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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
60,409
| 173,019
|
42260
|
Discharge summary
|
report
|
Admission Date: [**2138-5-26**] Discharge Date: [**2138-6-1**]
Date of Birth: [**2073-3-24**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/posterior L3-S1 decompression and fusion
History of Present Illness:
Mr. [**Known lastname **] has a long history of back pain. He has attempted
conservative therapy but has failed. He now presents for
surgical intervention.
Past Medical History:
PMHx:
Moderate LV Dysfunction, EF~35%
h/o MI [**2110**]
OA
GERD
Anemia
Glaucoma
Psoriasis
HTN
HPLD
PSHx:
Laminectomy [**2096**]
Lumbar Spine Nerve Release
Left TKR [**2136**]
Bilateral Inguinal Hernia Repair
Bilateral Shoulder Arthroscopy
Left Knee Arthroscopy
Bilateral Thumb Repair
Social History:
Lives: [**Location (un) **], NH with his wife
Smoking history: None
Alcohol: [**4-11**] glasses of wine daily
Family History:
Denies any family history of migraines, backache, or rheumatoid
arthritis
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2138-5-31**] 07:55AM BLOOD WBC-5.0 RBC-3.33* Hgb-10.2* Hct-31.2*
MCV-94 MCH-30.6 MCHC-32.6 RDW-15.1 Plt Ct-233
[**2138-5-30**] 06:31AM BLOOD WBC-5.3 RBC-2.70* Hgb-8.2* Hct-25.1*
MCV-93 MCH-30.4 MCHC-32.7 RDW-15.8* Plt Ct-178
[**2138-5-29**] 01:56PM BLOOD WBC-5.3 RBC-2.80* Hgb-8.6* Hct-25.8*
MCV-92 MCH-30.7 MCHC-33.2 RDW-15.6* Plt Ct-149*
[**2138-5-29**] 02:00AM BLOOD WBC-6.3 RBC-3.05* Hgb-9.5* Hct-28.6*
MCV-94 MCH-31.0 MCHC-33.1 RDW-16.0* Plt Ct-148*
[**2138-5-28**] 08:03PM BLOOD WBC-5.3 RBC-2.96* Hgb-9.0* Hct-27.6*
MCV-93# MCH-30.4 MCHC-32.7 RDW-15.4 Plt Ct-106*
[**2138-5-29**] 02:00AM BLOOD Glucose-140* UreaN-13 Creat-0.5 Na-135
K-3.9 Cl-101 HCO3-21* AnGap-17
[**2138-5-28**] 08:03PM BLOOD Glucose-118* UreaN-12 Creat-0.5 Na-137
K-3.8 Cl-104 HCO3-22 AnGap-15
[**2138-5-27**] 06:09AM BLOOD Glucose-85 UreaN-15 Creat-0.7 Na-134
K-3.9 Cl-100 HCO3-25 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**5-26**] and taken to the Operating Room for L3-S1 interbody fusion
through an anterior approach. Please 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 given per standard
protocol. Initial postop pain was controlled with a PCA. On HD#2
he returned to the operating room for a scheduled L3-S1
decompression with PSIF as part of a staged 2-part procedure.
Please refer to the dictated operative note for further details.
The second surgery was also without complication and the patient
was transferred to the PACU in a stable condition. Postoperative
HCT was stable. A bupivicaine epidural pain catheter placed at
the time of the posterior surgery remained in place until postop
day one. He was kept NPO until bowel function returned then diet
was advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. Foley was removed on
POD#2 from the second procedure. He was fitted with a lumbar
warm-n-form brace for comfort. 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.
Medications on Admission:
Amlodipine 2.5mg
ASA 81mg
Carvedilol 2.5mg [**Hospital1 **]
Celexa 10mg
Lansoprazole 30mg
Lisinopril 20mg
Finacea 15% gel
Brimonidine 0.2% TID ophthalmically
Dorzolamide 2% [**Hospital1 **]
Restasis 0.05% [**Hospital1 **]
Lumogen 0.03% qhs
Gemfibrozil 600mg [**Hospital1 **]
Viagra 100mg prn
Cialis 'daily'
Timolol
Androgel
Ketoconazole cream
MVI
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. amlodipine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. carvedilol 12.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. gemfibrozil 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*90 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
11. hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar stenosis/ spondylosis
Discharge Condition:
Awake and alert/ comfortable/ ambulating independently
Discharge Instructions:
Keep incisions clean and dry/ ambulate as tolerated
Followup Instructions:
10 days in office [**Telephone/Fax (1) 3573**]
Completed by:[**2138-9-12**]
|
[
"530.81",
"V43.65",
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"721.3",
"401.9",
"412",
"272.4",
"E878.1",
"365.9",
"998.11",
"285.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"81.07",
"77.79",
"81.06",
"84.52",
"80.99",
"81.62",
"03.90"
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icd9pcs
|
[
[
[]
]
] |
5875, 5881
|
2476, 3981
|
282, 334
|
5954, 6011
|
1583, 2453
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973, 1048
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4007, 4356
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6035, 6088
|
1063, 1564
|
233, 244
|
362, 521
|
543, 829
|
845, 957
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,737
| 190,424
|
14941
|
Discharge summary
|
report
|
Admission Date: [**2142-7-15**] Discharge Date: [**2142-7-24**]
Date of Birth: [**2110-7-1**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 32 year old
gentleman transferred from an outside hospital, status post a
fall backwards down three steps while carrying a large box.
The patient denies drug use. Toxicology screen positive for
benzodiazepines and opiates. Though given Dilaudid for pain
at the outside hospital, benzodiazepine source is unknown.
The patient was transferred from [**Hospital 4415**]
for magnetic resonance scan for question of thoracic fracture
and paraplegia. CT scan with sagittal and coronal
reconstructions was negative as well as negative cervical
plain films.
PAST MEDICAL HISTORY: Motor vehicle accident in [**2126**], with
questionable brain injury.
PHYSICAL EXAMINATION: On physical examination, the patient
has lower extremity reflexes bilaterally. Strength is 0/5
bilaterally in the lower extremities. The patient's
sensation is 0 below T8. Positive rectal tone, positive
bulbar cavernosus and upper extremities normal bulk and tone.
He is awake but drowsy, oriented times three.
Magnetic resonance scan with and without gadolinium was
negative for any fracture or canal compromise.
HOSPITAL COURSE: The patient was felt to be having a
conversion reaction and within a couple days of being in the
hospital, his paraplegia resolved. The patient was screened
for rehabilitation although due to his extended hospital stay
found to fall at a level and was discharged to home no
[**2142-7-24**], with home safety evaluation. He was cleared by
physical therapy. He was followed by psychiatry for his
conversion reaction as well as seen by neurology service who
had no further input into his care. He was discharged to
home in stable condition with prescription for Percocet for
pain and home safety evaluation. He was in stable condition
with stable vital signs at the time of discharge.
[**Name6 (MD) 6911**] [**Name8 (MD) **], M.D. [**MD Number(1) 6913**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2142-7-24**] 11:02
T: [**2142-7-30**] 20:16
JOB#: [**Job Number **]
|
[
"E880.9",
"722.4",
"493.90",
"724.2",
"799.4",
"300.11",
"E980.3"
] |
icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
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]
] |
1293, 2222
|
855, 1275
|
168, 738
|
761, 832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,713
| 169,181
|
54466
|
Discharge summary
|
report
|
Admission Date: [**2181-1-2**] Discharge Date: [**2181-1-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
weakness, back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 20113**] is an 87 year old Russian-speaking man with a PMH
significant for CAD s/p inferior non-Q wave MI, s/p CVA in [**2171**]
with right eye vision loss, DMII, hyperlipidemia, & HTN who
presents as a transfer from [**Hospital6 **] with 1 day
h/o weakness, shortness of breath, and low-grade fever. Via an
interpreter, the patient and his family recount that one day
prior to admission, the patient was feeling "weak" with
"numbness" in his feet and hands. He had little appetite and did
not eat or drink much. Early on the day of admission, the
patient was walking to the bathroom with the aid of his walker
and felt weak and was unable to support himself so he "slid" to
the floor. He denies loss of consciousness or injury to his
head. He called for his wife, but he does not remember any
events after this until he was in the ambulance on the way to
the hospital. His wife reports that when she found her husband
on the floor, he was awake and alert, but she was unable to lift
him, so she called her son, who came over. He was concerned as
he stated that his father did not look "all there" even though
he was awake, so he called the ambulance. At the OSH, the
patient was hypoglycemic with a FSG of 40 that resolved with
D50. Cardiac enzymes were drawn, demonstrating a troponin of
9.08 with an unconcerning EKG. He received ASA and Plavix before
being transferred to the [**Hospital1 18**]. In the emergency room at [**Hospital1 18**],
the patient denied chest pain, but was tachypneic to 25-30 and
appeared diaphoretic and felt warm. Initial vitals were:T 100.6
HR 85, BP 148/61, RR 25, O2 Sat 100% on 4L. In addition to the
ASA & Plavix, he was then placed on a heparin gtt and given
Tylenol for his fever.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
ROS: + chronic back pain, + chronic toe numbness
Past Medical History:
1. CARDIAC RISK FACTORS: + Type II Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Coronary artery disease
s/p inferior non-Q wave MI, [**7-/2166**] with catheterization
revealing two vessel disease 40% occlusion of the proximal LAD,
diffusely diseased mid and distal circumflex with 95% stenosis.
OM1 had a significant 90% stenosis proximal to its distal
bifurcation with associated thrombus. F/U balloon angioplasty
was performed on the OM1 stenosis, leaving 40-50% residual
stenosis. The RCA was subtotally occluded proximally, but with
left to right collaterals present and competitive flow to the
RCA.
Echocardiogram [**3-/2179**] - EF 50%, 1+AR, trivial MR
[**Name13 (STitle) **] exercise stress test, [**2169**], no evidence of ischemia
Holter Monitor, [**2171**] for persistent chest pain, negative for
arrythmia
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: PTCA of OM1, [**7-/2166**]
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
s/p hemorrhagic CVA, [**2171**] with residual right eye blindness
Stage III-IV CKD, GFR 34 in [**3-/2179**] (baseline Cr 1.7-2.0)
Epidural abscess s/p decompressive laminectomy L4-S1/discectomy
L5-S1, [**2165**]
DJD with sciatica since [**2165**]
Shoulder bursitis/arthritis bilaterally
Left rotator cuff tear s/p left arthroscopic subacromial
decompression, synovectomy, debridement of labral tear, & cuff
repair, [**2168**]
s/p appendectomy
s/p prostate surgery
s/p left testicular surgery
cataracts
Social History:
The patient immigrated to the US in [**2163**]. He is retired & lives
with his wife in [**Name (NI) 86**]. He walks with a walker because of leg
fatigue.
-Tobacco history: Former smoker, 60-70 pack years
-ETOH: Occasional
-Illicit drugs: None
Family History:
Family history positive for diabetes and hypertension. No family
history of early MI, arrhythmia, cardiomyopathies.
Physical Exam:
VS: T 98.0 BP 101/36 HR 58 RR 21 O2 sat 94% on 4L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Multiple flesh
colored umbilicated papules scatter over the upper face and
forehead. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. Upper dentures in place. No xanthalesma.
NECK: Supple with JVP of ~ 7 cm
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations were mildly labored, no accessory muscle use. Trace
crackles at L base. No wheezes or rhonchi.
ABDOMEN: Soft, mildly tender to deep palpation of the RUQ.
Moderately-distended. No HSM. Abd aorta not enlarged by
palpation. No abdominal bruits.
EXTREMITIES: 1+ Pedal edema bilaterally. No cyanosis or
clubbing. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or scars.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
NEURO: A&Ox3, CNII-CNXII grossly normal except for loss of
vision in R eye. Iliopsoas 4+/5 strength bilaterally,
gastroc/soleus & anterior tibialis [**5-2**] on L, 4+/5 on R. Toes
downgoing b/l.
Pertinent Results:
EKG [**2180-1-3**]: NSR at 74. Normal axis. 1st degree AV conduction
delay. Borderline prolonged QRS. No concerning ST or T wave
abnormalities.
EKG: [**2180-12-18**]: NSR 59/[**Last Name (LF) **], [**First Name3 (LF) **] conduction delay 244 ms, normal
axis,
loss of anterior R waves, no significant other ST/T wave
abnormalities.
.
2D-ECHOCARDIOGRAM [**2179-4-14**]: The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal for the patient's body size.
Overall left ventricular systolic function is low normal (LVEF
50%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened, and display somewhat reduced
systolic excursion, but frank aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
CXR (Portable AP) [**2181-1-2**]: Cardiac silhouette appears normal. The
mediastinal and hilar silhouette appears normal. The aorta and
pulmonary vasculature appear unremarkable. Bilateral lungs
appear clear. Multiple degenerative changes of the spine are
noted with bridging osteophytes.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mr. [**Known lastname 20113**] is an 87 year old Russian-speaking man with a PMH
significant for CAD s/p inferior non-Q wave MI, s/p CVA in [**2171**]
with right eye vision loss, DMII, hyperlipidemia, & HTN who
presents as a transfer from [**Hospital6 **] with 1 day
h/o weakness, shortness of breath, and low-grade fever.
.
# Shortness of breath/weakness/low-grade fever: Patient with 1
day of shortness of breath and weakness/numbness in his feet and
hands leading to 2 mechanical falls at home in the past 24
hours. Patient reports little appetite, poor PO's x 2 days. No
other localizing symptoms. On admission to the [**Hospital1 18**], FSG was
40. Normal Gap, lactate, WBC. Patient did have low grade fever
intermittently that resolved with Tylenol. No consolidation on
CXR. Blood and urine culture were negative. This may represent
viral infection causing low grade fever, poor PO's and shortness
of breath. Furthermore, given his CXR finding of hyperinflation
and smoking history, it is likely that patient has COPD that
hasn't been diagnosed. Patient has no PFT in our system, and
has never seen a pulmonologist. Patient was given standing
albuterol and ipratropium nebs during this hospital stay. Also,
given the history of "shortness of breath leading to feeling of
impending doom" that finally came out when Dr. [**Last Name (STitle) 171**] talked to
the patient in Russian without family presence, PE was also on
the differential. D-dimer elevated at 1380. LENIS and V/Q scan
were done, which showed no DVT or PE. TTE was also done which
showed no significant changes compared to the TTE done last
year. PT evaluated the patient and determined that he required
[**Hospital 3058**] rehab. The family and patient declined, despite the
medical team's recommendation, so the patient was sent home with
PT and assurances that the patient would not be left unattended
or get up by himself at home.
.
# CAD w/ Elevated CK & Troponins: Patient with long-standing h/o
CAD and an inferior MI in [**2165**] (Cath from [**2165**] demonstrated 2VD,
40% occlusion proximal LAD, 95% stenosis of mid & distal L [**Name (NI) **],
PTCA of OM1). Now, patient with weakness, shortness of breath,
elevated CE's with Troponin of 1.51 on admission & report of
Troponin I of 9.08 at OSH. His last exercise stress test was
negative in [**2169**]. Patient had no chest pain, chest pressure,
discomfort in arm or jaw . While CK, CK-MB, Troponin are all
elevated, MBI is not elevated, EKG unconcerning for ACS.
Elevated enzymes may represent a myositis or injury after his
fall. CK eventually came down. Statin was held given elevated CK
levels. Patient was continued to metoprolol and aspirin.
.
# Acute on chronic renal insufficiency: Patient with known stage
III-IV CKD. A GFR was 34 in [**3-/2179**] (baseline Cr 1.7-2.1), Cr on
admission 2.5. Etiology likely pre-renal given clinical history
of poor PO's x 2 days, which was confirmed by urine lytes.
Patient was given a 500cc NS bolus on admission, and was then
encouraged to take POs. ACEI and lasix were held initially given
acute renal failure. Creatinine down-trended as a result. On
discharge, his creatinine was at his baseline 2.0.
.
# Hypertension: Patient with long-standing, previously
uncontrolled blood pressures causing CKD & hemorrhagic CVA in
[**2171**]. Recent blood pressures per [**Hospital **] clinic visits appear to be
well-controlled with sbp's in the 120's. Blood pressure on
admission elevated with sbp's in 140's in the context of
shortness of breath, now sbp's of 120's-140's on the floor. ACEI
and Lasix were held initially given acute renal failure.
Metorpolol and Nifedipine were continued. Patient's BP was
well-controlled during this admission. He was restarted on his
ACE at discharge, but his Lasix was held until follow-up with
his PCP next week.
.
# PUMP: Patient with shortness of breath on admission, requiring
4L NC. Most recent ECHO in [**3-/2179**] revealed EF of 50% along with
1+ AR and trivial MR. CXR negative for effusions, congestion, or
cardiomegaly. He did not not appear fluid overloaded on exam and
without elevation of JVP or S3, despite mild R basilar crackles
& chronic mild pedal edema. Repeat TTE showed no significant
changes compared to the TTE done last year.
.
# RHYTHM: Patient with no prior h/o arrhythmia. Out of concern
for persistent unexplained chest pain, patient had a Holter
Monitor device in [**2171**] that was negative for any arrythmia.
Patient was observed on tele which showed no significant
abnormalities. Patient was on metoprolol during this hospital
stay.
.
# DMII: Patient takes Glyburide 2.5mg PO daily at home. Given
episode of hypoglycemia on admission in context of poor PO's and
impaired renal function, glyburide was held, and patient was on
Humalog ISS for glucose control. Patient's glucose was
well-controlled during this hospital stay.
.
# Hyperlipidemia: Patient's statin was held given elevated CK.
He will not restart until he sees his PCP in [**Name Initial (PRE) **]/u next week.
.
# Chronic back & shoulder pain: Patient s/p L4-S1
laminectomy/L5-S1 discectomy & L rotator cuff repair with
long-standing bilateral shoulder arthritis, low back DJD,
sciatica, and resulting numbness in his toes. Walks with the
assistance of a walker for leg fatigue. Patient has been seen by
pain management in [**2175**] and prescribed Vicodin & Tizanadine, but
did not follow-up and per more recent OMR records, has not
continued to take these medications. Neurologic exam
demonstrates 4/5 strength in iliopsoas bilaterally that
patient's family estimates is patient's baseline. Patient
received tylenol for pain control.
.
# FEN: Patient received cardiac heart healthy/diabetic/renal
diet. He tolerated POs well.
.
# PROPHYLAXIS: Patient received heparin sc for DVT prophylaxis.
.
# CODE: FULL CODE
.
# COMM: [**Name (NI) **] & patient's wife, son and daughter-in-law. Of
note, interpreter service was used to gather more accurate
history from patient, but the family was providing most of the
history even when the interpreter was present. Dr. [**Last Name (STitle) 171**] was
able to gather more history from the patient when speaking to
patient directly in Russian in the absence of family.
Medications on Admission:
Lipitor 10mg daily
Furosemide 40mg daily
Glyburide 2.5mg daily
Lisinopril 40mg daily
Toprol XL 50mg daily
Nifedipine 30mg SR daily
ASA 81mg daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary
Acute on Chronic Renal Failure
Obstructive Lung Disease
Diabetes Mellitus Type 2
Secondary
CAD s/p MI
HTN, Dyslipidemia
s/p CVA
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted with weakness and after a fall. When you
arrived at the hospital, we were concerned about your heart.
Multiple tests were performed that indicated that your weakness
was not caused by a problem with your heart or from a blood clot
in your lungs. It appears that you may have had a viral
infection which caused your weakness and some kidney
dysfunction. Your poor kidney function then led to toxic levels
of your diabetes medication leading to low blood sugars. In the
hospital, your kidney function resolved and your blood sugars
returned to a safe level. You continued to have some wheezing
and which may be related to a viral illness and your smoking
history, so you were started on a new inhaled medication to help
your breathing. As your difficulty breathing was worse at night,
there was some concern that you have a condition called "Sleep
Apnea" and we recommend that you discuss getting a sleep study
with your PCP.
Finally, physical therapy evaluated you while you were in the
hospital and recommended that you go to a [**Hospital 3058**]
rehabilitation facility to assist with your walking. You and
your family declined placement in a rehabilitation facility
despite this recommendation, so you were sent home with a plan
for home physical therapy.
MEDICATION CHANGES
New Medication:
SPIRIVA - an inhaler for your lungs and breathing troubles.
Please take this once a day every day as directed.
ALBUTEROL - an inhaler for your lungs and breathing troubles.
Please take this every 4 hours AS NEEDED for wheezing or
shortness of breath.
STOP Medications:
ATORVASTATIN - discuss with Dr. [**Last Name (STitle) **] before restarting
LASIX - discuss with Dr. [**Last Name (STitle) **] before restarting
Followup Instructions:
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] on Thursday, [**1-11**], at 1:30pm. To reschedule,
call: [**Telephone/Fax (1) 5308**].
.
Please see your new pulmonologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. on
[**2-2**] at 9:00AM. To reschedule, call:[**Telephone/Fax (1) 612**]. Prior
to that appointment, please go to the PULMONARY FUNCTION LAB on
[**2-2**] at 8:40AM to have lung function tests performed.
.
Please follow-up with your cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**2-7**] at 2:00PM. To reschedule, please call:
Phone:[**Telephone/Fax (1) 62**].
|
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"272.4",
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"414.01",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13244, 13319
|
6813, 13047
|
281, 288
|
13508, 13508
|
5341, 6790
|
15408, 16148
|
4031, 4149
|
13340, 13487
|
13073, 13221
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13653, 15385
|
4164, 5322
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2384, 3217
|
221, 243
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316, 2266
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13522, 13629
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3248, 3752
|
2288, 2364
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3768, 4015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,747
| 154,792
|
12976
|
Discharge summary
|
report
|
Admission Date: [**2133-1-6**] Discharge Date: [**2133-1-14**]
Date of Birth: [**2080-6-29**] Sex: M
Service:
ADMISSION DIAGNOSES:
1. Aortic regurgitation.
2. Ascending aortic dilation.
DISCHARGE DIAGNOSES:
1. Aortic regurgitation.
2. Ascending aortic dilation.
3. Status post aortic valve replacement and ascending aorta
replacement with coronary artery reimplantation.
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is a 51-year-old
gentleman who had a history of congenital aortic stenosis
which was repaired at the [**Hospital 3340**] Clinic at age 12. The
patient has subsequently been without problems.
Echocardiogram performed on [**2132-11-13**] revealed [**2-10**]+ aortic
regurgitation and mild aortic stenosis. Dilation of the
aortic root was detected with markedly dilated ascending
aorta and moderately dilated aortic arch. Symptomatically,
the patient does report shortness of breath with heavy
exertion for the past several years. No dyspnea on exertion
with stair climbing or walking is reported; no chest pain.
The patient is referred to Dr. [**Last Name (Prefixes) **] for aortic valve
and aortic surgery following cardiac catheterization.
PAST MEDICAL HISTORY: 1. He has a 40-pack-year smoking
history. 2. Congenital aortic stenosis. 3. Status post
aortic valvuloplasty, age 12. 4. Status post vasectomy.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: The patient is a middle-aged gentleman
in no acute distress. His chest was clear to auscultation
bilaterally. Cardiovascular examination was regular rate and
rhythm, with grade 3/6 systolic ejection murmur. Abdomen was
soft, nontender, nondistended. Extremities were well,
noncyanotic, nonedematous x 4. Neurologically he was intact.
LABORATORY DATA: Chemistries were 136/4.5/94/26/9/0.8. INR
was 1.0.
HOSPITAL COURSE: The patient was admitted for preliminary
cardiac catheterization to his probable aortic valve surgery.
Cardiac catheterization performed on [**2133-1-6**] revealed an
ejection fraction of 45% with global hypokinesis; right
dominant coronary angiography and no significant coronary
disease. There was 3+ aortic insufficiency with moderate to
large thoracic ascending aortic aneurysm.
The patient had a redo aortic valve replacement and aortic
root replacement with 23 mm homograft and 26 mm tube graft
respectively on [**2133-1-7**]. The patient tolerated the
procedure well. The patient was sent to the intensive care
unit postoperatively for close monitoring. The patient was
on nitroglycerin, Nipride and propofol drips at that time.
The patient was weaned off his vasodilators on the evening of
postoperative day zero. He was initially sedated but the
propofol was weaned as well. The patient was transfused one
unit of packed red blood cells in the early morning of
postoperative day one for a low hematocrit and low urine
outpatient. The hematocrit was 27. The patient continued to
do well and was extubated later on postoperative day one
without incident. Subsequent to this, the patient had an
unremarkable intensive care unit course and was transferred
to the floor on postoperative day number two. The patient's
chest tubes were pulled on postoperative day five. The
patient did have a short run of rapid atrial fibrillation on
the evening of postoperative day five but spontaneously
converted back to sinus rhythm before any medications were
given. Otherwise, the patient progressed appropriately on
his floor stay and worked with physical therapy in order to
regain strength and conditioning. Physical therapy had
cleared him for home discharge on postoperative day number
six. The patient was discharged to home on postoperative day
seven tolerating a regular diet with adequate pain control on
p.o. pain medications and otherwise doing well.
Physical examination on discharge showed the patient to be in
no acute distress, vital signs were stable, afebrile. His
chest was clear to auscultation bilaterally, no click. There
was no drainage. Cardiovascular examination was regular rate
and rhythm without murmur, rub or gallop. Abdomen was soft,
nontender, and nondistended. Extremities were warm and well
perfused. Of note, there was no pedal edema. He was
neurologically intact.
Laboratory studies on discharge showed a complete blood count
of 7.8/34.9/210. Chemistries were
127/4.3/89/27/10/0.7/93/8.8/1.7/4.2.
DISCHARGE MEDICATIONS::
1. Colace 100 mg b.i.d.
2. Aspirin q.d.
3. Tylenol p.r.n.
4. Percocet p.r.n.
5. Captopril 50 mg t.i.d.
6. Lopressor 50 mg b.i.d.
7. Trazodone 25 mg q.h.s. p.r.n.
DISPOSITION: The patient is discharged to home.
CONDITION: Good.
DIET: Cardiac.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient should follow up with
his cardiologist in [**12-11**] weeks. He should follow up with Dr.
[**Last Name (Prefixes) **] in four weeks. Of note, the patient is not
discharged on Lasix secondary to his excision diuresis during
the hospital course. In addition, on physical examination
the patient has no edema to speak of.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2133-1-14**] 11:56
T: [**2133-1-14**] 12:08
JOB#: [**Job Number 39790**]
|
[
"305.1",
"746.3",
"441.2",
"427.31",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"39.61",
"88.42",
"37.23",
"39.59",
"88.56",
"88.53",
"35.21",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
228, 1202
|
4454, 5351
|
1880, 4431
|
151, 207
|
1450, 1862
|
1225, 1427
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,962
| 118,719
|
31008
|
Discharge summary
|
report
|
Admission Date: [**2184-4-20**] Discharge Date: [**2184-4-28**]
Date of Birth: [**2107-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Infected ICD pocket
Major Surgical or Invasive Procedure:
Extraction of infected ICD with one lead unable to extract
Temporary pacer wire placed
PICC placed
History of Present Illness:
This is a 76 yo M w pmh CAD s/p CABG in [**2158**], Heart failure (EF
15-20%), VT s/p ICD, afib, who was found to have an infected ICD
pocket. He initially presented to an OSH with c/o a reddened
erythematous area surround the insertion site of the ICD. The AV
pacer leads were placed 4 years ago and his CS and ICD leads are
one year old (placed in [**8-12**]). He was afebrile on presentation.
He was started on ceftrioxone and vancomycin and transferred to
[**Hospital1 18**] for evaluation for device extraction. His pacer pocket was
noted to be clearly infected. On [**2184-4-22**] the patient went to the
OR for ICD removal. In the OR the right ICD leads and the CS
leads were removed. The left ICD lead was not fully extracted
(lead broked, the end was capped). A temporary pacemaker (VVI)
was placed via L subclavian access.
.
In the CSRU the patient remained intubated and a warming blanket
was placed due to T of [**Age over 90 **]F. He became hypotensive with SBP in
the 50's. Levophed was started. However, his BP quickly
recovered when the Propofol was decreased. He was also started
on Zosyn for broader coverage.
.
Past Medical History:
CAD s/p CABG in [**2158**],
EF 15-20%,
VT s/p ICD
afib on coumadin
HTN,
hyperlipidemia,
DJD,
arthritis,
h/o GIB s/p AVM with cauterization,
CRI,
Depressiom,
Anxiety,
renal stones,
hypothyroidism.
Social History:
smoked for 30 years, quit many years ago. no etoh or drugs.
Lives with wife. Drives, is independent, needs no walker or cane
significant for the absence of current tobacco use. There is no
history of alcohol abuse.
Family History:
M: died of MI at 75
F: died of aneurysm at 75.
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 96.8 BP 120/84 HR 68 rr 18 97RA
Gen: WD man in bed in NAD
HEENT: Intubated.
CV: RRR, non murmurs
Chest: temporary pacer wires on left, dressed. Pacer pocket
open, oozing blood, no pus.
Resp: CTA anteriorly
Abd: Soft, non-distended, BS normoactive
Ext: WWP, non edematous, pneumoboots in place, 2+DP pulse
bilaterally
Pertinent Results:
[**2184-4-20**] 05:03PM BLOOD WBC-5.2 RBC-3.89* Hgb-13.3* Hct-38.8*
MCV-100* MCH-34.2* MCHC-34.3 RDW-15.8* Plt Ct-171
[**2184-4-20**] 05:03PM BLOOD PT-21.0* PTT-28.7 INR(PT)-2.0*
[**2184-4-26**] 07:12AM BLOOD PT-13.2* PTT-24.8 INR(PT)-1.2*
[**2184-4-20**] 05:03PM BLOOD Glucose-87 UreaN-26* Creat-1.4* Na-141
K-5.0 Cl-106 HCO3-27 AnGap-13
[**2184-4-20**] 05:03PM BLOOD Calcium-9.3 Phos-3.6 Mg-2.3
[**2184-4-22**] 08:07PM BLOOD Cortsol-5.5
[**2184-4-27**] 09:20PM BLOOD Vanco-12.8
.
[**2184-4-22**] wound culture coag negative staph, pan sensitive
Blood cultures 5/17,18,19 no growth to date by discharge.
.
[**2184-4-23**] ECHO (post lead extraction):
A catheter or pacing wire is seen in the RA.
Dynamic interatrial septum.
LEFT VENTRICLE: Dilated LV cavity. Severely depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size.
AORTIC VALVE: Mildly thickened aortic valve leaflets.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic signs of tamponade.
.
[**2184-4-20**] CXR:
External pacing device overlies the right anterior chest. Three
leads arise from this pacer, one coursing to the right atrium, a
second to the right ventricle, and a third with an unusual
posterior course, presumably for the purpose of biventricular
pacing. Additionally, there is a single lead coursing via the
left subclavian vein with tip terminating in the right
ventricle. There is no evidence of lead fracture or disruption.
The heart is moderately enlarged, but there is no evidence of
congestive heart failure. No pleural effusions are present.
Relatively symmetrical biapical thickening is incidentally
noted. There has been previous median sternotomy.
Brief Hospital Course:
This is a 76 yo M with CAD s/p CABG, EF of [**4-15**]%, VT s/p ICD,
afib. found to have an infected ICD pocket. His device was
extracted and a temporary pacer placed. Pt was briefly intubated
and sedated and transferred to CCU for procedure. Patient was
transiently hypotensive after the procedure requiring briefly
Levophed and Neo. His BP meds were held. He was also orthostatic
and received 1L IVF with improvement of his BP. His Hct dropped
down to 26 the next day and he received 2U of pRBC with Lasix in
between. He was transferred back to the floor and stabalized.
.
# Infected device pocket: s/p removal of RA, RV, CS from right
side on [**2184-4-22**]. Attempted extraction of chronic lead -
unsuccessful with laser. Lead broke, capped, left in pocket.
Temporary screw-in lead PM FROM LEFT SUBCLAVIAN VEIN placed.
Plan for abx IV 4 weeks (start [**4-23**]) and then 2 weeks after the
permanent pacer placed. Device and wound swab with coag neg
staph, oxacillin sensitive. Numerous blood culture from
[**Hospital1 **] [**4-19**] and here at [**Hospital1 18**] have remained negative.
Patient will need to call to have pacer placement scheduled per
d/c paperwork. Amiodarone restarted on discharge.
.
# A.fib- pt. with history of a.fib on digoxin and lopressor at
home and chronically anticoagulated. Coumadin was d/c'd prior
to procedure to remove device. Lopressor held to better evaluate
HR per EP (and PR prolonged when hypotensive). Plan is to not
restart coumadin, especially since patient maintaining sinus
rhythm and upcoming procedures. Restarted lopressor at home
dose.
.
# Bleeding at op-site: In the CSRU, the pacer pocket continued
to ooze. Pts. INR was 1.5. This was resolved spontaenously w/
presure. NO significant recurrent issues, aspirin restarted
prior to discharge.
