearing intact to loud voice bilaterally as followed
commands
IX, X: unable to test
[**Doctor First Name 81**]: [**4-6**] unable to test
XII: unable to test
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. No asterixis noted. Patient withdrew LUE
and LLE briskly to noxious. She withdrew her RLE slowly to
noxious, with no triple flexion noted. She did not withdraw her
RUE to noxious.
-Sensory: withdrawal to noxious as above
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on the left and very minimally
upgoing on the R.
-Coordination: reached for ETT accurately with RUE until she was
placed in restraints
-Gait: Deferred, pt intubated
Pertinent Results:
[**2115-6-5**] 07:54PM PH-7.41 COMMENTS-GREEN TOP
[**2115-6-5**] 07:54PM GLUCOSE-110* LACTATE-1.1 NA+-139 K+-4.9
CL--111* TCO2-19*
[**2115-6-5**] 07:54PM HGB-9.1* calcHCT-27 O2 SAT-95 CARBOXYHB-4 MET
HGB-0
[**2115-6-5**] 07:40PM PT-11.0 PTT-25.2 INR(PT)-1.0
[**2115-6-5**] 07:40PM FIBRINOGE-540*
CT Perfusion:
1. Evolving infarct in the left MCA territory with
hypoattenuation and
effacement in the left insular ribbon.
2. Occlusion of the left distal M1 segment before the
bifurcation.
3. Mismatch on CT perfusion suggesting penumbra in the left MCA
territory.
4. Thyroid asymmetry with right lobe coarse calcification. This
could be
further evaluated with nonurgent thyroid ultrasound if
clinically indicated.
CTA head and Neck:
1. Evolving infarct in the left MCA territory with
hypoattenuation and
effacement in the left insular ribbon.
2. Occlusion of the left distal M1 segment before the
bifurcation.
3. Mismatch on CT perfusion suggesting penumbra in the left MCA
territory.
4. Thyroid asymmetry with right lobe coarse calcification. This
could be
further evaluated with nonurgent thyroid ultrasound if
clinically indicated.
TTE: No ASD or PFO seen. Normal global and regional
biventricular systolic function.
[**6-6**] CT Head:1. Intraparenchymal hemorrhage at the site of prior
left MCA infarct.
2. Small left subdural hematoma layering on the tentorium, new
from prior.
3. No midline shift or evidence of transtentorial herniation.
4. No evidence of obstructive hydrocephalus.
[**6-6**] CT Head
Hyperdensity in the left frontal lobe with mild sulcal
effacement, likely represents diffusion of permeated contrast
after
angiography rather than hemorrhagic transformation in an area of
left MCA
stroke. Continued followup is recommended.
[**6-7**] CT abd and pelvis:
1. No evidence of intra-abdominal or pelvic hemorrhage. Trace
free simple
appearing fluid in the pelvis.
2. Multiple bilateral rib fractures at various stages of healing
from acute to
remote.
3. Moderate complex right pleural effusion, likely hemorrhagic
and related to
rib fractures. Trace left pleural effusion. Small intramuscular
hemmorhage
related to fourth right rib fracture.
4. Small hyperdense rounded lesion in the upper pole of the
right kidney, may
represent hemorrhagic cyst, though cannot exclude malignancy.
Recommend
further evaluation with ultrasound.
5. Nodular thickening of medial limb of left adrenal gland may
represent
underlying nodule, or given recent trauma, a small hemmorrhage.
Attention on
follow-up
6. Diverticulosis without diverticulitis.
7. Enteric catheter terminates in the distal esophagus and
should be advanced.
[**6-7**] MRI brain
1.Acute infarct noted within the left frontal, insular cortex
extending to involve majority of the left temporal cortex with
preservation of the left basal ganglia.
2. Vasculature not completely evaluated on this study, as an
MRA of the brain was not performed due to patient's
deteriorating condition. Within this limitation, the mean M1
segment of the left MCA demonstrates normal
intracranial flow void; however, the distal M2 segments could
not be
evaluated. Once the patient's condition is stable then an MRA
of the brain and a GRE sequence is recommended.
3. Sphenoid sinus disease.
4. Sequelae of chronic small vessel ischemic disease.
[**6-8**] MRA brain
Resolution of occlusion of the left M1 segment of the left
middle
cerebral artery, with persistent diminished flow in its branches
compared to the right.
Brief Hospital Course:
Neuro:
The patient presented with sudden onset aphasia and right sided
weakness at
approximately 1730 on [**2115-6-5**]. EMS was called, and patient was
intubated secondary to GCS = 3 and poor respiratory drive. At
[**Hospital6 3105**], patient noted to have right-sided
weakness and left eye deviation. Initial OSH CT scan was
negative for hemorrhage or acute process. Patient transferred
to the [**Hospital1 18**]; OSH concerned with administering thrombolytics in
setting of sedated patient without
conclusive exam. Per ED Evaluation of patient, right sided
weakness and left gaze preference were evident when weaned from
sedation. Emergent CT/CTA performed revealing left MCA clot at
bifurcation with perfusion mismatch consistent with territory
stroke. Initial NIHSS stroke scale was 11. Thrombolytics were
administered
at [**2111**] on [**6-5**] and patient sent to interventional suite where
intraarterial thrombolytics were administered.
On [**6-6**], pt was noted to have improved right handed function, and
was responsive to commands. Pt was extubated in AM without
complication and transferred to the stroke service on [**6-7**].
Since leaving the ICU the patient was less inattentive, and
globally aphasic with minimal response to commands. Her
strength has improved on the right side in upper and lower
extremities. The patient was seen to have failed several speech
and swallow evaluations for which her family authorized the
placement of a PEG tube, accomplished on [**6-13**]. During this
procedure, anesthesia noted a traumatic intubation and as a
result the patient could not be immediately extubated and
required mechanical ventilation in the ICU with plans to attempt
later extubation. The patient was sedated with seroquel and
propofol for a short course and was able to be successfully
extubated on [**6-16**], at which point repeat neurologic evaluation
revealed her to remain globally aphasic with minimal
responsiveness to command, but showed increased strength in her
right extremities.
On [**6-18**] the patient was observed to have right facial twitching
as well as decreased alertness. She was placed on long term EEG
monitoring. No epileptic activity was noted.
Cardiac:
The patient on admission was allowed to autoregulate blood
pressure with anti-hypertensives prescribed on an as needed
basis for more severe hypertension. We did start lower doses of
her home antihypertensives after the acute post-stroke period
and titrated up for goal blood pressure less than 140. Workup
for this cerebrovascular event included a transthoracic
echocardiogram which revealed no atrial septal defect or patent
foramen ovale, and normal global and regional biventricular
systolic function. However, due to the limitations of the
study, a thrombus could not be excluded. Due to the traumatic
intubation, a transesophageal echocardiogram was deferred and a
cardiac MR was obtained. This was a poor study due to patient
movement but it did not reveal any thrombus in the atrium or
aorta.
Heme:
The patient was noted to have anemia with hematocrit to the
mid-low 20s so CT abdomen and pelvis was obtained to assess for
source of bleed but none was noted. The CT did note "Small
hyperdense rounded lesion in the upper pole of the right kidney"
which will need to be followed up. Concurrent with this anemia
was a thrombocytosis and elevated WBC in the 20s with the only
infection nidus from a pan-culture found to be a positive urine
culture. Per the patient's PCP, [**Name10 (NameIs) **] patient has had a chronic
leukocytosis and had refused previous outpatient workup. A
hematologic malignancy consult was placed which noted an
unremarkable peripheral smear. They felt the patient's
leukocytosis and thrombocytosis are most likely reactive,
perhaps due to continued aspiration while she was in the
hospital. They recommend a repeat CBC after discharge.
ID:
A urine culture was obtained grew enterococcus requiring a
course of Amoxicillin therapy. Repeat urine cultures grew no
further bacteria. Her oxygen saturation remained stable and she
remained afebrile despite elevated WBC counts.
Endocrine:
The patient was covered with sliding scale insulin, and an HgB
A1c was obtained measuring 5.6%.
GI:
The patient was started on prophylaxis against gastroesophageal
acid reflux and after several failed attempts at swallow
evaluation, a PEG tube was placed for enteral feeding
successfully.
PENDING Results: Repeat urine culture
Transition of care issues:
Needs repeat CBC in [**1-5**] weeks to ensure downtrending platelets
and WBCs
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 77) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
() non-smoker - (x) unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PCP.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H prn pain
2. Citalopram 40 mg PO DAILY
3. BuPROPion (Sustained Release) 100 mg PO BID
4. Verapamil SR 180 mg PO Q24H
5. Simvastatin 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Lisinopril 40 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
10. Hydrochlorothiazide 25 mg PO DAILY
11. Cyclobenzaprine 10 mg PO HS
12. Lorazepam 0.5 mg PO HS
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Simvastatin 20 mg PO DAILY
2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
3. Aspirin 325 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Lisinopril 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5 mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Left sided Stoke (left frontal, insular cortex extending into
left temporal lobe)
Discharge Condition:
spontaneously moves both right and left UE/LE. Remains Globally
aphasic. no clear gaze preference. Does not follow commands.
Withdrawals both legs to scratch. now with social wave.
Discharge Instructions:
Dear Ms [**Known lastname 111870**],
You were admitted for an ischemic stroke. It is unclear what
the cause of this was. You were continued on Aspirin for stroke
protection. Your stroke risk factors were checked. You should
continue to not smoke. Your cholesterol was 77 You were
continued on a statin. You had a cardiac echocardiogram
which demonstrated no cardioembolic source. You were checked for
blood glucose control with a HgB A1c. The level was 5.6 which
is normal. Because you were unable to swallow safely you
received nutrition through a tube in your mouth and then a PEG
tube was placed directly in your stomach through the skin. You
also had some abnormal blood tests for which we consulted the
hematology service. They feel that this is most likely due to a
reaction of your body to acute illness but you will need to
follow up with them when you are better. You need to continue
your blood pressure control.
It was a pleasure taking care of you.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) **] on [**8-20**] 4:30pm
call to register ASAP [**Telephone/Fax (1) 87261**]
Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office of Hematology [**Telephone/Fax (1) 9645**] if you
decide to persue further evaluation for your elevated white
blood cells and platelet or if CBC in 1 month is still not
normal.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
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[
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14501, 14575
|
8211, 13572
|
305, 360
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14701, 14886
|
4679, 5929
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15910, 16415
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2185, 2220
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14209, 14478
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13598, 14186
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14910, 15887
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3549, 4660
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2235, 3198
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229, 267
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388, 1925
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5937, 8188
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3213, 3532
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1947, 2096
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2112, 2169
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,968
| 148,727
|
6740+55784
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-4-2**] Discharge Date: [**2123-4-29**]
Service: [**Hospital1 **] MED
CHIEF COMPLAINT: Fevers and shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
man with a history of coronary artery disease, congestive
heart failure, end-stage renal disease on hemodialysis, type
2 diabetes, peripheral vascular disease (numerous lower
extremity bypass surgeries). He was admitted with a one day
history of fever and shortness of breath.
The patient reports sudden onset of shortness of breath at
rest and he was feeling feverish on the day of admission. He
denied chills, night sweats, headaches, changes in vision,
cough, nasal congestion, nausea, vomiting, diarrhea, chest
pain or urinary symptoms. He called for EMS and on arrival
they found him to have a blood pressure of 160/100, a pulse
of 58, a respiratory rate of 48 and oxygen saturation of 83.
His skin was warm to touch. The oxygen saturation increased
to 95% on 100% nonrebreather. His fingerstick blood glucose
was found to be 265 at that time. In the Emergency
Department his temperature was found to be 105.1, his pulse
was 124, his blood pressure was 105/65, respiratory rate 24.
His oxygen saturation was 90% on nonrebreather. Chest x-ray
revealed a right lower lobe and right middle lobe infiltrate.
Blood cultures were also sent. The patient received
ceftriaxone 1 gram IV, metronidazole 1 gram IV and Tylenol 1
gram by mouth.
REVIEW OF SYSTEMS: The patient reports stable one pillow
orthopnea, no paroxysmal nocturnal dyspnea or lower extremity
edema. He has exertion limited by hip pain. He is not short
of breath nor does he suffer from chest pain at rest. He has
had no sick contacts or recent travel.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post percutaneous coronary
intervention of left anterior descending artery. Status post
non-Q wave myocardial infarction in [**2122-7-18**]. He did not
undergo cardiac catheterization at that time because of renal
disease and his stress echocardiography was unremarkable and
his ejection fraction was 20%.
2. Cardiac catheterization in [**2120-2-17**] showed two vessel
disease with an ejection fraction of 35%.
3. Global hypokinesis was appreciated on the echocardiogram.
4. End-stage renal disease on hemodialysis Tuesday, Thursday
and Saturday for six months prior to presentation. He has a
history of diabetes and renal artery stenosis.
5. Type 2 diabetes. He has required insulin for over 15
years.
6. Hypertension secondary to bilateral renal artery
stenosis.
7. Hypercholesterolemia.
8. Anemia of chronic disease.
9. Status post abdominal aortic aneurysm repair.
10. Peripheral vascular disease status post bilateral femoral
artery to popliteal artery bypass grafting in [**2122-8-17**]. He
underwent excision of a left femoral pseudoaneurysm.
11. Status post bilateral cataract surgery.
12. Status post bilateral toe amputations.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 105.1,
pulse ranged from 124-100, blood pressure ranged 90-105/60,
respiratory rate 24, oxygen saturation 95-99% on
nonrebreather. Generally, he was awake, alert and oriented
speaking in full sentences in no acute distress. HEENT:
Extraocular movements intact. Anicteric sclerae. Oropharynx
clear. Neck: Supple, no lymphadenopathy, no jugular venous
distention. Heart: Regular rate, tachycardic. No murmur
appreciated (but has +3 mitral regurgitation). Of note, the
chest had a Quinton catheter in the right subclavian vein.
Lungs: Crackles one-third of the way up, decreased breath
sounds at the bases. There was no fremitus or egophony.
Abdomen: Soft, non-tender, non-distended with normal bowel
sounds. Extremities: Warm without edema. There were
chronic venous stasis changes. There were superficial
ulcerations over the tibia and dry skin. Neurologic:
Examination was unremarkable.
LABORATORIES: White blood cell count 6.8, hematocrit 42.2,
platelets 215,000. INR 1.1. Chemistry panel was significant
as follows: 135/3.9/97/22/26/3.3, glucose 275.
ADMITTING MEDICATIONS:
1. Metoprolol 75 mg twice daily.
2. Amiodarone 200 mg daily.
3. Enteric coated aspirin 325 mg daily.
4. Folic acid 1 mg daily.
5. Aggrastat 10 mg daily.
6. Colace 100 mg twice daily.
7. Protonix 40 mg daily.
8. Iron sulfate 325 mg three times daily.
9. Nephrocaps one daily.
10. Captopril 6.25 mg three times daily.
11. Plavix 75 mg daily.
Of note, the patient states he does not take any of his
medications.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] quit tobacco in
[**2122-8-17**]. He smoked half a pack a day for 60 years. He
does not drink alcohol. He is a retired engineer. Prior to
presentation he was able to perform all his activities of
daily living independently except for limitation from chronic
hip pain.
ELECTROCARDIOGRAM: Significant for left bundle branch block,
no acute ST/T wave changes.
HOSPITAL COURSE: The patient had a long complicated hospital
course. He was initially admitted to the Medical Intensive
Care Unit for hypertension and treatment of fevers. An
extensive workup revealed infection of his dialysis catheter
with methicillin-resistant Staphylococcus aureus. That line
was eventually discontinued, however, the patient was unable
to clear his infection in that he developed peritonitis after
peritoneal dialysis was initiated. Similarly, attempts to
place central catheters revealed clots in his left subclavian
as well as his right internal jugular vein suggesting
endovascular infection as well. Serial echocardiograms
showed worsening mitral regurgitation, however, after one
transesophageal echocardiogram, the patient refused further
tests requiring intubation.
Of note, the patient was also found to have a paraspinal
abscess also growing methicillin-resistant Staphylococcus
aureus. He underwent one drainage by Interventional
Radiology with minimal improvement in his pain. Serial blood
cultures continued to grow methicillin-resistant
Staphylococcus aureus after this procedure. Also the
patient's pneumonia did not resolve completely after
initiation of appropriate antibiotic therapy.
The [**Hospital 228**] hospital course was also marked by several
episodes of a sustained ventricular tachycardia with
hypotension. He received a successful defibrillatory shock
upon transfer to the Medical Intensive Care Unit. On [**2123-4-24**], amiodarone was administered intravenously.
Continuous venovenous hemodialysis was initiated in the
Medical Intensive Care Unit. In consultation with the
patient's wife and daughters, decision was made to
discontinue further invasive therapy, to not continue further
testing, to provide pressor medications for electrical shock.
The patient was transferred to the Medical floor.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2123-4-29**] 14:16
T: [**2123-4-29**] 14:15
JOB#: [**Job Number 25646**]
Name: [**Known lastname 4411**], [**Known firstname 422**] P Unit No: [**Numeric Identifier 4412**]
Admission Date: [**2123-4-2**] Discharge Date: [**2123-5-1**]
Date of Birth: [**2042-4-3**] Sex: M
Service: MEDICINE
The patient expired on [**2123-5-1**] at approximately 4 a.m.
The patient was on comfort measures only when transferred
from the Medical Intensive Care Unit to the medical floor on
[**2123-4-30**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **], M.D.
Dictated By:[**First Name3 (LF) 2816**]
MEDQUIST36
D: [**2123-5-1**] 11:21
T: [**2123-5-1**] 11:50
JOB#:
|
[
"567.2",
"996.68",
"996.62",
"453.8",
"038.11",
"324.1",
"427.1",
"403.91",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"03.31",
"88.72",
"54.93"
] |
icd9pcs
|
[
[
[]
]
] |
4966, 7741
|
1482, 1746
|
123, 156
|
185, 1462
|
1768, 4526
|
4543, 4948
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,393
| 135,261
|
50683
|
Discharge summary
|
report
|
Admission Date: [**2194-5-6**] Discharge Date: [**2194-5-12**]
Date of Birth: [**2147-5-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Small Bowel Bleed
Major Surgical or Invasive Procedure:
Inbutation and extubation
Interventional radiology intestinal artery embolization
History of Present Illness:
Mrs [**Known lastname 14654**] is a 46 yo female with hx gastric bypass, chronic
abd pain, DM who was evaluated last Wed at the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for 17
days of N/V/D. At that time, she was given fluids, started on
levaquin/flagyl and discharged home with dx of gastroenteritis.
She re-presented to [**Hospital3 4107**] [**2194-5-5**] for LLQ abd pain,
nausea, dry heaves and lightheadedness and melanotic stools and
was found to have GI bleed. At [**Hospital3 4107**], crit was
initially 35 but dropped to 25 on [**5-6**]. She subsequently
had a syncopal episode while on the commode, and was transferred
to the intensive care unit for SBP of 84. She was transfused 2
units of PRBCs with post-transfusion crit of 23, was therefore
transfused an additional 2 L PRBCs. Blood pressure was stable
with SBP greater than 100, upper endoscopy was negative
therefore bleeding scan was performed and showed small bowel
bleed. She was transferred to [**Hospital1 **] for interventional radiology
evaluation. She was continued on levaquin and flagyl for
possible bacterial enterocolitis.
.
On the floor, pt continues to complain of abd pain. She is
tearful and concerned about her 9 yr history of abd pain. No
other complaints.
.
Review of systems:
(+) Per HPI, decreased appetitite
(-) 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 dysuria, frequency, or urgency. Denies arthralgias or
myalgias.
Past Medical History:
DM2
s/p gastric bypass surgery
Gi ulcers
hx anemia
hx gastritis
back pain
peripheral neuropathy
morbid obesity
colon adenoma
cervical disectomy
hysterectomy
c-section
Social History:
6 yo daughter, lives alone, mother lives nearby.
- Tobacco: currently smokes 1 ppd, 30 py hx
- Alcohol: none
- Illicits: none
Family History:
dad with DM, CHF
Physical Exam:
Admission Exam:
Vitals: T:100.1 BP:113/63 P:110 R:22 O2:98%
General: Alert, oriented, tearful
HEENT: Sclera anicteric, MMM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffusely 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
Neuro: aao x3, CNs, motor funx grossly intact.
Discharge exam: improved abdominal pain with "soreness" in lower
quadrants. Crackles over left lung base.
Pertinent Results:
Admission Labs:
[**2194-5-6**] 10:34PM PT-15.1* PTT-23.8 INR(PT)-1.3*
[**2194-5-6**] 10:34PM PLT COUNT-561*#
[**2194-5-6**] 10:34PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-1+ STIPPLED-1+
[**2194-5-6**] 10:34PM NEUTS-77.3* LYMPHS-18.8 MONOS-3.4 EOS-0.2
BASOS-0.4
[**2194-5-6**] 10:34PM WBC-15.3*# RBC-3.17*# HGB-9.6*# HCT-27.5*#
MCV-87 MCH-30.4 MCHC-35.1* RDW-15.3
[**2194-5-6**] 10:34PM CALCIUM-6.9* PHOSPHATE-2.7 MAGNESIUM-1.4*
[**2194-5-6**] 10:34PM LIPASE-18
[**2194-5-6**] 10:34PM ALT(SGPT)-3 AST(SGOT)-9 LD(LDH)-136 ALK
PHOS-38 TOT BILI-0.8
[**2194-5-6**] 10:34PM estGFR-Using this
[**2194-5-6**] 10:34PM GLUCOSE-141* UREA N-18 CREAT-0.3* SODIUM-143
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-27 ANION GAP-9
[**2194-5-6**] 10:49PM freeCa-1.03*
[**2194-5-6**] 10:49PM LACTATE-1.0
[**2194-5-6**] 10:49PM TYPE-[**Last Name (un) **] PH-7.45
WBC and Hct
[**2194-5-6**] 10:34PM BLOOD WBC-15.3*# Hct-27.5*#
[**2194-5-7**] 08:22AM BLOOD Hct-20.0*#
[**2194-5-7**] 10:59AM BLOOD WBC-21.0*# Hct-26.0*
[**2194-5-7**] 03:39PM BLOOD Hct-22.7*
[**2194-5-7**] 11:43PM BLOOD WBC-24.1* Hct-31.4*#
[**2194-5-8**] 12:47PM BLOOD WBC-15.3* Hct-28.5*
[**2194-5-9**] 04:05PM BLOOD Hct-30.1*
[**2194-5-10**] 05:05PM BLOOD Hct-33.6*
[**2194-5-12**] 05:43AM BLOOD WBC-7.0 Hct-30.8*
Iron studies
[**2194-5-11**] 05:15AM BLOOD Iron-26*
[**2194-5-11**] 05:15AM BLOOD calTIBC-150* VitB12-233* Folate-6.9
Ferritn-205* TRF-115*
[**2194-5-12**] 05:43AM BLOOD CHROMOGRANIN A- pending on discharge
MICROBIOLOGY:
URINE CULTURE (Final [**2194-5-9**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood cx - no growth to date
IMAGING:
CXR ([**2194-5-9**]): FINDINGS: In comparison with study of [**5-8**], there
are continued low lung volumes. There is evidence of mild
pulmonary venous congestion with atelectatic changes especially
at the left base. Elevation of the right hemidiaphragmatic
contour is again seen. Central catheter remains in place, though
the endotracheal tube has been withdrawn. Cervical fusion device
is again seen.
CT enterography:
IMPRESSION:
1. Long segment of abnormal jejunal wall thickening and
associated stranding of the mesenteric fat in the left upper
quadrant just distal to the jejunojejunostomy. This is the
territory supplied by the vessels which were embolized on [**5-7**], [**2194**] and the appearance of the bowel wall may be secondary
to the embolization procedure rather than indicative of the
underlying cause of the GI bleeding.
2. Diffuse anasarca with small amount of free fluid around the
left kidney. Bilateral pleural effusions, larger on the left.
3. Atelectasis in the right lower lobe.
Chromogranin A 2.8 Ref Range 1.9-15.0 ng/mL
Brief Hospital Course:
46 yo woman with DM2, hx GI ulcers, gastritis, initially
admitted to the ICU for abdominal pain and GI/jejunal bleed,
transferred to the general medical floor when stabilized.
.
ACTIVE ISSUES
.
# Jejunal bleed: She was transferred from an OSH ICU for
hemodynamic instability related to a GI bleed after having
several weeks of melenotic stools. Prior to transfer, endoscopy
had failed to reveal a bleeding source, and a tagged RBC scan
demonstrated that it was likely small bowel bleeding source.
She was transferred to [**Hospital1 18**] for IR intervention. She was
hemodynamically stable on admission with a HCT of 27. Her first
IR procedure on [**5-7**] showed a transient bleeding source in the
jejunum that had unfortunately vanished prior to intervention.
She was transferred back to the MICU and became hypotensive to
SBP=60s with rectal bleeding. Massive transfusion protocol was
activated, and she received 8 units of blood, 2FFP, 1 unit
platelets. She was intubated for airway support due to clinical
instability, and was transferred back to the IR suite. 2 coils
were placed for a likely jejunal bleeding source, however the
observed bleeding pattern was concerning for a tumor/malignancy.
She was extubated [**5-8**] without incident. Both the surgical and
GI teams were consulted. Her HCT remained relatively stable
thereafter requiring [**5-8**] one unit PRBC for HCT 28.
Conversations with radiology/GI suggested CT enterography to
further elucidate the source of her bleed, which showed
nonspecific findings s/p embolization procedure. The source of
the GI bleed was thought to be tumor vs. jejuno-jejunal
anastamotic ulcer and will be further evaluated as an outpatient
with MR [**First Name (Titles) 105453**] [**Last Name (Titles) **]. capsule endoscopy. On the floor, her
hematocrits stabilized and she did not exhibit any active
bleeding. GI and surgery were following, with some concern for
small bowel tumors including carcinoid, lymphoma, and NET.
Serum chromogranin was sent and was within normal range. Urine
5-HIAA could not be sent due to patient drinking tea and a
special tube for serum serotonin was not able to be obtained.
Given her GI anatomy, routine iron studies were sent and
detected low iron and B12/folate levels (likely secondary to
malabsorption), so she was discharged with supplementation.
Total blood products used during hospitalization: 16 RBCs, 4
FFP, 2 platelets, 2 cryo. By the time of discharge, pt had
mobilized this extra fluid and had minimal edema.
.
# Fever/UTI/infection: She was cultured for a temperature of
100.6 in the ICU with a resistant-E.coli UTI in the context of a
Foley catheter, and was started on Bactrim. She will continue a
7-day course for treatment of a complicated UTI and her Foley
catheter was discontinued. Her leukocytosis trended down over
the hospitalization.
.
# Abdominal pain: This was likely related to her GIB as well as
baseline chronic pain. She described it more like a "soreness",
much different than her initial left-sided abdominal pain on
admission. Low concern for GI infection given downtrending WBC
and normal lactates. LFTs and lipase were within normal limits.
She was transitioned to PO pain meds and was discharged with
5-7 days worth of oxycodone.
.
INACTIVE ISSUES
.
# DM2: Serum glucoses within normal range. She was continued on
an ISS and a diabetic diet.
.
# Neuropathy: She was continued on gabapentin.
.
# Hyperlipidemia: She was continued on simvastatin.
.
TRANSITIONAL ISSUES
.
# Follow-up: She will follow-up with Gastroenterology for
further imaging studies in a few weeks following discharge. She
was instructed to return to the hospital immediately if she has
another bleeding or syncopal episode. GI will assist with
further malignancy work up as an outpt.
.
# Communication: [**Name (NI) **] (mother, [**Name (NI) 382**] [**Telephone/Fax (1) 105454**]
Medications on Admission:
Lunesta 3 mg daily
Metformin 500 mg BIDomeprazole 40 mg
simvastatin 20 mg daily
excedrin
gabapentin 300 mg daily 6x/day
metronidazole 250 daily
ciprofloxacin 250 daily
nystain
humalog 2-8 units daily
On transfer from OSH
-simvastatin 20 mg q PM
-Pantoprazole 40 mg [**Hospital1 **]
-morphine 2 mg q2 PRN
-metronidazole 250 q 8
-levofloxacin 500 mg daily
-ondansetron 4 mg IV q 6 hrs
-zolpidem
-dilaudid
Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Lunesta 3 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Gastrointestinal bleed (jejunum)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 14654**],
It was a pleasure taking part in your care at the [**Hospital1 771**]. You were transferred here from [**Hospital1 **] for a gastrointestinal bleed. One of the imaging tests
revealed that the bleeding site was around one of the
connections of bowels created during your gastric bypass
surgery. You required a large amount of blood transfusions to
keep up with the amount of blood that you lost. You were
briefly intubated, but then quickly extubated once your
condition was more stable. The Interventional Radiologists
stopped the bleeding in this area by "embolizing" 2 blood
vessels by placing coils in them. During the time you had the
Foley catheter in, you developed a urinary tract infection that
we are treating with antibiotics. We have also started you on
folate and cyanocobalamin (vitamin B12) for your anemia.
You have recovered from a life-threatening situation. You
should be very attentive to any further symptoms you have,
including increased abdominal pain, bloody or dark black stools,
fevers/nausea/vomiting.
Please be sure to follow up with GI in a few weeks. They will
decide which testing is best indicated for you.
We have made the following changes to your medications:
START Bactrim for 3 more days (to treat your urinary tract
infection)
START folate and cyanocobalamin to help treat your anemia
START oxycodone as needed for pain
Followup Instructions:
We have scheduled the following appointments for you:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: Tuesday [**2194-5-20**] 3:45pm
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2194-5-27**] at 3:00 PM
With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
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icd9cm
|
[
[
[]
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[
"39.79",
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icd9pcs
|
[
[
[]
]
] |
11882, 11888
|
6541, 10434
|
299, 383
|
11984, 11984
|
3126, 3126
|
13564, 14344
|
2394, 2412
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10460, 10865
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2427, 3000
|
3016, 3107
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13377, 13541
|
1699, 2044
|
242, 261
|
412, 1680
|
3142, 6518
|
11928, 11963
|
11999, 12111
|
2066, 2234
|
2251, 2378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 183,332
|
43045
|
Discharge summary
|
report
|
Admission Date: [**2187-7-24**] Discharge Date: [**2187-7-27**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
nausea, vomiting, abd pain
Major Surgical or Invasive Procedure:
Femoral line.
History of Present Illness:
This is a 39 yo M with DM1 c/b ESRD and severe gastroparesis,
HTN, CAD s/p STEMI, and multiple line infections who presents
with nausea, vomiting, abdominal pain, and hypertensive urgency.
He was discharged from [**Hospital1 18**] on [**7-20**] for hypotension and rectal
bleeding. Colonoscopy revealed colitis in the ascending and
transverse colon that was thought to be either ischemic or
infectious in etiology. Stool cultures were negative and his
ACE-I was d/c'd but labetalol and clonidine continued. He also
recently completed a course of IV vancomycin for coag negative
staph bacteremia and a course of caspofungin for fungemia
(trichosporon). Since then, the pt was feeling in his USOH until
this am when he awoke with 10/10 diffuse abd pain, nausea and
began to vomiting innumerable times. Denies hemetemesis, fever,
chills, diarrhea, headache, chest pain, shortness of breath,
palpitations, blurry vision, or focal numbness or weakness. He
has not had further episodes of BRBPR or melena.
.
In the ED, initial BP 200/121, HR 115, RR 27, O2 sat 97% 2L NC.
He was given dilaudid 2 mg IM X 2, ativan 2 mg IM x 1, and
clonidine 0.1 mg po X 1. CXR showed interval development of
pulmonary vascular congestion. He was initially sent to HD and
plans were for admission to the medical floor thereafter;
however, his SBPs remained elevated after having 3.8 L UF
removed. He then returned to the ED where a right femoral TLC
was placed and was given labetaolol 20 mg IV X 2, zofran 4 mg IV
X 1, ativan 1 mg IV X 1. The pt was also noted to vomit
approximately 200 ccs of coffee ground emesis and was given
protonix 40 mg IV X 1 prior to being admitted to the MICU.
.
Currently, he continues to complain of [**11-23**] diffuse abd pain
and nausea. No active vomiting or dry heaving.
.
Past Medical History:
1. Diabetes Mellitus Type I
- Gastroparesis with chronic hospitalizations
- ESRD on HD since [**2-/2184**]
- Autonomic dysfunction, frequent HTN emergency & orthostatic
hypotension
- Peripheral neuropathy
2. Coronary artery disease
- STEMI [**2186-12-17**] in setting of cocaine, s/p BMS to LAD
3. Aortic valve endocarditis ([**4-21**])
- In the context of coag neg staph bacteremia ([**Month (only) 404**] and
[**2187-3-16**]) and positive intravenous catheter tip [**2187-4-6**] had
his HD catheter changed over a wire. known MRSE bacteremia for
which he completed a course of vancomycin for possible
endocarditis on [**5-18**]
4. Hypertension
5. History of line sepsis with coag negative staph and
priors with klebsiella and enterobacteremia
6. Esophageal ulceration: H pylori neg, active esophagitis seen
on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
7. History of substance abuse (cocaine, marijuana, alcohol)
9. History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in
place
10. Fungemia completed caspofungin IV on [**2187-7-12**]
11. GI bleed associated with hypotension-colonscopu showed
friable and inflammed ascending and transverse colon,suggestive
either of ischemia or infection [**2187-7-19**]
Social History:
Patient has a prior history of tobacco and marijauna use, but he
does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs. Currently lives
with his mother and brothers.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. Two sisters, one with diabetes. Six brothers, one
with diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
VS: Temp 98.4 BP 200/132 HR 83 RR16 O2 sat 100% RA
GEN: mild distress [**3-17**] pain
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, slightly dry MM
Neck: supple, no LAD, no carotid bruits, JVP approximately 10 cm
above sternal notch
Chest: tunneled HD line over RSV, no active oozing, NT to
palpation
CV: RRR, nl s1, s2, no m/r/g
PULM: bibasilar rales
ABD: soft, diffusely slightly tender to palpation, + BS, no HSM
EXT: warm, dry, +1 distal pulses BL, no femoral bruits, R
femoral TLC in place
NEURO: alert & oriented x3, CN II-XII grossly intact, [**6-18**]
strength throughout. No sensory deficits to light touch
appreciated.
Pertinent Results:
[**2187-7-27**] 10:00AM
White Blood Cells 5.6 K/uL 4.0 - 11.0
Red Blood Cells 3.96* m/uL 4.6 - 6.2
Hemoglobin 10.2* g/dL 14.0 - 18.0
Hematocrit 33.4* % 40 - 52
MCV 85 fL 82 - 98
MCH 25.7* pg 27 - 32
MCHC 30.4* % 31 - 35
RDW 19.6* % 10.5 - 15.5
Platelet Count 204 K/uL 150 - 440
[**2187-7-27**] 10:00AM
Glucose 176* mg/dL 70 - 105
Urea Nitrogen 27* mg/dL 6 - 20
Creatinine 7.0*# mg/dL 0.5 - 1.2
Sodium 135 mEq/L 133 - 145
Potassium 4.7 mEq/L 3.3 - 5.1
Chloride 94* mEq/L 96 - 108
Bicarbonate 28 mEq/L 22 - 32
Anion Gap 18 mEq/L 8 - 20
Brief Hospital Course:
39 year old man with hx of DM1 c/b gastroparesis, autonomic
instability, ESRD on HD, CAD s/p MI presenting with hypertensive
urgency in the setting of nausea, vomiting, and abdominal pain.
With regard to HTN urgency, he presented with his usual pattern
of abdominal pain, nausea, and vomiting which leads to
hypertensive urgency. Autonomic dysfunction also contributing.
Although SBPs did improve slightly at HD, it still remianed
above 200 even after labetalol 20 mg IV X 2, and therefore was
trnsferred to the ICU for further managment with Labetalol drip
to titrate SBP < 160. He had no focal neurologic complaints or
deficits on exam. he also was continued on clonidine patch. Once
goal SBP was achiefed and remained stable, medication was
changed to his oral regiment and he was called out to the floor,
where hisl BP remained well controlled.
.
With regard to his gastroparesis he was no longer vomiting with
his outaptient regiment but continued complaining of abd pain
and nausea, which improved on tthe floor.
.
He had one episode of coffee ground emesis (approximately 200
ccs in ED after multiple episodes of vomiting prior). Possible
small [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear vs. PUD vs. gastritis/esophagitis.
Doubt that source of blood could be related to recent colitis in
ascending and descending colon. He declined NGL. HCT remined
stable and no further episode of coffee ground emesis was
observed.
.
DM1 with complications: Continued home dose lantus with insulin
sliding scale. Home regimen of gastroparesis meds: reglan,
dilaudid, ativan IV on initial presentaton which was switched to
PO on the medical floor.
.
# CAD s/p MI - With continued ST elevations on EKG, unchanged
from prior. No clinical symptoms of active ischemia. Continued
[**Last Name (NamePattern1) **], [**Last Name (NamePattern1) 4532**], statin.
.
# ESRD on HD: Did have increased pulmonary vascular congestion
on admission CXR but without resp distress on exam and sating
100% on RA. Continued nephrocaps, lanthanum and HD q Tues,
Thurs, Sat.
.
# h/o recent line infection - s/p treatment with vancomycin and
caspofungin for coag negative staph bacteremia and fungemia (sp.
Trichosporon). No fevers, chills, exit site of HD line appears
clean.
Medications on Admission:
Clopidogrel 75 mg DAILY
Aspirin 325 mg DAILY
Insulin Glargine 6 units at bedtime
Clonidine 0.3 mg/24 hr Patch weekly
Atorvastatin 80 mg DAILY
Gabapentin 300 mg PO 3X/WEEK (TU,TH,SA).
Gabapentin 200 mg 4X/WEEK ([**Doctor First Name **],MO,WE,FR).
Lanthanum 1000 mg TID W/MEALS
B-Complex-Vitamin C-Folic Acid 1 mg DAILY
Pantoprazole 40 mg Q12H
Labetalol 200 mg TID
Lisinopril 20 mg DAILY
Metoclopramide 10 mg QIDACHS
Hydromorphone 4 mg Q4H
Lorazepam 1 mg Q6H
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q TUES,
THURS, SAT ().
4. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q SUN, MON,
WED, FRI ().
5. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS .
10. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
13. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
15. Insulin
Insuling sliding scale, as instructed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hypertensive urgency
Secondary:
1. Diabetes Mellitus Type I
2. Gastroparesis
3. ESRD on HD since [**2-/2184**]
4. Autonomic dysfunction, frequent HTN emergency & orthostatic
5. Peripheral neuropathy
6. Coronary artery disease
Discharge Condition:
Hemodynamcially stable. Tolerating PO medications and food.
Discharge Instructions:
You were admitted with elevated blood pressure and
nausea/vomiting with abdominal pain. It is extremely important
that you continue taking all your medications, as prescribed.
No changes have been made to your medication regimen. Please
also continue with [**Year (4 digits) 2286**], as before.
Followup Instructions:
Please call your primary care physician to schedule [**Name Initial (PRE) **] follow-up
appointment. Also please continue with [**Name Initial (PRE) 2286**], as before.
|
[
"305.23",
"305.03",
"412",
"305.63",
"V58.67",
"V12.51",
"414.01",
"403.91",
"V45.1",
"V15.82",
"585.6",
"337.1",
"250.61",
"536.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9316, 9322
|
5291, 7565
|
341, 357
|
9606, 9668
|
4732, 5268
|
10013, 10186
|
3821, 4036
|
8073, 9293
|
9343, 9585
|
7591, 8050
|
9692, 9990
|
4051, 4713
|
275, 303
|
385, 2172
|
2194, 3505
|
3521, 3805
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,990
| 107,852
|
53446
|
Discharge summary
|
report
|
Admission Date: [**2153-6-9**] Discharge Date: [**2153-6-14**]
Date of Birth: [**2101-2-9**] Sex: M
Service: MED
CHIEF COMPLAINT: Hypertensive episode with hypoxia.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with multiple medical problems and complex past medical
history recently discharged from [**Hospital1 190**] in early [**2153-5-26**] after extensive two month
hospital stay initially for dyspnea on exertion/shortness of
breath with right-sided heart catheterization showing fluid
overload, initially improved with palliative therapy using
Swan in the Coronary Care Unit. However, [**Hospital 228**] hospital
course was complicated by intubation for hypercapnia and
sedation and then subsequent difficulty in being off a
ventilator. He was subsequently transferred to the Medical
Intensive Care Unit for respiratory failure management at
which point he was treated for a right lower lobe pneumonia,
presumed Staph in origin, with intravenous vancomycin. He
subsequently underwent placement of a trach for prolonged
respiratory care and also underwent a percutaneous endoscopic
gastrostomy tube. These procedures were ultimately
complicated at the PEG by a large gastric hematoma requiring
multiple units of packed red blood cells. Ultimately, the
patient required aggressive body fluid resuscitation and
several units of packed red blood cells and was returned to
the Intensive Care Unit for symptoms of volume overload. He
was then diuresed again to near euvolemia. His hospital
course was mired by difficulties in managing his fluid
balance; he was constantly fluctuating between hyper and
hypovolemia and congestive heart failure versus acute renal
failure. Ultimately, he did develop increased renal failure
of unclear etiology and ultimately was started on
hemodialysis. Later during his hospital course from a
respiratory standpoint, he developed a Pseudomonas and
Enterobacter pneumonia for which he was treated with
ceftazidime and Levaquin. Also during his hospital course he
had an Enterococcus bacteremia. Ultimately he was discharged
off of trach ventilation support to [**Hospital1 **] on [**2153-5-28**].
He had been weaned off the ventilator for five days.
However, on this admission the patient presented with an
increased lethargy and was found to have acute desaturations
into the 60's and 70's on trach mask 50 percent while being
on the commode. The patient was noted to become cyanotic and
was thought to be unresponsive. The patient was subsequently
bagged with a recovery of oxygen saturations but systolic
blood pressures dropped into the 60's and 70's. The patient
then received one liter of normal saline and was transferred
to the [**Hospital1 69**] Emergency
Department where patient had improvement in his pressures
into the 70's and 80's and was asymptomatic at this point;
however, patient received additional three liters of
intravenous fluids, aspirin, heparin, empiric vancomycin and
was transferred to the Intensive Care Unit. Currently the
patient is comfortable without complaints. He denies any
shortness of breath, coughing, fever or chills. He denies
chest pain currently but does report fleeting chest pain at
the time of the hypoxia and hypotension episode subsequently
resolved spontaneously. No abdominal pain, nausea or
vomiting.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post one vessel coronary
artery bypass graft in [**2132**], left internal mammary artery
to left anterior descending artery with subsequent
catheterization in [**2153-3-26**] showing patent graft and 30
percent lesion in his circumflex.
2. Status post mitral valve replacement times two, one in
[**2142**] and one in [**2133**], St. Jude valve.
3. Congestive heart failure. Ejection fraction [**11-9**] percent
in [**2153-4-26**].
4. Staph endocarditis necessitating mitral valve replacement
complicated by septic emboli and brain abscesses.
5. Atrial fibrillation on Coumadin.
6. Type 2 diabetes mellitus.
7. Upper GI bleed and history of duodenal ulcers.
8. Unclear interstitial restrictive lung disease.
9. Gout.
10. Left lower extremity cellulitis.
11. Respiratory failure status post tracheostomy in
[**2153-3-26**].
12. Status post percutaneous endoscopic gastrostomy tube
placement in [**2153-3-26**] complicated by hematoma.
13. Acute renal failure, persistent, now on hemodialysis
via Quinton left subclavian.
14. History of nonsustained ventricular tachycardia in
the setting of electrolyte abnormalities and pressors.
15. History of anemia.
16. Sacral decubiti.
17. Recent Enterobacter bacteremia and ventilator-
associated pneumonia.
18. History of questionable ankylosing spondylitis HLAB-
27 negative and now thought to be DISH.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Coumadin 3 q. hs.
2. Lentis 23 q. hs. sliding scale.
3. Digoxin 0.125 q. three days.
4. Coreg 3.125 b.i.d.
5. Epogen 5000 units with dialysis.
6. Reglan 5 q. hs.
7. Vitamin B.
8. Zinc.
9. Albuterol and Atrovent nebs.
10. Oxycodone p.r.n.
11. Ativan p.r.n.
12. Lexapro 10 q. day.
PHYSICAL EXAMINATION ON ADMISSION: Afebrile, 97.3. Blood
pressure 91/57, pulse 54, respiratory rate 20 on control of
20, tidal volume 400, PEEP 5, FiO2 0.4. Satting in the mid
90's. General: Lethargic but responding appropriately to
questions. HEENT: Significant jugular venous pressure to
tragus of ear. Cardiovascular: Irregularly irregular with
3/6 systolic ejection murmur. Lungs: Coarse breath sounds
bilaterally. Abdominal examination shows J-tube PEG site
with mild erythema and exudate, not purulent. Otherwise soft
and non-distended. Extremities: Trace lower extremity
edema.
LABORATORY: White count 13.3, hematocrit 30.9 at baseline,
platelet count 208,000. INR 1.6, PTT 31.9. His chemistry
shows sodium 145, potassium 4.9, chloride 107, bicarb 25, BUN
77, creatinine 4.4, sugar 238. Calcium, magnesium and
phosphorus: 8.8, 2.1 and 1.7. His ABG was 7.53 and 26.3 at
the time of admission. Lactate was 4.1 and 3.2. His CK was
41, troponin-I 0.26. Digoxin level was 1.1. He had ALT 8,
AST 21, amylase 45, alk phos 181 chronic, lipase 26, total
bilirubin 0.5.
RADIOLOGY: Chest x-ray showed a small right-sided pleural
effusion unchanged, cardiomegaly and question of mild
____________ on chest x-ray.
ELECTROCARDIOGRAM: Shows atrial fibrillation 103-94, low
voltage. Question of old inferior Q-waves and old T-wave
inversions in anterolateral leads.
HOSPITAL COURSE:
1. Hypotension. It is unclear as to the exact etiology of
his hypotension. Initially, there were concerns about
possible sepsis given particularly the elevated lactate.
However, patient's blood cultures were negative. A
cortisol level was checked as patient's cortisol has been
_____________ in the past which were all within normal
limits. Possible concerns for hypotension with hypoxia
with aggressive positive pressure ventilation therefore
decrease in preload. Other thoughts were possible
pulmonary embolism which could possibly explain hypoxia
and hypotension. At any rate, however, by the time he
returned to the Emergency Department had pressures that
were running into the 80's and 90's which is near his
baseline. A further workup for pulmonary embolism was not
sought after. He needed to be heparinized for his
mechanical valve and for question of troponin leak. Given
the fact that they were concerned about preserving
possible kidney function, contrast dye with CT was not
desired. As mentioned above, the patient has low blood
pressures into the 70's and 80's but has been
asymptomatic. He will be given cautious amounts of a beta
blockade as per his initial outpatient regimen.
1. Congestive heart failure. Patient with a history of
cardiomyopathy of [**11-9**] percent and by time of Intensive
Care Unit evaluation was grossly overloaded although
compensated on positive pressure ventilation with sats in
the mid 90's. The patient was challenging in terms of
marginal blood pressures and also being anuric. Renal
team was consulted and patient underwent dialysis with
removal of approximately two liters with each session. He
will also continue on his Coreg and will continue on his
digoxin dosing by levels. At the current time he is being
dosed every three days.
1. Troponin leak. It is unclear the etiology of the
patient's troponin leak. His ECG is unremarkable for
impressive ischemic changes. Furthermore, he had a
catheterization in [**2153-3-26**] which was essentially
unremarkable. His CK's remained flat. He was given
aspirin and beta blockade and he was heparinized also in
the setting of having a subtherapeutic INR for his mitral
mechanical valve.
1. Subtherapeutic INR. As mentioned above, patient has
several reasons to be anticoagulated, namely atrial
fibrillation and his mechanical mitral valve. There is
also a question of troponin leak in an individual with
several high risk cardiovascular features. He was started
on heparin and was later converted to Coumadin at 1 mg q.
hs. His final dose of Coumadin remains to be determined
at this time. Again, it was a delicate balance between
making him therapeutic with INR avoiding supertherapeutic
given the fact that he has history of gastrointestinal
bleed. His goal INR will be 2 to 2.5 per review of all
notes from previous admissions.
1. Respiratory failure. As mentioned above, patient
initially admitted with hypoxia of unclear etiology. This
eventually improved with bag ventilation and by the time
of patient's arrival to the Intensive Care Unit he was
satting well into the mid 90's on his traditional assist
control ventilation. The patient has a history of being a
difficult wean from mechanical ventilation. The etiology
of his desaturation remains unclear. Several theories
have been proposed including mucus plugging, possible
pulmonary embolism or even a question of aspiration
pneumonia. He was dialyzed for his congestive heart
failure. His sputum ended up growing out Pseudomonas for
which he has been treated with Ceptaz. Furthermore, he
has been treated with intravenous heparin for his
subtherapeutic INR on mechanical valve. At the current
time he remains on positive pressure ventilation, assist
control with the use of a tracheostomy. It will be the
goal of the team possibly weaning him to pressure support
and then trach collar. Please see discharge diagnoses for
this information.
1. End-stage renal disease. The patient was followed by the
Renal team. During this admission he was dialyzed for
removal of excess fluid. Also during this admission,
discussions had been made for pursuit of a more long term
site for hemodialysis. He is to undergo vein mapping of
his upper extremities during this admission and presumably
Renal will be in touch with Transplant Surgery for
possible placement of a long term dialysis catheter.
1. Anemia. The patient did receive one unit of packed red
blood cells initially during his hospital course for a
hematocrit dropped into the mid 20's in the setting of
increased body fluids and also in the setting of a
troponin leak. His hematocrit had remained stable
thereafter. It is believed that his baseline hematocrit
is about 30. He is receiving Epogen at this time per
Renal recommendations. He has a history of
gastrointestinal bleeding but his stools have been guaiac
negative to this point.
1. Atrial fibrillation and mechanical valve. As mentioned
above, patient came in with subtherapeutic INR on Coumadin
for his mechanical valve. Given his history of
gastrointestinal bleed, suitable INR for him has been
changed to 2.5. His exact doses of Coumadin will be
dictated at the time of discharge.
1. Sacral decubiti. The patient has been evaluated by Wound
Care nurse and will begin receiving DuoDerm dressing
changes. He will also be started on long dose pain
regimen. The exact medication and doses will be dictated
at the time of discharge.
1. Question of depression. The patient was re-evaluated by
Psychiatry for question of depression. It is felt that a
large component of his depression is difficulty he has
dealing with his many severe medical conditions. At this
point his Lexapro will be increased from 10 to 15 mg q.
day.
1. Code status remains full at this point.
1. Access. Patient at this point continues with a left
subclavian Quinton catheter. As mentioned above, talks
have been initiated for looking into a longer term more
permanent access for his hemodialysis.
DISPOSITION: He will return to [**Hospital **] Rehabilitation.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSES:
1. Hypoxia and respiratory failure of unclear etiology.
2. Transient hypotension.
3. Congestive heart failure.
4. End-stage renal disease.
5. Diabetes mellitus.
6. Depression.
7. Subtherapeutic INR for mitral mechanical valve.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D: [**2153-6-14**] 17:05:01
T: [**2153-6-14**] 17:59:04
Job#: [**Job Number 100558**]
|
[
"585",
"285.9",
"428.0",
"427.31",
"458.9",
"466.0",
"250.40",
"518.81",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13007, 13532
|
6588, 12954
|
152, 188
|
217, 3346
|
5218, 6571
|
3368, 5203
|
12979, 12986
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,143
| 163,828
|
35623
|
Discharge summary
|
report
|
Admission Date: [**2106-11-26**] Discharge Date: [**2106-12-3**]
Service: MEDICINE
Allergies:
Lipitor / Corgard
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Septic Shock
Major Surgical or Invasive Procedure:
ERCP
IJ central line placement
History of Present Illness:
86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD
stent presents with persistent vomitting, diarrhea, fevers. The
pt reports her symptoms began at 2am Tuesday night during which
she had episodes of emesis, diarrhea and shaking chills. These
symptoms continued into Wednesday where she reported decreased
PO. Per the pt, on Thursday she developed confusion and
subsequently was brought to an OSH ED. Upon arrival to the OSH,
initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L, FS 110, the
pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and the
pt was subsequently transferred to [**Hospital1 18**] for presumed ascending
cholangitis.
.
Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked
well appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr
1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and
a dilated intrahepatic duct. The pt was noted to be hypoglycemic
and subsequently received an Amp D50, KCL. ERCP consulted
(pending). Subsequently the pt SBP dropped to 70, received 4L of
NS, 40meq KCl, Foley with 200cc UOP. Morphine 2mg IV x1, RIJ
placed. Prior to transfer to the floor vitals 82 108/47 98% RA
on .12 of Levophed.
.
Upon arrival to the floor the pt is resting comfortably. She
states she feels improved. She denies headache, shaking chills,
chest pain, shortness of breath. She reports mild right upper
quadrant pain and yellowing of the eyes.
Past Medical History:
?????? IDDM2 for five years
?????? Myopathy s/p statin 3 years ago; continues with methotrexate
and prednisone taper
?????? Hypertension
?????? Anxiety
Social History:
Lives with her husband in [**Hospital3 **]. No history of smoking,
drinking or recreational drug use.
Family History:
No history of pancreatic or liver cancers
History of DM2, otherwise non-contributory
Physical Exam:
T=97.8 BP=161/52 (Levophed .12) HR=75 RR=16 O2= 98 2L
PHYSICAL EXAM
GENERAL: Pleasant, well appearing eldery female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. Mild
scleral icterus. PERRLA/EOMI. Dry MMM.
NECK: RIJ in place Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Clear anteriorly
ABDOMEN: Tenderness to palpation in RUQ. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2106-11-25**] 11:45PM WBC-25.4*# RBC-3.34* HGB-10.2* HCT-30.4*
MCV-91 MCH-30.4 MCHC-33.4 RDW-15.1
[**2106-11-25**] 11:45PM NEUTS-95* BANDS-0 LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2106-11-25**] 11:45PM PLT SMR-NORMAL PLT COUNT-184
[**2106-11-25**] 11:45PM PT-14.7* PTT-27.8 INR(PT)-1.3*
[**2106-11-25**] 11:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2106-11-25**] 11:45PM URINE RBC-0-2 WBC-[**1-21**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2106-11-25**] 11:45PM ALT(SGPT)-191* AST(SGOT)-120* ALK PHOS-169*
TOT BILI-4.9*
[**2106-11-25**] 11:45PM LIPASE-31
[**2106-11-25**] 11:45PM GLUCOSE-56* UREA N-29* CREAT-1.7* SODIUM-138
POTASSIUM-2.9* CHLORIDE-105 TOTAL CO2-19* ANION GAP-17
[**2106-11-25**] 11:51PM LACTATE-2.2*
[**2106-11-26**] 05:54AM BLOOD Cortsol-10.8
.
EKG: Sinus rhythm at upper limits of normal rate with sinus
arrhythmia. Borderline low voltage. Q waves in leads V1-V2.
Consider septal myocardial infarction. Since the previous
tracing of [**2106-10-4**] the rate is faster.
.
CXR: Left basilar atelectasis, unlikely pneumonia.
.
RUQ U/S
1. Stent within the CBD, measuring 1.4 cm. Intrahepatic biliary
ductal
dilation to 4 mm.
2. Stones and sludge within a slightly distended gallbladder,
but no wall
thickening, or pericholecystic fluid. The patient was not tender
over the
gallbladder.
3. If there is concern for a pancreatic mass, CTA would be
recommended.
.
ERCP [**2106-11-26**]:
A plastic stent placed in the biliary duct was found in the
major papilla. The stent appeared to be clogged and there was no
bile draining through or around the stent. The previously placed
plastic biliary stent was removed with a snare successfully.
After the stent was removed, pus and sludge drained from the
common bile duct.
Evidence of a previous sphincterotomy was noted in the major
papilla.
Cannulation of the biliary duct was performed with a
sphincterotome after a guidewire was placed. Contrast medium was
injected resulting in complete opacification. A single irregular
stricture of malignant appearance that was 2 cm long was seen at
the lower third of the common bile duct. There was moderate
post-obstructive dilation.
A 6cm by 10mm covered metal Wallflex (LOT# [**Serial Number 81062**]) biliary
stent was placed successfully.
Discharge Day Laboratories:
[**2106-12-3**] WBC-7.3 RBC-3.51* Hgb-10.2* Hct-32.3* MCV-92 Plt Ct-260
[**2106-12-3**] Glucose-58* UreaN-16 Creat-1.2* Na-142 K-3.5 Cl-103
HCO3-29
Brief Hospital Course:
86F with hx of pancreatic CA s/p biliary stenting presenting
with ascending cholangitis.
.
#: Septic Shock: Pt with fever, leukocytosis, increased LFTs in
setting of dilated CBD, thus infected source likely biliary,
consistent with ascending cholangitis. Patient received IVF, but
remained hypotensive so was started on Levophed. CVL placed in
ED. Initial lactate 2.2, trended down to 1.8. Patient underwent
ERCP with replacement of her temporary biliary stent with a
permanent stent. Frank pus was drained from the CBD. With
decompression of CBD, sepsis resolved and patient was weaned off
pressors. Pt was covered with Zosyn, Vanco initially. Cultures
remained no growth to date. She was weaned to Zosyn alone
successfully, which was transitioned to Augmentin several days
prior to discharge to complete a total of ten days of
antibiotics.
.
#: Ascending Cholangitis: Pt with elevated transaminases, Alk
Phos, TB in setting of a stent 1.4cm in the CBD. Ultrasound
revealing dilated intrahepatic ducts at 4mm and radiographic
findings suggestive of small stones and sluge in the GB. No
evidence of acute cholecystitis. Treatment for her infection
occurred as per above.
.
# Gap Metabolic Acidosis: Bicarb of 17 on initial labs with gap
of 14. Lactate slightly elevated at 2.2. Diarrhea (Non-Gap) may
also be contributing to decreased bicarb. Patient received large
amount NS, and hyperchloremic metabolic acidosis was also a
contributor to her acid-base picture. Anion gap improved over 24
hours.
.
# DMII/Hypoglycemia: Pt hypoglycemic to 56 while in ED, received
1 Amp of D50. DDx included sepsis, decreased PO in setting of
regular insulin dosing. Patient was re-started on her home Lasix
when transferred to the general medicine floor, which she
tolerated well.
.
#: ARF: Cr 1.7 at presentation from baseline 1.0 to 1.4. Pt with
300 UOP at OSH. BUN at 29 up from 12. DDx Pre-renal from
hypoperfusion in the setting of septic shock, less likely
post-renal, intrinsic. Improved with IVF hydration to a baseline
of 1.2 prior to discharge.
.
# Myositis: Pt was on long term steroids and methotrexate. Pt
currently on 10mg prednisone. AM cortisol was wnl. She was
given stress dose steroids which were weaned back to her
baseline of prednisone 10mg daily and she remained
hemodynamically stable. She should resume her Methotrexate as an
outpatient.
.
#Oncology: Patient without a tissue diagnosis, and interested in
knowing her options.
She was seen by oncology in the ICU. She underwent CT A/P with
contrast to discern if mass had grown or spread. She obtained
follow up in oncology clinic for further assessment. Rad onc
was also consulted for potential palliative XRT in the future.
CA19-9 was pending at discharge. She was noted to have a right
adnexal mass on abdominal CT; follow-up pelvic ultrasound was
non-diagnostic. This should be further discussed at her Oncology
follow-up appointment.
#Diarrhea: Patient complained of loose stools upon resumption of
her diet after stent placement. Differential diagnosis includes
antibiotic-associated diarrhea, malabsorption in setting of
recent biliary manipulation. C.Diff was negative x 2. Patient
was able to maintain adequate PO's with no electrolyte
abnormalities. Would continue to follow as she advances to a
regular consistency diet and completes her antibiotics.
#Lower extremity edema: Secondary to fluid repletion in the ICU.
Patient had trace bilateral edema at the time of discharge, and
was given TEDs and advised to elevate her feet and ambulate
frequently. She had no respiratory complaints throughout her
stay.
Medications on Admission:
Prednisone 10mg PO Daily
Methotrexate 15mg PO Friday
Aspirin 81mg PO Daily
Hydrochlorothiazide 25mg PO Daily
Lisinopril 20mg PO QHS
Folic Acid 1mg PO Daily
Fosamax 70mg PO once a week.
Insulin Glargine 100 unit/mL Solution Sig: Four (4) units
Subcutaneous After breakfast.
Calcium 600 + D(3)
Ergocalciferol (Vitamin D2) Oral
Multi-Vitamin HP/Minerals Capsule Oral
Omega-3 Fatty Acids Oral
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 6 days: To be completed on
[**2106-12-9**].
Disp:*12 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Cartridge Sig: Four (4) units Subcutaneous
at bedtime.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Cholangitis
Biliary obstruction
Pancreatic cancer
Myositis
Hypertension, benign
Hypokalemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted with an infection in your biliary tree
(cholangitis). You underwent repeat metal stenting to open the
obstruction. You were also treated with IV antibiotics, which
were changed to oral antibiotics at discharge. Please take your
antibiotic as prescribed to complete a course on [**2106-12-9**]. You
also underwent further evaluation of your pancreatic cancer with
oncology consultation and CT scan. You must follow up closely
with them for further care.
.
Other than the addition of your antibiotic, no other changes
were made to your home medications.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] [**2106-12-16**] 10:30
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 14916**] [**2106-12-8**] at 2:15
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2106-12-15**] 9:30
|
[
"E947.8",
"576.1",
"276.2",
"401.1",
"787.91",
"785.52",
"995.92",
"996.69",
"157.0",
"574.20",
"584.9",
"250.80",
"576.2",
"038.9",
"359.4",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.10",
"97.05"
] |
icd9pcs
|
[
[
[]
]
] |
9955, 10016
|
5362, 8949
|
239, 271
|
10151, 10151
|
2809, 5339
|
10926, 11302
|
2029, 2116
|
9394, 9932
|
10037, 10130
|
8975, 9371
|
10327, 10903
|
2131, 2790
|
187, 201
|
299, 1716
|
10165, 10303
|
1738, 1892
|
1908, 2013
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,887
| 163,176
|
13027
|
Discharge summary
|
report
|
Admission Date: [**2137-5-26**] Discharge Date: [**2137-5-31**]
Date of Birth: [**2088-4-14**] Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
transferred for cholecystitis
Major Surgical or Invasive Procedure:
ERCP
HIDA
History of Present Illness:
This is a 49yo M with h/o HCV undergoing interferon who was
transferrred from [**Hospital3 4107**] for?DIC, hyperbilirubinemia,
fever and RUQ pain. He presented to [**Hospital3 **] with 3-4
[**Last Name (un) 32460**] of fever/chills, cough, anorexia and RUQ/R flank pain. He
was found to have WNC of 10(from 2.5), Plt count of 18(down from
37) and INR 2.0(unknown baseline). He was initially treated for
a pneumonia despite a clear CXR(cefotaxime and azithromycin),
but was switched to Zosyn when he was found to have some RUQ
pain and an elevated Total Bili. He was transferred to [**Hospital1 18**] for
further management
Past Medical History:
HCV diagnosed in1996(bx [**2127**] shows severe scarring)
-Rx [**2129**] with IPN:relapse
-Rx [**2132**] with IFN:relapse
-[**2-13**] started daily interferon and ribavirin
interferon
IV drug abuse
h/o gallstone
h/o left femur fracture
h/o right clavicle fracture.