.
# Hypotension: After the OR pt was hypotensive to the 50's (SBP)
on neosynephrine, levophed was started. However, with weaning of
propofol his pressure rebounded. Levophed and neo were quickly
weaned off. Hypotension was likely [**1-9**] to sedation, resolved.
.
# Cardiac - S/p CABG. Initial held aspirin in setting of ICD
pocket bleed, but restarted prior to d/c without complications.
Restarted ACE I (held d/t Cr), lopressor, and imdur. Patient was
on lasix on admission, but due to renal insufficiency, held
restarting this - will need to monitor and consider restarting
at outpatient dose of 20 PO QD.
# HTN: Held BB, ACE I, imdur intially, all restarted on
discharge.
.
# CRI: Cr 1.4, unknown baseline. Restarted ACE I but held
lasix with plan for extended care/rehab to monitor and restart
as needed.
.
# hypothyroidism: continued synthroid at home dose
.
# depression: continue sertraline 100mg qday
.
# Contacts: MD [**First Name (Titles) 73262**] [**Last Name (Titles) **] [**Telephone/Fax (1) 73263**]
Medications on Admission:
Vanco 1 gm IV daily LD at 12noon,
Ceftriaxone 1 gm LD 5/14/9pm
ASA 81 mg daily LD 9am
Metoprolol 25 mg [**Hospital1 **] LD 9am
Zocor 40 mg daily LD [**4-19**] 9pm
Amiodorone 100 mg [**Hospital1 **] LD 9am
Digoxin 0.125 mg daily LD [**4-19**] 9pm
Imdur 30 mg daily LD 9am'
Lasix 20 mg po daily LD 9am
Levoxyl 125 mcg daily LD6am
MVI 1 tab daily LD 9am
Folic Acid 2mg daily LD 9am
Zoloft 100 mg daily LD [**4-19**] 9pm
Vasotec 5 mg daily LD [**4-19**] 9pm
Primidone 125 mg daily LD [**4-19**] 9pm
Resteril 7.5 mg prn LD 11pm
Patient takes fish oil at home but none at [**Hospital1 **]
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Primidone 250 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 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) as needed.
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Vancomycin 500 mg Recon Soln Sig: One (1) g Intravenous Q
12H (Every 12 Hours).
15. Outpatient Lab Work
Safetly labs with Cr, Vanc level, CBC with diff on [**5-3**]. Please
fax results to [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] at [**Numeric Identifier 73264**].
16. Restoril 7.5 mg Capsule Sig: One (1) Capsule PO at bedtime.
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
18. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO twice a day.
19. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
20. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
21. Vasotec 5 mg Tablet Sig: One (1) Tablet PO once a day: hold
for sbp <100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Infected device pocket
Discharge Condition:
Good. Patient ambulating, breathing comfortably.
Discharge Instructions:
Please take all of your medications as prescribed.
Please call your PCP or return to the ED if you have chest pain,
shortness of breath, palpatations, dizziness, fevers, chills,
nausea, vomiting, or any other symptom that is of concern to
you.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2184-5-5**]
2:30
####### Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Numeric Identifier 73265**] in 2 weeks from
now to arrange for reimplantation of ICD in 3 weeks from now on
right.
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] on [**5-28**] at 10 am [**Numeric Identifier 73264**])
|
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[
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[]
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[
"37.77",
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"88.72",
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icd9pcs
|
[
[
[]
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,283
| 194,488
|
3502
|
Discharge summary
|
report
|
Admission Date: [**2195-8-21**] Discharge Date: [**2195-8-23**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
Asian American male who was discharged from [**Hospital 10073**]
[**Hospital 7637**] Hospital on the day prior to his admission to the
[**Hospital1 69**]. He was found
ambulating across the street in [**Last Name (un) 813**] with an unsteady gait
and subsequently collapsed. There was no noted seizure
activity per the EMTs who ultimately picked him up. He was
taken by ambulance to the Emergency Department where he was
found with eyes open but not responsive, GCS of 6. He was
found to have two bottles of Benadryl, one open but none
taken and the other apparently empty.
In the Emergency Department at the [**Hospital1 190**], her vital signs were a blood pressure of
154/84, pulse of 184, and respiratory rate of 22, 100% on
nonrebreather face mask. He was given an amp of Narcan
without response. He had no response to painful stimuli. He
was subsequently intubated for airway protection and was
charcoal lavaged. He was also given five liters of normal
saline via peripheral intravenous. The patient was
subsequently transferred to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY: Depression and question of
hypercholesterolemia.
ALLERGIES: None known.
SOCIAL HISTORY: As mentioned, he was recently released from
[**Hospital 10073**] [**Hospital 7637**] Hospital after being admitted there from
the [**Hospital 4415**]. He was admitted there for
intent to poison himself. He is married for two years.
MEDICATIONS:
1. Depakote 500 mg p.o. b.i.d.
2. Paxil 37.5 mg p.o. q.d.
3. Olanzapine 50 mg p.o. q.h.s.
His primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) 16072**] and Dr. [**First Name4 (NamePattern1) 5627**]
[**Last Name (NamePattern1) 16073**] at [**Hospital 4415**], [**Telephone/Fax (1) 16074**]. He is
followed by Dr. [**First Name (STitle) **] Shaven, who is a neurologist at [**Hospital 14852**].
PHYSICAL EXAMINATION: On admission to the Medical Intensive
Care Unit, his blood pressure was 166/122, and his pulse was
99. Temperature was 97. He was on the ventilator with FIMV
800/10, 100% oxygen. The pupils were three millimeters and
reactive to two millimeters bilaterally. There was no
corneal reflex. There was a positive essential eye response.
There was no lymphadenopathy. No thyromegaly and no jugular
venous distention. The lungs were clear to auscultation.
Cardiovascular revealed S1 and S2 with tachycardic rhythm, no
murmurs. His abdomen was soft, nontender, nondistended,
positive bowel sounds, no hepatosplenomegaly. The
extremities were 4+ good pulses bilaterally. There was no
cyanosis, clubbing or edema. There was a right forearm
abrasion.
LABORATORY DATA: On admission, complete blood count revealed
a white count 10.5, hematocrit 48.3, platelets 317,000.
Chem7 revealed sodium 139, potassium 3.4, chloride 97,
bicarbonate 21, blood urea nitrogen 16, creatinine 1.2,
glucose 106. Coagulation studies revealed prothrombin time
of 12.4, partial thromboplastin time 20.0 and INR of 1.0.
Liver function tests revealed AST of 22, ALT 21, amylase 51,
lipase of 27. Dilantin level was less than 0.6. Serum
toxicology and urine toxicology were negative. Arterial
blood gases was pH 7.41, pCO2 37, pO2 466.
Chest x-ray showed a left retrocardiac opacity most likely
thought to be an aspiration event. Head CT had no evidence
of acute intracranial pathology.
HOSPITAL COURSE: The patient as mentioned was brought to the
Medical Intensive Care Unit where he was given supportive
measures for his Benadryl overdose. He extubated rapidly
after only a couple hours in the Medical Intensive Care Unit.
He maintained after being intubated that he was depressed and
had suicidal ideation. He was subsequently seen by
psychiatry who at the time of this dictation is trying to
arrange for appropriate disposition to a psychiatric
facility.
From a medical prospective, the patient had no acute medical
issues. He had a residual tachycardia thought to be
secondary to the anticholinergic aspect of his Benadryl
overdose but otherwise was not hemodynamically unstable, was
afebrile and had no physical complaints to speak of. The
patient is set to be discharged from a medical prospective
pending bed opening at an inpatient psychiatric facility.
DISCHARGE MEDICATIONS:
1. Depakote 500 mg p.o. b.i.d.
2. Paxil 30 mg p.o. q.d.
3. Haldol 2 mg p.o./IV q.i.d. p.r.n. for delirium.
4. Olanzapine is being held at this point in time.
All his psychiatric medications are going to be adjusted by
psychiatrist to follow.
DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] 12-644
Dictated By:[**Last Name (NamePattern1) 16075**]
MEDQUIST36
D: [**2195-8-23**] 11:35
T: [**2195-8-23**] 12:43
JOB#: [**Job Number 16076**]
|
[
"E950.4",
"780.09",
"963.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4501, 4984
|
3613, 4478
|
2125, 3595
|
155, 1265
|
1288, 1363
|
1380, 2102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,230
| 157,814
|
30062
|
Discharge summary
|
report
|
Admission Date: [**2119-5-3**] Discharge Date: [**2119-5-17**]
Date of Birth: [**2049-3-15**] Sex: M
Service: MEDICINE
Allergies:
Unasyn
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
left lower extremity ischemia, dyspnea/chest pain
Major Surgical or Invasive Procedure:
1. Diagnostic angiogram
2. Left superficial femoral artery/bypass graft, Dacron patch
angioplasty
3. Aortic valvuloplasty
History of Present Illness:
VASCULAR SERVICE: 70M s/p left SFA-PT with NRSVG on [**2118-3-22**]
for a non-healing left toe ulcer presents for bilateral lower
extremity angiogram and angioplasty for bilateral great toe
ulcers with dry gangrene. He reports having had rest pain in
the left forefoot x 1 year in the same distribution as the
duskiness in that foot. He reports rest pain in the right foot
as well to a lesser extent.
.
CARDIOLOGY SERVICE: 70 y/o male with severe aortic stenosis,
diabetes, peripheral vascular disease, hyperlipidemia, carotid
disease, recent peripheral bypass surgery, remote tobacco abuse,
mild coronary disease, who is POD 3 from a left superficial
femoral artery/bypass graft Dacron patch angioplasty (preveious
bypass SFA--PT, origin of graft had become occluded. Vascular
surgery unable to harvest a [**Last Name (LF) 5703**], [**First Name3 (LF) **] did a patch angioplasty of
bypass, with restored flow and palpable pulse). His course has
been complicated by acute respiratory distress and intubation
(currently s/p extubation) who developed chest pain in the
setting of his respiratory distress. The patient reportedly
tolerated the procedure without difficulty, but in the
post-operative period, after receiving about 2-3 L of IVF, he
developed SOB and crushing chest pressure (says like an
"elephant on my chest"), and was intubated for a brief period.
He was aggressively diuresed, and post-extubation, he was
feeling better, with more comfortable breathing and no chest
pain.
.
On transfer, the patient resports being slightly SOB this AM,
though currently he feels fine. He reports baseline orthopnea.
Denies any chest pain or lightheadedness.
.
On cardiac review of symptoms, the patient endorses orthopnea,
lower extremity edema, presyncope with exertion, and lower
extremity claudication.
Past Medical History:
-Peripheral vascular disease: s/p endovascular AAA repair with a
[**Doctor Last Name **] EXCLUDER device on [**2116-5-4**]. 23 x 160 mm main body
device and a 12 x 100 mm right iliac contralateral limb device
CTA post implantation have failed to show any evidence of
endoleak. Non healing ulcer [**2118-3-22**]. He underwent
left femoral to posterior tibial bypass graft with nonreversed
saphenous [**Year (4 digits) 5703**] graft and angioscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
Following surgery, his left leg ulcer had improved.
-s/p right carotid endarterectomy with patch angioplasty [**2116-5-18**].
-Hypertension, essential
-Hyperlipidemia
-Right eye cataract last year; left cataract is pending.
-Chronic renal insufficiency
-History of osteomyelitis
-OSA
-History of GI bleed [**12/2115**]
-Chronic back pain
-Chronic tremor
Social History:
Pt lives with his sister. [**Name (NI) **] quit smoking but reports h/o 3 ppd
x 20 years. He denies EtOH consumption.
.
He has been living with his sister since [**2115**] with his medical
disability. He does not currenly smoke but did smoke 3 packs
per day for 20 years. He does not drink alcohol.
Family History:
Mother died at age [**Age over 90 **] years with Alzheimers. Father died at 69
of diabetes and coronary artery disease. He has three healthy
children.
.
There is a family history of diabetes and heart disease. There
is no history of hypertension or strokes. His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.
Physical Exam:
Vitals: Tm: 99.1, BP: 124/60, HR: 97, O2 sat: 99% 2L
CONSTITUTIONAL: No acute distress. Patient able to relay
history.
EYES: No conjunctival pallor. No icterus.
ENT/Mouth: MMM.
THYROID: No thyromegaly or thyroid nodules.
CV: Tachycardic Regular rhythm. nl S1, S2. No extra heart
sounds. Harsh, 3/6 systolic ejection murmur, radiating to neck.
JVP difficult to assess due to size, but does not appear
elevated.
LUNGS: Good air entry bilaterally with crackles at bases. No
rhonchi or wheezing.
GI: Soft, NT, ND. +bowel sounds No HSM. No abdominal bruits.
HEME/LYMPH: 2+ peripheral edema in LE bilaterally DP/PT:
difficult to assess due to edema, but dopplerable.
SKIN: Right lower extremity is cool. LLE has venous stasis
changes. Healing incision without erythema or pus near medial
malleolus. Healing, staped wound on anterior aspect of left
thigh. Well-demarcated ulcers at the tips of his toes.
Pertinent Results:
LABS ON ADMISSION:
[**2119-5-3**] 09:00PM BLOOD WBC-4.8 RBC-4.20* Hgb-12.2* Hct-34.9*
MCV-83 MCH-29.0 MCHC-34.9 RDW-14.0 Plt Ct-214
[**2119-5-3**] 09:00PM BLOOD PT-12.1 PTT-25.5 INR(PT)-1.0
[**2119-5-3**] 09:00PM BLOOD Glucose-229* UreaN-35* Creat-1.4* Na-143
K-3.3 Cl-102 HCO3-30 AnGap-14
[**2119-5-9**] 09:05PM BLOOD CK(CPK)-69
[**2119-5-8**] 01:06PM BLOOD CK-MB-2 cTropnT-<0.01
[**2119-5-9**] 09:05PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2119-5-3**] 09:00PM BLOOD Calcium-9.5 Phos-3.6 Mg-1.7
[**2119-5-9**] 07:45PM BLOOD Type-ART Temp-37.6 Rates-/30 FiO2-92
pO2-87 pCO2-59* pH-7.25* calTCO2-27 Base XS--2 AADO2-523 REQ
O2-86 Intubat-NOT INTUBA Comment-NON-REBREA
[**2119-5-9**] 09:17PM BLOOD Lactate-1.2
.
LABS ON DISCHARGE:
[**2119-5-17**] 05:30AM BLOOD WBC-5.3 RBC-3.35* Hgb-9.5* Hct-28.0*
MCV-84 MCH-28.3 MCHC-33.8 RDW-15.3 Plt Ct-323
[**2119-5-17**] 05:30AM BLOOD Plt Ct-323
[**2119-5-17**] 05:30AM BLOOD Glucose-119* UreaN-23* Creat-1.1 Na-137
K-3.9 Cl-101 HCO3-24 AnGap-16
[**2119-5-16**] 05:35AM BLOOD CK(CPK)-35*
[**2119-5-17**] 05:30AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2119-5-10**] 08:16AM BLOOD Type-ART pO2-107* pCO2-38 pH-7.44
calTCO2-27 Base XS-1
.
ECHO [**2119-5-15**]
.
There is symmetric left ventricular hypertrophy. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened.
.
Compared with the prior study (images reviewed) of [**2119-5-10**],
the peak gradient across the aortic valve has decreased from
95mm Hg (mean 64mm Hg) to 69mm Hg (mean 40mm Hg).
.
CATH [**2119-5-15**]
.
COMMENTS:
1. Resting hemodynamics revealed critical aortic stenosis with a
calculated valve area of 0.53mm2. There were elevated left and
right
sided filling pressures with a PCWP of 25mmHg and an RVEDP of
18mmHg.
The central aortic pressure was normal at 133/65 with a mean of
94mmHg.
2. Successful aortic balloon valvuloplasty using a 20mm x 5cm,
22mm x
6cm, and 25mm x 6cm Tyshak II balloon.
3. Following aortic balloon valvuloplasty, the calculated valve
area
improved to 0.83mm2.
4. Supravalvular aortography demonstrated trace aortic
regurgitation.
5. Abdominal aortography demonstrated vessel diameter > 6mm from
the
aorta to the femoral arteries.
.
FINAL DIAGNOSIS:
1. Critical aortic stenosis.
2. Elevated left and right sided filling pressures.
3. Successful aortic balloon valvuloplasty.
.
CXR PA and lateral [**2119-5-11**]:
.
FINDINGS: As compared to the previous examination, the patient
has been
extubated. The lung volumes are normal. However, on today's
examination,
bilateral pleural effusions of moderate extent are seen. This
leads to
bilateral basal areas of hypoventilation.
.
No other focal parenchymal opacities. Persistent minimal
pulmonary edema.
Unchanged normal size of the cardiac silhouette.
.
LENI [**2119-5-10**]:
IMPRESSION:
.
1. Limited evaluation of the left superficial femoral [**Month/Day/Year 5703**];
however, no
definite deep venous thrombosis identified.
2. Bilateral subcutaneous edema.
.
ECHO [**2119-5-10**]
.
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). 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.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Severe calcific aortic stenosis.
.
Compared with the prior study (images reviewed) of [**2119-3-6**],
the degree of aortic stenosis was probably OVERmeasured on the
prior. However, both studies show severe aortic stenosis.
Brief Hospital Course:
70 y/o male with severe aortic stenosis ([**Location (un) 109**] ~ 0.8), diabetes,
PVD, HLD, carotid disease, multiple peripheral bypass surgeries,
remote tobacco abuse, and minimal coronary disease with 30% RCA
on cath from [**7-19**], who is POD 2 from Left superficial femoral
artery/bypass graft Dacron patch angioplasty, complicated by
post-operative volume overload and presents with chest pain at
rest.
.
# VASCULAR: the patient was admitted to Dr. [**Last Name (STitle) 1391**] service for
left lower extremity ischemia and bilateral lower extremity
ulcers. Started on broad spectrum antibiotics and Heparin drip.
Patient was hydrated with bicarb and given mucomyst pre-angio.
On [**2119-5-4**], the patient was taken to the angio suite, underwent
bilateral lower extremity angiograms. He was determined to need
left SFA-bypass graft jump graft, and right femoral-PT or
peroneal bypass. On [**5-3**], patient had [**Date Range 5703**] mapping to
determine bypass conduits in preparation for his up coming lower
extremity bypass surgery. Left SFA-bypass graft jump graft, and
right femoral-PT or peroneal bypass was booked for Monday
[**2119-5-8**]. On [**2119-5-8**], the patient underwent Left superficial
femoral artery/bypass graft Dacron patch angioplasty, and
tolerated procedure well. Palpable pulse in graft.
.
In the afternoon of [**2119-5-9**], the patient developed progressive
dyspnea and was transferred to the CVICU where he was intubated
and briefly maintained on neo. Symptoms were thought to be
secondary to fluid overload and diuresis was started. He had a
troponin = 0.03. Repeat CXR showed pulmonary edema. Echo was
performed which showed a gradient accross aortic valve of 95
mmHg, improved from previous echo on [**2119-3-9**], otherwise stable.
LENIs were negative. On [**2119-5-11**], Patient complained of chest
pain. ECG showed new ST depressions across precordial leads.
Serial troponins were 0.84 (11:05), 1.03 (19:45). Patient was
transferred to cardiology service and accepted for transfer for
planned aortic valvuloplasty.
.
# Non ST elevation myocardial infarction: In the setting of
respiratory distress and fluid overload, the patient had
ischemic EKG changes consistent with global involvement of his
LV. Troponins showing rise: 0.8--1--1.45. Currently chest pain
free. Etiology not felt to be plaque rupture. Patient was
treated for exacerbation of heart failure and diuresed. He was
monitored on telemetry without events. On discharge, patient was
oxygenating well on RA. He was continued on aspirin, statin,
metoprolol. There are no new medication changes from a cardiac
perspective.
.
# Acute exacerbation of heart failure: The patient was given
fluids in the setting of surgery and has severe aortic stenosis
which likely precipitated his heart failure. He had acute
respiratory distress and chest pain. He has been aggressively
diuresed. Admission weight: 105.2 kg. Initial goal fluid
balance: negative [**Telephone/Fax (1) 1999**] mL per day for several days. Since
has aortic stenosis, runs the risk of becoming too hypotensive
if diuresed too aggressively. Patient was continued on lasix,
metoprolol and on discharge there were no changes to home
regimen.
.
# Severe aortic stenosis: Not a surgical candidate for aortic
valve replacement due to calcification. Echo on [**2119-5-10**] showed
severe aortic stenosis with a valve area of 0.8-1 cm2. Patient
underwent percutaneous valvuloplasty for temporary improvement
in symptoms. The peak gradient across the aortic valve has
decreased from 95mm Hg (mean 64mm Hg) to 69mm Hg (mean 40mm Hg).
On formal cath report, resting hemodynamics revealed critical
aortic stenosis with a calculated valve area of 0.53mm2. There
were elevated left and right sided filling pressures with a PCWP
of 25mmHg and an RVEDP of 18mmHg. Following aortic balloon
valvuloplasty, the calculated valve area improved to 0.83mm2.
Final diagnosis: Successful aortic balloon valvuloplasty without
complications.
.
# Peripheral vascular disease: The patient had a AAA in [**4-/2116**]
and extensive wounds in the tips on his toes on the lower
extremities. Has a history of poor wound healing. Now s/p left
superficial femoral artery/bypass graft Dacron patch
angioplasty. Continued on vancomycin, metronidazole, and cipro
while in house. Discharged with 2 weeks of bactrim, per ID recs.
.
# Diabetes Mellitus Type II: Controlled. Last hemoglobin A1C in
[**7-/2118**] was 6.0. Continued home NPH and HISS. Home glimepiride
held in setting of cath, resumed on discharge.
.
# Hypertension: Goal SBP<130/90. Evidence of mild symmetric LVH
on Echo. Continued on metoprolol, furosemide
.
# Hyperlipidemia: No fasting lipid panel in system. Continued
atorvastatin; discharged on home dose of rosuvastatin.
.
# Chronic renal insufficiency: Cr=1.1, at baseline. Received
pre-cath hydration.
.
# Dispo: discharged to rehab, PCP [**Name9 (PRE) 702**] arranged, outpatient
follow-up with Dr. [**Last Name (STitle) 1391**] in [**2-11**] weeks
Medications on Admission:
Furosemide 60 mg DAILY
Gabapentin 800 mg TID
Glimepiride 4 mg DAILY
Metolazone 5 mg WEEKLY
Metoprolol Tartrate 50 mg [**Hospital1 **]
Oxazepam 10 mg TID PRN anxiety/tremors
Rosuvastatin 5 mg DAILY
Aspirin 325 mg DAILY
Docusate Sodium 100 mg [**Hospital1 **]
Potassium Chloride 10 mEq DAILY
NPH Insulin and Novalog SS
Epinephrine [EpiPen] PRN emergency
Nitroglycerine PRN emergency
Discharge Medications:
1. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO twice a day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a week.
8. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day) as needed for anxiety/tremors.
9. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: 28
units qAM, 24 units qPM units Subcutaneous DAILY.
14. Humalog 100 unit/mL Solution Sig: PER SLIDING SCALE units
Subcutaneous DAILY.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 25576**]
Discharge Diagnosis:
PRIMARY:
1. left superficial femoral artery/bypass graft Dacron patch
angioplasty
2. severe aortic stenosis
3. aortic valvuloplasty
.
SECONDARY:
1. peripheral vascular disease
2. hypertension
3. hyperlipidemia
4. chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital and underwent left superficial
femoral artery/bypass grafting. You developed some chest pain
and shortness of breath subsequently, likely in the setting of
receiving too much intravenous fluids. You also underwent aortic
valve valvuloplasty for your aortic stenosis.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- START bactrim 800-160 mg tablet: one tablet by mouth twice a
day for 2 weeks
.
Otherwise, please continue your prior medications.
.
Please seek medical attention for chest pain, shortness of
breath, difficulty breathing, fevers, abdominal pain, or any
other concerning symptoms. Please weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
Followup Instructions:
Please call Dr.[**Name (NI) 1392**] office for follow-up in 2 weeks.
Phone: [**Telephone/Fax (1) 1393**]. Staples will be removed on this visit.
.
You already have an appointment with your primary care doctor,
Dr. [**Last Name (STitle) 28949**], on [**5-25**] at 1:15 pm.
Completed by:[**2119-5-17**]
|
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icd9cm
|
[
[
[]
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[
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,795
| 198,805
|
19558
|
Discharge summary
|
report
|
Admission Date: [**2170-7-22**] Discharge Date: [**2170-7-25**]
Date of Birth: [**2131-4-27**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Percodan / Darvocet-N 100
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Abdominal pain, vomiting, fingerstick glucose 600
Major Surgical or Invasive Procedure:
None
History of Present Illness:
39F h/o DM1 (last A1C 11.0 [**3-/2170**]), multiple admissions for DKA,
h/o gastroparesis, presents with cc 2 day hx of nausea,
vomitting, and abdominal pain with blood sugar readings of 600
at home. Patient presented to the ED when she became unable to
tolerate PO intake. She also was having n/v, RUQ and L flank
pain. Uncontrolled diabetes has been complicated by peripheral
neuropathy, severe gastroparesis, stroke (pure sensory lacunar
infarct 3 years ago, though no report in OMR) with recent
admission in [**Month (only) 116**] for DKA. She claims this felt like a typical
DKA episode. She thinks the trigger was recent menstruation and
personal stress. She admits to missing her insulin doses
recently bc of stress. Some flecks of blood in emesis which she
says is not uncommon for her. Has vomitted for past 2 days twice
each day. Denies dairrhea. Her sugars have been above 600 at
home. Her RUQ abdominal pain is what she typcally feels during
DKA however the left flank pain is new. Additionally endorses
recent nasal congestion, headache and mild cough along with
known sick contact (husband had recent cold). Denies
fevers,chills.
On arrival to MICU [**7-22**], anion gap was already closed. Patient
reported mild nausea and pain in extremities at site of
necrobiosis lipoidica diabeticorum (NLD). No events overnight.
On AM [**7-23**], patient has no abdominal pain and can tolerate food.
No complaints on transfer.
ROS
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
-DM type I: dx age 27, poorly controlled, complicated by
peripheral neuropathy, necrobiosis lipoidica, gastroparesis
-GI bleed 8/[**2168**].
-Aneurysm [**2166**]: 1mm aneurysm in L cavernous segment of ICA
-Raynaud's syndrome
-Migraines
-Hx pre-eclampsia with birth of twins in [**2157**]
-D&C for abnormal uterine bleeding
-s/p appendectomy [**2148**]
-s/p tubal Ligations [**2159**]
-s/p cholecystectomy [**2168**]
Social History:
Lives with husband and two 12 year old children. On disability
related to illness. Prior tobacco (17PY, quit [**2163**]), denies
alcohol, drugs.
Family History:
Mother had DVT in the setting of lung cancer; otherwise family
history unknown
Physical Exam:
ON ADMISSION
Physical Exam:
:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucosa, oropharynx clear, EOMI,
PERRL
Neck: supple, no LAD
CV: Regular rhythm, mild tachycardia, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, plaque like lesion on left foot with tenderness to
palpation plaque like lesion with tenderness to palpation on
left foot.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
ON DISCHARGE
T- Afebrile P-88, BP- 100/60, RR-16, 98%RA FSG bedtime- 187
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucosa, oropharynx clear, EOMI,
PERRL
Neck: supple, no LAD
CV: Regular rhythm, mild tachycardia, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, very mild
TTP in LUQ, no guarding, no rebound no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, plaque like lesion on left foot with tenderness to
palpation over erythematous plaque like lesion with tenderness
to palpation on left foot.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
ON ADMISSION
[**2170-7-22**] 07:00PM GLUCOSE-539* UREA N-13 CREAT-0.7 SODIUM-128*
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-13* ANION GAP-24*
[**2170-7-22**] 07:00PM ALT(SGPT)-18 AST(SGOT)-15 ALK PHOS-44 TOT
BILI-0.3
[**2170-7-22**] 07:00PM LIPASE-46
[**2170-7-22**] 07:00PM WBC-7.4 RBC-4.15* HGB-12.8 HCT-38.0 MCV-92
MCH-30.8 MCHC-33.7 RDW-12.8
[**2170-7-22**] 07:00PM NEUTS-60.7 LYMPHS-30.7 MONOS-3.8 EOS-4.2*
BASOS-0.6
[**2170-7-22**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-7-22**] 11:10PM %HbA1c-13.3* eAG-335*
[**2170-7-24**] 05:52AM BLOOD Triglyc-137 HDL-60 CHOL/HD-2.4 LDLcalc-56
ON DISCHARGE
[**2170-7-25**] 09:07AM BLOOD Glucose-340* UreaN-11 Creat-0.5 Na-137
K-3.9 Cl-99 HCO3-29 AnGap-13
[**2170-7-25**] 09:07AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.6
Brief Hospital Course:
39F with PMHx DM1 who presents with elevated FSG's in context of
recent URI and vomiting, consistent with DKA. Her anion gap
closed with IVF and insulin and she shortly was able to be
transferred to [**Location (un) **] Medicine floor where her insulin dosing
was uptitrated after HgA1c was 13.3.
#Diabetic Ketoacidosis-
Patient's anion gap closed while in MICU overnight and was
transferred the next day, [**7-24**], to general medicine floor on home
insulin regimen. A1c checked was 13.3. [**Last Name (un) **] was consulted who
recommended increasing AM lantus from 25 to 30U and adding 10U
premeal humalog to humalog premeal sliding scale. The patient
has voiced many concerns regarding affordability of her
medications. She at times has run out of her insulin and other
necessary materials and this has led to recurrent episodes of
DKA. Social stressors, including underlying depression and a
busy home life, with an alcoholic husband, have also complicated
her situation. Though she does have health insurance, social
work here was able to request for a discounted copay for her
Pregabalin. She has been instructed to reach out to social
workers at [**Last Name (un) **] during her appointment [**2170-7-26**].
#Nausea/Vomiting
The patient initially presented with nausea and vomiting which
resolved with PRN metoclopromide and odansetron. She did not
require these meds for 24 hours prior to discharge.
#Left Upper quadrant pain
Patient reported recent hematemesis, though H/H stable and
BUN/Cr not elevated. However, patient had been complaining of
LUQ pain after meals since her transfer. Somewhat resolved with
PO Dilaudid. Patient treats this pain at home with large amounts
of marijuana. Last EGD in [**2167**] showed gastritis. She has been
given 10 days of omeprazole to carry her to her [**Company 191**] appointment.
She may need repeat EGD as outpatient is symptoms do not resolve
with omeprazole.
#L foot pain
The patient has a history of necrobiosis lipoidica diabeticorum
on dorsum of left foot. She treats this at home with marijuana
and duloxetine. She will continue to take this duloxetine and
she has been prescribed pregabalin. Social work here submitted a
form to help decrease copay costs for this medication. The
patient has been told to take her duloxetine every day and not
to miss doses as withdrawal from this medication can make her
feel ill and cause electrolyte abnormalities. She was also
encouraged to refrain from using marijuana.
Transitional Issues
-The patient will follow-up at [**Last Name (un) **] on [**7-26**]. She should have
Social Work follow-up at that time. Social workers in house at
[**Hospital1 18**] felt she would most benefit from any services they have to
offer.
-The patient also has a FU appointment with [**Company 191**] [**8-2**]. At this
appointment, the patient should be asked whether she attended
her [**Last Name (un) **] Appointment. She also may need Psych follow-up
-Patient has been started on PO omeprazole as outpatient. She
was also given prescriptions for one month supply for insulin,
duloxetine and pregabalin. These should be refilled during her
next [**Company 191**] appointment.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Duloxetine 60 mg PO DAILY
2. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*10
Capsule Refills:*0
2. Duloxetine 60 mg PO DAILY
RX *duloxetine [Cymbalta] 60 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
3. Pregabalin 50 mg PO TID
RX *pregabalin [Lyrica] 50 mg 1 capsule(s) by mouth three times
daily Disp #*21 Capsule Refills:*0
4. Glargine 30 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [One Touch Ultra Test] as directed
Disp #*1 Pack Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL 30 Units before BKFT;
Disp #*1 Vial Refills:*0
RX *lancets [One Touch Delica Lancets] as directed Disp #*1
Packet Refills:*0
5. Insulin Syringe *NF* (insulin syringe-needle U-100) 1 mL 30 x
[**4-4**] Miscellaneous as directed
RX *insulin syringe-needle U-100 [Advocate Syringes] 31 gauge X
[**4-4**]" as directed Disp #*1 Pack Refills:*0
6. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous 10 U
TID and as directed sliding scale
RX *insulin lispro [Humalog] 100 unit/mL 10 U TID and as
directed sliding scale see above Disp #*2 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
SECONDARY:
DM type I uncontrolled with complications
peripheral neuropathy
necrobiosis lipoidica diabeticorum
gastroparesis
depression
marijuana abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain and
vomiting. You were found to have another episode of diabetic
ketoacidosis. This improved in the ICU with IV fluids and
Insulin.
You HgbA1c was checked. It is 13. It is very important you
control your sugars at home. A1c levels like these are very
dangerous and put you at risk for serious consequences of your
Diabetes including eye disease, kidney failure, and limb
necrosis. We have increased your insulin doses and written you
for prescriptions for all necessary medications and materials.
INCREASE Lantus to 30U each AM
START Humalog 10U Premeal Standing
CONTINUE current Humalog Sliding Scale
You mentioned your PCP has left the country. We have scheduled
you an appointment with a new PCP here at our [**Company 191**] Offices. You
also have a follow-up appointment at the [**Hospital **] Clinic tomorrow.
It is VERY important you attend this appointment, especially
because they will have additional resources to help you obtain
your medications.
You mentioned that you have missed doses of your Duloxetine.
Please take this medication every day as missing doses, as you
know, can cause many side effects. It also can cause
abnormalities in your electrolytes.
We have also started you on a new medication for nerve pain
called Pregabalin (Lyrica). Our social worker will try to help
you obtain this medication at decreased cost.
You also have a history of gastritis and have experienced
abdominal pain. We have written you for a proton pump inhibitor
called omeprazole to help treat this.
While in the hospital, Social Workers met with you to try and
discuss ways to help make it possible for you to continue taking
your medications and making your follow-up appointments. We urge
you seek social work assistance if you do have difficulty
obtaining medications in the future.
It was a pleasure taking care of you, Ms. [**Known lastname 38829**].
Followup Instructions:
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appointment: Thursday [**2170-7-26**] 10:00am
*This is a follow up appointment for your hospitalization. You
will be reconnected with your primary endocrinologist after this
visit.
Department: [**Hospital3 249**]
When: THURSDAY [**2170-8-2**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48120**] is your new physician in [**Name9 (PRE) 191**] and Dr. [**Last Name (STitle) 48120**]
works closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in
your care. For insurance purposes please indicate Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] as your Primary Care Physician. [**Name10 (NameIs) **] needs to be done
before this appointment.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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icd9cm
|
[
[
[]
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icd9pcs
|
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|
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|
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26,532
| 167,088
|
25774
|
Discharge summary
|
report
|
Admission Date: [**2187-6-27**] Discharge Date: [**2187-7-13**]
Date of Birth: [**2144-6-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lisinopril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Cath
CABGx4(LIMA->LAD, SVG->PDA, OM, Diag) [**2187-7-3**]
History of Present Illness:
43M with PMH notable for HIV c/b nephropathy requiring HD, CAD
s/p MI [**5-11**] was originally admitted yesterday for AV fistula
placement. In the holding area preoperatively, the pt admitted
that he had had some CP the day prior. He [**Month/Year (2) 1834**] stress test
[**2187-6-27**] with myocardial perfusion which was notable for a
moderate, partially reversible perfusion defect of the distal
inferior wall and apex. He also "ruled in" for NSTEMI by
troponin (.46->.52) in the setting of sigificant renal failure.
His operation was postponed and the pt went for a cardiac cath.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction, End-Stage
Renal Disease on Hemo-dialysis, Hypertension,
Hypercholesterolemia, HIV+, Asthma, Gastroesophageal Reflux
Disease, Neuropathy, Lung nodules, Anemia, +VRE in past, s/p
Appendectomy, s/p Tonsillectomy, s/p Tracheostomy x 2, h/o Deep
Vein Thrombosis, Hyperparathyroidism, Anal HPV
Social History:
Attorney. Lives with roommates. Has a partner. Quit smoking 6
years ago. Drinks a glass of wine on occasion. Denies drug use.
Family History:
CAD in many relatives but not at a young age.
Physical Exam:
Vitals: 132/83, 82, 18, 100% RA
Gen: NAD
HEENT: no JVD, OP clear, MMM
Heart: RRR, S1, S2, no rmg
Lungs: diffuse wheeze, no rhonchi
Abd: soft, NT, ND
Ext: wwp, no cce
Pertinent Results:
CXR [**7-11**]: Persistent right middle and right lower lobe
atelectasis. If persistent consider bronchoscopy to exclude
mucous plugging or fixed obstructing lesion in bronchus
intermedius.
Echo [**7-3**]: PRE-BYPASS: There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). There are complex (>4mm) atheroma in the descending
thoracic aorta. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. POST_BYPASS: Preserved biventricular
systolic function. Overall LVEF 55%. Trace MR, TR.
BLE U/S [**7-6**]: No evidence of DVT on either side.
EKG: NSR 87 bpm, nl axis, nl intervals, no ST changes, no T wave
inversions, no q waves
P-MIBI [**2187-6-27**]: Moderate, partially reversible perfusion defect
of the distal inferior wall and apex, not significantly changed
from prior exam. Hypokinesis of the distal inferior wall. EF
56%. Stress: No anginal type symptoms or ischemic EKG changes.
Cadiac Cath [**2187-6-28**]: LMCA: 30% LAD: 90% Px, diffuse dz distally
LCx: Moderate to severe diffuse disease RCA: Diffuse disease,
total occlusion distally REC: ASA, RF modification, CABG vs PCI
[**2187-6-27**] 03:40PM BLOOD WBC-5.1 RBC-2.67* Hgb-9.3* Hct-26.9*
MCV-101* MCH-34.8* MCHC-34.6 RDW-16.3* Plt Ct-182
[**2187-6-30**] 05:30AM BLOOD WBC-5.1 RBC-3.27* Hgb-11.3* Hct-33.1*
MCV-101* MCH-34.4* MCHC-34.1 RDW-17.5* Plt Ct-201
[**2187-7-3**] 06:20PM BLOOD WBC-11.1* RBC-2.22* Hgb-7.6* Hct-22.1*
MCV-100* MCH-34.3* MCHC-34.3 RDW-18.9* Plt Ct-196
[**2187-7-13**] 07:40AM BLOOD WBC-8.9 RBC-2.81* Hgb-9.0* Hct-26.5*
MCV-95 MCH-32.1* MCHC-33.9 RDW-17.5* Plt Ct-322
[**2187-6-28**] 04:40AM BLOOD PT-12.6 PTT-29.6 INR(PT)-1.1
[**2187-7-6**] 03:11AM BLOOD PT-13.6* PTT-28.9 INR(PT)-1.2*
[**2187-6-27**] 03:40PM BLOOD Glucose-149* UreaN-61* Creat-11.9*#
Na-137 K-4.7 Cl-96 HCO3-24 AnGap-22*
[**2187-7-13**] 07:40AM BLOOD Glucose-142* UreaN-82* Creat-10.4*#
Na-130* K-5.5* Cl-89* HCO3-25 AnGap-22*
[**2187-6-27**] 03:40PM BLOOD CK-MB-9 cTropnT-0.46*
[**2187-7-13**] 07:40AM BLOOD Albumin-3.6 Calcium-9.7 Phos-7.1* Mg-2.7*
UricAcd-9.0*
[**2187-7-7**] 11:30PM URINE RBC-3* WBC-560* Bacteri-NONE Yeast-NONE
Epi-2
[**2187-7-13**] 07:40AM BLOOD WBC-8.9 RBC-2.81* Hgb-9.0* Hct-26.5*
MCV-95 MCH-32.1* MCHC-33.9 RDW-17.5* Plt Ct-322
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 10680**] [**Last Name (Titles) 1834**] a cardiac cath
which revealed severe three vessel disease. Prior to surgery he
needed extensive work-up which included blood work, urinalysis,
cxr, echo, pulmonary consult with PFT's and right arm ABG's.
During this time and throughout hospital course renal followed
patient along with him receiving hemodialysis. He was eventually
ready for surgery on hospital day seven and following receiving
consent he was brought to the operating room where he [**Last Name (Titles) 1834**]
a coronary artery bypass graft x 4. Please see operative report
for surgical details. He tolerated the procedure well and was
then transferred to the CSRU in stable condition for invasive
monitoring. Later on op day he was weaned from sedation, awoke
neurologically intact and was extubated. His HIV medications
were restarted. He did require multiple blood transfusions
post-operatively. After several days in the CRSU he appeared
stable and was transferred to the telemetry floor. Chest tubes
and epicardial pacing wires were removed per protocol. Physical
therapy followed patient during entire post-op course for
strength and mobility. Antibiotics were started for a UTI. Beta
blockers were titrated for maximum BP and heart rate control.
Electrolytes were repleted. He continued to make good progress
with minimal complications. He appeared stable and doing well
with normal vs and stable labs. He was eventually discharged
home on POD #10 with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
ASA 325 mg daily
metoprolol XL 200 mg daily
monteleukast sodium 10 mg daily
flovent
albuterol
calcium acetate [**2182**] mg TID
zantac 150 mg [**Hospital1 **]
[**Doctor First Name 130**] 60 mg daily
lipitor 10 mg daily
ferrous sulfate 325 mg daily
diphenoxylate-atropine prn
protomix 40 mg daily
norvsc 10 mg dialy
efavirenz 600 mg daily
abacavir 300 mg [**Hospital1 **]
Vit. D
ropinirole 0.5 mg HS
nephrocaps one daily
percocet 1-2 tabs prn
lamivudine 25 mg 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. Lanthanum 250 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
4. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO QID (4 times a day) as needed.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**1-8**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
7. Ropinirole 0.25 mg Tablet Sig: Two (2) Tablet PO qhs ().
8. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day).
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-12**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
15. Montelukast 10 mg Tablet Sig: One (1) Tablet 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*2*
19. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) as needed for UTI for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
20. Lamivudine 10 mg/mL Solution Sig: One (1) mg PO DAILY
(Daily): 25 mg PO daily. mg
21. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] vna
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Myocardial Infarction, End-Stage Renal Disease on
Hemo-dialysis, Hypertension, Hypercholesterolemia, HIV+, Asthma,
Gastroesophageal Reflux Disease, Neuropathy, Lung nodules,
Anemia, +VRE in past, s/p Appendectomy, s/p Tonsillectomy, s/p
Tracheostomy x 2, h/o Deep Vein Thrombosis, Hyperparathyroidism
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds.
Call our office with sternal drainage, temp>101.5.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 14166**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Completed by:[**2187-8-6**]
|
[
"997.5",
"355.8",
"V08",
"530.81",
"585.6",
"414.01",
"410.71",
"518.0",
"V12.51",
"934.1",
"281.9",
"272.0",
"599.0",
"583.9",
"493.20",
"403.91",
"276.7",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.95",
"88.56",
"99.04",
"36.13",
"39.61",
"38.93",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8308, 8359
|
4110, 5684
|
300, 367
|
8769, 8775
|
1756, 4087
|
9114, 9289
|
1504, 1551
|
6199, 8285
|
8380, 8748
|
5710, 6176
|
8799, 9091
|
1566, 1737
|
250, 262
|
395, 982
|
1004, 1344
|
1360, 1488
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,384
| 155,843
|
11743
|
Discharge summary
|
report
|
Admission Date: [**2191-6-19**] Discharge Date: [**2191-6-24**]
Date of Birth: [**2146-4-15**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
male with past medical history significant for myocarditis at
age 15 who presents with retrosternal pain that radiates to
his back and shoulders. The patient states that the pain
began shortly after finishing a match of tennis. Of note,
the patient had also taken Viagra on the morning of
admission. The pain, which reached a "[**7-30**]" was constant and
was greatest actually in the back "between the shoulders."
The pain was somewhat improved by rest. He states that he
has experienced similar pain though to a lesser degree and
for short durations after exercise on several other
occasions. He denies any associated shortness of breath,
nausea, or vomiting, diaphoresis, or pallor. On ED
admission, the patient's blood pressure was 160/115. Initial
EKG shows a normal sinus rhythm of rate 55 beats per minute
with normal axis and normal intervals with hyperacute T waves
in V2 through V5 as well as T-wave inversions in 3 and F.
The patient was given a total of 10 mg of Lopressor IV as
well as 40 mg of labetalol IV, 10 mg of hydralazine, and 4 mg
of morphine.
PAST MEDICAL HISTORY: Myocarditis at the age of 15. The
patient states that this occurred in the setting of inflamed
tonsils. He states he was recommended to take several weeks
off from sports and was treated with antibiotics for this
illness. This occurred in [**Country 2784**].
GI bleed. The patient states that he had an episode of
hematochezia as well as iron deficiency anemia. The patient
underwent apparently flexible sigmoidoscopy, which revealed
patchy erythema in the rectum and sigmoid.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Motrin p.r.n.
2. Viagra p.r.n.
SOCIAL HISTORY: The patient is a biologist currently on
sabbatical at the [**Hospital1 18**]. He is single, though in a
relationship with a girlfriend. [**Name (NI) **] smoked occasionally as a
student but does not currently smoke, has 1 to 2 glasses of
alcohol per week. Denies any intravenous drug use.
FAMILY HISTORY: There is no known family history of CAD or
of MI.
PHYSICAL EXAMINATION: Blood pressure 130/80, heart rate of
72, respiratory rate of 16, O2 saturation of 100 percent on 2
liters. In general, the patient was found lying flat in bed,
talking with a partner in no acute distress. Pupils were
equal, round, and reactive to light. Extraocular muscles
were intact. Mucous membranes are moist with no associated
lesions in the oropharynx. There was no JVD. No cervical
bruits. The patient has a regular rate and rhythm. Normal
S1 and S2. No murmurs, rubs, or gallops. He is clear to
auscultation bilaterally. Abdomen soft, nontender, and
nondistended. Positive bowel sounds. No HSM or masses. No
CVA tenderness. There was no peripheral edema. No calf
tenderness. He has 2 plus DP and PT pulses. There were
femoral bruits.
LABORATORY ON ADMISSION: Sodium 141, potassium 4.1, chloride
106, bicarb 25, BUN 26, creatinine 1.3, glucose 101. White
count of 13.7 with differential of 87 percent neutrophils and
5 percent bands. Hematocrit of 48.6 and platelets of 187,
PTT 21, and INR of 1.0. His first set of cardiac enzymes
reveals a CK of 199 with a CK-MB 6 and troponin T of 0.03.
Subsequent ECG during "[**1-29**] pain" reveals T-wave set are less
acute in the anterior leads than in the prior ECG and now
bibasic T-waves in 3 and aVF.
HOSPITAL COURSE:
1. Myocardial infarction. The patient ruled in for
myocardial infarction on his second set of cardiac
enzymes. His second set of enzymes had a CK of 1459 and
CK-MB of 261, and MB index of 17.9 percent and troponin T
of 0.84. His CK max before the admission was 5254 with
max CK-MB of greater than 500 and max MB index of 17.9 and
maximum troponin T of 12.42. The patient was initially
managed with aspirin, beta blocker, p.r.n. morphine and
after ruling in he was also began on Integrilin as well as
a nitroglycerin drip. The patient was noted to have
increasing oxygen requirement and required 5 liters of
oxygen by nasal cannula for his adequate oxygenation.
Pulmonary examination prior to cardiac catheterization
revealed significant pulmonary edema. Cardiac
catheterization revealed a total occlusion of the LAD mid
vessel with thrombus present and distal filling via faint
left to left collaterals. The left circumflex also had 80
percent stenosis after the takeoff of the first obtuse
marginal branch. A Taxus drug-eluting stent was placed in
the LAD culprit lesion. Resting hemodynamics revealed
moderately elevated right and left sided filling pressures
with mean RA of 13 mmHg and RVEDP of 15, pulmonary
capillary wedge pressure of 20 and the LVEDP of 28.
Cardiac index was 2.2. Left ventriculography revealed an
EF of 42 percent. The patient was transferred to the
Cardiac Intensive Care Unit for further management. He
was maintained on aspirin, Plavix, beta blocker, ACE
inhibitor, and Lipitor. Echocardiogram on the first of
[**Month (only) **] revealed left ventricular systolic dysfunction with
akinesis of the distal two thirds of the anterior septum
and anterior wall as well as distal inferior wall and
apex. The patient's ejection fraction was estimated at 25
percent to 30 percent. The patient was taken for a second
cardiac catheterization on [**2191-6-22**] to address his left
circumflex artery lesion. The patient underwent placement
of second Taxus drug-eluting stent at this time in left
circumflex. There was no residual stenosis. The patient
tolerated the procedure well. Cholesterol panel revealed
a total cholesterol of 153 with HDL of 45 and LDL of 89.
The patient was therefore begun on high dose of statin
therapy with Lipitor 80 mg q.d. The patient was
maintained on telemetry and noted only to have one episode
of NSVT x5 beats within 24 hours of his presentation. The
patient was maintained on heparin anticoagulation given
his significant wall motion abnormalities and risk for
mural thrombus and the stroke. The patient was
transitioned on discharge to Lovenox as a bridge to
Coumadin, which he began 2 days prior to discharge.
1. Fever. The patient was noted to have intermittent low
grade fevers up to 101 degrees with first elevated on
admission. These fevers resolved spontaneously. All
blood and urine cultures were negative. Chest film did
not reveal any acute pulmonary process. It was felt that
his fevers most likely were secondary to myocardial
inflammation related to his infarction. The patient was
discharged in stable condition.
DISCHARGE DIAGNOSES: Anterior myocardial infarction.
Coronary artery disease (2 vessels).
Hyperlipidemia.
FOLLOWUP: The patient will follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on Friday, [**2191-7-1**]. His LFTs and CKs
will be checked given his recent initiation of high dose
Lipitor therapy. He will also follow up with Dr. [**First Name8 (NamePattern2) 4559**]
[**Last Name (NamePattern1) 37053**] and Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] on [**2191-8-1**]. In addition, he
will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2191-7-27**] for
consideration of electrophysiology study and possible ICD
placement. He will have an echocardiogram on [**2191-7-21**] prior
to this visit. In addition, his blood will be drawn on the
Monday and Wednesday following discharge from monitoring of
his INR and his Coumadin dose will be adjusted accordingly
prior to his visit with his primary care physician. [**Name10 (NameIs) **]
primary care physician will then assume dosing of his
Coumadin.
MEDICATION ON DISCHARGE:
1. Aspirin 325.
2. Plavix 75 q.d.
3. Lipitor 80 q.d.
4. Coumadin 5 mg h.s.
5. Lisinopril 20 mg q.d.
6.
Lovenox 80 mg b.i.d. until INR therapeutic.
7. Toprol XL 100 mg q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4958**]
Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D: [**2191-6-24**] 23:08:31
T: [**2191-6-26**] 10:07:41
Job#: [**Job Number 37150**]
|
[
"414.01",
"V12.59",
"410.11",
"780.6",
"427.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"88.56",
"37.22",
"88.55",
"99.20",
"36.01",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
2218, 2269
|
6884, 8016
|
1855, 1891
|
3588, 6862
|
2292, 3065
|
8030, 8474
|
165, 1268
|
3080, 3571
|
1291, 1829
|
1908, 2201
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,207
| 184,002
|
53422
|
Discharge summary
|
report
|
Admission Date: [**2101-8-24**] Discharge Date: [**2101-8-31**]
Date of Birth: [**2036-7-12**] Sex: M
Service:
ADMISSION DIAGNOSIS: Angina
HISTORY OF PRESENT ILLNESS: This is a 65 year old man with a
history of chronic lymphocytic leukemia and angina who
underwent a cardiac catheterization two days prior to
admission which demonstrated triple vessel disease. The
patient was having exertional angina, status post walking 10
feet, five days prior to the cardiac catheterization. He
also had pain at rest which resolved with sublingual
nitroglycerin. The pain was 2/10 chest pain radiating to the
left arm. The patient had a positive stress and the cardiac
catheterization showed triple vessel disease. He was
discharged home with a goal to decrease his white count prior
to coronary artery bypass grafting, however, the patient was
home for 7 hours after discharge and was laying in bed when
he started developing chest pain again which radiated to the
left arm which did not resolve with sublingual nitroglycerin.
He was transferred to the Emergency Room at which time he was
having nausea and shortness of breath with chest pain.
PAST MEDICAL HISTORY:
1. Chronic lymphocytic leukemia
2. Coronary artery disease
3. Asthma
MEDICATIONS:
1. Enteric coated Aspirin
2. Lopressor 25 mg p.o. b.i.d.
3. Flovent 2 puffs b.i.d.
4. Albuterol 2 puffs q. 6 hours prn
5. Sublingual Nitroglycerin
ALLERGIES: Penicillin
SOCIAL HISTORY: Tobacco, stopped in [**2084**].
PHYSICAL EXAMINATION: In the Emergency Room he was found to
have a heartrate of 62, blood pressure 152/72 and respiratory
rate of 18, sating 99%. His physical examination was clear
to auscultation with regular rate and rhythm, no murmurs,
rubs or gallops. His extremities showed no edema and had 2+
pulses distally. His troponin was found to be 2.9. At this
point the cardiac surgery team was consulted and it was
determined that he would go for coronary artery bypass
grafting the next day.
HOSPITAL COURSE: On [**2101-8-25**], the patient
underwent coronary artery bypass grafting times three as
follows: saphenous vein graft to left anterior descending,
saphenous vein graft to obtuse marginal 1, saphenous vein
graft to right posterior descending artery, performed by Dr.
[**Last Name (STitle) 70**], assisted by Dr. [**Last Name (STitle) **] as well as physician
assistant, [**Name9 (PRE) **]. The cardiopulmonary bypass time was 83
minutes with a crossclamp time of 44 minutes.
Postoperatively the patient did well without any pressor
requirement or inotrope requirement. However, he did go into
atrial fibrillation on postoperative day #2 and was started
on Amiodarone. The patient subsequently converted back to a
normal sinus rhythm on postoperative day #3 and remained in
such for the remainder of his admission. He did, however,
have chilled rigors and was found to be febrile to 101 on
postoperative day #4. At this point he was examined and
noted to have erythema and induration at the site of an
intravenous line which was located in his left forearm. The
intravenous line was removed and there was pus noted coming
from the site of the entry of the intravenous line into the
skin. After a 24 hour period of observation, it was noted
that there was not significant improvement in the induration
or erythema and pus was expressible from the wound. Given
these findings, the patient underwent an incision and
drainage of pus from this suppurative thrombophlebitis that
had occurred at the site of his intravenous. The patient
tolerated his procedure well and by postoperative day #6
remained afebrile for 24 hours with resolution of the
induration of the cellulitis of the left arm. He was clear
to auscultation with regular rate and rhythm. Given this, it
was felt that he was stable for discharge.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Motrin prn
4. Albuterol metered dose inhaler 2 puffs q. 4 to 6 hours
prn
5. Flovent 100 mcg metered dose inhaler 2 puffs b.i.d.
6. Amiodarone 400 mg p.o. t.i.d. times three days and then
400 mg p.o. b.i.d. times 7 days, then 400 mg p.o. q.d.
7. Aspirin 81 mg p.o. q.d.
8. Tetracycline 500 mg p.o.q.i.d. times seven days
9. Percocet prn
The patient was tolerating a regular diet.
DISCHARGE DIAGNOSIS:
1. Chronic lymphocytic leukemia, status post chemotherapy
times two.
2. Coronary artery disease, status post angioplasty.
3. Asthma.
4. Status post coronary artery bypass graft [**8-25**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 02-358
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2101-8-31**] 19:00
T: [**2101-8-31**] 19:22
JOB#: [**Job Number 109874**]
|
[
"427.31",
"493.90",
"997.1",
"411.1",
"204.10",
"V45.82",
"272.0",
"999.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"86.04",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
3852, 4305
|
4326, 4745
|
2013, 3829
|
1520, 1995
|
153, 161
|
190, 1162
|
1184, 1447
|
1464, 1497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,059
| 142,582
|
28527
|
Discharge summary
|
report
|
Admission Date: [**2150-8-7**] Discharge Date: [**2150-8-13**]
Date of Birth: [**2081-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
1. Endoscopic Gastroduodenoscopy (EGD)
2. Banding of esophageal varices
3. Transfusion of packed red blood cells
History of Present Illness:
69 y.o. man with hx of brisk ulcer bleed in the [**2123**]'s for which
he was treated with blood transfusions from which he contracted
Hep C. He has had no other episodes of GI bleeding until [**8-6**]
when he had a dark tarry bowel movement followed a few minutes
later by a large amount of dark emesis "full of clots". Denies
any abdominal pain or nausea. Did notice a lack of appetite
immediately about an hour before the episode but other felt in
his USOH. He went to [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) 69102**] where per record, he had two
episodes of hemetmesis in the ED after he was started on an
ocreotide drip and he was found to have a HCT from 32.9 down to
21. On the day of transfer patient had an EGD which showed no
obvious source of bleedingbut did show [**2-7**]+ esophageal varices
which were treated with schlerotherapy. There were also some
gastric folds concerning for ?gastric varices. After the EGD, he
continued to have hematemesis and per record, was transiently
hypotensive and tachycardiac. He was then transferred to [**Hospital1 **] on
an octreotide and protonix drip for further work-up and
treatment.
Past Medical History:
Hepatitis C - followed by Dr. [**First Name (STitle) 26390**] at [**University/College **] Pilgram
- hx of ascites treated with diuretics
PUD with bleed requiring transfusion in [**2125**]
?esophageal varices
HTN
anemia - patient says he is followed by a hematologist for
decreased HCT
s/p prostate biopsy with + prostate CA
Social History:
Married, retired from [**Company 22957**], tobacco: smoked "off and on" [**1-9**]
cigs per day x 46 years, quit 5 years ago; alcohol: quit 40
years ago, drank socially, no drugs
Family History:
Mom with Breast CA
Physical Exam:
VS: Temp: BP: 133/58 HR: 82 RR: 11 O2sat: 100% on RA
GEN: man lying in bed NAD
HEENT: PERRLA, anicteric, EOMI, MMM, OP clear, neck supple, no
bruits, no JVD
RESP: CTAB, no m/r/g
CV: regular, nl s1, s2, no m/r/g
ABD: soft, NT, ND, + BS, no HSM, tympanic
EXT: no edema, +2 DP pulses
Skin: no stigmata
Pertinent Results:
Abdominal Ultrasound [**2150-8-8**]
1. Coarse hepatic echotexture consistent with cirrhosis. Patent
portal vein with hepatopetal flow. Small amount of ascites.
2. No evidence of hydronephrosis.
.
Endoscopy (EGD) [**2150-8-12**]
Impression: Varices at the gastroesophageal junction, lower
third of the esophagus and middle third of the esophagus.
Granularity, friability, erythema, congestion, abnormal
vascularity and mosaic appearance in the whole stomach
compatible with portal gastropathy. Otherwise normal EGD to
second part of the duodenum.
.
[**2150-8-7**] 10:32PM BLOOD WBC-19.8* RBC-2.92* Hgb-9.7* Hct-26.0*
MCV-89 MCH-33.1* MCHC-37.1* RDW-16.2* Plt Ct-108*
[**2150-8-8**] 06:39AM BLOOD Hct-17.3*#
[**2150-8-13**] 05:22AM BLOOD WBC-14.5* RBC-3.21* Hgb-10.4* Hct-29.2*
MCV-91 MCH-32.4* MCHC-35.6* RDW-16.5* Plt Ct-111*
[**2150-8-11**] 05:45AM BLOOD ALT-45* AST-53* LD(LDH)-260* AlkPhos-50
Amylase-114* TotBili-1.1
[**2150-8-13**] 05:22AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
Brief Hospital Course:
The patient was brought to [**Hospital1 18**] and admitted to the medical
intensive care unit. Including the outside hospital and our
MICU the patient was transfused 5 units of PRBC and 3 units of
FFP. After stabilizing in the MICU the patient was transferred
out to the hepatorenal service where his hematocrit and vital
signs were seen to stabilize. Ultimately the patient's melena
ceased. An EGD was performed with banding and an apointment for
repeat EGD with Dr. [**First Name (STitle) 679**] in two weeks was set up. The patient
was discharged home with further follow up with Dr. [**Last Name (STitle) 69103**] the
liver clinic.
Medications on Admission:
Spironolactone - doesn't know dose.
lisinopril - doesn't know dose.
Propranolol - 12.5qd
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. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
3. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Upper GI bleed secondary to esophageal variceal bleed
2. Hepatitis secondary to Hepatitis C Virus infection with
evidence of portal hypertension including ascites, esophageal
varices.
3. Hypertension.
4. Renal failure. Creatinine is a measure of how well your
kidney's are filtering your blood. Your creatinine is 1.6 on
discharge. This is an improvement of where it was (2.4) when you
got here. You should get follow up with your primary care doctor
regarding this issue.
Discharge Condition:
Vital signs stable. Hematocrit has been stable for 3 days.
Discharge Instructions:
Please return to the hospital if you vomit, especially if you
vomit blood, if you have black or tarry stools, if you have
bright red blood in your stool, if you have abdominal pain, or
if you notice that your abdominal girth is rapidly increasing.
Please take your medications as prescribed.
Followup Instructions:
- Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 30186**]
([**Telephone/Fax (1) 69104**]regarding your recent hospitalization and the
diagnoses that are detailed above.
- Will need a follow up upper endoscopy in 2 weeks on [**2150-8-26**] at
12:200PM for repeat banding of esophageal varices with Dr. [**First Name (STitle) 679**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],[**First Name3 (LF) **] PROCEDURES ENDOSCOPY SUITES
Date/Time:[**2150-8-26**] 1:00
- Please follow up with Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2150-9-22**] 10:00 - he is also a GI
specialist.
Completed by:[**2150-8-14**]
|
[
"456.20",
"571.5",
"789.5",
"572.3",
"070.70",
"401.9",
"287.5",
"584.9",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
5090, 5096
|
3558, 4200
|
327, 445
|
5616, 5678
|
2552, 3535
|
6020, 6763
|
2197, 2217
|
4340, 5067
|
5117, 5595
|
4226, 4317
|
5702, 5997
|
2232, 2533
|
273, 289
|
473, 1635
|
1657, 1984
|
2001, 2180
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,899
| 162,232
|
46768
|
Discharge summary
|
report
|
Admission Date: [**2165-3-5**] Discharge Date: [**2165-3-8**]
Date of Birth: [**2097-1-2**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Procardia / Morphine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
Patient is a 68 year old female with past medical history of
hypertension, hyperlipidemia, congenital right-sided aortic arch
staus post aorta-aorta bypass many years ago. She was
transferred from an outside hospital after presenting with
shortness of breath. She reports that the night prior to
presentation she awoke from sleep around 11 PM with severe
shortness of breath, which improved with sitting up. Of note,
patient reports several episodes of orthopnea and PND over the
past 3-4 weeks. She also admits to dietary indescretions with
lots of salty foods over the past 4 weeks. She was very anxious
and started to experience [**8-8**] burning chest pain over her left
breast with radiation to the left arm. EMS was called. She was
given NTG and 325 ASA and taken to [**Hospital3 **]. There her
initial vitals were: 97.7, 115/60, 79, 20, 95% RA. She was given
sublingal nitroglycerin, 20 mg of IV lasix (to which she put out
300 cc urine). Her labs were significant for a DDIMER of 386.2
(0-230 nl), BNP 704, Trop 0.02, WBC 11.6. Patient was
transferred to [**Hospital1 18**].
.
In [**Hospital1 18**] ED: initial vitals were 97.7, 118, 60, 79, 19, 97% 3L
NC. She was given mucomyst 600mg x1, NTG SL. Of note, she became
transiently hypotensive with nitroglycerin with systolic present
to the 50's only briefly. She was also given levaquin 750mg IV
x1, dilaudid 0.5mg iv, started on integrillin and heparin GTT. A
CTA was done which was negative for any pulmonary embolus. A
chest x-ray showed a small bilateral effusion but no overt
pulmonary edema. Patient continue to have intermittent chest
pain with question of ST changes on ECG but negative enzymes.
Cardiology was consulted and patient was admitted to the medical
intensive care unit.
.
ROS: Patient noted increasing ankle edema over the past 3 weeks.
Patient also reports increased dyspnea on exertion with climbing
stairs over the same time period. Denies recent fever or chills,
chest pain as detailed in HPI. denies abd pain, reports urinary
frequency but no dysuria. No weight gain/loss.
Past Medical History:
- Hypertension
- Hyperlipidemia
- CAD (1 VD 60% stenosis of D1)
- Congenital right-sided aortic arch, status post aorta/aorta
bypass surgery at 27 y.o. Also status post stenting of the
aorta/aorta bypass graft in [**2158**] (3 stents in aorta-aorta
bypass), restenosis in [**2159**] req. PTCA/stentin, and stenting of
coarctation of the aorta in [**2160**].
- Laproscopic cholecystecomy
- Right sided aortic arch, aberrant left subclavian.
- Seasonal asthma and bronchitis.
- Tonsillectomy
Social History:
No smoking, occasional alcohol, no drug use. Patient is married
and lives with her husband and children.
Family History:
The patient's father had a cerebrovascular accident at the age
of 60. Her mother had lung cancer and cardiac surgery.