Social History:
smokes [**4-12**] pk/d
quit ETOH In [**2131**]
no IVDA since [**2131**]
Family History:
noncontributory
Physical Exam:
T98.7 BP125/70 P56 R20 97% on RA
Gen- sleepy, jaundiced, cooperative
HEENT-scleral icterus, oral mucosa dry, neck supple, no spider
angioma on chest
CV-rrr, no r/m/g
resp-CTAB
[**Last Name (un) 103**]-active BS, nondistended, liver edge 1cm below costal
margin, no RUQ tenderness(patient was given ativan b/c just came
back from HIDA)
ext-no edema, DP1+ b/l
neuro-too sleepy to assess orientation, no asterixis, move all 4
limbs symmetrically
Pertinent Results:
DOPPLER LIVER ULTRASOUND: No prior studies are available for
comparison. The liver demonstrates a coarsened echo texture,
consistent with the patient's known hepatitis C. Several
gallstones are present within the gallbladder. The gallbladder
wall is markedly thickened measuring up to 1 cm. No definite
pericholecystic fluid collection is seen. There is no intra- or
extrahepatic biliary ductal dilatation, with the common bile
duct measuring 3 mm. There is marked splenomegaly, with the
spleen measuring 18.8 cm. Visualized portions of the pancreas
were unremarkable. The right kidney measured 10.8 cm and the
left measures 11.6 cm. There is a 2.4 x 2.0 cm cyst in the upper
pole of left kidney. There is no hydronephrosis.
Doppler evaluation of blood flow to the liver shows patent
portal vein with antegrade flow. The right and left portal veins
are both patent. The hepatic veins and arteries are also patent
with appropriate waveforms. There is no ascites.
IMPRESSION:
1) Echogenic liver consistent with the patient's known hepatitis
C cirrhosis.
Patent portal vein. No ascites or focal mass visualized.
2) Cholelithiasis. Gallbladder wall thick, but the gallbladder
is not
overtly distended. The gallbladder wall thickening could simply
be due to
underlying liver disease, but continued followup is recommended.
3) Splenomegaly with spleen measuring 18.8 cm. No ascites.
Brief Hospital Course:
49 year old male with HCV (diagnosed in [**2128**]. He is now on his
third treatment of interferon and ribavirin who presented to
[**Hospital3 **] on [**5-25**] with several days of fevers/chills,
cough, congestion, and anorexia. While in the hospital, several
issues were addressed:
#acute cholecystitis
He had RUQ ultrasouns that showed 1cm GB wall thickening, CBD
3mm suggests biliary obstruction. He also had elevated total
bilirubin without elevation in alkaline phosphatase. HIDA scan
on [**5-27**] was consistent with cystic duct obstruction. Surgery was
consulted for evaluation. They did not want to operate given
that his was clinical improving. He was initially on zosyn but
was switched to levofloxacin and flagyl upon discharge to
complete a 14 days course. His blood culture remained negative.
He gradually tolerated oral intake and had decreasing abdominal
tenderness
#HCV cirrhosis
He was reported to have elevated INR of 2.0 and an albumen of
2.4 from OSH; likely reflecting chronic liver disease and poor
synthetic function. He also other clincia sign of liver failure
given thrombocytopenia and splenoplenomegaly. HE never displayed
any sign or symptoms of encephalopathy. He was continued on
lactulose. Hepatology service and transplant surgery was
consulted. MRI liver and MRCP was obtained. On his discharge,
radiology was contact[**Name (NI) **] regarding preliminary read:chronic liver
disease with no acute process, cirrhosis, small nodules with no
dominant nodules,recommend follow up MRI, small gallstones in
gallbladder, gall bladder wall thickening, no biliary tree
dilatation, portal vein patent. His hepatitis serology, EBV, HIV
and toxo titer pending at the time of discharge. He has
appointment with transplant service and these result will be
followed up. He also had an echocardiogram as part of the
transplant workup and it showed EF 60% with no other
abnormality.
#BRBPR
He had one episode of bright red blood per rectum. EGD [**5-29**]:non
bleeding varices at lower 3rd esophagus. He had no further
episode of blood lost. His hematocrit was stable. It was felt
that colonoscopy could be done as outpatient. This decision was
discussed with the hepatology service.
#headache
On the day of discharge, he complained of left sided throbbing
headache. He has no photophobia/focal neurological
symptoms/meningismus/gait disturbances/earahce. It was felt that
this is more like a tension headache. He agreed to trying
naproxen and follow up with his PCP. [**Name10 (NameIs) **] understands that he
should return to the hospital if worrisome symptoms occur.
#pneumonia
CXR showed RLL infiltrate and he was already on antibiotic for
cholecystitis
#thrombocytopenia
THis is likely secondary to chronic liver disease and
interferon. RIbavarin and interferon was held in house and he
will follow up with the transplant clinic
Medications on Admission:
interferon
Ribavirin [**Hospital1 **]
prilosec
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. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1800 ML(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
5. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
Hepatitis C cirrhosis
Discharge Condition:
stable
Discharge Instructions:
Please return to the hospital or call your doctor if you have
worsening abdominal pain, fever or if you have any concerns at
ll.
Please take all prescribed medication to ensure that you do not
return repeatedly to the hospital
It is CRUCIAL that you follow up with all the appointments
suggested below. Good follow up will ensure that you stay out of
hospital
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-6-10**] 8:00
Provider: [**First Name8 (NamePattern2) **] [**Known firstname **], [**Name12 (NameIs) 1046**] Where: TRANSPLANT SOCIAL WORK
Date/Time:[**2137-6-10**] 10:00
PLease call [**Telephone/Fax (1) 250**] to schedule an appointment with a
primary care doctor. He/She will follow up with your headache
Completed by:[**2137-5-31**]
|
[
"569.3",
"574.01",
"456.21",
"571.5",
"287.5",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6879, 6885
|
3258, 6118
|
300, 311
|
6972, 6980
|
1853, 3235
|
7391, 7877
|
1358, 1375
|
6215, 6856
|
6906, 6951
|
6144, 6192
|
7004, 7368
|
1390, 1834
|
231, 262
|
339, 965
|
987, 1253
|
1269, 1342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,606
| 121,211
|
34434
|
Discharge summary
|
report
|
Admission Date: [**2158-8-4**] Discharge Date: [**2158-8-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
VTach
Major Surgical or Invasive Procedure:
ICD placement
History of Present Illness:
86yo gentleman with h/o CAD s/p CABG in [**2138**], HTN, and DM
admitted after an episode of symptomatic VTach.
Mr. [**Known lastname 52730**] was walking out of [**Company 79153**], where he works doing food
demonstration (yesterday was lemonade day), when he began to
feel faint. He stated he was weak all over and felt short of
breath and diaphoretic. He denies chest pain, pressure, or
palpitations. Some coworkers came to him and helped lie him
down. They called EMS. Although he does not remember it, he
was told he lost consciousness.
Of note, he stopped his ASA about 2 weeks ago because of ?
hematuria.
When EMS arrived, he was noted to be in ventricular tachycardia
at 200bpm. He abruptly converted to an accelerated junctional
rhythm in the 70s and then to sinus tachycardia per their
report. He received ASA.
At [**Hospital3 3583**], he was given amiodarone 150mg followed by
gtt at 1mg/min. He also received 600mg plavix and heparin gtt
was started for ? STE in V1-V2. He was transferred to [**Hospital1 **]
because of concern for ACS.
In the ED at [**Hospital1 18**], his VS were: no temp recorded 85 116/60
18 99% NRB. He was continued on amiodarone gtt at 1mg/min.
STE were less pronounced, and after discussing with cardiology,
the patient was not felt to have ACS. He was admitted to the
CCU for further management.
Upon presentation to the CCU, the patient stated he was feeling
well. Although he was requiring a NRB in the ED, he was
breathing comfortably on 2L oxygen by NC.
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. +hematuria about 2 weeks ago.
+Dyspnea on exertion, though he walks about a mile around the
mall, only having to stop a few times. Cardiac review of
systems is notable for absence of chest pain, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, or palpitations.
Past Medical History:
CAD s/p 3 vessel CABG in [**2138**], anatomy unknown
HTN
DM II
Dyslipidemia
s/p CCY
BPH
Macular Degeneration
ALLERGIES: NKDA
OUTPATIENT CARDIOLOGIST: ([**Doctor Last Name **]?) [**Doctor Last Name **] in [**Location (un) 3320**]
PCP: [**Name10 (NameIs) 79154**] [**Name11 (NameIs) 79155**] of [**Hospital **] Medical Group
Social History:
Social history is significant for the absence of current tobacco
use: he smoked briefly as a teenager. There is no history of
alcohol abuse; he drinks a beer occasionally. He is married and
lives with his wife. [**Name (NI) **] does not use a cane or walker.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 95.5, BP 137/60, HR 78, RR 26, O2 98% on 2L
Gen: Pleasant elderly gentleman in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 5-6cm. No thyroid enlargement.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: +sternotomy scar, well healed. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored though
he was mildly tachypneic. Able to speak in full sentences
without difficulty, no accessory muscle use. +Scattered
crackles at bases. No wheeze or rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKGs: no baseline for comparison
17:10 NSR with LAHB, left axis deviation. STE in aVR, V1 and
V2 as well as Q waves in V1-V2.
19:04 LAHB as above except decreased STE as compared with
prior (absent in aVR and only 0.5mm in V1-V2.
VTach strips: rate about 200 with negative QRS in inferior
leads
.
TELEMETRY demonstrated: NSR in 60s
.
2D-ECHOCARDIOGRAM: none
.
ETT: none
.
CARDIAC CATH: none
.
HEMODYNAMICS: none
.
LABORATORY DATA:
Na/K 141/5
Cl/HCO3 109/23
BUN/Cr 40/1.5
Gluc 190
Mg 2.3
.
CK 160
MB 5
Trop 0.03
.
ALT 30
AST 34
.
WBC 10.8
Hct 34.4
Plt 187
.
CXR [**2158-8-4**] (MY READ): No infiltrate; +mild pulmonary edema
Brief Hospital Course:
86yo gentleman with CAD s/p CABG in [**2138**], HTN, and DM admitted
with presyncope and wide complex tachycardia.
.
# Rhythm:
Patient presented with wide complex tachycardia. Patient's
episode was not associated with chest pain or typical anginal
symptoms, EKG changes not evolving and enzymes negative x3, so
it seemed unlikely that he had an ischemic event. It was thought
that he might have scar mediated VT. Different EKGs showed LAFB
vs. RBBB. Episodes of wide complex tachycardia while inpatient
appeared more likely consistent with SVT. However, EPS showed
inducible VT, degenerating into VF, leading to ICD placement.
ICD was interrogated by electrophysiology and found to be
functioning normally. PA/Lateral CXR was done, showing good lead
placement. He was discharged on three days of prophylactic
Keflex. Finally, his outpatient Coreg regimen was changed to
Toprol XL 100QD. A decision was made to change from carvedilol
to metoprolol because it was felt that his blood pressure was
unable to tolerate increases in carvedilol.
.
# Pump:
Patient noted to have LV systolic and diastolic failure with EF
15-20%, severe LV hypokinesis except at basal and lateral
segments, dystolic dysfunction, mild MR. [**Name13 (STitle) **] was initially
somewhat volume overloaded, with signs of pulmonary edema and
bibasilar crackles. He was diuresed well, responding well to
Lasix 20mg PO. He likely developed some mild pulmonary edema in
the setting of possible VT, which resolved with diuresis. By the
time of discharge, he was oxygenating well, with good oxygen
saturation on room air, and appeared fairly euvolemic. His
Diovan was initially held, but he was restarted on his
outpatient dosage of 80QD prior to discharge.
.
# CAD s/p CABG:
No signs of active ischemia were noted. No EKG changes
suggestive of ischemia were noted, and cardiac enzymes were
negative x3. His aspirin, lipitor and diovan were continued. He
was switched from carvedilol to metoprolol.
.
# ARF:
Baseline Cr unknown, creatinine while inpatient was
approximately 1.3 and fairly stable. This may have been related
to transient poor perfusion in the setting of VT. Initially,
Diovan was held, but it was restarted prior to discharge.
.
# HTN:
Beta blocker switched from Carvedilol to Metoprolol because his
blood pressure would not tolerate further increases in
carvedilol. Initially, Diovan was held, but it was restarted
prior to discharge.
.
# DM:
Metformin was held and he was covered with sliding scale
insulin.
.
# Anemia:
He was noted to be somewhat anemic, but his hematocrit was
fairly stable. This was not worked up while inpatient, but he
was advised to consider an outpatient colonoscopy following
discharge.
Medications on Admission:
Metformin 500mg daily
Coreg 6.25mg [**Hospital1 **]
Lipitor 20mg QHS
Diovan 60mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin (Lipitor) 40 mg Tablet Sig: One (1) Tablet PO
once a day.
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for ICD implantation for 3 days.
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Metformin 500mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Ventricular tachycardia s/p ICD
2. Supraventricular tachycardia
Secondary
1. HTN
2. DM Type 2
3. CAD s/p CABG
4. Acute renal failure
5. Dyslipidemia
6. BPH
7. Macular Degeneration
8. S/p cholecystectomy?
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after passing out. You underwent a
study which found a dangerous, abnormal heart rhythm, for which
you received a defibrillator. You tolerated the procedure well.
You were started on the following new medications:
Aspirin 325mg PO every day
Cephalexin 500 mg PO every 8 hours for another two days (you
will need a total of three days, but you received one day of
Cephalexin while in the hospital)
Metoprolol Succinate XL 100 mg daily
For the earlier part of your stay here at [**Hospital1 18**], you were not
given your regular dose of Diovan 80 mg daily. We restarted you
on Diovan 80 mg daily before discharging you, and you should
continue this medication.
The following medications were changed:
- Lipitor was increased to 40 mg daily
The following medications were discontinued:
- Coreg 6.25 mg [**Hospital1 **]
Please take all medications as prescribed. You may discuss
decreasing or discontinuing the aspirin with your cardiologist
at a later time.
If you experience chest pain, lightheadedness, loss of
consciousness, or other concerning symptoms, please call 911 or
go to the ED.
Followup Instructions:
Cardiovascular:
DEVICE CLINIC at [**Hospital1 18**] Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2158-8-14**]
11:30
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Location (un) 3320**] Phone: [**Telephone/Fax (1) 13266**] Date/Time:
Wednesday [**8-23**] at 9:30am
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] Phone: [**Telephone/Fax (1) 62**] Date/Time:
Friday [**8-25**] at 11:20AM
.
Primary care:
Dr. [**Last Name (STitle) 79156**] [**Name (STitle) 79155**] Phone: ([**Telephone/Fax (1) 79157**] Date/Time: Monday
[**8-28**] at 10:30am.
|
[
"362.50",
"584.9",
"401.9",
"250.00",
"285.9",
"428.40",
"428.0",
"414.00",
"V45.81",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
8165, 8171
|
4841, 7536
|
266, 282
|
8430, 8440
|
4169, 4818
|
9621, 10241
|
3092, 3174
|
7673, 8142
|
8192, 8409
|
7562, 7650
|
8464, 9598
|
3189, 4150
|
221, 228
|
310, 2448
|
2470, 2798
|
2814, 3076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,659
| 181,242
|
16219
|
Discharge summary
|
report
|
Admission Date: [**2173-8-7**] Discharge Date: [**2173-8-12**]
Date of Birth: [**2096-12-2**] Sex: F
Service: NEUROLOGY
Allergies:
Ondansetron
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
PCA stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The pt is a 76-year-old woman R handed woman with end stage
PD, Sz disorder and dementia who is transferred from OSH for
further management of her "PCA stroke and other medical
problems."
According to transfer records (incomplete at best), it appears
that on [**2173-8-2**] she had a ? Sz at her NH. She was brought to the
[**Hospital 4199**] Hospital ED, where VS were 93/54, O2 sat of 85% on
unknown amount of O2. Due to "difficulty" maintaing O2 sats, she
was intubated in the ED. Of note, was also found to have small
amount of coffee ground emesis. Course was complicated by R PNX
after a subclavian line placement. At this point, she was
admitted to [**Hospital1 8**] ICU for "? shock". Her course was
complicated by R PNX, VAP, severe hypertension, then
hypotension,
electrographic evidence of Sz, dropping HCT and acute stroke on
[**8-7**]. She was transfered to [**Hospital1 18**] for further managment and
evaluation of the stroke and medical problems.
On admission to [**Hospital 8**] hospital ICU, it appears that patient
was noted to have elevated WBC to 24K and CXR w/ ? LLL
infiltrate. For this she was started on Vancomycin/Cefepime for
/
aspiration PNA. Subsequent ET suction tube SpCx grew out MRSA.
As
respiratory status improved, intubation was planned, however
patient had persistently "altered mental status." EEG was
performed that showed "moderate number of bursts and runs of
epileptiform activity in L parietal region and becoming more
generalized.." Given this, her Keppra dose was increased from
250mg [**Hospital1 **] to 750mg [**Hospital1 **]. She remained w/o improvedment, and on
[**8-7**]
she was given 1g of ativan IV, and loaded w/ 500mg of Dilantin.
Given that no improvement was noted, she underwent a NCHCT on
[**8-7**]. This showed a new (compared to [**8-2**] HCT) L hypodensity in L
PCA territory w/ L cerebellar hemishpere hypodense focus in the
L
cerebellum. No mass effect or hemorrhage was noted. Given this
she was started on ASA 81mg and transferred to [**Hospital1 18**] for further
management. Of note, she had episodes of hypertension on [**8-4**] abd
[**8-5**] to max of 240s/140s. This was felt to be due to pain from
chest tube, treated w/ labetalol, morphine and captopril. There
was report (verbal) that patient was felt to be in HF and thus
received lasix IV, with signficant diuresis and episode of
hypotension to 90s systolic. She was resuscitaed w/ IVF w/ SBPs
returning to 120s. There was also report of elevated Troponin to
0.83, however, no documentation was provided. Her ECGs were
sinus
tachycardia with PACs. On [**8-7**] she was also noted to have green,
loose stools, Cdiff neg x1.
She had been on Zonisomide for ? Tremors, but has been tx for Sz
disorder with this as well. The dose had been increased by Dr.
[**First Name (STitle) **] as a neurology consultant at [**Hospital6 12736**] for
a
series of "possible convulsions." - desribed as becoming
unresponsive, shaking and vomiting in front of her husband. At
this time [**7-21**] she was also started on Keppra 250mg [**Hospital1 **]. Per
that
note, prior MRIs were remarkable for b/l GP atrophy,
mineralizatonof BG on b/l and cerebellar midline atrophy.
During her last visit with Dr. [**First Name (STitle) 951**], [**3-11**], she was unable to do
so very much herself or provide much history. She needed help in
order to get out of the car. She has had frequent falls and
episodes of LOC. She sleeps much of the day. She requires
assisst
w/ ADLs.
Exam at that time was notable for being alert, mostly with eyes
closed but following simplevoice commands. No spontaneous
speech.
Disoriented to date/place, but knew her husbands name, poor
recall and naming. She also had facial hypomimia, monotone and
hypophonic speech, mild UE rigidity and nl LE tone. Flx
contractures of
the left hand, RAMs impaired and slow heel taps. She could arise
easily and quickly from the chair without assistance, gait was
slow.
She was admitted to [**Hospital 4199**] Hospital [**Date range (1) 46278**]/09 with ? seizure.
Head CT was "negative," her zonegran was increased to 50 mg q
AM,
100 mg at night.
ROS could not be obtained.
Past Medical History:
*Multiple falls - First episode in Summer [**2168**] - found
unresponsive on kitchen floor, woke up in minutes - single
episode not worked up extensively; second episode [**2170-5-13**] -
found down, extensive w/u at [**Hospital1 2025**] d/c [**2170-5-25**] with no known
etiology and plan for Holter; [**5-31**] - found down with LOC ended
up going to [**Hospital1 2025**] MICU for unclear reasons: (-) EEG, (-) [**Name (NI) 1608**]
*Parkinson's disease x 18 years- followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] as
outpt.
*h/o asthma/?COPD- dx at [**Hospital1 2025**] with occasional albuterol
*Seizure disorder, hx of head trauma at age 3, Sz since 5-6
years.
Social History:
Lives at home with her husband until increased
episodes of Sz. Currently lives in [**Location **]. Spends most of time
sleeping, dependent on ADLs.
Family History:
nc
Physical Exam:
Vitals: T: 98.7F P:72 R: 16 BP:106/78 SaO2:95% on 4LNC.
General: eyes closed, moaning, not responding to voice.
HEENT: NC/AT, dMM, no lesions noted in oropharynx, missing
multiple teeth. NGT in place w/ bilious material.
Neck: Supple, no carotid bruits, R subclavian line.
Pulmonary: Crackles B/l up to apices
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: cool, dry, no edema. 2+ radial, 1+ DP pulses
bilaterally.
Skin: no rashes, L forarm stage II ulcers, dressing on.
Neurologic:
-Mental Status:
Eyes closed, moning spontaneously, does not open eyes to command
or sternal rub, but grimaces to sternal rub with moans.
PEERL 5->3mm b/l, oculocephalic reflex intact, corneals present,
eyes were forced open by examiner w/ patient resistance noted.
VF
- blinks to threat b/l. Mouth was opened by examiner with
resistance from patient. Palate appeared to be midline. She did
not localize w/ UEs to noxious at orbital location.
Patient would move L wrist spontaneously, which at rest is
flexed
and fisted. There is cogwheeling on L > R, tone increased b/l in
UEs. She withdrew flexor to b/l UEs and localized to pain in the
clavicle b/l. Increased tone in [**Last Name (LF) **], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46279**] flx to pain,
there was no localization.
DTRs were 2+ at biceps and triceps and 3+ at patella R, 2+ on L.
No reflex at achilles. Clonus in L foot for 4 beats, none at R
LE. Plantar flx on L and extensor on R.
Pertinent Results:
[**2173-8-8**] 03:06AM BLOOD WBC-12.8* RBC-3.21* Hgb-9.4* Hct-29.9*
MCV-93 MCH-29.2 MCHC-31.4 RDW-13.1 Plt Ct-284
[**2173-8-7**] 09:55PM BLOOD Neuts-81.2* Lymphs-10.0* Monos-5.3
Eos-3.4 Baso-0.1
[**2173-8-7**] 09:55PM BLOOD PT-12.9 PTT-25.8 INR(PT)-1.1
[**2173-8-8**] 03:06AM BLOOD Glucose-103 UreaN-7 Creat-0.6 Na-141
K-3.6 Cl-108 HCO3-25 AnGap-12
[**2173-8-7**] 09:55PM BLOOD ALT-1 AST-18 LD(LDH)-348* CK(CPK)-41
AlkPhos-88 TotBili-0.6
[**2173-8-8**] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2173-8-8**] 03:06AM BLOOD Calcium-8.8 Phos-1.9* Mg-1.9
[**2173-8-7**] 09:55PM BLOOD %HbA1c-6.2*
[**2173-8-7**] 09:55PM BLOOD Triglyc-165* HDL-35 CHOL/HD-5.5
LDLcalc-126
[**2173-8-7**] 09:55PM BLOOD TSH-3.0
[**2173-8-8**] 09:29AM BLOOD Vanco-22.3*
[**2173-8-7**] 09:55PM BLOOD Phenyto-5.4*
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2173-8-8**]
11:26 AM
HISTORY: 76-year-old woman with Parkinson's, with large stroke.
Had recent
pneumothorax after placement of central venous catheter by
report.
Questionable free air under the right diaphragmatic contour.
Concern for
bowel perforation.
COMPARISON: None.
TECHNIQUE: Helical MDCT images were acquired from the bases of
the lungs to
the pubic symphysis after administration of oral and IV
contrast. Multiplanar
reformatted images were obtained.
FINDINGS:
CT ABDOMEN WITH CONTRAST: Dependent atelectasis is seen at the
bases of the
lungs and a small right-sided pleural effusion is noted. Along
the lateral
right chest wall, there is subcutaneous emphysema tracking to
the axillary
region. Linear atelectasis is present in the bilateral upper
lobes.
Nodular density at right lung base is likely rounded
atelectasis. The lungs
are otherwise clear without pneumothorax. The visualized heart
is normal. In
the abdomen, there is one subcentimeter hypodense lesion in the
liver, the
right hepatic lobe, incompletely evaluated. The gallbladder is
nondistended
without CT evidence of stone. The pancreas, spleen, adrenal
glands are normal.
There are bilateral subcentimeter hypodensities in the renal
parenchyma, too
small to be evaluated but likely to be cysts, and left
parapelvic cysts. There
is bilateral prompt excretion of contrast into the collecting
system and
proximal ureter although patchy heterogeneity of the nephrograms
particularly
on the left are of uncertain signficance. The stomach, duodenum
and loops of
small bowel are normal. There is no lymphadenopathy. There is no
free air or
free fluid in the intra- abdominal cavity.
CT PELVIS WITH CONTRAST: There is an indwelling Foley catheter
within a
normally distended bladder. The uterus is normal in size for a
postmenopausal
female. The colon and loops of small bowel are within normal
limits. There
is no lymphadenopathy. There is no free air or fluid in the
pelvic cavity.
BONE WINDOWS: No acute fracture or dislocation. No suspicious
lytic lesions
or sclerotic lesions. There is a single level degenerative
disease at L3 and
4 with anterior osteophytosis.
Of note, the NG tube is seen with tip in the stomach.
IMPRESSION:
1. No evidence of pneumoperitoneum or bowel perforation.
Subcutaneous
emphysema in the right lateral chest wall and axillary region.
This may relate
to a reported recent right pneumothorax seen at an outside
hospital.
2. Mild heterogeneity of nephrograms of uncertain significance
although
correlation with renal function is advised.
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2173-8-8**] 12:07 AM
CTA OF THE HEAD AND NECK WITH CONTRAST, [**2173-8-8**]
HISTORY: 76-year-old woman with Parkinson's disease with "large
posterior
circulation stroke, at OSH"; assess for bleed, thrombi, or
dissection.
TECHNIQUE: Routine [**Hospital1 18**] study including contiguous 5-mm axial
MDCT sections
from the skull base to the vertex prior to contrast
administration, with
helical 1.25-mm axial sections from the level of the aortic arch
through the
vertex during dynamic intravenous administration of 80 mL
Optiray-320.
Sagittal, coronal, and axial 10-mm sections, as well as
rotational 3D
volume-rendered reconstructions of both the cervical and
intracranial vessels,
and rotational curved multiplanar reformations of the cervical
vessels were
reviewed on the workstation.
FINDINGS: The study is compared with the NECT of the head
([**Hospital 8**]
Hospital) obtained some nine hours earlier.
There has been no overall short-interval change in the
appearance of the
large, virtually complete left posterior cerebral arterial
territorial
infarction with extensive cytotoxic edema throughout this region
and
involvement of the lateral portion of the ipsilateral thalamus,
likely
splenium of corpus callosum and posteromedial temporal lobe.
There are
scattered curvilinear internal relatively hyperattenuating foci,
also not
significantly changed, which may represent petechial hemorrhage
or, less
likely, "islands" of spared brain. There is a vaguely triangular
low-attenuation focus within the right hemipons, not clearly
present earlier
and difficult to confirm on the post-contrast images, which may
be artifactual
or represent additional relatively acute infarction. There is no
evidence of
involvement of additional vascular territories.
While there is atherosclerotic mural calcification involving the
superior
aspect of the aortic arch, as well as the left subclavian
arteries, there is
little atherosclerotic disease involving the common and internal
carotid
arteries throughout their course, to the level of the carotid
termini. These
vessels demonstrate normal caliber, with the left ICA measuring
6 mm at its
proximal portion, just distal to the bifurcation and 5 mm at the
skull base,
and the right internal carotid artery measuring 7 mm proximally,
just distal
to the bifurcation and 5 mm, more distally, at the level of the
skull base,
with, therefore, no flow-limiting stenosis. The vertebral
arteries are
roughly co-dominant and demonstrate normal caliber, contour, and
contrast
enhancement throughout their course, with no flow-limiting
stenosis or
evidence of dissection. There is a normal appearance to the
vertebrobasilar
confluence, and normal contrast opacification and caliber of the
principal
vessels of the circle of [**Location (un) 431**], without significant mural
irregularity or
flow-limiting stenosis. Specifically, there is a normal
appearance to the
left posterior cerebral artery from its basilar artery origin
throughout its
more distal portion, which can be followed to the periphery of
the infarcted
vascular territory.
IMPRESSION:
1. No significant further interval extension of the large,
virtually complete
left PCA arterial territorial infarction since the [**Hospital 8**]
Hospital study
obtained some nine hours earlier. This infarct involves the
ipsilateral
thalamus, medial temporal lobe and, likely, [**Last Name (un) 46280**] portions of
the splenium
of the corpus callosum.
2. Internal round and linear relatively hyperattenuating foci,
in this
context, suspicious for "petechial" hemorrhagic conversion.
3. Vaguely triangular low-attenuation focus within the right
hemipons, not
clearly present earlier and difficult to confirm on the
post-contrast images,
which may be artifactual or represent additional relatively
acute infarction.
4. Unremarkable appearance to the circle of [**Location (un) 431**] without
significant mural
irregularity or flow-limiting stenosis; specifically, the left
PCA is normal
in caliber and opacification throughout its course through the
infarcted
territory, and may be recanalized.
5. Normal appearance to the common and internal carotid and
vertebral
arteries, bilaterally, with no significant mural irregularity or
flow-limiting
stenosis.
Brief Hospital Course:
Ms. [**Known lastname 46281**] is a 76 year-old woman w/ hx of advanced PD,
dementia, and Sz disorder, with worsening Sz frequency, recently
admitted to [**Hospital 8**] hospital s/p seizure and intubation for
"hypoxic respiratory failure", VAP, hypertensive emergency,
hypotension, who now presents with a new stroke in posterior
circulation distribution, most likely embolic in nature.
The patient was initially admitted to the Neuro ICU for her
large posterior circulation infarct. Blood pressures were
allowed to autoregulate, and she was evaluated for remediable
stroke risk factors. Given her known seizure disorder, she was
continued on Keppra and Zonegran. She had an elevated white
count, which was attributed to pneumonia, for which she was
continued on Vancomycin, with repeat cultures.
After extensive discussion with the family, based on her
multiple severe medical problems, and deteriorating condition,
the decision was made to make the patient CMO. She was placed
initially on a morphine drip, later transitioned to Dilaudid,
with Ativan as needed. She remained comfortable, with her
family present. She passed away early in the morning on [**8-12**].
Medications on Admission:
- ASA 81mg daily
- Lipitor 80mg daily
- Zonegran 100 mg [**Hospital1 **]
- Keppra 750mg [**Hospital1 **]
- Sinemet 15/100 [**12-4**] tab Q8H, then 1 tablet Q11,14,17,20
- Zosyn IV 3.375 Q6H
- Vanco IV 1g Q12
- Protonix 40mg IV daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Large posterior circulation stroke
Seizure disorder
Parkinson's disease
Discharge Condition:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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[
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[]
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,068
| 145,625
|
44837+44851
|
Discharge summary
|
report+report
|
Admission Date: [**2161-11-20**] Discharge Date: [**2161-12-12**]
Date of Birth: [**2084-1-12**] Sex: F
Service: GENERAL [**Doctor First Name **]
Date of Discharge is pending and is planned for [**2161-12-12**].
HISTORY OF PRESENT ILLNESS: This is a 77 year old female,
status post right nephrostomy tube placement for
hydronephrosis, who, in the past had had a left colectomy
with a coloanal anastomosis, who, also underwent XRT which
was the cause of her hydronephrosis, who, presented with
increasing right flank pain and right lower quadrant pain and
abdominal distention. Her husband had placed the nephrostomy
tube which was clamped to gravity and started her on
Ciprofloxacin for a possible urinary tract infection and
brought her to the hospital. She had abdominal pain with no
fevers or chills and had a regular bowel movement with no
blood and no diarrhea. She did notice some decreased
appetite and increasing pain in her abdomen.
PAST MEDICAL HISTORY: Her past medical history is
significant for her colon cancer. She has a seizure disorder
due to encephalitis. She has Methicillin resistant
Staphylococcus aureus urinary tract infections in the past.
MEDICATIONS: Her medications on admission were:
1. Neurontin 300 mg p.o. t.i.d. and then 600 mg p.o. q hs.
2. Ciprofloxacin prn.
ALLERGIES: She had no known drug allergies.
SOCIAL HISTORY: She lives with her husband.
PHYSICAL EXAM: On physical exam, she was afebrile. Her
vital signs were stable. Her pupils are equal, round, and
reactive to light. Extraocular muscles intact. Her lungs
were clear. Her heart was regular rate and rhythm with no
murmurs, rubs or gallops. Her abdomen was distended and
tender and tympanitic with no masses and no
hepatosplenomegaly and positive bowel sounds. She had mild
edema and her neurological exam was unchanged from prior.
LABORATORY: Her white count was 1.3. Hematocrit, 32.7 and
platelet count of 355. Sodium, 137; potassium, 2.9;
chloride, 102; bicarbonate, 18; BUN, 33; creatinine, 1.9;
blood sugar, 120. Baseline creatinine is approximately 1.3
to 1.4. Urinalysis was sent which showed positive nitrites
and positive leukocyte esterase and from 10 to 20 white blood
cells.
HOSPITAL COURSE: The patient is admitted with urinary tract
infection to the Medical Service and given antibiotics to
cover both Methicillin resistant Staphylococcus aureus and
gram negative rods and continued on her medications.
During her hospital course, a CT scan was obtained which
found a large abscess in her low pelvic region which also
showed mild air in that region as well consistent with a
perforation near her anastomosis of her colon. She was
stable at that time and it was decided that she could be
watched with conservative management.
Her antibiotics were widened. Her white count was slowly
increased and on [**2161-11-21**] it was 20.7. She was followed
very closely by the Surgical Service and Urology was also
consulted for the evaluation of left hydronephrosis which was
noted on CT scan. It was decided at that time that the
patient would be followed for that.
On [**2161-11-21**], in the evening, the patient was noted to have
increasing abdominal pain and temperature to 101.5. On exam
by the Surgical Service, it was noted that she had feculent
material coming out of her Foley catheter and a colovesicular
fistula was diagnosed. A three way Foley was placed and
Urology continues to follow.
It was decided that Urology would not operate on the patient
unless a full exploration by the General Surgery Service was
done and at that time colovesicular fistula could be
evaluated.
She continued to have increasing abdominal pain with
increasing white count and on [**2161-11-22**], it was decided that
the patient should go to the Operating Room for a diverting
loop transverse colostomy.
The patient was taken to the Operating Room where an
exploratory laparotomy, lysis of adhesions and loop colostomy
was performed. She did well postoperatively, however, her
blood pressure was quite labile and she had a temperature
spike to 103.2 and was hypotensive. Therefore, it was
decided that she would be transferred to the Intensive Care
Unit for a closer monitoring.
In the Intensive Care Unit, she slowly improved with widened
antibiotics and Neo-Synephrine was used for blood pressure
support, however, it was able to be weaned off after initial
episodes of hypotension. She was continued on Vancomycin,
Levofloxacin and Flagyl for both Methicillin resistant
Staphylococcus aureus as well as for her colovesicular
fistula.
The patient's Neo-Synephrine requirement slowly weaned and
pain medication was found to be very effective on this
patient, however, it would cause hypotension. Therefore,
pain medication was slowly titrated to an adequate amount of
pain control, however, without the side effect of
hypotension.
The patient was started on TPN for nutritional support
through her long Intensive Care Unit stay and did turn p.o.
status. She had significant dilated loops of bowel
intraoperatively as well as postoperatively and was required
on significant fluid volume. TPN was brought to goal and the
patient tolerated the procedure well. A PIC line was placed
for long term TPN and for access purposes.
On postoperative day #6, the patient was transferred to the
Floor. She was started on continuous bladder irrigation at a
very slow rate and this was found to help clear the feculent
material from the bladder and her blood pressure slowly
resolved. Her temperature curve came down. Her white count
stayed elevated for a significant time before returning to
normal prior to discharge.
She was slowly started on sips which she tolerated, however,
when she had been advanced to a full diet, she began having
episodes of emesis and was made NPO. A repeat KUB at the
time showed dilated loops of small bowel and it was decided
that she would be made NPO.
Physical Therapy was also consulted when the patient arrived
on the floor for strengthened ambulation due to her prolonged
Intensive Care Unit stay as well as her decreased nutritional
status. Physical Therapy felt that the patient would achieve
optimal health with the short term rehabilitation stay prior
to being able to go home.
The patient continued to have continuous bladder irrigation
and a Foley catheter was used to flush the distal aspect of
the colon. At that time a significant amount of stool was
removed from the distal colon and postoperatively, two days
after that, the distal aspect of the diverting loop colostomy
was closed using chromic stitches at the bed side. The
patient tolerated the procedure well and the output of the
colovesicular fistula reduced.
At that time, it was decided that the continuous bladder
irrigations could be stopped and the patient continued to put
out clear urine through her Foley. Therefore, it was decided
that the Foley catheter would be removed and the patient was
monitored from that point. The patient was able to void
adequately in spite of having the colovesicular fistula after
closure of the diverting loop colostomy distal end.
On postoperative day #12, the patient's staples were removed
and the right nephrostomy tube was changed as per planned
change from six months status. Urology was following for
that purpose. The patient's antibiotics were
.................... The Vanco was stopped after Methicillin
resistant Staphylococcus aureus was not identified in the
urine and Flagyl was stopped after cultures were negative for
anaerobes. It was decided that the Levofloxacin would be
continued for 21 days, a complete three week course. The
patient took all 21 days prior to discharge.
The patient's nasogastric tube was removed postoperatively
after the ileus ................... resolved and the patient
was slowly advanced on her diet which she tolerated.
Nutrition was following for calorie counts at the time of
discharge to assess nutritional requirements as well as
whether or not the patient could meet her nutritional needs.
The patient was on a full regular diet at the time of
discharge.
Her TPN was cycled in order to increase the amount of time
she would be without infusion and the patient tolerated this
well. It was achieved that the patient could take a liter of
TPN with near goal amino acids at night over a 12 hour time
frame and have it weaned off in the morning, therefore,
allowing the patient to be able to eat throughout the day.
The patient did well and was found to have a stable TPN order
for the last multiple days with normal chemistries.
The patient's white count, as stated before, returned to
[**Location 213**], the last one being 10.1 prior to discharge. Her
chemistries all returned back to her baseline with a BUN of
38 and a creatinine of 1.3.
The patient, at this time, is deemed for rehabilitation and
planned for placement at an acute care level of
rehabilitation where TPN could be continued. The patient
continued to improve.
The patient had calorie count which were done, however, for
two of the three days, the patient was kept NPO for
procedures, therefore, the calorie counts were continued
until this time as an adequate and correct count could be
done.
DISCHARGE DIAGNOSIS: The patient is discharged to a
rehabilitation facility at this time with the discharging
diagnosis of:
1. Colovesicular fistula, status post exploratory laparotomy
and diverting loop colostomy.
MEDICATIONS: Her discharge medications include:
1. ................... 25 mg p.o. q d.
2. Diphenhydramine 25 mg p.o. intravenous q 6 prn.
3. Miconazole powder applied to the affect area.
4. Neurontin, which is unchanged, 300 mg p.o. t.i.d. and 600
q hs.
5. She is also kept on Insulin sliding scale for her TPN
coverage and her blood sugars were well controlled with that.
6. She also had Sarna Lotion placed in the affected areas
b.i.d.
7. Heparin subcutaneously 5,000 units b.i.d.
8. TPN per her order sheet and plan to have TPN labs checked
twice weekly until completely stable.
She had ostomy care done and was planned to be continued at
her rehabilitation facility and also her right nephrostomy
tube will be left to gravity through this time in order to
have adequate drainage of her right kidney.
DIET: The patient was discharged on a regular diet with
Boost supplementation at this time. She was instructed to
follow up with her Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on an as
needed basis.
The patient is discharged to a rehabilitation facility at
this time. The discharge date is not set yet and is pending
bed availability. The date of this dictation is [**2161-12-10**].
She is discharged in the rehabilitation facility in stable
condition at this time. The date of this dictation is
[**2161-12-10**]. The date of actual discharge is still pending
bed availability. Please see Addendum for the actual date.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 11126**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2161-12-10**] 13:03
T: [**2161-12-10**] 13:20
JOB#: [**Job Number 95927**]
Admission Date: [**2161-11-20**] Discharge Date: [**2161-12-16**]
Date of Birth: [**2084-1-12**] Sex: F
Service: GENERAL SURGERY HEPATOBILIARY/GOLD SURGERY
ADDENDUM: Please see previous discharge summary for
description of hospital course.
The patient had a PICC line and new nephrostomy tube placed
on postoperative day number 23 and 22 respectively and the
patient was stable on her total parenteral nutrition dose as
well as tolerating a regular diet and she was accepted to a
rehab facility Mt. [**Hospital 13247**] Rehab and was discharged to that
rehab facility on [**2161-12-16**] postoperative day number four.
The patient was doing well. Her discharge medications had
not changed and the patient was discharged to rehab in stable
condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 11126**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2161-12-16**] 06:02
T: [**2161-12-16**] 06:08
JOB#: [**Job Number **]
|
[
"998.59",
"596.1",
"038.9",
"593.5",
"780.39",
"997.4",
"591",
"560.1",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"46.03",
"55.93"
] |
icd9pcs
|
[
[
[]
]
] |
9255, 12243
|
2253, 9233
|
1436, 2235
|
263, 969
|
992, 1374
|
1391, 1420
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,989
| 128,312
|
7081
|
Discharge summary
|
report
|
Admission Date: [**2147-5-22**] Discharge Date: [**2147-5-30**]
Date of Birth: [**2104-8-20**] Sex: M
Service: MEDICINE
Allergies:
Niaspan Starter Pack
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Palpitations / Chest Pressure
Major Surgical or Invasive Procedure:
Ventricular Tachycardia Ablation by Electrophysiology.
History of Present Illness:
42 yo M with h/o CAD, MI at age 20, s/p CABG and PCI, ischemic
cardiomyopathy with EF of 30% s/p [**Hospital 26418**] transferred from [**Hospital 6451**] with slow VT (120s). Patient has had a 1-1.5 month
history of intermittent episodes of chest pressure and left
sided sharp chest pain that radiates to the left arm. He had
associated diaphoresis, n/v, without SOB. On the day of
admission to [**Hospital3 **] ([**2147-5-20**]) he woke up with 6/10 sharp
L-sided chest pain radiating to the left arm and other symptoms
as described above. He could not get off of the couch for an
hour and was scared so he called EMS. He said these episodes
were similar to episodic VT episodes he had in the past. Of
note, they are different from his Anginal pain and MI symptoms
in the past which were substernal chest pressure with numbness
down the whole left side of his body and sever diaphoresis. He
presented to [**Hospital3 **] where he was initially started on
lidocaine drip and also received IV amiodarone. Cardiac enzymes
were flat. While on telemetry at [**Hospital3 **] the patient was noted
to have multiple episodes of slow VT associated with
light-headedness and diaphoresis. There were at least 4 episodes
that lasted approximately 5 minutes and ended spontaneously.
Valsalva maneuvers were attempted with no effect. The patient
reports similar episodes for last month. Cardiology at [**Hospital3 **]
saw the patient and recommended stopping lidocaine and
amiodarone. He is transferred on po mexiletine, metoprolol, and
sotalol.
.
On arrival to the floor, patient is currently asymptomatic. He
denies chest pain, shortness of breath, nausea. While in the
PACU he had sustained VT after endocardial VT ablation coming to
the unit overnight for monitoring. He was given Quinidine, and
mexilitine as it was deemed he failed his sotalol therapy. one
amp of lidocaine, which helped break the VT and was in sinus
rhythm at the time of transfer.
.
REVIEW OF SYSTEMS
(+) lower back pain, R knee pain -- both chronic
On review of systems, 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 dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2142-3-7**] anatomy as follows: LIMA->LAD, SVG->Diagonal,
SVG-> Posterolateral branch of RCA.
-PERCUTANEOUS CORONARY INTERVENTIONS: Percutaneous coronary
intervention, s/p multiple RCA stents (at least 5) AND s/p PDA
angioplasty x2 and cypher stenting [**2139**]
-PACING/ICD: St. [**Hospital 923**] Medical ICD, Atlas II VR V-168, in [**11-12**]
for NSVT and systolic CHF - EF 30%.
3. OTHER PAST MEDICAL HISTORY:
# GERD
# h/o drug seeking behavior
# Chronic back pain
# Anxiety with panic attacks/PTSD from repeated ICD firing
# ADHD
# Hypertension
# Dyslipidemia
Social History:
He smokes [**3-16**] cigarettes per day currently, but has a 80
pack-year history. [**2-12**] alcohol drinks on special occasions;
denies heavy alcohol use. Denies illicit drug use ever. He lives
alone near his sister and brother. Used to live in [**Hospital1 **] with
his mom who passed away of breast cancer.
Family History:
His father had a CABG x 3; Mother with myocardial infarction at
57 yo s/p PCI, and had diabetes and breast cancer.
Physical Exam:
ADMISSION EXAM
VS: T= 97.9 BP= 135/81 HR= 52 RR= 18 O2 sat= 99% on RA
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVD 6cm, no carotid bruits.
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: Resp were unlabored, no accessory muscle use. CTAB
anteriorly and best as I could hear posteriorly although patient
was supine secondary to, no crackles, wheezes or rhonchi.
ABDOMEN: Large abdomen with +BS, Soft, NTND. No HSM or
tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP dopplerable PT dopplerable
Pertinent Results:
I. Labs
A. Admission
[**2147-5-22**] 05:45PM BLOOD WBC-5.2 RBC-4.86 Hgb-15.3 Hct-44.4 MCV-92
MCH-31.4 MCHC-34.4 RDW-15.5 Plt Ct-183
[**2147-5-22**] 05:45PM BLOOD PT-12.9 PTT-27.7 INR(PT)-1.1
[**2147-5-22**] 05:45PM BLOOD Glucose-130* UreaN-11 Creat-0.9 Na-138
K-4.5 Cl-106 HCO3-26 AnGap-11
[**2147-5-22**] 05:45PM BLOOD Calcium-9.3 Phos-3.7 Mg-1.8
B. Discharge
[**2147-5-30**] 06:35AM BLOOD WBC-7.1 RBC-4.90 Hgb-15.8 Hct-45.9 MCV-94
MCH-32.3* MCHC-34.5 RDW-14.8 Plt Ct-246
[**2147-5-30**] 06:35AM BLOOD Glucose-122* UreaN-17 Creat-1.0 Na-136
K-4.2 Cl-99 HCO3-27 AnGap-14
[**2147-5-30**] 06:35AM BLOOD Calcium-9.8 Phos-4.7* Mg-1.9
II. Cardiology
A. Admission ECG
Cardiology Report ECG Study Date of [**2147-5-22**] 12:22:04 PM
Sinus bradycardia. Consider inferior myocardial infarction of
indeterminate
age, although is non-diagnostic. Cannot exclude myocardial
ischemia. Clinical
correlation is suggested. Since the previous tracing of [**2147-4-23**]
accelerated
idioventricular rhythm with right bundle-branch block
configuration is now
absent.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
49 192 110 480/460 13 54 64
Brief Hospital Course:
42-year-old male with CAD s/p CABG and PCI, ischemic
cardiomyopathy with EF of 30% s/p [**Hospital 26418**] transferred from [**Hospital 6451**] with slow VT.
.
# Recurrent monomorphic ventricular tachycardia: Patient has had
symptoms for the past month that seem to be related to recurrent
VT. He is currently in sinus rhythm and bradycardic. There were
several episodes of slow vtach s/p endocardial ablation. He was
still having VT and came to the CCU for observation. His sotalol
was discontinued. He was started on quinidine with final dose of
648 mg PO TID. His mexilitine 300mg PO Q8H was decreased to
150mg PO Q8H in setting of QTc prolongation. He was started on
dabigatran 150mg [**Hospital1 **] to reduce thrombus risk however this was
discontinued. He had several episodes of slow VTach (HR low
100s) that broke with lopressor 5mg IV. He was discharged on
metoprolol succinate 150 mg PO qD in addition to magnesium. He
was considered for an another ablation by EP, but he had no
further episodes of ventricular tachycardia since [**2147-5-27**]. He
was monitored in the hospital with no further occurences and
discharged. He will follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
It would be appropriate at follow-up to assess if the patient
should continue to take ritalin with structural heart disease
and history of ventricular tachycardia.
# CORONARIES: Pt has known CAD with most recent catheterization
showing reocclusion of SVG, but patent LIMA to LAD. EKG without
dynamic ischemic changes and flat enzymes at OSH. He was
continued on ASA, plavix, imdur, simvastatin, and reduced dose
of metoprolol (150 mg PO qD) based on blood pressure and heart
rate.
# PUMP: No clinical signs of heart failure. Last documented EF
30% in [**2144**], however no ECHO for 3 years. He was continued on
toprol, lisinopril, spironolactone.
# GERD: Asymptomaic. Continued on ranitidine and prilosec.
.
# Chronic lower back pain: Continued on oxycontin 40mg PO Q12H
.
# HTN: Continued antihypertensives as above
.
# Dyslipidemia: continue simvastatin and fenofibrate.
# Transitions of care
- Follow-up with EP, consider uptitration of metoprolol
succinate and imdur to prior home dose
Medications on Admission:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO twice a day.
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID
7. mexiletine 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. sotalol 160 mg Tablet Sig: One (1) Tablet PO twice a day.
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO twice a day.
14. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
15. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day). Disp:*120 Tablet(s)* Refills:*2*
16. Fenofibrate 160 mg daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
12. quinidine gluconate 324 mg Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO TID (3 times a day).
Disp:*180 Tablet Extended Release(s)* Refills:*2*
13. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Ventricular Tachycardia
.
Secondary Diagnoses:
Coronary Artery Disease,
Hypertension
Chronic Systolic congestive Heart 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 an abnormal heart rhythm
called ventricular tachycardia. Changes were made to your
defibrillator and your medications to keep you out of this heart
rhythm. You also underwent an ablation procedure to help
prevent this rhythm. You have not had this rhythm for 72 hours
and we hope it doesn't come back.
.
The following changes were made to your medications:
-- STOP Sotalol and Sulcrafate
-- START quinidine gluconate 648 mg Three times a day to prevent
ventricular tachycardia
-- Decrease Mexilitine to 150 mg every 8 hours to prevent
ventricular tachycardia
-- DECREASE metoprolol succinate to 150 mg daily
-- Decrease Imdur to 30 mg daily for your heart arteries
-- Start magnesium oxide to keep your magnesium levels up
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
It was a pleasure taking care of you. Please make sure to
follow-up with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **]
Followup Instructions:
Name: Dr [**First Name8 (NamePattern2) 26317**] [**Last Name (NamePattern1) **]
Specialty: Primary Care
Location: [**Hospital **] MEDICAL GROUP
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 26328**]
Phone: [**Telephone/Fax (1) 26303**]
Appointment: [**6-9**] at 10am
Name: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty:CARDIAC SERVICES
Address: 15 [**Name (NI) **] Brothers [**Name (NI) **], [**Name (NI) **], [**Location (un) **], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 1536**]
When: [**6-22**] at 2:40pm
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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|
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|
319, 376
|
11190, 11190
|
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|
3412, 3724
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,329
| 189,105
|
49964
|
Discharge summary
|
report
|
Admission Date: [**2124-10-5**] Discharge Date: [**2124-10-8**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain, hypertensive emergency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
The patient is a 45 year old man with type I Diabetes Mellitis,
End stage renal disease on hemodialysis, who is presenting today
with chest pain and ekg changes in the setting of high blood
pressure while at hemodialysis. The chest pain occurred during
the third hour of hemodialyis, was stabbing in nature,
substernal without radiation, and associated with ST depressions
in V4-V6. His blood pressure at the time was 200/100.
.
On presentation to the ED the patient was placed on a nitro
drip. His blood pressure remained at 200/100 and his chest pain
persisted. He was also given morphine 8mg IV with minimal
relief. His first set of troponins are 0.15.
.
The patient had been discharged to a nursing home from the
hospital yesterday, after which he was hospitalized for chest
pain and ruled out for myocardial infarction. During this
hospitalization he was transferred to psychiatry for suicidal
ideation the day the primary team intended for discharge. He
was on the psychiatry service for 10 days awaiting placement.
During this time he had experienced labile blood pressures and
was eventually managed on valsartan 160mg, lisinopril 40mg,
carvedilol 25mg and nifedipine 60mg.
.
The patient was transferred from psychiatry to medicine after a
hypotensive episode which occurred after the patient was given
sublingual nitroglycerin for chest pain. He remained on the
medicine service for four days during which the only change to
his antihypertensives was decreasing nifedipine from 120mg to
60mg. He also had a history of being hypertensive after his
hemodialysis sessions.
.
On arrival to the CCU, patient had a BP of 201/105. Complained
of headache and chest pain. Regarding chest pain, it is
described as sharp without radiation to his back or arm or jaw.
The pain is worse when he moves his left arm and with chest
palpation. No sensation of pressure/chest tightness. Denies any
shortness of [**First Name3 (LF) 1440**]. No history of angina or MI. Reports
headache that has been going on all day. Located in bilateral
temporal regions with no radiation. Associated blurry vision.
Denies any LOC.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. Reports chest pain
(reproducible, sharp, non-radiating)
Past Medical History:
Past psychiatric history (per [**First Name3 (LF) **], since pt did not want to
discuss this):
-Dx: reported h/o depression. Also when suicidal has had
auditory hallucinations. None recently.
-Hospitalizations: multiple - denies any recent hospitalization
(last was in [**2112**] per pt).
-H/o multiple suicide attempts (4 per pt) via OD - per pt, last
SA was 7-8 years ago.
-Neuropsych testing ([**4-21**]) - "significant problems in
attention and executive functioning".
-Treaters: Has not seen one [**Month/Year (2) **] or psychiatrist for a
consistent period of time. Has counselor ([**Doctor First Name 892**]) [**Hospital1 104344**] who pt sees when he sees his PCP. [**Name10 (NameIs) **] seen [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) **] (psychologist) w/ the [**Last Name (NamePattern1) **] service a few times.
Of note, per [**Last Name (NamePattern1) **], recommendations have been repeatedly made for
him to see a psychiatrist as an integral part of his treatment
in
lieu of possible kidney [**Last Name (NamePattern1) **], but patient has not followed
through for unclear reasons. Of note, on his discharge from [**Hospital1 **]
several weeks ago ([**7-/2124**]), pt was supposed to follow up with
mental health at [**Hospital1 **] St.
-Med Trials: Pt states that he has tried antidepressants
for "years" but that they "do not work for me." Does not
remember
names. Per [**Hospital1 **] previous meds include: Remeron, Celexa, Doxepin,
and Klonopin. Pt was discharged from [**Hospital1 18**] in [**2124-7-17**] with
prescription for Celexa 20mg daily and Methylphenidate 5 mg PO
BID.
Past Medical History:
DM with ESRD on HD TuTHSa
Hypertension, poorly controlled
hx chronic L flank pain s/p extensive w/u (? diabetic thoracic
neuropathy)
Diverticulosis
CHF (diastolic dysfunction)
Foot ulcers
Esophagitis
gastroparesis
fibromyalgia
Allergies: NKDA
Social History:
Patient born in PR, reports moving to US in [**2093**]. Reports he has
4 children 2 girls, 2 boys, ages 23 to 10, wages/ social
security being decreased to pay for delinquent child support.
Divorced. Receives [**Year (4 digits) 31500**] for dm/esrd and ?of depression. Lives
alone with 1 cat. Graduated HS, used to work as janitorial
service employee, floor tech. Denies EtOH, tobacco or drug use.
Mother passed away 1 year ago. Failed attempt at renal
[**Year (4 digits) **] in PR earlier this year.
Family History:
Mother - depression per [**Name (NI) **], Diabetes in multiple relatives on
both sides
Physical Exam:
VS: T= BP=201/105 HR=81 RR= 13 O2 sat= 100% on 3L NC
GENERAL: somnolent, awakens to voice, answers questions, nodding
off during interview.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVP.
CARDIAC: PMI located in 6th intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1. Split S2. Diastolic
murmur best heard in the LUSB. No r/g. No thrills, lifts. No S3
or S4.
LUNGS: Bibasilar inspiratory crackles. Good respiratory effort.
No chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT [**Name (NI) **]
Pertinent Results:
[**2124-10-5**] 12:55PM PT-15.8* PTT-28.7 INR(PT)-1.4*
[**2124-10-5**] 12:55PM WBC-3.5* RBC-4.60 HGB-11.8* HCT-39.4* MCV-86
MCH-25.7* MCHC-30.0* RDW-18.3*
[**2124-10-5**] 12:55PM NEUTS-60.0 LYMPHS-26.9 MONOS-7.9 EOS-4.9*
BASOS-0.3
[**2124-10-5**] 12:55PM cTropnT-0.15*
[**2124-10-5**] 12:55PM CK(CPK)-79
[**2124-10-5**] 09:45PM CK-MB-NotDone cTropnT-0.15*
[**2124-10-5**] 09:45PM CK(CPK)-69
[**2124-10-5**] 12:55PM GLUCOSE-99 UREA N-22* CREAT-3.8*# SODIUM-135
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-31 ANION GAP-15
.
[**10-5**] CXR: There has been interval insertion of right subclavian
intravenous catheter, the tip within the mid superior vena cava.
There is no pneumothorax, pleural effusion or focal pulmonary
consolidation. Right mid lung linear atelectasis is noted. The
heart is enlarged. The aorta is normal in contour.
IMPRESSION:
Interval placement of right subclavian central venous catheter
without
evidence of pneumothorax. Right mid lung linear atelectasis.
Cardiomegaly.
.
[**10-6**] ECHO: The left atrium is mildly dilated. The estimated
right atrial pressure is 10-20mmHg. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is abnormal diastolic septal motion/position consistent
with right ventricular volume overload. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No significant aortic valve disease. Moderate to severe
tricuspid regurgitation with elevated right atrial pressures.
Compared with the prior study (images reviewed) of [**2123-6-30**],
right-sided pressures are higher and tricuspid regurgitation is
more severe, most consistent (in a [**Year (4 digits) 2286**] patient) with higher
volume status today.
Brief Hospital Course:
This is a 45 year old man with PMH significant for type I DM,
ESRD on hemodialysis, and labile blood pressure, presenting with
hypertensive emergency.
# Hypertensive emergency: The patient has history of labile
blood pressure with ranges 80-220 systolic. He has historically
been most hypertensive after [**Year (4 digits) 2286**]. On admission, he was
started on a labetolol drip. Pressures were reduced from 200s
to 170s within 30 minutes. Was then transitioned to PO
metoprolol with good BP control. EKG did not show any changes.
BP down to the 70's overnight- gave 250cc of fluids. Pressures
normalized to SBP in 120s. Pressures remained [**Last Name (un) 15970**] during
stay, especially after [**Last Name (un) 2286**]. Because of this, his home med
regimen was changed to carvedilol and lisinopril in AM and
carvedilol, valsartan and nifedipine in PM. Valsartan dose was
increased to 320mg daily, per renal recs. Patient educated on
importance of taking BP meds the day of [**Last Name (un) 2286**], something he
had not been doing in the past. Upon discharge, patient was
stable with SBP in 130s. Recommend outpatient workup for
secondary hypertension (pheochromocytoma, etc).
# Hypotension - Had two episodes of symptomatic hypotension
while in hospital. Experience lightheadedness and nausea. Was
given bolus of 250cc on [**10-6**] and 500cc on [**10-8**] with response
each time to SBP of 100s-110s. Most likely was related to
cumulative effect of his anti-hypertensives. Because of these,
his home BP medication regimen was altered to 2 drugs in the AM
and 3 in the PM.
# Long QT - Admission EKG showed QTc of 495. Patient has known
history of long QT. Drugs that prolong QT interval were avoided
(i.e- zofran or phenergan for nausea).
# Chest Pain: Patient presented with a stabbing chest pain that
worsened with movement of his left arm and with palpation of his
chest. Denied any chest pressure, radiation to jaw/arm or
shortness of [**Month/Year (2) 1440**]. Most likely was musculoskeletal in origin.
Outside EKG showed 0.5mm ST depressions in V4-V6- most likely
demand ischemia. Enzymes were trended with no signs of
ischemia/infarct. First set of troponins was .15, which is his
baseline. Upon discharge, patient denied any chest pain or
shortness of [**Month/Year (2) 1440**].
# Chronic Diastolic Heart Failure: LVEF over 60%. Remained
euvolemic without signs of heart failure while in hospital. We
continued valsartan and lisinopril. He also received labetolol
gtt and was transitioned to PO metoprolol. TTE showed moderate
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. No significant aortic
valve disease. Moderate to severe tricuspid regurgitation with
elevated right atrial pressures
#) ESRD on HD: His HD was continued on a Tuesday, Thursday,
Saturday schedule. His home sevelamer and calcium acetate were
continued.
#) Depression/SI: He was recently on the psychiatry service for
10 days. Trazodone was discontinued secondary to prolonged QT.
Methylphenidate was also discontinued.
He was restarted on celexa at 40mg. The patient did not have
suicidal thoughts this admission. He reports enjoying group
therapy sessions for his depression and would like to continue
these sessions.
#) Right foot wound- Received wound care while in hospital.
Recommend outpatient follow-up with podiatry.
#) DM: He takes 70/30 4 units at breakfast and 5 units at
dinner. He was also covered with a Humalog sliding scale.
#)Gastroparesis: Home metoclopramide and glycopyrrolate were
continued.
#)Flank pain: Chronic in nature, attributed to his diabetic
peripheral neuropathy. Home gabapentin, lidocaine patch, and
percocet were continued.
#)Erythromycin- Patient was on erythromycin on admission,
however it was unclear why he was on this medication. We looked
through his records and it was not evident when/why he was on
it. For this reason, we chose not to continue while in
hospital. PCP can decide on whether or not to resume the
medicine.
#) The patient was confirmed as full code during this admission.