Physical Exam:
VS: Temp: 98.9 BP: 115/57 HR: 77 RR: 21 95% on venti-mask 50%
GEN: anxious, sitting up in bed, ventimask in place.
HEENT: dry mucous membranes, EOMI.
NECK: JVD elevated at 90 degrees
RESP: bilateral rales [**1-30**] way up, soft expiratory wheezes
CV: III/VI holosystolic murmur throughout precordium
ABD: NT/ND, normoactive BS, soft
EXT: 1+ bilateral DP, 1+ bilateral pitting edema at ankles.
SKIN: no rashes/no jaundice
Pertinent Results:
[**2165-3-7**]: Cardiac Catherization
COMMENTS:
1. Coronary angiography of this right dominant system revealed
mild
single vessel coronary artery disease. The LMCA, LAD, and LCx
had no
angiographically evident flow limiting stenosis. The RCA was a
dominant
vessel with a distal 40% lesion.
2. Supravalvular aortography revealed known right sided aorta.
Previously placed stent in the native aortic arch coarctation is
widely
patent. Aorta-aorta bypass graft is widely patent except at the
origin,
which has a 40-50% in stent restenosis.
3. Resting hemodynamics revealed mildly elevated right sided
filling
pressures, with RVEDP of 14 mm Hg. PA systolic pressure is
mildly
elevated at 43 mm Hg. Mean PCWP is 14 mm Hg. A modest 20 mm Hg
gradient is present across the native aortic coarctation.
Cardiac index
is preserved at 3.32 l/min/m2.
4. Nipride infusion to a maximum dose of 1.0 mcg/kg/min
resulted in a
decline in gradient between ascending and descending aorta to 10
mm Hg
and LVSP decline to 110 mm Hg. The patient remained
asymptomatic for
the duration of the study.
FINAL DIAGNOSIS:
1. Mild single vessel coronary artery disease.
2. 40-50% ISRS of proximal aorta-aorta graft stent. Remaineder
of ao-ao
graft stents are widely patent.
3. Widely patent native aortic arch coarctation stent.
4. Recommend aggressive blood pressure control; goal RUE BP 100
mmHg or
LUE BP 90mm Hg, which corresponds to LVSP of 120 mm Hg. Titrate
[**Last Name (un) **] to
maximal dose; if RUE BP remains over 120 mm Hg with exertion
begin
clonidine 0.1 mg daily as tolerated.
.
CTA [**2165-3-5**]:
IMPRESSION:
1. No pulmonary embolism within central through segmental
branches. Subsegmental evaluation is limited due to motion.
There is no acute aortic pathology.
2. Status post stent placement through and bypassing right
aortic arch coarctation.
3. Small bilateral pleural effusions with associated
atelectasis. Cannot exclude superimposed pneumonia within the
left lung base.
.
[**2165-3-6**] Transthoracic [**Month/Day/Year **]
Conclusions
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 0-10mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. 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. Increased velocity consistent with a significant
gradient/coarctation at the distal aortic arch. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. There is no aortic valve
stenosis. The mitral valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2162-6-18**], LVOT obstruction is no longer present.
Coarctation of the aorta is now appreciated.
Brief Hospital Course:
Patient is a pleasant 68 year old female with past medical
history of hypertension, hyperlipidemia, and congential
right-sided aortic arch s/p bypass and multiple stents who
presents with chest pain and shortness of breath.
.
#. Coronary artery disease: Patient has no known occlusive
coronary artery disease. She was continued on 81 mg of aspirin
for prevention. Her cardiac enzymes were negative throughout her
stay and she was ruled out for a myocardial infarction. It was
felt that her chest pain was in large part due anxiety causing
much increased left-sided pressures due to her anatomy and
hemodynamics. She was given ativan and sublingual nitroglycerin
cautiously as tolerated by her blood pressure.
She had no pain for several days prior to discharge.
.
#. Congestive heart failure: Patient's presentation was
consistent with volume overloaded state in the setting of
dietary indiscretion and a lot of salt intake. This was
supported by an elevated BNP, as well as a history of PND and
dyspnea. She responded well to gentle diuresis. An echo
completed today revealed normal LVEF with unusually small LV
cavity, mild symmetric LVH, and coarctation of the aorta. Prior
studies have demonstrated diastolic dysfunction. At time of
discharge, she appeared euvolemic without any dyspnea, elevated
JVP, edema, or rales on exam. She was maintained on a low salt
diet. A beta-blocker was continued, and losartan was initiated
and titrated upward. She was discharged on 12.5 mg of HCTZ
daily, instead of 25 mg on Monday/Wednesday/Friday. Importance
of a low salt diet was stressed and dietary education was
reviewed.
.
#. Rhythm: She remained in normal sinus rhythm throughout her
stay.
.
#. Coarctation, right-sided aorta, prior bypass: Patient's
stents are patent as noted in catherization report. Based on the
data and information obtained in the catherization lab, due to
her anatomy and hemodynamics, her left arm blood pressures were
consistently [**11-18**] points lower than her right due to a
hypoplastic segment. In the setting of worsening anxiety, her
left ventricular pressures rise significantly, which are not
reflected in her blood pressure (especially left arm). For this
reason, a goal blood pressure of left arm around 100 systolic
(110s with exertion) and right arm around 90 systolic would be
optimal.
- Plavix was continued
- Blood pressure management was stressed as noted below.
.
#. Hyperlipidemia: Her home dose of atorvastatin was continued.
.
#. Hypertension: Patient was continued on a betablocker, but was
switched to Toprol XL 100 mg daily due to her renal
insufficiency. Her home dose of amlodipine was continued. Her
HCTZ was increased to daily at a dose of 12.5 mg.
She was initated on losartan which was titrated up to the
maximum dose. Given that her blood pressure was still above
goal, clonidine was recommended, but patient stated she had not
tolerated this medication well in the past. She was therefore
initiated on hydralazine 25 mg every 8 hours, with improvement
in her blood pressures to goal, using measurements from her
right arm.
.
#. Renal insufficiency: Patient was given pre and post cath
hydration fluids, and her creatinine remained at 1.3 to 1.5,
which appears to be within her baseline.
.
#. Dispo: Patient was assessed by physical therapy and felt to
be safe for discharge. She will follow up with Dr. [**First Name (STitle) **] within
a few weeks after discharge.
Medications on Admission:
- Atenolol 100 qdaily
- Lipitor 5mg qdaily
- Plavix 75 mg qdaily
- HCTZ 25mg MWF
- Norvasc 10mg [**Hospital1 **]
- ASA 81mg daily
.
Allergies: keflex (rash), procardia (pre-syncope), morphine
(hallucinations)
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Toprol XL 100 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*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Dyspnea, hypertension
Secondary diagnoses:
- Coarctation of the aorta
- Congential right-sided aorta s/p bypass
- Hyperlipidemia
Discharge Condition:
Stable, ambulating without assistance, without pain.
Discharge Instructions:
You were admitted due to shortness of breath and chest pain, and
transferred here for further evaluation and work-up. You
underwent cardiac catherization and it was found that your
stents were all patent. It was felt that elevated blood pressure
and anxiety were likely a large part of your symptoms.
.
Please contact your primary care physician, [**Name10 (NameIs) 2085**], or go
to the emergency room if you experience any chest pain,
shortness of breath, palpitations, fever, chills, headache,
dizziness, bleeding, leg or groin pain, or other concerning
symptoms.
.
The following changes have been made to your medications:
1. Atenolol 100 mg has been changed to Toprol XL 100 mg.
2. Hydralazine 25 mg three times a day has been added.
3. Losartan 100 mg daily has been added.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] at an appointment made for you
on
[**2165-4-9**] at 2:00 PM. The number for the office is
[**Telephone/Fax (1) 920**].
.
Follow up with your primary care physician as needed.
.
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2165-7-30**]
1:00
|
[
"272.4",
"401.9",
"V45.82",
"593.9",
"414.01",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
11146, 11152
|
6716, 10138
|
347, 371
|
11346, 11401
|
3685, 4772
|
12230, 12562
|
3108, 3227
|
10397, 11123
|
11173, 11173
|
10164, 10374
|
4789, 6693
|
11425, 12207
|
3242, 3666
|
11237, 11325
|
276, 309
|
399, 2456
|
11192, 11216
|
2478, 2970
|
2986, 3092
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,122
| 100,504
|
753
|
Discharge summary
|
report
|
Admission Date: [**2175-1-29**] Discharge Date: [**2175-2-4**]
Date of Birth: [**2089-2-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
shortness of breath and chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 year old man with CAD, chronic systolic CHF EF40%, HTN, HLD,
CKD, peripheral vascular disease, presents with shortness of
breath and chest pain. Pt states that two days ago he developed
some CP pain and sob. He took ntg with resolution of CP, however
the sob got progressively worse. He felt that he had a "lack of
O2", and also that there was "fluid on his lungs". He denies
n/v/diaphoresis but did have some coughing with "pinkish
phlegm". He denies acute onset but states rather that the SOB
progressed over night, worse with exertion and laying flat. He
also notes some increased LE edema. He denies f/c/n/v. He also
notes that 2wks ago he had flu like symptoms and since then has
been feeling generally unwell.
.
In the ED, initial vitals were 97.7 78 136/86 18 100% RA. Labs
significant for trop 2.13, Na 129, Cr 1.9, K 5.7, Hct 32.8, INR
1.1. CXR showed bilateral pulmonary edema. ECG showed NSR at
75bpm, borderline left axis, q waves V1-V3 and III and avF, t
wave inversion avL, no other ST/T changes. He was given 20mg IV
lasix. Most recent vitals prior to transfer:
.
On arrival to the floor, patient was seen with the nurse who
speaks Russian. The patient states that approximately 7-10 days
ago, he started developing shortness of breath and fatigue on
exertion. He states that around the same time, he developed a
cold that involved sinus congestion and a cough and a cold sore
on his lip. The patient states that his shortness of breath got
progressively worse as the days passed. He states that he has
also gained approx 9 pounds and now weighs 209 pounds, since
these symptoms began. He also states that approx 3 days ago, he
developed chest pain. He states that the pain did not radiate
anymore. He states that the pain resolved after 2-3 hours when
he took 2 sublingual nitroglycerin tabs. He denies any nausea,
vomiting, GI upset, changes in stools, or any other symptoms
with the chest pain. The patient states that he was seen as an
outpatient approx 10 days ago and had an EKG and an ECHO done.
THe patient now presented with concerns with his worsening
shortness of breath.
.
On the floor, he was initially treated with heparin drip for
NSTEMI, but then dced. He was started on a lasix drip for CHF.
Down 1.5L at 5pm, pressures tending down from SBP 160s/90s to
100s/40s, then 70s-80s/30s-40s. Flipped into Afib with RVR
today at 11pm. PMH of Afib on one occasion following epistaxis
in [**2173**]. He got 2.5 Metoprolol, BP trended down, now high
60s/70s. Got 500cc bolus, considering amiodarone, but decided
to transfer to CCU for further management.
.
Currently, he is alert and orientated x 3, denies any chest
pain, headache, dizziness, palpitations, dyspnea. BP improved
to high 80s/60, remains tachycardic around 120s. He was given 5
mg IV metoprolol, but remained tachycardic, and dropped BP to
70s systolic, MAP around 55.
Past Medical History:
Percutaneous coronary intervention, in [**2167**] with stent of distal
LCx
PERIPHERAL VASCULAR DISEASE with CLAUDICATION
CORONARY ARTERY DISEASE with ANGINA
HYPERTENSION
HYPERCHOLESTEROLEMIA
ABDOMINAL AORTIC ANEURYSM
GERD
MONOCLONAL GAMMOPATHY
GOUT
MEMORY LOSS
HEARING LOSS
PSORIASIS
H/O RETINAL ARTERY OCCLUSION
H/O PYELONEPHRITIS
Social History:
The patient emigrated to the United States from [**Country 532**]. The
patient is retired, used to be on an Armenian submarine in
[**Country 532**]. The patient quit smoking in [**2137**] after 20 pack year
history, has an average of one drink a week, no history of
recreational drug use.
Family History:
The patient states his father had heart problems but lived until
84 years of age. No other known medical history.
Physical Exam:
ON ADMISSION
VS: T= 97.7 BP= 145/98 HR= 75 RR= 22 O2 sat= 97 RA
GENERAL: some dyspnea. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Nasal Cannula in place. Sclera anicteric. PERRL,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. holosystolic murmur. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. some
dyspnea. bilateral crackles in bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. no masses. no rebound
tenderness or guarding
EXTREMITIES: 1+ pitting edema in lower extremities bilaterally,
warm and well perfused
Rectum - stools are guaiac negative.
.
PT [**Name (NI) 5485**].
Pertinent Results:
CBC:
[**2175-1-29**] 01:50PM BLOOD WBC-6.8 RBC-3.28* Hgb-10.8* Hct-32.4*
MCV-99* MCH-33.0* MCHC-33.5 RDW-15.2 Plt Ct-190
[**2175-2-4**] 03:15AM BLOOD WBC-12.6*# RBC-2.64* Hgb-9.2* Hct-26.4*
MCV-100* MCH-34.8* MCHC-34.9 RDW-16.2* Plt Ct-262
DIFF:
[**2175-1-29**] 01:50PM BLOOD Neuts-84.2* Lymphs-10.7* Monos-4.0
Eos-0.6 Baso-0.4
COAGS
[**2175-2-4**] 03:15AM BLOOD PT-12.1 PTT-134.6* INR(PT)-1.1
ELECTROLYTES:
[**2175-1-29**] 01:50PM BLOOD Glucose-155* UreaN-53* Creat-1.9* Na-129*
K-5.7* Cl-96 HCO3-19* AnGap-20
[**2175-1-30**] 07:50PM BLOOD Glucose-129* UreaN-73* Creat-2.4* Na-130*
K-4.7 Cl-95* HCO3-21* AnGap-19
[**2175-2-2**] 03:49AM BLOOD Glucose-213* UreaN-71* Creat-1.9* Na-131*
K-3.8 Cl-94* HCO3-21* AnGap-20
[**2175-2-4**] 03:15AM BLOOD Glucose-95 UreaN-111* Creat-2.2* Na-136
K-4.4 Cl-97 HCO3-24 AnGap 19
LFTS:
[**2175-1-31**] 07:50AM BLOOD ALT-125* AST-87* CK(CPK)-226 AlkPhos-141*
TotBili-1.1
CEs:
[**2175-1-29**] 01:50PM BLOOD CK-MB-8 proBNP-[**Numeric Identifier 5486**]*
[**2175-1-29**] 01:50PM BLOOD cTropnT-2.13*
[**2175-1-29**] 05:30PM BLOOD CK-MB-9 cTropnT-2.41*
[**2175-1-30**] 01:49AM BLOOD CK-MB-10 MB Indx-5.8 cTropnT-2.77*
[**2175-1-30**] 03:00AM BLOOD CK-MB-9 cTropnT-2.55*
[**2175-1-31**] 05:00PM BLOOD CK-MB-36* MB Indx-13.2* cTropnT-2.68*
[**2175-2-4**] 03:15AM BLOOD CK-MB-5 cTropnT-2.67*
OTHER:
[**2175-2-1**] 10:28AM BLOOD Lactate-1.2
[**2175-2-4**] 12:18PM BLOOD Lactate-8.5*
[**2175-2-4**] 12:18PM BLOOD Type-CENTRAL VE pO2-39* pCO2-28* pH-7.30*
calTCO2-14* Base XS--11
.
URINE:
[**2175-1-29**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2175-1-29**] 06:33PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE CULTURE (Final [**2175-1-30**]): NO GROWTH.
URINE CULTURE (Final [**2175-1-31**]): NO GROWTH.
blood cultures no growth to date on day of death.
.
IMAGING:
CXR [**2175-1-29**]
FINDINGS: Frontal and lateral views of the chest were obtained.
Low lung
volumes limit evaluation. There are bilateral pulmonary
opacities which are most confluent in the lung bases. Central
pulmonary hilar engorgement with interstitial and alveolar edema
is present. Bilateral pleural effusions are small to moderate.
No pneumothorax. Heart size appears enlarged though poorly
assessed. Mediastinal contour is stable with atherosclerotic
calcification along the aortic knob. Bony structures are intact.
IMPRESSION: Findings compatible with pulmonary edema/heart
failure.
Small-to-moderate bilateral pleural effusions also present.
.
CXR: [**2175-2-2**]
FINDINGS: As compared to the previous radiograph, there is a
decrease in
extent of the bilateral pleural effusions. Sequence decrease in
severity of the basal areas of atelectasis. Unchanged moderate
cardiomegaly, currently without evidence of pulmonary edema.
.
KUB [**2175-2-4**]
ABDOMEN, SUPINE
The distribution of gas in the abdomen is unremarkable. No
edematous areas of bowel are seen. There is no evidence of
obstruction or infarction. Vascular calcification is noted.
.
EKG on admission [**2175-1-29**]: Rate 133, atrial fibrillation with
RVR, occasional PVCs, normal/borderline left axis deviation., LV
hyprtrophy. normal rhythm, normal/borderline left axis, Q waves
in III, V2-V4. ST segments depressed in I, AVL, V6 but unchaged
from prior EKG.
.
ECHO [**2175-1-2**]: The left atrium is mildly dilated. The right
atrium is moderately dilated. The left ventricular cavity is
moderately dilated. There is mild to moderate regional left
ventricular systolic dysfunction with inferolateral akinesis,
inferior akinesis/hypokinesis and apical hypokinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are moderately thickened. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
On color Doppler imaging, there is an interatrial shunt
consistent with stretched PFO or an atrial septal defect.
(Images of the interatrial septum were suboptimal in the prior
study).
Compared with the prior study (images reviewed) of [**2174-7-4**],
the mid anterolateral wall now appears more hypokinetic and the
anterior apex is now hypokinetic (may have been foreshortened in
the prior study). The aortic valve gradient is similar.
Estimated pulmonary artery systolic pressure is now higher.
.
CARDIAC CATH: [**4-/2173**]:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated severe three vessel disease. The LMCA had mild
disease. The LAD had a 90% occlusion before S1 with filling of a
small, diffusely diseased distal vessel via septal collaterals
that was unchanged from [**2169**]. The LCx had four widely patent
stents with no significant disease in the large major marginal.
The very small marginals before the major marginal and AV Cx
were occluded which was also unchanged from [**2169**]. The RCA was
known occluded and was not injected; the distal vessel fills via
septal collaterals.
2. Limited resting hemodynamics revealed moderate systemic
hypertension with SBP of 162 mm Hg and DBP of 76 mm Hg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with patent LCx stents,
unchanged from [**2169**].
2. NSTEMI related to collateral insufficiency during rapid
atrial
fibrillation.
.
ECHO [**2175-1-31**]
The left atrium is moderately dilated. Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect, but this could not be confirmed on the basis of this
study. The estimated right atrial pressure is at least 15 mmHg.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe regional left
ventricular systolic dysfunction with inferior akinesis,
inferolateral akinesis/hypokinesis, anteroseptal
hypokinesis/akinesis and apical akinesis. No left ventricular
thrombus identified but cannot exclude. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] There is no ventricular
septal defect. The remaining left ventricular segments contract
normally. Right ventricular chamber size is normal with moderate
global free wall hypokinesis. The aortic valve leaflets are
severely thickened/deformed. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
to severe (3+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2175-1-2**],
left ventricular systolic function is now worse. Right
ventricular systolic function is now worse. Tricuspid
regurgitation is now more prominent.
Brief Hospital Course:
85 year old gentleman with extensive cardiac history including
BMS, CAD, CHF (EF40%), moderate AS 1.0-1.2, 3+ MR, CKD, HTN, HL,
presents with 7-10 days of worsening SOB, edema in legs b/l,
increased weight. These symptoms began with a URI at the same
time. Had one episode of chest pain that resolved with sl nitro.
Pt found to be in Afib with RVR.
.
# Chronic congestive heart failure with acute exacerbation:
patient had increasing weight and pitting edema in lower
extremities and increased shortness of breath prior to
admission. These symptoms began with "URI symptoms" and one
episode of chest pain that was likely a cardiac event. The
patient takes 10 mg lasix daily at home. Was diuresed 2L on
admission to floor but given back almost 1L in response to
hypotension after developing afib/RVR. Lasix was held at that
time. ECHO [**2175-1-31**] revealed severe AS valve area 1.0-1.2cm2 with
3+ mitral and tricuspid regurg and EF of 20%.
.
# abdominal distension and pain with elevated lactate - unclear
etiology however on [**2175-2-4**] pt developed abdominal pain and
distension which progressively worsened, KUB without evidence of
obvious pathology. Suspicion for volvulus or some other
intra-abdominal process causing ischemia. Pt developed worsening
hypotension. Pt had been otherwise improving from a
cardiovascular standpoint. Pt declined any surgical intervention
and was made CMO. Pt [**Date Range **] on [**2175-2-4**].
.
# Atrial Fibrillation with RVR: Pt was initially admitted to
[**Hospital1 **]. On day of admission he flipped into AFib around 11pm, with
decreased BP to 70s systolic. Was given 2.5 mg metoprolol with
no improvement in HR, worsening BP. Patient has history of
paroxysmal A-fib. Was given 5mg metoprolol with BP drop to MAP
of 50 and minimal improvement in rate. Amiodarone was started
for rate/rhythm control. Cardioversion was attempted x3 200,
300, 300 - unsuccessful. Pt received ketamine and versed during
cardivoersion ettempt with further hypotension after shocks see
hypotension below. The afternoon after cardioversion on [**2175-1-31**]
pt spontaneously converted to sinus rhythm. He went back into
afib on [**2175-2-1**] until he received IV metoprolol for an episode
of ventricular tachycardia, see below, at which point he
converted back to sinus with frequent ectopy. Infectious
processes were ruled out as pt had no growth on blood and urine
cultures and without evidence of localized infiltrate on CXR.
.
#ventricular tachycardia - on [**2175-2-2**] pt was in Afib but had
roughly 3 minutes of ventricular tachycardia - this was
asymptomatic and pt remained stable with slight decrease in
blood pressure, maintained on pressors see hypotension below. Pt
had no further episodes of sustained VT.
.
# Hypotension: In the setting of 2L diuresis on admission and
recurrence of afib with RVR. Lowest MAPs were in the 50s
immediately after metoprolol, but MAP generally around 60. Held
home antihypertensives (isosorbide, metoprolol, lisinopril,
lasix). Cardioversion was attempted, unsucessful as above but
followed by further hypotension Maps in the 50s. Pt was started
on neosynephrine for MAPs consistently below 55. PICC was placed
on [**2175-2-1**].
.
# Acute on Chronic Renal Failure: baseline creatinine is
1.3-1.5. He presented with creatinine of 1.9, creatinine trended
up to peak at 2.4. Likely pre-renal given severe AS and severe
MR. Pt then required pressors for 48 hours which was felt to be
responsible as well. Pt was diuresed successfully and creatinine
remained stable at roughly 2.0
.
# Elevated troponins - likely MI. patient had one episode of
chest pain that resolved with 2 SL nitroglycerin tabs. Patient
has extensive cardiac history. Was found to have elevated
cardiac enzymes in ED. Patient denies any other symptoms with
chest pain including acute SOB, sweating, nausea, vomiting.
Patient's EKG shows some changes since a year ago, but mainly q
waves. The heart axis is more leftward than a year ago. It was
suspected that pt had experienced an MI which explained the
troponin bump and symptoms.
.
# Hypertension: history of hypertension. Held home
antihypertensives in the setting of hypotension. Is on
lisinopril, isosorbide, lasix at home.
.
# Hypercholesterolemia: started atorvastatin 80 (on simva 80 at
home).
.
# oliguria - felt to be secondary to poor perfusion of kidneys
in setting of hypotension requiring pressors, see [**Last Name (un) **] above.
Resolved with successful diuresis in response to lasix.
.
#Hyperkalemia - K of 5.7 on presentation, felt secondary to [**Last Name (un) **].
Resolved, pt asymptomatic. No ECG changes of hyperkalemia.
.
#hyponatremia: presented with Na of 129. Sodium remained in the
low 130s for several days but improved with optimization of
volume status, see CHF above.
Medications on Admission:
ALLOPURINOL - 300 mg daily
CLOPIDOGREL [PLAVIX] - 75 mg daily
DUTASTERIDE [AVODART] - 0.5 mg qHS
FUROSEMIDE - 10 mg QDAILY
ISOSORBIDE MONONITRATE - 60 mg daily
LISINOPRIL - 10 mg daily
METOPROLOL SUCCINATE [TOPROL XL] - 200 mg daily
SIMVASTATIN - 80 mg daily
ASCORBIC ACID [VITAMIN C] - 500 mg daily
ASPIRIN - 81 mg daily
DOCUSATE CALCIUM - 240 mg daily
FERROUS SULFATE - 325 mg daily
Discharge Medications:
n/a
Discharge Disposition:
[**Last Name (un) **]
Discharge Diagnosis:
congestive heart failure
Discharge Condition:
[**Last Name (un) **]
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
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icd9cm
|
[
[
[]
]
] |
[
"99.61",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
338, 344
|
17352, 17375
|
4821, 10204
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10221, 11978
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17399, 17404
|
4048, 4802
|
264, 300
|
372, 3240
|
3262, 3595
|
3611, 3902
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,797
| 163,801
|
46614
|
Discharge summary
|
report
|
Admission Date: [**2171-7-18**] Discharge Date: [**2171-7-24**]
Date of Birth: [**2101-9-5**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Pneumovax 23
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 1305**] is a 69 year old gravida 3, para 3 female with Stage
IIIC optimally debulked primary peritoneal serous cancer with
further disease progression since, presenting with left upper
quadrant abdominal pain that started the night prior to
admission. The pain is consant and accompanied by nausea.
Multiple episodes of small-volume emesis today. Last bowel
movement yesterday. No flatus or bowel movement since. She was
seen for her regularly scheduled medical oncology appointment
today by Dr. [**Last Name (STitle) **] and a stat CT abdomen/pelvis was
ordered showing a bowel obstruction with transition point in
LUQ. Given zofran, ativan, and morphine in clinic with little
relief of symptoms.
Of note, Ms. [**Known lastname 1305**] [**Last Name (Titles) 1834**] a exploratory laparotomy/lysis of
adhesions/ radical hysterectomy/rectosigmoid resection with
reanastamosis/ cystotomy repair/ Low anterior resection/
omentectomy in [**2168-11-28**] and was considered optimally
debulked at that point. She initially [**Year (4 digits) 1834**] 6 cycles of
carboplatin and taxol followed by repeated chemotherapy
treatments including carboplatin/doxil, avastin, and gemcitabine
until [**2170-11-28**]. She was found to have disease progression
by CT and CA-125 in [**Month (only) 547**] of this year. She is currently
enrolled in a clinical trial for ciplatin vs. olaparib in
advanced solid tumors.
Past Medical History:
Past Medical History: Stage IIIc primary peritoneal serous
cancer, DCIS of L breast,BRCA1, Stage 1A SCC of lung, Asthma,
Hypertension
Past Surgical History: Left mastectomy with latissimus
reconstruction ([**2152**],[**2153**]); Prophylactic bilateral salpingo
oopherectomy ([**2160**]); Optimal debulking- exploratory
laparotomy/lysis of adhesions/ radical hysterectomy/rectosigmoid
resection with reanastamosis/ cystotomy repair/ Low anterior
resection/ omentectomy ([**2167**])
Ob-Gyn History: Spontaneous vaginal delivery x 3, uncomplicated.
No abnormal PAPs prior to procedure.
Social History:
She does not smoke or drink. She is a former smoker of 30 pack
years. She is an artist.
Family History:
Mother- ovarian cancer
Physical Exam:
Admission Physical Exam:
T: 99 HR: 85 RR: 18 BP: 110/86 O2sat: 95%RA
General: No acute distress, alert, awake, oriented x 3
HEENT: Healing oral mucosa lesion
Chest: Clear to auscultation bilaterally
Heart: Regular rate and rhythm
Abdomen: soft, mildly distended, tenderness to palpation in
upper quadrants and periumbilically, hypoactive bowel sounds. No
rebound/ guarding.
Discharge Physical Exam:
Vital signs stable
General: No acute distress, alert, awake, oriented x 3
Chest: Fine crackles at right base, otherwise clear to
auscultation
Heart: Regular rate and rhythm
Abdomen: soft, non distended, no tenderness to palpation, +
bowel sounds. No rebound/ guarding.
Extremities: non tender, non edematous
Pertinent Results:
IMAGING:
CT Abdomen/pelvis with contrast ([**7-18**]):
FINDINGS:
CHEST: The base of the heart is unremarkable without pericardial
effusion.
The lung bases have minimal bilateral atelectasis. There are no
pleural
effusions, focal consolidation, or nodules.
ABDOMEN: The liver, gallbladder, pancreas, and spleen are
unremarkable. There are no intra- or extra-hepatic biliary duct
dilation. The portal venous system is patent. The bilateral
adrenals are unremarkable. The bilateral kidneys are
unremarkable and enhance and excrete contrast appropriately. The
stomach is distended. The small bowel is also distended from the
proximal duodenum through to a transition point best seen in
image 2, 43. There were no masses seen adjacent to the
transition point. Distal to this transition point is completely
collapsed small bowel. This is consistent with an early complete
small bowel obstruction. There is fecalization of the small
bowel contents directly proximal to the obstruction. There is no
free air or ascites in the abdomen. The large bowel is
unremarkable and noted to have stool from the rectum to the
cecum. This could mean that the obstruction is either early or
partial, but given the severity of the distal small bowel
collapse, it likely is an early complete obstruction. There is
minimal stranding in the mesentery. There are small periaortic
lymph nodes, none of which meet criteria for pathological
enlargement. There are multiple surgical clips in the abdomen.
The patient appears to be status post omentectomy. The
urinary bladder is not distended, but unremarkable. There is no
free fluid in the pelvis. There is no pelvic or inguinal
lymphadenopathy. The patient is s/p total abdominal
hysterectomy.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
bony lesions.
SOFT TISSUES: The patient is status post left mastectomy with
breast implant. There are no soft tissue nodules or hernias.
IMPRESSION:
1. Early complete small bowel obstruction with transition point
in the left upper quadrant. Of note, the colon is not yet
collapsed and has stool
throughout, which indicates early obstruction.
Portable abdominal radiograph ([**7-19**]): FINDINGS: Portable supine
and upright views of the abdomen are provided. There is a
paucity of small bowel gas consistent with the finding of a
small-bowel obstruction. There is no free air or pneumotosis
identified in this film.
CONCLUSION: No signs of free air. Bowel gas pattern consistent
with
small-bowel obstruction.
Portable chest radiograph ([**7-19**]): The lungs are low in volume
and show bilateral lower lobe opacities. The cardiac silhouette
is enlarged. The mediastinal silhouette and hilar contours are
normal. No pleural effusions or pneumothorax. A left-sided
subclavian line terminates with its tip in the cavoatrial
junction. An NG tube passes out of view below the diaphragm.
IMPRESSION: Bibasilar opacities could represent sequelae of
aspiration or atelectasis
CT Chest/Abdomen ([**7-19**]): CT OF THE CHEST WITH AND WITHOUT
CONTRAST: The imaged portion of the thyroid gland is normal in
appearance. There is no axillary, hilar, mediastinal or
supraclavicular pathologic lymphadenopathy with scattered
nonenlarged nodes seen. Heart and pericardium are unremarkable
without pericardial effusion. The aorta and major branches are
patent with normal three-vessel arch. Central venous catheter
is seen terminating in the superior cavoatrial junction with no
acute aortic pathology identified. No pulmonary embolism is
seen. Trace right pleural effusion with resultant atelectasis is
seen. Hypoenhancing consolidative process is seen in the left
base concerning for aspiration. The remainder of the lungs are
clear. Nasogastric tube is seen coursing through the esophagus
and terminating in the stomach.
CT OF THE ABDOMEN WITH CONTRAST: The liver is normal in
appearance without
focal lesion or intra- or extra-hepatic biliary ductal
dilatation. Portal and hepatic veins appear patent. Gallbladder,
pancreas, spleen, and bilateral adrenal glands are unremarkable.
The kidneys enhance and excrete contrast symmetrically without
hydronephrosis or focal lesion.
Stomach is not as distended as on the prior study after
decompression with
nasogastric tube. Proximal small bowel loops are dilated,
slightly less so
than on the prior study with likely transition point within the
left upper
quadrant and decompressed distal loops compatible with
small-bowel
obstruction. Compared to the prior study, there is some passage
of oral
contrast administered at that time one day prior with contrast
seen within
loops of distal ileum as well as in large bowel. There is a
decrease degree of intraperitoneal fluid since the prior study.
No free air is seen. No mesenteric or retroperitoneal pathologic
lymphadenopathy is identified with scattered nonenlarged likely
are reactive in nature. Atherosclerotic calcification of the
aorta is seen with patent appearing vessels. A small fat
containing ventral hernia is again seen. Post surgical
appearance from bowel resections and likely omentectomy noted.
CT OF THE PELVIS WITH CONTRAST: Foley catheter is seen in the
bladder with a large amount of air, likely related to Foley
catheter replacement. Patient is status post hysterectomy. The
rectum is unremarkable. No free pelvic fluid is seen. There is
no pelvic or inguinal pathologic lymphadenopathy.
OSSEOUS STRUCTURES: No lytic or sclerotic bony lesions seen
concerning for
osseous malignant process. Patient is status post left
mastectomy with breast implant.
IMPRESSION:
1. No pulmonary embolism.
2. Left base opacification is new and concerning for aspiration
or pneumonia.
Trace right effusion is seen.
3. Small-bowel obstruction with decompressed distal loops and
transition
point in the left mid abdomen as before with slight apparent
interval
improvement with a small amount of contrast passing into the
distal ileum and large bowel.
Portable Chest Radiograph ([**7-20**]):
Left Port-A-Cath catheter tip is at the level of cavoatrial
junction. The NG tube tip is in the stomach. Heart size is
normal. Mediastinum is normal. Bibasilar opacities are noted
associated with small amount of bilateral pleural effusion.
There is no evidence of pneumothorax.
The increased opacity in the left lower lobe might represent
aspiration
process and should be closely monitored.
MICROBIOLOGY:
Urine culture ([**7-19**]): no growth
Blood cultures ([**7-19**]): no growth x 2
PERTINENT LABS:
On admission:
[**2171-7-18**] 09:15AM WBC-9.8 RBC-3.62* HGB-10.9* HCT-32.5* MCV-90
MCH-30.1 MCHC-33.5 RDW-17.7*
[**2171-7-18**] 09:15AM NEUTS-74.6* LYMPHS-19.0 MONOS-5.9 EOS-0.1
BASOS-0.4
[**2171-7-18**] 09:15AM PLT COUNT-234
[**2171-7-18**] 09:15AM PT-11.8 PTT-18.6* INR(PT)-1.0
[**2171-7-18**] 09:15AM LIPASE-19 GGT-38*
[**2171-7-18**] 09:15AM TOT PROT-6.3* ALBUMIN-4.5 GLOBULIN-1.8*
CALCIUM-9.7 MAGNESIUM-1.9
[**2171-7-18**] 09:15AM CA125-460*
[**2171-7-18**] 09:15AM LD(LDH)-242 AMYLASE-59
[**2171-7-18**] 09:15AM UREA N-22* CREAT-0.7 SODIUM-140 POTASSIUM-3.8
CHLORIDE-98
[**2171-7-18**] 09:15AM GLUCOSE-153*
HD#2 ([**Hospital Unit Name 153**] transfer)
Glucose 241
Urea Nitrogen 22
Creatinine 0.8
Sodium 136
Potassium 3.0
Chloride 100
Bicarbonate 28
Anion Gap 11
Creatine Kinase (CK) 27 Creatine Kinase, MB Isoenzyme 2
Troponin T <0.01
Calcium, Total 8.1
Phosphate 1.8
Magnesium 1.2
White Blood Cells 1.3
Red Blood Cells 2.68
Hemoglobin 8.0
Hematocrit 23.1
MCV 86
MCH 29.9
MCHC 34.6
RDW 18.1
DIFFERENTIAL
Neutrophils 59
Bands 12
Lymphocytes 27
Monocytes 2
Eosinophils 0
Basophils 0
Atypical Lymphocytes 0
Metamyelocytes 0
Myelocytes 0
Day of discharge:
White Blood Cells 4.7
Red Blood Cells 3.63
Hemoglobin 11.1
Hematocrit 31.2
MCV 86
MCH 30.5
MCHC 35.4
RDW 15.8
Platelet Count 215
Urea Nitrogen 9
Creatinine 0.5
Sodium 141
Potassium 2.9
Chloride 100
Bicarbonate 28
Anion Gap 16
Calcium, Total 8.5
Phosphate 2.7
Magnesium 1.7
Brief Hospital Course:
Ms. [**Known lastname 1305**] was admitted to the Gyn-Oncology service for further
management of a small bowel obstruction. Her hospital course is
as follows:
*Small Bowel Obstruction: Given that Ms. [**Known lastname 1305**] was initially
hemodynamically stable with a soft abdomen, surgical management
was deferred. A nasogastric tube was placed for conservative
management of her symptoms. She was made NPO and received
intravenous fluids, scheduled anti-emetics, and IV Dilaudid &
Ativan prn. On hospital day #2, Ms. [**Known lastname 1305**] developed acute onset
tachycardia, desaturation to 86%, temperature of 102, and
altered mental status. She was subsequently transferred to the
Surgical Intensive Care Unit for 3 days where a thorough work-up
was negative for bowel perforation, pulmonary embolism, and
sepsis. A chest radiograph and CT chest were consistent with
what was likely an aspiration pneumonia and/or atelectasis. Ms.
[**Known lastname 1305**] was started on levofloxacin and metronidazole in order to
broadly cover possible intrabdominal process and/or aspiration
pneumonia. All blood and urine culture data was negative. She
was transferred back to the floor in stable condition on
hospital day #4 (afebrile, normal heart rate, stable on room
air, intact mental status). Upon transfer to the floor, she was
noted to have minimal nasogastric output and improved nausea
with evidence of good bowel function. Her nasogastric tube was
subsequently clamped and discontinued. She was advanced to a
regular diet slowly which she tolerated well with improved bowel
function.
*) Cardiovascular : Ms. [**Known lastname **] home Lisinopril was initially
held while NPO and restarted on day of discharge. She was given
IV hydralazine as needed for blood pressure spikes. An EKG
performed during the acute episode on hospital day #2 showed
non-specific ST changes which was likely secondary to her
tachycardia at that point. Cardiac enzymes were negative.
.
*) Pulmonary : Following the desaturation on room air as noted
above, Ms. [**Known lastname 1305**] was initially placed on 2L nasal canula and was
easily weaned to room air prior to transfer back to the floor.
As outlined above, a CTA was negative for pulmonary embolism.
Findings on this CT and a chest radiograph were suspicious for a
possible aspiration pneumonia.
.
*) Renal: A foley catheter was placed during her SICU stay, with
adequate urine output throughout her stay. Patient's creatinine
was stable throughout stay.
.
*) Hematology: During the acute episode on hospital day #2, Ms.
[**Known lastname 1305**] was noted to have a hematocrit drop from 29.9 to 23.1 She
was given 2 units of packed red blood cells in the SICU, with a
subsequent improvement in hematocrit to 32. On day of discharge
her hematocrit and vital signs were stable.
.
*) Endocrine: Prior to admission, Ms. [**Known lastname 1305**] was taking 15 mg
prednisone daily as prescribed by her oncologist for oral
mucosal lesions. As she was steroid dependent on admission and
given her acute medical status, she was initially given 2 doses
of stress steroids intravenously ( IV dexamethasone 10' [**7-18**] ->
[**7-19**] IV hydrocortisone 100). She was then placed on IV
hydrocortisone 20 every 8 hours (equivalent to home prednisone
dose) for maintenance. She had no adrenal symptoms while
inpatient. She was transitioned to PO Prednisone 10mg when she
started tolerating a regular diet.
*) Hypokalemia, hypomagnesemia: Despite daily repletion (both
intravenously and orally) Ms. [**Known lastname 1305**] was peristently hypokalemic
and hypomagnesemic. Per oncology, this was likely related to her
cisplatin treatment. She will follow up with her oncologist to
obtain labs to recheck her electrolytes on [**Last Name (LF) 766**], [**7-29**]. She
was discharged home with a prescription for PO potassium.
*) Oncology: Per Ms. [**Known lastname **] primary medical oncology team, she
is still eligible for the current clinical trial she is enrolled
in for cisplatin vs. olaparib in advanced solid tumors. She will
follow up with Dr. [**Last Name (STitle) 98986**] after discharge.
.
*) Prophylaxis: Ms. [**Known lastname 1305**] was given subcutaneous heparin and
pneumatic boots.
Ms. [**Known lastname 1305**] was discharged home on hospital day #5 in stable
condition- afebrile, stable vital signs, tolerating a regular
diet with evidence of good bowel function, ambulating and
voiding without difficulty.
Medications on Admission:
albuterol prn, senna, colace, oxycodone, Prilosec, lisinopril
5', ativan 0.5 prn, nystatin, prednisone 15'
Discharge Medications:
1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral discomfort.
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*4 Tablet(s)* Refills:*0*
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
6. potassium chloride 20 % Liquid Sig: Fifteen (15) mL PO once a
day: Please adjust according to potassium level check on [**7-29**], [**2170**].
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction, Possible aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 1305**], you were admitted for management of a small bowel
obstruction which has now resolved.
Discharge Instructions:
Please call your doctor for:
* fever > 100.4
* severe abdominal pain
* shortness of breath
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
General instructions:
* Take your medications as prescribed.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* You may eat a regular diet.
* The only new prescriptions we are sending you home with is for
Levofloxacin (antibiotic), pantoprazole, bisacodyl suppositories
and potassium. You may resume the rest of your home medications.
* Please get your labs drawn on [**Last Name (LF) 766**], [**7-29**] so that your
electrolyte levels can be followed up.
Followup Instructions:
[**2171-8-1**] 09:00a [**Last Name (LF) **],[**First Name3 (LF) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
Completed by:[**2171-7-25**]
|
[
"V10.11",
"112.0",
"507.0",
"560.9",
"493.90",
"275.2",
"276.8",
"V70.7",
"158.9",
"401.9",
"E933.1",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16469, 16475
|
11227, 15691
|
318, 325
|
16574, 16574
|
3282, 9729
|
17599, 17912
|
2510, 2534
|
15849, 16446
|
16496, 16553
|
15717, 15826
|
16867, 17576
|
1955, 2386
|
2574, 2928
|
246, 280
|
353, 1776
|
9759, 11204
|
16589, 16701
|
9745, 9745
|
1820, 1932
|
2402, 2494
|
2953, 3263
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,956
| 154,518
|
7184
|
Discharge summary
|
report
|
Admission Date: [**2167-4-28**] Discharge Date: [**2167-5-3**]
Date of Birth: [**2117-10-9**] Sex: F
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
Mrs [**Known lastname **] is a 49F with hx DM, Hep C, pacer, ESRD s/p 2 live
donor transplant (last in [**2164**]) who presented to the ED today
with 3d of n/v/d, abd pain subjective f/c. She has not been
taking any of her meds for the last 2 days including her
insulin, per her husband. [**Name (NI) **] reports she babysits for children
who were sick and she assumed she had a viral illness or the flu
for the last few days. She had progressive malaise and weakness
and had difficult getting OOB this AM. He also reports she has
had decreased PO intake and increasking confusion. She does not
report any recent urinary symptoms however she does straight
cath at home.
.
In the ED, initial vs were: 98.6 98 134/66 16 99%. Labs were
notable for anion gap of 20, creatinine 1.5, glucose was 479,
white count 23.4, HCT 33.2. UA notable for + leuks, nitrites,
and moderate bacteria, + ketones. Lactate 2.8. Patient was given
4L IVF, tylenol, zosyn, vancomycin, insulin drip at 8 u/hr on
transfer. Renal US and CT were performed and concerning for air
in the renal pelvis and ureter. CXR was concerning only for mild
fluid overload. Transfer vitals 100.9, 134/53, HR 118, RR 24,
91% on RA.
.
On arrival to the ICU, pt is incooperative with exam and
questioning. Continues to c/o abd pain.
.
Review of systems:
Unable to complete due to pt non-compliance.
Past Medical History:
-Diabetes type 1 with neuropathy nephropathy
-end-stage renal disease status post MI
-status post living-related renal transplant in [**2145**], repeat
living related transplant on [**2164-11-6**] from her brother
-hep C with mildly elevated liver function tests.Biopsy shows
grade I disease.
-Recurrent UTIs in the past, neurogenic bladder with
self catheterization QID
-hypertension.
- [**Hospital1 **]-v pacer implantation for paroxysmal AV block [**2165-10-21**]
-Left 2nd toe amputation [**2166-10-2**]
-LT PT, peroneal PTA [**2166-3-28**]
-RT 1st toe, hallux amputation [**1-8**]
-PTA/stent of LT PT, LT AT PTA [**8-8**]
-RT peroneal, RT tibial PTA [**7-9**]
Social History:
Lives w/ her husband and son; never smoked; does not drink
alcohol or use illicit drugs. Previously worked in commercial
banking, but does not currently work. Is supposed to be off of
her feet in wheelchair but reports she does walk around the
house. Husband works full time but is able to return home
frequently to her pt.
Family History:
non-contributory
Physical Exam:
Admission Exam:
Vitals: T:101.5 BP:123/58 P:102 R: 10 O2: 98%
General: Uncooperative, answers yes and no, but otherwise not
answering orientation questions
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at 9 cm, 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
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moves all extremities freely, PERRLA, not answering
orientation questions
Pertinent Results:
I. Microbiology
[**2167-5-3**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2167-5-2**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2167-5-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2167-5-1**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2167-4-30**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2167-4-29**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2167-4-29**] BLOOD CULTURE Blood Culture,
Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram
Stain-FINAL INPATIENT
[**2167-4-29**] 12:19 pm BLOOD CULTURE Source: Line-CVL.
**FINAL REPORT [**2167-5-5**]**
Blood Culture, Routine (Final [**2167-5-5**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2167-4-30**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 8:58AM
[**2167-4-30**].
[**2167-4-29**] URINE URINE CULTURE-FINAL INPATIENT
[**2167-4-28**] URINE URINE CULTURE-FINAL {ESCHERICHIA
COLI} INPATIENT
[**2167-4-28**] 10:55 pm URINE Source: Catheter.
**FINAL REPORT [**2167-5-1**]**
URINE CULTURE (Final [**2167-5-1**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2167-4-28**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
[**2167-4-28**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
II. Studies
[**2167-4-28**] EKG: Sinus rhythm with atrial sensed and ventricular
paced rhythm with capture.Compared to the previous tracing of
[**2167-4-21**] the atrial rate is increased andthere is now evidence of
ventricular pacing. Clinical correlation issuggested.
[**2167-4-28**] RENAL TRANSPLANT ULTRASOUND: Normal-appearing left lower
quadrant renal transplant without hydronephrosis or perinephric
fluid. Stable normal resistive indices.
[**2167-4-28**] CHEST PA/LAT: Interstitial markings may be mostly due to
crowding due to markedly low lung volumes, however, mild volume
overload cannot be entirely excluded on the basis of this
examination.
[**2167-4-29**] CT ABDOMEN/PELVIS NON-CON: 1. Status post bilateral
nephrectomy with two renal grafts in the pelvis, one atrophic on
the right and the other a normal sized graft on the left. Tiny
foci of gas in the pelvicaliceal system in both renal grafts may
have been introduced via bladder catheterization. Although,
emphysematous pyelitis cannot be excluded. Clinical correlation
is recommended. Assessment for pyelonephritis is limited without
the administration of IV contrast.
2. Extensive atherosclerotic disease.
[**2167-4-30**] TTE/BUBBLE STUDY: The left atrium is normal in size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. There is abnormal septal motion/position. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad. IMPRESSION: Normal global and
regional biventricular systolic function. Negative bubble study.
Abnormal septal motion most likely due to conduction
abnormality.
[**2167-4-30**] Chest port line placement
HISTORY: 49 year old female with new left PICC.
COMPARISON: Chest radiograph from [**2167-4-29**]
PORTABLE AP CHEST RADIOGRAPH:
The new left PICC crosses the midline and then curves upwards.
The location
of the tip may be within the proximal SVC or azygos vein. Dual
chamber
pacemaker leads are intact and overlie the right atrium and
right ventricle.
There is no pneumothorax. Cardiomediastinal and hilar contours
are normal.
There is mild vascular engorgement and stable mild cardiomegaly.
IMPRESSION:
1. New left PICC, tip pointing superiorly, possibly in proximal
SVC or azygos
vein. No pneumothorax.
2. Mild pulmonary edema and cardiomegaly.
Dr. [**First Name (STitle) 26664**] [**Name (STitle) 26665**] communicated the PICC position to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 26666**] (IV
therapy) at 9:19 am on [**2167-4-30**] by telephone.
[**2167-5-1**] Foot AP,LAT & OBL BILAT
INDICATION: Question osteomyelitis with heel ulcers.
COMPARISON: [**2165-2-5**], [**2166-1-2**].
THREE VIEWS, LEFT FOOT: The patient is status post
transphalangeal amputation
of the first digit at the level of the mid shaft of the proximal
phalanx and
the second digit at the base of the second proximal phalanx. The
amputated
margins are smooth and there is no evidence of osteomyelitis. In
the heel,
there is mild subcutaneous lucency but a discrete ulcer is not
identified.
There is a small plantar calcaneal spur. The overlying cortex is
preserved
and there is no osteolysis or periosteal reaction. A vascular
stent noted.
Vascular calcifications are also noted.
THREE VIEWS, RIGHT FOOT: The patient is status post amputation
at the level
of the first metatarsal with some heterotopic bone formation.
There are
chronic fractures of the second and third metatarsal distal
shafts. The
patient is also status post transphalangeal amputation of the
second proximal
phalanx. There is no acute fracture. There are vascular
calcifications.
There is a small plantar ulcer superficial to the calcaneus
which does not
extend to bone. Overlying cortex of the calcaneus is intact
without
osteolysis or periosteal reaction. There is a small plantar
calcaneal spur.
IMPRESSION: No radiographic evidence of osteomyelitis. If there
is continued clinical concern, MRI can be performed.
II. Laboratory
A. Admission
[**2167-4-28**] 03:20PM BLOOD WBC-23.4*# RBC-3.53* Hgb-10.8* Hct-33.2*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.5 Plt Ct-161
[**2167-4-28**] 03:20PM BLOOD Neuts-91.9* Lymphs-4.1* Monos-3.8 Eos-0
Baso-0.2
[**2167-4-28**] 03:20PM BLOOD PT-12.9 PTT-26.8 INR(PT)-1.1
[**2167-4-28**] 03:20PM BLOOD Glucose-479* UreaN-32* Creat-1.5* Na-133
K-4.6 Cl-97 HCO3-16* AnGap-25
[**2167-4-28**] 10:23PM BLOOD Albumin-3.3* Calcium-8.4 Phos-0.6*#
Mg-1.6
[**2167-5-2**] 06:15AM BLOOD %HbA1c-8.8* eAG-206*
[**2167-4-29**] 01:16AM BLOOD tacroFK-LESS THAN
[**2167-4-30**] 03:28AM BLOOD tacroFK-10.9
[**2167-4-28**] 01:52PM BLOOD Glucose-460* Lactate-2.8* Na-135 K-5.8*
Cl-99*
B. Discharge
[**2167-5-3**] 06:02AM BLOOD WBC-4.1 RBC-2.81* Hgb-8.6* Hct-25.5*
MCV-91 MCH-30.6 MCHC-33.8 RDW-14.7 Plt Ct-185#
[**2167-5-3**] 06:02AM BLOOD Glucose-126* UreaN-14 Creat-1.2* Na-137
K-4.1 Cl-108 HCO3-24 AnGap-9
C. Urine
[**2167-4-28**] 01:53PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2167-4-28**] 01:53PM URINE Blood-TR Nitrite-POS Protein-30
Glucose-1000 Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2167-4-28**] 01:53PM URINE RBC-7* WBC-376* Bacteri-MOD Yeast-NONE
Epi-<1
[**2167-5-2**] 09:58AM URINE Hours-RANDOM UreaN-397 Creat-73 Na-59 K-9
Cl-83
[**2167-5-2**] 09:58AM URINE Osmolal-352
[**2167-4-28**] 01:53PM URINE UCG-NEGATIVE
### Pending studies: Blood culture ([**5-3**], [**5-2**], [**5-1**], [**4-30**])
Brief Hospital Course:
49 yo woman with DM c/b renal failure, ESRD s/p transplant who
presented with diabetic ketoacidosis in setting from sepsis from
urinary source with E. coli bacteremia.
# Diabetes Type I with diabetic ketoacidosis (A1c 8.8):
She developed DKA In the setting of medication non-adherence and
sepsis. She was initially placed on an insulin gtt per ICU
protocol with q1hr FSG. Her anion gap closed rapidly with
fluids and insulin, and she was transitioned to SQ insulin by
the following morning. She had intermittently refused
fingersticks and insulin, citing that her FSG were
"satisfactory." Her glargine was uptitrated to 12 units qam,
10units Qpm with improved glycemic control. Fluids were
discontinued when she was taking adequate PO. [**Last Name (un) **] was
consulted to help guide glycemic control with home lantus 20
units SC qHS and attached sliding scale at discharge. She was
advised to follow-up with [**Last Name (un) **] for further optimization.
# Sepsis from a urinary source with E. coli bacteremia
Urinalysis indicative of urinary tract infection with risk
factors including diabetes and straight catheterization in
setting of probable neurogenic bladder. She was started on
vancomycin and zosyn in the emergency department and
transitioned to ciprofloxacin and vancomycin due to her history
of beta-lactam resistant enterobacter previously. She was
broadened to cefepime, ciprofloxacin, and vancomycin when she
developed worsening fevers and rigors on [**4-30**] with E. coli
bacteremia. She subsequently was afebrile with negative
surveillance cultures for at least 48 hours. She was
transitioned to ciprofloxacin 500 mg PO BID for a 14-day total
course ([**2167-4-29**] - [**2167-5-12**]).
# Hypoxia: Patient with transient desaturations to the 70s, with
improvement to the 90s with arousal and upright positioning.
Given normal CXR, low concern for PNA. Some concern for
influenza. No evidence of shunt on ECHO. She refused flu swab,
and [**Last Name (LF) **], [**First Name3 (LF) **] droplet precautions were lifted secondary to low
suspicion of influenza.
Patient subsequently had no further issues with oxygenation.
Consider outpatient sleep study for OSA.
# Acute renal failure with history of renal transplant: She is
on chronic immunosuppresion. Her baseline creatinine is around
0.9 with elevation to 1.5 during hospitalization likely
consistent with intrinsic process including urinary tract
infection and ATN in setting of sepsis given many WBC and
granular casts. She was continued on prednisone and tacrolimus
(goal level [**5-6**]). Discharge Cr was 1.2.
# GERD: continue PPI
# HLD: continue pravastatin
# Anemia: normocytic, stable. Likely anemia of chronic
inflammation. Consider iron supplementation given Fe/TIBC of 8 %
and Ferritin 139 in setting of chronic disease.
# Impaired skin integrity on heel
Patient with impaired skin integrity noted on admission likely
from DM and PVD on bilateral heels. No apparent superinfection
or cellulitis. Plain film of both feet not suggestive of
osteomyelitis. She will need careful monitoring of area as high
risk for infection.
# Communication: pt, husband [**Name (NI) **] [**Telephone/Fax (1) 26667**]
# Code: Full (confirmed with husband [HCP])
# Transitions of care
- [**Last Name (un) **] follow-up for optimization of diabetes
- Repeat tacrolimus level and creatinine at renal follow-up
visit
- consider iron supplementation
- completion of ciprofloxacin course with follow-up of pending
surveillance blood cultures
- consider outpatient sleep study given desaturations noted
during hospitalization
- aggressive wound care for bilateral heel ulcers
Medications on Admission:
Vitamin D 1,000 Unit [**Hospital1 **]
Stool Softener 100 Mg take 1 capsule (100MG) by ORAL route
QHS:PRN
Prograf 1 Mg 4mg [**Hospital1 **]
Prilosec 20 Mg take 1 capsule (20MG) by ORAL route every day
Prednisone 5mg 1 once a day
Pravastatin Sodium 80 Mg take 1 tablet (80MG) by ORAL route
every day
Metoclopramide Hcl 10mg 1 prn gastroparesis symtpoms (nausea)
Lyrica 100 Mg take 1 capsule (100MG) by ORAL route 3 times every
day
Lasix 40 Mg as needed
Lantus 100 Unit/ml 20 units/night
Humalog 100 Unit/ml per sliding scale up to 50 units per day
Glucagon Emergency Kit 1 Mg as directed
Fish Oil 1,000 Mg [**Hospital1 **]
Diovan 40 Mg take 2 tablet (80MG) by ORAL route every day
Cranberry 400 Mg [**Hospital1 **]
Cipro 500 Mg take 1 tablet (500MG) by oral route every 12 hours
Cellcept [**Pager number **] Mg once capsule [**Hospital1 **]
Aspirin 81 Mg 1 time per day
Alprazolam 1 Mg take 1 by Oral route every bedtime PRN insomnia
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
6. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
8. pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Fish Oil 1,000 (120-180) mg Capsule Sig: One (1) Capsule PO
twice a day.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as
needed for swelling.
13. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a
day as needed for indigestion.
14. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
15. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
16. Insulin Sliding Scale
Breakfast Lunch Dinner Bedtime
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
71-99 mg/dL 0 Units 0 Units 0 Units 0 Units
100-150 mg/dL 5 Units 5 Units 5 Units 0 Units
151-200 mg/dL 7 Units 7 Units 7 Units 2 Units
201-250 mg/dL 9 Units 9 Units 9 Units 3 Units
251-300 mg/dL 11 Units 11 Units 11 Units 4 Units
301-350 mg/dL 13 Units 13 Units 13 Units 5 Units
351-400 mg/dL 15 Units 15 Units 15 Units 6 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
Sepsis from a urinary source with GNR bacteremia
Acute renal failure with history of renal transplant
Impaired skin integrity on heel ulcers
HTN
HLD
GERD
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with a urinary tract infection and we
found that you have very elevated blood sugars that required us
to observe you in the medical ICU. We also found that you were
very dehydrated and had bacterial infection in your blood. You
were given antibiotics and you made very good recovery.
Please note we made the following changes to your medications.
STARTED:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
2. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
3. ISS:
Bedtime Glargine 20 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
71-99 mg/dL 0 Units 0 Units 0 Units 0 Units
100-150 mg/dL 5 Units 5 Units 5 Units 0 Units
151-200 mg/dL 7 Units 7 Units 7 Units 2 Units
201-250 mg/dL 9 Units 9 Units 9 Units 3 Units
251-300 mg/dL 11 Units 11 Units 11 Units 4 Units
301-350 mg/dL 13 Units 13 Units 13 Units 5 Units
351-400 mg/dL 15 Units 15 Units 15 Units 6 Units
> 400 mg/dL Notify M.D.
Please follow up with the following doctors. see below.
It was a pleasure taking care of you, we wish you well in the
future.
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2167-5-7**] at 10:40 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: CARDIAC SERVICES
When: MONDAY [**2167-5-25**] at 10:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2167-5-25**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call [**Last Name (un) **]
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
|
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"995.91",
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"584.5",
"250.63",
"250.43",
"599.0",
"403.90",
"276.1",
"707.14",
"V42.0",
"583.81",
"585.9",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18792, 18798
|
12246, 15896
|
332, 349
|
19007, 19007
|
3404, 12223
|
20499, 21499
|
2775, 2793
|
16878, 18769
|
18819, 18986
|
15922, 16855
|
19158, 20476
|
2808, 3385
|
1683, 1729
|
266, 294
|
377, 1664
|
19022, 19134
|
1751, 2417
|
2433, 2759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,039
| 171,974
|
6042
|
Discharge summary
|
report
|
Admission Date: [**2157-3-29**] Discharge Date: [**2157-4-8**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo female with PMH of severe diastolic heart
failure and atrial fibrillation who presents with 3 days of
shortness of breath, cough, and decreased PO intake. Per her
daughter, she has been decompensating since her last hospital
admission for CHF, 1 month ago and has been living at [**Hospital 100**]
Rehab since discharge. For the past 3 days, she has been
increasingly short of breath. She has been holding her food in
her mouth and not swallowing and her daughter noticed swelling
to her right jaw which is causing her pain. She was given lasix
at rehab and had little urine output in the past day. Her CXR at
rehab showed pneumonia so she was given vanc and zosyn at 21:45
[**3-28**] and sent to the ED on a non-rebreather. ABG was 7.54/28/68.
Her daughter states she has not had any documented fevers.
.
In the ED, initial VS were: 98.7 110 130/86 38 99%. Exam was
notable for crackles on right greater than left. She does not
have good pleth, and was placed on [**6-11**] in ED. Pt has not had a
lot of secretions. Right parotid also enlarged on examination.
Labs showed lactate 3.8, WBC 11.1 with 90% PMN's, Hct 35, INR
3.7, BNP 15,000, trop 0.04, Na 146, Cr 1.8 (baseline 1.1-1.2),
AG 15. Blood cultures were sent. ECG showed AF @ 94, ST dep +
TWF laterally, which is unchanged per report. CXR showed left
upper lobe opacity, right basilar infiltrates and likely some
pulmonary edema. She was given 500cc NS in the ED for elevated
lactate.
VS prior to transfer 92 128/81 94% 20 [**6-11**]. She has 18g right
arm, 24g right hand for acccess.
.
On arrival to the MICU, patient appears uncomfortable and is
accompanied by her daughters. A foley was placed a put out 250cc
concentrated urine.
.
Review of systems:
(+) Per HPI, unable to obtain additional information at time of
admission.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (non-insulin dependent),
Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Paroxysmal atrial fibrillation
- Severe diastolic congestive heart failure.
- Pulmonary hypertension.
- Moderate-to-severe mitral regurgitation.
- Moderate tricuspid regurgitation.
- Question of restrictive cardiomyopathy.
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Osteoporosis.
- Glaucoma.
- Gout.
- Appendicitis with septic shock.
Social History:
Mrs. [**Known lastname **] lives at [**Hospital 100**] Rehab in the last month, previously
lived at home and was independent before [**2157-2-6**]. She is
Mandarin speaking only, but understands some english.
Supportive daughters very involved in her care.
Family History:
non-contributory
Physical Exam:
Admission Physical:
Vitals: T:97.5 BP: 105/65 P:92 R:13 O2: 96% NRB
General: appears uncomfortable, moaning
HEENT: mucous membranes dry, right submandibular mass
nonerythematous and tender on palpation
Neck: supple, JVP not elevated
CV: a fib, S1, S2
Lungs: very faint crackles at right base, exam limited [**3-10**]
moaning
Abdomen: soft, non-tender, non-distended
GU: foley in place
Ext: warm, well perfused, no edema
Neuro: unable to cooperate with neuro exam
Discharge Physical:
Pertinent Results:
Imaging:
CXR [**3-29**]:
IMPRESSION: Multifocal pneumonia. Under appropriate clinical
circumstances
peripheral consolidation can be seen with chronic eosinophilic
pneumonia.
TTE [**3-29**]:
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with hypokinesis
of the distal half of the anterior septum and dyskinesis of the
distal half of the anterior wall. The remaining segments
contract normally (LVEF = 45 %). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Severe (4+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. There is a very small pericardial
effusion.
IMPRESSION:Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (mid-LAD distribution).
Severe mitral regurgitation. Pulmonary artery hypertension.
Moderate to severe tricuspid regurgitation. Biatrial
enlargement.
Compared with the prior study (images reviewed) of [**2154-7-26**],
regional left ventricular systolic dysfunction is now
identified.
CT head w/o [**3-29**]:
IMPRESSION:
1. No acute intracranial process. If ischemia is of concern, MRI
is more
sensitive if not contraindicated.