Medications on Admission:
[**Month/Year (2) **] 325mg daily
Carvedilol 25mg PO QHS
Citalopram 40mg daily
Diphenhydramine 50mg PO Q predialysis
Docusate 100mg [**Hospital1 **]
Erythromycin 250mg TID
FeSO4 325mg PO TID
Gabapentin 300mg PO BID
Glycopyrrolate 1mg PO BID
Insulin SC [**Hospital1 **] and fixed Insulin 70/30 4 units qam, 5 units for
dinner.
Lisinopril 40mg daily
Lidocaine patch daily
Metoclopramide 5mg PO QIDACHS
Methylphenidate 5mg [**Hospital1 **]
Nifedipine CR 60mg
Nicotine gum
Oxycodone- Acetaminophen Q6PRN
Pantoprazole 40mg daily
Senna [**Hospital1 **] PRN
valsartan 160 QHS
Sevelamer 800 TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q
[**Hospital1 **] ().
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Glycopyrrolate 1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hrs
on/12 hrs off.
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
10. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QPM (once a day (in the evening)).
12. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for flank pain.
16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
17. Valsartan 320 mg Tablet Sig: One (1) Tablet PO qPM: one
tablet every evening.
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
19. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO twice a
day.
20. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: One (1) Subcutaneous twice a day: 4 units qAM
5 units with dinner.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) 1121**] - [**Location (un) 4310**]
Discharge Diagnosis:
Hypertensive emergency
Secondary diagnoses:
- DM1 x over 20 years
- ESRD, on HD T,Th,Sa at [**Location (un) **] [**Location (un) **]
- HTN, poorly controlled
- h/o chroninc L flank pain since [**2119**] with multiple admissions
and extensive work-up, possibly due to diabetic thoracic
polyneuropathy
- Diastolic CHF: LVEF >=60% by echo
- Esophagitis on EGD [**10-21**] with negative H. Pylori
- Gastroparesis
- Depression, prior SI and attempt (pill overdose)
- Fibromyaglia
- Adhesive capsulitis of left shoulder
- Mod-severe cognitive deficits per neuropsych testing in [**2121**]
- h/o R foot ulcer s/p R foot operation - bone excision
- h/o Cellulitis in right antecubital
Discharge Condition:
Stable, afebrile, ambulatory
Discharge Instructions:
You were admitted to the [**Hospital1 **] Hospital for
chest pain during [**Hospital1 2286**] associated with high blood pressures.
Your blood pressures have been difficult to control in the past
as well. Please follow the changes that have been made to your
home medication regimen in order to better control your blood
pressures.
The following changes have been made to your home medication
regimen:
-Your aspirin dose has been changed from 325mg to 81mg.
-Your carvedilol dose has been changed from 25mg at bedtime to
12.5mg twice daily.
-Your lisinopril dose of 40mg is to be taken in the morning
-Your valsartan dose was increased to 320mg daily
-Please take your medications before you go to [**Hospital1 2286**].
Please follow-up with all of your outpatient medical
[**Hospital1 4314**] listed below.
Please seek medical care if your experience any concerning
symptoms such as chest pain, shortness of [**Hospital1 1440**], headache,
dizziness, lightheadedness, or nausea.
Followup Instructions:
Please follow-up with all of your outpatient medical
[**Hospital1 4314**] listed below:
1. Provider: [**Name10 (NameIs) 8673**] [**Last Name (NamePattern4) 8674**], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2124-10-17**] 1:00
Completed by:[**2124-10-8**]
|
[
"428.0",
"585.6",
"357.2",
"458.9",
"250.41",
"250.81",
"428.32",
"729.1",
"707.14",
"296.80",
"536.3",
"583.81",
"403.01",
"250.61",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15698, 15799
|
9024, 13151
|
349, 364
|
16522, 16553
|
6661, 9001
|
17587, 17854
|
5535, 5623
|
13789, 15675
|
15820, 15844
|
13177, 13766
|
16577, 17564
|
5638, 6642
|
15865, 16501
|
275, 311
|
392, 3086
|
4756, 5001
|
5017, 5519
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,522
| 100,260
|
46629
|
Discharge summary
|
report
|
Admission Date: [**2152-9-10**] Discharge Date: [**2152-9-12**]
Date of Birth: [**2091-11-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
left hand numbness, neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 year old restrained driver S/P MVA [**2152-9-10**] was taken to
[**Hospital3 4107**] and transferred to [**Hospital1 18**] with C3-4 disc
protrusion. He complained of numbness in left hand and fingers
as well as neck pain and right shoulder pain. He was admitted
to the Trauma Service for further management.
Past Medical History:
Type II Diabetes
Hypercholesterolemia
Social History:
Tobacco ; none
ETOH : occasionally
Family History:
non contributory
Physical Exam:
Temp 98.8 HR 65 BP 173/79 RR 12 O2 sat 98%
HEENT NCAT conjunctiva pink, sclera anicteric, PERRLA
Neck some tenderness to palpation, collar in place
Chest clear, equal breath sounds, no deformity
COR RRR
Abd soft, non tender
Ext non tender, no lacerations, no edema
Pertinent Results:
[**2152-9-10**] 10:40AM PT-12.0 PTT-26.6 INR(PT)-1.0
[**2152-9-10**] 10:40AM PLT COUNT-234
[**2152-9-10**] 10:40AM NEUTS-69.3 LYMPHS-23.6 MONOS-4.8 EOS-1.7
BASOS-0.5
[**2152-9-10**] 10:40AM WBC-10.6 RBC-4.90 HGB-13.7* HCT-41.1 MCV-84
MCH-28.0 MCHC-33.5 RDW-14.5
[**2152-9-10**] 10:40AM GLUCOSE-93 UREA N-14 CREAT-0.8 SODIUM-141
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
[**2152-9-10**] Abdominal CT : . No acute intrathoracic, abdominal or
pelvic injury or evidence of
fracture.
2. Probable bilateral simple renal cysts.
3. Small paraesophageal hernia.
[**2152-9-10**] Head CT :1. No acute intracranial abnormality.
2. Fluid level in the left maxillary sinus may be related to
chronic sinus
disease. Limited evaluation of the facial bones demonstrates no
evidence of
fracture. However, clinical correlation is recommended to
evaluate for facial
trauma versus sinus disease.
NOTE AT ATTENDING REVIEW: The left maxillary sinus finding could
represent a
minor degree of mucosal thickening, although the complete
maxillary sinuses
were not imaged on this stud
[**2152-9-10**] C Spine CT : 1. No evidence of acute fracture or
malalignment.
2. Multilevel degenerative change, most evident at C3-4, where
there is a
moderate central disc protrusion causing indentation of the
anterior thecal sac and cord compression. Acuity of this finding
is unknown. In addition, there is ossification of the posterior
longitudinal ligament at C3. These findings may predispose the
patient to cord injury in the setting of trauma, and MRI is
recommended for further evaluation if clinically indicated.
[**2152-9-10**] MRI C Spine : Disc protrusion at C3-4, which has mass
effect on the ventral aspect of the cord. There is
artifactually-increased T2-signal in the cord,
without definitivee evidence of cord edema. While this could
represent an
acute disc herniation, an acute-on-chronic, or simply chronic
process are also
possible.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the TSICU and evaluated by the Trauma
Service and the Ortho/spine service. He remained hemodynamically
stable, his neck was stabilized with a cervical collar and
within 24 hours his left hsnd paresthesias resolved.
He underwent an MRI of the C spine which showed a C3-4 disc
protrusion with no evidence of cord edema. This could be acute,
acute on chronic or just a chronic finding. As his physical
exam improved he was transferred out of the ICU and was up and
ambulating on the surgical floor with a cervical collar in
place.
His blood sugars were checked QID however he was not placed on
his routine Janumet as his sugars were in the 100-130 range. He
will continue to check his sugars at home, record them and call
his endocrinologist tomorrow for further management.
After follow up by the ortho/spine service he was cleared for
discharge with instructions to wear his cervical collar at all
times except for showers and follow up with Dr. [**Last Name (STitle) 1007**] in 2
weeks.
At the time of discharge he was up and ambulating without
difficulty, tolerating a diabetic diet and his pain was
controlled with Ibuprofen. He was placed on Prilosec for use
during his therapy with Ibuprofen.
Medications on Admission:
Janumet 50/1000 mg Po QAM
Janumet 50/500mg PO QPM
Zocor 20mg PO Daily
ASA 81 mg po Daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache, fever.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Janumet 50-1,000 mg Tablet Sig: One (1) Tablet PO QAM.
6. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
MVA with C3-4 protrusion with cord indentation/compression
Type II Diabetes
Discharge Condition:
stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
* Check your blood sugar three times a day and record. Call
your endocrinologist tomorrow with most recent blood sugars to
discuss resuming Janumet.
* continue to wear cervical collar at all times until seen by
Dr. [**Last Name (STitle) 1007**]. You may remove it for showers only.
*No driving until cleared by Dr. [**Last Name (STitle) 1007**]
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Call Dr. [**Last Name (STitle) 1007**] [**Telephone/Fax (1) 1228**] for a follow up appointment in 2
weeks
Call Dr. [**Last Name (STitle) 10543**] at [**Telephone/Fax (1) 4475**] for a follow up appointment in 2
weeks
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2152-9-12**]
|
[
"272.0",
"250.00",
"782.0",
"E812.0",
"839.08",
"E849.5",
"V58.67",
"784.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.17",
"88.93"
] |
icd9pcs
|
[
[
[]
]
] |
5162, 5168
|
3111, 4358
|
344, 351
|
5288, 5297
|
1141, 3088
|
6252, 6609
|
823, 841
|
4497, 5139
|
5189, 5267
|
4384, 4474
|
5321, 6229
|
856, 1122
|
275, 306
|
379, 694
|
716, 755
|
771, 807
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,420
| 105,646
|
30869
|
Discharge summary
|
report
|
Admission Date: [**2138-5-28**] Discharge Date: [**2138-6-4**]
Date of Birth: [**2069-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
transferred from OSH after airway compromise following CABG
[**2138-5-11**] for eval of TBM seen on bronchoscopy.
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
68 yo male s/p CABG [**2138-5-11**] c/b inominate artery compromise.
Post op had airway compromise and bronch revealed
TBM-transferred for eval.
Past Medical History:
PAST MEDICAL HISTORY:
CRI, baseline Cr 1.2
Diabetes with peripheral neuropathy.
paroxysmal A-fib on coumadin
H/O multiple myeloma(Dr. [**Last Name (STitle) 66059**], last chemo 3 weeks ago); ?left
femur
hypertension
CAD-stentx2 [**2135**]
Social History:
smoke [**1-21**] ppd for 30-40 years, quit 20 y ago, used to drink but
quit in his 30s. Was in the navy once, then became meat cutter.
now retired. no drug use. currently lives with wife.
Family History:
CAD in family
Physical Exam:
PHYSICAL EXAMINATION:
T96.9 P87 BP107/44 R18 97% 4L
Gen- pleasant Caucasian male in no apparent distress
HEENT- anicteric, PERRLA, moist mucus membrane, normal
oropharynx, neck supple
CV- regular, no r/m/g
RESP- clear bilaterally(anterior)
ABDOMEN- soft, nontender, nondistended
EXT- no edema
NEUROLOGICAL:
.
Mental status: AAOx2. He thinks that this is [**2108**]. Able to say
month of year forward but not backward. Comprehension intact;
follows commands. Speech fluent. Normal affect.
.
Cranial Nerves:
I: Not tested
II: PERRL, 2->1 mm
III, IV, VI: EOMI
V: Facial sensation intact and symmetric to PP, LT.
VII: Face symmetric with intact strength.
VIII: Hearing intact bilaterally to finger rub
IX, X: Palatal elevation symmetric
[**Doctor First Name 81**]: SCM, trapezius strength intact
XII: Tongue midline without fasciculations
.
Motor: Normal bulk. No pronator drift.
.
Delt Tri [**Hospital1 **] WE FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
RT: 5 4 5 5 5 5 5 5 5 5 5 5 5
LEFT: 5 4 5 5 5 5 5 4 4 5 5 5 5
.
Sensation: decreased sensation in lower extremities bilaterally
up to level of ankle, decreased proprioception in lower
extremity, normal sensation and proprioception in upper
extremity
.
Reflexes: Bic T Br Pa Ac
Right 0 0 0 0 0
Left 0 0 0 0 0
Toes equivocal
.
Coordination: FNF, H->S intact
.
Gait: Deferred because patient is very afraid to stand.
.
Pertinent Results:
CT trachea
1. No evidence of tracheobronchomalacia or stenosis.
2. Findings that may be consistent with recent median sternotomy
and thoracic surgery if sternotomy was performed within the past
15 days. Please correlate with time of surgical procedure.
3. Several slightly enlarged mediastinal nodes which are likely
hyperplastic but could be followed to ensure resolution or
stability if warranted clinically.
4. Bilateral small pleural effusions with likely lower lobe
atelectasis.
5. Splenic hypodensity which could represent a hemangioma or
possibly an infarct. Consider ultrasound for further
characterization, if warranted clinically.
[**2138-5-30**]: ECHO
Conclusions:
Technically suboptimal study due to poor image quality.
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 and free wall motion
are normal. The
aortic valve is not well seen, but Doppler does not suggeste
aortic stenosis.
No aortic regurgitation is seen. The mitral valve is not well
seen. No
definite mitral regurgitation is seen. The pulmonary artery
systolic pressure
could not be determined. No pericardial effusion is seen.
Brief Hospital Course:
Pt was admitted to the ICU from OSH after reportedly suffering
V-fib arrests prior to transfer. Once stabilized, pt underwent a
bronchoscopy [**2138-5-29**] that showed no evidence of TBM. CTA
confirmed no TBM. transferred from ICU on HD #3. Evaluated by
neurology for autonomic dysfxn. Recommended Tilt table and other
recommendations: Evidence of autonomomic dysfunction on formal
testing (full report to follow). Pt. had labile blood
pressures,
which if sustained, may cause symptoms of orthostatic
intolerance. Autonomic dysfunction may be secondary to DM
and/or
multiple myeloma. With regards to his neuropathy, this may be
related to DM, multiple myeloma, and/or Velcade.
Treatment recommendations:
For treatment we recommend ample hydration and salt intake.
Generally, we recommend 2L of fluid and 10gm of salt per day.
Given his recent cardiac history, this may not be possible to
achieve, but maximize therapy as can be tolerated. Avoid
medications that may worsen orthostatic hypotension.
Deconditioning will also contribute to this problem and we
recommend physical therapy as tolerated. Light compression
stockings and an abdominal binder may help prior to physical
therapy. It may be necessary to avoid heavy compression given
his diabetic neuropathy. If he remains orthostatic and is
unable
to tolerate physical therapy, it may be necessary to start low
dose midodrine, 2.5mg at 7am, noon, and 4pm. This can be
titrated up as needed by 2.5mg per dose. As it may contribute
to
supine hypertension, it should not be given after 4pm or prior
to
the patient lying supine. Another option would be to dose
midodrine prior to physical therapy. If midodrine is started,
it
would be best to check orthostatic blood pressures 1/2 hour
before the dose, and [**1-21**] after the dose.
Medications on Admission:
NPH 48units QAM, 20units Q10pm; Novolog 12units QAM, 20units
Q5pm; Coumadin 7.5mg QHS -Patient and wife deny that pt is
taking coumadin. I have called his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 73038**]-awaiting call back.
Tricor 160'
Metoprolol 50"
ASA 81'
Temazepam 30 QHS PRN
Procrit PRN
Velcade? (Chemo Every other week)
Zometta?
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. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. NPH insulin
48 units sq aqm, 20units q10pm
8. novolog
12 units qam, 20 nuits q5pm
9. finger stick
ac and qhs
Discharge Disposition:
Extended Care
Facility:
Rehab Hospital of [**Doctor Last Name **]
Discharge Diagnosis:
autonomic dysfunction
Discharge Condition:
deconditioned
Discharge Instructions:
Follow up with your primary care doctor and cardiologist after
you leave rehab. for medication review.
Followup Instructions:
Follow up your cardiologist and your primary care doctor after
you leave rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2138-6-4**]
|
[
"V45.81",
"410.71",
"V58.61",
"362.01",
"250.60",
"585.9",
"337.9",
"428.0",
"357.2",
"203.00",
"403.90",
"427.31",
"250.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6776, 6844
|
3887, 5688
|
433, 448
|
6910, 6926
|
2531, 3864
|
7077, 7278
|
1106, 1121
|
6119, 6753
|
6865, 6889
|
5714, 6096
|
6950, 7054
|
1136, 1136
|
1158, 1445
|
280, 395
|
476, 622
|
1642, 2512
|
1460, 1626
|
666, 885
|
901, 1090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,770
| 186,640
|
9761
|
Discharge summary
|
report
|
Admission Date: [**2146-10-10**] Discharge Date: [**2146-10-17**]
Date of Birth: [**2066-7-17**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
Tracheostomy
History of Present Illness:
Mr. [**Known lastname 32913**] is an 80 yo M with h/o recent ex lap with repair of
bile leak/duodenal enterotomy now with PEG tube and several
percutaneous biliary drains who presented from rehab with
tachypnea and respiratory distress. Before arrival, EMS placed
him on BiPAP.
According to the rehab note, patient was getting chest therapy
at nursing home, and during this he became acutely short of
breath. Also, he had altered mental status today worse than
baseline.
In the ED, he continued to be tachypneic but was unable to
answer further history questions. His ABG showed respiratory
acidosis so he was intubated. After intubation, he became
hypotensive with pressures nadiring at 67/37. He was started on
norepinephrine for this hypotension and right IJ CVL was placed.
Because of concern for sepsis, he underwent CT C/A/P which
showed left lower lobe collapse and no acute intra-abdominal
process. His vital signs prior to transfer were 119 129/68 22
100%, CMV fi02 100%, Vt 460, RR 22, PEEP 5.
On arrival to the MICU, he is intubated and sedated. He does
not grimace to abdominal exam. He was suctioned for large
amounts of mucus.
Review of systems:
unable to obtain
Past Medical History:
Medical History: HTN, prostate CA, duodenal ulcer
Surgical History: lap cholecystectomy c/b bile leak and
duodenal injury, B II recontruction, prostatectomy with
bilateral
inguinal node dissection, lateral duodenostomy tube, [**Name (NI) 32914**],
PTBD, feeding jejunostomy tube
Social History:
He lives in a long term care facility. He does not drink
alcohol, and has not smoked for 20 years.
Family History:
Non-contributory
Physical Exam:
ADMIT:
Vitals: T: 98.8, BP: 111/36, P: 125, R: 22, O2: 100% CMV
General: intubated, sedated, opens eyes to voice but does not
follow commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL but pupils
2 mm bilaterally
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: firm on the midline and left side with involuntary
muscle contraction, right side soft, non-distended, bowel sounds
present, no organomegaly
GU: foley
Ext: cool, well perfused, 2+ pulses DP and radial, no clubbing,
cyanosis or edema
Neuro: intubated, sedated, opens eyes to voice but does not
follow commands
Discharge:
General: trached, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, edentuolus,
PERRL
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: clear bilaterally
Abdomen: non-tender/distended. J tube present, as are JP [**Name (NI) 19843**],
along with biliary [**Name (NI) 19843**]
GU: foley
Ext: 2+ pulses DP and radial, no clubbing, cyanosis or edema
Neuro: following commands
Pertinent Results:
Admit labs:
[**2146-10-9**] 08:50PM LIPASE-39
[**2146-10-9**] 09:02PM freeCa-1.19
[**2146-10-9**] 09:02PM GLUCOSE-113* LACTATE-1.9 NA+-143 K+-4.5
CL--108 TCO2-28
[**2146-10-9**] 09:02PM TYPE-[**Last Name (un) **] PH-7.33* COMMENTS-GREEN TOP
[**2146-10-9**] 09:30PM URINE AMORPH-RARE
[**2146-10-9**] 09:30PM URINE HYALINE-34*
[**2146-10-9**] 09:30PM URINE RBC-12* WBC-76* BACTERIA-FEW YEAST-FEW
EPI-<1
[**2146-10-9**] 09:30PM URINE UHOLD-HOLD
[**2146-10-9**] 09:30PM URINE HOURS-RANDOM
[**2146-10-9**] 09:35PM PLT COUNT-906*
[**2146-10-9**] 09:35PM PLT COUNT-906*
[**2146-10-9**] 10:58PM O2 SAT-99
[**2146-10-9**] 10:58PM TYPE-ART TEMP-38.3 RATES-18/ TIDAL VOL-400
PEEP-5 O2-100 PO2-252* PCO2-69* PH-7.19* TOTAL CO2-28 BASE XS--3
AADO2-397 REQ O2-69 INTUBATED-INTUBATED
[**2146-10-10**] 03:00AM CORTISOL-23.9*
[**2146-10-10**] 03:00AM ALT(SGPT)-47* AST(SGOT)-42* LD(LDH)-206 ALK
PHOS-579* TOT BILI-0.6
[**2146-10-10**] 03:00AM ALT(SGPT)-47* AST(SGOT)-42* LD(LDH)-206 ALK
PHOS-579* TOT BILI-0.6
[**2146-10-10**] 03:50AM FIBRINOGE-324
[**2146-10-10**] 03:50AM FIBRINOGE-324
Discharge labs:
[**2146-10-17**] 03:56AM BLOOD WBC-10.3 RBC-2.70* Hgb-8.4* Hct-25.9*
MCV-96 MCH-31.1 MCHC-32.5 RDW-14.2 Plt Ct-656*
[**2146-10-17**] 03:56AM BLOOD Glucose-104* UreaN-32* Creat-1.3* Na-142
K-4.3 Cl-108 HCO3-28 AnGap-10
[**2146-10-17**] 03:56AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1
CT ABD & PELVIS WITH CONTRAST Study Date of [**2146-10-9**] 9:53 PM
IMPRESSION:
1. Bilateral lower lobe pneumonia, with necrotic consolidation
of the left lower lobe, and fluid versus soft tissue attenuation
of the left lower lobe bronchus. This may represent mucus
plugging, or an obstructive lesion. There is marked mediastinal
lymph node enlargement in all visualized stations.
2. Small bilateral non-hemorrhagic pleural effusions.
3. Calcified pleural plaques reflect prior asbestos exposure.
4. Multiple abdominal drains, with no residual fluid collection
or acute
intra-abdominal pathology noted.
[**2146-10-15**] Change of drains
IMPRESSION:
Successful exchange and repositioning of a 10 French PTBD,
internal/external [**Month/Day/Year 19843**].
[**2146-10-16**] Chest X-ray:
IMPRESSION:
1. Left subclavian PICC line and tracheostomy tube remain in
satisfactory
position. Overall, cardiac and mediastinal contour is difficult
to assess
given patient rotation on the current examination. There
continues to be
bilateral patchy airspace opacities with a more confluent
opacity at the left base, which may reflect multifocal
pneumonia. An element of superimposed edema cannot be entirely
excluded as the pulmonary vasculature appears somewhat
indistinct. There is a layering left effusion and a smaller
right effusion. No pneumothorax.
Brief Hospital Course:
80 yo M with recent ex lap with repair of bile leak/enterotomy
and placement of PTCB and PEG tube who presented from rehab with
hypercarbic respiratory failure and altered mental status.
.
# Hypercarbic respiratory failure/septic shock: CT compatible
with necrotizing pneumonia, enterobacter growing from the sputum
as well as MRSA. Due to witnessed aspiration event at rehab.
Low compliance/high resistance on the vent. Started on
vanc/zosyn for HCAP coverage now switched to vanc/cefepime and
transiently on pressors. Pt underwent tracheostomy on [**10-14**].
Patient will go out on ID recommendations vanco for 21 days and
cefepime for a total of 8 days. The patient should have weekly
Chem7, vancomycin troughs, CBC, LFTs.
.
# Hypernatremia: Given free water replacement with D5W and
corrected quickly.
.
# Eosinophilia: Was up to 5.3% of 6.8 wbc. Question remained as
to if this is medication-related due to zosyn, so this was
exchanged for cefepime on [**10-15**].
.
# Recent bile leak s/p surgery: PTBD (percutaneous biliary [**Month/Year (2) 19843**]
and JP [**Month/Year (2) 19843**] also in place) replaced by IR [**2146-10-15**] with
improvement in alkaline phosphotase today. Surgery team
continued to follow with no additional recommendations.
# CKD: His admission Cr is 1.3 which is at his recent baseline
1.4
# Nutrition: Continued on TPN, as tube feeds not viable at this
time given aspiration occurred shortly after tubefeed
initiation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Carbidopa-Levodopa (25-100) 1 TAB PO TID
3. Pantoprazole 40 mg PO Q24H
4. Metoprolol Tartrate 25 mg PO TID
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Heparin 5000 UNIT SC TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Carbidopa-Levodopa (25-100) 1 TAB PO TID
3. Heparin 5000 UNIT SC TID
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
5. Aspirin 325 mg PO DAILY
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Metoprolol Tartrate 25 mg PO TID
8. Pantoprazole 40 mg PO Q24H
9. CefePIME 1 g IV Q12H
10. Vancomycin 1000 mg IV Q 24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
aspiration pneumonia
septic shock
Secondary:
Parkinson disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for aspiration pneumonia. You were
treated with antibiotics, and a tracheostomy was placed to
reduce risk of further complications.
You will continue the antibiotic vancomycin for a total of 3
weeks (until [**10-31**]). You will continue cefepime for one
more day after your discharge.
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Followup Instructions:
Please followup with your primary care physician regarding the
course of this hospitalization.
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2146-11-4**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"507.0",
"567.22",
"934.1",
"E878.6",
"403.90",
"V10.46",
"276.2",
"285.9",
"V15.82",
"E930.0",
"584.9",
"V44.1",
"288.3",
"997.49",
"038.9",
"276.0",
"785.52",
"998.59",
"332.0",
"482.42",
"518.81",
"482.83",
"995.92",
"585.9",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"31.1",
"97.05",
"99.15",
"33.24",
"96.72",
"38.91",
"38.97",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8194, 8265
|
5982, 7443
|
311, 325
|
8381, 8381
|
3204, 4307
|
9097, 9521
|
1982, 2000
|
7797, 8171
|
8286, 8360
|
7469, 7774
|
8561, 9074
|
4323, 5959
|
2015, 3185
|
1526, 1545
|
262, 273
|
353, 1507
|
8396, 8537
|
1567, 1849
|
1865, 1966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,633
| 174,576
|
30113
|
Discharge summary
|
report
|
Admission Date: [**2114-4-11**] Discharge Date: [**2114-4-30**]
Date of Birth: [**2046-12-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Lower Extremity Edema
Major Surgical or Invasive Procedure:
IVC Filter Placement
Upper Endoscopy
History of Present Illness:
67 year old man with PMH of DM, HTN, and recently diagnosed
adenocarcinoma who presents with leg swelling to the ED. He
reports that he was in his usual state of health until [**3-23**],
when he fell and hit his head in a [**Company 39532**] in [**State 26110**]. He got
a CTA for syncope and a mass was found in his pancrease with
similar liver masses. Biopsy showed moderate to poorly
differentiated adenocarcinoma, consistent with upper GI origin.
His children all live in [**Last Name (LF) 86**], [**First Name3 (LF) **] he decided to come here for
treatment. He reports that they went to [**Hospital1 2025**] straight from the
airport, but for unclear reasons then decided to come to the
[**Hospital1 18**] instead.
In the ED, he was complaining of LE edema over the last few
weeks. He was evaluated and found to have a HCT of 30 from 41.5
on [**2114-4-5**] and tachycardia, but otherwise his vitals were normal.
He had guaiac positive stool and repeat hct went to 26, so he
was admitted to the ICU and GI was contact[**Name (NI) **] who agreed to scope
in the morning.
ROS: He complains of [**5-10**] abdominal pain in the RLQ worse with
cough that is occasionally productive. He has also been somewhat
more fatigued over the last few weeks. He denies any shortness
of breath, chest pain, fever, chills, nausea, vomiting,
lightheadedness, diarrhea.
Past Medical History:
DM type 2 since [**2098**]
HTN
LE edema
recent diagnosis of adenocarcinoma, with liver mets
hyperlipidemia
possible h/o hypothyroidism
colon polyps removed in [**2110**]
pancreatitis with elevated triglyceridemia in [**2108**]
depression
erectile dysfunction
Social History:
Lived in [**State 26110**] until yesterday, alone. Divorced with many
chilren in [**Location (un) 86**]. 20 pack year smoking history, quit 25 years
ago. Denies alcohol or other drug use.
Family History:
Father and mother died of CAD in their 80's. 1 brother with
alcoholic cirrhosis, other two brothers healthy.
Physical Exam:
PE: T99.1 BP 123/60 P122 R32 96% 2LNC
HEENT: PERRLA, OP clear, MMM
RESP: clear bilaterally, with cough with inspiration
CV: tachycardic, nl s1s2 no M
Abd: soft, slight nonspecific TTP diffusely
Ext: 3+ pedal edema bilaterally - 2+ in legs
Neuro: CN 2-12 intact, str [**5-5**] UE and LE. Oriented x 2 - to self
and [**Hospital1 **], but not date. Slightly slowed speech
Pertinent Results:
Laboratory studies on admission:
[**2114-4-11**]
CK-MB-NotDone cTropnT-0.01
ALT-42* AST-62* CK(CPK)-16* AlkPhos-425* Amylase-15 TotBili-1.8*
ALT-33 AST-73* AlkPhos-263* TotBili-4.1*
Glucose-474* UreaN-46* Creat-1.1 Na-131* K-5.6* Cl-92* HCO3-26
PT-13.0 PTT-24.3 INR(PT)-1.1
WBC-11.5* RBC-3.31* Hgb-9.3* Hct-30.2* MCV-91 MCH-28.2
MCHC-30.9* RDW-17.3* Plt Ct-170
Other laboratory studies:
[**2114-4-14**]
CEA-279* PSA-0.8 CA [**25**]-9 [**Numeric Identifier 71783**]
Radiology outside hospital ([**2114-3-23**])
CT head - no enhancing masses
CT pancreas: 2/8x2/3 rounded solid lesion in the tail of the
pancreas, highly suspicious for malignancy. Liver hypodensities.
No adenopathy
Bone scan- no osseous metastatic disease
Radiology [**Hospital1 18**]
[**4-12**] Chest CT: Evaluation for pulmonary embolism is slightly
limited due to non-optimal timing of contrast bolus, however,
the main and subsegmental branches of the pulmonary vessels
appear patent without filling defects bilaterally. A 3.5 mm
pulmonary nodule was noted within the right upper lobe with an
additional 1-2 mm pulmonary nodule was noted within the right
middle lobe (2:27, 30). A slightly likely calcified nodule is
identified more medially within the right middle lobe (2:27)
likely representing calcified granuloma. A 3-mm nodule was noted
along the major fissure in the left lobe (2:33) with an
additional 2-3 mm nodules noted more posteriorly within the left
lower lobe (2:33,37). There are areas of bilateral dependent and
subsegmental atelectasis within the lower lobes with no enlarged
pericardial or pleural effusion identified. No pathologically
enlarged axillary, hilar, or mediastinal lymph nodes are
identified. There are calcifications noted within the LAD and
circumflex vessels.
[**4-12**] CT abdomen/pelvis: There is diffusely infiltrating
hypoattenuating liver lesions consistent with extensive
metastatic disease. No intrahepatic biliary dilatation is
identified in the portal and hepatic veins appear patent. A 2.6
x 2.8 cm hypoattenuating pancreatic tail mass is identified with
a probable necrotic center just adjacent to the splenic hilum.
Remaining pancreatic parenchyma appears unremarkable. There is
no pancreatic ductal dilatation. A small splenule is noted
adjacent to a normal appearing spleen. Multiple collateral
vessels and gastric varices are noted throughout the abdomen
related to thrombosis noted within the distal splenic vein with
patent splenic hilum vessels and recanalization more proximally.
The stomach, intraabdominal bowel, adrenal glands, and kidneys
appear otherwise unremarkable. There is a slightly prominent
retroperitoneal lymphadenopathy, however, none meet CT criteria
for pathologically enlarge. No pathologically enlarged
mesenteric lymphadenopathy is identified. There is a moderate
amount of ascites noted throughout the abdominal cavity with no
free air noted. Small amount of free fluid is noted within the
pelvic cavity with the intrapelvic bowel, prostate, and urinary
bladder appearing otherwise unremarkable. No pathologically
enlarged pelvic or inguinal lymph nodes are identified. There is
evidence of colonic diverticulosis without acute diverticulitis.
[**2114-4-13**] MRI/A Head: No evidence of acute infarct. Chronic
right-sided basal ganglia lacune. No enhancing brain lesions,
mass effect or hydrocephalus.
[**4-15**] CTA Chest Filling defect is seen in a left lower lobe
pulmonary artery segment consistent with pulmonary embolism.
More subtle filling defect in right lower lobe suggests possible
pulmonary emboli on the right side. Multiple sub- centimeter
pulmonary nodules are again seen bilaterally, little change from
study three days prior. Wedge shaped linear opacities at the
bases suggest infarct vs. atelectasis. Limited views of the
upper abdomen again demonstrate multiple low-attenuation lesions
scattered throughout the liver consistent with metastatic
disease. Free fluid again seen within the abdomen. No new
suspicious lytic or blastic lesions are identified within the
osseous structures.
Pathology:
Cell block, peritoneal fluid:
Rare atypical degenerated epithelioid cells present singly and
in clusters, in a background of mesothelial cells and
inflammatory cells, suspicious for adenocarcinoma.
Brief Hospital Course:
67 year old male with newly diagnosed metastatic adenocarcinoma
(likely pancreatic in origin) admitted with gastrointestinal
bleed. Hospital course notable for pulmonary embolism and
rapidly declining performance status.
1) Gastrointestinal bleeding: The patient was admitted to the
medical ICU and transfused with PRBC. He underwent an EGD, which
revealed portal gastropathy, likely due to large metastatic
burden in liver along with splenic vein thrombosis. He was
started on a [**Hospital1 **] PPI and his hematocrit stabilized after 5 units
of blood.
2) Pulmonary embolism: Following transfer to the general medical
floor, given persistent sinus tachycardia and mild oxygen
requirement, a chest CTA was obtained, which revealed a LLL
pulmonary embolism. He was initially anticoagulated with a
heparin drip. However, given recent significant upper GI bleed
requiring ICU admission and high risk for recurrent bleeding due
to known portal gastropathy, an IVC filter was placed on
[**2114-4-18**].
3) Metastatic pancreatic CA (liver/lung): CA [**25**]-9 [**Numeric Identifier 71783**]. The
oncology service was consulted, who felt that the patient would
need an improved functional status before palliative chemo could
be considered. However, during the patients hospital course,
the patient's performance status declined significantly, and he
essentially became bed bound. Because of this and his poor
prognosis (rising liver function tests, new renal failure), the
decision was made with the family and patient to pursue hospice
care as home as he was unlikely to become strong enough to be
eligible for palliative chemotherapy.
4) Ascites: The patient underwent a paracentesis [**4-17**]; analysis
was consistent with portal hypertension without spontaneous
bacterial peritonitis. Cytology was suggestive of
adenocarcinoma.
5) Type II DM poorly controlled with complications: The
patient's glargine dose was titrated to 34 units qhs.
The patient was discharged home with hospice care. He is
DNR/DNI.
Medications on Admission:
KCL 8 meq po qd
lasix 20 mg po qd
avandia 8 mg po qd
zetia 10 mg po qd
metoprolol 50 mg po qd
HCTZ 12.5 mg po qd
lantus ?20 units daily
glucophage 1000 mg po bid
amlodipine 10 mg po qd ; benazapril 20 mg po qd - not takign
since [**3-23**]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day) as needed for pain.
Disp:*240 Tablet(s)* Refills:*0*
4. Methylphenidate 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Please give at 8 am, 2 pm.
Disp:*120 Tablet(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Solution Sig: Thirty Four (34) Units
Subcutaneous at bedtime.
Disp:*qs 1 month supply* Refills:*0*
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for low back pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
8. Insulin Syringe 1 mL 27 x [**5-8**] Syringe Sig: One (1)
Miscellaneous as directed.
Disp:*100 * Refills:*2*
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Metastatic Pancreatic Cancer with Liver/Lung metastases
Upper GI bleed
Pulmonary Embolism s/p IVC filter placement
Hypertension
Ascites
Type 2 DM poorly controlled with complications
Anasarca
Discharge Condition:
being discharged home with hospice services
Discharge Instructions:
Please take all your medications as prescribed. Please return
to the hospital if you are experincing pain or shortness of
breath that cannot be controlled with medications at home.
Followup Instructions:
1) Primary Care: Your new primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6739**]
[**Last Name (NamePattern1) 71784**] ([**Telephone/Fax (1) 71785**]) who works in the [**Company **]
system. Please contact her office with any questions or concerns
2) Oncology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2114-5-23**] 2:00 p.m.
Provider: [**First Name11 (Name Pattern1) 14497**] [**Last Name (NamePattern1) 25880**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2114-5-23**] 2:00
p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2114-4-30**]
|
[
"197.7",
"197.0",
"415.19",
"157.8",
"572.3",
"401.9",
"280.0",
"276.1",
"250.02",
"263.9",
"197.6",
"289.59",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"38.93",
"45.13",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10619, 10668
|
7069, 9082
|
337, 376
|
10904, 10950
|
2781, 2800
|
11180, 11950
|
2266, 2376
|
9373, 10596
|
10689, 10883
|
9108, 9350
|
10974, 11157
|
2391, 2762
|
276, 299
|
404, 1762
|
2814, 7046
|
1784, 2045
|
2061, 2250
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,224
| 189,120
|
44998
|
Discharge summary
|
report
|
Admission Date: [**2152-12-16**] Discharge Date: [**2152-12-19**]
Service: MEDICINE
Allergies:
Clindamycin / Vancomycin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 83 yo female with history of bilateral PEs, HTN,
pulmonary HTN on 2 L home O2 who presents with SOB/vomiting and
found to be hypoxic. Pt states that yesterday she felt short of
breath and lightheaded ("dizzy"- which was not the room
spinning) when standing up. She vomited x 1 and her family
called 911. Pt denies recent F/C/N. No cough. No dysuria. Stable
2 pillow orthopnea. No PND.
Pt states that she has been taking her medication and partakes
in a low salt diet. No CP. Of note, per ED note, pt states that
she did have chest pain.
.
In the ED, VS on arrival were: T: 95.7; HR: 90; BP: 155/79; RR:
18; O2: 91 2L NC. She was given 500 mg IV levaquin x 1,
prednisone 60 mg po x 1, combivent x 2, sodium bicarb in D5w and
furosemide 40 mg IV x 1.
.
Now, pt states that she feels much better. She denies CP/SOB/
feeling lightheaded or dizzy.
.
Last admission was in [**Month (only) 216**] of this year when pt came in with
SOB. She was diuresed and it was thought to be [**2-10**] increased BPs
leading to pulmonary edema in setting of other pulmonary
problems.
Past Medical History:
s/p THR 22 years ago complicated by clot in leg
s/p cataract surgery
Back pain s/p corticosteroid injections
PFTs [**8-13**]- FEv1- 52; FVC- 54%, FEV1/FVC 104.
Spirometry is consistent with a restrictive ventilatory defect
as
demonstrated by the reduced TLC measured on [**2152-8-29**].
Echo [**8-13**]-Left ventricular wall thicknesses and cavity size are
normal. Regional left ventricular wall motion is normal.
Overall
left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular systolic function is borderline normal.
There is
abnormal septal motion/position. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis
is not present. Mild (1+) aortic regurgitation is seen. The
mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation.
There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
Social History:
Originally from [**Country 3399**]. Came to the US in [**2106**]. Widowed, lives
by self. Family involved in care. No smoking. No EtOH.
Family History:
No heart or lung disease in family.
Physical Exam:
VS: T: 97.7; BP: 134/117; HR: 121; RR: 17; O2: 94 50% venti
mask.
Gen: SPeaking in full sentences in accent in NAD
HEENT: Right surgical pupil. Left RRLA. EOMI; sclera anicteric;
OP clear without exudate.
Neck: JVD difficult to tell. ? 9 cm. No LAD
CV: Distant S1S2.
Lungs: Scant crackles at right base, otherwise clear with good
air movement
Abd: NABS. soft, nt, nd
Back: No spinal, paraspinal, CVA tenderness
Ext: Trace edema b/l.
Neuro: CN II-XII tested and intact. MS [**5-12**] throughout. Biceps,
brachio, patellar reflexes [**2-10**].
Pertinent Results:
Admission Labs:
[**2152-12-16**] 05:16PM URINE EOS-NEGATIVE
[**2152-12-16**] 04:59PM CREAT-1.6* POTASSIUM-3.8
[**2152-12-16**] 04:59PM cTropnT-<0.01
[**2152-12-16**] 11:06AM GLUCOSE-210* UREA N-24* CREAT-1.5* SODIUM-136
POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-29 ANION GAP-18
[**2152-12-16**] 11:06AM CK(CPK)-76
[**2152-12-16**] 11:06AM CK-MB-NotDone cTropnT-<0.01
[**2152-12-16**] 11:06AM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-1.9
[**2152-12-16**] 11:06AM WBC-12.1* RBC-3.83* HGB-11.0* HCT-33.4*
MCV-87 MCH-28.8 MCHC-32.9 RDW-16.6*
[**2152-12-16**] 11:06AM PLT COUNT-263
[**2152-12-16**] 11:06AM PT-28.4* PTT-28.9 INR(PT)-2.9*
[**2152-12-16**] 11:05AM URINE HOURS-RANDOM UREA N-91 CREAT-9
SODIUM-116
[**2152-12-16**] 11:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2152-12-16**] 11:05AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2152-12-16**] 02:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2152-12-16**] 02:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2152-12-16**] 02:25AM URINE HYALINE-0-2
[**2152-12-16**] 01:07AM LACTATE-3.5*
[**2152-12-15**] 11:59PM K+-5.5*
[**2152-12-15**] 11:40PM estGFR-Using this
[**2152-12-15**] 11:40PM ALT(SGPT)-30 AST(SGOT)-85* LD(LDH)-675*
CK(CPK)-106 ALK PHOS-132* AMYLASE-94 TOT BILI-0.9
[**2152-12-15**] 11:40PM LIPASE-72*
[**2152-12-15**] 11:40PM CK-MB-3 cTropnT-<0.01
[**2152-12-15**] 11:40PM ALBUMIN-4.1
[**2152-12-15**] 11:40PM WBC-10.9 RBC-3.94* HGB-11.6* HCT-35.9* MCV-91
MCH-29.4 MCHC-32.3 RDW-16.3*
[**2152-12-15**] 11:40PM NEUTS-74.5* LYMPHS-21.9 MONOS-2.9 EOS-0.6
BASOS-0.2
[**2152-12-15**] 11:40PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
[**2152-12-15**] 11:40PM PLT COUNT-264
[**2152-12-15**] 11:40PM PLT COUNT-264
[**2152-12-15**] 11:40PM PT-24.6* PTT-26.5 INR(PT)-2.5*
.
Micro:
Blood culture NGTD
Urine culture genital contaminated
Radiology:
CTA [**2152-12-16**]- IMPRESSION:
1. No evidence of pulmonary embolism.
2. Ground-glass opacities in the lung fields with smooth
interlobular septal thickening, most likely represents pulmonary
vascular congestion as well as pulmonary edema or congestive
heart failure.
3. Stable but continued enlargement of mediastinal and hilar
lymph nodes not significantly changed. The etiology of this
lymphadenopathy is unclear, however may be in part due to
congestive heart failure.
4. Patchy peribronchial opacities in the right middle lobe may
be infectious or inflammatory in etiology.
5. Atherosclerotic calcifications of the thoracic aorta and
coronary artery calcifications.
.
CXR AP [**2152-12-16**]
1. No evidence for congestive heart failure or infiltrate.
2. Stable right hilar and mediastinal adenopathy, better seen
on the chest CT done subsequent to this examination.
Brief Hospital Course:
Pt is a 83 yo female with severe pulmonary HTN, HTN, history of
bilateral PE and recent admissions for CHF and PNA who presents
with lightheadedness, found to be hypoxic. Her hospital course
is as follows:
.
Hypoxia: Normally on 2 L NC likely [**2-10**] severe pulmonary HTN;
PFTs also showed a restrictive pattern. The patient was given
levaquin, prednisone, and lasix in the ED. Given clinical
concern, she was transferred to the MICU for observation. In
the MICU, she was ruled out for MI and PE. CT did demonstrate
findings concerning for possible edema, infectious pneumonia, or
COP. She was diuresed well in the MICU, and started on
levaquin. She improved clinically and was transferred to the
floor. On the floor she achieved her baseline oxygenation on
2-3L NC. Pt worked with her and cleared her for home. Her
outpatient pulmonologist was made aware of her admission. Given
her improvement on lasix and levaquin, we felt her symptoms were
related to fluid overload and an underlying CAP. She was
discharged to complete a course of antibiotics, she was
maintained on her home oxygen, and she was told to follow up
closely with her pulmonologist.
.
Dizziness: Was thought to be related to her initial hypoxia.
Her old records were reviewed. Her dizziness resolved with her
improvement in symptoms. She experienced no additional
dizziness during her admission.
.
Renal failure: Chronic renal failure with cr baseline of 1.0.
Her renal failure was thought secondary to pre-renal azotemia.
After her CTA she was hydrated with bicarb and her cr
subsequently improved during admission and remained stable.
.
HTN: Her beta blocker and ACEI were continued with good effect.
.
history of PE: Her coumadin was initially continued. However,
it was held when her INR was supratherapeutic. Her INR improved
to the normal range and she was restarted on a lower dose of
coumadin at 3mg PO qHS. She will need frequent INR checks and
adjustment of her coumadin as needed.
.
Glaucoma: continued timolol eye drops
.
Code: Patient was unable to definitively decide during
admission. This should be addressed as an outpatient for future
potential admissions.
Medications on Admission:
Toprol XL 50 mg qday
Atrovent and albuterol nebs MDI q 6 hours
Lisinopril 5 mg qday
Coumadin - 4mg Monday and Friday nights
Coumadin- 3 mg Tuesday, Wednesday, Thursday, Saturday, and
Sundays
Timolol eye drops
Atrovent, albuterol MDI prn
Discharge Medications:
1. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
Disp:*1 inhaler* Refills:*2*
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 vial* Refills:*2*
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): Please have your INR checked on [**12-21**] and adjust your
medication according to your PCP. [**Name10 (NameIs) 18303**] INR is [**2-11**].
Disp:*90 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
9. Home Oxygen
Patient's oxygen saturation less than 87% on room air.
Home oxygen via nasal cannula at 2.5 Liters
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
.
Secondary Diagnoses:
Restrictive Lung Disease
Hypertension
s/p Pulmonary Embolus
Glaucoma
Discharge Condition:
Good, afebrile, hemodynamically stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters per day
.
Please take all medications as prescribed. Please keep all
follow up appointments. Please return to the hospital if you
experience chest pain, worsening shortness of breath or any
other symptoms that concern you.
.
Please have your INR checked in 2 days, and then thereafter
according to your primary physician.
.
Please follow up with your primary physician and call your
pulmonologist Dr. [**Last Name (STitle) **] to schedule a follow up appointment
with him.
Followup Instructions:
Please have your INR checked on [**12-21**]. You can go to Dr. [**First Name (STitle) **]
office or have your visiting nurse check and send the results to
Dr. [**First Name (STitle) **].
.
A follow up appointment has been made with Dr. [**First Name (STitle) **] on [**12-26**] at
2:45PM. Please have your INR checked at that time.
.
Please schedule a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
of pulmonology in 4 weeks. ([**Telephone/Fax (1) 513**]
|
[
"V12.51",
"403.90",
"584.9",
"285.9",
"428.0",
"518.89",
"799.02",
"585.9",
"365.9",
"486",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9781, 9867
|
6119, 8284
|
241, 248
|
10032, 10073
|
3183, 3183
|
10726, 11236
|
2568, 2605
|
8571, 9758
|
9888, 9888
|
8310, 8548
|
10097, 10703
|
2620, 3164
|
9940, 10011
|
194, 203
|
277, 1351
|
3199, 6096
|
9907, 9919
|
1373, 2399
|
2415, 2552
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,854
| 109,829
|
52885+59479
|
Discharge summary
|
report+addendum
|
Admission Date: [**2201-3-19**] Discharge Date: [**2201-3-24**]
Date of Birth: [**2121-8-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
fever and blood from rectum
Major Surgical or Invasive Procedure:
None
See discharge summary from [**3-17**] for previous admission
procedures.
History of Present Illness:
79M with a complicated 6 week course involving ischemic colitis
following AAA repair. Procedures from previous admission were
the following: open pararenal AAA, takeback for retroperitoneal
bleeding, L colectomy for ischemia, extended L colectomy, end
transverse colostomy, s/p attempted abd closure, fascial
closure, and bedside perc trach.
He was discharged on [**3-17**] to vent rehab to complete another 10
day course of Zosyn for MSSA & Klebsiella PNA.
He was transferred back to the [**Hospital1 18**] ED from rehab on [**3-19**] for
BRBPR and fever
to 101.4.
Past Medical History:
1. CAD s/p MI (EF 40%), CABG [**4-/2184**], multiple PCI's/stent to
circ/RCA
2. Hyperlipidemia
3. HTN
4. Cervical myelopathy
5. s/p cervical fusion
6. GERD
7. Schatzki's ring
8. Mohs surgery
9. s/p open pararenal AAA [**2201-2-2**] ([**Doctor Last Name **])
10. s/p takeback for retroperitoneal bleeding [**2201-2-2**] ([**Doctor Last Name **])
11. s/p L colectomy [**2201-2-3**] ([**Doctor Last Name **])
12. s/p completion sigmoid colectomy, proctectomy, transverse
colectomy [**2201-2-4**] ([**Doctor Last Name **])
13. s/p end transverse colostomy [**2201-2-6**] ([**Doctor Last Name **])
14. s/p fascial closure [**2201-2-10**] ([**Doctor Last Name **])
15. s/p bedside perc trach [**2201-2-17**] ([**Doctor Last Name **])
Social History:
Married with three children and worked as a lawyer, rare alcohol
Family History:
NC
Physical Exam:
Admission PE
VS - T103.0 88 98/47 16 100%VM
NAD, lying on stretcher. pt interactive.
No jaundice or icterus
ronchi bilaterally right > left
RRR
Abd soft, NT, ND. abdominal wound dressing intact, not removed.
ostomy pink and healthy. bag with air and liquid green stool.
Rectal: small amount of bloody mucous
No LE edema.
R AC PICC line in place
pulses fem [**Doctor Last Name **] AT pt
r 2+ 2+ d 2+
l 2+ 2+ d 2+
Pertinent Results:
On arrival to ED he was also noted to have a respiratory
acidosis
(pH 7.23 pCO2 58) and placed back on the ventilator.
[**2201-3-19**] WBC-14.4 Hct-23.2*
[**2201-3-20**] WBC-10.7 Hct-30.1*
[**2201-3-21**] WBC-9.2 Hct-31.4*
[**2201-3-22**] WBC-10.1 Hct-29.8*
[**2201-3-23**] WBC-9.4 Hct-28.5*
[**2201-3-24**] WBC-8.9 Hct-27.6*
[**2201-3-19**] UreaN-53* Creat-2.9* Na-148* K-4.5 Cl-116* HCO3-22
AnGap-15
[**2201-3-20**] UreaN-50* Creat-2.5* Na-146* K-4.7 Cl-117* HCO3-21*
AnGap-13
[**2201-3-23**] UreaN-43* Creat-2.3* Na-147* K-5.5* Cl-116* HCO3-22
AnGap-15
[**2201-3-24**] UreaN-45* Creat-2.2* Na-146* K-5.2* Cl-115* HCO3-21*
AnGap-15
[**2201-3-19**] 10:49AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2201-3-19**] 10:49AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2201-3-18**] 9:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
[**Female First Name (un) **] PARAPSILOSIS.
[**2201-3-19**] 10:49 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2201-3-19**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2201-3-21**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Brief Hospital Course:
The blood from rectum was most likely retained blood from his
Hartmann's Pouch. No scope was performed and the bleeding did
not recur.
In the ER, he was febrile to 103 and requiring
ventilation. He was hypotensive to the high 80s but did not
require pressors. He was transfused two PRBC for a hct of 23.
He was treated in the ER with vancomycin, levofloxacin and
flagyl, but was started on empiric therapy with
vancomycin and Zosyn in the SICU. His fever was initially
thought to be due to
partial lobar collapse discovered on a [**3-20**] CT torso. There was
no evidence of abscess in the abdomen or pelvis. Postoperative
changes from AAA repair were seen.
However a blood culture from [**3-18**] grew yeast. Following his
fevers in the ER he became hypothermic consistent with a
fungemia. An ID consult was obtained. He was started on
mycofungin and the vanco/zosyn was stopped. He became
normothermic and his white count decreased from 14 to 9. An
echo on [**3-23**] showed no vegetations and an EF of 40-45%.
Opthalmology was consulted to rule out fungal endophthalmitis.
They recommended tobramycin for 5 days.
His mental status was alert, oriented, and cooperative with
occasional episodes of confusion. He would become more
lethargic in the evenings. He was rested on the ventilator
overnight and placed to trach collar during the day. He had a
tracheostomy change on the 14th and passy muir valve was
employed successfully.
His foley catheter was removed [**3-20**]. He pulled out his picc
line on [**3-21**] which was to be removed anyway because of infection
risk.
He was advanced to a regular diet, eating full meals and taking
in over a liter of fluid and supplements by HD 3. He became
hypernatremic to 150, but this resolved with IV free water.
His abdominal wound was intially treated with wet to dry
dressings and then with a vac. His sacral pressure ulcer was
treated by the wound nurse and frequent positioning changes.
He was seen by PT and he was able to get OOB to a chair.
Prior to discharge his fungal coverage was changed from
mycofungin to fluconazole. A picc line was placed by IR for
access.
Medications on Admission:
[**Last Name (un) 1724**]:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]
2. Albuterol Sulfate 90 mcg 4 Puff Inhalation Q4H prn
3. Heparin 5,000 unit/mL TID
4. Ursodiol 300 mg PO BID
5. Hydromorphone 2-4 mg PO Q4H prn
6. Camphor-Menthol 0.5-0.5 % Lotion QID prn
7. Bisacodyl 10 mg Rectal HS prn.
8. Aspirin 81 mg DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Acetaminophen 325 mg PO Q6H prn
11. Pantoprazole 40 mg PO Q24H
12. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment
13. Erythromycin 5 mg/g QHS
14. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25g
Recon Solns Intravenous Q6H (every 6 hours) for 10 days.
15. Heparin as needed for line flush.
16. Metoclopramide 5 mg/mL Q6H prn.
Discharge Medications:
Fluconazole 200 mg IV Q24H to finish [**4-2**]
Tobramycin 0.3% Ophth Soln 1 DROP LEFT EYE TID to finish [**3-26**]
Insulin SC Sliding Scale 03/14 @ 0936 View
Acetaminophen 325-650 mg PO Q6H:PRN [**3-21**] @ 0929 View
Metoclopramide 5 mg PO QIDACHS [**3-19**] @ 0045 View
Pantoprazole 40 mg PO Q24H [**3-19**] @ 0045 View
Metoprolol Tartrate 12.5 mg PO BID [**3-19**] @ 0045 View
Aspirin 81 mg PO DAILY [**3-19**] @ 0045 View
Ursodiol 300 mg PO BID [**3-19**] @ 0045 View
Heparin 5000 UNIT SC TID [**3-19**] @ 0045 View
Albuterol Inhaler 4 PUFF IH Q4H:PRN [**3-19**] @ 0045 View
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab
Discharge Diagnosis:
Fungemia
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
Draw creatinine, LFTs in one week to assess for elevation from
Fluconazole.
It is normal to feel weak and tired, this will last for [**6-15**]
weeks
Increase activities as pt can tolerate- do not do too much right
away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-10**]
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
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? 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:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks.
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Keep ostomy bag on. Change as needed. Monitor ostomy output.
If ostomy output decreases significantly or pt is unable to
tolerate po intake then call office.
Followup Instructions:
Please call Dr.[**Name (NI) 1720**] Office for follow up appt. at ([**Telephone/Fax (1) 19173**].
Call Dr.[**Name (NI) 1482**] Office for follow up appt at ([**Telephone/Fax (1) 8818**].
Completed by:[**2201-3-24**] Name: [**Known lastname 17873**],[**Known firstname **] Unit No: [**Numeric Identifier 17874**]
Admission Date: [**2201-3-19**] Discharge Date: [**2201-3-24**]
Date of Birth: [**2121-8-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 270**]
Addendum:
Additional diagnosis:
Left Ischemic optic neuropathy
Additional medications:
Tobramycin ointment TID OS
Lacrilube TID OU
Bacitracin skin ointment to peri-orbital zoster lesions.
Additional Follow up:
[**Hospital **] Medical Eye Center in 1 week at ([**Telephone/Fax (1) 17875**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2201-3-24**]
|
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"276.0",
"412",
"V45.81",
"V44.3",
"584.9",
"V55.0",
"272.4",
"707.22",
"377.41",
"518.83",
"999.31",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"97.23",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11181, 11402
|
3825, 5962
|
341, 420
|
7506, 7514
|
2340, 3230
|
10274, 11067
|
1869, 1873
|
6723, 7380
|
7475, 7485
|
5988, 6700
|
7538, 9658
|
9684, 10251
|
1888, 2321
|
3274, 3802
|
11078, 11158
|
274, 303
|
448, 1017
|
1039, 1770
|
1786, 1853
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,821
| 150,216
|
35319
|
Discharge summary
|
report
|
Admission Date: [**2176-2-23**] Discharge Date: [**2176-3-21**]
Date of Birth: [**2095-1-2**] Sex: F
Service: SURGERY
Allergies:
Norvasc / Clonidine / Pollen Extracts
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Bilateral lower extremity ischemia
Major Surgical or Invasive Procedure:
[**2176-2-23**] - Endovascular stent graft repair of abdominal aortic
aneurysm.
[**2176-2-23**] - Bilateral groin explorations with aortoiliac,
superficial femoral artery, profunda thrombectomy, right femoral
endarterectomy with Dacron patch angioplasty, left external
iliac, common femoral, superficial femoral artery endarterectomy
and Dacron patch angioplasty, left leg fasciotomy.
[**2176-3-2**]
1. Evacuation of infected hematoma.
2. Debridement of skin and subcutaneous tissues left groin.
[**2176-3-13**]
1. Excisional preparation and pulsed lavage washout of left
groin wound - 66 sq. cm.
2. Ipsilateral rectus abdominis muscle flap transfer to left
groin wound.
3. Split-thickness skin graft coverage of transferred left
rectus flap measuring 66 sq. cm.
4. Application of negative pressure dressing to left groin
wound.
5. Intermediate layered closure of left calf wound - 10cm.
History of Present Illness:
Mrs. [**Known lastname 77254**] is a 81F with A fib well-known to our service who,
on [**2-6**], underwent emergent left lower extremity embolectomy for
a cold pulseless left foot. That surgery was complicated by a
post-operative hematoma which required reoperation on [**2-7**]. She
then developed another groin hematoma approximately a week after
surgery while on heparin. Therefore it was decided that the
patient could not be anticoagulated because of her risk of
bleeding. Today she presents as a transfer from [**Hospital3 26615**]
hospital with approximately 5 hours of bilateral lower extremity
ischemia. She was in her usual state of health until 8:45pm the
night prior to admission when she felt acute onset pain in her
legs and then numbness. The patient presented to [**Hospital **] hospital
where she was immediately given 5000U bolus of heparin and
started on a heparin drip. She then was transferred to [**Hospital1 18**]
emergently. On arrival she had no sensation or motor function of
both of her legs and was complaining of back pain. She also had
bilateral foot drop.
Past Medical History:
CAD
CABG
AS
prothetic valve
a fib
CHF
h/o of CVA with residual right sided weakness
NIDDM
Social History:
N/C
Family History:
N/C
Physical Exam:
Physical Exam
Pain [**8-31**] 99.7 90-100 170/60 18 100 3L
Mod distress
CTAB
Tachycardic
s, nt, nd
lower extremities cold and [**Doctor Last Name 352**] without cap refill bilaterally.
no fem [**Doctor Last Name **] dp or pt pulses present
bilateral foot drop
loss of sensation and motor function bilateral lower extremities
Pertinent Results:
[**2176-2-23**] 12:30AM BLOOD WBC-12.1* RBC-3.95* Hgb-12.7 Hct-37.1
MCV-94 MCH-32.2* MCHC-34.3 RDW-16.7* Plt Ct-462*#
[**2176-2-24**] 03:15AM BLOOD WBC-13.5* RBC-3.10* Hgb-10.0* Hct-26.3*
MCV-85 MCH-32.1* MCHC-37.9* RDW-17.4* Plt Ct-137*
[**2176-3-3**] 01:00AM BLOOD WBC-23.2* RBC-2.68* Hgb-8.4* Hct-24.2*
MCV-90 MCH-31.2 MCHC-34.5 RDW-18.2* Plt Ct-171
[**2176-3-4**] 05:51AM BLOOD WBC-25.8* RBC-3.02* Hgb-9.3* Hct-27.4*
MCV-91 MCH-30.8 MCHC-33.9 RDW-18.4* Plt Ct-266#
[**2176-3-21**] 04:08AM BLOOD WBC-13.0* RBC-2.58* Hgb-8.3* Hct-27.3*
MCV-106* MCH-32.2* MCHC-30.4* RDW-20.3* Plt Ct-430
[**2176-2-23**] 12:30AM BLOOD PT-14.4* PTT-134.6* INR(PT)-1.3*
[**2176-2-23**] 11:50AM BLOOD PT-17.6* PTT-150* INR(PT)-1.6*
[**2176-2-29**] 02:37AM BLOOD PT-13.4 PTT-72.2* INR(PT)-1.1
[**2176-3-19**] 02:54PM BLOOD PT-28.3* PTT-34.4 INR(PT)-2.8*
[**2176-3-21**] 04:08AM BLOOD PT-29.9* PTT-33.4 INR(PT)-3.1*
[**2176-2-23**] 12:30AM BLOOD Glucose-208* UreaN-34* Creat-1.6* Na-136
K-3.9 Cl-99 HCO3-21* AnGap-20
[**2176-3-20**] 04:39AM BLOOD Glucose-173* UreaN-63* Creat-2.0* Na-131*
K-5.0 Cl-107 HCO3-17* AnGap-12
[**2176-3-21**] 04:08AM BLOOD Glucose-153* UreaN-67* Creat-1.9* Na-133
K-5.2* Cl-108 HCO3-17* AnGap-13
[**2176-2-23**] 12:30AM BLOOD CK(CPK)-54
[**2176-2-24**] 03:15AM BLOOD ALT-45* AST-210* LD(LDH)-588*
CK(CPK)-[**Numeric Identifier 80543**]* AlkPhos-57 TotBili-0.8
[**2176-2-26**] 04:51AM BLOOD CK(CPK)-3436*
[**2176-2-23**] 11:22AM BLOOD CK-MB-42* MB Indx-1.4
[**2176-2-23**] 09:39PM BLOOD CK-MB-118* MB Indx-1.2
[**2176-2-25**] 06:46PM BLOOD CK-MB-29* MB Indx-0.5
[**2176-2-23**] 11:22AM BLOOD Calcium-9.5 Phos-5.9*# Mg-3.2*
[**2176-3-21**] 04:08AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.5
[**2176-3-4**] 05:51AM BLOOD Vanco-9.2*
[**2176-3-20**] 08:15PM BLOOD Vanco-22.3*
[**2176-2-23**] 02:16AM BLOOD Type-ART pO2-307* pCO2-31* pH-7.45
calTCO2-22 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2176-2-23**] 02:16AM BLOOD Glucose-167* Lactate-2.4* Na-131* K-4.1
Cl-99*
Brief Hospital Course:
Pt was admitted [**2176-2-23**] and taken urgently to the operating room
for her bilateral lower extremity critical limb ischemia. The
previously aforementioned procedures were performed.