2. Small vessel ischemic disease and age-related involution.
Microbiology:
[**2157-3-29**] 01:36AM BLOOD WBC-11.1* RBC-3.32* Hgb-11.4* Hct-35.3*
MCV-106* MCH-34.3* MCHC-32.3 RDW-15.6* Plt Ct-294
[**2157-3-29**] 02:25PM BLOOD WBC-13.1* RBC-3.48* Hgb-11.6* Hct-36.0
MCV-103* MCH-33.2* MCHC-32.1 RDW-15.6* Plt Ct-227
[**2157-3-30**] 01:34AM BLOOD WBC-13.3* RBC-3.37* Hgb-11.0* Hct-34.7*
MCV-103* MCH-32.7* MCHC-31.7 RDW-15.6* Plt Ct-227
[**2157-3-31**] 10:00AM BLOOD WBC-9.9 RBC-3.76* Hgb-12.5 Hct-40.6
MCV-108* MCH-33.2* MCHC-30.8* RDW-15.4 Plt Ct-303
[**2157-4-1**] 07:05AM BLOOD WBC-7.9 RBC-3.34* Hgb-11.2* Hct-34.8*
MCV-104* MCH-33.6* MCHC-32.2 RDW-15.9* Plt Ct-263
[**2157-4-1**] 09:45AM BLOOD WBC-6.4 RBC-3.36* Hgb-11.2* Hct-35.6*
MCV-106* MCH-33.2* MCHC-31.4 RDW-15.6* Plt Ct-279
[**2157-4-2**] 10:15AM BLOOD WBC-8.1 RBC-3.33* Hgb-11.1* Hct-35.0*
MCV-105* MCH-33.3* MCHC-31.7 RDW-15.6* Plt Ct-230
[**2157-3-29**] 02:25PM BLOOD Neuts-94.3* Lymphs-4.2* Monos-0.8*
Eos-0.5 Baso-0.2
[**2157-3-29**] 01:36AM BLOOD PT-37.4* PTT-38.2* INR(PT)-3.7*
[**2157-3-29**] 06:04AM BLOOD PT-34.2* PTT-44.6* INR(PT)-3.3*
[**2157-3-30**] 01:34AM BLOOD PT-47.1* PTT-48.8* INR(PT)-4.7*
[**2157-3-31**] 10:00AM BLOOD PT-42.4* PTT-47.9* INR(PT)-4.2*
[**2157-4-1**] 06:55PM BLOOD PT-69.4* INR(PT)-7.0*
[**2157-4-2**] 10:15AM BLOOD PT-81.5* PTT-55.1* INR(PT)-8.3*
[**2157-3-29**] 01:36AM BLOOD Glucose-78 UreaN-55* Creat-1.8* Na-146*
K-4.4 Cl-106 HCO3-25 AnGap-19
[**2157-3-29**] 06:04AM BLOOD Glucose-83 UreaN-52* Creat-1.6* Na-147*
K-4.0 Cl-106 HCO3-24 AnGap-21*
[**2157-3-29**] 02:29PM BLOOD Glucose-397* UreaN-44* Creat-1.5* Na-142
K-3.6 Cl-105 HCO3-25 AnGap-16
[**2157-3-30**] 01:34AM BLOOD Glucose-120* UreaN-40* Creat-1.2* Na-144
K-3.5 Cl-109* HCO3-27 AnGap-12
[**2157-3-31**] 10:00AM BLOOD Glucose-253* UreaN-43* Creat-1.3* Na-143
K-3.5 Cl-106 HCO3-20* AnGap-21*
[**2157-4-1**] 07:05AM BLOOD Glucose-124* UreaN-41* Creat-1.2* Na-152*
K-3.2* Cl-118* HCO3-20* AnGap-17
[**2157-4-1**] 09:45AM BLOOD Glucose-129* UreaN-38* Creat-1.2* Na-152*
K-3.1* Cl-118* HCO3-21* AnGap-16
[**2157-4-1**] 12:48PM BLOOD Glucose-192* UreaN-39* Creat-1.3* Na-150*
K-3.3 Cl-115* HCO3-19* AnGap-19
[**2157-4-1**] 06:55PM BLOOD Glucose-193* UreaN-42* Creat-1.5* Na-148*
K-3.9 Cl-114* HCO3-16* AnGap-22*
[**2157-4-2**] 02:22AM BLOOD Glucose-126* UreaN-41* Creat-1.4* Na-148*
K-3.1* Cl-114* HCO3-21* AnGap-16
[**2157-4-2**] 10:15AM BLOOD Glucose-190* UreaN-40* Creat-1.4* Na-147*
K-4.1 Cl-112* HCO3-21* AnGap-18
[**2157-3-29**] 01:36AM BLOOD proBNP-[**Numeric Identifier 23731**]*
[**2157-3-29**] 01:36AM BLOOD cTropnT-0.04*
[**2157-3-29**] 02:29PM BLOOD CK-MB-3 cTropnT-0.03*
[**2157-3-31**] 10:00AM BLOOD Vanco-79.4*
[**2157-4-1**] 07:05AM BLOOD Vanco-15.9
[**2157-3-29**] 05:52PM BLOOD Type-ART Temp-36.7 pO2-120* pCO2-30*
pH-7.51* calTCO2-25 Base XS-2 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2157-3-29**] 01:43AM BLOOD Lactate-3.8*
[**2157-3-29**] 01:39PM BLOOD Lactate-2.1*
[**2157-3-31**] 10:50AM BLOOD Lactate-3.8*
[**2157-4-3**] 03:30PM BLOOD Lactate-4.0*
Brief Hospital Course:
Brief Course:
Ms. [**Known lastname **] is a [**Age over 90 **]yo female with PMH of severe diastolic heart
failure and atrial fibrillation who presents with 3 days of
shortness of breath, cough, and decreased PO intake, who was
admitted to the MICU given concern for respiratory distress. She
was hypoxic at rehab, and placed on CPAP briefly in the ED. On
arrival to the MICU, she was improved, and bipap was weaned off.
She was initially continued on antibiotics for concern for
pneumonia, with cultures pending. However, her mental status
declined. After discussion with her family, given her goals of
care, she was made DNR/DNI. Her multifocal pneumonia and
diastolic heart failure did not improve. The patient went into
respiratory distress on the floor and had a persistently
altered-non responsive mental state. At this point, the family
opted for inpatient hospice and comfort focused care. The
patient passed away at the age of 91 on [**2157-4-8**] at 810am,
peacefully with her family at the bedside.
# Hypoxic respiratory distress: Pt had an ABG at her
rehabilitation facility with low PaO2 (unclear what level of
oxygen she was on at that time). She was initially placed on
broad-spectrum antibiotics for HCAP. Her CXR showed multilobar
pneumonia. In the ICU, she was weaned to nasal cannula and
symptomatically improved. Her TTE showed mildly depressed EF and
severe MR. Diuresis was held given pt was clinically dry with
acute renal failure (see below). Cultures showed no growth Her
antibiotics were changed to vanc zosyn.
# Acute on chronic renal failure: Patient's creatine was found
to be 1.8 (baseline 1.2) and calculated GFR is 26. The etiology
was determined to be pre-renal, and she improved with gentle
fluid resuscitation. .
# Acute on chronic diastolic heart failure: Patient has a
history of severe diastolic heart failure. Last EF > 55%.
Repeat TTE showed EF 45% and severe MR. As above, lasix
initially held. BNP on admission was [**Numeric Identifier 3301**].
# Atrial fibrillation/RHYTHM: Patient is in atrial
fibrillation, on coumadin and amiodarone. Cardioversion has been
unsuccessful in the past. Her INR was supratherapeutic on
admission, and this was held on admission.
# Cognitive decline: Per daughter, patient with slow cognitive
decline over 6 months and has worsened since last admission 1
week ago. At baseline for the past month, she has been sleeping
throughout the day, has been more lethargic, has decreased PO
intake, and periods of irregular bleeding. It is unclear whether
or not this started acutely. A fib does put her at risk for
embolic stroke. She had a CT head which showed no acute process.
Likely toxic metabolic encephalopathy contributing to overall
picture. Her mental status declined during her admission to the
point of non-responsiveness.
Medications on Admission:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. metformin 500 mg Tablet Sig: 0.5 Tablet PO once a day.
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Take 1 tablet Sun, Mon, Tues, Thurs, Fri; take 1.5 tab Wed,
Sat.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
9. Humalog ss sq 2 u
10. clotrimazole
Discharge Disposition:
Expired
Discharge Diagnosis:
hospital acquired pneumonia
acute on chronic diastolic heart failure
sepsis
atrial fibrillation
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"427.31",
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icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11800, 11809
|
8266, 11082
|
261, 267
|
11948, 11957
|
3451, 8243
|
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|
2910, 2928
|
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|
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2269, 2513
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295, 2045
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2544, 2619
|
2163, 2249
|
2635, 2894
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,113
| 193,324
|
54980
|
Discharge summary
|
report
|
Admission Date: [**2129-7-21**] Discharge Date: [**2129-7-28**]
Date of Birth: [**2063-11-10**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 32912**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2129-7-21**]:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Mobilization, and resection of cholecystoduodenal fistula.
4. Subtotal cholecystectomy.
5. Common bile duct exploration with retrieval of multiple
stones.
6. Transduodenal sphincteroplasty with removal of impacted
stone.
7. Nissen closure of duodenum.
8. Placement of 12-French T tube.
History of Present Illness:
Mr. [**Known lastname **] is a 65-year-old man who underwent a long
hospitalization associated with bleeding duodenal ulcer 30 years
ago, which resulted in a right thoracotomy, right subcostal
incision, and a midline incision for distal gastrectomy with
apparent Billroth II reconstruction. Over the last months, he
has had intermittent periumbilical and epigastric abdominal
pain, which he notes to be worse with food and meat in
particular. His pain radiates to his chest. He underwent a
stress test, the results of which are not yet available.
Mr. [**Known lastname **] was found at the time of ERCP to have two stones
within a dilated bile duct as well as a mass at the apex of the
duodenum and unassociated cholecystoduodenal fistula. The
biopsies from this region are benign inflammatory material, and
his CEA and CA [**35**]-9 are normal. Furthermore, his liver function
studies, despite his prior history of heavy alcohol intake, are
normal, except for an alkaline phosphatase of 188. Mr. [**Known lastname **] [**Last Name (Titles) 8783**]t a CT scan and chest x-ray for staging. He has no
evidence of acute pulmonary disease, except for [**Last Name (un) 68224**] and has
scattered bilateral liver hemangiomas and radiopaque material in
the right upper quadrant, gallstones, and a contracted
gallbladder. Since his discharge from the hospital, Mr. [**Known lastname **]
has continued
to have periumbilical abdominal pain, which is stabbing and
nonradiating. It resolved spontaneously after 20 minutes. He
has had no nausea, vomiting, change in his appetite, fevers,
chills, weight, or melena.
Mr. [**Known lastname **] appears most likely to have had chronic
cholecystitis, resulting in a cholecystoduodenal fistula and
common bile duct stones. Mr. [**Known lastname **] is quite anxious about
surgery, which will require reoperation through his right
subcostal incision with repair of his cholecystoduodenal
fistula, partial or total cholecystectomy, common bile duct
exploration, and placement of a T-tube type biliary drain as
access to the bile duct is not possible endoscopically. The
patient had a detailed discussion about goals, risks and
possible outcomes of the surgery with Dr. [**Last Name (STitle) **] in his
[**Hospital 45932**] clinic. Mr. [**Known lastname **] asked numerous questions
and wished to proceed as outlined.
Past Medical History:
PMH:
PUD
PSH:
BII for PUD
Social History:
Lives alone on [**Social Security Number 112276**]social security. 240 pack year history of smoking
but quit 10 years ago. 30 year history of heavy EtOH abuse (3
cases of beer daily + multiple shots of rum and vodka.
Family History:
Patient reports his father died of pancreatic cancer. He states
his father's "entire" family died of different cancers (breast,
ovarian, stomach and bladder). He states he has previously
undergone genetic screening.
Physical Exam:
Upon discharge:
VS: 98.7, 95, 146/89, 12, 98% RA
GEN: Somewhat confused, AAO x 3, blunt affect
CV: RRR, no m/r/g
RESP; CTAB
ABD: Chevron incision open to air with staples and c/d/i. Right
flank with T-tube drain to gravity and drains bile, tube secured
with suture. Site with mild erythema and minimal purulent
drainage. RLQ old JPs site with DSD and c/d/i.
EXTR: Warm, no c/c/e
Pertinent Results:
[**2129-7-28**] 07:15AM BLOOD WBC-12.8* RBC-3.54* Hgb-10.5* Hct-31.2*
MCV-88 MCH-29.7 MCHC-33.7 RDW-15.7* Plt Ct-304
[**2129-7-28**] 07:15AM BLOOD Na-136 K-3.6 Cl-98
[**2129-7-27**] 06:55AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-135
K-3.1* Cl-96 HCO3-29 AnGap-13
[**2129-7-28**] 07:15AM BLOOD ALT-11 AST-21 AlkPhos-160* TotBili-0.7
[**2129-7-27**] 06:55AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.8
[**2129-7-24**] CXR:
IMPRESSION: Lungs clear
Brief Hospital Course:
The patient was admitted to the HPB Surgical Service for
elective choledocystoduodenal fistula repair. On [**2129-7-21**], the
patient underwent exploratory laparotomy, lysis of adhesions,
mobilization, and resection of cholecystoduodenal
fistula, subtotal cholecystectomy, common bile duct exploration
with retrieval of multiple stones, transduodenal
sphincteroplasty with removal of impacted stone, Nissen closure
of duodenum and placement of 12-French T tube, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO, on IV fluids and antibiotics,
with a foley catheter, and epidural catheter for pain control.
The patient was hemodynamically stable.
Neuro: The patient received Hydromorphone/Bupivacaine via
epidural. His epidural was splited on POD # 3 and Dilaudid PCA
was added for better pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications. The
patient was maintained on CIWA protocol post operatively and
only required minimal amount of Lorazepam. CIWA protocol was
discontinued prior discharge as patient was neurologically
stable.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Post operative
ECG was stable compare to preop.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO with IV fluids.
Diet was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. T-tube was kept to gravity drainage
and average output was between 600-750 cc. Patient had 2 JPs
drain placed post op, JPs was removed on POD # 7 as output was
low. Electrolytes were routinely followed, and repleted when
necessary.
GU: The foley catheter was discontinued at midnight of POD# 5.
The patient subsequently voided without problem.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound care was done
daily and no signs or symptoms of infection were noticed. T-tube
site has minimal purulent drainage around the tube. Please
continue to express fluid daily and wash the site with NS.
Please continue to change dressing daily. Wound dressing with
staples, please remove staples on [**8-4**] and apply steri strips.
Endocrine: No issues
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Mirtazapine 15mg po daily
Pantoprazole 40mg po daily
Klor-Con M20 20mEq daily
Risperdal 0.25mg po daily
Trazodone 50mg po daily
Discharge Medications:
1. Cyanocobalamin 50 mcg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) [**12-6**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-6**] tablet(s) by mouth
every four (4) hours Disp #*120 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
6. Senna 1 TAB PO BID
7. Thiamine 100 mg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K >
10. Mirtazapine 15 mg PO HS
11. Risperidone 0.25 mg PO DAILY
12. traZODONE 50 mg PO HS
Discharge Disposition:
Extended Care
Facility:
nevins nursing and rehab center
Discharge Diagnosis:
1. Acute and chronic cholecystitis.
2. Cholecystoduodenal fistula.
3. Impacted common bile duct stone.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for surgical
repair of the choledocystoduodenal fistula. You have done well
in the post operative period and are now safe to be discharge in
rehabilitation center to complete your recovery with the
following instructions:
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-14**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
T-tube care: Keep to gravity drainage. Please note color,
consistency, and amount of fluid in the drain. Call the doctor,
nurse practitioner, or VNA nurse if the amount increases
significantly or changes in character. Be sure to empty the
drain frequently. Record the output, if instructed to do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2129-8-11**] at 3:30 PM
With: [**Known firstname **] [**Last Name (NamePattern4) 104214**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2129-7-28**]
|
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icd9cm
|
[
[
[]
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icd9pcs
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[
[
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319, 677
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3366, 3585
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705, 3064
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8633, 8747
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3131, 3350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,145
| 105,119
|
15475+56680
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-9-23**] Discharge Date: [**2193-10-14**]
Date of Birth: [**2117-10-5**] Sex: M
Service: ACOVE
HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old man
with a history of CHF (EF 30-40% as of [**2193-6-2**]), CAD, status
post inferior MI in [**2183**], hypertension, dyslipidemia, COPD,
insulin-dependent diabetes mellitus, and chronic renal failure
presenting with bilateral purple color changes and edema of his
lower extremities present since the end of [**Month (only) 205**]. The history was
obtained through his wife as the patient only speaks [**Name (NI) 8230**].
Since the end of [**Month (only) 205**], his legs have been purple colored,
swollen, and tender to the touch, left greater than right. His
wife reports that he has been on multiple antibiotics for
presumed cellulitis starting with amoxicillin 500 mg b.i.d. from
[**2193-8-15**] to [**2193-8-21**] followed by Zithromax 500 mg starting
[**2193-8-21**] followed by 250 mg p.o. q.d. on [**2193-8-22**] through
[**2193-8-26**]. However, per the medical records these antibiotics
were actually for bronchitis.
On [**2193-9-10**], he visited Dr. [**First Name (STitle) **], a cardiologist, who was
concerned about possible cellulitis and he was started on
cephalexin 500 mg t.i.d. There was concern that the edema and
erythema could be due to a DVT, but on [**2193-9-12**], Mr.
[**Known lastname **] had venous duplexes negative for lower extremity DVT
bilaterally. His wife states that the discoloration is neither
improving nor worsening. She states that he feels "okay",
although has complained of decreased appetite. She also states
that he had long-standing lower extremity edema bilaterally as
well as numbness bilaterally. He also complains of orthopnea
(sleeps in a Lazy Boy chair) and PND.
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation.
2. CHF (echo in [**2193-6-4**]: LVEJ 30-40%, mild symmetric LVH,
severe hypokinesis of the inferior septum, inferior free
wall, and posterior wall, 1+ AR, 1+ MR, 1+ TR).
3. CAD, status post anterior MI in [**2183**].
4. Chronic renal failure with a baseline creatinine of 2.4.
5. Insulin-dependent diabetes mellitus.
6. COPD.
7. Hypertension.
8. Dyslipidemia.
9. Diabetic retinopathy.
10. Diabetic neuropathy.
11. Diabetic nephropathy.
12. Gout.
13. Urinary retention, likely secondary to BPH.
14. Status post bilateral cataract surgery in [**2189**].
15. Hyperkalemia in [**2193-5-2**] attributed to prerenal azotemia.
16. Bronchitis treated with antibiotics in [**2193-8-2**].
FAMILY HISTORY: Father with "heart congestion", died at the
age of 70 from pneumonia. Mother died at age 82 of an
unknown cause. Brother died at 75 years old from an MI.
SOCIAL HISTORY: The patient moved from [**Location (un) 6847**] in [**2149**].
Worked as a cook in the U.S. Has five grown children.
Reports [**Age over 90 **] year pack year history; however, quit smoking in
[**2183**] after his heart attack, denied alcohol.
ADMISSION MEDICATIONS:
1. Prednisolone eyedrops b.i.d.
2. Neurontin 100 mg t.i.d.
3. Metoprolol 25 mg b.i.d.
4. Avapro 75 mg q.d.
5. Flomax 0.4 mg q.d.
6. Fludrocortisone 0.1 mg q.d.
7. Lasix 80 mg p.o. q.d.
8. Senokot b.i.d.
9. Nexium 40 mg q.d.
10. Ferrous gluconate 325 mg q.d.
11. Allopurinol 100 mg q.d.
12. Colchicine 0.6 mg q.d. p.r.n. gout.
13. Lipitor 20 mg q.d.
14. Coumadin 2 mg q.d.
15. Oxycodone 5/325 one to two tablets q. four to six hours
p.r.n. pain.
16. Fluticasone propionate 110 micrograms two puffs b.i.d.
17. Albuterol sulfate/Ipratropium two puffs q.i.d.
18. Insulin NPH 46 units q.a.m., 20 units q.p.m., as well as
a regular insulin sliding scale.
ALLERGIES: The patient reports an allergy to Levaquin which
is manifested by a severe headache.
REVIEW OF SYSTEMS: The patient reports increased fatigue,
weakness, no fevers, chills, or night sweats. No shortness
of breath, a productive cough of light yellow sputum, history
of hypertension, orthopnea, PND, lower leg extremity,
however, currently denied chest pain, denied nausea,
vomiting, diarrhea, bright red blood per rectum, melena, or
abdominal pain. The patient does report urinary hesitancy,
no dysuria, however. Does report urinary dribbling.
PHYSICAL EXAMINATION ON ADMISSION: General: Appears stated
age, resting comfortably in bed, in no apparent distress.
Vital signs: Temperature 98.6, blood pressure 155/71, pulse
70, respiratory rate 22, 97% on room air. HEENT: The pupils
were asymmetric, not round; oropharynx clear without exudate;
no lymphadenopathy. Lungs: Crackles two-thirds of the way
up on the left, one-half of the way up on the right; some
decreased crackles with cough. Cardiovascular: Regular rate
and rhythm. No murmurs, rubs, or gallops. Laterally
displaced PMI; JVD not elevated. Abdomen: Positive bowel
sounds, soft, nontender, distended, no hepatosplenomegaly.
Vascular: 2+ femoral and popliteal pulses bilaterally,
unable to assess DP and PT pulses secondary to bilateral
edema of lower legs. Skin: Purple colored area on both
lower extremities two-thirds of the way up of the calf on the
left, half way up the calf on the right; scaling skin over
areas of color. Neurologic: The pupils were asymmetric and
not round. The extraocular movements were intact. No facial
droop. Facial movements were symmetric.
LABORATORY/RADIOLOGIC DATA: On admission, the patient had a
BUN of 47, creatinine 2.0, glucose 130. White blood cell
count 9.7, hematocrit 38.4, platelets 142,000.
HOSPITAL COURSE: 1. CORONARY ARTERY DISEASE: The patient
is status post MI in [**2183**]. An echocardiogram in [**2193-6-2**]
showed an EF of 30-40%, down from 45% in [**2193-5-2**]. When
the patient was admitted, he was taking a beta blocker, a statin,
and [**First Name8 (NamePattern2) **] [**Last Name (un) **]. Repeat echocardiogram on [**2193-9-24**],
hospital day number two, showed a moderate regional left
ventricular systolic dysfunction with an ejection fraction of
30-40% as well as severe hypokinesis of the inferior septum,
inferior wall, inferolateral walls. There was 1+ MR, AR, and TR
were noted. Compared to the study of [**2193-6-5**], there have been
no significant changes.
To optimize medical management, his dose of Valsartan was
increased to 150 mg p.o. q.d. He was started on an aspirin 325
mg p.o. q.d. Cardiology was consulted. On hospital day number
three ([**2193-9-25**]), the patient had a Persantine MIBI showing a
moderate sized reversible defect involving the lateral wall.
There was a severe fixed defect involving the base of the
inferior wall. There was global hypokinesia with an EF of 41%.
It was determined that the patient needed a cardiac
catheterization which was planned for hospital day number five
([**2193-9-27**]) but was postponed due to an INR of 2.1. The
catheterization was then rescheduled for hospital day number
eight ([**2193-9-30**]) but due to creatinine elevation to 2.9 as well
as the patient developing pneumonia, it was decided that the
patient would go home and follow-up with his cardiologist to
schedule a catheterization as an outpatient.
Due to the increased creatinine, the Valsartan was discontinued
on [**2193-9-29**] through [**2193-10-3**], at which point his
creatinine had normalized so the Valsartan was restarted at a
lower dose. However, the creatinine increased again. The
Valsartan was discontinued.
On hospital day number 12 ([**2193-10-4**]), he became
hypotensive to 70/palpable which was likely secondary to
dehydration. He was transferred to the MICU in the early morning
of [**2193-10-5**] (hospital day number 13) where he responded to
rehydration with normal saline. The MICU cardiac enzymes were
elevated, likely reflecting an acute MI. He was returned to the
floor on [**2193-10-7**].
2. ATRIAL FIBRILLATION: The patient has a history of paroxysmal
atrial fibrillation; however, during his hospitalization, the
patient was in sinus rhythm. The patient arrived on Coumadin,
was switched at one point to heparin in order to have the cardiac
catheterization, but once it was determined that he would not
have catheterization on this admission, he was put back on
Coumadin.
3. CONGESTIVE HEART FAILURE: The patient arrived with 2+ lower
extremity edema bilaterally thought to be due to fluid overload.
The patient was switched from his Lasix 80 mg p.o. q.d. to 40 mg
IV b.i.d. with good effect. He was also put on 2 gram per day
sodium chloride diet and fluid-restricted to 2 liters of water
per day. As he diuresed, the Lasix was decreased and eventually
he was returned to his home dose of 80 mg p.o. q.d. However,
once the creatinine increased, his Lasix was discontinued.
4. PNEUMONIA: Upon arrival at the hospital, the patient did
report a productive cough and had a history of bronchitis in
[**Month (only) 216**] of this year. His chest x-ray, however, at that time was
clear for infiltrates. On [**2193-9-27**] (hospital day
number five), his 02 saturations dropped to 88-90% on room air. A
chest x-ray still showed no changes and it was believed that
these saturations were due to CHF and he was given Lasix 40 mg IV
times one. However, on hospital day number six ([**2193-9-28**]), the patient had shaking chills, cough productive of sputum
and a chest x-ray that showed chronic bronchial and bronchiolar
abnormalities at the lung bases which could be due to either
recurrent or chronic aspiration or a persistent atypical
infection. At that point, he was started on ceftriaxone and
azithromycin. Sputum initially showed gram-positive clusters in
pairs and gram-negative rods. The patient was started on
ceftazidime and vancomycin. The sputum grew out pan sensitive
Pseudomonas and the antibiotics were then changed to
ceftazidime and ciprofloxacin.
At one point, the patient was started on vanco but it was thought
to be causing a drug fever and the vancomycin was discontinued.
When the patient was still feeling poor with the cough still
productive of sputum on hospital day number 17 ([**2193-10-8**]),
concern was raised of the possibility of the patient having TB.
The patient was placed in a negative pressure room. A PPD was
placed and sputum was obtained for AFB culture and smear. The
PPD was negative and as of this dictation, two sputums have been
obtained, both negative by smear for AFB. In addition, on
[**2193-10-8**] (hospital day number 17), the patient had an
abdominal chest CT which showed persistent multifocal pneumonia
but no evidence of bowel obstruction or abscess. The patient
will be discharged from the hospital and receive seven additional
days of cipro and ceftazidime in the rehabilitation facility.
5. INSULIN-DEPENDENT DIABETES MELLITUS: At home, the patient
takes NPH before breakfast and dinner as well as a sliding scale
of regular insulin. These medications were continued but on
hospital day number three when the patient was n.p.o. for the
MIBI, the patient had an episode of hypoglycemia to a glucose of
38. The hypoglycemia was resolved with an amp of D50 and food.
The patient's NPH was decreased and has been adjusted daily since
then.
6. ELECTROLYTES: When the patient was admitted, he was
taking Florinef for hypokalemia. The Florinef was discontinued
due to concern that it was exacerbating his CHF. When his sodium
began to drop and his potassium started to rise, a low dose
cortisone stimulation test was performed which showed that he was
not adrenally insufficient.
7. ACUTE ON CHRONIC RENAL FAILURE: The patient has a known
creatinine baseline of 2.4. When the patient was admitted,
his creatinine was 2.0. On [**2193-9-30**], his
creatinine bumped to 2.9 and Renal was consulted. His [**Last Name (un) **]
was discontinued. His creatinine normalized and the [**Last Name (un) **] was
started at a lower dose which then caused another bump in the
creatinine. At that point, the [**Last Name (un) **] was again discontinued.
All medications were renally dosed.
8. VASCULAR: The patient reported intermittent bilateral
leg pain. There was concern that this might represent
arterial insufficiency versus diabetic neuropathy. On
hospital day number four ([**2193-9-26**]), the patient
had Doppler studies of both lower extremities showing
essentially normal Doppler flow through the legs. His
Neurontin was increased from 100 mg t.i.d. to 300 mg t.i.d.
and was eventually decreased back down to 100 mg t.i.d. given
his renal failure. In addition, a chest CT of the abdomen on
[**2193-10-8**], showed findings concerning for chronic
aortic dissection involving a short segment of the descending
aorta. However, this appearance was unchanged from [**2193-1-2**] so it was decided not to pursue this further.
9. VENOSTASIS: Legs show violaceous changes consistent with
chronic venostasis. The patient was treated with diuresis,
TEDS, and Eucerin cream.
10. CELLULITIS: On hospital day number three, [**2193-9-25**], the medial side of his left calf had increasing warmth
and erythema. He was placed on Ancef for several days.
11. SKIN ULCERS: The patient developed small ulcers on both
heels and the patient's legs were placed in waffle boots.
The patient also developed erythema over the sacrum and the
patient was given a therapeutic mattress and encouraged to be
out of bed to chair.
12. BENIGN PROSTATIC HYPERTROPHY: The patient has a history
of BPH, treated with Flomax. On [**2193-9-30**], the
patient complained of inability to empty his bladder and a
Foley was placed. The next day, the patient had an eight
hour voiding trial and was able to void without difficulty.
The Foley was discontinued.
13. GOUT: The patient reports a history of gout, although
it is not clear if this has ever been confirmed by aspiration
or crystal analysis. On [**2193-10-3**] (hospital day number
11), the patient reported pain on the side of the ankle and a
Rheumatology consultation was obtained over concern that this
might represent a flare of gout. Aspiration of the left
ankle produced only a few drops of fluid which showed no
crystals, only a few polys on Gram's stain and grew no
organisms on culture. It was deemed unlikely for his pain to
be due to gout. An x-ray of his ankle was obtained showing
no fracture dislocation. His pain was most likely
multifactorial, being a combination of stasis dermatitis and
neuropathy from diabetes.
DISCHARGE DISPOSITION: The patient will be discharged to a
rehabilitation facility.
CONDITION ON DISCHARGE: Fair.
DISCHARGE MEDICATIONS:
1. Prednisolone acetate 1% drops, one drop to both eyes
twice a day.
2. Flovent 110 micrograms two puffs b.i.d.
3. Combivent two puffs q. six hours.
4. ASA 325 mg p.o. q.d.
5. Calcium acetate 667 mg p.o. t.i.d. with meals.
6. Gabapentin 100 mg p.o. t.i.d.
7. Allopurinol 100 mg p.o. q.d.
8. Lipitor 20 mg p.o. q.d.
9. Flomax 0.4 mg p.o. q.h.s.
10. Ciprofloxacin 500 mg p.o. q. 24 hours.
11. Metoprolol 12.5 mg p.o. b.i.d.
12. Warfarin 2 mg p.o. q.d.
13. Nitroglycerin 0.4 mg sublingual p.r.n. chest pain.
14. Percocet 5/325 mg p.o. q. four to six hours p.r.n. pain.
15. Insulin NPH as directed, a regular sliding scale as
directed.
16. Ceftazidime 2 grams IV q. 24 hours.
17. Atrovent nebulizer q. six hours p.r.n. shortness of
breath or wheezing.
18. Albuterol nebulizers q. four to six hours p.r.n.
shortness of breath or wheezing.
19. Hydromorphone 0.5 to 2.0 mg q. three to four hours p.r.n.
pain.
20. Nexium 40 mg p.o. q.d.
21. Dulcolax 10 mg p.o. q.d.
22. Colace 100 mg p.o. b.i.d.
23. Ferrous gluconate 300 mg p.o. q.d.
24. Senna 8.6 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Pseudomonal pneumonia.
2. Acute on chronic renal failure.
3. Coronary artery disease, status post myocardial
infarction.
4. Paroxysmal atrial fibrillation.
5. Congestive heart failure.
6. Insulin-dependent diabetes mellitus.
7. Chronic obstructive pulmonary disease.
8. Hypertension.
9. Dyslipidemia.
10. Diabetic retinopathy.
11. Diabetic neuropathy.
12. Diabetic nephropathy.
13. Gout.
14. Urinary retention, likely secondary to benign prostatic
hypertrophy.
15. Bilateral cataract surgery in [**2189**].
16. Hyperkalemia in [**2193-5-2**] attributed to prerenal
azotemia.
17. Bronchitis in [**2193-8-2**], treated with antibiotics.
DISCHARGE INSTRUCTIONS: Please take all medications as
directed. If the patient feels increasingly short of breath
or cough worsens, call the primary care physician. [**Name10 (NameIs) **] the
patient feels any chest pain or pressure go to the Emergency
Room. The patient is to see his primary care physician
within two weeks. The patient should also follow-up with his
cardiologist, Dr. [**First Name8 (NamePattern2) 1026**] [**Name (STitle) 1016**], call [**Telephone/Fax (1) 13450**] for an
appointment. The patient should also schedule a chest x-ray
in six to eight weeks. The patient also has an appointment
with Dr. [**Last Name (STitle) **] on [**2193-10-15**] at 1:45. The patient has
an appointment with Dr. [**First Name8 (NamePattern2) 3122**] [**Name (STitle) 1860**] on [**2193-10-21**] at
1:30. The patient also has an appointment with Dr. [**First Name8 (NamePattern2) 2197**]
[**Last Name (NamePattern1) 10895**] on [**2193-12-5**] at 1:00 p.m.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 44883**]
MEDQUIST36
D: [**2193-10-11**] 02:04
T: [**2193-10-11**] 18:17
JOB#: [**Job Number 44884**]
Name: [**Known lastname **], [**Known firstname **] YEOW Unit No: [**Numeric Identifier 8319**]
Admission Date: [**2193-9-23**] Discharge Date: [**2193-10-13**]
Date of Birth: [**2117-10-5**] Sex: M
Service: Medicine
ADDENDUM:
DISCHARGE MEDICATIONS:
1. Prednisolone acetate 1% drops, one drop b.i.d.
2. Flovent 110 micrograms two puffs b.i.d.
3. Combivent two puffs q. six hours.
4. Mineral oil/petroleum cream one application b.i.d.
5. Aspirin 325 mg p.o. q.d.
6. Calcium acetate 667 mg p.o. t.i.d. with meals.
7. Gabapentin 100 mg p.o. t.i.d.
8. Allopurinol 100 mg p.o. q.d.
9. Lipitor 20 mg p.o. q.d.
10. Tamsulosin 0.4 mg p.o. q.h.s.
11. Ciprofloxacin 500 mg p.o. q. 24 hours for seven days.
12. Metoprolol 25 mg p.o. b.i.d.
13. Coumadin 1 mg p.o. q.h.s.
14. Nitroglycerin 0.4 mg SL p.r.n. chest pain.
15. Percocet 5/325 mg p.o. q. four hours p.r.n. pain.
16. Insulin NPH 22 units q.a.m., 8 units q.p.m., titrate to
fingersticks.
17. Insulin regular sliding scale.
18. Ceftazidime 2 grams IV q. 24 hours.
19. Ipratropium bromide one neb q. six hours p.r.n. shortness
of breath, wheezing.
20. Albuterol neb q. four to six hours p.r.n. shortness of
breath, wheezing.
21. Hydromorphone 0.5 to 2.0 mg injection q. three to four
hours p.r.n. pain.
22. Nexium 40 mg p.o. q.d.
23. Dulcolax 10 mg p.o. q.d.
24. Colace 100 mg p.o. b.i.d.
25. Ferrous gluconate 300 mg p.o. q.d.
26. Senna one tablet b.i.d.
ADDITIONAL DISCHARGE INSTRUCTIONS: Hold Coumadin for the
night of [**2193-10-13**]. Check fingersticks q.i.d. Adjust NPH to
fingersticks.
DISPOSITION: The patient will be discharged to a
rehabilitation facility.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Doctor Last Name 8320**]
MEDQUIST36
D: [**2193-10-13**] 01:06
T: [**2193-10-13**] 13:19
JOB#: [**Job Number 8321**]
|
[
"428.0",
"410.71",
"427.31",
"682.6",
"707.14",
"584.9",
"482.1",
"585",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
14421, 14483
|
2590, 2747
|
17782, 18953
|
15625, 16273
|
5548, 14397
|
18978, 19403
|
3033, 3789
|
3809, 4272
|
4287, 5530
|
1848, 2573
|
2764, 3010
|
14508, 14515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,785
| 105,872
|
28314
|
Discharge summary
|
report
|
Admission Date: [**2162-4-23**] Discharge Date: [**2162-4-30**]
Date of Birth: [**2090-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2162-4-23**]
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-Diag, SVG-OM2,
SVG-RCA)
History of Present Illness:
71 year old man who underwent a coronary artery CT last week
which revealed multivessel coronary artery disease. He continues
to have some chest and left shoulder discomfort upon waking up
that normally resolves after gentle stretching in the mornings.
He himself thinks this is positional given that he often sleeps
on his left shoulder. He is very active by horseback riding and
walking his dog. When pressed, he reports one episode of dyspnea
on exertion when going briskly up a [**Doctor Last Name **] during deer hunting
season last Fall. He presented for a cardiac catheterization
which he was found to have three vessel coronary artery disease
and is now being referred to cardiac surgery.
Past Medical History:
Coronary artery disease
Hypertension
? Dyslipidemia
Abnormal Holter with ventricular ectopy
Valvular heart disease (1+ MR, 1+ TR)
Mildly dilated ascending aorta
Obesity
Presumptive complex partial seizures
Vitamin B12 deficiency
Uremia x2 [**59**]-15 years ago
Social History:
Last Dental Exam: >1 year ago
Lives with: Wife
Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 68738**]
Occupation: Works part-time as a CPA
Cigarettes: Smoked no [x] yes []
Other Tobacco use: Denies
ETOH: Drinks one glass of wine per day and [**12-21**] rum-and-cokes per
week
Illicit drug use: Denies
Family History:
Premature coronary artery disease- Father died at
56 of a CVA, and may have had hypertension. Mother died at 51 of
heart failure secondary to possible MI; also had a history of
congenital heart disease
Physical Exam:
Pulse: 57 Resp: 16 O2 sat: 100/RA
B/P: 168/85
Height: 6' Weight: 218 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/Varicosities:
None
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]: 2 Left:2
Radial Right: 2 Left:2
Carotid Bruit Right: - Left:
Pertinent Results:
Intra-op TEE [**2162-4-23**]
Conclusions
PRE-CPB: 1. The left atrium is mildly dilated. No thrombus is
seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with inferolaterqal
hypokinesis..
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. AV pacing temporarily.
Preserved biventricular systolic function, with the LVEF now
45-55%. Some inferolateral hypokinesis. MR remains 1+. AI
remains trace. The aortic contour is normal post decannulation.
.
[**2162-4-29**] 10:34AM BLOOD WBC-5.0
[**2162-4-29**] 05:16AM BLOOD Hct-26.7*
[**2162-4-28**] 04:25AM BLOOD WBC-5.1 RBC-2.56* Hgb-8.4* Hct-26.4*
MCV-103* MCH-32.7* MCHC-31.7 RDW-13.9 Plt Ct-218
[**2162-4-27**] 03:11AM BLOOD WBC-5.3 RBC-2.58* Hgb-8.5* Hct-26.8*
MCV-104* MCH-33.0* MCHC-31.8 RDW-13.8 Plt Ct-191
[**2162-4-26**] 09:30PM BLOOD WBC-5.5 RBC-2.45* Hgb-8.4* Hct-24.8*
MCV-101* MCH-34.3* MCHC-33.9 RDW-13.5 Plt Ct-196
[**2162-4-29**] 05:16AM BLOOD UreaN-13 Creat-0.9 Na-139 K-3.9 Cl-104
[**2162-4-28**] 04:25AM BLOOD Glucose-106* UreaN-16 Creat-0.9 Na-136
K-4.0 Cl-101 HCO3-25 AnGap-14
[**2162-4-27**] 03:11AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-28 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 68739**] was admitted to the [**Hospital1 18**] on [**2162-4-23**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent cornary artery bypass grafting
to 4 vessels. 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. On postoperative day one, he was
transferred to the step down unit for further recovery. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. On POD 3 he developed confusion and exhibited strange
behavior. He was returned to the CVICU. A head CT did not
reveal any acute process. Neurology was consulted. MRI/A was
negative and it was determined that the patient was affected by
multi-factorial delirium. He transferred back to the floor.
Mental status cleared to his baseline. He was oriented and
appropriate at the time of discharge.
By the time of discharge on POD 7 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions.
Medications on Admission:
LAMOTRIGINE [LAMICTAL] 200 mg [**Hospital1 **]
LAMOTRIGINE [LAMICTAL] 100 mg HS
LISINOPRIL 10 mg daily
LORAZEPAM [ATIVAN] 0.5 mg TID, PRN for aura take one tablet, can
repeat in 10 minutes, not to exceed 3 tabs a day
METOPROLOL TARTRATE 12.5 mg [**Hospital1 **]
NITROGLYCERIN 0.4 mg Tablet sublingually as needed for chest
pain
as needed for may repeat every five minutes up to a total of 3
doses
OXCARBAZEPINE 600 mg [**Hospital1 **]
SIMVASTATIN 20 mg Daily
ASPIRIN 81 mg Daily
CALCIUM CARBONATE-VITAMIN D3 [CALTRATE 600 + D]- Dosage
uncertain
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease
Hypertension
? Dyslipidemia
Abnormal Holter with ventricular ectopy
Valvular heart disease (1+ MR, 1+ TR)
Mildly dilated ascending aorta
Obesity
Presumptive complex partial seizures
Vitamin B12 deficiency
Uremia x2 [**59**]-15 years 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 - trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**2162-6-2**] at 1:00p
Cardiologist: Dr. [**Last Name (STitle) **] [**2162-5-11**] at 3:20
[**Name6 (MD) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2162-9-13**] 10:30
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 13532**],[**Doctor First Name **] G. [**Telephone/Fax (1) 2010**] in [**3-25**]
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:[**2162-4-30**]
|
[
"413.9",
"789.00",
"414.01",
"293.0",
"401.9",
"345.40",
"427.69",
"440.0",
"266.2",
"272.4",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7833, 7894
|
4587, 6006
|
330, 414
|
8199, 8417
|
2611, 4564
|
9306, 9964
|
1775, 1979
|
6602, 7810
|
7915, 8178
|
6032, 6579
|
8441, 9283
|
1994, 2592
|
271, 292
|
442, 1141
|
1163, 1425
|
1441, 1759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,463
| 149,427
|
33138
|
Discharge summary
|
report
|
Admission Date: [**2110-11-30**] Discharge Date: [**2110-12-3**]
Date of Birth: [**2061-11-30**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 4640**] is a 48yo male w/RLE BKA who initally presented to
an area hospital 1 day s/p fall. He reports he fell down
approximately 5 hardwood stairs one day earlier at a friend's
house. +LOC, wife found him about 15 minutes later. His wife
brought him to the hopsital after she found him difficult to
arouse. He was found to have a ?SDH on CT imaging and was then
transferred to [**Hospital1 18**] for further care.
Past Medical History:
Right BKA (traumatic)
+tobacco
Social History:
Married. Drinks beer daily.
ETOH use prior to event falling down stairs, denies drug use
Family History:
Noncontributory
Physical Exam:
Upon admission:
T: 99 P: 89 BP: 121/72 RR: 22 SaO2: 91% on 3L
Eyes: pupils: 3-->2 bilaterally
Ears: TM clear bilaterally
Chest: echhymosis, tenderness chest wall. rhonchi bilaterally,
with limited effort. + R clavicular stepoff
Abdomen: soft, none-tender
Musculoskeletal: no spine tenderness, R BKA, MAEW. R pelvic
pain
Pulses: @+DP L LE
Neurologic: intact, symmetric; A&Ox3
Pertinent Results:
on admission:
[**2110-11-30**] 10:06PM HCT-33.3*
[**2110-11-30**] 06:09PM GLUCOSE-82 UREA N-10 CREAT-0.7 SODIUM-127*
POTASSIUM-5.0 CHLORIDE-91* TOTAL CO2-24 ANION GAP-17
[**2110-11-30**] 06:09PM WBC-11.2* RBC-3.87* HGB-13.2* HCT-38.1*
MCV-98 MCH-34.1* MCHC-34.6 RDW-14.1
[**2110-11-30**] 02:40PM TYPE-ART PO2-83* PCO2-42 PH-7.35 TOTAL CO2-24
BASE XS--2
[**2110-11-30**] 02:40PM GLUCOSE-77 LACTATE-0.9 NA+-122* K+-4.9
CL--89* TCO2-23
[**2110-11-30**] 02:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2110-11-30**] 02:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
on discharge:
Imaging:
CT C-spine [**11-30**] (OSH): none
CT abd [**11-30**] (OSH): R iliac fx c hematoma
CT head/face [**11-30**]: nondispl R zygomatic fx, L temp contusion (no
change), SDH along L tentorium
XR pelvis [**11-30**]:
XR R clavicle [**11-30**]: comm fx of mid-distal R clavicle, no
angulation
XR chest [**12-1**]: bilat LL air space dz - ?aspiration with
superimposed pneumonia
CTA [**12-2**]: Slight increase in size of subdural hematoma layering
along
the posterior falx cerebri. No change in hemorrhagic contusion
of left temporal lobe. No intracranial aneurysms or vascular
malformations. No venous thrombosis.
Brief Hospital Course:
He was brought to [**Hospital1 **] Hospital on [**2110-11-30**] after
transfer from [**Hospital 48825**] hospital for falling down stairs. A
trauma basic was called. The patient immediately had a chest
x-ray, CT chest, abdomen, and pelvis, and labs as described
previously. He was admitted to the Trauma ICU, serial
hematocrits and neurologic checks were followed closely.
He was seen by the neurosurgery team and was loaded with
Dilantin, to continue on dilantin 100 mg po tid x10 days total.
Ortho trauma service was consulted regarding his iliac [**Doctor First Name 362**]
fractures, and his clavicular fracture. It was decided that
these fractures could be managed conservatively and he was given
a sling, and is allowed to weight-bear as tolerated.
On [**2110-12-1**] he was transferred to the floor in stable condition.
While his labs were being followed, he was found to have a low
sodium level. Salt tablets were started and he was placed on a
1 liter free water restriction. Telephone call was placed to
[**Last Name (un) **] [**Last Name (un) **], patients' primary care provider in [**Name9 (PRE) **]; she is
aware that he will need follow up of his hyponatremia. A copy of
the discharge summary is being faxed to his primary cae
provider. [**Name10 (NameIs) **] reports that last year he had a low sodium of 133.
[**Name (NI) **] wife reporting that patient drinks large quantities of
beer daily.
Physical therapy was consulted to assess for safety. He was seen
again by PT and OT on [**2110-12-2**] and was felt to be safe for d/c
home. He had a repeat head CT, and CTA to rule out the
possibility of AV fistula or AVM, which was negative.
On [**2110-12-2**], neurosurgery signed off; he will follow up with
Neurosurgery in 4 weeks for repeat head imaging.
Discharge Medications:
1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*24 Capsule(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain: please do not drink, drive,
or operate machinery while taking this medication as it may make
you drowsy.
Disp:*40 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking constipating narcotic medications.
Disp:*60 Capsule(s)* Refills:*2*
6. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day): continue until instructed by your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **].
Disp:*180 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
sodium (Na) level to be drawn on [**2110-12-4**] and discussed with PCP,
[**Last Name (NamePattern4) **]. [**First Name (STitle) 77025**].
Discharge Disposition:
Home
Discharge Diagnosis:
1. s/p fall
2. Right iliac fracture with hematoma
3. Non-displaced right zygomatic fracture
4. Subdural hematoma along left tentorium
5. Comminuted fracture of mid-distal right clavicle
Discharge Condition:
Good
Discharge Instructions:
You have been seen and treated at [**Hospital1 **] Hospital
after a fall. You have been seen by the trauma, neurosurgery,
and orthopedics teams.
You are allowed to weight-bear as tolerated with a platform
walker prn. You must wear your right arm sling, and do not lift
greater than 5 lbs.
Your sodium level was low. You will need to RESTRICT your
fluids to 1 liter a day. Additionally, salt tablets have been
prescribed. You will need to get your sodium checked tomorrow
AM.
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.
* Redness around your wounds or drainage from your wounds.
* 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.
Followup Instructions:
You must follow up with the [**Hospital6 **] in [**Location (un) 12017**] for
a lab draw. Dr. [**First Name8 (NamePattern2) 77025**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 77026**] (fax
[**Telephone/Fax (1) 77027**]to report your sodium level; she is placing an
order for your labs to be drawn on [**2110-12-4**].
.
Please follow up with Dr. [**Last Name (STitle) 1005**] in the orthopedics clinic in
2 weeks. Please wear your arm sling. Please inform them that
you will need x-rays: AP pelvis, and 2 views of your right
clavicle for this appointment. Please call [**Telephone/Fax (1) 1228**] to make
an appointment as soon as possible.
.
You will need to follow up with Dr. [**Last Name (STitle) **] in 4 weeks. Please
inform that you will need a non-contrast head CT for this
appointment. Please call [**Telephone/Fax (1) 2731**] to make an appointment.
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2110-12-10**]
|
[
"276.1",
"507.0",
"810.03",
"802.4",
"852.22",
"808.41",
"305.1",
"V49.75",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5547, 5553
|
2666, 4446
|
278, 285
|
5783, 5789
|
1356, 1356
|
7421, 8455
|
927, 944
|
4469, 5524
|
5574, 5762
|
5813, 7398
|
959, 961
|
2025, 2643
|
230, 240
|
313, 751
|
1370, 2010
|
773, 805
|
821, 911
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,962
| 125,835
|
1846
|
Discharge summary
|
report
|
Admission Date: [**2118-12-5**] Discharge Date: [**2118-12-15**]
Date of Birth: [**2068-5-9**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 6378**]
Chief Complaint:
Shortness of breath and tachycardia.
Major Surgical or Invasive Procedure:
IVC filter placed at [**Hospital1 18**] by vascular surgery [**12-5**] by
intravenous jugular catheter.
History of Present Illness:
Mr. [**Known lastname 10321**] is a 50 year old male with grade 1 pilocytic
astrocytoma s/p recent suboccipital carniotomy brought to [**Hospital1 18**]
from [**Hospital3 **] center due to tachycardia and dyspnea noted
by rehab radiology faculty. His post-cramotomy ([**11-18**]) course
was complicated by repeat craniotomy ([**11-24**]) for re-bleeding and
residual mass as well as by RLL pneumonia (completed 7 day
course on Levofloxacin). He was discharged to rehab on dilantin
ppx and DVT prophylaxis (heparin 5000 U SC TID, originally
written on [**11-18**] on initial admit). Following d/c from [**Hospital1 18**] on
[**11-30**] and prior to this admission, Mr. [**Known lastname 10321**] reports minimal
ambulation and activity (without HA, nausea, vomiting, or
palpitations) with severe R calf pain and dyspnea while getting
physical therapy at rehab that morning. At that time he was
noted to have LE swelling, tachycardia, and dyspnea. Bilateral
DVT's were discovered on ultrasound ([**12-5**]) and Mr. [**Known lastname 10321**] was
transfered to the [**Hospital1 18**] ED.
In the ED, vitals were T 97.8 HR 119 BP 129/97 RR 24 SaO2 98%RA.
Chest CT confirmed massive bilateral PEs. He was evaluated by
his neurosurgeon, Dr. [**Last Name (STitle) **], who recommended starting heparin
at 1000 units/hour without bolus and repeating a head CT once
the patient was therapeutic (PTT 50-70). He also advised
avoiding TPA. Vascular was also consulted in case of emergent
embolectomy. He was transfered to the MICU. ECHO at that time
showed RV free wall hypokinesis and abnormal septal motion with
a dilated RV. He remained on [**3-13**] L nc with oxygen sats > 95%. He
had an IVC filter placed by the vascular team through a right IJ
approach. Head CT (once PTT > 50) showed no acute bleeding.
On admission to the ED, his wife noted that his right facial
droop and dyarthria have been improving. He has also recently
had a corneal abrasion [**3-12**] being unable to close his right eye.
On admission to the [**Hospital **] medical service his vitals were T
97.7 HR 105, BP 124/82 R 24 SaO2 97%RA. Physical exam was
notable for reduced lung sounds at the bases bilaterally (L>R)
with inspiratory wheezes and mild crackles appreciated at the
mid right throax and lower left lung base respectively.
Past Medical History:
Pilocytic astrocytoma s/p craniotomy x2
allergic rhinitis
s/p bil knee surgery [**3-12**] patellar subluxation [**2090**]
deviated nasal septum
migraine headaches
h/o right foot dorsal bone spur s/p exostectomy
Social History:
married, 2 children
denies tobacco/IVDU
1 glass wine/nt
Family History:
sister with [**Name (NI) 10322**]
Physical Exam:
AT DISCHARGE:
Vitals: T:98.8 P:114 BP:116/96 R:27 SaO2:97%
General: Alert male in no apparent distress.
HEENT: PERRL, oropharynx moist and without exudates
Neck: supple, no JVP elevation
Pulmonary: Lungs CTA bilaterally. poor effort.
Cardiac: regular, tachycardic, S1S2, no m/r/g
Abdomen: soft, normal bowel sounds, nontender
Extremities: 2+ DP pulses bilaterally, trace nonpitting edema
b/L
Skin: no skin changes noted
Neurologic:
-mental status: alert and oriented x 3; pt aware of current
events, able to discuss his hospitalization and demonstrated
clear understanding of active issues in his medical care. Able
to narrate history of present illness without
distraction/interruption.
-CN:4-6Hz horizontal and upbeat nastagmus (bilateral) with
lateral and vertical gaze, respectively. Right eye medial gaze
intact but lateral gaze absent entirely, up/downward gaze
intact. Left eye tracking intact, but left medial gaze impaired.
Mild paralysis of the entire right face with mild/moderate
dysarthria, tongue midline, right facial droop, normal facial
sensation, no buccal contraction on right, inability to lift
eyebrow. Shoulder shrug symmetric.
-strength 5/5 in bilateral hand grip, intrinsic finger muscles,
wrist extension, hip flexion, ankle dorsiflexion &
plantarflexion; sensation intact to light touch bilateral UE and
LE, reflexes 2+ at bilateral biceps and patellar
Pertinent Results:
Labwork on admission:
[**2118-12-5**] 12:12PM WBC-13.1* RBC-4.67 HGB-14.1 HCT-39.3* MCV-84
MCH-30.3 MCHC-36.0* RDW-13.8
[**2118-12-5**] 12:12PM NEUTS-68 BANDS-3 LYMPHS-14* MONOS-8 EOS-3
BASOS-0 ATYPS-2* METAS-1* MYELOS-1*
[**2118-12-5**] 12:12PM GLUCOSE-132* UREA N-18 CREAT-0.7 SODIUM-136
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15
[**2118-12-5**] 12:12PM PT-15.6* PTT-23.7 INR(PT)-1.4*
[**2118-12-5**] 12:12PM CK(CPK)-36*
[**2118-12-5**] 12:12PM CK-MB-NotDone cTropnT-0.01
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2118-12-5**]
CTA CHEST: There is massive bilateral pulmonary embolism with
thrombus
filling the left pulmonary artery extending into all lobar
branches and their respective segmental and subsegmental
branches. There is oligemia of the left lung though there is no
evidence of infarct. On the right, there is a saddle embolus at
the bifurfaction of the right pulmonary artery with clot
involving the lobar and segmental branches and several
subsegmental branches in the right lower lobe. There is evidence
of right heart strain with slight flattening of the
interventricular septum. The aorta and remainder of great
vessels are unremarkable. There is no pleural or pericardial
effusion. There is bilateral minimal dependent atelectasis. No
pneumorthorax. Limited views of the upper abdomen reveal no
abnormality.
IMPRESSION:
Massive bilateral pulmonary embolism. The findings of this study
were
communicated with Dr. [**Last Name (STitle) **] and and placed on the ED dashboard
at the time of initial review.
.
Portable TTE (Complete) Done [**2118-12-6**]
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. Left ventricular wall thicknesses are
normal. Overall left ventricular systolic function is low normal
(LVEF 50-55%). Left ventricular dysnchrony is present. Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. There is no aortic valve stenosis. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CT HEAD W/O CONTRAST Study Date of [**2118-12-5**]
IMPRESSION:
1. Postoperative changes in the cerebellum with possible
residual
tumor in the surgical bed. Recommend correlation with MRI.
2. Hypodensity in the right frontal lobe related to prior
ventriculostomy
catheter.
3. No evidence for active hemorrhage. No other acute
intracranial pathology
.
CT HEAD W/O CONTRAST Study Date of [**2118-12-6**]
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Postoperative change in the cerebellum with likely resolving
hematoma in the surgical bed. Continued attention is recommended
on followup imaging to exclude residual tumor.
.
VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2118-12-9**]
IMPRESSION:
Aspiration of thin barium consistencies when administered in cup
sips despite rightward head turn positioning.
.
Labwork on discharge:
White Blood Cells 7.5 K/uL 4.0 - 11.0
Red Blood Cells 3.64* m/uL 4.6 - 6.2
Hemoglobin 10.9* g/dL 14.0 - 18.0
Hematocrit 31.0* % 40 - 52
MCV 85 fL 82 - 98
MCH 30.0 pg 27 - 32
MCHC 35.1* % 31 - 35
RDW 14.0 % 10.5 - 15.5
Platelet Count 551* K/uL 150 - 440
PT 35.2* sec 10.4 - 13.4
PTT 37.7* sec 22.0 - 35.0
INR(PT) 3.7* 0.9 - 1.1
Glucose 112* mg/dL 70 - 105
Urea Nitrogen 17 mg/dL 6 - 20
Creatinine 0.7 mg/dL 0.5 - 1.2
Sodium 139 mEq/L 133 - 145
Potassium 4.7 mEq/L 3.3 - 5.1
Chloride 101 mEq/L 96 - 108
Bicarbonate 31 mEq/L 22 - 32
Anion Gap 12 mEq/L 8 - 20
Magnesium 2.1 mg/dL 1.6 - 2.6
Brief Hospital Course:
50 year-old male with recently diagnosed pilocytic astrocytoma
status post suboccipital carniotomy [**2118-11-18**] with return to
operative [**2118-11-24**] now presenting with massive pulmonary
emboli. The patient developed heparin-induced thrombocytopenia
with heparin therapy.
.
1. Pulmonary emboli: Massive bilateral pulmonary emoboli
initially treated with heparin gtt and IVC filter placement.
The patient was changed to argatroban when the diagnosis of HIT
was made. Coumadin was started when platelet count rose to
above 150. There was a greater than expected response to
coumadin after two doses of 5 mg daily, leading to INR 16. This
was attributed to concurrent dilantin use which has been
switched to keppra. The patient was started on coumadin 2 mg
daily [**2118-12-14**], with INR 3.5 on discharge. Goal INR is 2.5-3.5,
to err on the side of supratherapeutic INR rather than
subtherapeutic INR.
.
2. Thrombocytopenia: Positive heparin dependent antibodies. The
patient's platelets improved with discontinuation of heparin
products and use of argatroban. The patient's platelet count is
551 on discharge. THIS PATIENT SHOULD NOT RECEIVE ANY HEPARIN
PRODUCTS EVER AGAIN (this includes flushes and subQ heparin).
.
3. Pilocytic astrocytoma status post craniotomy: The patient
remained stable postoperatively. His dilantin was changed to
keppra for seizure prophylaxis as above. He was scheduled for
an outpatient appointment at the brain tumor clinic.
.
The patient is discharged to a rehabilitation center for
physical, occupational, and speech therapy.
Medications on Admission:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-9**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
10. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic TID (3 times a day) as needed.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for pro-motility.
14. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day) as needed for proph for presumed corneal abrasion
for 5 days.
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-9**] Sprays Nasal
QID (4 times a day) as needed for dry nasal mucous membranes.
Discharge Medications:
1. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Artificial Tear Ointment Ointment Sig: One (1)
Ophthalmic every four (4) hours as needed for pain: Appl to
RIGHT EYE.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain: all HO if temp >101, max dose
3g daily.
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
5. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic [**Hospital1 **] (2
times a day) for 2 days.
6. Maalox 200-200-20 mg/5 mL Suspension Sig: One (1) ML PO Q8H
(every 8 hours) as needed for heartburn.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipatin.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Pulmonary embolus
Heparin-induced thrombocytopenia
Secondary:
pilocytic astrocytome s/p craniotomy
R corneal abrasion
R facial palsy + dysarthia
Discharge Condition:
Medically stable for transfer to rehab.
Discharge Instructions:
Dear Mr. [**Known lastname 10321**],
You were admitted on [**2118-12-6**] for shortness of breath and
tachycardia resulting from bilateral pulmonary emboli (PE).
Chest CT scans on [**12-5**] and [**12-6**] confirmed one large PE in the
left pulmonary artery and a second large PE in the inferior
branchs of the right pumonary artery. Prior to admission to the
medical service, while on the ICU service, an IVC filter was
placed by vascular surgery following ultrasound evidence of
bilateral deep venous thrombi in your legs which were the source
of the clot travelling to the lungs. Anticoagulation was
initiated on [**12-5**] in the MICU and was continued upon transfer
to the medical floor. The cause of the clots was likely a
reaction to heparin called heparin-induced thrombocytopenia.
Phenytoin was discontinued and Keppra was started according to
the neurosurgeon's recommendations. Anti-heparin/PF4 antibody
screen was positive consistent with a diagnosis of Heparin
Induced Thrombocytopenia (HIT). Heparin was discontinued and
argatroban was initiated. Serial PT/PTT/INRs were measured and
coumadin was added [**12-9**] as per protocol. Serial INRs used to
titrate coumadin. During your admission, physical therapy worked
with you to continue your rehab schedule with good success in
helping you to ambulate with a walker. Speech/Swallow monitoring
was also performed while you were here and showed increased risk
for aspiration of thin liquids. Consequently, they recommended
thick liquid and soft solid diets as well as turning your head
to the right while swallowing during meals. You are being
discharged back to the rehab facility to continue with your
post-operative care and rehabilitation. Please continue to
follow up with neurosurgery service regarding post-operative
management.
The following were the changes to your medications:
Coumadin was started with an INR goal of 2.5-3.5
Dilantin changed to Keppra 1000 mg PO BID
Acetaminophen not to exceede 3g/day in setting of daily
coumadin.
Please take all medications as prescribed. A sheet is attached
with all the medications you should be taking.
Please keep all preciously scheduled appointments.
Followup Instructions:
Please call [**Telephone/Fax (1) 4775**] to schedule a follow-up appointment
with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 838**], two weeks
from discharge.
Brain [**Hospital 341**] Clinic: [**Name6 (MD) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2118-12-26**] 4:00pm on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]
Completed by:[**2118-12-15**]
|
[
"415.11",
"351.0",
"191.9",
"289.84",
"997.2",
"918.1",
"E878.6",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
12931, 13001
|
8484, 10063
|
312, 418
|
13200, 13242
|
4525, 4533
|
15470, 16106
|
3076, 3111
|
11588, 12908
|
13022, 13179
|
10089, 11565
|
13266, 15096
|
3126, 3126
|
3140, 3559
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7869, 8461
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15125, 15447
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236, 274
|
446, 2752
|
4547, 7855
|
3574, 4506
|
2774, 2986
|
3002, 3060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,809
| 110,341
|
48882
|
Discharge summary
|
report
|
Admission Date: [**2133-7-17**] Discharge Date: [**2133-7-20**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. [**Known lastname 18741**] is a 54 year old F with history of DMI, severe
gastroparesis, HTN, Grave's Disease and Hep C, who presents to
the ED with altered mental status. Of note, patient has been
admitted multiple times within the past year for DKA. Most
recent admission was [**Date range (1) 11768**] for DKA.
.
According to report the patient was brought in by EMS for change
in mental status and increased weakness. Glucose per EMS was
>800. According to ER notes, patient had spoken to PCP earlier
in the day regarding feeling lethargic. She was told to drink
lots of fluids. No trauma and no focal weakness. No further
history available in medical record.
.
In the ED, vitals were T 96, BP 171/85, HR 142, RR 18, O2sat
100% on FM. Initial labs showed a glucose of 872, AG 30 with
HCO3 3. Lactate was 5.9, K 7.0. She was combative and confused
and was intubated for airway protection. Intravenous access was
obtained with left femoral line. She received a total of 5L NS,
insulin bolus of 10U/hr followed by gtt at 6U/hr. CXR without
acute pulmonary process. Head CT was done due to altered mental
status and showed no evidence of ICH. Admitted to the [**Hospital Unit Name 153**] for
further management
.
On arrival to the [**Hospital Unit Name 153**] the patient is intubated, sedated. She is
tachycardic to the 120s.
Past Medical History:
1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**]
Several episodes of DKA (last one in [**2129**]), managed on 36U
Lantus plus HISS
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease s/p RAI [**2129**]
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
never been on antiviral therapy, acquired via blood transfusion
during surgery in [**2110**]
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-24**]
11.s/p TAH and pelvic floor surgery with bladder lift
12.Depression
13. Bone spurs in feet
Social History:
No smoking/EtOH/drugs. Lives at home with 2 daughters. [**Name (NI) **] lives
downstairs. She does not work.
Family History:
Mother: died of colon cancer
+ for DM-2
Physical Exam:
T 97.1 BP 123/87 HR 126 RR 16-18 O2 sat 100% on CPAP+PS 5/5,
FiO2 50%, RR 16
Gen: Patient is intubated, sedated.
[**Name (NI) 4459**] -
CV: Tachycardic, nl s1 s2, no m/r/g
Lungs: Clear bilaterally
Abd: Soft, NT, ND, +BS
Ext: No edema
Neuro -
Pertinent Results:
[**2133-7-17**] 06:15PM GLUCOSE-872* LACTATE-5.9* NA+-130* K+-7.0*
CL--97* TCO2-3*
[**2133-7-17**] 06:42PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2133-7-17**] 06:42PM GLUCOSE-937* UREA N-34* CREAT-2.0*#
SODIUM-128* POTASSIUM-5.2* CHLORIDE-90* TOTAL CO2-LESS THAN
[**2133-7-17**] 07:07PM GLUCOSE-747* LACTATE-5.4* NA+-136 K+-4.2
CL--106 TCO2-4*
[**2133-7-17**] 08:05PM GLUCOSE-664* LACTATE-3.7* NA+-138 K+-3.9
CL--111 TCO2-5*
[**2133-7-17**] 09:06PM GLUCOSE-588* LACTATE-2.7* NA+-140 K+-4.4
CL--112 TCO2-6*
[**2133-7-17**] 10:02PM GLUCOSE-526* LACTATE-2.2* NA+-140 K+-4.4
CL--115* TCO2-7*
[**2133-7-17**] 11:03PM GLUCOSE-468* LACTATE-1.9 NA+-139 K+-4.4
CL--114* TCO2-7*
Brief Hospital Course:
The patient was admitted to the ICU intubated due to DKA and
altered mental status. She was placed on an insulin drip and
her glucose steadily decreased from the 900's to the 200's, and
her anion gap closed from 20's to 10. She had a transient
decrease to blood glc of 33, but was given [**3-24**] an amp of D50 and
placed on D5W. Her glucose subsequently increased to 150,
stabilized throughout the next day, and was extubated. She then
was placed on Lantus [**Hospital1 **] with an insulin sliding scale which was
titrated to 20 units glargine [**Hospital1 **] by the [**Last Name (un) **] service with
plans for close outpt f/u.