Post-operatively the patient was admitted to the CV-ICU,
remained intubated, the patient was cautiously volume
resuscitated, she received 4 Units PRBC, 2 Units FFP, 2
Platelets, heparin gtt was initiated, the lower extremities were
monitored for compartment syndrome. Labs were serially checked,
blood products were transfused as necessary, the wound VAC was
continued, although there continued to be significant oozing
from this dressing. On POD #3 the patient was extubated without
event. Beta-blockers were utilized for rate control, as the
patients rhythm was atrial fibrillation. On POD#5 the a bedside
swallow evaluation was performed and it was determined the
patient was unsafe for PO medication, video swallow the
following day confirmed this, she was left NPO at that time, and
a dobhoff was placed, TF were initiated and advanced to goal.
The patient continued to have hct drops, CT peformed
demonstrated left groin hematoma. On POD #7 the patient was
transfered out of the CV-IVU to the VICU. Heparin gtt was
continued, 1 of the groin drains was discontinued, lopressor was
used prn for a-fib rate control. The left groin had increase in
drainage, the patient was take back to the operating room as
aforementioned for evacuation of infected hematoma. At this time
antibiotic therapy was intiated with Vanc/Cipro/Flagyl, heparin
gtt was continued, TF were again advanced to goal. Cultures from
the operating room were positive for pseudomonas, and
bacteroides. On [**3-5**] a R IJ triple lumen CVL was placed without
incident, placement was confirmed with CXR. Plastic surgery was
consulted for the possibility of tissue coverage for the groin
wound. On [**3-13**] the patient was taken to the operating room by
the plastic surgery team for rectus flap with STSG coverage. A
VAC dressing was then applied to be managed by the plastic
surgery team. The pt remained on bedrest post-operatively, TF
were advanced to goal. Repeat swallow evaluation was performed
with recommendations that the patient take nectar thick liquids
and pureed solids, PO intake was encouraged in order, and tube
feeds were cycled overnight. The patient did not have adequate
caloric intake PO, TF were continued. The patient was
transitioned from heparin to coumadin, INR was checked, and
coumadin dosed daily. On [**3-19**] the VAC was taken down by the
plastic surgery team, there was 100% STSG take, and the flap was
viable. Recommendations for dry sterile gauze to the wound. At
this time the patient was deemed fit for discharge, the patients
pain was controlled, she was tolerating TF at goal, and was
therapeutic on coumadin.
Medications on Admission:
Lopressor 50", Nifedical 60', detrol 2', amiodarone 200', plavix
75', hydralazine 20"", Lasix 20', acidophilus 1", colace 100
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing, SOB.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Ascorbic Acid 90 mg/mL Drops Sig: Five (5) mL PO DAILY
(Daily).
10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five
(5) mL PO DAILY (Daily).
11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed for insomnia.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Continue until follow-up appointment.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Continue until follow-up appointment.
15. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
16. Acetaminophen 500 mg Tablet Sig: 1.3 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: Coumadin to be dosed daily for goal INR of 2.5 - 3.
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
20. Outpatient Lab Work
Please draw INR daily and dose coumadin daily for goal INR of
2.5-3
21. Outpatient Lab Work
Please draw electrolytes [**3-22**] - check potassium
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Aortoilliac thrombosis; bilateral
Discharge Condition:
Improved
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
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 skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**9-5**] lbs) until your follow up appointment.
check INR daily and dose coumadin daily with goal INR of 2.5-3
check potassium [**3-22**]
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] - Vascular Surgery - in 2 weeks,
call([**Telephone/Fax (1) 2867**] for appointment
Follow-up with Dr. [**First Name (STitle) 3228**] - Plastic Surgery - in 2 weeks, call
([**Telephone/Fax (1) 50951**] for appointment
Completed by:[**2176-3-21**]
|
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icd9cm
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icd9pcs
|
[
[
[]
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9778, 9848
|
4864, 7680
|
332, 1237
|
9926, 9937
|
2875, 4841
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1265, 2359
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2381, 2472
|
2488, 2494
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,043
| 131,471
|
24076
|
Discharge summary
|
report
|
Admission Date: [**2117-2-19**] Discharge Date: [**2117-2-23**]
Date of Birth: [**2067-8-26**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Neck pain and arm weakness
Major Surgical or Invasive Procedure:
1. Bilateral laminotomy, C3, C4.
2. Posterior cervical fusion, C3-C4, C4-C5.
3. Posterolateral spinal instrumentation C3, C4, C5.
4. Application of local autograft for fusion augmentation.
5. Application of allograft for fusion augmentation
History of Present Illness:
[**Known firstname **] [**Known lastname 61229**] is a 49-year-old male who was
diagnosed with metastatic melanoma in [**2104**]. Since that time,
he has been diagnosed with multiple metastases including
skeletal metastases. Recently, he developed neck pain which
was progressive, and then associated with weakness of his
left arm in the C5 distribution with deltoid and also biceps
weakness. This caused considerable loss of function. He
underwent an MRI as recommended by his medical oncologist,
which demonstrated an infiltrative lesion within C4, causing
spinal cord compression as well as severe nerve root
compression. CSF space was obliterated and there was spinal
cord signal change. There was considerable instability within
the C4 vertebral body. Due to the nature of this disease, in
concert with the severity of symptoms, pending spinal
instability and spinal cord compression, he elected to
undergo surgical treatment to help accomplish the goals of
anterior cervical spinal cord decompression with interbody
reconstruction and fusion.
Past Medical History:
Past Oncologic History:
Mr. [**Known lastname 61229**] was diagnosed with a 1.45 mm thick,
[**Doctor Last Name 10834**] level IV melanoma from his lower back in [**2104**]. He
underwent wide local excision and bilateral inguinal negative
sentinel lymph node biopsies. He developed left inguinal
recurrence in [**12/2111**], undergoing completion left inguinal lymph
node dissection on [**2112-2-8**] with pathology revealing melanoma
in four of nine nodes with extracapsular extension. He received
radiation therapy to the left inguinal region completing in
05/[**2111**]. He began interferon off protocol in [**5-/2112**] with
therapy discontinued on [**2112-10-19**] due to radiation colitis. In
[**2-/2113**], he underwent biopsy of a right clavicular lesion by Dr.
[**First Name (STitle) 1022**] revealing a 0.45 mm thick, [**Doctor Last Name 10834**] level III melanoma. He
underwent wide local excision in 04/[**2112**]. In [**6-/2114**], he had
biopsy of a left mandible skin lesion revealing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10834**] level
III, 0.51 mm thick melanoma with three mitoses per mm2. On
[**2114-7-23**], he underwent wide local excision and sentinel lymph
node biopsy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] with no residual
melanoma
at the primary site, but one of three lymph nodes showed a
microscopic deposit of melanoma. He underwent modified left
neck
dissection on [**2114-7-30**] with no melanoma noted in seven
additional nodes. In [**2115-6-4**], he underwent biopsy of a new
right chest wall skin lesion by Dr. [**First Name (STitle) 1022**] revealing metastatic
melanoma not seen at the margin without an epidermal component
and two mitoses per mm2. It was unclear whether this
represented
an in-tranist metastasis from his right clavicle melanoma or an
epidermatrophic metastasis. He underwent right chest wide local
excision and right axillary sentinel lymph node biopsy by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**] on [**2115-7-18**]. There was no evidence of residual
melanoma in the chest or in the sentinel lymph node. Staging
scans were negative and he began GM-CSF off protocol on
[**2115-9-4**], completing 13 cycles in [**2116-8-4**]. Torso CT in
[**9-11**] revealed new small bilateral pulmonary nodules and an
abnormal right kidney. CT guided biopsy of the right kidney on
[**2116-10-27**] confirmed metastatic melanoma. He began the Phase I/II
RAF 265 trial on [**2116-12-22**]. Therapy was held on C1W4, [**1-12**], due
to
visual problems, fatigue and anorexia.
.
Other Past Medical History:
None
Social History:
Lives with wife, daughter, 10 and son, 8 in [**Hospital1 3597**], NH.
- Tobacco: No
- EtOH: No
- Illicits: No
Family History:
noncontributory, no melanoma
Physical Exam:
He is comfortable at rest, alert, and
oriented. He is on a neck brace. Vital signs are stable. Mood
and affect are stable. His pain score was about [**2-4**] and he is
on
analgesic medications for this. Eyes, ears, nostrils, and
oropharynx are unremarkable. Neck is soft. No nodes, elevated
JVP, or thyroid swelling. Lymphatics: No generalized
lymphadenopathy. Chest: Good expansion on percussion. Normal
breath sounds. Normal heart sounds. Abdomen is soft. No mass,
tenderness, or hepatosplenomegaly. Neurological examination
showed some weakness in the left upper limb, 4+/5, associated
with some numbness with pinprick and touch sensation. No other
cranial nerve, sensory, motor, or neurological dysfunction.
Pertinent Results:
[**2117-2-19**] 11:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2117-2-19**] 11:35PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2117-2-19**] 11:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2117-2-19**] 08:29PM GLUCOSE-128* UREA N-15 CREAT-1.1 SODIUM-136
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-11
[**2117-2-19**] 08:29PM estGFR-Using this
[**2117-2-19**] 08:29PM ALT(SGPT)-33 AST(SGOT)-17 CK(CPK)-50 ALK
PHOS-164* TOT BILI-0.7
[**2117-2-19**] 08:29PM LIPASE-19
[**2117-2-19**] 08:29PM CK-MB-2 cTropnT-<0.01
[**2117-2-19**] 08:29PM CALCIUM-8.6 PHOSPHATE-4.8* MAGNESIUM-2.0
[**2117-2-19**] 08:29PM WBC-2.4* RBC-3.11* HGB-8.2* HCT-24.7* MCV-79*
MCH-26.3* MCHC-33.2 RDW-17.9*
[**2117-2-19**] 08:29PM PLT COUNT-481*
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical
therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Patient was scheduled for lumbar spinal decompression and fusion
but the surgery was cancelled due to persistent fever and on the
advise of Oncology team.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*40 Tablet Sustained Release 12 hr(s)* Refills:*0*
4. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q3H (every 3
hours) as needed for pain for 7 days.
Disp:*200 mL* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) for 10 days.
Disp:*80 Tablet(s)* Refills:*0*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
7. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 5028**]
Discharge Diagnosis:
Metastatic melanoma, C4, status
post C4 corpectomy.
Discharge Condition:
Stable
Alert and oriented and tolerating oral diet.
Discharge Instructions:
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. . Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
Activity as tolerated. TLSO when ambulating.
Please perform OT eval.
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Treatments Frequency:
Site: posterior cervical
Type: Surgical
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
Site: Posterior Neck
Description: staples to posterior neck clean, dry and intact.
dressing to posterior neck c/d/i intact.
Care: change dressing daily, cont to monior for signs and
symptoms of infection.
Site: Anterior Neck
Description: steri-strips OTA, incision clean and dry.
Care: cont. to monitor for s+s of infection.
Followup Instructions:
Follow up in 2 weeks with Dr [**Last Name (STitle) 1007**]. Please call [**Telephone/Fax (1) 9769**] to
make an appointment
Completed by:[**2117-2-25**]
|
[
"V87.41",
"995.92",
"198.5",
"486",
"038.9",
"V10.82",
"336.3",
"E878.1",
"998.59",
"518.5",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
8104, 8174
|
6158, 7184
|
346, 589
|
8270, 8324
|
5283, 6135
|
11603, 11758
|
4488, 4519
|
7207, 8081
|
8195, 8249
|
8348, 8437
|
4534, 5264
|
10915, 11102
|
11124, 11580
|
10336, 10897
|
8470, 8693
|
280, 308
|
9264, 10324
|
617, 1668
|
4336, 4342
|
4358, 4472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,736
| 161,333
|
22260
|
Discharge summary
|
report
|
Admission Date: [**2179-2-12**] Discharge Date: [**2179-2-18**]
Date of Birth: [**2121-12-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
GI Bleeding
Major Surgical or Invasive Procedure:
[**2179-2-13**] Endoscopy
History of Present Illness:
The patient is a 57 yoM w/ a h/o hep C cirrhosis w/ a h/o
encephalopathy, varicies, and ascites who is transferred from
[**Hospital3 **] Hospital for management of upper GI bleed. The patient
began having hematemesis x 2 episodes [**11-21**] cup to 1 cup day of
admission to [**Hospital3 **] on [**2179-2-11**]. He has had no recurrent
hematemesis but has been having marroon stool since. He denies
abdominal pain. No nausea currently. No change in abdominal
girth. Last variceal bleed was 2 years ago. He currently feels
well, slightly thirsty. No edema or sob, no chest pain. No f/c
or any other symptoms.
.
At the OSH the patient was noted to have a hct of 28 which
dropped to 25 and transfused 1uPRBC, in the afternoon [**2-12**] he
was noted to have a hct of 24. His INR was 1.8, he was given
4uFFP and INR dropped to 1.5. He was given 40mg IV protonix and
8mg IV zofran, he was given an octreotide bolus and started on a
drip of 50mcg / hr. EGD at [**Hospital3 **] hospital with ulcerations
over the area of banding but no active bleeding. Grade II
varicies in the mid and lower esophagus. He had 2PIV (22, and
20) and his SBP was 102, HR 90 prior to transfer to the [**Hospital1 18**]>
He rec'd 3.8L in IVF. He also recd carafate 1g q6hrs and
cefazolin prior to EGD.
.
In the ICU the patient had 100cc marroon stool.
Past Medical History:
Hep C (genotype 1) cirrhosis c/b ascites, h/o variceal bleed,
and encephalopathy (h/o IVDU)
Diverticulosis
Anxiety/Depression
HTN
Social History:
Patient smoking [**11-21**] ppd x 30 years, no ETOH. Quit drinking etoh
and using IVD 10 yrs ago. Stopped using methadone 4 years ago.
Family History:
Father with hypertension. No fhx of liver disease.
Physical Exam:
Vitals - T: 98.3 BP: 136/76 HR: 75 RR: 20 02 sat: 100% on RA
GENERAL: NAD, AOX3, cachectic
HEENT: MMM, JVP 11cm, EOMI, sclera anicteric, PERRL
CARDIAC: RRR, 2/6 SEM at the RUSB without radiation
LUNG: bibasilar rales
ABDOMEN: soft, moderate distension, + fluid wave, no
hepatosplenomegaly, non tender
EXT: WWP, no edema
NEURO: AOx3, grossly normal
DERM: no stigmata of chronic liver disease
.
DISCHARGE WEIGHT: 136.7 pounds
Pertinent Results:
ADMISSION LABS:
[**2179-2-12**] 08:21PM PT-16.4* PTT-33.7 INR(PT)-1.5*
[**2179-2-12**] 08:21PM PLT COUNT-94*
[**2179-2-12**] 08:21PM WBC-5.5# RBC-2.66*# HGB-8.4*# HCT-24.7*#
MCV-93 MCH-31.5 MCHC-33.9 RDW-17.0*
[**2179-2-12**] 08:21PM CALCIUM-7.9* PHOSPHATE-2.5* MAGNESIUM-1.8
[**2179-2-12**] 08:21PM GLUCOSE-94 UREA N-20 CREAT-0.5 SODIUM-140
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-27 ANION GAP-11
.
MICRO:
[**2179-2-14**] Peritoneal Fluid:
GRAM STAIN (Final [**2179-2-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
IMAGING:
[**2179-2-13**] RUQ US:
1. Liver cirrhosis, with splenomegaly and view large ascites.
Gallbladder
with diffusely thickened wall probably due to liver disease and
third spacing.
2. Patent hepatic vasculature, with normal direction of flow
within the
portal vein.
3. No focal liver lesion seen
.
[**2179-2-13**] CXR: No active pulmonary disease.
.
[**2179-2-14**] Peritoneal fluid cytology: negative for malignant cells
.
[**2179-2-14**] KUB:
Left lateral decubitus view of the abdomen is technically
nondiagnostic for assessment for free intraperitoneal air and
could be
repeated at no additional charge to the patient. A
nonobstructive bowel gas pattern is visualized. Central
displacement of small and large bowel loops is suggestive of
ascites, confirmed on recent ultrasound one day earlier.
.
[**2179-2-13**] EGD: Ulcers in the lower third of the esophagus
The stomach was entirely normal. There was no evidence of a
current or recent UGIB.Otherwise normal EGD to third part of the
duodenum
.
[**2179-2-13**] Sigmoidoscopy: Copious amounts of melena and dark,
clotted blood was noted from the rectum to the splenic flexure.
The mucosa beneath the heme was not fully explored, though no
large lesions were identified. The procedure was terminated due
to poor visibility.
Otherwise normal sigmoidoscopy to splenic flexure
Brief Hospital Course:
57 yoM w/ a h/o hep C cirrhosis presents as a transfer from [**Location (un) 21541**] hospital with an upper GI bleed.
.
# UGIB: Initial upper endoscopy on presentation revealed no
active bleeding. Sigmoidoscopy did reveal significant melena.
Patient had another episode of hematemesis later in the day and
required repeat endoscopy. This endoscopy revealed bleeding .
Glue was applied and bleeding was terminated. He received a
total of 3 u pRBC. He tolerated the procedure well. His
hematocrit remained stable for the remainder of his ICU
admission. His diet was slowly advanced over the next two days
without evidence of rebleed. Patient was continued on octreotide
drip for a total of 5 days. He should continue on omeprazole
40mg [**Hospital1 **]. Recommend completing 5 day course of ciprofloxacin.
He should also continue sucralfate 1gm QID for 10 more days.
His discharge weight was 136.7 pounds.
.
# Hep C cirrhosis: Given active bleeding beta blockers and
diuretics were initially held.
.
# Abdominal distension/pain: Prior to leaving the ICU the
patient was noted to have extreme abdominal discomfort and
distension. 10 liters were drained via paracentesis and the
patient was started on diuretics with rapid symptomatic relief.
.
# Pancytopenia: Patient was noted to have pancytopenia on labs.
This was discussed with Dr. [**Last Name (STitle) **] of hematology oncology who
felt it was reasonable to attribute this to HCV, however
recomended checking HIV. HIV was checked and was negative.
Medications on Admission:
MEDICATIONS:
(home)
CLONAZEPAM 1mg po bid prn anxiety
FUROSEMIDE 40 mg po daily
SPIRONOLACTONE 200mg po daily
NADOLOL 40mg po daily
SUCRALFATE 1 gram po qid
.
(transfer)
Octreotide drip 50mcg / hr
Protonix 40mg IV q12hrs
Carafate 1g po q6hrs
Cefazolin 1g prior to EGD
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
3. Simethicone 80 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day) as needed for bloating.
Disp:*270 Tablet, Chewable(s)* Refills:*0*
4. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
Disp:*30 packet* Refills:*0*
5. 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*
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Ensure Plus Liquid Sig: One (1) Can PO five times a day.
Disp:*150 cans* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Post banding Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Your were admitted after endoscopic banding of esophogeal
varices. Unfortunately this led to an ulcer which bled. You
were taken to [**Hospital3 **] where endoscopy was performed a clot
was seen, removed and treated with glue. You had abdominal pain
which was relieved after 10 liters of fluid was removed from
your abdomen. An HIV test was sent and the results were not
back at the time of your discharge. You must have Dr.
[**Last Name (STitle) 58040**] follow this up at your appointment.
.
The following changes were made to your medications:
You were started on lactulose 30ml per day. You may increase
this if you are not having [**1-21**] bowel movements per day. You may
decrease this is if you are having diarrhea.
You were started on rifaximin 200mg three times per day
You were started on simethicone 80mg three tablets three times
per day
You were started on polyethylene glycol 1 packet daily
You were started on omeprazole 40mg 1 tablet twice per day
You were started on ciprofloxacin 500mg by mouth twice daily for
3 more days
Your spironolactone was decreased to 100mg per day.
The following changes were made to your home medications:
Followup Instructions:
Department: LIVER CENTER
When: FRIDAY [**2179-3-19**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ENDO SUITES
When: TUESDAY [**2179-4-6**] at 8:30 AM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2179-4-6**] at 8:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], 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) 3202**]
Campus: EAST Best Parking: Main Garage
Completed by:[**2179-2-19**]
|
[
"562.10",
"572.3",
"518.0",
"070.54",
"284.1",
"789.59",
"285.1",
"571.5",
"456.20",
"537.89",
"305.1",
"287.4",
"300.4",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"54.91",
"45.13",
"96.71",
"45.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7672, 7733
|
4513, 6026
|
332, 359
|
7805, 7805
|
2574, 2574
|
9137, 9945
|
2052, 2105
|
6345, 7649
|
7754, 7784
|
6052, 6322
|
7953, 9095
|
2120, 2555
|
9114, 9114
|
281, 294
|
387, 1728
|
2590, 4490
|
7820, 7929
|
1750, 1881
|
1897, 2035
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,609
| 177,315
|
55007+59643
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-7-22**] Discharge Date: [**2129-8-3**]
Date of Birth: [**2073-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
acute mental status changes, fevers
Major Surgical or Invasive Procedure:
[**2129-7-26**]
1. Coronary artery bypass grafting x 2 with left internal
mammary artery to left anterior descending artery and
reverse saphenous vein graft to the obtuse marginal
artery.
2. Pericardial patch of aortomitral curtain abscesses x 2.
3. Aortic valve replacement with a 25 mm On-X mechanical
valve, serial number [**Serial Number 112311**], reference number [**Serial Number 42227**].
4. Mitral valve replacement with a 27/29 mm On-X mechanical
valve
,serial #[**Serial Number 112312**], reference number [**Serial Number **].
History of Present Illness:
Mr. [**Known lastname **] is a 56 year old man who was admitted with acute mental
status change with word finding difficulties x 2 days, fever to
103, no headache neck pain. Per patient the symptoms got worse
today when he was out in the junkyard in the heat working.
Patient thought he had heat stroke. No chest pain. Complaining
of his chronic R shoudler pain at chronic level. His head CT
and chest x-ray were negative. Patient was given vancomycin,
zosyn, ampicillin and ceftriaxone. He was noted to have
leukocytosis of 13.2, a negative urine for blood, positive
troponin of 2.9 (their upper limit neg is 0.3).
Past Medical History:
Hypertension
Social History:
No alcohol, no tobacco, currently on disability. No recent sick
contacts. [**Name (NI) **] recent travel.
Family History:
Patient claims no conditions run in family
Physical Exam:
#ADMISSION PHYSICAL EXAM:
VS T 98.2 BP 112/60 HR 86 RR 16
GEN: Alert, oriented to person place, and month/year, no acute
distress
HEENT: NCAT, MMM, EOMI, sclera anicteric, some injection of left
sclera, OP clear
NECK: supple, no LAD
PULM: Good aeration, mild expiratory wheeze
CV: S1/S2, no murmurs auscultated
ABD: soft, non-tender, distended, umbilical hernia, normoactive
bowel sounds
EXT: WWP, right arm in sling, 2+ pulses palpable bilaterally, no
c/c/e
NEURO CNs [**1-31**] intact, no Kernig or Brudzinski signs, motor
function grossly normal
SKIN: erythematous papules and tumors in area of left axilla
Pertinent Results:
[**2129-7-26**] TEE:
Pre-Bypass:
The left atrium is normal in size.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction in the inferior wall.
Right ventricular chamber size and free wall motion are normal.
The aortic root, arch, and descendcing aorta are mildly dilated.
There are simple atheroma throughout the aorta.
The aortic valve is bicuspid. There is a probable vegetation on
the aortic valve. An aortic annular abscess is seen. There is an
aoritc root abcess cavity measuring 1.1cmx0.5cm adjacent to the
anterior mitral valve leaflet.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post Bypass #1:
Patient is AV paced on phenylepherine infusion. Aortic
prosthesis is well seated witout paravalular leaks. Peak
gradient 20, mean 12 mm Hg. There is a [**1-23**]+ jet of eccentric MR
directed posteriorly. Jet improves to [**12-24**]+ when pacing paused
and sbp <100, but worsens to 3+ in sinus rhythm with SPB 120.
Post Bypass #2:
Patient is AV paced (later a paced) on phenylepheine infusion.
There is a mechanical posthesis in the Mitral valve position
with normal washing jets and good leaflet motion, but without
paravalular leaks. Mean gradient 5 mm Hg. Aortic valve
prosthesis unchanged. Aortic contours unchanged. LVEF preserved
and at baseline. Remaining exam unchanged. All findings
discussed with Dr. [**Last Name (STitle) **] at the time of the exam.
[**2129-8-2**] 06:26AM BLOOD WBC-11.2* RBC-2.89* Hgb-8.6* Hct-27.1*
MCV-94 MCH-29.9 MCHC-31.8 RDW-15.3 Plt Ct-326#
[**2129-8-2**] 06:26AM BLOOD PT-26.0* PTT-54.9* INR(PT)-2.5*
[**2129-8-1**] 04:20AM BLOOD PT-26.4* PTT-45.3* INR(PT)-2.5*
[**2129-7-31**] 12:07PM BLOOD PT-25.3* PTT-51.0* INR(PT)-2.4*
[**2129-8-2**] 06:26AM BLOOD Glucose-132* UreaN-36* Creat-1.7* Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
[**2129-8-1**] 04:20AM BLOOD Glucose-138* UreaN-32* Creat-1.5* Na-137
K-4.3 Cl-102 HCO3-28 AnGap-11
[**2129-7-31**] 12:06PM BLOOD UreaN-30* Creat-1.5* Na-141 K-4.3 Cl-103
Brief Hospital Course:
Mr. [**Known lastname **] is a 56 year old man with a history of hypertension who
presented to an outside hospital on [**2129-7-24**] with acute mental
status changes and fevers, transferred to [**Hospital1 18**] for further
workup. A lumbar puncture was performed which showed elevated
WBCs in the aseptic meningitis range with a monocytic
predominance, cultures negative. On admission he also had acute
kidney injury, elevated liver function tests, a troponin of 0.3
and a total creatinine kinase of [**2116**] (troponin was felt
secondary to rhabdo by cardiology). Initially he was treated as
bacterial meningitis on
vancomycin/ceftriaxone/ampicillin/acyclovir. His hospital course
was significant for MSSA bacteremia, vanc/CTX discontinued per
infectious disease, septic right shoulder s/p washout in the
operating [**2129-7-25**], also for transient diplopia likely due
to multiple septic emboli seen on MRI, diplopia now resolved.
Remained on nafcillin/acyclovir as HSV PCR. He was getting
routine EKGs daily for PR monitoring in setting of possible
endocarditis. A TEE confirmed aortic vale vegetation and aortic
root abscess. During his cardiac catheterization he developed
heart block and a temporary wire was placed. He went urgertly
to the operating room and underwent : 1)Coronary artery bypass
grafting x 2 with left internal mammary artery to left anterior
descending artery and reverse saphenous vein graft to the obtuse
marginal artery. 2)Pericardial patch of aortomitral curtain
abscesses x 2.
3) Aortic valve replacement with a 25 mm On-X mechanical valve,
serial number [**Serial Number 112311**], reference number [**Serial Number 42227**]. 4) Mitral valve
replacement with a 27/29 mm On-X mechanical valve serial
#[**Serial Number 112312**], reference number [**Serial Number **]. Please see operative note for
further details.
Overall the patient tolerated the long procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He was initally
on Neosynepherine and in AJR with occasional PAC's. This drug
was weaned off and he maintained a junctional rhythm but with
stable hemodynamics. He extubated POD#1 without difficulty. The
patient was neurologically intact. He returned to SR with
frequent PAC's, Beta blocker was started slowly on POD#3. CT and
PW were remove wihtout difficulty. He was very fluid overloaded
and was started on lasix. His creatine rose to 1.7 and diureses
was adjusted. He tranferred to the floor on POD#6. On the floor
he developed rapid afib and was started on Amiodarone. Presently
he is in rate controlled afib. He was started on anticoaulation
for double mechanical valve goal INR 3.0-3.5. He was febrile in
the post-op period and was pan cultured, all cultures returned
negative. His shoulder culture grew out MSSA and he was followed
by infectious disease, the nafacillin was continued which he
will need to remain on for total of 6 weeks from surgery. The
acyclovir was discontinued. His right shoulder wound remained
clean, dry, and intact. He developed a decubitus to coccyx/left
upper buttocks area. The patient was evaluated by the physical
therapy service for assistance with strength and mobility, he is
weak and deconditioned. By the time of discharge on POD 8 the
patient needed assistance with walking. The upper pole of his
sternum drained small amount of serosanguinous drainage and
should be painted daily with betadine until resolved. His pain
is controlled with oral analgesics. The patient was discharged
to North Eastern [**Hospital1 **] in [**Location (un) 701**] in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Lisinopril Dose is Unknown PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO BID Duration: 2 Weeks
titrate per creatinine and toward goal pre-op weight of 147kgs
2. Potassium Chloride 40 mEq PO DAILY Duration: 2 Weeks
Hold for K >4.5, titrate per lasix dose
3. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
4. Aluminum Hydroxide Suspension [**3-31**] mL PO Q4H:PRN heartburn
5. Amiodarone 400 mg PO DAILY
take 400mg daily for one week, then decrease to 200mg daily
ongoing
6. Aspirin EC 81 mg PO DAILY
if extubated
7. Calcium Carbonate 500 mg PO QID:PRN indigestion
8. Docusate Sodium 100 mg PO BID
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Nafcillin 2 g IV Q4H
12. Oxycodone-Acetaminophen (5mg-325mg) [**11-22**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**11-22**] tablet(s) by mouth
every four hours Disp #*40 Tablet Refills:*0
13. Pantoprazole 40 mg PO Q12H
14. Senna 2 TAB PO BID
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Warfarin MD to order daily dose PO DAILY
for double mechanical valves
17. Warfarin 10 mg PO ONCE Duration: 1 Doses
titrate for goal INR of [**1-22**].5 for double mechanical valves
18. Simvastatin 10 mg PO DAILY
19. Metoprolol Tartrate 75 mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Endocarditis
Aorto-mitral curtain abscess
Coronary Artery Disease
Hypertension
Sebaceous cysts
hernia umbilical
Past Surgical History:
Right shoulder w/ rotator cuff tear s/p repair 4years ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - superior pole with serosanguinous drainage,
no erythema
Edema 2+
Discharge Instructions:
While on Nafcillin will need weekly CBC, BUN/Cre
Place mepilex to ulcer at coccyx. Frequent turning.
Paint sternal incision daily with betadine until sternal
drainage abates
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**8-11**] 10:30 [**Telephone/Fax (1) 170**]
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**9-8**] 1PM [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] (orthopedics for shoulder) [**8-23**] 2:45 ([**Telephone/Fax (1) 112313**]
Please call to schedule the following:
Wound check [**2129-8-11**] at 10:00am
Cardiologist: Dr [**Last Name (STitle) **] in 3 weeks (office will call patient)
Primary Care in [**2-24**] weeks
Infectious Disease: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-8-16**] 10:45
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for double mechanical valves
Goal INR 3-3.5
First draw day after discharge
Then please do daily INR checks until INR stabilized and then
decrease as directed by rehab
On discharge from rehab, please arrange INR follow-up with
primary care physician or cardiologist
Completed by:[**2129-8-3**] Name: [**Known lastname 5493**],[**Known firstname **] Unit No: [**Numeric Identifier 18434**]
Admission Date: [**2129-7-22**] Discharge Date: [**2129-8-3**]
Date of Birth: [**2073-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 135**]
Addendum:
Mr. [**Known lastname 18435**] troponin rise was thought by cardiology to be due to
rhabdomyolysis rather than to be of cardiac origin. During his
admission he was also ruled out for bacterial meningitis. He
was diagnosed with MSSA bacteremia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2129-8-17**]
|
[
"338.29",
"378.86",
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"426.11",
"414.01",
"424.0",
"038.11",
"349.82",
"278.00",
"272.0",
"746.4",
"047.9",
"V85.42",
"790.92",
"728.88",
"421.0",
"707.20",
"285.9",
"711.01",
"429.89",
"584.9",
"995.91",
"427.31",
"287.5",
"706.2",
"401.9",
"449"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"37.49",
"80.81",
"39.61",
"88.56",
"38.91",
"36.11",
"35.22",
"37.78",
"38.97",
"35.24",
"77.81",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
13080, 13307
|
4520, 8189
|
344, 905
|
10089, 10274
|
2416, 4497
|
11236, 13057
|
1726, 1770
|
8402, 9757
|
9873, 9985
|
8215, 8379
|
10298, 11213
|
10008, 10068
|
1811, 2397
|
269, 306
|
933, 1551
|
1573, 1587
|
1603, 1710
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,383
| 134,868
|
23306
|
Discharge summary
|
report
|
Admission Date: [**2100-11-13**] Discharge Date: [**2100-12-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
85 yo female with hx of HTN, atrial fibrillation, osteoporosis,
presented to [**Hospital3 **] on [**11-8**] with N/V and epigastric
pain
Major Surgical or Invasive Procedure:
1. placement of nasogastric tube
2. esophagogastroduodenoscopy with biopsy
3. blood transfusion
4. VATS procedure with placement of 2 chest tubes
5. intubation x2
6. placement of PICC line
History of Present Illness:
Pt was feeling well until [**12-18**] prior to admission, when she
developed increasing nausea/vomiting and epigastric pain. She
felt it was difficult to get food into her stomach. Pt was
found to be in a fib, and a CT of abdomen was done, which
revealed a 6cm mass in the region of the head of the body of
pancreas. Also had thickening of duodenal as well as cecal
walls. EGD done and scope could not be passed past the duodenal
bulb. A clot was found and random duodenal biopsies were taken.
Patient then dropped her SBP and found to be in afib with RVR
with ST depressions in V3-V6 and with supratheraputic INR at 7.
Patient then dropped her HCT from 33- 28 and noted to be
bleeding from NGT and Rectal tube. Patient transfused PRBC and
HCT stabilized.
Past Medical History:
hypertension
hypercholesterolemia
atrial fibrillation
glaucoma
status post appendectomy
Social History:
10 pack year tobacco history, quit years ago; occasional
alcohol, no IVDU
lives in [**Hospital3 **] facility
has a son, very active in her care
Family History:
no malignancy or CAD
Physical Exam:
on admission:
VS: 98.9 144/80 99 26 100% 4LNC
Gen: mildly lethargic, no acute distress
HEENT: NC/AT, EOMI
Neck: supple, no JVD
CV: irregularly irregular, no murmurs, rubs, or gallops
Pulm: CTA bilaterally but poor effort
Abd: hypoactive bowel sounds, soft, NT/ND, no rebound or
guarding
Ext: 2+ LE edema bilaterally
Neuro: A&O x3
Skin: no rashes
Rectal: light brown stool, no clots, mildly guaiac positive
on discharge:
VS: Tm 97.8 Tc 97 130/60 80 22 96% 35% shovel mask
Gen: elderly woman, hard of hearing, NAD
HEENT: PERRL, EOMI, no cervical LAD, OP clear, NG tube in
place, shovel mask in place; voice is hoarse
CV: irregularly irregular, reg rate; nl S1/S2, no murmurs
appreciated
Chest: bandages covering sites of 2 chest tubes, appear clean
Pulm: decreased breath sounds bilaterally with somewhat poor air
movement, diffuse end-expiratory wheezes; no crackles
appreciated
Abd: soft, NT/ND, +BS, no masses appreciated
Ext: pneumoboots in place, 3+ pitting edema, 2+ PT pulses
Pertinent Results:
[**2100-11-13**] 06:59PM TYPE-ART PO2-210* PCO2-42 PH-7.43 TOTAL
CO2-29 BASE XS-3
[**2100-11-13**] 06:59PM LACTATE-1.2 NA+-147 K+-3.3* CL--117*
[**2100-11-13**] 06:59PM HGB-10.8* calcHCT-32
[**2100-11-13**] 06:59PM freeCa-1.07*
[**2100-11-13**] 06:59PM WBC-13.9* RBC-3.82* HGB-11.3* HCT-33.7*
MCV-88 MCH-29.6 MCHC-33.6 RDW-15.1
[**2100-11-13**] 06:59PM NEUTS-73.0* LYMPHS-18.8 MONOS-3.4 EOS-4.4*
BASOS-0.3
[**2100-11-13**] 06:59PM POIKILOCY-1+
[**2100-11-13**] 06:59PM PLT COUNT-260
[**2100-11-13**] 06:47PM GLUCOSE-100 UREA N-14 CREAT-0.6 SODIUM-154*
POTASSIUM-3.5 CHLORIDE-117* TOTAL CO2-29 ANION GAP-12
[**2100-11-13**] 06:47PM ALT(SGPT)-18 AST(SGOT)-23 LD(LDH)-167
CK(CPK)-35 ALK PHOS-73 AMYLASE-112* TOT BILI-0.8
[**2100-11-13**] 06:47PM LIPASE-129*
[**2100-11-13**] 06:47PM ALBUMIN-3.0* CALCIUM-7.4* PHOSPHATE-1.3*
MAGNESIUM-1.0* IRON-37
[**2100-11-13**] 06:47PM calTIBC-176* FERRITIN-579* TRF-135*
[**2100-11-13**] 06:47PM WBC-12.4* RBC-3.66* HGB-10.8* HCT-32.4*
MCV-89 MCH-29.6 MCHC-33.4 RDW-15.2
[**2100-11-13**] 06:47PM NEUTS-73.2* LYMPHS-18.7 MONOS-3.6 EOS-4.2*
BASOS-0.3
[**2100-11-13**] 06:47PM PLT COUNT-228
[**2100-11-13**] 06:47PM PT-13.8* PTT-21.3* INR(PT)-1.2
[**2100-12-5**] 03:00AM BLOOD WBC-7.8 RBC-3.67* Hgb-10.8* Hct-33.3*
MCV-91 MCH-29.4 MCHC-32.4 RDW-16.6* Plt Ct-246
[**2100-12-9**] 05:19AM BLOOD WBC-7.3 RBC-3.43* Hgb-9.8* Hct-31.4*
MCV-92 MCH-28.6 MCHC-31.2 RDW-17.2* Plt Ct-220
[**2100-12-9**] 05:19AM BLOOD Plt Ct-220
[**2100-12-9**] 05:19AM BLOOD Glucose-128* UreaN-15 Creat-0.5 Na-142
K-3.3 Cl-107 HCO3-35* AnGap-3*
[**2100-11-22**] 04:16AM BLOOD LD(LDH)-222
[**2100-11-21**] 02:58PM BLOOD ALT-8 AST-17 LD(LDH)-241 CK(CPK)-31
AlkPhos-80 Amylase-52 TotBili-0.3
[**2100-11-21**] 02:58PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2100-11-14**] 07:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2100-11-13**] 06:47PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2100-12-9**] 05:19AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.6
[**2100-11-13**] 06:47PM BLOOD calTIBC-176* Ferritn-579* TRF-135*
[**2100-11-22**] 04:16AM BLOOD TSH-1.3
[**2100-11-19**] 05:23PM BLOOD PTH-291*
[**2100-12-8**] 02:00AM BLOOD Vanco-15.3*
[**2100-12-4**] 04:40AM BLOOD Digoxin-0.5*
[**2100-11-29**] 04:30AM BLOOD Gastrin-121
[**2100-12-6**] 02:32PM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-31* pCO2-60*
pH-7.41 calHCO3-39* Base XS-10 Intubat-NOT INTUBA
[**2100-12-2**] 06:04PM BLOOD Lactate-1.1
[**2100-12-7**] CXR (after chest tubes pulled):
AP UPRIGHT VIEW OF THE CHEST: The cardiac and mediastinal
contours are stable. There are persistent bilateral pleural
effusions, unchanged compared to the prior study. There is a
left lower lobe opacity consistent with collapse/consolidation.
There is right basilar minor atelectasis. No evidence of
pneumothorax. The lines and tubes are unchanged.
IMPRESSION: No interval change compared to the study of one day
prior of bilateral pleural effusions and bibasilar opacities.
[**2100-12-1**] CTA abdomen/pelvis:
CT ABDOMEN WITH IV CONTRAST: A chest tube is noted on the left,
with a small pneumothorax. Bilateral pleural effusions are
noted, right greater than left, with bibasilar atelectatic
changes.
The liver, gallbladder, spleen, adrenals and kidneys appear
normal.
The previously noted soft tissue density below the liver hilum,
surrounding hepatic artery branches, is once again identified,
though appears slightly smaller since [**2100-11-14**], previously
measuring approximately 3.4 cm x 3.1 cm, now measuring
approximately 2.8 cm x 2 cm. This area of soft tissue density
surrounds the gastric antrum, and is not associated with the
pancreas, which appears normal. No evidence of pancreatic mass.
No enlarged lymph nodes are seen within the vicinity.
No free interperitoneal air.
CT PELVIS WITH IV CONTRAST: Extensive diverticula are seen
within the sigmoid colon, without evidence of acute
diverticulitis. The colon is otherwise unremarkable. The uterus
is within normal limits. The urinary bladder contains gas,
presumably from recent Foley catheterization. Minimal free fluid
is seen within the pelvis.
BONE WINDOWS: No suspicious osseous lesions. Degenerative
changes are seen within the spine.
Multiplanar reconstructions confirm the above findings, and were
essential for diagnosis.
IMPRESSION: 1) Slight decrease in soft tissue density below the
liver hilum, associated with the gastric antrum, but separate
from the pancreas. This area of soft tissue density is felt to
represent inflammatory changes surrounding the gastric antrum,
and is compatible with the patient's known peptic ulcer disease,
as demonstrated by recent EGB ([**2100-11-15**]).
[**2100-11-22**] echocardiogram:
Conclusions:
1. The left atrium is mildly dilated. The right 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 right ventricular cavity is mildly dilated. Right
ventricular systolic function appears depressed.
4. The aortic valve leaflets (3) are mildly thickened.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6. Severe [4+] tricuspid regurgitation is seen. There is severe
pulmonary
artery systolic hypertension.
[**2100-11-22**] pleural fluid negative for malignant cells
[**2100-11-15**]: gastric mucosal biopsies
A. Antrum:
1. Chronic inactive gastritis.
2. [**Doctor Last Name 6311**] stain for Helicobacter organisms is negative
(positive control slide).
B. Duodenum:
Chronic active duodenitis with focal
fibrinoinflammatory exudate
(consistent with surface of an ulceration). No
neoplasm identified (multiple levels are examined).
Micro data:
[**11-15**] E faecalis in blood culture x1 bottle, [**Last Name (un) 36**] to vanco, amp
[**11-17**] stool neg for C diff
[**11-17**] urine culture MRSA
[**11-17**] blood culture negative x2
[**07**]/5 blood culture negative x2
[**11-22**] pleural fluid + MRSA, vanc sensitive
[**11-22**] Urine culture + MRSA
[**11-23**] urine culture negative
[**11-24**] blood cultures negative x2
[**11-26**] cath tip negative
[**11-26**] C diff negative
[**11-26**] sputum contamination with OP flora
[**11-30**] sputum culture Pseudomonas aeruginosa, sensitive to ceftaz
[**12-2**] sputum culture + MRSA
Brief Hospital Course:
1. GI bleed at outside hospital - EGD was done, scope could not
be passed past duodenal bulb; clots were found. Duodenal
biopsies take; Hct dropped from 33 to 28; pt was found to be
bleeding from NG tube and rectal tube. Transfused PRBCs, Hct
stabilized, and was brought to [**Hospital1 18**] for further workup of
?pancreatic mass found on CT abdomen, as well as [**Hospital1 4939**] EGD.
EGD biopsies were benign but felt to be nondiagnostic.
Transfused 1 unit on [**2100-11-24**] with appropriate response.
Transfused 1 more unit on [**2100-12-1**] with good UOP response. Last
guaiacs have been negative. Hct has been stable since then,
with a Hct of 31.4 on discharge.
.
2. empyema/pneumonia - pt was noted to be hypotensive with a
rising leukocytosis initially thought to be due to aspiration.
Pt was started on levo/flagyl and given IVF. CXR showed a LLL
pneumonia with a left sided pleural effusion, and hypotension
was thought to be due to sepsis. Pt was then transferred to the
MICU on [**2100-11-22**]. There, MRSA grew from sputum, as well as from
pleural fluid. In fact, the pleural effusion was loculated, and
pt underwent a VATS procedure on [**11-26**], with drainage of 600cc
pleural fluid (no organisms grew) and lysis of loculations. Pt
had 2 chest tubes placed. She was intubated peri-procedure and
extubated the same day. Chest tube #1 was removed [**11-28**], and
chest tube #2 was removed [**12-5**]. Pt was started on vanco for a
21 day course ([**Date range (1) 59849**]; now getting 1g IV q12). Sputum from
another culture also grew out Pseudomonas which was sensitive to
ceftazidime; pt placed on ceftaz for a 14 day course
([**Date range (1) 59850**]). Pt has a hard time clearing her secretions and
continues to require frequent suctioning.
.
3. atrial fibrillation - Pt has been in a fib, and initially
had RVR. Pt now well-controlled on po metoprolol [**Hospital1 **]. Pt was
transiently on digoxin, but this has been discontinued.
Coumadin was restarted on [**12-6**], and pt was placed on a heparin
bridge, which was then discontinued on [**12-8**]. Of note, pt's INR
is still subtherapeutic on discharge. Caution should be taken,
as pt's INR was supratherapeutic on admission, which likely
contributed to her original GI bleed.
.
4. CHF - EF was 55% on last echo, but pt with severe TR and
pulmonary artery systolic hypertension. CTA was negative for
PE. Pt was diuresed with lasix; however, has developed a
contraction alkalosis in the last few days. Pt placed on diamox
to help correct this; last dose was on [**12-7**]. Pt appears to be
euvolemic on discharge, with significant peripheral edema but
with comfortable breathing and satting well.
.
5. CAD - no acute issues. Pt on statin and BB. EKG changes at
OSH and here show ST depressions and TWI diffusely felt to be
demand ischemia.
.
6. pancreatic/duodenal mass - initially noted on CT abdomen at
OSH. S/P EGD with multiple random duodenal biopsies on [**11-15**]
which did not show malignancy. [**11-30**] CT abdomen showed mass to
be unchanged. [**12-1**], a CT angio was performed, which showed
that the mass was not pancreatic and is most consistent with
post-inflammatory changes. Gastrin is normal. Plan is for
repeat CT angio in 1 month (scheduled for [**12-31**]), and there is no
need for endoscopic ultrasound-guided biopsy as was originally
planned.
.
7. hypercarbic respiratory failure - of note, pt developed
hypercarbic respiratory failure and was transiently intubated on
[**11-30**], extubated on [**12-2**]. Thought to be due to poor airway
clearance, with increased secretions that could not be managed
well by pt. Still with weakness and poor cough at this time.
ENT evaluated pt and found edema of vocal cords on flexible
laryngoscopy. Steroids were not started as pt was with active
infection. Of note, pt has developed a new hoarseness, which
could be from repeated intubation. If it does not clear in 2
weeks, it should be addressed with the ENT doctor [**First Name (Titles) **] [**Last Name (Titles) 4939**] in
[**Month (only) 404**].
.
8. FEN/GI - Pt has failed 2 speech and swallow studies, the
last one being [**12-6**]. An NGT was placed on [**11-27**] with tube
feeds. Pt has been on tube feeds since that time. The tube
feeds were held for the last 2 days of hospitalization as they
could not be given via the NG tube on the floor. However, she
had tolerated them well until that point. Discussion was had
with pt's son about the possible placement of a PEG tube, since
it is unclear why pt is still aspirating. Pt and her son agree
that they do not want a PEG tube placed. A repeat speech and
swallow study may be needed, as pt's aspiration may be due to
transient oropharyngeal issues in the setting of repeated
intubation. Pt has a hard time clearing her secretions, with a
weak cough, and will need frequent suctioning.
.
9. hearing loss - pt was noted to be more hard of hearing, and
according to the son, this may have happened somewhat acutely,
around the [**12-3**]. ENT evaluated the patient and thought that an
outpatient audiogram with ENT [**Month/Year (2) 4939**] would be most appropriate
to further characterize the hearing loss. There is a question
of a serous effusion.
Medications on Admission:
Protonix gtt
digoxin 0.125mg daily
flagyl 500mg tid
ativan prn
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
5. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Start:
[**2100-11-15**]
Indication: nausea
12. 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
13. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q8H (every 8 hours) for 5 days: ends
[**12-13**].
14. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
Q12H (every 12 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8971**] Rehabilitation Center (at [**Hospital6 8972**])
- [**Location (un) 8973**]
Discharge Diagnosis:
Primary:
1. gastrointestinal bleed
2. empyema
3. Pseudomonas pneumonia
4. Methicillin resistant Staphylococcus aureus pneumonia
5. atrial fibrillation
6. pulmonary artery systolic hypertension
7. hearing loss
8. aspiration
9. abdominal mass close to the pancreas
Discharge Condition:
stable, NG tube in place, feeling comfortable, heart rate well
controlled, PICC in place with IV antibiotics
Discharge Instructions:
Please take all of your medications and let the staff know if
you are having any pain, shortness of breath, or other
concerning symptom.
[**Location (un) **] Instructions:
Audiogram: Provider: [**Name10 (NameIs) 6410**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], AU.D. Where: LM [**Hospital Unit Name **] OTOLARYNGOLOGY (ENT) Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2100-12-24**] 10:30
Follow up with ENT: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Where: LM
[**Hospital Unit Name 59851**] (ENT) Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2100-12-24**] 11:00
Repeat CT scan of abdomen: Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2101-1-4**] 11:45
Dr. [**Last Name (STitle) 7307**] will follow up on the results of the CT scan with
you. Please call him at ([**Telephone/Fax (1) 33689**] to make an appointment
with him for after your CT scan.
|
[
"482.41",
"507.0",
"510.9",
"482.1",
"427.31",
"518.82",
"276.0",
"401.9",
"041.86",
"416.8",
"389.9",
"428.0",
"V09.0",
"532.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.34",
"45.16",
"38.93",
"34.59",
"96.04",
"96.05",
"96.71",
"96.6",
"34.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15886, 16007
|
9073, 14337
|
400, 597
|
16323, 16433
|
2729, 9050
|
1675, 1697
|
14450, 15863
|
16028, 16302
|
14363, 14427
|
16457, 16595
|
1712, 1712
|
2140, 2710
|
224, 362
|
16630, 17554
|
625, 1386
|
1726, 2126
|
1408, 1498
|
1514, 1659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,189
| 143,910
|
36599
|
Discharge summary
|
report
|
Admission Date: [**2145-6-27**] Discharge Date: [**2145-6-30**]
Service: MEDICINE
Allergies:
Epinephrine / Cephalosporins / Omeprazole
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI bleed, hypotension
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
[**Age over 90 **] y/o female with hx AF on coumadin, CVA, CAD s/p CABG, HTN,
PVD, CHF admitted to [**Hospital1 18**] from rehab following hypotension to
69 systolic, in setting of 1 week history of tarry stools. Pt
was noted to have an ashen appearance. In preceding weeks she
had developed worsening weakness/fatigue particulary on
ambulation, decreased appetite, occaisional
lightheadedness/dizziness.
HCT at rehab noted at 25.8, giuac postive stools with referral
to ED. No prior hx GI bleeds.
ROS: no BRBPR, f/n/v/chills/chest pain/abdominal pain. At
baseline produces ~7 stools/day.
Past Medical History:
Bowel impaction, requiring manual decompaction, '[**42**].
Atrial fibrillation on coumadin, s/p PPM
s/p CVA s/p R ICA stent
CAD s/p CABG ([**2136**])
Hyperlipidemia
Hypertension
Chronic kidney disease, baseline 1.2-1.5
Systolic heart failure, EF 40% [**2139**], mild MR, severe TR.
Hiatal hernia
Gout
Diverticulosis
Hemorrhoids
PVD
Anemia
Non-small cell lung CA [**2141**]
Uterine prolapse/pessary
Social History:
Lives at [**Hospital1 100**] Life, DNR/ DNI, sons actively involved.
Family History:
non contributory
Physical Exam:
GENERAL: Pleasant, frail, pale appearing elderly female in no
apparent distress.
HEENT: Normocephalic, atraumatic. No scleral icterus.
PERRLA/EOMI. MMM. OP clear. Neck Supple.
CARDIAC: Irregular rhythm, normal rate. Normal S1, S2. Systolic
ejection murmur.
LUNGS: CTAB, good air movement biaterally. No rales or wheezing.
ABDOMEN: NABS. Soft, tenderness to deep palpation in LLQ, ND. No
HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: Scattered ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Nonfocal
neuro exam.
Rectal: Guaiac positive stool, small external hemorrhoids. Some
pain with rectal exam.
Pertinent Results:
[**2145-6-27**] 07:05PM WBC-7.8 RBC-3.01* HGB-8.6* HCT-28.3* MCV-94
MCH-28.7 MCHC-30.5* RDW-15.0
[**2145-6-27**] 07:05PM PLT COUNT-273
[**2145-6-27**] 07:05PM GLUCOSE-137* UREA N-88* CREAT-2.0* SODIUM-142
POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-28 ANION GAP-17
[**2145-6-27**] 07:15PM LACTATE-1.9
[**2145-6-27**] 11:48PM PT-19.4* PTT-28.0 INR(PT)-1.8*
[**2145-6-27**] 11:48PM HCT-22.6*
[**2145-6-27**] 11:48PM CK-MB-NotDone cTropnT-0.07*
[**2145-6-27**] 11:48PM ALT(SGPT)-33 AST(SGOT)-53* LD(LDH)-199
CK(CPK)-57 ALK PHOS-79 TOT BILI-1.0
Brief Hospital Course:
Pt continued to have lightheadedness on ambulation on the
floor.. Triggered on floor for BP to 68 noted at time to be
diaphoretic, grey, with abdominal pain and malaise, bp's
remaining in 80s with IV fluids, PRBCs and trendelenburg with
subsequent triage to MICU.
In the MICU, given FFP, vit K with goal INR 1.5. 3units PRBC w/
increase in HCT to >37. Had un trending CE's with evoloving
ischemic changes on EKG. Discussed with family goals of care,
and they along with the patient, decided against cardiac cath
and desired anticoagulation since risk of GIB was less in their
minds compared to risk of stroke from Afib. Pulmonary edema
worsened on auscultation, pt given small dose of lasix, while
watching UOP. Transfered back to MACU for patient comfort.
.
During her MICU stay the following problems were managed:
GI bleed:
Received endoscopy revealing gastritis, mild esophagitis, 2
superficial duodenal erosions. Pt was started on PPI.
Colonoscopy was considered however HCT improved with clinical
improvement thus was not pursued.
Cardiac Ischemia: CE's trended along with EKGs. ASA given and
coumadin restarted. Lasix for pulmonary edema. Pt did not want
cath.
HYPOTENSION: Thought secondary to GIB and hypovolemia.
Pancultured and abx empiric coverage subsequently discontinued
after 48 hours with 3 days.
Constipation: Had prior hx on impaction, with constipation
possible cause of abdominal pain. Started on bowel regimen of
lactulose, mirulax, senna, dulcolace, with subsequent BMs.
Anemia: Likely a chronic anemia exacerbated by acute GIB. Pt
started on.
Renal Failure: Acute on chronic with contribution from
hypotension, with improvement on IV fluids. Medications were
renally dosed and home doses lasix/ACEI held.
Hyperkalemia resolved.
Medications on Admission:
Aspirin 81mg daily
Calcium 650mg [**Hospital1 **]
Lasix 20mg daily
Lisinopril 20mg daily
Metoprolol SR 50mg daily
Senokot 8.6mg HS
Coumadin 1.5mg daily
Vitamin D 3 1000U daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for CONSTIPATION.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for CONSTIPATION.
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for CONSTIPATION.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Upper gastrointestinal bleed
secondary: Cardiac Ischemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted due to hypotension and melena presumed to be
from a bleeding in your stomach or intestine. Your blood thinner
(coumadin) was stopped. Your were given 3 units of packed red
blood cells. Your heart was stressed by this experience and
showed signs of not getting enough oxygen. You declined a
cardiac intervention. You indicated that preventing stroke was
the most important health objective, even if you were to have
another stomach/intestinal bleed. You were restarted on your
coumadin.
Followup Instructions:
MACU with PT/OT.
Follow up with your PCP regarding your hospital course,
especially regarding the on-going cardiac ischemia and your
desires for limited intervention.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"403.90",
"V58.61",
"564.09",
"428.0",
"428.20",
"427.31",
"276.52",
"272.4",
"V12.54",
"285.1",
"530.85",
"V10.11",
"585.9",
"584.9",
"443.9",
"414.9",
"458.9",
"V45.01",
"293.0",
"578.1",
"V45.81",
"553.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5490, 5556
|
2722, 4490
|
278, 289
|
5667, 5676
|
2147, 2699
|
6228, 6534
|
1434, 1452
|
4718, 5467
|
5577, 5646
|
4516, 4695
|
5700, 6205
|
1467, 2128
|
217, 240
|
317, 910
|
932, 1332
|
1348, 1418
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,684
| 149,909
|
30531
|
Discharge summary
|
report
|
Admission Date: [**2102-2-5**] Discharge Date: [**2102-3-1**]
Date of Birth: [**2051-9-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Acute pancreatitis,
Acute Renal Failure
Acute Respiratory Distress Syndrome
Major Surgical or Invasive Procedure:
Percutaneous Gastrostomy
Percutaneous Tracheostomy
History of Present Illness:
This is a 50 yo male HX of ETOH abuse. He presented to an OSH
with abdominal pain and found to be extremely hypertensive
218/134, elevated lipase and
amylase. Pt was placed on the floor. WBC at this point was [**Numeric Identifier 3652**]
pan cultures were sent negative to the date. He was placed on a
CIWA scale, and after receiving Ativan the pt became
tachypneic,
needing intubation.
After this, pt started deteriorating progressively. He became
hypoxic in spite mechanical ventilation, developed renal failure
now with a creatinine of 3.8 from 1.0 baseline.
We received this patient in the ICU on an Ativan drip of 75
mg/hour.
Past Medical History:
HTN
Splenectomy (~30 years ago)
Social History:
EtOH abuse. Drinks heavily daily
Smokes tobacco
Family History:
N/C
Physical Exam:
VS: 100.5, 105 st, 92/45 Sao2 91% on 100% FIO2
Chest: Lungs coarse
Heart: ST
ABD: firm, decreased BS, no obvious masses
Ext: Clammy
Pertinent Results:
CT ABDOMEN W/O CONTRAST [**2102-2-5**] 9:22 PM
IMPRESSION:
1. Findings consistent with severe pancreatitis. Diffuse
peripancreatic stranding and multiple enlarged mesenteric lymph
nodes. Pancreatic necrosis cannot be adequately evaluated
without IV contrast. Evaluation of the surrounding vasculature
is also limited without IV contrast.
2. No evidence of intraperitoneal free air.
3. Moderate sized bilateral pleural effusions with associated
atelectasis.
4. Small foci of subcutaneous emphysema anterior to the anterior
abdominal wall.
.
CT HEAD W/O CONTRAST [**2102-2-5**] 9:21 PM
IMPRESSION:
1. Ovoid hypodensity in the left caudate head, likely due to a
subacute lacunar infarction.
2. Moderate paranasal sinus and mastoid air cell mucosal
thickening. Equivocal sphenoid sinus air-fluid levels.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2102-2-6**] 8:27 AM
IMPRESSION:
1. No definite intra or extrahepatic biliary ductal dilatation.
No gallstones seen.
2. Gallbladder wall edema likely related to the patient's
pancreatitis.
.
MR HEAD W/O CONTRAST [**2102-2-8**] 10:10 AM
IMPRESSION:
1. Small early-subacute infarction in the subcortical white
matter of the posterior right frontal lobe, most likely embolic.
2. Chronic lacunar infarctions in the periventricular white
matter, in the head of the left caudate nucleus, in the left
pons, and in the left middle cerebellar peduncle.
3. Fluid in the sphenoid and bilateral maxillary air cells,
which may indicate acute sinusitis. Opacification of the ethmoid
and mastoid air cells may be related to intubation, but an
infectious process cannot be excluded.
4. Normal MRA of the circle of [**Location (un) 431**].
.
Cardiology Report ECHO Study Date of [**2102-2-10**]
Conclusions:
The left atrium is elongated. No thrombus/mass is seen in the
body of the left
atrium. The right atrium is moderately dilated. No atrial septal
defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size
are normal. Regional left ventricular wall motion is normal. No
masses or
thrombi are seen in the left ventricle. Left ventricular
systolic function is
hyperdynamic (EF>75%). 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 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.
.
CT CHEST W/CONTRAST [**2102-2-14**] 4:00 PM
IMPRESSION:
1. No significant interval change in extent of peripancreatic
fat stranding involving the body and tail of the pancreas
consistent with pancreatitis. No evidence of pseudocyst, or
areas of pancreatic necrosis. Associated peripancreatic
lymphadenopathy is unchanged.
2. Normal spleen not identified in the left upper quadrant.
Multiple soft tissue density implants seen within the left upper
quadrant and left anterior abdomen are suggestive of splenosis.
4. Moderate sized bilateral pleural effusions with bibasilar
atelectasis, unchanged. Diffuse ground glass opacities in both
lungs suggestive of mild pulmonary edema.
.
CT HEAD W/O CONTRAST [**2102-2-21**] 10:37 PM
IMPRESSION:
1. Technically limited study secondary to contrast
extravasation.
2. No evidence of acute intracranial hemorrhage.
3. Worsening sinus disease, with air-fluid levels suggesting
acute sinusitis.
.
MR HEAD W/O CONTRAST [**2102-2-21**] 8:32 am
IMPRESSION:
1. New early-to-subacute infarction involving the left
precentral sulcus/gyrus and subcortical white matter. Normal
progression of previously identified right posterior frontal
infarct.
2. Stable appearance to chronic small vessel ischemia changes
within the periventricular white matter, left pons, left middle
cerebellar peduncle.
3. Increased opacification of paranasal sinuses.
.
CTA NECK W&W/OC & RECONS [**2102-2-22**] 8:16 AM
IMPRESSION:
1) Minimal atherosclerotic calcification involving the carotid
bulbs and ICA origins bilaterally without evidence of
significant stenosis. Otherwise unremarkable CT angiogram of the
neck.
2) Bilateral pleural effusions with evidence of volume
overload/CHF.
3) Pansinus disease as above.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2102-2-28**] 03:00AM 10.8 2.66* 9.1* 27.2* 102* 34.2* 33.5
15.7* 483*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2102-2-28**] 03:00AM 105 14 0.9 138 4.6 102 26 15
ENZYMES & BILIRUBIN ALT AST CK(CPK) AlkPhos TotBili DirBili
[**2102-2-27**] 10:00AM 80* 89* 31* 143* 0.4
Brief Hospital Course:
This was a 50-year-old man who had entered the hospital on
[**2102-2-5**] with acute
pancreatitis and most recently an acute cerebrovascular accident
affecting the caudate lobe.
Neuro: Patient initially on Ativan gtt. His neurologic exam on
admission was very limited given his sedation, he is not moving
any extremity or responding to pain. Of note he does not have
any extraocular movements with dolls, which, given his history,
is concerning for Wernicke's encephalopathy. He has a small,
ovoid, L caudate hypodensity on CT, read by radiology as
subacute. It is hard to
tell by history how acute this is. It is possible that it is a
small vessel lacunar infarct, which would most likely be due to
small vessel atherosclerotic disease.
He was found to have L frontal CVA, R subcortical CVA (both
subacute). Altered mental status for 2 weeks, and was very
difficult to wake. His mental status remained depressed. On
[**2-23**], Versed were weaned. He recovered on [**2-24**] and was opening
his eyes on command, much awake and afebrile. On [**2-27**], he was
stable neurologically. He now inconsistently follows commands
and was still requires Ativan for agitation and soft wrist
restraints.
.
Resp: He was started on Levaquin and Flagyl for an aspiration
PNA at the OSH. He was intubated (reportedly for tachypnea,
although they were also increasing
Ativan at this point so this is unclear). [**Name2 (NI) **] had a generalized
seizure during his hospital course and was given Dilantin IV for
treatment of this, along with the Ativan. Abd CT was repeated
and showed evidence of
pneumoperitoneum, so he was transferred to [**Hospital1 18**] for further
management.
He had a prolonged course on the ventilator. He had proven
difficult to wean from the ventilator. After consultation with
his family, it was elected to proceed with placement of a
tracheostomy and gastric feeding tube. He finally received a
Trach on [**2102-2-21**]. After tach placement, he was weaned from the
Trach vent and tried on the Trach mask. He was requiring
respiratory care for rhonchi and needing frequent suction. He
gets easily agitated and drops with O2 sats.
.
CV: He was tachycardic on admission. He was resuscitated with
several fluid boluses and ordered for IV Lopressor. He was
tachycardic at times, up to 130-150's, mostly when agitated.
.
Renal: He developed renal failure. His creatinine was 3.8 from
1.0 baseline. This slowly improved with continued fluid
resuscitation. His renal status was WNL and he was auto
diuresing well.
.
GI/Abd: His abdomen was firm and distended on admission. His
Pancreatitis resolved during this hospitalization. HIs Amylase
was 117 at admission and Lipase was 74. These both resolved
while he was NPO and getting IVF.
He was having significant diarrhea. C.diff were all negative,
and tubefeedings were temporarily held while the diarrhea
resolved. He continued with the Lansoprazole and Imodium. He was
also receiving Pancrease.
.
FEN: He was NPO, IVF, TPN. He had a PEG tube placed at the
bedside on [**2102-2-21**]. He was off TPN and tolerating tube feedings.
.
Left UE Infiltrate: On [**2102-2-21**], approximately 90cc of Optiray IV
contrast was accidentally infiltrated into the patient's left
arm. Due to the patient's baseline underlying edema, the injury
was not immediately noticed; however, within 30
minutes infiltration was confirmed via contrast enhancement of
the patient's left upper extremity on scout films. His IV was
immediately removed and a warm compress was placed. This
improved with conservative management.
.
-----Imaging: [**2-22**] CT neck: b/l no significant stenosis.
[**2-21**] MRI: new CVA in L frontal lobe, acute>subacute, precentral
area extending to subcortical white matter; LENIs: neg
[**2-20**]-TEE-PFO, LVH mild outflow tract obstruction;
[**2-18**] KUB: few dilated loops of bowel, No free air, air fluid
levels.
[**2-14**] CTA C/A/P: no change. no areas of necrosis or pseudocyst.
[**2-10**] ECHO: EF> 75%, nrm valves; [**2-9**] EEG -> very slow waves
[**2-8**] MRI/A: New post R frontal subcortical infarct, old lacunars
[**2-6**] RUQ US: gb wall edema; [**2-5**] CT: severe pancreatitis, b/l
eff.
.
-----Micro:[**2-16**] cath-NG. [**2-15**] Stool-neg, BCx - MSSE ([**1-13**]); 3/6,7
cdiff - neg; VRE+; [**2-14**] CVL/BCx/UCx - P, SCx - MRSA;
.
-----ABX: Linezolid [**2-17**], Flagyl [**2-15**], (po vanco [**2-18**])([**Last Name (un) 2830**]/fluc
[**Date range (1) 72508**])
.
Activity: He was being [**Doctor Last Name 2598**] to the chair and sitting-up for
several hours during the day.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor Last Name **]: One (1)
Injection TID (3 times a day).
2. Miconazole Nitrate 2 % Powder [**Doctor Last Name **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for apply to groin & L foot erythema.
3. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
4. Hydralazine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP >140.
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Clonidine 0.1 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly
Transdermal QFRI (every Friday).
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) [**Last Name (STitle) **]: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
10. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
11. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Linezolid 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every
12 hours) for 2 days.
13. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: Regular
Sliding Scale Injection ASDIR (AS DIRECTED): See Sliding Scale.
14. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
15. Lorazepam 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QID (4 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Pancreatitis
Alcohol withdrawl
Acute Renal Failure
Acute Respiratory Distress Syndrome
CVA
Deconditioning
Mental Status Change
Discharge Condition:
Fair
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] as needed. Call ([**Telephone/Fax (1) 5323**]
with questions or concerns.
Please follow-up with Neurology in [**1-15**] weeks. Call ([**Telephone/Fax (1) 8951**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2102-2-28**]
|
[
"525.8",
"305.1",
"E879.8",
"276.2",
"434.91",
"518.81",
"303.90",
"577.0",
"401.9",
"787.91",
"584.9",
"291.81",
"999.9",
"348.31",
"790.7",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.09",
"99.15",
"43.11",
"89.64",
"38.91",
"38.93",
"96.72",
"88.72",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
12651, 12731
|
6223, 10791
|
387, 440
|
12902, 12909
|
1415, 6200
|
13179, 13583
|
1240, 1245
|
10846, 12628
|
12752, 12881
|
10817, 10823
|
12933, 13156
|
1260, 1396
|
272, 349
|
468, 1104
|
1126, 1159
|
1175, 1224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,079
| 103,782
|
23494
|
Discharge summary
|
report
|
Admission Date: [**2189-11-2**] Discharge Date: [**2189-11-9**]
Date of Birth: [**2113-2-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
bile leak
Major Surgical or Invasive Procedure:
sp ERCP/stent [**11-2**]
History of Present Illness:
76M sp lap chole and intra op cholangiogram [**10-28**] @ an OSH sp
ERCP/stent showing active extravasation; ? R hepatic duct
ligation vs cystic duct sump leak.
Past Medical History:
Chronic AFib, mild CHF, h/o GI bleed/ulcers
Family History:
NC
Physical Exam:
NAD, mild jaundice
A&O X 3
CN II-XII intact
icteric sclera
AF, RR
CTAB
obese, mild distention, NT
Bilious fluid draining out of R port site, otherwise lap sites
C/D/I
+ 1 E, No C/C
Pertinent Results:
[**2189-11-2**] 10:35PM ALT(SGPT)-17 AST(SGOT)-21 ALK PHOS-178*
AMYLASE-101* TOT BILI-5.0* DIR BILI-3.6* INDIR BIL-1.4
[**2189-11-2**] 10:35PM LIPASE-1574*
[**2189-11-2**] 10:35PM GLUCOSE-100 UREA N-11 CREAT-0.6 SODIUM-133
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-30* ANION GAP-13
[**2189-11-2**] 10:35PM ALBUMIN-3.0* CALCIUM-8.9 PHOSPHATE-2.2*
MAGNESIUM-2.0
[**2189-11-2**] 10:35PM WBC-11.1* RBC-3.47* HGB-11.3* HCT-33.2*
MCV-96 MCH-32.5* MCHC-34.0 RDW-14.0
[**2189-11-2**] 10:35PM PLT COUNT-326
[**2189-11-2**] 10:35PM PT-14.3* PTT-24.6 INR(PT)-1.3
[**2189-11-2**] 09:00AM BLOOD WBC-9.4 RBC-3.54* Hgb-11.4* Hct-33.9*
MCV-96 MCH-32.3* MCHC-33.7 RDW-14.5 Plt Ct-321
[**2189-11-6**] 06:00AM BLOOD WBC-11.4* RBC-3.58* Hgb-11.3* Hct-33.1*
MCV-92 MCH-31.5 MCHC-34.1 RDW-13.7 Plt Ct-433
[**2189-11-9**] 05:57AM BLOOD PT-16.4* PTT-34.4 INR(PT)-1.7
[**2189-11-8**] 09:00AM BLOOD PT-14.9* INR(PT)-1.4
[**2189-11-9**] 05:57AM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-137 K-4.0
Cl-99 HCO3-30* AnGap-12
[**2189-11-3**] 06:39AM BLOOD ALT-15 AST-22 AlkPhos-168* Amylase-88
TotBili-3.6* DirBili-2.4* IndBili-1.2
[**2189-11-4**] 06:30AM BLOOD ALT-15 AST-21 AlkPhos-163* Amylase-16
TotBili-2.6*
[**2189-11-5**] 06:37AM BLOOD ALT-29 AST-47* AlkPhos-189* Amylase-9
TotBili-2.2*
[**2189-11-6**] 06:00AM BLOOD ALT-34 AST-49* AlkPhos-179* TotBili-1.9*
[**2189-11-7**] 06:45AM BLOOD ALT-48* AST-59* AlkPhos-182* TotBili-1.9*
[**2189-11-8**] 06:14AM BLOOD ALT-38 AST-37 AlkPhos-156* TotBili-1.3
[**2189-11-9**] 05:57AM BLOOD ALT-37 AST-34 AlkPhos-155* TotBili-1.2
Brief Hospital Course:
The pt was admitted and started on IV AUnasyn, NPO, IVF. A CT
abdomen was performed to R/O biloma fromation which showed the
following:
No drainable fluid collections. Post surgical changes in the
gallbladder fossa. Calcified densities in the posterior liver,
below the level of the diaphragm/? calcified granulomas,
Prostatic enlargement, and small bilateral pleural effusions.
A HIDA scan was obtained on HD #2 which showed no evidence of
extravasation. The ostomy bag draining bilious fluid over the R
post site steadily decreased throughout the [**Hospital **] hospital stay.
TB of the fluid was measured at the beginning and at the end of
the hospital course measuring 6.9 and 2.1 respectiveley. The
pt's LFT's and PE were monitored throughout his stay and his
LFT's steadily improved throughout his hospital stay. (see lab
result section). With the pt's clinical improvement post
stenting and review of his cholab=ngiogram, it was thought that
the leak was most likely from the cystic duct stump.
The [**Hospital **] hospital course was remarkable for diarrhea. CDIFF was
sent and was negative X 3.
The pt tolerated a regular diet, was voiding on his own,
abulating without difficulty, and had stable VS and an
unremarkable PE upon discharge. The pt was cleared by physicial
therapy and was DC'd on prophalyctic antibiotics
(ciprofloxacin)and with VNA for drain care. The pt preferred to
have his follow up care done through the VA system but was to
return for a repeat ERCP in approximately 10 days.
Medications on Admission:
Protonix 40', digoxin 0.125', lopressor 50", albuterol MDI/neb
prn, lasix 20', quinine, coumadin 7.5'
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Discharge Disposition:
Home With Service
Facility:
CAPECOD VNA
Discharge Diagnosis:
bile leak
Discharge Condition:
stable
Discharge Instructions:
Please call your physician if experiencing fevers/chills,
nausea/vomiting, shortness of breath or chest pain.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] for a repeat ERCP in [**10-8**]
days; appointment to be set up by Hepatobiliary NP.
Follow up with Dr. [**Last Name (STitle) **] after ERCP. Appointment to be set up
by Hepatobiliary NP.
Follow up for coumadin dosing/INR checks with PCP.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2189-11-12**]
|
[
"997.4",
"427.31",
"E878.6",
"428.0",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.86"
] |
icd9pcs
|
[
[
[]
]
] |
4793, 4835
|
2418, 3935
|
323, 350
|
4889, 4897
|
845, 2395
|
5055, 5507
|
624, 628
|
4087, 4770
|
4856, 4868
|
3961, 4064
|
4921, 5032
|
643, 826
|
274, 285
|
378, 541
|
563, 608
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,065
| 191,475
|
28634
|
Discharge summary
|
report
|
Admission Date: [**2182-8-2**] Discharge Date: [**2182-8-28**]
Date of Birth: [**2122-5-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain, Dyspnea on exertion
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 4(LIMA->LAD, SVG->RCA, OM)
[**2182-8-9**]
History of Present Illness:
60 y/o male adm. to OSH w/CP, found to have elev. troponin and
pulmonary edema. Transferred to [**Hospital1 18**] for cardiac
catheterization.
Past Medical History:
Congestive Heart Failure, Diabetes Mellitus, Hypertension,
Chronic Renal Insufficiency newly started on hemodialysis
[**2182-7-29**], Anemia, Fournier's gangrene s/p scrotal surgery, s/p
appendectomy and tonsillectomy
Social History:
retired, smoked X 30 years, quit 5 years ago, rare ETOH
Family History:
non-contrib.
Physical Exam:
VS: 87 20 155/66 5'0" 84kg
General: Well-appearing w/ SOB
HEENT: NCAT, EOMI, perrl
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft NT/ND, +BS
Ext: Warm, well-perfused with 1 +edema, -varicosities
Neuro: MAE, non-focal, A&O x 3
Pertinent Results:
Cath [**8-2**]: Selective coronary angiography of this right dominant
system demonstrated severe 3 vessel disease. The LMCA was short
but normal. The LAD was subtotally occluded after S1, remainder
of the LAD was small with diffuse irregularities filling
antegrade and via RCA acute marginal collaterals. The LCX had
diffuse disease and the OM2 was occluded and filled via
collaterals. The RCA was occluded at mid vessel after the acute
marginal which filled the distal LAD. There was mild pulmonary
hypertension with PAP 40/16 mmHg). Left ventriculography
revealed severe global hypokinesis with LVEF 29%. No significant
mitral regurgitation was evident.
CNIS [**8-5**]: Bilateral less than 40% carotid stenosis. Likely left
subclavian stenosis.
Chest CT [**8-6**]: Moderate emphysema. Widespread interstitial
pulmonary abnormality including fibrosis and interstitial
pneumonitis, consistent with IPF.
Echo [**8-8**]: PreBypass: The left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. There is moderate regional
left ventricular systolic dysfunction with LVEF 30-40%. Resting
regional wall motion abnormalities include septal hypokinesis at
the base, septal akinesis from mid basal region to apex,
inferior wall hypokinesis at the base and inferior wall akinesis
at the apex. A prominent thrombus is seen in the left ventricle,
adherent to the ventricular wall near the apex. There are simple
atheroma in the aortic arch. There are complex (mobile) atheroma
in the descending aorta. There is no aortic valve stenosis. No
aortic regurgitation is seen.
Trivial mitral regurgitation is seen. Post Bypass: No new
regional wall motion or valvular abnormalities observed. LVEF
30-40%. No new aortic abnormalities observed.
CXR [**8-25**]: Right IJ line is unchanged with tip in the right
atrium. Compared to [**2182-8-21**], there has been no significant change
in the lower lobe volume loss, prominent interstitial markings
versus scarring in the left lateral lung, mild cardiomegaly.
[**2182-8-3**] 10:55AM BLOOD WBC-8.5 RBC-4.10* Hgb-12.3* Hct-36.2*
MCV-88 MCH-30.1 MCHC-34.0 RDW-15.6* Plt Ct-170
[**2182-8-15**] 04:34AM BLOOD WBC-6.9 RBC-1.69* Hgb-4.9* Hct-14.4*
MCV-85 MCH-28.8 MCHC-33.8 RDW-16.9* Plt Ct-205
[**2182-8-28**] 08:15AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.6* Hct-32.1*
MCV-90 MCH-29.7 MCHC-32.9 RDW-16.6* Plt Ct-247
[**2182-8-2**] 02:46PM BLOOD PT-16.6* INR(PT)-1.5*
[**2182-8-13**] 06:25AM BLOOD PT-30.1* INR(PT)-3.2*
[**2182-8-14**] 01:23PM BLOOD PT-70.2* PTT-45.4* INR(PT)-9.0*
[**2182-8-28**] 10:15AM BLOOD PT-19.5* PTT-30.2 INR(PT)-1.9*
[**2182-8-2**] 02:46PM BLOOD Glucose-149* UreaN-37* Creat-3.2* Na-142
K-3.7 Cl-106 HCO3-22 AnGap-18
[**2182-8-12**] 08:40AM BLOOD Glucose-135* UreaN-47* Creat-4.7* Na-134
K-4.3 Cl-99 HCO3-27 AnGap-12
[**2182-8-28**] 08:15AM BLOOD Glucose-174* UreaN-21* Creat-3.6* Na-140
K-3.9 Cl-99 HCO3-32 AnGap-13
[**2182-8-28**] 08:15AM BLOOD Calcium-7.4* Phos-3.7 Mg-1.5*
[**2182-8-6**] 05:46AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-8-6**] 08:23PM URINE RBC-[**5-25**]* WBC-[**2-17**] Bacteri-MOD Yeast-NONE
Epi-[**2-17**]
Brief Hospital Course:
Pt. was admitted to the medical service, medical management was
optimized, he received regular hemodialysis treatments, and was
taken to the OR on [**2182-8-8**] with Dr. [**Last Name (STitle) 914**]. He underwent a CABG
X 4 (LIMA > LAD, SVG>Diag>OM, SVG>PDA). Please see operative
note for details of surgical procedure. Pt. was transported to
the cardiac surgical recovery unit for invasive monitoring in
stable condition. Later on op day he was weaned from sedation,
awoke neurologically intact and was extubated. His epicardial
wires and chest tubes were removed on POD # 1, and warfarin was
initiated(due to finding of LV thrombus in the OR). He remained
hemodynamically stable and was transferred to the telemetry unit
on POD # 2. He continued on regular dialysis, was being
anticoagulated, and had remained stable until early am on [**8-15**].
At that time, he had a bloody BM, was lightheaded, and
diaphoretic. He was transferred to the ICU. His INR which had
been in the 3's had rapidly increased to 6, then to 9 just prior
to this incident. His hematocrit dropped to the mid-teens. He
was transfused RBC's & plasma, received vitamin K. GI was
consulted, and he underwent UGI endoscopy (on [**8-15**])which showed
gastritis (not actively bleeding). EGD was repeated on [**8-16**] which
showed gastritis & duodenitis. He remained hemodynamically
stable after his anticoagulation was reversed, and he was again
transferred to the telemetry floor. He underwent a colonoscopy
on [**2182-8-21**], which revealed polyps, and normal mucosa.
Anticoagulation was again initiated (for post-op AF, as well as
the LV thrombus noted in the OR) with warfarin and IV heparin
was given while waiting for the INR to become therapeutic. On
[**2182-8-26**], he was noted to have some bleeding in his left eye,
ophthalmalogy was consulted (pt. has long-standing history of
retinopathy, prev. vitreous hemmorhage, legally blind). He was
found to have vitreous hemmorhage, and eye drops were initiated
as recommended. His eye was patched, and anticoagulation was
stopped. Throughout post-op course he received regular
hemodialysis treatments and worked with physical therapy for
strength and mobility. He appeared stable and suitable for
discharge home on post-op day 20. He was not restarted on
coumadin seoncadry to the his sensitivity and bleeding
complications. He was discharged home with VNA services and the
appropriate follow-up appointments.
Medications on Admission:
Toprol 50 mg PO daily, Glyburide 1.25 mg PO daily, Norvasc 20 mg
PO daily, Albuterol, Doxazosin 2 mg PO daily, Nephrocaps, ASA
325 mg PO daily, Plavix 75 mg PO daily, Lasix 20 mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
7. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
10. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
Disp:*1 vial* Refills:*2*
11. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
Disp:*1 vial* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
14. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
15. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 vial* Refills:*2*
17. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Health and Hospice Care, [**Location (un) 686**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 4
PMH: Congestive Heart Failure, Diabetes Mellitus, Hypertension,
Chronic Renal Insufficiency newly started on hemodialysis
[**2182-7-29**], Anemia, Fournier's gangrene s/p scrotal surgery, s/p
appendectomy and tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, powders, or lotions on wounds.
Call our office with sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 12816**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Completed by:[**2182-9-12**]
|
[
"535.40",
"427.31",
"276.7",
"515",
"428.20",
"369.4",
"250.42",
"285.21",
"285.1",
"584.9",
"458.21",
"362.02",
"428.0",
"535.61",
"211.3",
"790.92",
"403.91",
"250.52",
"379.23",
"585.6",
"410.91",
"414.01",
"275.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"00.17",
"99.04",
"45.23",
"36.15",
"88.56",
"37.23",
"39.61",
"88.53",
"88.72",
"45.13",
"36.13",
"44.43",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9194, 9278
|
4469, 6909
|
350, 424
|
9605, 9611
|
1227, 4446
|
9939, 10115
|
926, 940
|
7147, 9171
|
9299, 9584
|
6935, 7124
|
9635, 9916
|
955, 1208
|
279, 312
|
452, 596
|
618, 837
|
853, 910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,638
| 170,369
|
27071
|
Discharge summary
|
report
|
Admission Date: [**2169-2-13**] Discharge Date: [**2169-4-10**]
Date of Birth: [**2110-8-16**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2169-2-13**] Placement of IABP
[**2169-2-14**] Coronary bypass graft x 3 utilizing the left internal
mammary
artery to diagonal branch of LAD, saphenous vein graft to distal
left anterior ascending artery, saphenous vein graft to ramus
intermediate branch.
History of Present Illness:
This is a 58 year old male with multiple cardiac risk factors.
He presented to OSH with chest tightness/pressure associated
with diaphoresis and dizziness. He also complained of shortness
of breath and palpitations. He was noted to have EKG changes and
ruled in for a myocardial infarction. He was urgently
transferred to the [**Hospital1 18**] for cardiac catheterization.
Past Medical History:
Diabetes mellitus type II, Peripheral Vascular Disease,
Hypertension, Hypercholesterolemia, Anxiety/Depression, s/p Toe
amputation
Social History:
Lives with niece in [**Location (un) 12595**], MA. Close relationship with niece
and nephew. Divorced, no children. ETOH: admits to 1 drink per
week. Drugs: hx of marijuana cocaine use - denies recent use.
Tobacco: active smoker, 50 pack year history.
Family History:
+DM, HTN, CAD in several first degree relatives
Physical Exam:
Vitals: BP 129/58, HR 52, RR 16
General: well developed male in no acute distress, anxious
appearing
HEENT: oropharynx benign, MMM, EOMI
Neck: supple, no JVD
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities, necrotic foot ulcer noted
right foot
Pulses: decreased distally , no carotid bruits
Neuro: nonfocal
Pertinent Results:
[**2169-2-13**] BLOOD WBC-13.8* RBC-4.13* Hgb-12.0* Hct-34.6* MCV-84
MCH-29.0 MCHC-34.7 RDW-12.9 Plt Ct-227
[**2169-2-13**] BLOOD PT-13.2* PTT-83.6* INR(PT)-1.2*
[**2169-2-13**] BLOOD Glucose-173* UreaN-28* Creat-1.1 Na-135 K-4.5
Cl-99 HCO3-21* AnGap-20
[**2169-2-13**] BLOOD CK(CPK)-198* CK-MB-13* MB Indx-6.6* TropnT-0.081*
[**2169-2-13**] BLOOD Calcium-9.1 Phos-3.9 Mg-2.1
[**2169-2-13**] %HbA1c-7.1*
Brief Hospital Course:
CARDIAC: On admission, Mr. [**Known lastname 63255**] [**Last Name (Titles) 1834**] cardiac
catheterization which was significant for severe three vessel
disease. PTCA of the distal RCA restored flow but a Cypher stent
could not be placed. Two Mini-vision stents were then attempted
to the distal RCA but unsuccessful, resulting in poor flow. An
IABP was subsequently placed for low cardiac indeces, around
1.5. Cardiac surgery was urgently consulted for surgical
revascularization. An echocardiogram was obtained prior to
surgical intervention which revealed normal left ventricular
function, normal aortic valve leaflets and only trivial mitral
regurgitation. On [**2-14**], Dr. [**Last Name (STitle) **] performed three
vessel coronary artery bypass grafting. In the immediate postop
period, he developed high grade AV block. He initially required
ventricular pacing, and all nodal agents were withheld. The EP
service was consulted and observation was recommended with
serial EKGs. Repeat echocardiogram was unremarkable with normal
left and right ventricular function. Over several days, his high
grade AV block improved. He maintained stable hemodynamics and
remained in a normal sinus rhythm. He was gently diuresed
toward his preoperative weight. Beta blockade and aspirin were
resumed. Physical therapy was consulted to assist with
strengthening and conditioning.
NEUROLOGY: Initially had a difficult time weaning from
sedation(Propofol) as he would become hypotensive and hypoxic.
He would concomitantly became agitated with questionable seizure
activity. A head CT scan was obtained on [**2-17**] which
revealed no evidence of a cortical territorial infarction or
intracranial hemorrhage. The neurology service felt his
agitation/possible seizure could be related to withdrawal from
Xanax and ETOH. Lumbar puncture was performed to rule out CNS
infection. Propofol was switched to Versed and he was started on
Thiamine, Folate and multivitamin. An EEG on [**2-18**] was
abnormal, findings most consistent with an encephalopathy. No
focal or epileptiform features were seen. His Clonipin and
Haldol were weaned.
RESPIRATORY: Initially had difficulty weaning from mechanical
ventilation secondary to neurological issues. Therapeutic
bronchoscopy was performed.
GASTROINTESTINAL:
RENAL:
HEMATOLOGY: Platelet count dropped as low as 75K on
postoperative day two. Eventually diagnosed with HIT with a
positive Heparin PF4 antibody assay on [**2-25**]. The
initial assay on [**2-16**] was negative. He was placed on
argatroban and coumadin was started. The Hemetology service was
consulted and argatroban/coumadin were inititated. Once he was
therapuetic on argatroban (INR>4) for five days of coumadin the
argatrban was discontinued. He will remain on Coumadin, target
INR 2.0-2.5 for three months
INFECTIOUS DISEASE: Initially febrile in the immediate postop
period. Remained on antibiotics for right lower extremity
cellulitis related to his peripheral vascular disease.
VASCULAR: Vascular consulted for his lower extremity cellulitis.
Angiogram was recommended when his clinical status stablized.
On [**2169-3-13**] Mr. [**Known lastname 63255**] was transferred to the vascular service
for further management
NUTRITION: Due to prolonged sedation, initially started on tube
feedings. However, postoperatively he eventually cleared
Patient transfered to care of Dr.[**Name (NI) 1392**] service.
major issues continue to be adequate pain control and
progressive ischemic changes.
[**2169-3-20**] Dr.[**Last Name (STitle) 1391**] recommended a lt. leg amputation
.Anticoagulation continued.Mild delerium secondary to nacrotics,
dosing adjusted.Required a 1:1 sitter on [**2169-3-25**] overnight.
transfused 2 uits PRBC's.
[**2169-3-27**] super thearpeutic on coumadin, coumadin held. (INR
3.4-3.9) poor resopnse to transfusion, HCT post transfusion
27.3-26.5-25.3 transfused 2 u packed red cells.\
Patient still undecided reguarding amputation.
[**Date range (1) **] foot ischemia stable. pain well controlled. discussion
with patient Dr. [**Last Name (STitle) 1391**] felt amputation should be defered for
present. Moniter foot and if becomes increasingly ischemic or
infected than consider amputation. Cast managment to arrange for
dispo.
[**2169-4-4**] Patient's foot ischemic pain and foot cyanosis
progressed over the week end.Patient take to surgery for BKA.
The day of surgery developed fever 103, patient cultured.Blood
cultures are negative but not finalized. CXR negative for
pulmonary infiltrates.
[**2169-4-5**] episode of hypoxia and sedation secondary to narcotics,,
improved with holding of analgesics. Also of note elevated
troponins 0.19 - 0.12 these finding were discussed with
cardology who felt this was secondary to demand ischemia
secondary to anemia and was not indicative of acute coronary
syndrome. Patient was transfused with resolution of anemia.
[**2169-4-10**] Patient transfered to Rehab stable. wound skin edges
clean dry and intact pre patella area with mild brusing but
stable. rt. second toe with dry eschar and no erythema.INR 2.0
Medications on Admission:
Metformin 500 [**Hospital1 **], Glyburide 5 [**Hospital1 **], Tagamet, Cartia XL 180 qd,
Lipitor 10 qd, Percocet prn, Xanax 0.25-0.5 [**Hospital1 **], Candesartan 16
qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Heparin Induced
Thrombocytopenia, Acute myocardial infarction, s/p Failed
percutaneous transluminal coronary angioplasty, Diabetes
mellitus type II, Peripheral Vascular Disease, Hypertension,
Hypercholesterolemia, Anxiety/Depression, s/p Toe amputation,
Folliculitis,
Ischemic left foot,s/p left BKA [**2169-4-4**]
postoperative confusion secondary to narcotics, resolved
postoperative hypoxia secondary to respiratory depression from
narcotics resolved
postoperative blood loss anemia, transfused corrected.
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.
amputation skin clips remain until patient seen folloup 4 weeks
with Dr. [**Last Name (STitle) 1391**]
[**Name (STitle) **] stump shrinkers
Moniter INR for goal 2.0-3.0, adjust coumadin dosing as required
( patient on coumadin for HIT )
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-12**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15264**] in [**2-10**] weeks - call for appt. to followup
INR and coumading dosing
Local cardiologist in [**2-10**] weeks - call for appt.
followup with Dr. [**Last Name (STitle) 1391**] 4 weeks, call for an appointment.
[**Telephone/Fax (1) 1393**]
Completed by:[**2169-4-10**]
|
[
"414.8",
"250.00",
"707.15",
"998.12",
"305.1",
"518.5",
"287.4",
"440.24",
"414.01",
"410.41",
"707.14",
"682.7",
"292.81",
"E937.9",
"285.1",
"E934.2",
"426.10",
"704.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"00.66",
"33.24",
"84.15",
"39.61",
"96.6",
"36.06",
"00.40",
"37.23",
"36.12",
"96.72",
"37.61",
"88.56",
"03.31",
"99.20",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
7637, 7710
|
2326, 7418
|
285, 547
|
8299, 8306
|
1898, 2303
|
8861, 9292
|
1390, 1439
|
7731, 8278
|
7444, 7614
|
8330, 8838
|
1454, 1879
|
235, 247
|
575, 950
|
972, 1104
|
1120, 1374
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,389
| 192,258
|
20854
|
Discharge summary
|
report
|
Admission Date: [**2198-1-7**] Discharge Date: [**2198-1-10**]
Date of Birth: [**2123-9-15**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Fall, question of seizure, altered mental status and new
right-sided weakness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 74 y/o M with a PMH of CAD (s/p MI and CABG in
[**2196**]), CHF, NIDDM, and chronic Afib on coumadin, who presented
to the ED of OSH after being found slumped over in a chair by a
neighbor with slurred speech and question of right sided
twitching. NCHCT at OSH showed new hemorrhage involving left
parasagital posterior frontal lobe. ROS was significant for
recent fall on [**1-3**] when patient slipped on the ice while
walking dog. Denies LOC from that fall, but did require staples
for occipital laceraction. Head CT at that time (per records)
was negative. No URI symptoms, no SOB, no CP. INR at ED was 1.7.
CXR showed bilateral LL opacities and patient received Lasix for
pulm edema. Also received Dilantin 1 gm, Ativan 0.5mg for
seizure prophylaxis. Exam at OSH was notable for right-sided
weakness and confusion. Patient was transferred to [**Hospital1 18**] for
further management.
Past Medical History:
1. NIDDM - on amaryl, recent HgA1C 6.7,
2. Coronary artery disease status post CABG [**7-19**]
3. Congestive heart failure
4. GERD
5. Hypercholesterolemia
6. Hypertension - on Metoprolol and Lisinopril
7. Atrial fibrillation - on coumadin, toprol xl
8. Prostate cancer status post prostatectomy [**6-18**]. Per son,
disease local only.
9. Gout - on Allopurinol
10. Right eye blindness
Social History:
Wife recently died [**2198-1-6**] at home after prolonged illness.
Smoked occasional cigars and alcohol but stopped 6 months ago.
Family History:
Father died of hemorrhagic [**Month/Day/Year **] and mother died of MI. Both
aged less than 60.
Physical Exam:
Tc: 98.9 BP: 133/102 HR: 110 RR: 20 O2Sat.: 95%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: Posterior occipital sutures. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E. Some right shoulder
pain with passive range of motion since recent fall
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person and place, not to date. Speech slow,
appears to have word finding difficulties. No dysarthrias, but
frequent paraphasias. Able to repeat simple sentences but
problems with [**Name2 (NI) **] twisters with paraphasias. Naming intact
for
high and low frequency items. Able to follow midline and
appendicular commands. No apraxia. No neglect.
Cranial Nerves: PERRL, 3 to 2 mm bilaterally. Blinks to threat
on left. EOMI in left eye. Does not fully bury right sclerae on
abduction. Right nasolabial fold flattening. Hearing intact to
finger rub bilaterally. Palatal elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. [**Name2 (NI) **]
midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Left sided strength
full. On right:
D T B FE WE FF IP Q H TA G
3 4 5 4- 5- 5 4 4- 4 5 5
Right pronator drift.
Sensation: Withdraws to light touch x 4.
Reflexes: B T Br Pa Ac
Right 1 1 1 3 4
Left 1 1 1 3 4
Bilateral LE clonus. Right toe upgoing. Left toe downgoing.
Coordination: Left FNF slow, accurate. Unable to perform on
right secondary to weakness.
Gait: Did not assess.
Pertinent Results:
WBC-12.3, HCT-35.2, PLT COUNT-214
PT-14.8* PTT-29.6 INR(PT)-1.4
GLUCOSE-254* UREA N-43* CREAT-2.2* SODIUM-138 POTASSIUM-3.7
CHLORIDE-103 TOTAL CO2-24 CK(CPK)-134
CK-MB-7 cTropnT-0.02*
Repeat NCHCT - [**1-7**] Stable appearance of right frontal lobe
intraparenchymal hemorrhage.
LENIs - No DVT in bilateral LE.
MRI - pending
Brief Hospital Course:
1. Neuro: Patient was initially brought to the ICU for
management of intracranial bleed and right sided weakness. A
repeat NCHCT showed no extension of bleed. He received 2 units
of FFP on [**1-8**] and another 2 units on [**1-9**] to correct INR of 2.1
for goal of 1.5-1.7. Since his bleed was stable and since he
will need continued long-term anticoagulation given his risk for
ischemic [**Month/Year (2) **], it was decided not to give vitamin K, but
rather to follow his INR and correct with FFP as needed. On day
of discharge, INR was 1.7. Until [**2198-1-17**] (10 days
post-hemorrhage) goal INR should remain 1.5-1.7 (or less). After
that time, coumadin should be restarted with goal INR 2-2.5.
Additionally, his blood pressure was maintained below 130
systolic to minimize changes of worsenig bleed. His outpatient
medications were used. Lisinopril was increased to 10 mg, but
now that his toprol xl has been increased to his home dose, it
may be necessary to decrease his lisinopril again.
Secondary prevention for future [**Year (4 digits) **] was also assessed.
Cholesterol was excellent (total 152 LDL 74, HDL 62, TG 82), and
lipitor was continued. HgbA1C was 6.7, and his amaryl was
continued, in addition to insulin sliding scale.
He was maintained on Dilantin 100mg PO TID for seizure
prophylaxis given initial presentaion with possible right-sided
shaking, and the cortical location of teh bleed. Has been
therapeutic with level of 15.2 since [**1-9**].
Etiology of bleed unclear, most likely amyloid angiopathy vs
hypertension. He will need repeat CT with contrast in [**5-23**] weeks
to evaluate for any underlying mass or lesion.
2. ID: He was started on 14 day course of Levofloxacin 250 mg PO
QD for possible aspiration pneumonia.
3. Cardiac: He has remained on cardiac telemetry and has had
persistent atrial fibrillation with occasional sustained
tachycardia to 117, exacerbated by dehydration, and requiring NS
fluid boluses. Patient has not received maintanence fluids given
concern for fluid overload due to his baseline CHF. Toprol XL
was increased to home dose of 100mg to improve rate control.
His home dose of lasix for his CHF was held as he had elevated
creatinine and was dehydrated. He has tolerated this well,
though may need to be restarted as outpatient.
4. Renal/GU: In the ICU, he was noted to have decreased urinary
output and a creatinine of 2.2. ICU staff was unable to pass
foley and urology called to perform flex cystoscopy and
placement of foley over guidewire at bedside, and drained 900cc
of urine from bladder. They diagnosed him with bladder neck
contraction. Patient's creatinine has since returned to baseline
at 1.3. Urology recommends that his foley remain in place for 5
days, and then he should have a voiding trial beginning at
midnight.
Serial neurological exams show patient to be oriented to place
and time but with abulic affect and poor attention and recall.
He continues to have spastic hypertonicity in bilateral LEs,
symmetric face, full strength on left and improving strength on
right. At time of discharge, strength on right as follows:
deltoid 3, biceps 5, triceps 4, WE 3, FE 4, FF 5, IP 3, H 4, Q
4, TA 4, G 4, [**Last Name (un) 938**] 3, EDB 3.
Of note, patient's wife died at home on [**2198-1-6**] (day prior to
admission) after prolonged illness and hospice. Patient has
started to express his grief in the last few days, and has been
eating poorly. He would greatly benefit from social work
consultation. In the hospital, he refused pastoral care.
Additionally, patient expressed some desire for DNR status. When
asked he said "I will go join her." It is currently unclear if
this is a long-standing desire or if this is due to his acute
grief over her death. I do not believe he is currently in the
right frame of mind to think about this objectively, and
therefore he is currently full code. As he gets further away
from her death, this discussion would be more appropriate.
Medications on Admission:
1. Toprol XL 50 mg po bid
2. ASA 81 mg po qd
3. Colace 100 mg po bid
4. Protonix 40 mg po qd
5. Lipitor 40 mg po qHS
6. Allopurinol 200 mg po qd
7. Niferex 150 mg po qd
8. MOV 1 capsule po qd
9. Paxil 40 mg po qd
10. Amaryl 2 mg po bid
11. Amiodarone 200 mg po qd
12. Lisinopril 5 mg po qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 10 days.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation for 7 days.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 7 days.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for 7 days.
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO bid ().
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day) for 7 days.
16. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
18. Insulin Regular Human 300 unit/3 mL Syringe Sig: varies
units Subcutaneous QIDACHS: Sliding scale insulin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Intracranial hemorrhage involving left parasagital posterior
frontal lobe.
Diabetes mellitus
Congestive heart failure, EF20-25%
Paroxysmal atrial fibrillation
Coronary artery disease, s/p CABG
Pneumonia
Obstructive uropathy, s/p cystoscopic placement of foley
Depression vs adjustment disorder
Discharge Condition:
Stable, still with right hemiparesis and some abulia in addition
to acute grief reaction.
Discharge Instructions:
Take all medicines as prescribed.
Keep all follow-up appointments.
Call your doctor or return to the emergency department if you
develop confusion, worsening weakness, headache, chest pain or
shortness of breath.
Followup Instructions:
Follow up with your primary care provider [**Last Name (NamePattern4) **] [**1-19**] weeks for
further maangement of your blood pressure, diabetes and other
medical problems.
Follow-up with neurology in the [**Hospital1 **] [**First Name (Titles) 4038**] [**Last Name (Titles) **]c in [**1-18**] weeks. Call [**Telephone/Fax (1) 1694**] to schedule an
appointment.
Patient had foley placed by urology on [**2198-1-8**]. Per urology, it
should remain in place for 5 days. It then should be removed at
midnight [**1-13**], and a voiding trial undertaken. He may need to
have it replaced if still unable to urinate. Follow-up with
urology at [**Hospital3 3583**] or with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**] two weeks
after foley removal.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**0-0-0**]
|
[
"276.5",
"427.31",
"431",
"596.0",
"250.00",
"428.0",
"507.0",
"V45.81",
"274.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94",
"99.07",
"57.32"
] |
icd9pcs
|
[
[
[]
]
] |
9991, 10049
|
4000, 7966
|
350, 357
|
10387, 10478
|
3648, 3977
|
10741, 11633
|
1861, 1958
|
8307, 9968
|
10070, 10366
|
7992, 8284
|
10502, 10718
|
1973, 2427
|
232, 312
|
385, 1289
|
2872, 3629
|
2442, 2856
|
1311, 1697
|
1713, 1845
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,352
| 196,346
|
10168
|
Discharge summary
|
report
|
Admission Date: [**2200-1-5**] Discharge Date: [**2200-1-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Midline placement
History of Present Illness:
[**Age over 90 **]yo Russian woman (was English teacher) with h/o HTN,
hyperlipidemia who presents to the ED after having been found
down and minimally responsive by home health aid this morning;
last seen normal at approximately 10pm last night. Home health
aid reports having found pt. in her bedroom on the floor not
speaking well nor moving well. EMS was called and she was
transferred to [**Hospital1 18**] ED for further evaluation. Further details
surrounding events prior to having been found down are unclear.
.
En route to the emergency department she was reportedly febrile
to 101.5 (no EMS note in chart), however on arrival to the ED,
initial vitals were 98.6 159/80 77 20 95% RA. Labs revealed a
WBC count of 19.5 with neutrophilia of 82%. Chemistries
demonstrated creatinine of 2.2 up from previous baseline
0.7-0.9. Urinalysis was also c/w UTI. Urine and serum tox
screens were negative. CXR on wet read was thought concerning
for infiltrate, however official read was negative for
consolidation. She received 750mg IV levofloxacin, 500mg IV
flagyl, and 1g IV vancomycin. She had one episode of vomiting in
the ED and received 4mg IV zofran. Troponin was elevated to 0.41
with CK MB of 36, no EKG changes and she received ASA 600mg PR.
She was started on IV NS at 150cc/hour.
.
Trauma w/u including CT C-spine and X-ray of right hip were
negative for fracture/dislocation. CT head demonstrated possible
loss of [**Doctor Last Name 352**]-white matter differentiation seen in the region of
the left insular cortex, concerning for acute infarct. Neurology
was consulted and felt CT head and exam c/w probable left MCA
stroke, but outside window for thrombolytics. MRI/MRA was
recommended although not performed in the ED.
.
ROS: Unable to assess. However, niece [**Name (NI) **] who last spoke w/
aunt last night says her aunt was feeling well, had eaten 3 full
meals yesterday and was not c/o N/V/diarrhea/abdominal pain,
dysuria/hematuria, cough, fevers/chills,
numbness/tingling/weakness.
Past Medical History:
1. Hypertension.
2. Hypercholesterolemia.
3. Depression.
4. Dizziness.
5. Incontinence
6. Glaucoma
7. s/p Right iridectomy
Social History:
Lives at home alone with daily home aide's help. No
etoh/tob/illicits. Born in [**Country 532**]
Family History:
Unknown
Physical Exam:
VS: Temp:97.4 BP: 140/60 HR:72 RR:15 O2sat 97% RA
GEN: pleasant, comfortable, NAD
HEENT: Right pupil larger and w/ abnormal shape s/p iridectomy
and unresponsive to light. Left pupil round and responsive to
light, EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: Rhonchorus anteriorly however appears to be upper airway
sounds transmitting, fine rales bibasilar
CV: RRR, S1 and S2 wnl, no m/r/g appreciated on exam
ABD: nd, +b/s, soft, nt, +hernia just superior to umbilicus,
reducible
EXT: trace-1+ bipedal edema, 1+ DP/PT pulses b/l
SKIN: chest with ?senile purpura
NEURO: Alert, not following commands in English (per neuro note
in ED, not following commands in Russian either). Moving all 4s.
Right biceps with 3.5/5, grip [**3-5**]. Left biceps with 4.5/5, full
grip (although does not grip when instructed to do so). Unable
to assess for sensory deficits. Moving b/l LEs however does not
cooperate with strength exam. 2+DTRs patellar, biceps,
brachioradialis (right sl. more brisk than left). Downgoing toes
b/l.
Pertinent Results:
[**2200-1-5**] 10:01PM %HbA1c-6.2*
[**2200-1-5**] 06:22PM GLUCOSE-172* UREA N-53* CREAT-2.2* SODIUM-141
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-15* ANION GAP-20
[**2200-1-5**] 06:22PM ALT(SGPT)-12 AST(SGOT)-57* LD(LDH)-421*
CK(CPK)-3347* ALK PHOS-110 TOT BILI-0.6
[**2200-1-5**] 06:22PM CK-MB-58* MB INDX-1.7 cTropnT-0.66*
[**2200-1-5**] 06:22PM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-4.1
MAGNESIUM-2.0
[**2200-1-5**] 10:34AM GLUCOSE-223* LACTATE-2.1* K+-5.0
[**2200-1-5**] 10:32AM URINE HOURS-RANDOM UREA N-518 CREAT-115
SODIUM-89
[**2200-1-5**] 10:32AM URINE OSMOLAL-492
[**2200-1-5**] 10:32AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2200-1-5**] 10:32AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2200-1-5**] 10:32AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2200-1-5**] 10:32AM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0 RENAL EPI-0-2
[**2200-1-5**] 10:32AM URINE GRANULAR-0-2 HYALINE-<1
[**2200-1-5**] 10:15AM GLUCOSE-247* UREA N-55* CREAT-2.2* SODIUM-137
POTASSIUM-6.7* CHLORIDE-107 TOTAL CO2-15* ANION GAP-22*
[**2200-1-5**] 10:15AM estGFR-Using this
[**2200-1-5**] 10:15AM CK(CPK)-1870*
[**2200-1-5**] 10:15AM CK-MB-36* MB INDX-1.9 cTropnT-0.41*
[**2200-1-5**] 10:15AM CALCIUM-9.6 PHOSPHATE-4.5 MAGNESIUM-2.4
[**2200-1-5**] 10:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2200-1-5**] 10:15AM WBC-19.5*# RBC-4.26 HGB-12.5 HCT-37.3 MCV-88
MCH-29.3 MCHC-33.4 RDW-13.0
[**2200-1-5**] 10:15AM NEUTS-82.3* LYMPHS-12.6* MONOS-4.6 EOS-0.2
BASOS-0.2
[**2200-1-5**] 10:15AM PLT COUNT-229
[**2200-1-5**] 10:15AM PT-12.7 PTT-20.3* INR(PT)-1.1
.
CT HEAD:
FINDINGS: The study is slightly limited by motion. The loss of
[**Doctor Last Name 352**]-white matter differentiation and hypodensity within the
left insular cortex, anterior left temporal lobe, and the left
frontal lobe is today more conspicuous and increased in size
consistent with an evolving left MCA territorial infarct. There
is no mass effect or shift of normally midline structures. The
ventricles are normal in size and symmetric. There is no
evidence of intracranial hemorrhage. Limited views of the
paranasal sinuses demonstrate mild sphenoid sinus mucosal
thickening. Osseous structures are unremarkable. Cataract
surgical change of the right globe is seen.Right nasogastric
tube is in place.
IMPRESSION: Evolution of enlarged left MCA territorial
infarction with no evidence of intracranial hemorrhage or mass
effect.
Brief Hospital Course:
[**Age over 90 **] year old woman with h/o HTN, hyperlipidemia admitted to MICU
after having been found down with L MCA stroke, NSTEMI, ARF, and
UTI c/b L thigh hematoma. Hemodynamically stable on admission
but with poor mental status. She was treated empirically for
UTI with quinolones. Her MICU course was complicated by atrial
fibrillation with rapid ventricular response. This eventually
was controlled with metoprolol and amiodarone. She had been
started on heparin gtt for the NSTEMI and the atrial
fibrillation but this had to be discontinued as the patient
developed a thigh hematoma associated with a ten point decline
in hematocrit. She was given two units of pRBC with appropriate
rise. She did also receive lasix for volume overload.
Subsequently she was called out to the floor. Her mental status
had not improved at this point. She was unable to take PO's and
was receiving nutrition via NG tube. Of note, her code status
during her MICU stay was changed by her niece--the next of
[**Doctor First Name **]--to DNR/DNI. She was stabilized on transfer to the floor
and per disciussion with the patient's niece, palliative care
team, social worker and medical team, the niece conveyed that
the patient would not like any heroic measures. NGT was
discontinued for pt's comfort. She received tylenol around the
clock adn morphine for pain control. She received occasional
Haldol and Zyprexa for agitation. On [**1-17**] the patient appeared
close to death and decision was made to hold off on transferring
her to an outside care facility. On [**2200-1-17**] the patient expired.
.
# Communication: HCP niece [**Name (NI) **] [**Name (NI) 33931**] [**Telephone/Fax (1) 33932**] (c),
Sister-in-law [**Name (NI) 33933**] [**Name (NI) 33931**] [**Telephone/Fax (1) 33934**]
Medications on Admission:
Clonidine
Metoprolol
Ambien
Lipitor
Prozac
Zyprexa
Nitroglycerin
Senna
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY:
stroke
SECONDARY
myocardial infarction
urinary tract infection
pneumonia
hypertension
dysphagia
Discharge Condition:
deceased
Discharge Instructions:
expired
Followup Instructions:
deceased
|
[
"401.9",
"427.31",
"459.0",
"728.88",
"276.6",
"584.9",
"599.0",
"272.0",
"E934.2",
"434.11",
"410.71",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8358, 8367
|
6408, 8207
|
271, 290
|
8516, 8527
|
3784, 5541
|
8583, 8595
|
2604, 2613
|
8329, 8335
|
8388, 8495
|
8233, 8306
|
8551, 8560
|
2628, 3765
|
221, 233
|
318, 2327
|
5550, 6385
|
2349, 2474
|
2490, 2588
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,093
| 147,947
|
41854
|
Discharge summary
|
report
|
Admission Date: [**2184-5-20**] Discharge Date: [**2184-5-25**]
Date of Birth: [**2118-3-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea, fatigue
Major Surgical or Invasive Procedure:
[**2184-5-21**]
1. Mitral valve repair with a resection of the middle
scallop of the posterior leaflet of the mitral valve and
implantation of a [**Doctor Last Name 4726**]-Tex chordae to the middle scallop
at the anterior leaflet and a mitral valve annuloplasty
with a 28-mm [**Doctor Last Name 405**] annuloplasty band.
2. Modified left-sided maze procedure.
3. Left atrial appendage ligation and oversewing.
4. Coronary artery bypass grafting x1 with reverse
saphenous vein graft to the marginal branch.
History of Present Illness:
66 year old male with mitral valve prolapse and atrial
fibrillation has been recently experiencing worsening symptoms
of fatigue and dyspnea. He describes having these symptoms since
[**Month (only) 956**] while he was in [**State 108**] for the
winter. The dyspnea can occur while lying in bed or walking. He
does report episodes of PND occurring a few times per week. He
has also noticed chest heaviness/tightness unrelated to
activity. He feels very weak and fatigue and has limited
activity tolerance which is significantly new and has been
worsening since [**Month (only) 956**]. He has also been experiencing frequent
lightheadedness unrelated to exertion.
Past Medical History:
Past Medical History:
atrial fibrillation; diagnosed in [**7-/2183**]
s/p unsuccessful cardioversion in [**State 1727**]
mitral regurgitation
hyperlipidemia
osteoarthritis
carpal tunnel of left wrist s/p repair
compound tib-fib fracture 25 yrs ago
Past Surgical History:
s/p carpal tunnel repair
s/p repair of compound tib-fib fracture 25 yrs ago
Social History:
Lives with:wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 90891**]
Occupation:Retired from construction company
Cigarettes: Smoked no [x] yes []
Other Tobacco use:rare cigar
ETOH: 1 beer/ day and +/- shot of whiskey/day
Illicit drug use:denies
Family History:
Family History:Premature coronary artery disease- mother had
multiple strokes
Physical Exam:
Pulse: AF 72 Resp:18 O2 sat: 98% RA
B/P Right: Left:95/63
Height:6'1" Weight: 93.8 kg
General:AAO x 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x], no bruits [x]
Chest: Lungs clear bilaterally [x]
Heart: [x] Irregular [x] Murmur systolic grade 1
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [-]
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2184-5-24**] 04:38AM BLOOD WBC-9.7 RBC-3.40* Hgb-10.7* Hct-32.7*
MCV-96 MCH-31.4 MCHC-32.7 RDW-14.1 Plt Ct-124*
[**2184-5-25**] 04:42AM BLOOD PT-18.9* INR(PT)-1.8*
[**2184-5-24**] 04:38AM BLOOD Glucose-106* UreaN-16 Creat-0.9 Na-136
K-4.1 Cl-104 HCO3-21* AnGap-15
[**Known lastname **] [**Known lastname 3947**],[**Known firstname **] [**Medical Record Number 90892**] M 66 [**2118-3-17**]
Radiology Report CHEST (PA & LAT) Study Date of [**2184-5-24**] 3:14 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2184-5-24**] 3:14 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 90893**]
Reason: r/o inf, eff
Final Report
INDICATION: 66-year-old male post-CABG and mitral valve
replacement.
COMPARISON: [**2184-5-23**].
CHEST, PA AND LATERAL: Changes of median sternotomy and CABG.
There are
small bilateral pleural effusions. Improved aeration, with
decreased left
lower lobe atelectasis. Moderate cardiomegaly is stable.
Multilevel
degenerative changes in the thoracic spine.
IMPRESSION: Post-surgical changes, with improved left lower
lobe aeration.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 10307**] HO
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No mass/thrombus is seen in the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is moderate/severe P2 leaflet and A2
leaflet mitral valve prolapse. An eccentric, anteriorly directed
jet of moderate to severe (3+) mitral regurgitation is seen as
well as a central jet. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results at time of
surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Left ventricular function is unchanged. The right
ventricle is mildly hypokinetic. There is a well-seated mitral
annuloplasty ring in place. There is a mean gradient of 3 mmHg
at a cardiac output of 5.5 L/min. No mitral regurgitation is
seen. The aorta is intact post-decannulation.
Brief Hospital Course:
The patient was admitted [**2184-5-20**] and was started on Heparin. He
underwent MV repair( 28mm ring)/CABGx1(SVG->OM)/MAZE on [**5-21**].
He tolerated the procedure well and was transferred to the CVICU
in stable condition on Propofol. He was extubated on post op
night and was transferred to the floor on POD#1. His chest
tubes and wires were discontinued on POD#2. He was
anticoagulated with coumadin and progressed well. On POD#4 he
was discharged to home in stable condition and in sinus rhythm.
His coumadin will be followed by Dr. [**Last Name (STitle) **].
Medications on Admission:
CARVEDILOL 6.25 mg [**Hospital1 **]
DIAZEPAM 2 mg HS
HYDROCODONE-ACETAMINOPHEN 10 mg/660 mg Tablet - 1 tablet 3-4
times daily for arthritis pain in neck and shoulder
WARFARIN 5 mg Daily -stopped [**5-15**]
Simvastatin 20mg Daily
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 3 days: Decrease dose to 400 mg PO daily for seven
days after this dose complete, after 1 week decrease dose to 200
mg PO daily.
Disp:*40 Tablet(s)* Refills:*0*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 7 days.
Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*0*
10. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
titrate for INR of [**2-6**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
River [**Hospital **] Homecare
Discharge Diagnosis:
CAD
atrial fibrillation; diagnosed in [**7-/2183**]
s/p unsuccessful cardioversion in [**State 1727**]
mitral regurgitation
hyperlipidemia
osteoarthritis
carpal tunnel of left wrist s/p repair
compound tib-fib fracture 25 yrs ago
Past Surgical History:
s/p carpal tunnel repair
s/p repair of compound tib-fib fracture 25 yrs ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2184-6-28**] 2:20
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2184-6-30**] 1:00
Please call Dr. [**Last Name (STitle) 27295**] for a wound check appointment in 1
week and a follow up appointment in [**4-8**] weeks.
Completed by:[**2184-5-25**]
|
[
"715.90",
"427.31",
"V17.1",
"416.8",
"V15.51",
"272.4",
"414.01",
"424.0",
"429.5",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"37.36",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
8019, 8080
|
5771, 6342
|
290, 819
|
8453, 8665
|
2975, 5748
|
9453, 9893
|
2195, 2260
|
6622, 7996
|
8101, 8331
|
6368, 6599
|
8689, 9430
|
8354, 8432
|
2275, 2956
|
234, 252
|
847, 1512
|
1556, 1782
|
1899, 2164
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,223
| 126,972
|
13489+56461
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-5-29**] Discharge Date: [**2165-6-3**]
Date of Birth: [**2081-12-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
[**2165-5-29**] - Coronary artery bypass grafting x2 (Left internal
mammary-Left anterior descending artery, saphenous vein
graft-Obtuse marginal artery).
History of Present Illness:
This 83 year old gentleman with a history of coronary artery
disease underwent angioplasty in [**2153**]. He has recently had
worsening dyspnea on exertion and angina. A cardiac
catheterization was performed which revealed significant three
vessel disease and mild aortic stenosis. he was admitted for
elective revascularization.
Past Medical History:
Coronary artery disease
Mild Aortic stenosis
Hyperlipidemia
Hypertension
Non-insulin dependent diabetes mellitus
Benign Prostate hypertrophy
Mild chronic renal insufficiency
Anemia of uncertain etiology
Social History:
Retired.
Lives with his wife.
[**Name (NI) 4084**] smoked and rarely drinks alcohol.
Family History:
Brother s/p bypass surgeries.
father had coronary artery disease
Physical Exam:
Admission:
On examination, his heart rate is 72 and regular. Blood
pressure on the right is 160/70 and on the left of 142/70. He
is 6 feet tall weighing approximately 198 lbs. He does have a
faint intermittent tremor, which may be intention. I do not
believe, it has been worked up. His skin is unremarkable.
Pupils are equal round and reactive to light and accommodation.
EOMs are intact. Sclerae is anicteric. Oropharynx is
unremarkable. Neck is supple with full range of motion. No JVD
is appreciated. Lungs are clear bilaterally. Heart has regular
rate and rhythm with a grade IV/VI systolic ejection murmur
heard throughout his precordium and up into his carotids.
Abdomen is soft, nontender, and nondistended with positive bowel
sounds. No hepatosplenomegaly or CVA tenderness is detected.
Extremities are warm and well perfused without any varicosities.
He does have trace bilateral lower extremity edema. He is
neurologically grossly intact with a nonfocal examination and
moving all extremities with 5/5 strengths. He has 2+ bilateral
femoral DP, PT, and radial pulses. His murmur transmits into
his carotids versus possible carotid bruit.
Pertinent Results:
[**2165-5-29**] ECHO
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No thrombus is seen in the 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. Regional left ventricular wall motion
is normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Right ventricular chamber size and free wall motion
are normal. The aortic root is moderately dilated at the sinus
level. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly to moderately thickened. There is
moderate aortic valve stenosis with valve area of 1.2cm2
calculated by Doppler assessment and valve area of around 1.5
cm2 by planimetry. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the operating
room at the time of the study.
POST-BYPASS: The patient is in sinus rhythm. There is normal
biventricular systolic function. The left ventricular ejection
fraction is about 70%. There is no change in valvular function
compared to the pre-bypass study. The thoracic aorta appears
intact.
[**2165-6-1**] 07:30AM BLOOD WBC-10.5 RBC-3.19* Hgb-9.9* Hct-29.3*
MCV-92 MCH-31.0 MCHC-33.7 RDW-13.5 Plt Ct-141*
[**2165-6-1**] 07:30AM BLOOD Glucose-76 UreaN-41* Creat-1.9* Na-137
K-3.7 Cl-105 HCO3-25 AnGap-11
[**2165-6-3**] 05:35AM BLOOD WBC-7.1 RBC-3.06* Hgb-9.4* Hct-27.5*
MCV-90 MCH-30.9 MCHC-34.3 RDW-13.4 Plt Ct-188
[**2165-6-3**] 05:35AM BLOOD Glucose-79 UreaN-44* Creat-1.7* Na-136
K-3.9 Cl-103 HCO3-24 AnGap-13
[**2165-5-30**] 03:42AM BLOOD Glucose-135* UreaN-29* Creat-1.3* Na-138
K-5.6* Cl-113* HCO3-18* AnGap-13
[**2165-6-1**] 07:30AM BLOOD Glucose-76 UreaN-41* Creat-1.9* Na-137
K-3.7 Cl-105 HCO3-25 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 16098**] was admitted to the [**Hospital1 18**] on [**2165-5-29**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to two vessels. Of note, intraoperative transeosphageal
echocardiogram did not reveal significant enough aortic stenosis
to warrant surgical replacement of his valve. Please see
operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours, he awoke neurologically
intact and was extubated. Aspirin, statin and beta blockade were
resumed. On postoperative day one, he was transferred to the
step down unit for further recovery.
He was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
strength and mobility. The patient did develop atrial
fibrillation and was treated with IV amiodarone. He converted
to sinus rhythm thereafter. Chest tubes and pacing wires were
discontinued without complication.
He remained in sinus rhythm and his metoprolol was changed to
Atenolol as preoperatively. His diuretics will be continued at
discharge for a week to get him to his preop weight. He was
ready for discharge and was transferred to a rehabilitation
facility before eventual discharge to home.
He will be kept on warfarin for the paroxysmal atrial
fibrillation he had postop. The goal INR is 2 to 2.5. He
received 5 mg of Coumadin on [**6-2**] and will receive 5 mg today
([**6-3**]). The duration of this will be determined by his
cardiologist.
Medications on Admission:
simvastatin 20', lisinopril 40', atenolol 50', HCTZ 25',
Terazosin 2', Glipizide 40", Protonix 40', ASA 81', Plavix 75',
Iron, Vit B 12
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. Simvastatin 10 mg Tablet Sig: Two (2) 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. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 2 weeks. Tablet(s)
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days. Tab Sust.Rel. Particle/Crystal(s)
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks: decrease to 200mgm [**Hospital1 **] after that for two
weeks additionally.
15. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: INR goal 2--2.5.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass grafts
Mild Aortic stenosis
Hyperlipidemia
Hypertension
Non-insulin dependent diabetes mellitus
Benign Prostate hypertrophy
Mild chronic renal insufficiency
Anemia
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness of,
or drainage from or increased pain from incisions.
Please report any fever greater then 100.5
Report any weight gain of 2 pounds in 24 hours or5 pounds in a
week.
Shower daily, no baths or swimming.
No lotions powders or creams to incision until it has fully
healed.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month and off all narcotics.
Take all medications as directed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 14522**] in 2 weeks.
Please follow-up with Dr. [**First Name (STitle) 1356**] in [**3-5**] weeks ([**Telephone/Fax (1) 40833**]).
Call all providers for appointments.
Completed by:[**2165-6-3**] Name: [**Known lastname 7356**],[**Known firstname **] S. Unit No: [**Numeric Identifier 7357**]
Admission Date: [**2165-5-29**] Discharge Date: [**2165-6-3**]
Date of Birth: [**2081-12-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Mr. [**Known lastname **] failed to void after his Foley catheter was
removed. His Terazosin was resumed and the catheter replaced on
[**2165-6-1**]. Urinalysis was unremarkable. He was transferred with
the catheter in place and it should be removed when he is
ambulatory .
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
[**2165-5-29**] - Coronary artery bypass grafting x2 (Left internal
mammary-Left anterior descending artery, saphenous vein
graft-Obtuse marginal artery).
History of Present Illness:
see summary
Past Medical History:
Coronary artery disease
Mild Aortic stenosis
Hyperlipidemia
Hypertension
Non-insulin dependent diabetes mellitus
Benign Prostate hypertrophy
Mild chronic renal insufficiency
Anemia of uncertain etiology
Social History:
Retired.
Lives with his wife.
[**Name (NI) 7358**] smoked and rarely drinks alcohol.
Family History:
Brother s/p bypass surgeries.
father had coronary artery disease
Physical Exam:
see summary
Pertinent Results:
[**2165-5-30**] 03:01PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
see summary
Medications on Admission:
see summary
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. Simvastatin 10 mg Tablet Sig: Two (2) 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. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 2 weeks. Tablet(s)
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days. Tab Sust.Rel. Particle/Crystal(s)
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks: decrease to 200mgm [**Hospital1 **] after that for two
weeks additionally.
15. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: INR goal 2--2.5.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) 3876**]
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass grafts
Mild Aortic stenosis
Hyperlipidemia
Hypertension
Non-insulin dependent diabetes mellitus
Benign Prostate hypertrophy
Mild chronic renal insufficiency
Anemia
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness of,
or drainage from or increased pain from incisions.
Please report any fever greater then 100.5
Report any weight gain of 2 pounds in 24 hours or5 pounds in a
week.
Shower daily, no baths or swimming.
No lotions powders or creams to incision until it has fully
healed.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month and off all narcotics.
Take all medications as directed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 2092**]
Please follow-up with Dr. [**Last Name (STitle) 7359**] in 2 weeks.
Please follow-up with Dr. [**First Name (STitle) 2861**] in [**3-5**] weeks ([**Telephone/Fax (1) 7360**]).
Call all providers for appointments.
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2165-6-3**]
|
[
"403.90",
"285.21",
"424.1",
"585.9",
"788.20",
"250.00",
"600.01",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"88.72",
"39.61",
"36.15",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
12269, 12388
|
10674, 10687
|
9865, 10022
|
12647, 12654
|
10522, 10651
|
13183, 13613
|
10409, 10475
|
10749, 12246
|
12409, 12626
|
10713, 10726
|
12678, 13160
|
10490, 10503
|
9802, 9827
|
10050, 10063
|
10085, 10290
|
10306, 10393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,767
| 147,191
|
26344
|
Discharge summary
|
report
|
Admission Date: [**2168-4-6**] Discharge Date: [**2168-4-22**]
Date of Birth: [**2091-1-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Nitroglycerin / Nitrofurantoin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Increased dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2168-4-13**]
1. Mitral valve replacement with a size 27-mm St. [**Male First Name (un) 923**] Epic
tissue valve.
2. Left atrial appendage ligation.
3. Maze procedure with radiofrequency ablation probe.
4. Closure of patent foramen ovale.
5. Coronary artery bypass graft x1: Saphenous vein graft
to posterior descending artery.
6. Removal of suspected fibroelastoma from the aortic
valve.
History of Present Illness:
77 year-old female who was admitted to [**Hospital3 3583**] on [**2168-4-3**]
with worsening dyspnea on exertion and was found to be in acute
diastolic heart failure and recurrent atrial fibrillation. She
reports she has been SOB since [**Month (only) **].
It has progressively gotten worse to the point that she could
not take a shower or wash her face without getting SOB. She also
has had worsening palpitations and knows she has been in Afib
more often than usual since then. On the evening of admission to
[**Hospital1 46**] she "thought she was going to die" so called the
ambulance and was taken to the OSH ED. Initial ECG showed afib
with rate in
the 90s and chronic LBBB. She was given IV Lasix and bipap and
after a few hours felt better. She underwent an echo which
showed [**4-1**] + MR (worse from previous echos) and regional wall
motion abnormalities. EF was reportedly at 50-55%. She is being
transferred to [**Hospital1 18**] for further evaluation of her mitral
regurgitation. She has been referred to cardiac surgery for
evaluation of a mitral valve replacement.
Past Medical History:
- mild CAD by cath in [**2163-2-13**] (Left main had a discrete 30%
lesion. LAD had a discrete 30% mid vessel lesion. Left
circumflex
showed no significant disease. RCA also demonstrated only mild
disease. A large ramus had a 60% mid vessel lesion with normal
flow distal to the lesion.)
- Atrial fibrillation (on Coumadin. refractory to amiodarone and
now on sotalol); has a history of many cardioversion and
medication trials
- Diabetes Mellitus
- Hypercholesterolemia
- Hypertension
- TIA
- Renal Insufficiency (baseline creatinine 1.4)
- Carotid stenosis
- PVD/Right S Fem Art stenosis s/p angioplasty no stents or
grafts
Past Surgical History:
- s/p Colectomy [**3-2**] diverticulitis/sigmoid resection
Social History:
Lives with:husband
Occupation:retired
Tobacco:quit smoking 20 years ago,history of [**1-31**] packs per day
x40 years
ETOH:denies
Family History:
Non-contributory
Physical Exam:
Pulse:48 Resp:16 O2 sat:97/2L
B/P Right:105/71 Left: 122/73
Height:5'3" Weight:142 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Incision well-healed LLQ
Extremities: Warm [x], well-perfused [x] Edema 0
Varicosities: None [+2]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2168-4-22**] 04:15AM BLOOD WBC-12.4* RBC-3.29* Hgb-10.7* Hct-30.9*
MCV-94 MCH-32.6* MCHC-34.7 RDW-14.0 Plt Ct-274
[**2168-4-22**] 04:15AM BLOOD Glucose-124* UreaN-38* Creat-1.1 Na-139
K-4.5 Cl-105 HCO3-24 AnGap-15
[**2168-4-21**] 04:25AM BLOOD WBC-13.2* RBC-3.12* Hgb-10.3* Hct-29.1*
MCV-93 MCH-33.2* MCHC-35.5* RDW-14.0 Plt Ct-224
[**2168-4-20**] 04:32AM BLOOD WBC-11.4* RBC-3.40* Hgb-10.7* Hct-31.6*
MCV-93 MCH-31.5 MCHC-33.8 RDW-14.3 Plt Ct-183
[**2168-4-21**] 04:25AM BLOOD PT-13.6* INR(PT)-1.2*
[**2168-4-20**] 04:32AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2*
[**2168-4-19**] 02:34AM BLOOD PT-13.2 PTT-23.7 INR(PT)-1.1
[**2168-4-18**] 02:10AM BLOOD PT-13.3 PTT-25.1 INR(PT)-1.1
[**2168-4-21**] 04:25AM BLOOD Glucose-129* UreaN-37* Creat-1.2* Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
[**2168-4-20**] 04:32AM BLOOD Glucose-128* UreaN-36* Creat-1.2* Na-138
K-4.3 Cl-103 HCO3-26 AnGap-13
[**2168-4-19**] 10:03PM BLOOD Glucose-125* UreaN-37* Na-136 K-5.0
Cl-103
[**2168-4-19**] 02:34AM BLOOD Glucose-129* UreaN-37* Creat-1.2* Na-138
K-4.1 Cl-104 HCO3-27 AnGap-11
TEE Intra-op [**2168-4-13**]
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-40 %). The septal wall appears to be
dyskinetic, although this may be due to dyssynchrony (the septal
wall does not thin during systole.)
Right ventricular chamber size is normal. The RV systolic
function is borderline normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. No thoracic aortic
dissection is seen.
The aortic valve leaflets (3) with good leaflet excursion and no
aortic stenosis. There is a filamentous mobile strand on the tip
of the right coronary cusp that is concerning for fibroelastoma.
The non-cororary cusp appears slightly redundant. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. A moderate to severe (3+) central jet of
mitral regurgitation is seen. There is moderate MAC.
POST-CPB:
There is a bioprosthetic valve in the mitral position. The valve
is well-seated with normal leaflet mobility. The native MV
support structures are still in place. There is trace central
MR, there is no paravalvular leak. The peak gradient across the
mitral valve is 14mmHg, the mean gradient is 6mmHg with CO 4.5.
The filamentous structure on the aortic valve is no longer seen,
consistent resection. There is no AS or AI.
There is no residual PFO after PFO repair.
The LV systolic function appears improved with the patient being
on Epi, Norepi, and Milrinone infusions; estimated EF = 45%. The
septal wall shows dyssynchronous movement. The RV is mildly
hypokinetic.
There is no aortic dissection.
Dr. [**Last Name (STitle) **] was notified in person of the results at the
time of study.
Brief Hospital Course:
The patient was brought to the operating room on [**2168-4-13**] where
the patient underwent MVReplacement with 27mm tissue valve,
CABG, PFO closure, Maze Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. Amiodarone was
initiated for atrial fibrillation. The patient did go into
complete heart block. EP was consulted and antiarrhythmics were
discontinued. Transvenous wire was placed. She progressed to
junctional rhythm and eventually to sinus rhythm. Atrial
fibrillation returned and beta blocker was resumed. She did
convert to sinus rhythm and transvenous wire was removed.
Anticoagulation was resumed for atrial fibrillation after wire
was removed. She is to take 7.5 mg Coumadin on [**4-22**] for atrial
fibrillation with INR to be checked [**4-23**] for goal INR [**3-3**]. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 9, the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to the [**Hospital 1319**]
Rehab Hospital-[**Hospital3 **] in good condition with appropriate
follow up instructions.
Medications on Admission:
MEDICATIONS ON TRANSFER:
ASA 81mg daily
lisinopril 2.5mg daily
Lasix 20mg daily
Glipizide 2.5mg daily
Levothyroxine 25mcg daily
Simvastatin 40mg daily
Ferrous gluconate 325mg daily
Vitamin D 1000units daily
Albuterol inhaler twice daily
Diltiazem 120mg daily
HOME MEDICATIONS: (from OSH H&P)
Sotalol 20 mg po bid
ASA 81 mg po daily
Warfarin 2.5 mg alternating with 5 mg po daily
Lisinopril 5 mg po daily
Diltiazem 120 mg po daily
Lasix 20 mg po daily
Glipizide 2.5 mg po daily
Levothyroxine 25 mcg po daily ? (unsure about this dose as the
OSH paper had a mark on the dose)
Simvastatin 40 mg po daily
Ferrous gluconate 325 mg po daily
Vitamin D 1000 units po daily
Albuterol HFA 1-2 puffs [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: then decrease to 20 mg po daily per home dose
regimen.
4. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever/pain.
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
13. 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.
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
18. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
19. warfarin 5 mg Tablet Sig: 1.5 Tablets PO ONCE (Once): Take
as directed for INR goal [**3-3**]. Take 7.5 mg on [**4-22**] and INR to be
drawn [**4-23**] with further dosing instructions to be given.
20. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Sliding Scale
70-120 - 0 units
121-150 - 2 units
151-180 - 4 units
181-210 - 6 units
211-240 - 8 units
>240 - 10 units and [**Name8 (MD) 138**] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
- mild CAD by cath in [**2163-2-13**] (Left main had a discrete 30%
lesion. LAD had a discrete 30% mid vessel lesion. Left
circumflex
showed no significant disease. RCA also demonstrated only mild
disease. A large ramus had a 60% mid vessel lesion with normal
flow distal to the lesion.)
- Atrial fibrillation (on Coumadin. refractory to amiodarone and
now on sotalol); has a history of many cardioversion and
medication trials
- Diabetes Mellitus
- Hypercholesterolemia
- Hypertension
- TIA
- Renal Insufficiency (baseline creatinine 1.4)
- Carotid stenosis
- PVD/Right S Fem Art stenosis s/p angioplasty no stents or
grafts
Past Surgical History:
- s/p Colectomy [**3-2**] diverticulitis/sigmoid resection
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- 2+ bilateral LEs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**], [**2168-5-9**] 1:15
Please call to schedule the following:
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] at [**Hospital3 3583**] [**Telephone/Fax (1) 65191**]
in 3 weeks
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 275**] G [**Telephone/Fax (1) 36604**] in [**5-3**] 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 atrial fibrillation 7.5 mg to be given [**4-22**]
Goal INR [**3-3**]
First draw [**2168-4-23**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2168-4-22**]
|
[
"424.0",
"427.31",
"585.3",
"250.00",
"426.0",
"V15.82",
"428.21",
"414.01",
"428.0",
"272.4",
"433.10",
"V58.61",
"440.20",
"745.5",
"V58.67",
"403.90",
"425.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"88.53",
"35.71",
"37.78",
"88.56",
"36.11",
"37.36",
"35.23",
"88.72",
"37.22",
"39.61",
"37.99"
] |
icd9pcs
|
[
[
[]
]
] |
11203, 11330
|
6543, 8271
|
326, 732
|
12082, 12264
|
3443, 6520
|
13136, 14133
|
2741, 2759
|
9028, 11180
|
11351, 11977
|
8297, 8297
|
12288, 13113
|
12000, 12061
|
2774, 3424
|
8575, 9005
|
256, 288
|
760, 1845
|
8322, 8557
|
1867, 2493
|
2593, 2725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,252
| 182,037
|
48952
|
Discharge summary
|
report
|
Admission Date: [**2145-5-11**] Discharge Date: [**2145-5-14**]
Service: MEDICINE
Allergies:
Keflex / Penicillins / Erythromycin Base / Codeine
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Transferred from [**Hospital **] Hosp for rapid atrial fibrilliation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo female with history of chronic atrial fibrillation who was
admitted to [**Hospital **] Hosp with bradycardia. She was recently
admitted to [**Hospital1 18**] fro umbilical hernia repair, post-op
complicated by rapid atrial fibrillation that required IV
diltiazem. She was discharged to rehab and then to home on
Diltiazem XR 180 mg daily and metoprolol 150 mg [**Hospital1 **]. On [**2145-5-9**]
she complained of generalized weakness and fatigue. VNA noted a
HR of 40. She was sent to [**Hospital1 **] ER and found to be in afib with
HR 40, hyperkalemic with K = 6.4 and ARF with creatinine of 3.8
(bl 2.1). She was given kayexalate and went into rapid afib, HR
130's and hypotension with SBP 90's. She was stated on esmolol
drip and HR decreased to 110's. She was transferred to [**Hospital1 18**] for
EP eval.
Past Medical History:
Incarcerated ventral hernia
Atrial fibrillation
GERD
HTN
CRI (bl creat 2)
h/o diverticulosis
Uterine CA [**56**] yrs ago
s/p appendectomy
s/p cholecystectomy
s/p TAH
s/p T&A
s/p L breast biopsy
s/p suprapubic tube placement
Social History:
Patient lives with son, denies ETOH, tobacco, drugs. Also has
daughter. [**Name (NI) **] to perform ADL's.
Family History:
Non-contributory
Physical Exam:
Afebrile, 118/67, 124, 16, 99%RA
Genl- NAD, A&Ox3
HEENT - MMM
CV - irreg irreg, II/VI systolic murmur at RUSB
Lungs - CTA
ABD - soft, NT, ND, healed umbilical midline scar, NABS
EXT - no edema, 2+ DP pulses BL
Pertinent Results:
OSH:
WBC 5.5, HCT 35.6, Plt 162
U eos neg
U Na 40
CK 17
Trop I 0.03, 0.06
UA >100,000 [**Name (NI) **]
PTH 136 ([**9-/2105**])
INR 2.8
Brief Hospital Course:
She was transferred from OSH with atrial fibrillation with rapid
ventricular response.
1. Afib: Etiology felt to be seocndary to volume depletion as
she was given kayexalate at OSH which resulted in diarrhea. She
was given IVF for volume repletion. She was started on a
diltiazem drip to control her HR. EP service was consulted for
possible need for pacemaker. She was transitioned to oral
metoprolol and diltiazem. EP felt she did not need pacemaker or
ablation at this time.
2. ARF: Her creatinine had normalized at time of transfer and
was felt to be prerenal. We monitored her fluid status. She was
sent home on a lower dose of lasix 40 mg versus 60 mg daily.
3. UTI: COntinued ciprofloxacin for 7 day course.
Medications on Admission:
Diltiazem XR 180 mg daily
Pantoprozole 40 mg dialy
Warfarin 1 mg QHS
Metoprolol 150 mg [**Hospital1 **]
Colace
Lasix 60 mg daily
KCL 40 meq daily
[**Doctor First Name **] 180 mg daily
Omeprazole 20 mg daily
CaCO3 500 mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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*
3. Fexofenadine HCl 60 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
7. Diltiazem HCl 240 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
8. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO Q Mon,
TUes, Thurs, Fri, Sat, Sun: 1 mg Q Mon, Tues, Thurs, Fri, Sat,
Sun
2 mg Q Wed.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
Follow up with Dr. [**Last Name (STitle) **] on Tuesday, [**2145-5-18**] as scheduled.
Take your medications as prescribed.
If you feel palpitations, Shortness of breath or chest pain,
call your doctor or go to the ER.
You need to have your INR checked on TUesday. COntinue to take 1
mg of coumadin each night (except Wednesday when you take 2 mg)
until you follow up with Dr. [**Last Name (STitle) **]
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] on Tuesday, [**2145-5-18**] as scheduled. Have
your INR check then.
You should also call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (Cardiology) for
an appointment in 2 months, [**Telephone/Fax (1) 2386**]
|
[
"427.31",
"428.0",
"599.0",
"593.9",
"276.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4079, 4150
|
2009, 2726
|
327, 334
|
4214, 4221
|
1850, 1986
|
4673, 4961
|
1586, 1604
|
3013, 4056
|
4171, 4193
|
2752, 2990
|
4245, 4650
|
1619, 1831
|
219, 289
|
362, 1198
|
1220, 1445
|
1461, 1570
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,154
| 180,739
|
21055
|
Discharge summary
|
report
|
Admission Date: [**2146-6-13**] Discharge Date: [**2146-7-7**]
Date of Birth: [**2081-2-6**] Sex: M
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
MCC, unhelmeted, thrown into fence
Major Surgical or Invasive Procedure:
[**2146-6-13**] I&D of scalp, repair of facial and scalp degloving
injuries. Ventriculostomy placement.
[**2146-6-20**] Anterior Cervical Diskectomy and fusion of C5-7
[**2146-6-22**] PEG tube placement @ bedside
[**2146-6-23**] ORIF of Leforte III fx's. Tracheostomy
History of Present Illness:
65 y.o. man, unhelmeted, involved in a MCC, who was thrown from
his bike into a fence at ~65MPH. GCS of 4 on scene, moving all 4
extremities. Pt was intubated on scene and taken to OHS. Pt was
transferred to [**Hospital1 18**] for management of his massive head and
facial trauma.
Past Medical History:
none
Social History:
lives with wife
Family History:
non-contributory
Physical Exam:
PE on admission
VS: Temp 37C HR 79 BP 132/50 Sat 100%
Gen: intubated
GCS 2I
HEENT: massive right-sided degloving injury to scalp with
palpable depressed skull fracture, avulsion of nose tip,
mid-face instability, bilateral orbital ecchymosis, PER 1mm
minimally reactive, TM clear, neck no crepitus
Chest: stable, no crepitus, equal breath sounds bilaterally
CV: RRR
Abdomen: soft, non-distended, FAST neg
Pelvis: stable to [**Doctor Last Name **]
Rectal: no tone, guiac neg
Ext: no visible deformity, paralyzed
Pertinent Results:
CT RECONSTRUCTION [**2146-6-13**] 7:00 PM
IMPRESSION: Fractures through the basion, C1, C2 and C6. The
fracture through the C1 lateral mass extends crossing the
vertebral artery foramen. In addition there is slight anterior
displacement of the right posterior arch of C1. Overall anterior
posterior alignment is preserved.
CT ORBIT, SELLA & IAC W/O CONTRAST [**2146-6-24**] 9:15 AM
CT OF THE FACIAL BONES: There has been interval reduction and
internal fixation with metallic plates and fixation screws seen
along the bilateral zygomatic bones, maxilla, and nasal bone.
There has also been placement of mesh material along the right
inferior orbit. There is near anatomic alignment of the reduced
fractures. A surgical drain is seen in the frontal scalp. There
are numerous other facial and skull fractures seen, as described
previously. Particular note is made of an osseous fragment seen
superior to the left cribriform plate which projects into an
area of hypodense brain parenchyma. There is persistent
opacification of the visualized sinuses.
IMPRESSION: Anatomic alignment of multiple fracture reductions
with fixation plates and screws, as well as placement of mesh
along the inferior right orbit.
C-SPINE (PORTABLE) [**2146-6-29**] 3:17 PM
AP and lateral bedside radiographs of the cervical spine are
suboptimal due to portable technique and large patient size.
There is anterior fusion of C5-7 with corresponding perforated
plate and vertebral body screws. However, the spine is
inadequately assessed below the C4-5 level in lateral projection
despite several attempts. A tracheostomy tube is in place and an
apparent left subclavian line has its tip just reaching the SVC.
There is a poorly visualized fracture of the posterior elements
of C1 and apparent fractures elsewhere in the spine. The
visualized upper lungs are clear. The previous apparent
intraoperative radiographs [**2146-6-20**] also inadequately assessed
the fusion.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2146-7-2**] 11:28 AM
IMPRESSION:
1. Near-anatomic alignment with multiple facial fractures with
microfixation plates and compression screws. There is placement
of mesh material in the right inferior orbit. No significant
interval change since [**2146-6-24**], examination.
2. Left cribriform plate fracture with an osseous fragment which
projects into the left inferior frontal lobe. This finding was
noted on [**2146-6-24**] as well and also discussed with house-staff at
that time. This raises concern for an area of potential future
cerebrospinal fluid leak and/or meningitis.
Brief Hospital Course:
[**2146-6-13**] overnight to [**2146-6-14**]: Transfer to [**Hospital1 18**]. Head CT
revealed bilateral SAH with left frontal lobe contusion, large
IPH, with ventricular bleed. Right occipital bone fx. No midline
shift. Pt taken to OR for I&D of open skull fx, cranialization
of frontal sinus, placement of ventricular catheter, and I&D of
scalp wound. Admitted to TSICU
[**2146-6-14**]: Ortho spine [**Month/Day/Year **] CT C-spine with C1 Left lamina fx
entering the vertebral foramen, C2 left facet fx, C6 left facet
fx.
Neurosurgery 6 vessel cerebral angio: no carotid or vertebral
injury
[**2146-6-16**] to [**2146-6-19**]: TSICU monitoring and ICP and Abx therapy,
Zosyn and Gent for possible sinus infection. Pt remains
intubated.
[**2146-6-20**]: Anterior Cervical Diskectomy and fusion of C5-7.
[**2146-6-22**]: PEG tube placement @ bedside. Plastic surgery consult
regarding nasal repair.
[**2146-6-23**] to [**2146-6-30**]: ORIF of Leforte III fx's by OMFS, Plastics,
and Neurosurgery. Tracheostomy. Vancomycin started on [**6-27**] for
continued fevers. Extubated and placed on trach collar.
Transferred to floor on [**6-30**] with continued Abx therapy on Zosyn
and Vanc.
[**2146-6-30**] to [**2146-7-7**]: Pt stable on floor with 1:1 sitter.
Neurologic status continued to improve. Pt fitted for PMV to
enable vocalization. Still unable to pass swallow [**Last Name (LF) **], [**First Name3 (LF) **]
continued on tube feeds. Fevers continued although no source was
identified. ID consult obtained on [**7-2**]--suggested persistent
fevers could be related to ABX. Zosyn/Vanc d/c after full 14/7
day course respectively. Fevers subsided by day 4 off Abx. Pt
continued with PT and was able to ambulate with assistance.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 15 mL dose
PO BID (2 times a day).
Disp:*60 15 mL dose* Refills:*2*
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Chlorhexidine Gluconate 0.12 % Liquid Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
Disp:*1350 ML(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 MDI* Refills:*2*
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-3**]
Drops Ophthalmic PRN (as needed).
Disp:*1 months supply* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*1350 ML(s)* Refills:*0*
7. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
Disp:*1 months supply* Refills:*2*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Haloperidol Lactate 2 mg/mL Concentrate Sig: Two (2) mL PO
TID (3 times a day) as needed for agitation.
Disp:*1350 mL* Refills:*2*
11. Acetaminophen 160 mg/5 mL Elixir Sig: Five (5) mL PO Q6H
(every 6 hours).
Disp:*600 mL* Refills:*2*
12. Ibuprofen 100 mg/5 mL Suspension Sig: Thirty (30) mL PO Q6H
(every 6 hours).
Disp:*3600 mL* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. I&D of scalp, repair of facial and scalp degloving injuries.
Ventriculostomy placement.
2. Anterior Cervical Diskectomy and fusion of C5-7
3. PEG tube placement @ bedside
4. ORIF of Leforte III fx's. Tracheostomy
Discharge Condition:
Improving
Discharge Instructions:
The pt should be continued on tube feeds with a goal of 80
cc/hr.
Oral hygeine is very important in this pt as he has a wound on
his hard palate. Continue Peridex 10-15 cc swish and swallow [**Hospital1 **]
and NS rinses every 4 to 6 hours. You may brush hard palate
gently two to three times a day.
Continue PT and consider reevaluation of swallowing function
when appropriate. Pt has PMV to enable speech.
Followup Instructions:
OMFS: Pt should follow-up with Oral Maxillofacial Surgery 2 to
3 weeks after discharge. Call the [**Hospital 40530**] clinic at ([**Telephone/Fax (1) 55915**].
The clinic is located at [**Hospital 55916**] Hospital. When you call
they will give you directions to the clinic.
OPTHOMOLOGY: Pt should follow-up in the [**Hospital1 **] eye clinic in 4 to 6
weeks. Call ([**Telephone/Fax (1) 18621**] to schedule an appt. They will give
you directions to the location of the clinic at that time.
NEUROSURGERY: The pt should follow up with Dr. [**Last Name (STitle) 739**] in
4 to 6 weeks. Prior to this appt the pt should have a repeat
Head CT. Please call ([**Telephone/Fax (1) 88**] and ask to schedule an appt
and time for Head CT.
TRAUMA: Pt should follow up in Trauma clinic in 2 weeks. Call
([**Telephone/Fax (1) 55917**] to schedule an appt for [**2146-7-26**]. The
clinic is located in the [**Hospital Unit Name **] [**Location (un) 470**] in Department
3A on [**Last Name (NamePattern1) **].
|
[
"861.21",
"518.5",
"804.70",
"805.01",
"805.06",
"041.7",
"805.02",
"E816.2",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"76.74",
"96.72",
"86.22",
"22.42",
"99.15",
"96.6",
"02.2",
"88.41",
"43.11",
"81.02",
"76.76",
"02.02",
"80.51",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
7579, 7676
|
4194, 5934
|
361, 635
|
7940, 7951
|
1588, 4171
|
8409, 9415
|
1023, 1041
|
5989, 7556
|
7697, 7919
|
5960, 5966
|
7975, 8386
|
1056, 1569
|
287, 323
|
663, 946
|
968, 974
|
990, 1007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,516
| 191,600
|
21791+57263
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-9-24**] Discharge Date: [**2106-9-30**]
Date of Birth: [**2062-10-25**] Sex: M
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
1. Left lateral canthotomy
2. ORIF of left orbital floor fracture with titanium mesh
placement
History of Present Illness:
43 y/o male, currently in prision, assaulted, struck in left
eye. +LOC, patient unconscious at the scene. Left pupil dilated
and unreactive. Patient intubated and transferred to [**Hospital1 18**] ER
via [**Location (un) 7622**].
Past Medical History:
1. Diabetes Mellitus, insulin dependent
2. HIV + (CD4 count 947)
3. HCV
4. HTN
5. asthma
6. migraine HA
Social History:
currently incarcerated at Old Colony Correction [**Location (un) 1475**], MA
Family History:
non-contributory
Physical Exam:
On arrival to the ED:
vitals: Temp 98.9 HR 83 BP 195/120, recheck 158/110, sat 100%
GCS 8T FSBG 350
GEN: intubated, sedated
HEENT: R pupil 3 mm reactive, L pupil 8 mm reactive. left
periorbital hematoma, with gross proptosis. TM intact
bilaterally, no hemotympanum. ET tube in place, NG tube in
place.
NECK: c-collar in place
CHEST: equal breath sounds bilaterally, no wheeze
CV: RRR
ABD: soft, non-distended, + BS, FAST neg
Rectal: decreased tone, guiac negative
Vasc: Pulses 2+ and symmetric bilaterally
Neuro: moving all 4 ext, withdraws to pain, does not follow
commands
Pertinent Results:
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2106-9-24**] 3:44 PM
1) Left optic nerve sheath hematoma.
2) Left orbital floor fracture which extends into the inferior
aspect of the medial wall. There is some herniation of the
extracoronal orbital fat but no evidence of herniation of the
inferior rectus muscle.
3) Blood fluid level in the left maxillary sinus.
Brief Hospital Course:
[**2106-9-24**]: On arrival to the ED, the patient had gross proptosis
and a large hematoma surrounding his left eye. A left lateral
canthotomy was performed to release any blood/pressure in the
retrobulbar space. The patient was taken to CT scan for further
analysis of his head, c-spine, abdomen and pelvis. He was
transferred to the trauma SICU for overnight observation and
management.
[**2106-9-25**] to [**2106-9-30**]: Patient was successfully extubated and
transferred to the floor. His head/face CT revealed a left
orbital floor fracture extending into the inferior aspect of the
medial wall, but with no muscular entrapment. The patient had no
other injuries other than those to his face. The patient did
well on the floor and will be taken to the operating room by the
plastics team next week for ORIF, titanium mesh placement of the
patient's left oribtal floor fx. The patient will return to his
facility in the interim until surgery. At the time of discharge
he was tolerating PO and his pain well controlled on oral pain
medication.
Medications on Admission:
Insulin NPH 30 U QAM and 20 U QHS
ASA 81 mg PO QD
Vasotec 5 mg PO QD
HCTZ 12.5 mg PO QD
Inderal 20 mg PO BID
Albuterol MDI 2 puffs Q4-6 H PRN
Elavil 75 mg PO QHS
Seroquel 500 mg PO QHS
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Erythromycin 5 mg/g Ointment Sig: One (1) d Ophthalmic [**Hospital1 **]
(2 times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-25**]
Drops Ophthalmic PRN (as needed).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
6. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO QD (once
a day).
7. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Enalapril Maleate 10 mg Tablet Sig: 0.5 Tablet PO QD (once a
day).
9. Amitriptyline HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection once a day.
Disp:*50 c* Refills:*2*
12. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
You may resume any medications not on this list that you were
previously taking prior to admission to the hospital.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Left traumatic proptosis
Left retrobulbar swelling
Left medial orbital floor fracture
Left optic nerve sheath hematoma
Diabetes Mellitus, insulin dependent
HIV + (CD4 count 947)
HCV
HTN
asthma
migraine HA
Discharge Condition:
good
Discharge Instructions:
You may have headaches, this is normal. You may change the
dressing on the left eye as needed. If develop worsening vision
changes prior to returning for surgery or purulent discharge
from eye please contact ophthalmology.
Followup Instructions:
please f/u with ophthalmology in 2 weeks
please f/u with Dr. [**First Name (STitle) **] from the plastics service. Call ([**Telephone/Fax (1) 57216**] to determine when you will need to return to [**Hospital1 18**] for
surgery.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Name: [**Known lastname 1985**],[**Known firstname 10652**] Unit No: [**Numeric Identifier 10653**]
Admission Date: [**2106-9-24**] Discharge Date: [**2106-9-30**]
Date of Birth: [**2062-10-25**] Sex: M
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5964**]
Chief Complaint:
unchanged
Major Surgical or Invasive Procedure:
1. Left lateral canthotomy
2. NO ORIF undertaken on this admission
Past Medical History:
1. Diabetes Mellitus, insulin dependent
2. HIV + (CD4 count 947)
3. HCV
4. HTN
5. asthma
6. migraine HA
Social History:
currently incarcerated at Old Colony Correction [**Location (un) **], MA
Family History:
non-contributory
Physical Exam:
Unchanged, no ORIF undertaken.
Brief Hospital Course:
ORIF of L orbital fxr and lateral cathotomy repair were not
undertaken due to displacement of OR time by emergency
procedures.
Pt will be re-admitted in one week for definitive procedure to
repair noted fracture
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Erythromycin 5 mg/g Ointment Sig: One (1) d Ophthalmic [**Hospital1 **]
(2 times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-25**]
Drops Ophthalmic PRN (as needed).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
6. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO QD (once
a day).
7. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Enalapril Maleate 10 mg Tablet Sig: 0.5 Tablet PO QD (once a
day).
9. Amitriptyline HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection once a day.
Disp:*50 c* Refills:*2*
12. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Left traumatic proptosis
Left retrobulbar swelling
Left medial orbital floor fracture
Left optic nerve sheath hematoma
Diabetes Mellitus, insulin dependent
HIV + (CD4 count 947)
HCV
HTN
asthma
migraine HA
Discharge Condition:
good
Discharge Instructions:
You may have headaches, this is normal. You may change the
dressing on the left eye as needed. If develop worsening vision
changes prior to returning for surgery or purulent discharge
from eye please contact ophthalmology.
Followup Instructions:
please f/u with ophthalmology in 2 weeks
please f/u with Dr. [**First Name (STitle) **] from the plastics service. Call ([**Telephone/Fax (1) 10654**] to determine when you will need to return to [**Hospital1 8**] for
surgery.
[**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**]
Completed by:[**2106-9-30**]
|
[
"V08",
"070.70",
"401.9",
"493.90",
"250.01",
"950.9",
"E960.0",
"376.30",
"802.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"08.51",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7517, 7532
|
6194, 6408
|
5803, 5873
|
7781, 7787
|
1564, 1932
|
8058, 8449
|
6106, 6124
|
6431, 7494
|
7553, 7760
|
3031, 3217
|
7811, 8035
|
6139, 6171
|
5754, 5765
|
466, 697
|
5895, 6000
|
6016, 6090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,245
| 100,102
|
7989
|
Discharge summary
|
report
|
Admission Date: [**2146-5-11**] Discharge Date: [**2146-5-14**]
Date of Birth: [**2068-2-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization with Drug eluting stent to Right
coronary Artery
History of Present Illness:
78 year-old male patient of Dr. [**First Name (STitle) 28622**] Attar and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 11493**] who has a history that includes CAD, s/p MI X 2, s/p CABG
in [**2139**], s/p prior stent to LAD and s/p prior PTCA of the
diagonal who was admitted to [**Hospital6 17032**] on
[**2146-5-7**] with shortness of breath. He was diagnosed with acute
on
chronic CHF with initial BNP 482. He was diuresed with IV Lasix
and ruled out for an MI with negative cardiac enzymes. A
nuclear
stress was performed on [**5-9**] showed several areas with
questionable reversible inferolateral and anteroapical ischemic
changes but no EKG changes or chest pain. It was believed that
his heart rate response was blunted [**2-14**] high dose BBlocker and
deconditioning. The overall duration of his treadmill time was
5 minutes with a heart rate max of 81 bpm. He was discharged to
home but returned to the [**Location (un) **]
ED with continued complaints of shortness of breath. Cardiac
enzymes were negative and he is now transferred for a cardiac
cathterization for further evaluation of his symptoms.
In cath lab, pt was unable to lie flat secondary to history of
PTSD, claustrophia, and anxiety and therefore required
intubation. A 90% distal lesion, just beyond the PDA was
stented with a [**Location (un) **]. At the end of the procedure, an NGT was
placed to dose plavix. Pt had already been started on
integrelin and heparin. Subsequently, the patient developed a
significant nose bleed. Heparin and integrelin were held, ENT
was called, pressure was held and the patient was given
intranasal afrin. Right heart cath also notable for elevated
RVEDP (16 mm Hg) and PCWP (28 mm Hg mean).
Past Medical History:
Coronary Artery Disease
s/p CABG in [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD)
s/p Myocardial Infarction X 2
s/p prior LAD stent and PTCA of diag
Chronic systolic heart failure [**2-14**] ischemic cardiomyopathy, last
known EF 20%
Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**]
Type 2 Diabetes Mellitus, insulin-dependent
Chronic Obstructive Pulmonary Disease, no home O2 requirement
Hypertension
Hyperlipidemia
Diabetic Nephropathy/Chronic Renal Insufficiency
Diabetic Neuropathy
s/p right renal artery stent
Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass in
[**2137**]
GERD
Anxiety
Depression
Post Traumatic Stress Disorder
Paroxysmal Atrial Fibrillation
Nonsustained Ventricular Tachycardia
Social History:
Married and lives with his wife. Retired from
Army. Most recently worked as a cook at the [**Hospital **] [**Hospital6 28623**]. He used to drink alcohol heavily, but has had none in
40
years. 40+ pack year h/o smoking, quit 40 years ago.
Family History:
Father died of an MI at age 48. Brother died of
an MI at age 64.
Physical Exam:
Vitals: 129/48 - 67 - 17 - 100% on room air
Neuro: Alert, oriented to person, place, and time. Hard of
hearing.
Cardiac: Regular rate and rhythm. Normal S1,S2. No
murmurs/rubs/gallops.
Resp: Lungs have fine crackles at the bases bilaterally.
Breathing is regular and unlabored at rest.
Periph vasc: Bilateral femoral pulses are palpable. Bilateral
DP
and PT pulses are palpable. 1+ pedal edema bilaterally.
ECG: SR 73 with PVC's
Pertinent Results:
Admission labs:
[**2146-5-11**] 09:52PM BLOOD WBC-9.5# RBC-4.34* Hgb-13.3* Hct-39.0*
MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 Plt Ct-280
[**2146-5-11**] 09:52PM BLOOD Neuts-76.0* Lymphs-13.9* Monos-6.5
Eos-3.2 Baso-0.4
[**2146-5-11**] 09:52PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2*
[**2146-5-11**] 09:52PM BLOOD Glucose-264* UreaN-29* Creat-1.6* Na-134
K-4.6 Cl-99 HCO3-27 AnGap-13
[**2146-5-11**] 09:52PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.4
.
Cardiac cath ([**5-13**]): 1. Coronary angiography of this right
dominant system revealed native three vessel coronary artery
disease. The LMCA had a distal 50% stenosis. The LAD was
occluded in the mid-vessel. The major diagonal branch had an
ostial 60% stenosis. The LCx had a long 60% lesion in OM1. The
RCA had a 90% stenosis just beyond the origin of the PDA.
2. Arterial conduit angiography demonstrated patent LIMA-D1 and
SVG-OM
grafts. The SVG-OM was occluded proximally. 3. Resting
hemodynamics revealed elevated right and left sided filling
pressures (RVEDP 16 mm Hg, PCWP mean 28 mm Hg). There was
moderate to severe pulmonary arterial hypertension (PASP 61 mm
Hg). The systemic arterial blood pressure was normal (SBP 122 mm
Hg). The cardiac index was normal at 2.7 l/min/m2. The systemic
vascular resistance was normal (911 dynes-sec/cm5). The
pulmonary vascular resistance was normal (PVR 135
dynes-sec/cm5). 4. Successful PTCA and stenting of the distal
RCA jailing the right PDA with a Xience (3x18mm) drug eluting
stent postdilated with a 3.25mm balloon. Final angiography
demonstrated no angiographically apparent dissection, no
residual stenosis and TIMI III flow throughout the vessel (See
PTCA comments). 5. Successful closure of the right femoral
arteriotomy site with a Mynx closure device.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. Patent LIMA-D1 and SVG-LAD grafts.
3. Occluded SVG-OM graft.
4. Moderate biventricular diastolic dysfunction.
5. Moderate pulmonary hypertension.
6. Successful PTCA and stenting of the distal RCA with a Xience
drug
eluting stent.
7. Successful closure of the right femoral arteriotomy site with
a Mynx
closure device.
.
Discharge labs:
[**2146-5-14**] 07:41AM BLOOD WBC-8.8 RBC-4.17* Hgb-12.7* Hct-36.9*
MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6 Plt Ct-275
[**2146-5-14**] 07:41AM BLOOD Glucose-206* UreaN-31* Creat-1.6* Na-137
K-4.1 Cl-99 HCO3-25 AnGap-17
[**2146-5-14**] 07:41AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.4
Brief Hospital Course:
78 year-old man who was referred from OSH for a cardiac
catheterization secondary to persistent shortness of breath.
# Coronary Artery Disease - Patient with known hx of CAD, prior
CABG, prior stent/PTCA was referred for cardiac ctah for
persistent shortness of breath. Patient did not tolerate lying
flat for procedure due to significant history of claustrophobia,
PTSD and anxiety and was intubated for the procedure. He was
started on heparin, integrillin and plavix loaded pre-procedure
however developed severe epistaxis after intubation and
integrilin was stopped. Cardiac cath showed distal 90% RCA
lesion and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] was placed. He was continued on aspirin,
plavix and statin. After cath, he remained intubated for airway
protection from epistaxis nad was admitted to CCU for closer
management. He was extubated on hospital day #2 without
complication.
.
# Chronic systolic heart failure - Ischemic cardiomyopathy, EF
20%. RHC notable for elevated RVEDP (16 mm Hg) and PCWP (28 mm
Hg mean). After catheterization he was diuresed with bolus lasix
and his home dose of lasix was increased to 100mg [**Hospital1 **]. He was
continued on Inspra, Diovan and Toprol. At time of discharge
exam was notable for lower extremity edema, but patient had no
evidence of pulmonary edema with no oxygen requirement so he was
instructed to continue higher dose of lasix until he could
discuss lasix titration with his cardiologist as an outpatient.
.
# Epistaxis - Developed during cardiac catheterization and ENT
was consulted. This was managed with Afrin. Estimated blood loss
of 200cc which stabilized without tranfusion. This resolved
within 24 hours with no recurrent events.
.
# Hypertension: He was continued on home [**Hospital1 4319**] of Lasix, Diovan,
Norvasc, Inspra and Toprol with good control
.
# Hyperlipidemia: We do not have most recent lipid panel. On
admission he was on tricor and statin was added to his regimen.
.
# Type II Diabetes, Insulin-Dependent: He was continued on home
regimen of basal-bolus insulin with good control. No changed
were amde to insulin regimen during admission.
.
# Stage 3 chronic renal failure - Baseline Cr 1.8, received
pre-cath hydration and mucomyst and creatinine remained stable
after contrast load during procedure.
.
# Depression: Mood was stable on admission . Patient not
currently on pharmacological treatment for depression.
Medications on Admission:
Flonase 50 mcg one spray to each nostril daily
Proventil inhaler two puffs four times daily prn shortness of
breath or wheezing
Tricor 145 mg one tab daily
Lasix 80 mg twice a day (reduced at time of d/c from
NVMC from prior dose of 120 mg [**Hospital1 **])
Aspirin 325 mg one tab daily
Imdur 30 mg one tab daily
Insulin 70/30 60 units subcutaneous injection breakfast
Insulin 50/50 60 unit subcutaneous injection dinnertime
Levemir 37 units subcutaneous injection at bedtime
Diovan 40 mg one tab daily (recently added by Dr. [**Last Name (STitle) 11493**]
Inspra 25 mg one tab daily
Norvasc 2.5 mg one tab daily
Toprol XL 200 mg one tab daily
(added at NVMC)
Plavix 75 mg one tab daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension
Sig: Sixty (60) units Subcutaneous twice a day.
8. Levemir 100 unit/mL Solution Sig: Thirty Seven (37) units
Subcutaneous at bedtime.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
12. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Epistaxis
Post Traumatic Stress Syndrome
Discharge Condition:
stable.
Discharge Instructions:
You had a cardiac catheterization with a drug eluting stent
placed in your right coronary artery. You will need to take
Plavix every day for one year. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop
taking Plavix unless Dr. [**Last Name (STitle) 11493**] tells you to. No lifting more
than 10 pounds in 1 week. No baths or pools for one week. You
may shower and take off the dressing on your groin. During the
procedure you were intubated and on a breathing machine. You had
a nose bleed that was caused by the blood thinners and needed to
have Afrin sprayed in your nose to stop the bleeding. You had a
fever and were on antibiotics for a short time. Your chest X-ray
did not show a pneumonia and the antibiotics were discontinued.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
.
Please call Dr. [**Last Name (STitle) 11493**] if you notice any increased trouble
breathing, chest pain, nausea, light headedness, increased
bruising or bleeding in your groin region, increasing coughs,
fevers or any other concerning symptoms.
Followup Instructions:
Primary Care:
ATTAR,[**Female First Name (un) **] Phone: [**Telephone/Fax (1) 24306**] Date/time: please call when you
get home for an appt in [**1-14**] weeks.
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:Friday [**6-10**] at 1:00pm
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2146-8-5**] 11:20
Completed by:[**2146-5-16**]
|
[
"250.40",
"784.7",
"414.02",
"414.01",
"496",
"428.0",
"300.29",
"V45.02",
"412",
"416.8",
"309.81",
"403.90",
"414.8",
"272.4",
"427.31",
"428.22",
"300.4",
"V45.82",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"00.40",
"36.07",
"96.04",
"00.44",
"00.66",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
10820, 10826
|
6207, 8672
|
333, 408
|
10935, 10945
|
3756, 3756
|
12138, 12635
|
3220, 3288
|
9409, 10797
|
10847, 10914
|
8698, 9386
|
5524, 5895
|
10969, 12115
|
5911, 6184
|
3303, 3737
|
274, 295
|
436, 2176
|
3773, 5507
|
2198, 2943
|
2959, 3204
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,433
| 145,479
|
53408
|
Discharge summary
|
report
|
Admission Date: [**2179-9-28**] Discharge Date: [**2179-10-23**]
Date of Birth: [**2129-10-5**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra / Lisinopril
/ Naprosyn / Bactrim DS / Phenytoin / Nitrofurantoin / Sulfa
(Sulfonamide Antibiotics) / Zofran / IV Dye, Iodine Containing /
Latex
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Cholecystectomy
Evacuation of perihepatic hematoma
History of Present Illness:
Ms. [**Known lastname **] is 49 year old F with multiple medical complications
including a urostomy, recurrent UTI, and chronic abodminal pain
with multiple abdominal surgeries who presents w/ 4 days of
nausea, vomiting and abdominal pain and 3 days of diarrhea.
In the ED, patient described her pain as most severe in
epigastrum, radiating to LUQ and RUQ. The pain is similar to
prior episodes of abdominal pain, but more severe this episode.
Her last reported BM was this morning, non-bloody and loose. She
denied f/c and is not sexually active. Pt was admitted 2+ months
ago s/p ERCP for choledocholithasis and last month for UTI,
presented with similar complaints. Notably, due to multiple
severe allergies to antibiotics, she required 5 days of
aztreonam for her last UTI.
Initial vs were 97.7, 60, 107/87, 16, 99%RA. Initial labs were
remarkable for plt of 60K and grossly positive UA. She received
morphine and reglan for pain and nausea, and aztreonam for her
UTI. Due to persistent pain, she underwent unremarkable
abdominal CT scan. She was admitted to medicine for further
management.
On arrival to the floor, patient appears acutely ill and is
groaning in pain. She is a very difficult historian, and reports
'all over' abdominal pain. She reports feeling feverish, but
denies SOB or cough. She notes signficant nausea and emesis, and
inability to take po for several days. She is unable to provide
additional ROS.
Past Medical History:
Recurrent bullous hypersensitivity reactions (IVIG, steroids)
-presents w/ intensely edematous dusky plaques along the
axilla, lat trunk and lat legs which have desquamtion at the
sites of edema, but never progress beyond this.
-previous admissions to [**Hospital1 112**] burn unit
Asthma/COPD
Hypertension
GERD
Urostomy
h/o VRE pyelonephritis
Spina bifida (myelomengiocele)
Paraperesis
Depression
Mild mental retardation
Psychogenic dysarthria and tremor
[**Hospital1 **] vs. pseudoseizures
- EEG work-up at [**Hospital3 **] in [**2165**] frequent runs of regular
bifrontal sharp delta activity although the clinical events
which occurred during the record were not associated with EEG
change
Atopic dermatitis
Back pain
Genital herpes
Uterine fibroid
Uterine prolapse
Diverticulosis
External hemorrhoids
[**Doctor Last Name **]-[**Known lastname **] syndrome in [**1-10**].
Drug allergies & reactions:
bactrim DS
ceftriaxone
flagyl
iodine
keppra
latex
lisinopril
naprosyn
nitrofurantoin
phenytoin
quinolones
sulfa
zofran
zosyn
Social History:
per OMR:
Lives alone in an apartment in [**Location (un) 86**]. She is able to transfer
w/ wheelchair. Reports [**Location (un) 269**] assistance daily. Has Tobacco: 1
pack/wk EtOH: denies Illicits:
Denies IVDU ever. History of smoking crack cocaine.
Family History:
Per OMR: 3 healthy children. Mother died of lung cancer. Father
killed by his girlfriend. Not in contact with her brother and
sister.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.4 142/82 90 18 98%RA
GEN: Holds eyes closed, but awakens to voice, groaning in pain,
inconsistently answers simple questions and can follow simple
commands. Perseverates on her abdominal pain and her nausea.
Oriented to person and 'hospital'.
HEENT: NCAT, dry MM, EOMI, sclera anicteric, 2->1pupils
bilaterally
NECK supple, no JVD, no LAD
PULM Fair air movement, coarse with bilateral rhonci throughout
CV RRR normal S1/S2, no mrg
ABD right urostomy in place, diffusely tender with voluntary
guarding, most pronounced in RUQ and LLQ, no rebound,
normoactive bowel sounds
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO Symetric face, tongue midline, pupils equal, EOMI, moving
all extremities
SKIN large hypopigmented plaques over legs bilaterally from
prior reactions as noted in PMH
LABS: reviewed, see below
DISCHARGE PHYSICAL EXAM:
O: 99.5 96-102/52-62 75-79 18-20 100%RA
General: Laying in bed, covered in sheet
Lungs: CTAB
CV: RRR, no murmurs, S1S2
Abd: somewhat distended, some tenderness (but distractable), no
rebound or guarding.
Ext: Pnuemoboots, 2+ pulses
Neuro: alert and oriented to person, place, not year
Pertinent Results:
Admission labs:
[**2179-9-28**] 02:40PM BLOOD WBC-4.2 RBC-4.43 Hgb-13.8 Hct-42.4 MCV-96
MCH-31.2 MCHC-32.6 RDW-14.4 Plt Ct-60*#
[**2179-9-28**] 02:40PM BLOOD Neuts-32* Lymphs-62* Monos-6 Eos-0 Baso-0
[**2179-9-28**] 02:40PM BLOOD Glucose-69* UreaN-3* Creat-0.9 Na-140
K-4.0 Cl-102 HCO3-31 AnGap-11
[**2179-9-28**] 02:40PM BLOOD ALT-6 AST-12 AlkPhos-66 TotBili-0.3
[**2179-9-28**] 02:40PM BLOOD Albumin-3.1*
[**2179-9-28**] 02:48PM BLOOD Lactate-1.6
[**2179-9-30**] 07:30AM BLOOD Valproa-104*
[**2179-10-2**] 01:10PM BLOOD Ammonia-39
[**2179-9-28**] 02:40PM BLOOD Lipase-16
[**2179-10-2**] 05:20PM BLOOD CK-MB-1 cTropnT-<0.01
[**2179-10-2**] 01:10PM BLOOD Valproa-52
[**2179-10-3**] 07:30PM BLOOD Valproa-30*
[**2179-10-1**] 03:35PM BLOOD Lactate-2.6*
[**2179-10-2**] 01:31PM BLOOD Lactate-1.0
Discharge labs:
[**2179-10-23**] 06:11AM BLOOD WBC-9.0 RBC-2.82* Hgb-8.9* Hct-27.6*
MCV-98 MCH-31.6 MCHC-32.2 RDW-18.7* Plt Ct-331
[**2179-10-21**] 05:44AM BLOOD PT-11.5 PTT-38.3* INR(PT)-1.1
[**2179-10-23**] 06:11AM BLOOD Glucose-68* UreaN-20 Creat-0.9 Na-138
K-4.5 Cl-105 HCO3-26 AnGap-12
[**2179-10-23**] 06:11AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.3
[**2179-10-22**] 05:24AM BLOOD Albumin-2.2* Calcium-8.9 Phos-3.8 Mg-2.3
Imaging:
CT Abd/Pelvis [**2179-9-28**] (no oral or IV contrast)
CT OF THE ABDOMEN:
Included views of the lung bases demonstrate mild dependent
atelectasis.
There is no pericardial or pleural effusion. The heart is
mildly enlarged.
Focal hepatic steatosis lies adjacent to the falciform ligament
(2:21).
Remainder of the liver is unremarkable. The gallbladder,
pancreas, spleen,
adrenal glands, stomach and intra-abdominal small bowel are
normal. Intramuralfat deposition is seen within the right and
transverse colon, but theremainder of the colon appears
unremarkable. Common bile duct dilatation to 11 mm is
unchanged, and no intra-hepatic biliary dilatation is grossly
noted.
The patient is post ileal conduit diversion via a right lower
quadrant stoma,with no evidence of obstruction. There is
expected mild bilateral ureteraldistension and renal
pelviectasis, but no hydronephosis is present. Corticalthinning
along the posterior right kidney (2:26) is unchanged since the
[**Month (only) 205**] [**Numeric Identifier 109842**] examination, likely noting prior infectious or
vascular insult.
CT OF THE PELVIS:
The rectum, sigmoid colon, and intrapelvic small large bowel are
unremarkable.Fibroid uterus is redemonstrated. Fecalized
material within the left pelvis(2: 73) is unchanged from prior
examinations. There is no intrapelvic freefluid or
lymphadenopathy.
OSSEOUS STRUCTURES:
Dysmorphic pelvic, spina bifida, and a sacral meningiocele are
again seen
(2:50). There are no bony lesions concerning for malignancy or
infection.
Cerclage wires surround the proximal femurs bilaterally (2: 80).
IMPRESSION: No acute intra-abdominal or intrapelvic process.
Abdominal Ultrasound [**2179-9-29**]
FINDINGS: Liver is homogeneous in echotexture without discrete
masses or
lesions. There is no intra- or extra-hepatic biliary ductal
dilatation withthe common bile duct measuring 4 mm. A large
shadowing stone is identified inthe gallbladder neck. The
patient was unable to participate in positionchanges to allow
assessment for gallstone mobility. No evidence ofcholecystitis
present; specifically, there is no gallbladder
distention,gallbladder wall edema or pericholecystic fluid. The
midline including thepancreas and proximal aorta are obscured by
gas. The demonstrated portions ofthe right kidney are
unremarkable. The spleen is not enlarged measuring 8.3cm.
Limited assessment of the inferior vena cava is normal. No
ascitic fluid evident
Doppler assessment of main portal vein shows patency and
hepatopetal flow.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Doppler assessment of the main portal vein shows patency and
appropriatedirectionality of flow.
Gallbladder Scan [**2179-10-1**]
IMPRESSION: Abnormal hepatobiliary scan with delayed
visualization of the
gallbladder consistent with chronic cholecystitis. There is
significant patientmotion during the study.
KUB [**2179-10-1**]
FINDINGS: Supine and left lateral decubitus images of the
abdomen demonstrate an unremarkable bowel gas pattern with no
evidence of ileus or obstruction.
There is no pneumatosis or intraperitoneal free gas. There is a
dysmorphic pelvis and sacral spina bifida is seen, correlating
to the previously seen findings on recent CT. There is
demineralization of the osseous structures. Cerclage wires are
seen around the bilateral femurs.
IMPRESSION: Unremarkable bowel gas pattern with no evidence of
ileus or
obstruction.
Head CT [**2179-10-1**]
FINDINGS: There is no acute intracranial hemorrhage, edema,
mass effect or major vascular territorial infarct.
Ventriculomegaly is unchanged from
[**2179-8-24**] but has progressed since [**2175-7-10**]. Cerebellar tonsils
extend into the foramen magnum, as before, which in setting of a
known sacral meningocele is compatible with Chiari II
malformation. There is no shift of normally
midline structures. [**Doctor Last Name **]-white matter differentiation is
preserved. No
osseous abnormality is identified. The visualized paranasal
sinuses and
mastoid air cells are clear.
IMPRESSION:
1. No evidence of an acute intracranial process.
2. Ventriculomegaly is stable since [**2179-8-24**] but progressed
since [**2175-7-10**]. Low lying cerebellar tonsils in the setting of a
Chiari II malformation.
CT ABDOMEN AND PELVIS [**2179-10-8**]: Visualized lung bases demonstrate
bibasilar
opacification, which may represent atelectasis, however,
aspiration or
pneumonia cannot be excluded in the correct clinical setting.
Visualized
heart and pericardium appear unremarkable.
Evaluation of solid organs and intra-abdominal vasculature is
limited by
non-contrast technique. Within this limitation, the liver,
spleen, bilateral
adrenal glands appear unremarkable aside from a diffusely low
density of the
liver consistent with hepatic steatosis. The pancreas is within
normal
limits. The patient is status post cholecystectomy. Cortical
thinning along
the posterior right kidney is unchanged since a prior
examination and dating
back to [**2179-8-7**], likely representing a prior infectious or
vascular
insult.
There is extensive hyperdense fluid surrounding the liver and
extending
through the right paracolic gutter into the pelvis consistent
with hemorrhage.
Tiny locules of intraperitoneal air are expected post recent
surgery. The
patient is status ileal conduit diversion after cystectomy, via
a right lower
quadrant stoma with no evidence of obstruction. Intramural
fat deposition
is noted within the right and transverse colon, but the
remainder of the colon
appears unremarkable. This is unchanged from the most recent
prior
examination. Retroperitoneal and mesenteric lymph nodes do not
meet CT size
criteria for pathology.
The bladder, rectum, sigmoid colon, and intrapelvic small and
large bowel
loops are unremarkable. The uterus appears mildly bulky but is
difficult to
distinguish from high-density blood. Again noted is blood
within the pelvis.
Pelvic side wall lymph nodes do not meet CT size criteria for
pathology.
Mildly prominent inguinal lymph nodes are noted bilaterally.
OSSEOUS STRUCTURES AND SOFT TISSUES: Dysmorphic pelvis, spina
bifida and
sacral meningocele are again noted (301B:43) similar to the most
recent prior
examination. Cerclage wires surrounding bilateral proximal
femurs (2:87) are
unchanged from the prior examination. A hematoma within the
right
anterolateral abdominal wall (2:30-59) is noted.
IMPRESSION:
1. Large introperitoneal hemorrhage/hematoma surrounding the
liver and
extending along the right paracolic gutter into the pelvis.
2. Right anterolateral abdominal wall hemorrhage.
3. Free intraperitoneal air, expected post-surgically.
Above findings were discussed with Dr. [**First Name (STitle) **] at 8:10 p.m.
approximately five
minutes after discovery of critical findings via telephone on
[**2179-10-8**].
4. Prominent bilateral inguinal lymph nodes.
5. Fatty infiltration of the right colon and transverse process
likely
representing chronic changes.
6. Hepatic steatosis.
CT Abdomen/Pelvis [**2179-10-18**]
FINDINGS: Visualized lung bases demonstrate small focal areas
of
consolidation which may represent atelectasis versus pneumonia
given the
correct clinical setting. The visualized portions of the heart
and
pericardium are unremarkable in appearance.
CT ABDOMEN: Evaluation of the intra-abdominal solid organs and
vasculature is
limited in this non-contrast study. Within this limitation, the
liver appears
diffusely hypodense, consistent with hepatic steatosis.
Otherwise, the liver
is unremarkable with no focal lesions. The gallbladder is
surgically absent.
The pancreas, spleen, and bilateral adrenal glands are
unremarkable in
appearance. Again seen is mild cortical thinning along the
posterior right
kidney likely representing prior ischemic or infectious insult.
There has been interval resolution of the previously appreciated
large
perihepatic hematoma as well as a right abdominal wall hematoma
with no
evidence of active bleed.
The stomach and small bowel are unremarkable with no evidence of
obstruction.
The large bowel is unremarkable in appearance. There is no
retroperitoneal or
mesenteric lymphadenopathy. There is no intra-abdominal free
air, free fluid,
or hernias.
CT PELVIS: The patient is status post cystectomy and ileal
conduit diversion
via right lower quadrant stoma with no evidence of obstruction.
There is
widespread hyperdense appearance of the soft tissues consistent
with anasarca.
The uterus is unremarkable in appearance. Bilateral ovaries are
not well
visualized on this examination. There is a small amount of
high-density fluid
within the pelvic cul-de-sac, likely representing remnant blood.
There are
stably enlarged inguinal lymph nodes bilaterally. There is no
pelvic wall
lymphadenopathy. The rectum is unremarkable in appearance.
OSSEOUS STRUCTURES: There is a dysmorphic pelvis, spina bifida
and sacral
meningocele unchanged from previous examination. There are
cerclage wires at
the bilateral proximal femurs. There are no focal blastic or
lytic lesions in
the visualized osseous structures concerning for malignancy.
IMPRESSION:
1. Interval resolution of perihepatic hematoma with no evidence
of active
bleed.
2. Slightly improved bibasilar consolidations likely
representing
atelectasis.
3. Generalized soft tissue edema representing anasarca.
4. Hepatic steatosis.
5. Scattered inguinal lymphadenopathy. This finding is
nonspecific and
clinical correlation is recommended.
6. Stable right renal cortical thinning consistent with a
previous vascular
or infectious insult.
7. Dysmorphic pelvis and spina bifida.
Microbiology:
Time Taken Not Noted Log-In Date/Time: [**2179-9-29**] 8:31 am
URINE TAKEN FROM CHEM# [**Serial Number 109843**]J,ADDED URI UCU @
08:31AM..
**FINAL REPORT [**2179-10-1**]**
URINE CULTURE (Final [**2179-10-1**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Brief Hospital Course:
49 year old female with history of urostomy, recurrent UTIs,
ERCP in [**Month (only) 116**], GERD, [**Month (only) 54422**]/pseudoseizures who presented with
abdominal pain, decreased PO intake, nausea and vomiting, s/p
cholecystectomy for cholecystitis c/b post-op hematoma:
# Abdominal pain: Abdomen initially diffusely tender, however as
admission progressed, worst pain was in the RUQ/epigastric area.
Patient with poor PO intake. Lactate 1.6 at presentation,
improved with IV fluids. Increased to 2.6 on [**10-1**] after fluids
had been discontinued, but again [**Month/Day (4) 53183**] well to fluid bolus
and maintenance fluids were begun. Patient was initially treated
for a UTI, as UA was suggestive of infection and patient had
similar symptoms with UTI on past admission in [**Month (only) 205**] which were
successfully treated with Aztreonam due to her extensive list of
drug allergies. However, she was persistently afebrile with
normal white count. Urine culture showed mixed bacterial flora.
A non-contrast CT of the abdomen and pelvis showed no acute
changes. Symptoms improved slowly with antibiotics, so RUQ
ultrasound was done, which showed cholelithiasis but not
cholecystitis. Her omeprazole dose was also increased, as there
was some concern for gastritis vs. peptic ulcer disease and an
H. pylori antibody assay was sent, which was negative. GI was
consulted, and at their recommendation a HIDA scan was done
which showed delayed gallbladder visualization suggestive of
chronic cholecystitis. Surgery was consulted, and patient had an
laparoscopic cholecystectomy on [**10-6**]. Days later, she sustained a
10-pt hematocrit drop and CT of the abdomen showed a perihepatic
and anterior abdominal wall hematoma around the cholecystectomy
site. Given poor IV access, she was emergently transferred to
the MICU for central line placement and pRBC transfusion. Her
hematocrit remained stable after 2 units pRBCs as she was
monitored in the ICU. She began to spike fevers and there was a
concern for an infection of the hematoma itself. She was taken
back to the OR for evacuation of the hematoma (500cc). She
received an additional 2 units of blood 9/17, as Hct had been
drifting down following transfer back to the floor. CT abdomen
and pelvis was done, which showed interval resolution of
hematoma and no signs of active bleeding. Hematocrit was stable
for the remainder of the admission. Urine culture also showed
recurrence of infection, initially covered with daptomycin and
aztreonam for history of VRE and prior infection. Culture grew
vancomycin sensitive enterococcus and she was subsequently
treated with IV vancomycin and completed a 10 day course. She
continued to be mildly hypotensive throughout her stay,
initially felt to be sepsis, but persisted after appropriate
treatments and asymptomatic. She continued to complain of
non-descript pain. Per the surgical service, she could continue
to have residual irritation from bleed for weeks following
surgery. She also developed constipation late in her
hospitalization, which was likely contributing. KUB on [**10-22**]
showed no signs of obstruction or ileus and she was treated
aggressively with laxatives. Had a BM on [**2179-10-23**].
# Malnutrition: Patient had poor oral intake for an undefined
amount of time prior to admission, and was unable to tolerate
oral intake throughout much of her hospitalization, leading to
low albumin (2.2 on [**10-10**]), coagulopathy (INR of 1.6 which
resolved after starting supplemental nutrition) and
hypoglycemia. Nutrition was consulted. Patient refused NG tube
placement for tube feeds, and TPN was begun. Patient began to
tolerate PO intake by mouth
# Thrombocytopenia: Patient had a platelet count of 60 on
admission, with nadir of 40 on [**2179-10-2**] before eventually
increasing back into the normal range. This was initially
attributed to infection, as platelets dropped into the 70s
during admission in [**Month (only) **] and then rebounded with UTI treatment.
Peripheral blood smear showed no signs of schistocytes. Low on
admission, so HIT was not in differential. Drug effects
considered, but no major recent changes. Heme/onc consulted, saw
no signs of consumptive process on peripheral blood smear,
attributed thrombocytopenia to infection.
# Mental status: Waxed and waned through admission, patient
initially lethargic and only intermittently able to answer
questions (none in detail). Per her PCP, [**Name10 (NameIs) **] is not her
baseline. Admission tox screen unremarkable, neuro exam
non-focal. Head CT done [**10-1**] showed no acute changes. Patient
did have some episodes which appeared to be her pseudoseizures
(see below), but nothing that appeared epileptic in nature.
#Pseudoseizures/?seizure disorder- Patient continued on home
divalproex, dose initially decreased to 125mg daily based on
communication with outpatient PCP (also, level supratherapeutic
on 250mg [**Hospital1 **]), but upon further investigation, it was discovered
that patient had been taking double prescribed dose at home.
Levels dropped out of therapeutic range, dose increased to 125mg
[**Hospital1 **], then to 250mg [**Hospital1 **] and then 250mg TID. Patient with no
witnessed seizure activity, did have a number of pseudoseizures,
which varied and included rocking back and forth with eyes
rolled back, shaking head from side to side, right arm
straightening, rolling back eyes while laughing inappropriately.
Chronic issues:
# depression: stable on home meds
Transitional issues:
- monitor patient's oral intake and nutritional status. Albumin
level still low at time of discharge, but can take some time to
respond.
- patient will need to follow up in surgery clinic for
post-surgical check as an outpatient
- Rehab stay is not to exceed 30 days.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
abdominal pain
3. Citalopram 20 mg PO DAILY
4. Divalproex (DELayed Release) 250 mg PO BID
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
6. Omeprazole 20 mg PO DAILY
7. Quetiapine Fumarate 25 mg PO QHS
8. traZODONE 50 mg PO HS:PRN insomnia
9. Montelukast Sodium 10 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Divalproex (DELayed Release) 250 mg PO TID
3. Montelukast Sodium 10 mg PO DAILY
4. Quetiapine Fumarate 25 mg PO QHS
5. traZODONE 50 mg PO HS:PRN insomnia
6. Clotrimazole Cream 1 Appl TP [**Hospital1 **]
to lower back and groin skin folds
7. Docusate Sodium 100 mg PO BID
8. Hydrocerin 1 Appl TP TID:PRN dry skin or itch
apply to dry areas prn
9. Domeboro 1 PKT TP [**Hospital1 **]
to skin folds
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Acetaminophen 1000 mg PO Q8
please do not exceed 3000mg/day
12. Heparin 5000 UNIT SC TID
13. Senna 1 TAB PO BID
14. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
hold for oversedation, RR<12
RX *oxycodone 5 mg [**2-1**] tablet(s) by mouth q4-6h Disp #*25 Tablet
Refills:*0
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
16. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
abdominal pain
17. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
18. Omeprazole 20 mg PO DAILY
19. Lactulose 30 mL PO DAILY:PRN constipation
hold for loose stools
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
hold for loose stools
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
UTI
Chronic cholecystitis
Perihepatic hematoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital with abdominal pain, nausea,
vomiting and inability to eat. You were diagnosed with a urinary
tract infection, and treated with antibiotics. Your pain did not
improve, and you were diagnosed with chronic cholecystitis
(inflammation of your gallbladder). Your gallbladder was
removed. You had internal bleeding after the procedure and a
second surgery was performed to remove the blood and make sure
the bleeding had stopped. You were also diagnosed with a second
urinary tract infection and were treated with a second course of
antibiotics.
Changes to your home medications include:
-START clotrimazole cream, Domeboro powder and hydrocerin for
skin care
-START prochlorperazine 10mg every 8 hours as needed for nausea
-For pain, you can take acetaminophen. You can also take
oxycodone 5-10mg every 4-6 hours for pain. Your pain should be
improving, so you should require less medication over time. You
should not need long term narcotic treatment.
It was a pleasure taking care of you during your hospitalization
and we wish you a speedy recovery and all the best going
forward.
Followup Instructions:
Please call your primary care doctor, Dr. [**Last Name (STitle) **], at
[**Telephone/Fax (1) 798**] to schedule a follow-up appointment after discharge
from rehab
Please call the surgery clinic ([**Telephone/Fax (1) 376**] to be seen in 2
weeks for post-operative assessment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
Completed by:[**2179-10-24**]
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52,594
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39977
|
Discharge summary
|
report
|
Admission Date: [**2192-10-15**] Discharge Date: [**2192-10-30**]
Date of Birth: [**2171-6-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
SDH with shift
Major Surgical or Invasive Procedure:
[**2192-10-15**] Bolt ICP monitor placement
History of Present Illness:
Patient intubated and sedated, history obtained from record and
patient's family
Mr. [**Known lastname 3234**] is a 21 y/o man with no PMH as per his family, who is
transferred from OSH for R SDH with shift. He was found by EMS
laying at the side of the road and was reportedly confused and
combative. It is unclear exactly what happened to the patient,
per notes he was struck by a car but he was not found to have
any
other injuries that would suggest this means of injury. He was
intubated by EMS at the scene. He was noted to have a blown
right
pupil at the OSH and given this finding and the head CT, he was
given Mannitol 50 gm. At the OSH, he was also loaded with
Dilantin and received 125 mg solumedrol, vecuronium 10 mg and
ativan. He was transferred to [**Hospital1 18**] for further management.
Past Medical History:
None
Social History:
As per mother, he did not do any drugs.
Family History:
unknown
Physical Exam:
On Admission:
O: T: 96.7 BP:119/57 HR: 80 R: on vent
Gen: laying in bed, intubated, sedated
HEENT: R forehead hematoma.
Lungs: CTA bilaterally anteriorly
Cardiac: RRR, S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated, sedated, unresponsive, no eye opening
Cranial Nerves: Pupils equally round and reactive to light 3 to
2.5 mm b/l, weak corneal reflexes, face symmetric, strong gag
relfex.
Motor: Initially was withdrawing all extremities to pain.
However, he later appeared to have extensor posturing of his
LUE.
No spontaneous movements. Whole body jerking on initial
assessment, ?myoclonus.
Reflexes: Clonus at ankles b/l. Toe upgoing on Left and mute on
right.
On Discharge: EO spontaneously. Tracheostomy. Cervical Collar in
place. Moves right sided spontaneously. No movement LUE, WD LLE
to noxious stimuli.
Pertinent Results:
CT head [**2192-10-15**]
1. Since the prior examination, interval development of
intraventricular
hemorrhage at the junction of the cerebral aqueduct and fourth
ventricle.
Stable ventricular size and configuration without evidence of
hydrocephalus.
2. Redistribution of a right subdural hemorrhage, which does not
appear to be increased in size, and maybe slightly decreased.
Minimal to no leftward
midline shift. Slight medial prominence of the right uncus, very
early uncal herniation cannot be excluded.
3. Contrast limits evaluation, though within these limitations,
new areas of linear high attenuation in the left frontal region
and right sylvian fissure, may be due to subarachnoid hemorrhage
vs contrast in vessel. Attention at follow-up.
4. Loss of sulcation (although young patient) suggests stable
diffuse
cerebral edema, with preservation of [**Doctor Last Name 352**]-white matter
differentiation.
CT HEAD W/O CONTRAST [**2192-10-16**]
1. Right subdural hemorrhage, smaller and redistributed since
the prior
examination. It measures approximately 6 mm in maximal
transverse dimension.
2. Further washout of intravenous contrast with no convincing
evidence of subarachnoid hemorrhage.
3. Stable focus of intraventricular hemorrhage at the junction
of the
cerebral aqueduct/fourth ventricle with stable size and
configuration of the ventricular system and no developing
hydrocephalus.
4. Some degree of diffuse cerebral edema with sulcal effacement-
correlate
with ICP measurements. Follow up as clinically indicated.
CT head [**2192-10-17**]:
1. Subdural hemorrhage along the right cerebral convexity is
less extensive and decreased in density since most recent study
of [**2192-10-16**]. No new focus of hemorrhage is noted.
2. Right frontal approach intracranial pressure monitoring
device is unchanged in position.
CT c-spine [**2192-10-17**]
No evidence of acute fracture or malalignment
MRI C-spine [**2192-10-18**]
Moderate upper cervical prevertebral soft tissue swelling,
certainly could be posttraumatic in etiology. No sign of
cervical cord
injury. Possible minimal traumatic disc injury at C6/7, as noted
above.
MRI Brain [**2192-10-18**]:
The principal vascular flow patterns are identified.
There is a very shallow (1 mm) residual right cerebral convexity
subdural
hemorrhage, overlying the right temporal and parietal lobes.
There is moderate mucosal thickening and/or fluid within the
mastoid sinuses, which presumably reflects the intubated status
of the patient, as well as fluid accumulating within the nasal
and oropharyngeal portions. There is a minimal degree of mucosal
thickening seen within the sphenoid sinus.
CONCLUSION: Extensive areas of restricted diffusion, of concern
for anoxic
damage. Other findings noted above.
CTA NECK [**2192-10-18**]:
Normal CTA of the head and neck.
CT HEAD W/O CONTRAST [**2192-10-20**]:
Continued diffuse cerebral edema. The apparent hyperdensity
along sulci may be likely due to brain edema. No acute
hemorrhage.
CXR [**2192-10-24**]:
opacification in the left lower lobe consistent with pneumonia
[**2192-10-24**] LENS
no DVT
[**2192-10-25**]
Markedly abnormal portable EEG due to the low voltage slow
background. There were no prominent focal abnormalities, but
encephalopathies may obscure focal findings. There were no
definite
epileptiform features. There was an occasional tachycardia.
[**2192-10-29**] KUB
PFI: Normal bowel gas pattern.
Brief Hospital Course:
21 y/o M found down on side of road by EMS, ? of assault,
presents from OSH with R SDH and cerebral edema. Patient was
admitted to neurosurgery for further management. A bolt ICP
monitor was placed at bedside with opening pressure of 10.
Mannitol x1 was given at OSH and d/t normal ICP, no further
mannitol was given. On examination, patient's pupils were
PERRLA, EO to noxious stimuli and w/d all 4 extremities. On
[**10-16**], patient's head CT showed improvement, ICPs still within
normal range and exam unchanged. He is intubated and c-collar in
place. He has also been febrile with Tmax of 102.3. He was
pancultured.
On [**10-17**] his dilantin level was 9.4. He required mannitol
overnight for increase in ICP's, as he was on a large amoumt of
sedation. CT was performed and this was stable. His WBC count
was 9.1 and he was febrile to 102 overnight. With increase in
sedation, his ICP was 15 in pm.
On [**10-18**], his ICP was well controlled and his bolt was removed
and the ancef was discontinued. His sputum was thought to be
cause of his fever. Cultures were sent. He was cleared for SQH.
Mannitol was decreased to 75TID. A family meeting was held. and
MRI brain and C-spine were discussed. It was decided that if he
was not awake enough to be extubated on [**10-19**] he should have a
trach/peg. His CTA of the neck was a normal imaging study.
On [**10-20**], the patient had a repeat CT for decreased mental
status today, showing continued diffuse cerebral edema and hyper
density along sulci likely due to brain edema. There was no
evidence of hemorrhage. The patient continued to have a poor
neurologic exam off propofol gtt.
On [**10-21**], his exam remained unchanged off propofol sedation.
Fentanyl boluses were intermittently given for pain control and
agitation. Mannitol was discontinued.
On [**10-23**], percutaneous tracheostomy was performed along with a
PEG tube for nutrition was inserted without issue.
On [**10-24**], patient continued to have intermittent low grade
fevers, with episodic hypertension and tachycardia. A BAL was
performed. Empiric antibiotic coverage was initiated for
ventilator-associated pneumonia as well as a UTI. HE was on
Cipro, Vancomycin and Cefepime.
On [**10-25**] he was tolerating a trach mask well and was transferred
to the step down unit.
On [**10-26**] his fever curve was declining, he vanco trough was low
so his dose was increased to 1GM tid. His BAL grew out Hflu so
his antibiotics were tailored to only Vanco and Cefepime.
On [**10-29**], patient was afebrile, had one episode of vomiting, a
KUB was order to evaluate for ileus. The was a normal gas
pattern. He did not have constipation.
He had some tachycardia with agitation overnight and Ativan was
ordered. Hematuria overnight was treated with an irrigating
cathter. This improved. He was discharged to rehab on [**2192-10-20**].
Medications on Admission:
None
Discharge Medications:
1. ibuprofen 100 mg/5 mL Suspension Sig: Six Hundred (600) mg
mg PO Q8H (every 8 hours) as needed for fever.
2. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
3. hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H
(every 6 hours) as needed for SBP>160.
4. lorazepam 2 mg/mL Syringe Sig: 0.5 mg
mg Injection Q6H (every 6 hours) as needed for agitation.
5. cefepime 2 gram Recon Soln Sig: Two (2) Recon Soln Injection
Q12H (every 12 hours).
6. propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25 mg Injection Q6H
(every 6 hours) as needed for pain.
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units
units Injection TID (3 times a day).
10. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 8H (Every 8 Hours).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
mg PO BID (2 times a day).
15. insulin regular human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): see SSIV.
16. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day) as needed for oral care.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
R SDH
Cerebral edema
Anoxic brain injury
Respiratory failure
VAP
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
**Your cervical collar must be worn for a total of 3 months.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks from the time of discharge.
You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment
You will need to wear your cervical collar for 3 months. You
should return to the office at that time with a MRI C-spine.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2192-10-30**]
|
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icd9cm
|
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[
"01.10",
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,514
| 195,795
|
44955
|
Discharge summary
|
report
|
Admission Date: [**2156-12-10**] Discharge Date: [**2156-12-16**]
Date of Birth: [**2100-10-6**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Bactrim / Fenofibrate
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
in-stent thrombosis
Major Surgical or Invasive Procedure:
Angioplasty of SFA
Cardiac Catheterization
History of Present Illness:
Ms. [**Known lastname 96136**] is a 56 year old woman with history of
hypertension, ESRD on dialysis (M,W,F), IDDM, PVD s/p left BKA
and right TMA, and recent admission complicated by NSTEMI/PEA
arrest x 2 ([**Date range (1) 46367**]) in which she received a prox and mid
LAD [**Date range (1) **] ([**10-20**]) admitted directly to the OR on [**2156-12-10**] for
elective femoral angiogram/angioplasty of SFA. At the end of the
procedure, the patient became hypertensive, tachycardic, and
went into flash pulmonary edema. ECG done after the event showed
inferior Q waves with baseline minimal inferior ST elevation and
lateral ST changes (unchanged from [**2156-11-29**]). She was intubated,
resuscitated, and transferred to the VICU. Since episode of
flash pulmonary edema, patient was seen by cardiology, who
recommended cath to evaluate for cause of flash pulmonary edema.
During catheterization, the patient was found to have in stent
thrombosis in the proximal LAD and a BMS was placed. She
received heparin and abciximab (iib/iiia for esrd). Patient was
also started on a nitro drip for hypertension during the cath.
.
On the floor, the patient states that she is doing well and
denied any discomfort. She noted that during the procedure she
felt some chest tightness but denied any pain.
.
REVIEW OF SYSTEMS:
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:
- ESRD on dialysis MWF, s/p thrombectomy and revisions in [**2-13**]
- DM2, c/b retinopathy, neuropathy
- HTN
- Hyperlipidemia
- Peripheral arterial disease
- smoking
- retinopathy
- neuropathy
- asthma
- nephrotic syndrome
- anemia
- morbid obesity
Social History:
Lives with family in [**Location (un) 86**], good support.
Tobacco: [**12-6**] ppd x 40 yrs
ETOH: denies
Family History:
brother, sister had [**Name2 (NI) **] in their late 50s. Two brothers on
dialysis with HTN, Mother with HTN.
Physical Exam:
On Admission:
VS - Temp F 98.0, BP 163/76, HR 77, O2-sat 96% 2L
GENERAL - comfortable, appropriate and in NAD
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat- w/r/r, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obsese abdomen but soft/NT/ND, no rebound/guarding
EXTREMITIES - left BKA no edema, right MTA
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
.
On Discharge:
vitals: 97.8, 119/55, 74, 20, 97RA
wt: 78.2
GENERAL - comfortable, appropriate and in NAD
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat- w/r/r, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obsese abdomen but soft/NT/ND, no rebound/guarding
EXTREMITIES - left BKA no edema, right MTA
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
On admission:
[**2156-12-10**] 10:20AM BLOOD WBC-16.7*# RBC-3.83*# Hgb-12.3# Hct-40.0#
MCV-104*# MCH-32.0 MCHC-30.7* RDW-15.1 Plt Ct-374#
[**2156-12-10**] 10:20AM BLOOD PT-11.7 PTT-150* INR(PT)-1.1
[**2156-12-10**] 10:20AM BLOOD Glucose-223* UreaN-54* Creat-7.4*# Na-145
K-7.3* Cl-102 HCO3-18* AnGap-32*
[**2156-12-10**] 11:34AM BLOOD ALT-8 AST-14 LD(LDH)-275* CK(CPK)-89
AlkPhos-179* Amylase-104* TotBili-0.1
[**2156-12-10**] 11:34AM BLOOD CK-MB-3 cTropnT-0.09* proBNP-[**Numeric Identifier **]*
[**2156-12-10**] 10:20AM BLOOD Calcium-10.8* Phos-12.2*# Mg-2.6
[**2156-12-10**] 10:46AM BLOOD pO2-78* pCO2-109* pH-6.96* calTCO2-27
Base XS--11
[**2156-12-10**] 11:51AM BLOOD freeCa-1.28
[**2156-12-10**] 10:46AM BLOOD Hgb-12.4 calcHCT-37 O2 Sat-83
.
On Discharge:
[**2156-12-15**] 03:26AM BLOOD WBC-5.8 RBC-3.25* Hgb-9.5* Hct-29.0*
MCV-89 MCH-29.4 MCHC-32.9 RDW-17.1* Plt Ct-230
[**2156-12-10**] 10:20AM BLOOD Neuts-50 Bands-0 Lymphs-39 Monos-5 Eos-6*
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-12-10**] 09:07PM BLOOD PT-11.6 PTT-21.6* INR(PT)-1.1
[**2156-12-15**] 03:26AM BLOOD Glucose-164* UreaN-41* Creat-7.7*# Na-136
K-4.5 Cl-93* HCO3-31 AnGap-17
[**2156-12-15**] 03:26AM BLOOD CK(CPK)-67
[**2156-12-15**] 03:26AM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 96138**]*
[**2156-12-15**] 03:26AM BLOOD Calcium-8.6 Phos-6.7* Mg-2.0
[**2156-12-11**] 09:16AM BLOOD Type-ART pO2-157* pCO2-47* pH-7.42
calTCO2-32* Base XS-5
[**2156-12-11**] 09:16AM BLOOD Type-ART pO2-157* pCO2-47* pH-7.42
calTCO2-32* Base XS-5
[**2156-12-11**] 12:57AM BLOOD freeCa-1.22
.
Sinus rhythm. Possible left atrial abnormality. Consider left
ventricular
hypertrophy. Non-specific ST-T wave repolarization
abnormalities. Compared to
the previous tracing of [**2156-12-11**] no diagnostic change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 154 90 350/400 76 45 122
.
ECHO
Conclusions
There is moderate regional left ventricular systolic dysfunction
with inferior/inferolateral hypokinesis. The remaining segments
contract normally (LVEF = 40%). Right ventricular chamber size
and free wall motion are normal. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Compared with the prior study (images reviewed) of [**2156-10-18**],
the findings are similar.
.
Cath:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrates three vessel coronary artery disease. There is
bulky
thrombus within the left anterior descending artery stents,
causing an
80% stenosis with 60% stensosis more distally. There appears to
be both
underexpansion as well as recoil of the previously placed stent.
The
circumflex artery contains a 50% lesion in the first obtuse
marginal and
a 40% lesion in the true circumflex proximally. The right
coronary
artery is proximally occluded and fills via collaterals. The
left main
coronary is patent.
2. Limited resting hemodynamics demonstrate severe systemic
hypertension.
3. Subacute stent thrombosis
4. Successful Export thrombectomy of proximal LAD stent
5. Successful direct stenting of proximal LAD with 3.0x18mm
Integrity
bare metal stent postdilated to final 3.5mm.
6. Successful PTCA only of distal previous LAD segment with
3.25mm NC
balloon to high pressure.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Subacute stent thrombosis
3. Severe systemic hypertension, treated with nitroglycerine
infusion
during the case.
4. Successful Thrombectomy, direct stenting of proximal LAD
previous
stent with BMS.
5. Successful PTCA of distal stent segment.
6. Successful IVUS evaluation of LAD.
Brief Hospital Course:
56 Year old lady with extensive history of PVD, smoking, DM2,
s/p BKA and toe amputations, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2 in [**2156-10-5**],
presented to the hospital for angioplasty of SFA. At the end of
the procedure, the patient developed HTN and flashed, requiring
intubation.
.
Pulmonary Edema/HTN - cardiac cause was suspected, so the
patient was taken for cardiac catheterization. In
catheterization, the patinet was found to have restenosis of her
[**Year (4 digits) **]. A bare metal stent was inserted in its place. The patient
was brought to our service at this time. We saw the patient, who
was doing well. We decided to increase her plavix dose in order
to help prevent restenosis. A platelet study was considered, but
the patient had received abciximab and so we were unable to do
so. The patient will ahve this done as an outpatient. The
patient was continued on her aspirin and her plavix dose was
doubled to 150mg
.
CKD - the patient requires dialysis MWF. She received her
dialysis session while on our service. Her cinacalcet was
increased to 4000 60 daily. Her sevelamir was increased to 4000
TID.
.
CHF - the patient has a known EF of 40%. She was continued on
her lisinopril (dose increased to 10) and metoprolol.
.
====================================
transitional issues- given her increase in cinacalcet, she is
at risk of having her calcium level drop. if her calcium level
drops to below 8.6, she is to have her cinacalcet dose decreased
to 30.
Medications on Admission:
1. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Tablet(s)* Refills:*1*
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
7. docusate sodium 50 mg/5 mL Liquid Sig: [**12-6**] PO BID (2 times a
day) as needed for constipation.
8. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*1*
9. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
11. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
three times a day: Dose as directed by sliding scale.
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. neomycin-bacitracnZn-polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical once a day for 7 days: apply
to affected area on left arm.
Disp:*1 bottle* Refills:*0*
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-6**] Inhalation every six (6) hours as needed for wheeze/cough.
16. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
with dialysis for 3 doses: HD sliding scale.
Disp:*3 doses* Refills:*0*
17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
18. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain: Do not drive or operate heavy machinery
while taking this medication.
Disp:*10 Tablet(s)* Refills:*0*
19. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime:
Stop this medication if you feel any muscle pain or weakness.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Medications:
1. pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*30 Capsule(s)* Refills:*2*
2. tizanidine 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): can be liquid form.
Disp:*30 Capsule(s)* Refills:*2*
4. senna 8.6 mg Capsule Sig: 1-2 Tablets PO at bedtime as needed
for constipation.
Disp:*30 * Refills:*0*
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. sevelamer carbonate 800 mg Tablet Sig: Five (5) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*30 Tablet(s)* Refills:*2*
8. cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every six (6) hours as needed for wheezing.
Disp:*30 30* Refills:*0*
12. clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous QHS.
Disp:*0 0* Refills:*0*
14. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
as directed: please see sliding scale and adjust your dose as
needed for glucose control.
15. Dilaudid Oral
16. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
17. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
In-stent restenosis with base metal stent placement
.
Secondary Diagnoses:
peripheral vascular disease
Type 2 Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed to wheelchair or prosthetic leg.
Discharge Instructions:
Ms. [**Known lastname 96136**], you came to the hospital for an angioplasty of
the artery in your leg. At the end of the procedure, your blood
pressure elevated and fluids entered your lungs as a result. You
were intubated to aid in your breathing. You underwent a cardiac
catheterization to look for an explanation of these events. An
old stent from [**Month (only) **] was found to be re-occluded. A bare
metal stent was placed to relieve the blockage. Because you
re-occluded your stent while on blood thinners, we will preform
testing on your platelets as an outpatient.
We have made the following changes to your medications:
Increase your lisinopril to 10mg daily
Increase your plavix dose to 150mg daily
Increase your cinacalcet to 60mg
Increase your sevelamir to 5 tablets three times a day (from 4
tabs)
Continue taking your atorvastatin
Start taking nephrocaps 1 tab daily
stop taking vancomycin
stop taking neomycin cream
increase aspirin to 325mg
It is extremely important to take your aspirin and plavix
EVERYDAY to prevent a future heart attack. Please do not stop
these medications unless talking to your cardiologist.
Weigh yourself every morning, call your cardiologist if weight
goes up more than 3 lbs.
Followup Instructions:
Name: NP-[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 96139**]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Thursday [**2156-12-23**] 10:30am
*This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care physician after this
visit.
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Department: Cardiology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Appointment: Thursday [**2157-1-6**] 8:30am
[**Location (un) **] Dialysis [**Location (un) **]
Phone: [**Telephone/Fax (1) 5972**]
Nephrologist:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Schedule: M/W/F
Department: TRANSPLANT CENTER
When: THURSDAY [**2156-12-30**] 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
Department: VASCULAR SURGERY
When: THURSDAY [**2156-12-30**] at 11:15 AM
With: VASCULAR LMOB (NHB) [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2156-12-30**] at 12:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
Completed by:[**2156-12-16**]
|
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"39.95",
"39.90",
"00.66",
"36.06",
"88.48",
"39.50",
"00.40",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12870, 12927
|
7357, 8897
|
318, 363
|
13131, 13131
|
3471, 3471
|
14550, 16487
|
2370, 2480
|
11063, 12847
|
12948, 12948
|
8923, 11040
|
7008, 7334
|
13300, 13903
|
2495, 2495
|
13042, 13110
|
4235, 6991
|
13932, 14527
|
1708, 1958
|
259, 280
|
391, 1689
|
12967, 13021
|
3486, 4220
|
13146, 13276
|
1980, 2231
|
2247, 2354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,008
| 174,424
|
24619
|
Discharge summary
|
report
|
Admission Date: [**2172-7-15**] Discharge Date: [**2172-7-30**]
Date of Birth: [**2111-5-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Colchicine / Bactrim
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
61 y/o F with PMH of NF, COPD on 2L home O2, adrenal
insufficiency [**12-18**] chronic steroid use, presents from [**Hospital 4199**]
hospital with altered mental status, fevers and increased oxygen
requirement.
.
Patient was recently discharged from [**Hospital 4199**] hospital 48hrs ago
to rehab facility. Today at rehab found to be desatting to 85%
on 2L and possibly more confused. Temperature 100.8 in am. She
was sent to [**Last Name (un) 4199**] ED for further evaluation. UA there grossly
positive (althoguh [**Last Name (un) **] ++) and CXR concerning for pneumonia.
She also had Head CT and LP with 0-2 WBC. She was given
vancomycin and ertapenem at 3PM, given 3L NS and transported to
[**Hospital1 18**] for further management.
.
In the ED at [**Hospital1 18**], initial vs were: 99.5 110 113/85 20 96%3L.
Exam notable for Labs notable for WBC of 11.4 (no bands), HCT
32.9 (baseline low thirties), sodium of 146, anion gap of 12,
lactate 1.8, creatinine 1.3 (baseline 0.8-1.0), calcium 10.6,
Alk phos 162 (low 100s previously), AST 42. UA showed >182 WBC
w/ moderate bacteria. Urine and [**Hospital1 **] cultures obtained. CXR
showed left lower lobe consolidation, mild alveolar edema,
possible small left pleural effusion. Patient was given
hydrocortisone 100mg IV given recently completed steroid taper.
Given 1L IVF. Vitals on transfer 99.5 99 113/55 100%3L. 22 and
18G for access.
.
On arrival to the ICU, patient was somnolent but rousable.
Responded to voice, but non-cooperative for examination,
history-taking.
vitals were: 96.6, 114, 152/84, 18, 98% 3L.
.
Review of systems:
Unable to obtain from patient given somnolence. She denied any
pain.
Past Medical History:
1. Coronary artery disease s/p revascularization, with STEMI
[**3-19**], BMS x 2 in [**2165**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, in [**2165**] and [**2170**] (RCA)
2. Congestive heart failure with LVEF 30%
3. Moderate COPD on home oxygen
4. Pulmonary embolism [**2158**]
5. Neurofibromatosis Type 1
6. Malignant nerve sheath tumor (s/p removal from left anterior
chest wall [**6-18**] and radiation [**2172**])
7. Depression
8. Hypothyroidism
9. Adrenal insuficiency [**12-18**] chronic steroid use for COPD
exacerbation
10. Hypercalcemia
11. Alcoholism per omr (patient denies current ETOH abuse)
12. Schizoaffective disorder
13. Gout
14. C. diff colitis [**1-/2172**], recurred [**3-/2172**]
Social History:
Ms. [**Known lastname 805**] lives with her boyfriend in a trailer in [**Name (NI) 3146**],
MA. Boyfriend has MR secondary to seizures. She is on
disability, used to work as a nursing aide. Is visited 2x/week
by VNA.
Tobacco: Quit smoking in past 2.5 weeks. Smoked for >30 years.
ETOH: Reports <1 drink a week.
Drugs: Denies IVDU.
Family History:
Mother/sister/nephew/son with Neurofibromatosis, Type I.
Father w/COPD.
Sister w/COPD.
Mother w/asthma.
Mother died of MI at age 72.
Father died of MI at age 86.
Physical Exam:
Admission PEx:
Vitals: 96.6, 114, 152/84, 18, 98% 3L
General: Obese, multiple neurofibromatoses all over face, body.
Somnolent but rousable. Unable to cooperate with examination.
HEENT: Small oral orifice. Dry-appearing mouth.
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral basal crackles. No wheeze appreciated but
patietn unable to take deep breaths.
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 with dark urine in bag.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
==========================================
Discharge PEx:
Pertinent Results:
Labs on Admission:
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] WBC-11.4* RBC-3.61* Hgb-10.7* Hct-32.9*
MCV-91 MCH-29.8 MCHC-32.7 RDW-18.0* Plt Ct-522*#
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Neuts-70.1* Lymphs-22.9 Monos-5.4 Eos-1.0
Baso-0.6
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] PT-14.5* PTT-23.5 INR(PT)-1.3*
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Glucose-93 UreaN-23* Creat-1.3* Na-146*
K-4.4 Cl-117* HCO3-17* AnGap-16
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] ALT-14 AST-41* LD(LDH)-421* AlkPhos-162*
TotBili-0.2
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Lipase-21
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Albumin-2.3* Calcium-10.6* Phos-4.3
Mg-2.2
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] TSH-12*
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] T4-5.6 T3-93
[**2172-7-16**] 01:36AM [**Month/Day/Year 3143**] Type-[**Last Name (un) **] pO2-52* pCO2-34* pH-7.37
calTCO2-20* Base XS--4
[**2172-7-16**] 10:42AM [**Month/Day/Year 3143**] Type-ART pO2-89 pCO2-24* pH-7.46*
calTCO2-18* Base XS--4
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Glucose-94 Lactate-1.8 Na-146* K-3.6
Cl-120* calHCO3-18*
[**2172-7-16**] 10:42AM [**Month/Day/Year 3143**] freeCa-1.37*
[**2172-7-15**] 09:50PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2172-7-15**] 09:50PM URINE [**Month/Day/Year **]-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2172-7-15**] 09:50PM URINE RBC->182* WBC->182* Bacteri-MOD
Yeast-NONE Epi-0
[**2172-7-15**] 09:50PM URINE CastHy-10* CastWBC-10*
[**2172-7-15**] 09:50PM URINE Mucous-MANY
[**2172-7-16**] 03:31AM URINE Eos-POSITIVE
[**2172-7-16**] 03:31AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2172-7-16**] 03:31AM URINE U-PEP-PND Osmolal-476
[**2172-7-16**] 03:31AM URINE Hours-RANDOM UreaN-371 Creat-45 Na-106
K-66 Cl-141 TotProt-33 HCO3-LESS THAN Prot/Cr-0.7*
Brief Hospital Course:
61 y/o F with PMH of neurofibromatosis, COPD on 2L home O2,
adrenal insufficiency [**12-18**] chronic steroid use, presented from
[**Hospital 4199**] hospital with altered mental status, fevers and
increased oxygen requirement.
.
Urinary Tract Infection: Patient completed a course of meropenem
(10 days ending [**7-25**]) for a citrobacter & ECOLI UTI. Her foley
catheter was removed.
.
Pneumonia: CXR findings suggestive of left lower lobe
consolidation with mild alveolar edema and small left pleural
effusion; however these findings appear only marginally changed
from prior. Received IV vancomycin, levaquin, and meropenem
empirically (patient is allergic to penecillins). IV vancomycin
and levaquin were discontinued ([**7-19**]) when CXR findings resolved
with diuresis.
.
Metabolic encephalopathy: Likely related to infection, uremia,
hypercalcemia. OSH CT head was negative. LP showed 2 WBCs only,
so not likely CNS source. Tox screen was negative. Electrolyte
abnormalities were corrected. infection was treated with
antibiotics. Her mental status improved during the course of the
admission. On discharge the pt was alert, oriented to name and
date.
.
Acute Kidney Injury: Likely related to sepsis and decompensated
heart failure. Her renal function improved with IVF initially
when septic and later diuresis.
.
Acute on chronic systolic heart failure: on [**7-17**] she
decompensated with IVF given for [**Last Name (un) **], but responded to lasix.
Most of her cardiac meds had been held in the ICU and were
restarted on [**7-17**]. Since then her heart failure symptoms have
improved. She returned to her baseline home oxygen
requirements. TTE demonstrated a globally depressed LVEF
consistent with cardiomyopathy of sepsis (discussed with
interpreting cardiologist, multivessel CAD also a possibility,
but felt to be less likely given clinical scenario).
.
COPD/adrenal insufficiency: Her last outpatient PFTs on [**2172-5-5**]
indicate moderate to severe COPD. Given COPD, recent steroid
taper, patient received hydrocortisone 100mg IV in the ED. She
was changed to PO prednisone 60 mg on [**7-17**], then slowly weaned to
20mg on [**2172-7-28**] with no decompensation in her respiratory
status. Albuterol and ipratropium nebs were continued. At
baseline she is on home O2 for COPD, 2L via NC. G6PD was checked
and when deficiency was ruled out, she was switched from
atovaquone to dapsone for PCP [**Name Initial (PRE) 1102**].
.
Acute pancreatitis - on [**7-18**] she developed significant tenderness
to palpation in RUQ of the abdomen. Abdominal ultrasound showed:
"Cholelithiasis (a single 2 cm gallstone) without evidence of
acute cholecystitis. CBD was not dilated. Portal vein patent."
It was a technically limited study. LFTs were normal with the
exception of a slightly elevated alk phos, which was unchanged.
However, lipase was elevated to 586 (was 21 three days earlier).
An abdominal CT was ordered (IV contrast could not be given due
to limitations of her PICC line). It showed stranding consistent
with acute pancreatitis. Symptomatically, this improved on [**7-19**],
and on discharge the pt was tolerating a normal diet.
.
Leukocytosis/diarrhea: After most of her abdominal pain had
begun to resolve, she developed a rapid rise in her WBC to 25
accompanied by voluminous diarrhea. As she had been treated for
CDIFF at [**Hospital1 18**] within the last month and at OSH within the last
two weeks, she was empirically started on po vancomycin and IV
flagyl. CDIFF toxin was negative x 2 and PCR finally returned
negative as well. ID was consulted and recommended treating
with PO vanco and IV flagyl for a full 14 day course
([**Date range (1) **]). Furthermore, she should receive po flagyl whenever
receiving broad spectrum abx in the future. That said, they
felt that the resolving pancreatitis was more likely the cause
of her leukocytosis.
Leukocytosis: The pt had persistent leukocytosis (ranging from
WBC of 15-19) during the last week of the hospitalization
without any localizing signs or symptoms. Heme onc reviewed her
smear and it was consistent with the effect of steroids (many
mature polys and lymphs). Her WBC should be checked one and two
weeks after discharge, and if it is peristently high she should
be referred to heme-onc as an outpatient.
Adrenal Insufficiency: On prednisone 60mg for almost 1 month,
tapered to 40 on [**7-21**]->30 on [**7-25**], then to 20 on [**7-28**].
Long-term basal dose is 10mg daily. She will be due to taper
down to 10 on [**8-4**].
.
Hypothyroidism: Continued on Levothyroxine.
IV Access:
Please d/c Left PICC on [**7-8**] after the pt's final dose of
metronidazole.
Medications on Admission:
Rosuvastatin 5mg qd
Furosemide 10mg qd
Prednisone 5mg qd
Spironolactone 25mg
Tiotropium 18 mcg 1capsule inh daily
Aspirin 325mg EC qday
Allopurinol 200mg qd
Clopidogrel 75 mg PO qd
Ferrous sulphate 325mg PO qd
Advair-diskus 250-50 1 puff po bid
Metoprolol 50 [**Hospital1 **]
Albuterol 2.5mg nebuliser qid
Calcium carbonate 500mg po bid
Gabapentin 300 mg po bid
Lantus 20 u subcut at night, regular insulin sliding scale
Levothyroxine 100 mcg qd
Oxycodone 5mg q4h prn
Ranitidine 150 mg po qd
Florastor probiotic supplement
Milk of magnesia PO qd PRN
Bisacodyl 10 mg PR qd
Fleet's enema qd prn
Prune juice po qd prn
Discharge Medications:
1. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please taper down to 10mg daily on [**8-4**].
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet PO DAILY (Daily).
7. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
10. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing.
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO twice a day.
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
17. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): STOP ON [**8-8**].
19. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
20. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
21. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1) inj
Injection three times a day: Please continue until patient is
ambulatory/participating with PT tid.
22. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
23. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin rash.
24. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing rehab center
Discharge Diagnosis:
Toxic-metabolic encephalopathy
Urinary tract infection
Acute pancreatitis
Acute of chronic systolic heart failure
Hypercalcemia, symptomatic
Clostridium difficile colitis
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 805**],
You were admitted to [**Hospital1 18**] for the treatment of multiple
infections. While you were here, you were also treated for heart
failure and acute pancreatitis.
Several changes have been made to your medications and a full
list of what you should be taking will be provided to the
rehabilitation facility to which we are transferring you.
Here are the changes that were made:
prednisone was increased
vancomycin po and metronidazole IV were started and will
continue until [**8-8**]
A PICC line was placed and should be removed on [**8-8**] after your
final dose of metronidazole.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2172-8-21**] at 3:50 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2172-10-21**] at 9:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"349.82",
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icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
13482, 13554
|
6038, 10706
|
317, 324
|
13770, 13770
|
4047, 4052
|
14597, 15169
|
3137, 3300
|
11373, 13459
|
13575, 13748
|
10732, 11350
|
13945, 14572
|
3315, 4028
|
1954, 2026
|
256, 279
|
352, 1935
|
4067, 6015
|
13785, 13921
|
2048, 2772
|
2788, 3121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,610
| 146,134
|
3432
|
Discharge summary
|
report
|
Admission Date: [**2147-8-19**] Discharge Date: [**2147-8-24**]
Date of Birth: [**2084-6-18**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Benadryl
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Neutropenic fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname 15849**] is a 63-year-old man with a history of
promyelocytic leukemia with a 15;17 translocation that is now in
remission. However, he now has
developed a therapy-related leukemia and is status post
remission induction with 7+3 and completed high-dose ARA-C on
[**2147-8-6**] (now Day 19 after therapy). His last bone marrow
biopsy showed complete response. However, his course has been
complicated by development of skin rash on extremities with
recent biopsy
revealing leukemia cutis. He has a donor and plan is for him to
have bone marrow transplant around [**2147-9-13**].
.
He was seen in clinic on [**8-18**]. His ANC was 100 and he received 1
U PRBC for chemotherapy induced anemia. This morning he felt
cold and took his temperature which was 100.5. By the time he
arrvied in the ER, his temperature had spiked to 102.8. He has
felt cold but no rigors. He feels tired and has generalized
muscle aches today with the fever but otherwise no localizing
signs of ifection. Specifically, he denies nausea/vomiting,
diarrhea (last normal BM this am) or abdominal pain. No SOB, CP,
palpitation, cough, URI sx, mouthsores, dysuria, hematuria. He
states that his skin is not significantly worse - though to him
some of the nodules appear more raised than before. He has not
noticed the development of any new lesions. He has had no easy
bruising or bleeding. Review of systems is otherwise
unremarkable.
.
In ER, he had blood cultures x2, urine culture, chest x-ray and
received Cefepime 2 gm IV and Tylenol. He felt slightly better
after his fever was a bit lower (101.6).
Past Medical History:
1. Duodenal adenocarcinoma in third segment of the duodenum
diagnosed in [**2142-7-25**], stage 2, T3, N1, M0, status post
resection and chemotherapy with 5-FU and leucovorin times six
cycles.
2. Congenital malrotation of the colon, status post surgical
correction.
3. Status post tonsillectomy.
4. Status post carpal tunnel release.
5. History of prostate cancer, diagnosed in [**2140**] due to an
elevated PSA, status post radical prostatectomy.
6. Status post adhesion lysis in [**2106**].
7. Hiatal hernia.
8. hypercholesterolemia
9. GERD
10. history of APML
Social History:
The patient is married and has a teenage daughter. [**Name (NI) **] works as
an attorney. Does mostly educational work. He is a lifelong
non-smoker; has about 1 alcoholic drink per day.
Family History:
Father died of prostate cancer at 80. Mother died at 90's of
unknown cause. He has no siblings or relatives with cancer.
Physical Exam:
GENERAL: The patient is a healthy-appearing man in no acute
distress.
VITAL SIGNS: Temperature is 100.6, O2
saturation is 98% on room air, pulse is 84 and blood pressure is
110/68.
HEENT: The sclerae are nonicteric. The extraocular motions are
full. The pupils are equal, round and reactive to light and
accommodation. There is no evidence of any oral thrush or
mucositis. There is no discharge from the nose at this time.
The posterior oropharynx looks normal. There is no injection or
exudates. Tonsils appear normal. There is no evidence of
gingival bleeding.
NECK: Supple. Thyroid is symmetric.
LYMPH NODES: No cervical, supraclavicular,
axillary, inguinal or epitrochlear lymph nodes.
CHEST: Clear to auscultation and percussion. No
wheezes, rhonchi or rales.
HEART: Sinus rhythm with normal S1 and S2. No
murmurs, rubs or gallops.
ABDOMEN: Soft. No hepatosplenomegaly. No
obvious ascites or other masses. He has a well-healed surgical
scar from previous surgery.
SKIN: Livid nodular rash on both legs and arms (increased since
last admission)
EXTREMITIES: Lower extremities show no clubbing, cyanosis or
edema.
NEUROLOGIC: Cranial nerves II through XII are normal. Motor,
sensory and cerebellar exams are also grossly normal.
Pertinent Results:
Admission labs: WBC 0.4, Hgb 10.6, Hct 29.9, platelets 68, ANC
70, BUN 13, Cr 1.0, Na 135, K 3.3, Cl 99, HCO3 27, AG 12.
U/A negative. LFTs - within normal range.
.
CXR [**2147-8-19**]: The heart size is normal. Mediastinal and hilar
contours are unremarkable. The lungs are clear. No pleural
effusions. No evidence of pneumothorax.
.
TTE [**2147-8-20**]: There is moderate global left ventricular
hypokinesis. LV systolic function appears depressed. The right
ventricular cavity is mildly dilated. Right ventricular systolic
function appears depressed. The mitral valve leaflets are mildly
thickened. At least mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2147-8-18**], biventricular systolic function is now worse. Mitral
and tricuspid regurgitation are now more prominent (in focused
views). Estimated pulmonary artery systolic pressure is now
higher.
.
CT chest/abd/pelvis [**2147-8-20**]:
CT CHEST WITH CONTRAST: The pulmonary arteries opacify without
filling
defects. The heart and great vessels of the mediastinum are
unremarkable and there is no evidence for acute aortic injury.
No pathologic axillary,
mediastinal, or hilar adenopathy is identified. There are very
small
bilateral pleural effusions with small dependent atelectasis.
Note is made of coronary artery calcifications.
.
CT ABDOMEN WITH CONTRAST: The liver enhances without focal
lesions. The
gallbladder is moderately distended with pericholecystic fluid.
No radiopaque stones are identified. The common bile duct is
difficult to measure. The patient reportedly has a history of
duodenal cancer, and atypical anatomy within the second portion
of the duodenum would be consistent with previous surgery.
Study is limited secondary to lack of oral contrast. The
pancreas is atrophic. The distal pancreas enhances greater than
pancreatic head, but this is of unclear importance given early
arterial phase. There is a small amount of free fluid about the
liver, spleen, and in the pelvis. Small bowel loops are normal
caliber. No pathologic adenopathy is identified, though
multiple small retroperitoneal nodes are present. There is a
suggestion of a faint heterogeneous enhancement of the upper
pole of the left kidney and upper
pole of the right kidney that is likely chronic. Comparison to
previous
studies would also be helpful.
.
CT PELVIS WITH CONTRAST: Multiple surgical clips are present in
the pelvis. The patient's prostate is not identified, consistent
with the patient's history of prostate cancer. The bladder
appears normal. The rectum, sigmoid, and large bowel is within
normal limits. No pathologic adenopathy is identified.
.
BONE WINDOWS: Small sclerotic focus is present in the right
posterior column of the acetabulum, as well as a small 8-mm
sclerotic focus within the left iliac and sacrum. Though these
likely represent bone islands, but given history of prostate
cancer, comparative imaging would be helpful.
.
Gallbladder US [**2147-8-21**]: The gallbladder is normal in appearance,
with no evidence of cholecystitis or gallbladder wall
thickening. Trace pericholecystic fluid is seen adjacent to the
fundus of the gallbladder. The extrahepatic portion of the
common bile duct is enlarged, measuring 11 mm in diameter. The
intrahepatic bile ducts are normal in appearance. No
ultrasonographic [**Doctor Last Name 515**] sign is appreciated. Visualized
portion of the liver is unremarkable.
.
Labs at time of discharge:
WBC 1.5
ANC 600
Hct 32
Plt 360
INR 1.1
Na 142
K 3.6
Cr 0.7
Ca 8.2
Mg 1.8
Culture data negative
Brief Hospital Course:
The patient was admitted to the Bone Marrow Transplant Unit for
treatment of neutropenic fever. He was continued on Cefipime.
Initially on the floor the patient was stable with BP 110/70.
Overnight however, the patient became hypotensive with bp
80s/50s. The patient was asymptomatic and denied
fevers/chills/sweats/, SOB at that time. Vancomycin was started
for concern for sepsis, and 3 1L boluses were given. AM cortisol
was high and there was no chronic steroid use. Patient was
initially unresponsive to fluids so he was tranferred to the
MICU for further management. Prior to transfer the patient
developed chest pain and hypoxia associated with hypotension so
a bedside echo was performed to r/o pericardial effusion. This
was neg for effusion, but notable for EF of 35%. EKG showed twi
in II, AVR and V1, as well as left anterior fascicular block and
RBBB, no change from prior, no acute ST changes. Pt was
transfused 2 units prbcs and given empiric flagyl and
caspofungin for anaerobic and fungal coverage, respectively.
Patient was transferred to ICU for further management. He had
no further episodes of chest pain.
.
In the ICU the patient's BP normalized following transfusion of
RBCs and IVF. He did not require any pressors. Broad-spectrum
antibiotics were continued and extensive work-up continued to
reveal no clear source of infection. He was tranferred back to
the floor on [**8-23**] and at the time of transfer he denied pain,
SOB, N/V, fever/chills. He continued to have normal bowel
movements and denied dizziness, weakness, cough, dysuria. On
the floor he remained afebrile and after his ANC increased to
600 on the day of discharge his antibiotics were discontinued.
The source of fever remained unclear. CXr and U/A on admission
were negative, Ucx subsequently was negative. BCx from [**8-19**] and
[**8-20**] show no growth to date. Patient has no central lines, no
focal signs of infection on exam. CT abdomen/pelvis was also
negative for focal infection. Gall-bladder US showed no
cholecystitis and patient did not have RUQ pain.
.
With regards to patient's AML, he is now 23 days post HIDAC.
ANC now 600. Patient has multiple violacious nodules on upper
and lower extremities that were biopsied on [**8-5**]: path showed
cells + for CD68 and CD15, neg. for myeloperoxidase. Radiation
oncology evaluated the patient for possible skin radiation and
the decision was made between Dr. [**Last Name (STitle) 776**] and Dr. [**First Name (STitle) **] to
send the patient to [**Hospital1 1012**] for further treatment. [**Doctor Last Name **] will go
home on Acyclovir prophylaxis. The patient had occasional
nausea during admission that responded well to ativan prn and he
was given a prescription for this upon discharge.
Medications on Admission:
acyclovir 400 Q8
levofloxacin 500 Q24
protonix 40 Q24
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Febrile neutropenia
2. AML
3. Leukemia cutis
Discharge Condition:
Hemodynamically stable, ANC 600, afebrile, tolerating PO
Discharge Instructions:
You were admitted to the hospital for fever and neutropenia. If
you have any fevers >100.4, shortness of breath, chest pain,
diarrhea, inability to eat or drink or any other concerning
symptoms, you should call your doctor or come to the emergency
room.
Please take all of your medications as directed.
Please keep all of your follow up appointments.
Followup Instructions:
You will need to follow up next week with your [**Hospital **] clinic.
They are aware and will contact you regarding your appointment
time and date.
|
[
"205.00",
"V10.46",
"995.94",
"272.0",
"553.3",
"205.01",
"397.0",
"288.0",
"038.9",
"424.1",
"530.81",
"V10.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11127, 11133
|
7917, 10672
|
305, 312
|
11225, 11284
|
4172, 4172
|
11685, 11837
|
2777, 2902
|
10777, 11104
|
11154, 11204
|
10698, 10754
|
11308, 11662
|
2917, 4153
|
248, 267
|
340, 1959
|
4188, 7894
|
1981, 2554
|
2570, 2761
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,604
| 152,041
|
15384
|
Discharge summary
|
report
|
Admission Date: [**2195-1-2**] Discharge Date: [**2195-1-8**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 88-year-old woman
with a history of a large MCA CVA one month ago status post
PEG placement, who has been living at the [**Hospital3 1186**] with
progressive decline.
On the day of admission, the patient was found to be
lethargic with a temperature of 103.2 degrees and hypoxic.
She was started on empiric antibiotics for aspiration
pneumonia, and was tachypneic and hypoxic with minimal urine
output, and hence, was taken to [**Hospital1 **].
Patient is nonverbal on admission and could provide no
further history.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident of middle cerebral artery.
2. Seizure.
3. Alzheimer's.
4. Lumbar stenosis.
5. Sacral decubitus ulcer.
6. Aspiration pneumonia.
7. Coronary artery disease.
8. Hypertension.
9. Degenerative joint disease.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 117/45,
pulse 69, and satting 97% on 6 liters, respiratory rate 23,
and temperature 96.3. General: This is an elderly,
chronically, and acutely ill appearing woman with some
accessory musculature use, obese. .............., but
noninfected looking decubitus sacrum to the bone.
Respiratory: Coarse breath sounds throughout.
Cardiovascular: Muffled by coarse breath sounds. Pulse
regular. Abdomen: G tube in place, no erythema, large
belly, tender to palpation diffusely. Extremities:
Nonedematous, dorsalis pedis pulses 1+ bilaterally. Feet
deformed and pointed toe position.
LABORATORIES: White count 24.6, hematocrit 38.2, platelets
582. Sodium 132, potassium 4.1, chloride 93, bicarb 21, BUN
89, creatinine 3.2. Glucose 137. Urinalysis: Moderate
leukocyte esterase, 21-50 reds, [**12-25**] whites, moderate
bacteria.
CHEST X-RAY: Low lung volumes, cardiomegaly, pulmonary
edema, bilateral effusions.
HOSPITAL COURSE:
1. Respiratory failure: This is felt to be secondary to
pulmonary edema and aspiration pneumonia. She was diuresed
with Lasix and treated with ceftazidime, levofloxacin, and
Flagyl for nursing home acquired aspiration pneumonia. She
had received chest physical therapy and aggressive suctioning
and nebulizers.
While on the floor, the patient became hypotensive to
systolic blood pressure 74, which responded to 1.5 liters of
IV fluids. Patient's code status was initially DNR/DNI, but
after family discussion, the patient was made intubatable
when she was hypoxic on the floor, it was decided to transfer
to the MICU for observation. The patient required BiPAP
overnight in the MICU, but then remained on face mask for the
rest of her stay.
The patient continued to have large amount of secretions,
which she could not clear. On chest x-ray, mucus plugging
with subsequent lobar collapse. After long discussion with
family, it was decided that the patient's status, status post
stroke would predispose her to recurrent aspiration events,
which she would do poorly with. It was therefore, decided by
the family to make the patient DNR/DNI and comfort measures
only.
The patient was then transferred back to [**Hospital3 1186**] for
CMO care.
2. Acute on chronic renal failure: The patient came in with
BUN and creatinine much above baseline. This is felt to be
prerenal in nature given the patient's FENa and BUN and
creatinine ratio. This improved over hospital course with
gentle IV fluids.
3. Dysrhythmia: The patient's initial EKG was felt to
represent a third degree heart block. EP consult was
obtained, who felt that this more likely represented
junctional rhythm with retrograde conduction, occasional
atrial flutter with variable conduction. There was felt to
be no indication for this patient.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: To [**Hospital 44670**] Hospital. The patient is CMO
per discussion with family and primary care provider.
DISCHARGE MEDICATIONS:
1. Scopolamine patch.
2. Morphine elixir sublingual 10 mg q.1h. prn.
3. Ativan 1 mg p.o. q.1h. prn.
FOLLOW-UP PLANS: Patient will be followed up by her primary
care provider at the [**First Name4 (NamePattern1) 44670**] [**Last Name (NamePattern1) **].
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 11246**]
MEDQUIST36
D: [**2195-1-8**] 01:32
T: [**2195-1-8**] 05:50
JOB#: [**Job Number 44671**]
|
[
"427.31",
"518.81",
"599.0",
"780.39",
"507.0",
"428.0",
"707.0",
"V66.7",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
3731, 3866
|
3889, 3990
|
1885, 3709
|
917, 1868
|
4008, 4391
|
111, 640
|
662, 894
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,724
| 151,526
|
36971
|
Discharge summary
|
report
|
Admission Date: [**2105-8-28**] Discharge Date: [**2105-9-6**]
Date of Birth: [**2041-9-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
lung mass
Major Surgical or Invasive Procedure:
[**2105-8-28**] Right thoracotomy, right pneumonectomy.
2. Buttress of bronchial stump with intercostal muscle.
3. Therapeutic bronchoscopy.
History of Present Illness:
63M with large R chest mass who presents for resection following
an abnormal x-ray. Patient underwent foot debridement by Dr.
[**First Name (STitle) 3209**] on [**2105-6-13**]. A preoperative x-ray revealed a large
right-sided lung tumor.
From the pulmonary perspective, the patient stated that he had
no current complaints. His last x-ray was at least 30 years ago.
He had no dyspnea or chest wall pain. He had noted a 10-pound
weight loss over the past month, which he attributed to his
recent foot infection and admission to the hospital. Lung core
biopsy suggested the lung mass to be sarcomatoid mesothelioma
vs. sarcoma. Mass was FDG avid on PET. CT chest suggested right
pulmonary mass had increased in size over the previous month.
Past Medical History:
Type 2 diabetes, recently diagnosed,not on active therapy.
right foot debridement
Social History:
lives at home with wife. active [**Name2 (NI) 1818**]
Family History:
non contributory
Physical Exam:
VS: T=98.8 HR=56 BP=110/62 RR=18 O2Sat=96%RA
HEENT: normal EOM, PERL, no lymphadenopathy
CVS: irregularly irregular RR, normal S1, S2, no murmurs
RESP: absent breath sounds right thorax, clear to auscultation
at left lung base
incision on posterior right thorax c/d/i, healing well, no
erythema
[**Last Name (un) **]: soft, NT/ND, no palpable masses
EXT: able to move all 4 extremities spontaneously, no edema
Pertinent Results:
[**2105-8-28**] 06:30PM TYPE-ART TEMP-36.7 O2 FLOW-5 PO2-238*
PCO2-52* PH-7.31* TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA
COMMENTS-SIMPLE FAC
[**2105-8-28**] 05:35PM GLUCOSE-157* UREA N-16 CREAT-0.7 SODIUM-138
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-30 ANION GAP-8
[**2105-8-28**] 05:35PM CALCIUM-8.7 PHOSPHATE-4.2 MAGNESIUM-1.9
[**2105-8-28**] 05:35PM WBC-8.7 RBC-3.85* HGB-11.2* HCT-34.8* MCV-91
MCH-29.2 MCHC-32.2 RDW-13.5
[**2105-8-28**] 05:35PM NEUTS-71.5* LYMPHS-22.3 MONOS-5.0 EOS-0.9
BASOS-0.3
[**2105-8-28**] 05:35PM PLT COUNT-281
[**2105-8-28**] 05:35PM PT-12.3 PTT-27.5 INR(PT)-1.0
[**2105-8-28**] 03:55PM GLUCOSE-156* LACTATE-1.0 NA+-138 K+-4.1
CL--99*
[**2105-8-28**] 03:55PM HGB-12.3* calcHCT-37
[**2105-8-28**] 03:55PM freeCa-1.16
[**2105-8-28**] 02:23PM TYPE-ART PO2-87 PCO2-45 PH-7.40 TOTAL CO2-29
BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2105-8-28**] 02:23PM GLUCOSE-149* LACTATE-1.3 NA+-137 K+-4.3
CL--99*
[**2105-8-28**] 02:23PM HGB-13.0* calcHCT-39
[**2105-8-28**] 02:23PM freeCa-1.20
Brief Hospital Course:
[**2105-8-28**]: transferred to SICU postop with CT x 1, thoracic
epidural in place, significant gastric distension on CXR.
[**2102-8-29**]: CT removed, resolution of gastric distension, started on
clears without difficulty.
[**2105-8-30**]: Transferred to floor tolerating regular diet
[**2105-8-31**]: AFib with RVR, given lopressor, diltiazem, became
hypotensive and was transferred back to SICU for futher
management, diltiazem drip and neo transiently required but
rapidly weaned off. Started on PO lopressor and received one
unit of packed red cells for a hematocrit 28.6->29.8. converted
to SR.
[**2105-9-1**]: back into a-fib, diltiazem drip restarted with stable
pressures. hematocrit remained stable, started on vancomycin +
cefepime for empiric HAP coverage given GPC and GNR on gram
stain of BAL.
[**2105-9-2**]: Po diltiazem held. started on heparin gtt in preparation
for cardioversion
[**2105-9-3**]: attempted cardioversion by cardiology failed,
spontaneously converted to SR, BAL cultures grew out
pan-sensitive pseudomonas for which ID recommended double
coverage with cefepime + cipro x 14 days total course,
vancomycin stopped.
[**2105-9-4**]: remained in SR
[**2105-9-5**]: suture from chest tube site removed, otherwise doing
well
[**2105-9-6**]: Patient stable in sinus rhythm, ambulating. Family
present, patient prepared for discharge. Will follow up in
cardiac clinic next week, patient's family to call [**Telephone/Fax (1) 62**]
to schedule appointment. Patient will have follow-up appt in
thoracic clinic in [**2105-9-17**] with Dr. [**First Name (STitle) **].
Medications on Admission:
Glipizide 5mg PO QD, Fluticasone 220", Bactrim DS"
Discharge Medications:
1. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 10 days: through [**2105-9-14**].
Disp:*20 Recon Soln(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day for while taking pain medication days.
Disp:*30 Capsule(s)* Refills:*0*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 14 days.
Disp:*40 Tablet(s)* Refills:*0*
6. Guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO TID (3
times a day).
Disp:*450 ML(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day for 30 days.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day for
ongoing months.
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: [**12-26**]
Inhalation every six (6) hours.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Lung Cancer
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, coug or sputum production.
-Incision develops drainage
-Complete Antibiotic course
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**2105-9-17**] on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Follow-up Cardiac Clinic Call [**Telephone/Fax (1) 62**] for appt ASAP.
|
[
"070.30",
"162.4",
"V15.82",
"482.1",
"715.90",
"492.8",
"250.00",
"997.1",
"458.9",
"427.31",
"E878.6",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"99.62",
"32.59",
"83.82",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6145, 6194
|
2974, 4569
|
329, 472
|
6250, 6259
|
1909, 2951
|
6525, 6879
|
1440, 1458
|
4670, 6122
|
6215, 6229
|
4595, 4647
|
6283, 6502
|
1473, 1890
|
280, 291
|
500, 1247
|
1269, 1353
|
1369, 1424
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,286
| 133,296
|
47739
|
Discharge summary
|
report
|
Admission Date: [**2195-5-2**] Discharge Date: [**2195-5-9**]
Date of Birth: [**2130-8-23**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 87305**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 year old female with stage IV lung cancer, CAD s/p MI, T2DM,
Afib, and HTN who presents with an acute exacerbation of her
shortness of breath.
.
She received chemo yesterday at [**Location (un) 2274**]. After she returned home,
she had the acute onset of SOB at 4-5pm yesterday. She denies
chest pain, but "just couldn't breathe." At first she drank
some juice and her husband tried to get her to eat but her
dyspnea worsened significantly and she called EMS. She also
reports low grade fevers 99-100 at night. Denies cough or
sputum production.
.
She went to the [**Hospital1 2436**] ED where she was febrile to 100.2.
CT chest was done which showed a left sided infiltrate and a
right sided filling defect with segmental PE. She was given
CTX/azithro and started on a heparin gtt without a bolus. Hct
was reportedly 28 with INR 1.3. She was then transferred to
[**Hospital1 18**].
.
In the ED, initial VS were: 97.6 84 171/29 16 97%. She desatted
to the high 80's on NC with SBP 90-100's. Labs were notable for
an initial Hct of 11.4 with repeat of 22.5 (without
intervention). INR 1.4, Creat 0.5, WBC 6.4. On heparin gtt @
1450/hr. Was on NRB for a while but now on 5L nasal cannula and
)2 sats in the mid-90's. SBPs 90-100's. Given 1L NS. Atrius
oncology is aware of admission. Uploaded CT into PACS. Most
recent vitals 90 (irregular) 100/49 22 97%5L. Has 2 PIVs.
.
Currently, she reports she is feeling back to baseline. At
baseline, she is short of breath with walking more than a few
steps. She walks with a walker and has profound leg weakness
due to a potential steroid myopathy that has been slowly getting
better over the last several weeks.
Past Medical History:
Stage IV NSCLC metastatic to liver and brain (left cerebellum),
s/p cyberknife resection and right lobectomy [**8-19**] on home O2
Coronary artery disease status post MI and two stents
Type 2 diabetes
Atrial fibrillation
Hypertension
Hypercholesterolemia
GERD
Probable planum sphenoidale meningioma
Right breast lumpectomy (negative)
Lipoma resection from left chest wall
Cholecystectomy
Bilateral cataract surgery
Resection of focal polyps
Tonsillectomy
Appendectomy
Resection of a uterine fibroid
Social History:
Social History: Married and lives with husband. [**Name (NI) **] 5 local
children and many grandchildren. Smoked 1-2ppd x 30 years, none
currently. She rarely drinks alcohol. No other drugs.
Family History:
The patient's father died at age 56 from a brain tumor and her
mother died at age 77 from Alzheimer's disease;
she has two half sisters who had lung cancer; a sister died of a
myocardial infarction.
Physical Exam:
PEx on admission:
Vitals: 98.1 109 99/58 28 91-96%5L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP mildly elevated, no LAD
Lungs: Clear to auscultation bilaterally with crackles at the
left base
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
Discharge Physical Exam:
Tm 97.9, Tc 97.9, BP 124/73 (89-124/66-80), 113 (74-158), 18,
98%3L NC (98%3L-96%4L NC)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP flat, no LAD
Lungs: Poor air movement, reduced breath sounds at left base
with some mild crackles, reduced sounds at right base and right
upper lobe.
CV: Irregular 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
Pertinent Results:
ADMISSION LABS:
[**2195-5-2**] 03:30AM BLOOD WBC-6.4 RBC-1.24*# Hgb-4.0*# Hct-11.4*#
MCV-91 MCH-32.1* MCHC-35.2* RDW-19.5* Plt Ct-315#
[**2195-5-2**] 03:30AM BLOOD Neuts-87.4* Lymphs-9.3* Monos-2.8 Eos-0.1
Baso-0.3
[**2195-5-2**] 03:30AM BLOOD PT-15.5* PTT-33.3 INR(PT)-1.4*
[**2195-5-2**] 03:30AM BLOOD Glucose-163* UreaN-13 Creat-0.5 Na-136
K-4.0 Cl-101 HCO3-23 AnGap-16
[**2195-5-2**] 10:00AM BLOOD CK(CPK)-42
[**2195-5-2**] 10:00AM BLOOD cTropnT-<0.01
[**2195-5-2**] 10:00AM BLOOD Calcium-7.4* Phos-3.4 Mg-1.3* Iron-58
[**2195-5-2**] 10:00AM BLOOD calTIBC-200* Ferritn-1518* TRF-154*
[**2195-5-2**] 10:00AM BLOOD Cortsol-28.9*
[**2195-5-2**] 10:00AM BLOOD Digoxin-0.6*
[**2195-5-2**] 04:39AM BLOOD Hgb-8.1* calcHCT-24
DISCHARGE LABS:
[**2195-5-9**] 06:00AM BLOOD WBC-5.2 RBC-3.24* Hgb-9.6* Hct-29.0*
MCV-89 MCH-29.5 MCHC-33.0 RDW-18.1* Plt Ct-164
[**2195-5-9**] 06:00AM BLOOD Neuts-57 Bands-1 Lymphs-18 Monos-12*
Eos-0 Baso-0 Atyps-4* Metas-5* Myelos-3*
[**2195-5-9**] 06:00AM BLOOD Glucose-80 UreaN-9 Creat-0.6 Na-137 K-3.9
Cl-99 HCO3-30 AnGap-12
[**2195-5-9**] 06:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.4*
[**2195-5-9**] 06:01AM BLOOD Vanco-22.2*
IMAGING:
CTA [**2195-5-7**]:
IMPRESSION:
1. Right pulmonary stable filling defect since [**2195-5-1**], in the
absence of
other sites of thrombi, this could represent tumor and/or in
situ thrombus, particularly as it is directly adjacent to the
site of resection.
2. Diffuse esophagitis.
3. Enhancing right moderately large pleural effusion, suspicious
for a
malignant effusion.
4. Moderately severe emphysema.
5. Diffuse ground-glass opacity, stable since [**2195-5-1**], but new
since [**2195-3-10**], may represent diffuse drug reaction, atypical
pneumonia or edema.
Brief Hospital Course:
64 year old female with stage IV lung cancer, CAD s/p MI, T2DM,
Afib, and HTN who presents with new right sided PE and increased
O2 requirement.
.
# CP/SOB: Patient had 3 episodes this admission of CP and SOB,
which after much investigation (including CTA which showed no
new process) was determined to be atrial fibrillation likely
causing some pain with demand ischemia (but negative cardiac
enzymes x3) and also severe GERD from esophagitis noted on CTA.
Ativan and maalox fixed the CP, and the SOB improved once
patient's HR was decreased with IV lopressor, and then we
uptitrated pt's metoprolol to 25mg TID to better control her
afib. She was given SL NTG, but this did not help as much as
controlling her HR. Her SOB also was mildly improved after
1uPRBCs [**5-7**]. She remained hemodynamically stable throughout
each of her episodes, although she did drop her BP to the low
90's after she was given 2 SL NTG and lopressor at the same
time, but this quickly resolved with IVF.
.
#. PE: Pt initially on heparin, has been transitioned to
lovenox. O2 requirement stable at 3L (baseline 2L). She has
remained hemodynamically stable without evidence of overload.
She has remained tachycardic in 100-140's (see above) throughout
this admission. Has been ruled out for MI. Therefore we
continued her lovenox, but she will likely need teaching for
this on dispo from rehab. She will need to be weaned back to
her home dose of 2L NC O2 as tolerated.
.
#. Pneumonia: Initially on Levoflox for CAP on admission, but as
Ms. [**Known lastname **] had been recently hospitalized and then in rehab for
an extended period, we felt this was not adequate tx. This was
especially true as she continued to be febrile after 48hrs on
antibiotics. Moderate right sided pleural effusion noted on CT
scan could represent an empyema, however, this has been noted on
prior CT scans making this less likely. She was broadened to
vanc + cefepime (day 1= [**5-3**]) given patient's exposure history
and poor pulmonary reserve to cover for Pseudomonas and MRSA.
UCx and urine legionella were negative. Sputum Cx had commensal
resp flora. She will need to complete a 14 day course of
antibiotics (last dose 5/7).
.
#. Atrial fibrillation: Has been in controlled afib w/ some
spikes
(as above) to HR in 140-150's. We continued her home diltiazem
and home digoxin. We stopped her home atenolol and put her on
metoprolol instead which was uptitrated to 25mg TID and her HR
was controlled on these medications in the 100-120's. She will
likely need this further uptitrated in the future.
.
#. Stage IV NSCLC: Mets to liver/brain, but currently getting
chemo by [**Location (un) 2274**] oncology. Plan per outpatient oncologist.
.
# Downtrending WBC: likely [**2-11**] chemotherapy. Not neutropenic on
this admission, and did begin to trend up. Will need to continue
to be monitored.
.
# CAD s/p 2 stents - continued lifelong ASA
.
#. Anemia: s/p transfusion in the ICU on arrival and transfusion
on the floor here [**5-7**]. Iron studies suggested anemia of chronic
disease with significantly elevated ferritin. Her guiacs have
been negative. She may need further transfusions in the future.
HCT at dispo is 26.8.
.
#. Type 2 DM: continued ome ISS plus lantus 28 units qpm
.
#. HTN: continued home BP meds with holding parameters
.
#. GERD: Home omeprazole
.
#. Pain control: Home oxycontin and oxycodone breakthrough
.
Code: DNR/DNI
Communication: Patient, HCP is husband [**Name (NI) 1692**] [**Name (NI) **]
[**Telephone/Fax (1) 100806**]
Medications on Admission:
Atenolol 25mg po bid
ISS plus lantus 28 units qpm
Digoxin 0.125mg po daily
Diltiazem ER 240mg po daily
Lorazepam 0.5mg po q8h prn anxiety
Omeprazole 40mg po bid
Oxycodone SR 10mg po q12h
Oxycodone-Acetaminophen 1 tab po q6h prn pain
ASA 325mg po daily
Zofran prn
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
9. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. Ondansetron 4-8 mg IV Q8H:PRN nausea
15. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day).
16. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for sob/wheeze.
18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
19. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous Qdinner.
20. insulin lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAHS.
21. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours): Last dose 5/7; dose is 2gm Q8H.
22. vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q 12H (Every 12 Hours): Last dose 5/7, dose is 750mg
Q12H.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 246**] Nursing Center - [**Location (un) 246**]
Discharge Diagnosis:
Primary: Pneumonia, pulmonary embolism
Secondary: Stage IV lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were seen in the hospital for shortness of breath. It was
found that you had a pulmonary embolism (a blood clot that
travelled to your lungs). In addition, you had pneumonia that
was then treated with intravenous antibiotics. While you were
here you had multiple episodes of chest pain, shortness of
breath and fast heart rates. We determined that you were having
atrial fibrillation and GERD, so we started you on a higher dose
of heart medication called metoprolol and started you on Maalox
four times a day to help treat and prevent GERD symptoms.
We made the following changes to your medications:
1) We STARTED you on METOPROLOL TARTRATE 25mg three times a day.
Your doctors [**Name5 (PTitle) **] choose to increase the dose of this medication
if your heart rate goes any higher.
2) We STOPPED your home ATENOLOL. Your doctors [**Name5 (PTitle) **] decide to
put you back on this instead of the METOPROLOL.
3) We STARTED you on SUBLINGUAL NITROGLYCERIN as needed for
chest pain.
4) We STARTED you on MAALOX four times a day for GERD>
5) We STARTED you on IPRATROPIUM NEBULIZERS every 6 hours.
6) We STARTED you on ALBUTEROL NEBULIZERS every 2 hours as
needed for shortnedd of breath or wheezing.
7) We STARTED you on MICONAZOLE POWDER four times a day as
needed for itching with rash.
8) We STARTED you on CEFEPIME 2grams every 8 hours
intravenously, with last dose on [**5-16**] to complete a 14 day
course.
9) We STARTED you on VANCOMYCIN 750mg every 12 hours
intravenously with last dose on [**5-16**] to complete a 14 day course.
If you experience any of the below listed Danger Signs, please
inform the doctor at your rehab facility or go to the nearest
Emergency Room.
It was a pleasure taking care of you during this
hospitalization.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) 2405**] at [**Location (un) **]
Oncology on [**2195-5-22**] at 9am.
You also have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22650**], RN at [**Location (un) **]
Oncology at 9:30am on [**2195-5-29**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,759
| 166,835
|
36790
|
Discharge summary
|
report
|
Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-5**]
Date of Birth: [**2072-6-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
[**9-2**]: craniotomy for tumor resection
History of Present Illness:
65 yo male with h/o headaches for 2-3 weeks found at outside
hospital to have intracranial mass. h/o prostate cancer
resected with increasing PSA levels per patient. No LOC but
does admit to vague gait abnormalities
Past Medical History:
NIDDM
HTN
hypercholesterolemia
prostate cancer
PVD
Social History:
40 pack year history
[**3-12**] drinks daily
Family History:
Non-contributory
Physical Exam:
Exam upon discharge:
Patient is A & O x 3.
Pupils 4-3mm bilaterally. EOMs intact.
Face symmetric. Tongue midline.
No drift.
Full strength throughout.
Incision clean, dry, intact. Sutures present.
Pertinent Results:
MRI Brain [**2137-8-29**]:
FINDINGS: There is a right frontal lobe area of edema identified
with a 2.5 x 2 cm mass and enhancing mass. There is mass effect
on the right lateral ventricle with minimum midline shift. No
hydrocephalus seen. Evaluation of the remaining brain is limited
due to artifacts. There are small foci of T2 FLAIR
hyperintensity seen including at the medial left temporal lobe
visualized on series 6, image 12. No distinct enhancement is
seen in this region, but as suggested above, the evaluation is
limited. There is additionally subtle increased signal seen
within the brainstem nature of which could not be determined.
There is a focus of increased signal in the left inferior
cerebellum which
demonstrates subtle enhancement on T1 axial images and could not
be confirmed on MP-RAGE images due to motion. This could be due
to an additional area of enhancing lesion.
IMPRESSION: Markedly limited study by motion. A 2.5 x 2 cm
enhancing mass is seen in the right frontal lobe with
surrounding edema and mass effect on the right lateral
ventricle. A second enhancing lesion is suspected in the
inferior left cerebellum and a signal abnormality is seen at the
left medial temporal lobe, but this could not be confirmed due
to motion on the images. For better evaluation of the brain, a
repeat study with sedation is
recommended.
CT Torso [**2137-8-30**]:
CT CHEST WITH INTRAVENOUS CONTRAST: There is mediastinal
lymphadenopathy,
with the largest nodal conglomerate in the subcarinal station
measuring
approximately 3.0 x 2.8 cm, with a mass effect on the bronchial
tree and
possibly esophagus. Smaller precarinal lymph nodes measure up to
13 mm in the short axis diameter. There is no pathologic hilar
or axillary
lymphadenopathy. Small left hilar lymph node measures up to 7 mm
in short
axis diameter. There is no pathologic axillary lymphadenopathy.
The thyroid
gland enhances homogeneously. The airways are patent to the
segmental levels bilaterally, however, left lower lobe bronchus
appears to be narrowed by the nodal conglomerate. There is no
concerning pulmonary mass. Note is made of centrilobular
emphysema, predominantly in the upper lobes. There is trace
atelectasis at the bases bilaterally. There is no pericardial or
pleural effusion. Coronary artery calcifications are noted.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: There are bilateral
enhancing adrenal
masses, measuring 2.9 x 1.6 cm on the right and 2.8 x 2.0 cm on
the left,
consistent with metastatic masses. There is no focal hepatic
lesion and no
biliary ductal dilatation. There is an area of focal fatty
infiltration
adjacent to the falciform ligament. The pancreas, spleen are
unremarkable.
The portal vein is patent. The kidneys enhance equally and
excrete contrast
normally. There is mild nonspecific perinephric stranding.
Atherosclerotic
calcifications in both aorta, which is normal in size. The
abdominal loops of large and small bowel are unremarkable, there
is no evidence of small bowel obstruction. There is stool
throughout the colon. Normal appendix is seen. There is no free
air, no free fluid, and no pathologic retroperitoneal or
mesenteric lymphadenopathy.
CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder and
distal ureters
are unremarkable. There are surgical clips anterior to the lower
aspect of
the bladder and the prostate. The rectum and sigmoid colon are
unremarkable. There is no free pelvic fluid and no pathological
inguinal or pelvic lymphadenopathy. In the common femoral vein
on the left, there is an apparent filling defect (series 3,
image 118), which is in the setting of malignancy, concerning
for thrombus.
BONE WINDOWS: There is a 13 x 7 mm lucent lesion in the L1
vertebral body.
There is no vertebral body height loss, there is no pathologic
fracture.
IMPRESSION:
1. Mediastinal lymphadenopathy, bilateral adrenal masses. These
findings are attributed to metastatic disease, rather than
primary malignancy. A small lucent lesion in L1 vertebral body
is indeterminate, however, suspicious for metastasis as well. No
definite primary malignancy identified. The adrenal lesions are
amendable to percutaneous biopsy.
2. Question of a filling defect in the left common femoral vein,
worrisome for DVT. Recommend further evaluation with vascular
ultrasound.
Pathology from right frontal lobe tumor [**2137-9-2**]:
Metastatic carcinoma
CT Head [**2137-9-2**]:
FINDINGS: There has been interval right frontal craniotomy and
resection of
the dominant right frontal mass. There is expected
pneumocephalus within and overlying the right frontal lobe.
Right frontal lobe edema of the white
matter is similar to slightly improved in comparison to the
preoperative
study, with mass effect on the right lateral ventricle. Leftward
shift of
midline structures by 5 mm persists. The smaller right frontal
and the left
posteromedial temporal lesions described on MRI of the brain
[**9-2**] are not appreciated on this non- contrast CT. Linear
high density within the surgical cavity may be small foci of
blood or related to postoperative change. There is no
hydrocephalus or intraventricular blood.
Marked atherosclerotic calcifications in the cavernous carotid
and distal
vertebral arteries are noted.
The visualized paranasal sinuses and mastoid air cells are well
aerated. Soft tissue swelling and subcutaneous gas overlies the
craniotomy site.
IMPRESSION:
1. Expected postoperative changes with resection of the dominant
right
frontal lobe mass.
2. Right frontal lobe edema with 5 mm leftward shift of midline
structures
and mass effect on the right lateral ventricle, similar to
slightly improved in comparison to the preoperative CT of [**8-29**], [**2137**].
MRV PELVIS W&W/O CONTRAST [**2137-9-4**]
IMPRESSION:
1. No evidence of pelvic deep venous thrombosis.
2. Atherosclerosis with high-grade stenosis of the proximal left
common iliac artery and moderate stenoses of the proximal right
common iliac and right common femoral arteries.
3. Moderate urinary bladder distension suggests bladder outlet
obstruction
related to prostatic enlargement.
Brief Hospital Course:
The patient was admitted to the ICU for Q1 hour neuro checks and
started on dexamethasone for the cerebral edema caused by the
mass. He had a CT torso which revealed: bilateral adrenal
masses, T12 lucency, hilar lymphadenopathy. The patient was
stable and was transferred to the neurosurgical floor while he
was continued on steroids. He went to the OR for mass resection
on [**2137-9-2**]. The procedure went well without complications and a
steroid taper to 2 [**Hospital1 **] was started. He was in the ICU overnight.
His neuro exam remained stable the following day and he was
transferred to the neurosurgical floor. The patient had an MRV
of the pelvis to assess for DVT on [**9-5**]. There was no DVT but
there was atherosclerosis and stenosis of the left common iliac,
right common iliac, and right common femoral arteries. The
patient was seen by hem-onc who planned to see him in follow-up
as an outpatient. He was evaluated by PT who felt that he was
safe to be discharged without services. The patient was also
scheduled to be seen in the Brain [**Hospital 341**] Clinic. He was
discharged home on [**2137-9-5**].
Medications on Admission:
Verapamil 240mg daily
ASA 81 mg daily
HCTZ dose?
Metformin 500mg daily
Discharge Medications:
1. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24
hours).
Disp:*0 Tablet(s)* Refills:*0*
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*60 Capsule(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q4 HOURS ().
Disp:*qs bottle* Refills:*2*
5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
Disp:*qs * Refills:*2*
6. Nepafenac 0.1 % Drops, Suspension Sig: One (1) drop
Ophthalmic TID (3 times a day).
Disp:*90 drop* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for reflux.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**2-8**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*1*
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO three times
a day for 1 doses: TAPER INSTRUCTIONS:
[**9-6**]: 1 tab [**Hospital1 **]
[**9-7**]: 1 tab daily, and continue until follow-up.
Disp:*20 Tablet(s)* Refills:*0*
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
brain mass
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Please follow the dexadron steroid taper below:
[**9-6**]: 1 tab by mouth 2 times per day
[**9-7**]: 1 tab once a day
[**9-8**] until follow-up: 1 tab once a day
?????? Please measure blood sugar levels at home. If high please call
your PCP.
?????? Take your pain medicine as prescribed.
?????? Please restart your home medications.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
If your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
?????? Please return to Dr.[**Name (NI) 9034**] office in [**8-16**] days(from your
date of surgery) for removal of your sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**].
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 4 weeks.
?????? Please follow up in the Brain [**Hospital 341**] Clinic with Dr. [**Last Name (STitle) 724**]. It
is located on [**Hospital Ward Name 23**] 8 on the [**Hospital Ward Name 516**]. The appointment has
aready been scheduled for [**9-23**] at 3pm.
?????? You will need an MRI of the brain with/without gadolinium
contrast (Cyberknife protocol). The Brain [**Hospital 341**] Clinic will set
this up.
?????? Please follow up with Hematology-Oncology at [**Hospital1 **]. The department has your contact information and will
call you with the name of the physician whom you will be seeing.
If you do NOT hear from anyone in the hematology-oncology
department by Monday, please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 9645**].
Completed by:[**2137-12-13**]
|
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icd9pcs
|
[
[
[]
]
] |
9805, 9811
|
7133, 8260
|
328, 371
|
9866, 9890
|
1022, 7110
|
11729, 12957
|
773, 791
|
8382, 9782
|
9832, 9845
|
8286, 8359
|
9914, 11706
|
806, 806
|
279, 290
|
399, 619
|
641, 694
|
710, 757
|
827, 1003
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,777
| 188,456
|
44430
|
Discharge summary
|
report
|
Admission Date: [**2121-11-13**] Discharge Date: [**2121-11-21**]
Service: SURGERY
Allergies:
Penicillins / Lisinopril
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Gastrointestinal stromal tumor of the duodenum with acute
hemorrhage.
Major Surgical or Invasive Procedure:
1. Pylorus-preserving Whipple resection.
2. Open cholecystectomy.
3. Placement of a jejunostomy tube.
4. Debulking of retroperitoneal tumor component.
.
5. Bedside opening of incision and drainage
History of Present Illness:
This totally healthy robust 91-
year-old man presented to me 2 weeks ago with evidence of a
presumed upper GI bleed and hemorrhage from a tumor in the
periampullary area. This was further worked up with
endoscopic ultrasound and a biopsy showed this tumor mass to
be highly suggestive of a GI stromal tumor. It was positive
for the c-kit mutation. Both CAT scan and ultrasound
examination revealed a hemorrhagic bleed extending into the
retroperitoneum from the periampullary area. There was a 4 cm
tumor which was hyperenhancing in the third portion of the
duodenum as it coursed close to the ligament of Treitz and
this was intimate with the pancreas tissue itself. The
patient was mildly symptomatic from this and we observed him
and cooled him down in the hospital and planned for an
operative approach in a few weeks' time to allow the hematoma
situation to reabsorb.
I met Mr. [**Known lastname **] with his daughter in my clinic prior to
the operation and talked to his primary doctor, [**First Name8 (NamePattern2) 11229**]
[**Last Name (NamePattern1) **], about this scenario. He is an absolutely vital and
robust man for his age and acts like a 60-year-old. He is
physiologically in excellent shape. I indicated to him that
he has had a symptomatic manifestation of a tumor which
likely is malignant in its nature. I indicated to him that
this should be removed and that medical therapy after a
surgical debulking would be most optimal. I told him this was
most likely a GIST but could be a neuroendocrine tumor of the
pancreas. I indicated that it was going to be more than
likely that he would require a Whipple resection of the
pancreatic head to remove this tumor.
Past Medical History:
PMH: CAD, HTN, Hyperlipidemia, BPH, CRI w/ baseline Cr of 1.5,
arthritis, depression, gout
PSH: tissue MVR & 3V CABG, R foot surgery
Social History:
He is married but his wife has multiple sclerosis. She lives on
[**Hospital3 **] with 24 hour assistance. During the work week, Mr.
[**Known lastname **] lives in an apartment he keeps in [**Location (un) 86**]. On the
weekends, he drives out to [**Location (un) **] to be with
his wife. [**Name (NI) **] is an army veteran. He is a retired tax attorney
who previously also worked for the IRS. He has three children,
one living in [**Country 480**], one in [**State 108**] and a daughter who lives in
Endeavor [**State 350**]. He names primarily his daughter [**Name (NI) **] as
his main support system. His usual routine is to have about two
cocktails a day, usually a scotch or [**Location (un) **]. Since the news
of his
retroperitoneal mass and plan for upcoming surgery has tapered
down to one glass of wine per day. He has no history of alcohol
abuse He smokes briefly in
college and has not smoked since. He has no other history of
exposures. He belongs to a gym and exercises twice a week doing
treadmill exercises and weight lifting.
Family History:
He has a sister who was almost [**Age over 90 **] years old. His brother died
of prostate cancer at age [**Age over 90 **]. Both of his parents lived to
their 60s.
Physical Exam:
Geriatric Pre-op Physical:
Vital Signs: Blood pressure today is 120/58, heart rate 76,
weight 175 pounds.
General: Mr. [**Known lastname **] is a very pleasant, well groomed, well
appearing man who appears younger than his stated age. He
initially seemed somewhat inpatient, but later showed a good
sense of humor and range of affect. He is alert, appropriate
and
has linear thought processes. He presents very professionally
dressed in a dress shirt and tie.
HEENT: He has mild dry cerumen, which is not occluding the
visualization of his tympanic membranes. In his left external
auditory canal, he had a small plastic foreign object which I
was
able to remove with a lighted curet. After he inspected it, he
told me this was a piece of a prior hearing aid. Pupils are
reactive to light and accommodation. Extraocular muscles are
intact. Conjunctivae is pink. Mucous membranes are moist. He
has his upper and lower bridge work with no dentures. Posterior
pharynx is clear. Tongue is midline.
Neck: Supple without carotid bruits or lymphadenopathy.
Heart: Regular rate and rhythm without ectopy or murmur.
Lungs: Good air movement at the bilateral bases. No rales,
rhonchi or wheezes.
Abdomen: Soft, nontender with normal active bowel sounds at
four
quadrants. No reproducible tenderness.
Back: No point tenderness diffusely.
Extremities: No edema.
Musculoskeletal: No active joint effusions. Range of motion is
well preserved without significant crepitus. Muscle strength is
[**5-26**] in the upper and lower extremities.
Neurologic: Deep tendon reflexes are 2+ and symmetrical in the
upper and lower extremities. No muscle rigidity or cogwheeling.
No tremor noted. Gait was observed for 25-foot walk. Mr.
[**Known lastname **] has a well preserved normal velocity and stride length
with normal arm swing. Base of support is within normal range.
He shows good safety awareness and does not need any additional
steps with the turning. Balance appears grossly normal.
Pertinent Results:
[**2121-11-16**] 04:12AM BLOOD WBC-11.6* RBC-3.26* Hgb-10.7* Hct-30.0*
MCV-92 MCH-32.7* MCHC-35.5* RDW-14.0 Plt Ct-206
[**2121-11-16**] 04:12AM BLOOD Glucose-142* UreaN-15 Creat-1.2 Na-136
K-3.8 Cl-101 HCO3-28 AnGap-11
.
DIAGNOSIS:
I. Retroperitoneal mass (A):
Gastrointestinal stromal tumor (see note).
II. Gallbladder, cholecystectomy (B):
Unremarkable gallbladder.
III. Jejunum, resection (C-D):
Unremarkable segment of small intestine.
IV. Retroperitoneal mass (E-F):
Gastrointestinal stromal tumor (see note).
V. Pancreaticoduodenectomy (G-Y):
- Gastrointestinal stromal tumor (see note).
- Margins are not involved.
- Eleven (0/11) lymph nodes with no malignancy identified.
- Pancreas with Pancreatic Intraepithelial Neoplasia (PanIN-2),
margin is free.
Note:
Tumor cells are positive for C-Kit, synaptophysin, and
chromogranin, but negative for cytokeratin (MNF116), desmin,
actin and S100. CD68 highlights abundant macrophages. The
tumor has a component with epithelioid morphology (epithelioid
GIST), multinucleated tumor cells and a brisk chronic
inflammation infiltrate. The tumor forms a unifocal,
encapsulated mass of 4.2 cm between the duodenum and pancreas
(duodenal GIST) without involvement of the pancreas,
gallbladder, or infiltration of the bowel wall. Mitoses number
up to 20/50 hpf and infarction and vascular invasion are noted.
Peripheral margins are negative with a 2 mm capsule at the
inferior pole.
The features suggest a GIST with high risk for progression.
Staining for endocrine markers has been described in the subset
of GIST formerly classified as gastrointestinal autonomic nerve
tumor (GANT).
Clinical: Neuroendocrine tumor of pancreas.
.
[**2121-11-19**] 10:12PM ASCITES Amylase-134
.
[**2121-11-19**] 1:01 pm SWAB Source: Abdomen.
GRAM STAIN (Final [**2121-11-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE
GROWTH
ANAEROBIC CULTURE (Preliminary):
.
Brief Hospital Course:
This is a [**Age over 90 **] year old male with Gastrointestinal stromal tumor
of
the duodenum with extension into retroperitoneum. He went to the
OR on [**2121-11-13**] for:
1. Pylorus-preserving Whipple resection.
2. Open cholecystectomy.
3. Placement of a jejunostomy tube.
4. Debulking of retroperitoneal tumor component.
He did well post-operatively and followed the "Whipple" pathway.
Geriatrics was also helping with post-op management and delirium
prevention.
Pain: He had a PCA for pain control and was followed by APS. He
was transitioned to a oral pain medications once tolerating a
diet.
GI/ABD: He was NPO, with a NGT and IVF. The NGT, per the
pathway, was removed on POD 3. His diet was slowly advanced as
he had return of bowel function. He was tolerating clears
liquids by POD 5. On POD 6, a JP Amylase was measured and was
134. The drain was subsequently removed the next day. He has
serous drainage from the previous drain site and a suture was
placed.
His abdomen was soft, nondistended and the incision with staples
had extensive erythema along the staple line. He was started on
Clindamycin and then switched to Vancomycin. On POD 6, the 5
staples were removed due to sero-sang, thick drainage. A culture
was send and showed STAPH AUREUS COAG +, MODERATE GROWTH.
The wound tracked medially 10cm and laterally 3cm. The erythema
improved after the wound was opened and drained.
Post-op Hyperglycemia: His blood sugars were noted to be
elevated and [**Last Name (un) **] was consulted. He was discharged with
Glipizide 10mg [**Hospital1 **], and will follow-up with [**Last Name (un) **] for blood
glucose checks.
He was discharged home with Keflex for 5 days and will continue
with wound care for his postop wound infection.
He was seen by Oncology and will follow-up with them for
continued treatment.
He was tolerating regular food and reported +flatus and +BM
prior to discharge.
Medications on Admission:
atenolol 50mg PO daily, pravastatin 20mg PO daily, terazosin 1mg
PO [**Last Name (LF) **], [**First Name3 (LF) **] 325mg PO daily (held pre-op), aricept 5mg PO [**First Name3 (LF) **]
(dosage uncertain, taking samples at the recommendation of his
neice, PCP [**Name Initial (PRE) 12309**])
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
6. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3
hours) as needed.
Disp:*25 Tablet(s)* Refills:*0*
12. One Touch Ultra 2 Kit Sig: One (1) Miscellaneous Kit.
Disp:*1 * Refills:*2*
13. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*150 * Refills:*2*
14. One Touch Test Strip Sig: One (1) In [**Last Name (un) 5153**] four times a
day.
Disp:*150 * Refills:*2*
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
16. GlipiZIDE 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Monitor blood sugars before meals and at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Gastrointestinal stromal tumor of the duodenum with extension
into retroperitoneum.
Post-op Wound Infection
Post-op Hyperglycemia
Discharge Condition:
Good
Wound Care
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 skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily. No heavy lifting (>10lbs)
for 6 weeks.
* Monitor your incisions for signs of infection (increased
redness, increased drainage).
* Continue with Wound care. Change dressing daily.
* Continue to check your blood sugars as instructed 4x/day.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet and low glucose diet.
Fluid Restriction:
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2121-12-8**] at 11:00am. Call
[**Telephone/Fax (1) 2835**] with questions or concerns.
.
Provider: [**Known firstname **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2121-12-3**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2121-12-3**] 9:30
.
Please follow-up with [**Last Name (un) **] on [**2121-12-8**]. Call ([**Telephone/Fax (1) 55238**] to
schedule an appointment.
Completed by:[**2121-11-21**]
|
[
"274.9",
"716.90",
"414.00",
"152.0",
"041.11",
"585.9",
"311",
"780.52",
"E878.6",
"998.59",
"V43.3",
"197.6",
"867.0",
"E928.9",
"251.3",
"272.4",
"403.90",
"600.00",
"354.0",
"V45.81",
"577.8",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7",
"54.4",
"46.39",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
11695, 11756
|
7798, 9711
|
303, 502
|
11929, 11947
|
5655, 7666
|
13687, 14285
|
3452, 3619
|
10051, 11672
|
11777, 11908
|
9737, 10028
|
11971, 13664
|
3634, 5636
|
193, 265
|
7695, 7738
|
531, 2212
|
7771, 7775
|
2234, 2370
|
2386, 3436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,603
| 144,946
|
12024
|
Discharge summary
|
report
|
Admission Date: [**2142-7-20**] Discharge Date: [**2142-7-23**]
Date of Birth: [**2096-10-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Bright red blood per rectum.
Major Surgical or Invasive Procedure:
1. Blood transfusion
2. Esophagealgastroduodenoscopy (EGD)
3. Flexible sigmoidoscopy
History of Present Illness:
45yoM with EtOH cirrhosis (h/o variceal bleeding, ascites, SBP),
DM2,
who presented to his PCP with bright red bloody diarrhea
starting 4am this morning with 4-5 episodes since. Last night
felt subjectively "warm" but no recorded fever, no vomiting or
abdominal pain, but feels weak and fatigued. Saw PCP, [**Name10 (NameIs) **] to
ED.
.
Initial ED vitals: 97.6 82 114/54 16 100%. Hct was 17.7, was
26.2 on [**2142-6-26**]. Pt noted to appear well enough but jaundiced.
Subjectively orthostatic. He had gross blood on rectal exam, but
he had clear NG lavage. BUN 35 and Cr 1.2 is slightly above
baseline. Na 132 also slightly below baseline. AST is elevated
to 84, above baseline, but rest of LFT's are within baseline.
Coagulopathy within baseline. Serum EtOH negative. Pt's blood
pressures trended down to 90/40 just before transfer, put pt
mentating well, no CVL was placed but pt has 3 PIV (16g and 18g
x2). GI was at the bedside in the ED, giving tap water enema and
plan for upper and lower scope on arrival to the MICU.
.
Pt received 1g IV Ceftriaxone, 500 mg IV Erythromycin, Protonix
gtt, Octreotide gtt, 2u FFP, 2L NS, getting 1st PRBC's on
transfer from ED. GI was consulted and by transfer were at the
bedside giving tap water enema with plan for emergent scope
above and below.
.
Pt reports not drinking since [**Month (only) 956**]. Office EtOH screens have
been negative since 1/[**2141**].
.
Of note, pt was admitted in [**5-/2142**] for first Dx of SBP
complicated by variceal bleeding with banding x3 and EtOH
hepatitis. He also had strep viridans bacteremia with negative
TEE and completed 14d Vancomycin. He was then admitted early
[**6-/2142**] for RUQ pain and fevers, had inconclusive U/S, no
diagnostic para due to paucity of fluid, pt thought to be poor
surgical chole candidate so managed medically, no other source
of fevers found, and symptoms improved by discharge.
.
Vitals before transfer: 89 20 90/40 100%RA
.
ROS: As above, otherwise with RUQ pain just started today from
people mashing on his abdomen, and increased confusion for [**3-15**]
wks noted as transposing numbers, trouble answering questions in
the ED. Notes some increased bruising on his L knee and R leg.
Otherwise no SOB, CP, palpitations, no increase in his BLE
edema, no urinary problems. [**Name (NI) **] has not been taking any NSAIDs.
Past Medical History:
ETOH Cirrhosis (c/b alcoholic hepatitis [**2-19**], portal
hypertension w/ esophageal rectal varices, SBP)
SBP [**5-/2142**]
Esophageal varices s/p banding
DMII - on home Humalong, 4u starting at 150
HTN
HL
H/o Viridans strep and MSSA bactermia s/p 14d course Vancomycin
in [**5-/2142**]
EtOH Abuse
GERD
Depression
OSA on CPAP
Depression
Panic d/o
Hypogonadism
H/o Afib s/p cardioversion not on anticoagulation
Social History:
Born in [**Name (NI) 37743**], NC (father was in the Army). Currently
lives alone in [**Location (un) 86**] with a pet cat. Not currently in a
relationship. Not sexually active in 8 years. Never smoker, no
IVDU. Former cocaine, ecstasy, special K abuse but stopped when
started seeing a therapist in [**2122**]. Brother and sister both live
in the area. Works as a bellman at a local hotel. He denies
EtOH since [**Month (only) 956**] with negative EtOH tests since [**Month (only) 404**].
Family History:
Father - deceased from an "infection," alcohol abuse
Sister - panic disorder
Mother - decrease [**2140**] after having a stroke in [**2137**]
Physical Exam:
Upon admission:
97.9 93/47 (SBP 108-115) p91 100%RA
Pleasant, well appearing gentleman in no distress, jaundiced
with gross scleral icterus, EOMI. No asterixis.
EOMI, PERRLA.
Mouth dry appearing with sublingual icterus, no gross lesions
Pulsations noted at the earlobe, no HJR
CTAB no w/c/r/r
RRR with early peaking systolic murmur at BUSB and LLSB
Abd distended but not tight, no TTP, no hepatomegaly, BS+
Trace to 1+ pitting edema to mid calf
CN 2-12 intact, no focal deficits, moves all four extrems,
conversant and clear, answers appropriately, attentive.
At discharge:
V/S: 97.8 138/62 81 18 100% RA
Gen: Pleasant, well appearing gentleman in no distress,
jaundiced HEENT: EOMI, PERRLA, scleral icterus, MMM no lesions
Neck: supple, JVP above the clavicle sitting up
Resp: decreased BS at the right base, few crackles
CV: RRR with faint systolic murmur
Abd: +BS, soft, nondistended, nontender, no HSM appreciated
Ext: wwp, no LE edema, distal pulses 2+
Neuro: CN 2-12 intact, no focal deficits, moves all four
extremities, no asterixis.
Pertinent Results:
Labs upon admission:
[**2142-7-20**] 10:00AM BLOOD WBC-8.2 RBC-1.55*# Hgb-6.4*# Hct-18.4*#
MCV-119* MCH-41.1* MCHC-34.5 RDW-14.6 Plt Ct-101*
[**2142-7-20**] 10:00AM BLOOD Neuts-78* Bands-2 Lymphs-9* Monos-8 Eos-2
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2142-7-20**] 10:00AM BLOOD PT-19.6* INR(PT)-1.8*
[**2142-7-20**] 02:20PM BLOOD PT-20.4* PTT-42.3* INR(PT)-1.9*
[**2142-7-20**] 08:02PM BLOOD Fibrino-193
[**2142-7-21**] 03:23AM BLOOD Fibrino-202
[**2142-7-21**] 07:36AM BLOOD Ret Man-6.1*
[**2142-7-20**] 10:00AM BLOOD UreaN-37* Creat-1.2 Na-132* K-5.2* Cl-105
HCO3-19* AnGap-13
[**2142-7-20**] 10:00AM BLOOD ALT-46* AST-80* AlkPhos-137*
TotBili-10.1*
[**2142-7-20**] 10:00AM BLOOD GGT-51
[**2142-7-20**] 02:20PM BLOOD Lipase-58
[**2142-7-20**] 02:20PM BLOOD Albumin-3.4* Calcium-9.8 Phos-3.7 Mg-2.2
[**2142-7-21**] 03:23AM BLOOD Hapto-<5*
[**2142-7-20**] 02:20PM BLOOD Ethanol-NEG
[**2142-7-20**] 02:32PM BLOOD Glucose-79 Lactate-1.7 K-4.8
[**2142-7-20**] 02:32PM BLOOD Hgb-5.9* calcHCT-18
Labs at discharge:
[**2142-7-23**] 05:15AM BLOOD WBC-7.0 RBC-2.38* Hgb-8.8* Hct-24.4*
MCV-103* MCH-37.0* MCHC-36.0* RDW-22.0* Plt Ct-66*
[**2142-7-23**] 05:15AM BLOOD Neuts-65.0 Lymphs-24.1 Monos-9.0 Eos-1.2
Baso-0.6
[**2142-7-20**] 10:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Burr-2+
Fragmen-OCCASIONAL
[**2142-7-23**] 05:15AM BLOOD PT-20.1* PTT-40.2* INR(PT)-1.8*
[**2142-7-23**] 05:15AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-134
K-4.3 Cl-103 HCO3-22 AnGap-13
[**2142-7-22**] 02:01AM BLOOD ALT-42* AST-69* AlkPhos-83 TotBili-13.7*
[**2142-7-21**] 03:23AM BLOOD ALT-40 AST-69* LD(LDH)-248 AlkPhos-93
TotBili-11.8* DirBili-3.0* IndBili-8.8
[**2142-7-23**] 05:15AM BLOOD Calcium-9.9 Phos-2.6* Mg-1.7
[**2142-7-23**] 05:15AM BLOOD Triglyc-78
Micro:
[**2142-7-20**] blood cultures pending x2
Imaging:
[**2142-7-20**] EGD: Varices at the distal esophagus, Ulcer in the
distal esophagus, Mosaic appearance in the stomach body
compatible with hypertensive gastropathy, Nodules in the antrum,
No gastric varices noted. Otherwise normal EGD to third part of
the duodenum.
[**2142-7-20**] flex sig: Solid yellow-brown stools noted in the
transverse colon. No stigmata of bleeding noted. Patchy
erythema in the rectum compatible with colopathy. Otherwise
normal sigmoidoscopy to distal transverse colon.
[**2142-7-21**] CT abd/pelvis: 1. No evidence of retro- or
intraperitoneal bleed.
2. Apparent thickening involving right lateral aspect of bladder
wall.
Recommend bladder US for further evaluation. 3. Findings of
hepatic cirrhosis with a moderate amount of low-attenuation
abdominal and pelvic ascites, splenomegaly and varices. 4.
Cholelithiasis.
[**2142-7-22**] RUQ u/s: 1. Coarsened liver echotexture compatible with
stated history of cirrhosis. 2. Marked splenomegaly and mild to
moderate ascites. 3. Gallbladder sludge and cholelithiasis
similar to prior.
Brief Hospital Course:
45 yo male with h/o EtOH cirrhosis (h/o variceal bleeds,
ascites, and SBP) and DM2 who presents with 1 day of bright red
blood per rectum and found to have nonbleeding esophageal ulcer,
grade [**2-11**] esophageal varices, and colopathy.
# GI bleed: Patient with known esophageal varices and rectal
varices as well as prior admissions for variceal bleeds
presented with BRBPR x1 day. He was found to have a hct of 17
from a baseline of 25, and was transfused 2 units FFP and 1 unit
PRBC in the ED. He initially had BP's at baseline in the 110's
but BP's decreased to the 90's in the ED. NG lavage was
negative and he had a grossly positive rectal exam in ED. He
was started on an Octreotide gtt and Pantoprazole gtt and
transferred to the MICU. In the MICU, he received 4 additional
units PRBC for a total of 5 units PRBC with hct 16.8 -> 23-24,
which remained stable subsequently. He maintained his BP's in
the 90's-110's. CT abdomen showed no evidence of
retroperitoneal bleed. Ceftriaxone was discontinued and the
patient was continued on his home Cipro for SBP prophylaxis.
The patient underwent an EGD and sigmoidoscopy which showed no
active bleed, but was significant for a small esophageal ulcer
and distal grade I-II esophageal varices, gastric antral
vascular ectasia, evidence of hypertensive gastropathy, and
patchy rectal erythema consistent with colopathy. He continued
to have small amounts of BRBPR in the MICU with a stable hct and
stable BP's, and he was re-started on his home Nadolol, Lasix,
and PPI [**Hospital1 **] with discontinuation of the PPI drip. He was
written for his home lactulose but this was held, as the patient
had 3 bowel movements with the first dose of lactulose, 2 of
which had small amounts of bright red blood. RUQ US showed
patent portal vein. He was transferred to the floor. He
continued to have blood coating his stools but this slowed down
prior to discharge. His bleeding was likely a result of
colopathy. He was continued on nadolol and a PPI [**Hospital1 **]. He was
tolerating a solid diet with stable hematocrit prior to
discharge.
# EtOH Cirrhosis: Patient reported he did not want to be a
candidate for transplant. His last drink was in [**3-23**]. He was
continued on lactulose, nadolol, thiamine, folate, and MVI. He
was continued on ciprofloxacin for SBP prophylaxis. A pleural
effusion was noted on exam thought to be hepatic hydrothorax
without evidence of fever or cough. Diuretics were initially
held given hypotension but restarted prior to discharge. A
social work consult was obtained. He will follow up with liver
after discharge.
# [**Last Name (un) **]: Resolved, likely prerenal in setting of GIB. Lasix and
spironolactone were reintroduced prior to discharge.
# Indirect hyperbilirubinemia: Differential includes hemolysis
from blood transfusions v. Zieve's syndrome. Triglycerides were
checked and were normal.
# Macrocytic Anemia: Secondary to GIB but now back at baseline,
likely secondary to bone marrow suppression from EtOH toxicity
and slow bleeding from colopathy. Ferrous sulfate was
continued.
# DM2: Sugars well controlled. He was continued on home humalog
4u starting at 150.
# Depression: Continue Effexor XR.
# Code Status: Confirmed as full code during this admission.
Medications on Admission:
- lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO BID titrated
to 3 BM daily
- venlafaxine 75 mg Capsule, Ext Release 24 hr: Two (2) Capsules
daily
- thiamine HCl 100 mg daily
- spironolactone 25 mg Tablet Sig: Two (2) Tablets PO DAILY
- furosemide 20 mg Tablet PO DAILY
- multivitamin Tablet PO DAILY
- lisinopril 20 mg Tablet PO DAILY
- folic acid 1 mg Tablet PO DAILY
- sucralfate 1 gram Tablet PO QID
- pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO Q12H.
- Cipro 500 mg Tablet PO daily
- ferrous sulfate 325 mg (65 mg iron) Tablet PO daily
- nadolol 40 mg Tablet [**Hospital1 **]
- testosterone cypionate 200 mg/mL Oil Sig: Two Hundred (200) mg
Intramuscular every 14 days.
- insulin lispro 100 unit/mL Cartridge Sig: 2-10 units
Subcutaneous four times a day: per sliding scale.
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO TID (3 times
a day) as needed for titrate to [**4-13**] BMs daily.
2. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. nadolol 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. testosterone cypionate 200 mg/mL Oil Sig: One (1) injection
Intramuscular q2weeks.
15. insulin lispro 100 unit/mL Solution Sig: 2-10 units
Subcutaneous four times a day: as per sliding scale.
16. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Bright red blood per rectum, Esophageal
varices, Esophageal ulcer, Colopathy
Secondary Diagnosis: Alcoholic Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of your during your stay here at
[**Hospital1 18**].
You were admitted for bright red blood per rectum. You were
given five units of blood. An EGD was done which revealed
nonbleeding esophageal varices which are varicose veins in the
esophageal lining. In addition, there was a nonbleeding ulcer
in the esophagus. A flexible sigmoidoscopy revealed varicose
veins in the rectum but no source of active bleeding either. As
a result, you may need a colonoscopy as an outpatient to
evaluate the rest of your colon for a site of active bleeding.
There were no changes were made to your medication regimen.
Followup Instructions:
Please attend the following appointments that were made for you:
Department: LIVER CENTER
When: WEDNESDAY [**2142-8-1**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ENDO SUITES
When: TUESDAY [**2142-8-21**] at 9:30 AM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2142-8-21**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], 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) 3202**]
Campus: EAST Best Parking: Main Garage
|
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icd9cm
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[
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icd9pcs
|
[
[
[]
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3245, 3737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,920
| 114,256
|
52411
|
Discharge summary
|
report
|
Admission Date: [**2114-11-9**] Discharge Date: [**2114-11-11**]
Date of Birth: [**2064-2-26**] Sex: M
Service: [**Hospital Ward Name **] ICU
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
male with end stage amyotrophic lateral sclerosis, who is
ventilator dependent at home. The patient was in his usual
state of health at home when his sister (not his usual care
giver), gave him an Albuterol nebulizer treatment prior to
going to bed and was unable to figure out how to reattach his
ventilator. The patient subsequently developed respiratory
distress and became cyanotic. EMS was called and the patient
was found to be cyanotic and apneic at arrival. The patient
was bagged with FIO2 100% and quickly regained consciousness
and mental status. The patient was brought to [**Hospital1 346**] Emergency Room where the patient was
found to be mentating and breathing with normal CBC and
Chem-7. He was placed on a ventilator A/C with 100% FIO2 and
transferred to [**Hospital Ward Name 332**] Intensive Care Unit for monitoring
overnight on ventilator status post respiratory arrest.
PAST MEDICAL HISTORY:
1. Amyotrophic lateral sclerosis status post tracheostomy
and PEG in [**2113-5-17**]. The patient is able to talk through
chronic cuff leak and eat p.o. diet.
2. Status post non-Q wave myocardial infarction in setting
of a respiratory arrest in [**2113-5-17**]. No history of
congestive heart failure.
3. Hypertension.
4. History of prostatitis.
5. Chronic constipation.
6. History of heavy alcohol use.
7. Anxiety.
MEDICATIONS:
1. Tamoxifen.
2. Klonopin.
3. Lactulose.
4. Lopressor.
5. Aspirin.
6. Relutek.
7. Celexa.
8. Combivent MDI.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married to a former [**Hospital1 1444**] nurse who is able to manage
medical condition and ventilator at home, thus the patient is
vent dependent and bed bound living at home with his wife and
two children. The patient has a history of heavy alcohol use
and continues to drink alcohol on a regular basis. He does
not smoke. No intravenous drug use. The patient is
completely paralyzed and unable to move out of bed.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Heart rate is sinus tachycardia at
110; blood pressure 121/73; temperature afebrile; saturation
100% on FIO2 100%. General appearance: A paralyzed male in
no acute distress breathing comfortably through tracheostomy;
able to speak through cuff leak. HEENT: Mucous membranes
were moist. Oropharynx clear. Pupils equally round and
reactive to light. Extraocular movements are intact. Neck
with tracheostomy site without erythema or purulence.
Positive moderate to severe cuff leak. Cardiovascular is
tachycardic, normal S1 and S2. No S3, S4, no murmurs.
Pulmonary: Vented breath sounds bilaterally, decreased at
the bases without rhonchi, wheezing or crackles. Abdomen
soft, nontender, nondistended. G-tube site clean, dry and
intact without purulence. Extremities with no cyanosis,
clubbing or edema, two plus distal pulses. Neurologic
examination is cranial nerves II through XII intact. Motor
strength zero out of five diffusely. Deep tendon reflexes
unable to be elicited. Sensation intact.
LABORATORY: CBC and chem-7 within normal limits. ABG with
pH of 7.41.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
[**Hospital Ward Name 332**] Intensive Care Unit for monitoring of hemodynamics and
respiratory status overnight. He did extremely well and
remained stable on his usual ventilator settings of assist
control 780 by 17 with FIO2 of 40% and PEEP of 5. The
patient required frequent suctioning of thick clear sputum
which he states is no different from normal. The patient
remained afebrile throughout this hospital admission.
Chest x-ray did show question of left lower lobe atelectasis
versus consolidation, however, as the patient was afebrile
with a normal white blood cell count it was felt that this
could be monitored at home.
The patient remained in the Intensive Care Unit for
approximately 48 hours until his care giver who was able to
manage his ventilator returned home. The patient remained
medically stable and was subsequently transferred to home on
[**2114-11-11**]. His wife is his full time care giver and
manages his respiratory needs, including ventilation and
suctioning at home.
Of note, the patient was placed on Methicillin resistant
Staphylococcus aureus precautions while in the Intensive Care
Unit given his recent three week hospital admission for
Methicillin resistant Staphylococcus aureus pneumonia. The
patient will have follow-up with his physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], or on an as needed basis for fevers and pneumonia,
given his high risk status. His cuff leak was also
discussed, however, it was felt that this was unchanged from
prior and that the patient likes to be able to talk around
his cuff leak, thus, no further work-up was done for changing
tracheostomy tube.
DISCHARGE DIAGNOSES:
1. Respiratory arrest status post mechanical dysfunction due
to operator error.
2. End stage amyotrophic lateral sclerosis, ventilator
dependent.
3. History of alcohol abuse.
4. History of prostatitis.
5. Hypertension.
6. Anxiety.
7. Constipation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is discharged to home with
ventilator and medical management per his wife. [**Name (NI) **]
follow-up with primary care physician on as needed basis and
wife will monitor closely for fevers and evidence of
pneumonia.
The patient will follow-up with pulmonologist on a p.r.n.
basis for management of cuff leak should this become more
problem[**Name (NI) 115**].
DISCHARGE MEDICATIONS: Unchanged from admission medications.
1. Temazepam.
2. Klonopin.
3. Lactulose.
4. Lopressor.
5. Aspirin.
6. Relutek.
7. Celexa.
8. Combivent MDI.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 8038**]
Dictated By: [**Name6 (MD) **] [**Name8 (MD) **], M.D.
MEDQUIST36
D: [**2114-11-14**] 12:44
T: [**2114-11-14**] 18:21
JOB#: [**Job Number 108306**]
|
[
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icd9cm
|
[
[
[]
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] |
[
"38.93",
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icd9pcs
|
[
[
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2205, 2223
|
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|
5819, 6255
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|
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|
1752, 2188
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,842
| 150,993
|
42501
|
Discharge summary
|
report
|
Admission Date: [**2101-2-22**] Discharge Date: [**2101-2-26**]
Date of Birth: [**2029-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2101-2-22**] 1. Aortic valve replacement with [**Street Address(2) 6158**]. [**Hospital 923**] Medical
Biocor Epic tissue valve. 2. Coronary artery bypass grafting x2
with a left internal mammary artery graft to left anterior
descending and reverse saphenous vein graft to diagonal branch.
History of Present Illness:
71 year old gentleman with a [**5-8**] year history of aortic stenosis
followed by serial echocardiograms. He notews increasing dyspnea
on exertion although he does have a prior history of pulmonary
fibrosis due to bleomycin toxicity as a result of chemotherapy
for Hodgkin's lymphoma. A recent echocardiogram showed severe
aortic stenosis with worsened gradients across the valve and
new, mild left ventricular hypertrophy. Given the progression of
his disease, he has now been referred for evaluation for an
aortic valve replacement.
Past Medical History:
Aortic stenosis
Hodgkin's lymphoma
Pulmonary fibrosis (bleomycin toxicity)
Hypertension
Osteoarthritis
Bilateral cataracts
Coronary artery disease
s/p L elbow surgery
s/p Right cataract surgery
Social History:
Race: Caucasian
Last Dental Exam: This Friday
Lives with: married
Contact: Phone #
Occupation: convenience store worker
Cigarettes: Smoked no [] yes [X] last cigarette 50 years ago.
Hx: 1ppd x 5years.
Other Tobacco use:
ETOH: < 1 drink/week [X] [**2-8**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
No Premature coronary artery disease
Physical Exam:
Pulse: 86SR Resp: 16 O2 sat: 99%
B/P Right: 127/91 Left: 132/88
Height: 67" Weight: 182lb
General: WDWN in NAD
Skin: Warm, Dry and intact.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in
fair repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, IV/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Trace LE Edema.
Scoliosis noted with some pectus/sternal skeletal abnormalities.
Varicosities: Right GSV suitable. Left with spider varicosity
with mild varicosity below knee.
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 Transmitted vs bruit
Discharge Exam
VS: T: 98.2 HR: 85-98 SR BP: 86-136/78 Sats: 96% RA
General: 71 year-old male sitting up in chair in no apparent
distress
HEENT: normocephalic, mucus membranes moist
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds otherwise clear
GI: benign
Extr: warm no edema
Incision: sternal clean, dry intact no erythema or discharge
Neuro: awake, alert oriented moves all extremities
Pertinent Results:
[**2101-2-22**] Echo: PRE-CPB: The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. No thoracic aortic dissection is
seen. The aortic valve leaflets (3) 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.
POST-CPB: There is a bioprosthetic valve in the aortic position.
The valve appears well seated with normal leaflet mobility.
There are no paravalvular leaks. There is no AI. The peak
gradient across the aortic valve is 37mmHg, the mean gradient is
12mmHg with a cardiac output of 3.3 L/min. The LV chamber size
appears small, consistent with hypovolemic state. The LV
systolic function remains normal, estimated EF=65%. There right
ventricular systolic function remains normal. Other valvular
function remain unchanged. There is no evidence of aortic
dissection. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of study.
.
CXR: [**2101-2-25**]: There is a minimal residual left apical
pneumothorax apparent on the current image. No evidence of
tension. No other changes. Unchanged appearance of the cardiac
silhouette after CABG.
[**2101-2-26**] WBC-10.0 RBC-3.06* Hgb-10.4* Hct-28.6* MCV-94 MCH-34.1*
MCHC-36.4* RDW-14.5 Plt Ct-182
[**2101-2-22**] WBC-18.3*# RBC-2.57*# Hgb-9.1*# Hct-25.2*# MCV-98
MCH-35.6* MCHC-36.3* RDW-12.1 Plt Ct-224
[**2101-2-26**] UreaN-32* Creat-1.0 Na-139 K-4.3 Cl-102
[**2101-2-22**] UreaN-18 Creat-0.7 Na-136 K-3.9 Cl-109* HCO3-22 AnGap-9
[**2101-2-26**] Mg-2.6
Brief Hospital Course:
Mr. [**Known lastname 2856**] was a same day admit and on [**2-22**] he was brought
directly to the operating room where he underwent an aortic
valve replacement and coronary artery bypass graft. Please see
operative note 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. On post-op day one he was
started on beta-blockers and diuretics and gently diuresed
towards his pre-op weight. Later on this day he was transferred
to the step-down floor for further care. Chest tubes and
epicardial pacing wires were removed per protocol. His
lopressor was titrated as needed. On discharge he was started
on Lisinopril 2.5 mg. He worked with physical therapy for
strength and conditioning was cleared for home. He continued to
make steady progress and was discharged home [**2101-2-26**] with VNA.
He will follow-up as an outpatient.
Medications on Admission:
lisinopril 10 mg/HCTZ 12.5 mg daily
diclofenac 75 mg [**Hospital1 **]
ASA 81 mg daily
fish oil 1000 mg [**Hospital1 **]
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. diclofenac sodium 75 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO at bedtime.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-8**]
hours as needed for fever or pain.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
10. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic stenosis and coronary artery disease s/p aortic valve
replacement and coronary artery bypass graft x
Past medical history:
Hodgkin's lymphoma
Pulmonary fibrosis (bleomycin toxicity)
Hypertension
Osteoarthritis
Bilateral cataracts
s/p L elbow surgery
s/p Right cataract surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon.
Look at your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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 cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call the cardiac surgery office for a follow-up
appointment on Monday [**2-28**] [**Telephone/Fax (1) 170**] with Dr. [**Last Name (STitle) **] and for
the wound clinic.
Cardiologist: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] please call his office for a
follow-up with in [**3-6**] weeks.
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 6700**] in [**4-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2101-2-26**]
|
[
"414.01",
"E930.7",
"V10.72",
"424.1",
"515",
"715.90",
"401.9",
"V87.41",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"35.21",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
7208, 7263
|
4991, 5974
|
326, 621
|
7590, 7808
|
3057, 4968
|
8577, 9278
|
1763, 1801
|
6144, 7185
|
7284, 7392
|
6000, 6121
|
7832, 8554
|
1816, 3038
|
267, 288
|
649, 1186
|
7414, 7569
|
1419, 1747
|
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