Of note, the patient's ARF, severe electrolyte abnormalities and
acidosis had completely resolved at time of discharge.
The pt had low grade fevers and a mildly positive U/A (although
asymtomatic) and given her prior hx and DM, was discharged on a
7 day course of cipro.
Pt to f/u closely with [**Hospital **] clinic.
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg Tablet PO BID
Simvastatin 10 mg Tablet DAILY
Methimazole 15 mg Tablet PO BID
Amitriptyline 25 mg Tablet PO HS
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device INH [**Hospital1 **]
Aspirin 81 mg Tablet, Delayed Release daily
Montelukast 10 mg Tablet PO DAILY
Pantoprazole 40 mg Tablet, daily
Sulfasalazine 500 mg Tablet PO TID
Albuterol 90 mcg 1-2 Puffs INH q6H PRN
Hyoscyamine Sulfate 0.125 mg Tablet, SL [**Hospital1 **]
Gabapentin 300 mg PO Q12H
Metoclopramide 10 mg Tablet PO QIDACHS
Metoprolol Tartrate 25 mg Tablet PO BID
Oxycodone-Acetaminophen 5-325 mg Tablet PO Q4H PRN
Insulin Glargine 20U [**Hospital1 **]
Humalog Insulin Per sliding scale.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: [**1-21**]
Tablet, Delayed Release (E.C.)s PO once a day.
10. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
11. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-21**] inh Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
12. Hyoscyamine Sulfate 0.125 mg Tablet, Rapid Dissolve Sig: One
(1) Tablet, Rapid Dissolve PO twice a day.
13. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: take per oupt rx.
17. Lantus 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous twice a day.
18. Humalog 100 unit/mL Cartridge Sig: per scale Subcutaneous
QACHS: Take QACHS per sliding scale given to pt at d/c.
19. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
Diabetic Ketoacidosis
DM 1 uncontrolled with Complications (neuropathy)
Diabetic Gastroparesis
HTN
Hep C
[**Doctor Last Name 933**] Disease s/p RAI
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to ED if having FS>500, SOB, light-headedness, chest
pain, fevers.
Followup Instructions:
Patient to f/u at [**Hospital **] Clinic with Dr. [**Last Name (STitle) 61114**] in 1 week.
Patient to schedule f/u PCP appt in 2 weeks.
|
[
"493.90",
"242.00",
"530.81",
"250.13",
"250.63",
"401.9",
"346.90",
"357.2",
"070.70",
"272.0",
"584.9",
"276.1",
"276.9",
"276.7",
"536.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6947, 7001
|
3511, 4466
|
276, 288
|
7193, 7214
|
2758, 3488
|
7336, 7477
|
2438, 2480
|
5229, 6924
|
7022, 7172
|
4492, 5206
|
7238, 7313
|
2495, 2739
|
233, 238
|
316, 1649
|
1671, 2294
|
2310, 2422
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,282
| 147,304
|
39292
|
Discharge summary
|
report
|
Admission Date: [**2159-8-7**] Discharge Date: [**2159-8-13**]
Date of Birth: [**2092-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Chief Complaint: Fatigue
.
Reason for MICU transfer: Hypotension
Major Surgical or Invasive Procedure:
mechanical ventilation/intubation
History of Present Illness:
67 year old male with relapsed AML on chemo who presents with
fatigue and weakness.
He was recently admitted [**Date range (1) 86908**]/11 with febrile neutropenia.
At that time, he was treated for multifocal pneumonia with a
course of vanc/meropenem, and it was ultimately felt that he had
aspergillosis and was started on voriconazole. He was also
discharged on a 7 day course of cipro. Also had a recent
admission for strep viridens and E Coli bacteremia.
He had been feeling well at home until 2 days ago. He was seen
in onc clinic at that time and had a low grade fever that
self-resolved. Then started to feel chills the next day and
decided to come in for evaluation. Denies cough, SOB, nausea,
vomiting, abdominal pain, diarrhea, dysuria, and headache
In the ED, he triggered for tachycardia with rate 156 on
arrival, temp 103.5. He was rigoring and very warm to the
touch. Denied nuchal rigidity. Labs were significant for WBC
1.3 with 88% blasts, platelets 17, and elevated LFTs. Lactate
2.0. CXR showed irregular density in the superior aspect of the
RLL, increased compared to prior, concerning for worsening
infectious process. He was given vanc, cefepime, levofloxacin,
and acetaminophen. RUQ ultrasound was normal. BP was in the
80's after 2L IVF and right IJ CVL was placed. Levophed was
then started, and subsequently neosynephrine was added for
refractory hypotension. Shock ultrasound showed a trace
pericardial effusion. CVP was measured to be 12. BP now 93/56
and close to being maxed out on neo. Did get stress dose
steroids in ED. Given 7L IV fluids total in ED. Tachypneic in
mid 20's to 40's. Full code.
.
On arrival to the MICU, he reports feeling very discouraged and
fatigued.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
AML, dx'ed [**7-4**]. Treated with 7+3 induction and then
reinduction with MEC [**2-2**]. Refractory leukemia [**4-4**], started
Dacogen. Recently completed cycle of dacogen [**7-25**].
Osteoarthritis
S/p L TKA - [**2155**]
S/p R THA - [**2154**]
Seasonal allergies - x 30 years
Hypertension - [**2151**]
H/o colonoscopy [**2154**] negative
GERD - [**2155**]
Right septic shoulder - [**10/2158**]
MSSA sepsis - [**10/2158**]
SVT while in ICU - [**10/2158**]
R calf nodule - [**11/2158**]
Hyperbilirubinemia - [**2158-10-25**]
Pulmonary nodules - [**11/2158**] (stable or resolved since thattime
aside from 6 mm LLL nodule on [**5-/2159**] scan)
Herniated disks with chronic back pain - [**2135**]
Social History:
Patient lives alone. Retired firefighter and Marine Corp
member. Photographer and car enthusiast. Never smoker, no
alcohol or other drug use.
Family History:
Father was obese and a heavy smoker, unknown cause of death.
Mother suffered from rheumatoid arthritis and died at age 59.
No known family history of pulmonary disease.
Physical Exam:
Vitals: 96.2 110 98/63 23 100%3L
General: Alert, oriented, diaphoretic and mildly tachypne
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, right IJ in place, no LAD
CV: Regular rate and rhythm with hyperdynamic heart sounds,
normal S1 + S2, no murmurs, rubs, gallops
Lungs: Few crackles at the bases, no wheezes, rales, ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: cool extremities, 1+ pulses, no edema.
Pertinent Results:
WBC 1.3 (12L 88blasts 15 NRBCs) Hgb 9.2 Hct 26.4 Plt 17
Na 137 K 4.0 Cl 102 Bicarb 22 BUN 25 Creat 1.1 Gluc 124
ALT 48 AST 44 AlkP 537 TB 2.3 LDH 450
Lactate 2.0
UA sm blood, <1RBC, <1 epi, otherwise negative
[**2159-8-12**] 02:47AM BLOOD WBC-21.3* RBC-3.29* Hgb-9.6* Hct-27.5*
MCV-84 MCH-29.1 MCHC-34.8 RDW-16.7* Plt Ct-11*
[**2159-8-6**] 10:44PM BLOOD WBC-1.3* RBC-3.27* Hgb-9.2* Hct-26.4*
MCV-81* MCH-28.2 MCHC-34.9 RDW-15.9* Plt Ct-17*
[**2159-8-12**] 02:47AM BLOOD Neuts-0 Bands-0 Lymphs-2* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-98* NRBC-1*
[**2159-8-6**] 10:44PM BLOOD Neuts-0 Bands-0 Lymphs-12* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-88* NRBC-15*
[**2159-8-12**] 02:47AM BLOOD Plt Smr-RARE Plt Ct-11*
[**2159-8-12**] 02:47AM BLOOD Glucose-103* UreaN-38* Creat-1.3* Na-139
K-3.6 Cl-111* HCO3-18* AnGap-14
[**2159-8-6**] 10:44PM BLOOD Glucose-124* UreaN-25* Creat-1.1 Na-137
K-4.0 Cl-102 HCO3-22 AnGap-17
[**2159-8-12**] 02:47AM BLOOD ALT-13 AST-22 LD(LDH)-526* AlkPhos-144*
TotBili-8.3* DirBili-6.2* IndBili-2.1
[**2159-8-6**] 10:44PM BLOOD ALT-48* AST-44* LD(LDH)-450* AlkPhos-537*
TotBili-2.3*
[**2159-8-10**] 11:02PM BLOOD CK-MB-3 cTropnT-0.02*
[**2159-8-12**] 02:47AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.9
[**2159-8-7**] 07:54AM BLOOD Albumin-2.8* Calcium-6.9* Phos-3.9
Mg-1.3*
[**2159-8-9**] 11:16PM BLOOD Tobra-2.1*
[**2159-8-12**] 03:18AM BLOOD Type-ART Temp-36.5 pO2-138* pCO2-37
pH-7.33* calTCO2-20* Base XS--5 -ASSIST/CON Intubat-INTUBATED
[**2159-8-12**] 03:18AM BLOOD Lactate-1.3
[**2159-8-10**] 08:27AM BLOOD O2 Sat-98
[**2159-8-12**] 03:18AM BLOOD freeCa-1.17
[**2159-8-8**] 06:40PM BLOOD VORICONAZOLE-Test Name
[**2159-8-7**] 07:54AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
IMAGING:
[**8-6**] CXR: Increasing conspicuous irregular opacity of right
lower lobe,
likely represents worsening infectious process though cannot
exclude
malignancy. Strongly advise imaging to resolution.
[**8-7**] RUQ US:
Normal right upper quadrant ultrasound, except for simple right
renal cyst.
[**8-7**] CT chest/abd/pelvis:
1. Progression of pulmonary opacities in bilateral lower lobes
of the lungs with non-enhancing wedge like opacity in the right
lung, and nodular opacities in the right upper lobe likely
inflammatory or infectious in nature. Associated likely reactive
mediastinal lymphadenopathy.
2. No acute intrabdominal process.
3. Mild periportal edema suggesting third spacing.
3. Bilateral cortical and parapelvic renal cysts.
4. Splenomegaly.
5. Lumbar spine and left hip DJD.
[**8-8**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Overall left ventricular systolic function is low normal (LVEF
50-55%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a prominent fat pad.
[**8-8**] Hip xray: 1. No evidence of joint effusion.
2. Right total hip arthroplasty without hardware complications.
3. Left hip degenerative changes.
[**8-8**] Knee xray:
Left total knee arthroplasty without hardware complications.
Small suprapatellar effusion.
Brief Hospital Course:
Primary Reason for Hospitalization: 67 year old male with
relapsed AML on chemo who presented with septic shock from
multiple organisms and who passed away in the MICU.
#. Septic Shock/Neutropenic Fever: The patient had positive
blood cultures with E. coli as well as VRE. He also appeared to
have a severe pulmonary process which was thought to be a
progression of his recent pulmonary aspergillosis. He was
treated with broad spectrum antibiotics and antifungals in
consulation with the infectious disease team but he continued to
decompensate. He required multiple pressors to maintain his
blood pressure. He began to have increased respiratory distress
and required intubation. As the patient's prognosis began to
look worse a family meeting was called with ICU and Oncology
Attendings present with the patient's brother [**Name (NI) **] [**Name (NI) 86903**](HCP)
and his wife. [**Name (NI) **] reported that the patient would not want a
long drawn out course if his condition was terminal. He reported
that the patient would want to be comfortable in his last hours.
The patient was made CMO. He was left on mechanical ventilation
but measures not supporting comfort were withdrawn. He passed
away on [**2159-8-13**] at 1420
.
#. Refractory AML: Was receiving palliative Dacogen infusions,
last dose 8/31 with chronic neutropenia with ANC=0 and blast 88%
of WBC. On admission he had a WBC count of 1.3 w ANC of 0 and
90% blasts, but throughout the course of his stay and
progression of his infection his WBC count rose to 20 w 98%
blasts. He was followed by Heme/Onc during his stay, who briefly
started him on hydroxyurea, however his prognosis remained
dismal. Following a goals of care discussion between his
family, ICU staff, and the heme/onc team, he was made CMO and
passed away.
.
#. Respiratory Failure: Grew increasingly tachypneic during his
hospital course due to compensation for significant metabolics
acidosis from his sepsis with underlying parenchymal
disease/infection. He eventually began to tire and had trouble
keeping up an adequate minute [**Last Name (LF) 86909**], [**First Name3 (LF) **] he required
intubation on [**8-9**]. He was still on the ventillator when he was
made CMO, and the decision was made to wait to extubate until he
passed from cardiac death. He was extubated following his
death.
# Acute renal insuffiency: Creatinine slightly elevated to 1.1
on admission from baseline 0.8-1.0, rose to 1.3 during
admission. This was attributed to low flow state due to sepsis
as well as effect of some obligate nephrotoxins with
antibiotics. This was managed with treatment of his underlying
sepsis and care to avoid any other unnecessary nephrotoxins.
.
#. Abnormal LFTs: Elevated bili to 2.3 with alk phos of 537.
Has had similar abnormalities on prior admissions for sepsis
which typically resolved with hydration.
Bilirubin continued to rise throughout his hospital stay, but
alk phos fell to nearly normal levels. No clear etiology, RUQ
US was unrevealing. Repeat abdominal imaging was considered,
however he never was stable enough to leave the floor for the
study.
Medications on Admission:
Cipro XR 500mg po daily x 7 days (last day [**2159-8-8**])
Voriconazole 400mg po q12h
Metoprolol tartrate 25mg po bid
Omeprazole 20mg po daily
Acyclovir 400mg po q8h
Multivitamin 1 tab po daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"205.02",
"995.92",
"780.61",
"486",
"284.1",
"288.03",
"038.42",
"518.81",
"427.89",
"E933.1",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"33.24",
"38.91",
"96.04",
"96.71",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
11172, 11181
|
7773, 10894
|
368, 403
|
11233, 11243
|
4176, 7750
|
11299, 11310
|
3466, 3636
|
11139, 11149
|
11202, 11212
|
10920, 11116
|
11267, 11276
|
3651, 4157
|
2180, 2564
|
281, 330
|
431, 2161
|
2586, 3287
|
3303, 3450
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,307
| 140,233
|
45573
|
Discharge summary
|
report
|
Admission Date: [**2120-5-21**] Discharge Date: [**2120-6-8**]
Date of Birth: [**2057-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
RLE wound infection
Major Surgical or Invasive Procedure:
Right BKA
History of Present Illness:
62M with h/o NASH Cirrhosis, ESRD on HD, non healing right ankle
wound [**3-12**] open fracture [**Month (only) **] of this year, who was recently
discharged on [**2120-5-10**] after a prolonged hospital course from [**3-26**]
to [**5-10**], during which time his right ankle wound was I/D'd 5
times, which grew out VRE / [**Female First Name (un) 564**] Galbrata, for which he was
put on Dapto / Micafungin, and vac dressing change q3d. His
hospital course was also complicated by cirrhosis
encephalopathy, GIB [**3-12**] esophageal/gastric varices, ESRD due to
hepatorenal syndrome requiring HD, and hypotension requiring
midodrine. Patient was discharged to [**Hospital1 **] on [**5-10**].
.
While in [**Hospital1 **], patient continued to make improvements. His
mental status was improving, and he had no pain, no more GIB.
His wounds were stable, and he had no fevers when he was there.
He was sent to [**Hospital3 **] for LVP yesterday, when
paracentesis was done with 4.5-5L fluid removed. His flexiseal
was pulled, and he started to use bed pans. He started to eat
better as well, but he was found to have some cough and
shortness of breath after he ate. He also had dysphagia, and
felt that the food was stuck in his throat after he ate. He
complained of pain in his mouth, on his tongue and at the back
of his throat. Because of these issues, he was not getting
enough nutrition. [**Hospital1 **] scheduled a barium swallow study for
him at [**Hospital1 18**] on this Thursday, and per patient's friend [**Name (NI) 26580**],
[**Name (NI) **] was going to start TPN tonight after his ortho
appointment.
.
Pt was seen in the ortho clinic today and found to have frank
purulence when the Vac dressing was removed. Patient was then
directed admitted to orthopedic service. Since the patient is
medically very complicated, patient was then transferred to
medicine service with ortho as a consulting service following
the patient.
.
On the floor, patient is alert and oriented x3. Pt denied
chest/abdominal pain, no shortness of breath, no leg pain, but
did complain of tongue/mouth/throat pain. No fever, chills.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- RLE infection: pt had a chronic RLE cellulitis and
osteomyelitis secondary to a traumatic R tibiotalar posterior
dislocation and open
trimalleolar fracture s/p external fixation [**2120-3-7**], s/p 5
debridements and revisions with non healing R ankle wound during
the last admission and was discharged to LTAC with vac dressing
and on daptomycin and micafungin to treat VRE and [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 563**] until [**2120-5-26**].
- Cirrhosis likely due to Steatohepatitis, followed by Dr. [**First Name (STitle) 679**].
Last tap [**2120-5-3**] when 13L was removed. Complicated by
encephalopathy and esophageal and gastric varices. Pt is not a
transplant candidate.
- H/o GIB due to esophageal and gastric varices
- ESRD due to hepatorenal syndrome, on HD
- Type 2 Diabetes Mellitus with extreme insulin resistence
- Hypotension requiring midodrine
- Hyperlipidemia
- Obstructive Sleep Apnea on CPAP
- Irritable Bowel Syndrome
- Gastroparesis
- Obesity
- Rheumatoid Arthritis
- Depression
Social History:
Has PhD in Psychology-retired Mass DMH psychologist. No tobacco,
no ETOH, no other drugs.
Family History:
No h/o clotting disorders. Mother died of PNA in 80s, also had
thyroid disease. Father died of heart disease in 70's, had
cancer (unknown type), tobacco and alcohol abuse. Family h/o
T2DM.
Physical Exam:
Vitals - T:96.0 BP:96/54 HR:65 RR:20 02 sat:95% on room air
GENERAL: Pleasant, well appearing, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. [**3-16**]
systolic murmur best heard at LUSB. No rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally when auscultating from
anterior.
ABDOMEN: Obese. NABS. Soft, NT, ND. No HSM.
EXTREMITIES: Right LE has a large deep ulcerated lesion, no pus;
dressing in place, c/d/i, no surround erythema. LLE has
dressing in place, and foot in soft boots. Both [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] chronic
stasis changes.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Mild asterixis
present.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
[**2120-5-21**] 05:45PM BLOOD WBC-7.0 RBC-3.72* Hgb-10.6* Hct-36.6*
MCV-98 MCH-28.5 MCHC-29.0* RDW-17.4* Plt Ct-106*
[**2120-5-21**] 05:45PM BLOOD Neuts-71.6* Lymphs-19.4 Monos-5.0 Eos-3.6
Baso-0.3
[**2120-5-21**] 05:45PM BLOOD Plt Ct-106*
[**2120-5-21**] 05:45PM BLOOD ESR-34*
[**2120-5-21**] 05:45PM BLOOD Glucose-77 UreaN-18 Creat-4.0* Na-141
K-4.2 Cl-101 HCO3-28 AnGap-16
[**2120-5-21**] 05:45PM BLOOD ALT-29 AST-69* AlkPhos-329* TotBili-2.0*
[**2120-5-21**] 05:45PM BLOOD Albumin-3.2* Calcium-9.4 Phos-3.5# Mg-2.0
DISCHARGE LABS:
MICROBIOLOGY:
- [**2120-5-27**] MRSA screen: negative
- [**2120-5-27**] Urine culture: no growth
- [**2120-5-28**] Peritoneal fluid: gram stain - 4+ PMNs, no organsims;
culture - PENDING **
- [**2120-5-28**] Peritoneal fluid (blood culture bottles): ESBL E. coli
- [**2120-5-28**] Blood culture: PENDING **
- [**2120-5-28**] C. difficile toxin: negative
- [**2120-5-29**] Stool culture: no salmonella/shigella/campylobacter;
no O&P; C. difficile negative
- [**2120-5-30**] Blood culture: PENDING **
- [**2120-5-30**] Peritoneal fluid: gram stain - 4+ PMNs, no organsims;
culture - PENDING **
- [**2120-6-1**] Blood culture: PENDING **
- [**2120-6-1**] Blood culture: PENDING **
STUDIES:
[**2120-5-27**] ECG: Sinus rhythm. Left atrial abnormality. Left
anterior fascicular block and possible additional
intraventricular conduction delay. Non-specific ST-T wave
abnormalities. Since the previous tracing of [**2120-4-12**] the rate is
faster and further ST-T wave changes are present.
[**2120-5-27**] CXR: There are persistent low lung volumes. Small
bilateral pleural effusions, left greater than right, associated
with adjacent atelectasis are unchanged. There is no evidence of
pneumothorax. Right hemodialysis catheter is in place. Left PICC
line has been repositioned, the tip is not clearly visualized,
likely ends at the cavoatrial junction. Cardiac size cannot be
evaluated.
[**2120-5-27**] CT C-spine, T-spine: IMPRESSION: 1. No obvious evidence
of interim diskitis/osteomyelitis on limited evaluation.
Evaluation for an epidural collection is markedly limited in the
absence of iv contrast. MRI would be more sensitive, even
without iv contrast, if the patient can tolerate MRI. 2. No
acute cervical fracture or malalignment. Unchanged DISH and
multilevel spondylosis.
[**2120-5-29**] Liver/GB ultrasound: IMPRESSION: 1. Cirrhosis and portal
hypertension, with splenomegaly and large ascites. 2.
Cholelithiasis, without evidence of acute cholecystitis.
[**2120-5-30**] TTE: Left ventricular wall thicknesses are normal. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). Doppler parameters are indeterminate for
left ventricular diastolic function. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is an anterior space which most
likely represents a prominent fat pad. IMPRESSION: Hyperdynamic
LV function. Suboptimal image quality.
[**2120-5-30**] ECG: Sinus tachycardia. Left atrial abnormality. Left
axis deviation. Left anterior fascicular block. ST-T wave
abnormalities. Since the previous tracing [**2120-5-27**] the rate is
faster.
[**2120-5-30**] Bilateral LE veins: IMPRESSION: No definite evidence of
lower extremity DVT. However, calf veins were not visualized.
[**2120-5-31**] CXR: IMPRESSION: Small right and moderately large left
pleural effusions are stable. Increasing consolidation in the
left perihilar region is most likely pneumonia. Early followup
is recommended.
[**2120-6-1**] CXR: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Unchanged moderate cardiomegaly,
unchanged position of monitoring and support devices. Unchanged
bilateral pleural effusion, left more than right, unchanged
mild-to-moderate pulmonary edema. No newly occurred focal
parenchymal opacities.
[**2120-6-1**] CXR:
[**2120-6-2**] CXR:
Brief Hospital Course:
62M with h/o NASH Cirrhosis, esophageal/gastric varices, GIB,
ESRD on HD, non healing right ankle wound [**3-12**] open fracture who
was recently hospitalized [**Date range (2) 97191**] was directly admitted
today after he was found to have frank pus coming out of his
right ankle wound following vac dressing removal in the ortho
clinic today.
.
# RLE infection: pt had a chronic RLE cellulitis and
osteomyelitis secondary to a traumatic R tibiotalar posterior
dislocation and open trimalleolar fracture s/p external fixation
[**2120-3-7**], s/p 5 debridements and revisions with non healing R
ankle wound during the last admission and was discharged to LTAC
with vac dressing and on daptomycin and micafungin to treat VRE
and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] until [**2120-5-26**]. He was seen in the ortho
clinic on [**5-21**], and after the vac dressing was removed frank pus
was seen. He was initially managed on daptomycin and
micafungin, orthopedics was also following during his stay. He
eventually was taken to the OR for a BKA on [**2120-6-3**] in hopes of
removing the source of bacteremia. Post operatively his wound
healed well, however his mental status failed to improve and his
mental status did not improve post operatively. Also
post-operatively he became more tachycardic, and with an
increasing white count and increased work of breathing. He had
a blood culture from his HD line that grew out yeast, and there
was concern that he was becoming fungemic, on [**2120-6-7**] he was
made DNR, with the decision not to escalate care any further.
That night he became progressively more hypotensive, was on
maximum doses of pressors and eventually expired early in the
morning on [**2120-6-8**].
.
# Cirrhosis: Large volume paracentesis were done on [**2120-5-3**] when
13L was removed, and [**2120-5-20**] when 4.5L was
removed. His liver disease had been complicated by
encephalopathy and esophageal and gastric varices/GIB during the
last admission. Patient was not a transplant candidate. He was
continued on lactulose, rifaximin, nadolol and PPI throughout
his stay. He periodically underwent paracenteses to help with
his work of breathing. His mental status deteriorated
throughout his stay and post operatively he did not fully
recover his mental status, remained intubated and expired early
in the morning on [**2120-6-8**].
.
# ESRD: thought to be due to hepatorenal syndrome. Patient was
continued on HD initially, also continued on calcium acetate and
midodrine. However, as he became more progressively hypotensive
requiring pressors, he was transitioned to CVVH for renal
replacement therapy for a period of time.
.
# Hypotension: Patient's blood pressure remained at baseline
80s and 90s initially during his hospital stay however as he
became septic requiring ICU care he needed pressors for blood
pressure support, and was never able to be weaned off pressors.
Medications on Admission:
- Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
- Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
- Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
- Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
- Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
- Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: please do not give> 2g per day.
- Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day): titrate to [**4-11**] loose BMS daily (not watery). this
is for hepatic encephalopathy NOT just simple constipation.
- Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
- Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a
day).
- Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
- Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
- Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Eight (8) MG
Injection Q8H (every 8 hours) as needed for nausea.
- Micafungin 100 mg Recon Soln Sig: One Hundred (100) MG
Intravenous Q24H (every 24 hours): last day [**2120-5-26**].
- Daptomycin 500 mg Recon Soln Sig: Nine Hundred (900) mg
Intravenous Q48H (every 48 hours): last day [**5-26**].
- Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
- Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
- Insulin Glargine 100 unit/mL Cartridge Sig: Fifty (50) unit
Subcutaneous at bedtime.
- Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS: please see the attached sliding scale.
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"730.07",
"713.5",
"V58.67",
"456.21",
"585.6",
"327.23",
"038.9",
"250.60",
"278.01",
"730.16",
"995.92",
"571.5",
"785.52",
"311",
"250.40",
"276.52",
"789.59",
"584.9",
"572.4",
"518.81",
"996.67",
"357.2",
"536.3",
"041.4",
"567.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"84.15",
"96.6",
"77.67",
"39.95",
"78.67",
"96.72",
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14130, 14139
|
9264, 12205
|
334, 345
|
14191, 14201
|
5107, 5107
|
14257, 14268
|
3926, 4118
|
14160, 14170
|
12231, 14107
|
14225, 14234
|
5660, 9241
|
4133, 5088
|
275, 296
|
373, 2746
|
5123, 5643
|
2768, 3803
|
3819, 3910
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,221
| 120,949
|
40451
|
Discharge summary
|
report
|
Admission Date: [**2121-5-26**] Discharge Date: [**2121-6-3**]
Date of Birth: [**2048-5-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2121-5-26**] Aortic valve replacement ([**First Name8 (NamePattern2) 11688**] [**Male First Name (un) 923**] epic tissue)
History of Present Illness:
This 72 year old gentleman with known aortic stenosis has been
followed by serial echocardiograms. His most recent
echocardiogram revealed severe aortic stenosis with new left
ventricular hypertrophy. His current symptoms include dyspnea on
exertion, exercise intolerance and fatigue. Given the
progression of his disease, he has been referred to Dr. [**Last Name (STitle) **]
for aortic valve surgery.
Past Medical History:
Aortic stenosis
Hypertension
Hyperlipidemia
Colonic polyps
History of Gastric Ulcer
Hepatitis A
Obesity
s/p Appendectomy
Social History:
Lives with: Wife in [**Name2 (NI) **], MA
Occupation: Retired
Tobacco: Smoked in service. 1-2ppd for 4-5 years.
ETOH: **5-6 beers daily**
Family History:
Non-contributory
Physical Exam:
Pulse: 70 SR Resp: 18 O2 sat: 98%
B/P Right: 170/63 Left: 160/66
Height: 68" Weight: 275
General: WDWN in NAD
Skin: Warm [X] Dry [X] intact [X] Well healed LLQ scar
HEENT: NCAT [X] PERRLA [X] EOMI [X] sclera anicteric, OP benign
Neck: Supple [X] Full ROM [X] FROM. No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, III/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] small umbilical hernia noted. Abdomen obese.
Extremities: Warm [X], well-perfused [X] Trace-1+ LE Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit - Transmitted bilaterally vs bruit
Pertinent Results:
[**2121-5-26**] Intraop TEE
PRE-CPB:
The left atrium is markedly dilated. 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. 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. There are three aortic valve leaflets. The
aortic valve leaflets are severely thickened/deformed.
Significant aortic stenosis is present. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is moderate thickening of the mitral valve
chordae. There is chordal [**Male First Name (un) **]. Trivial mitral regurgitation is
seen.
POST-CPB:
There is a bioprosthetic valve in the aortic position. The valve
appears well seated with normally mobile leaflets. There are no
apparent paravalvular leaks. The peak gradient across the aortic
valve is 33mmHg, the mean gradient is 19mmHg with a CO of
7L/min.
The LV systolic function is normal, estimated EF>55%. There is
no evidence of aortic dissection.
.
[**2121-6-3**] WBC-5.1 RBC-2.50* Hgb-8.9* Hct-25.3* Plt Ct-84*
[**2121-6-2**] WBC-5.0 RBC-2.42* Hgb-8.7* Hct-24.0* Plt Ct-70*
[**2121-6-1**] WBC-5.9 RBC-2.49* Hgb-8.9* Hct-25.1* Plt Ct-71*
[**2121-5-31**] WBC-5.3 RBC-2.60* Hgb-9.4* Hct-25.1* Plt Ct-68*
[**2121-5-30**] WBC-6.6 RBC-2.62* Hgb-9.3* Hct-26.6* Plt Ct-86*#
[**2121-5-29**] WBC-8.0# RBC-2.80* Hgb-9.7* Hct-28.5* Plt Ct-54*
[**2121-5-28**] WBC-19.6*# RBC-3.08* Hgb-10.8* Hct-31.0* Plt Ct-62*
[**2121-5-27**] WBC-12.4* RBC-3.21* Hgb-11.2* Hct-31.6* Plt Ct-51*
[**2121-6-3**] PT-31.1* PTT-74.0* INR(PT)-3.1*
[**2121-6-2**] PT-32.7* PTT-73.7* INR(PT)-3.2*
[**2121-6-2**] PT-33.4* PTT-60.4* INR(PT)-3.3*
[**2121-6-2**] PT-34.7* PTT-76.2* INR(PT)-3.5*
[**2121-6-1**] PT-30.9* PTT-75.4* INR(PT)-3.0*
[**2121-6-1**] PT-36.4* PTT-79.3* INR(PT)-3.7*
[**2121-6-3**] Glucose-105* UreaN-35* Creat-1.4* Na-137 K-3.8 Cl-102
HCO3-26
[**2121-6-2**] Glucose-104* UreaN-43* Creat-1.5* Na-135 K-3.7 Cl-101
HCO3-27
[**2121-6-1**] Glucose-103* UreaN-44* Creat-1.7* Na-135 K-3.6 Cl-100
HCO3-30
[**2121-5-29**] Glucose-103* UreaN-38* Creat-1.4* Na-135 K-4.1 Cl-103
HCO3-25
[**2121-5-28**] Glucose-120* UreaN-34* Creat-1.9* Na-136 K-4.7 Cl-103
HCO3-26
[**2121-5-27**] Glucose-132* UreaN-30* Creat-1.8* Na-135 K-4.8 Cl-103
HCO3-26
[**2121-6-3**] Calcium-7.9* Phos-3.8 Mg-2.3
Brief Hospital Course:
He was admitted for same day surgery and was brought to the
operating room for aortic valve replacement. See operative
report for further details. In summary he underwent an aortic
valve replacement with 23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic tissue valve. His bypass
time was 71 minutes with a crossclamp of 54 minutes. He received
Cefazolin for perioperative antibiotics. Following surgery, he
was transferred to the intensive care unit for post operative
management. That evening he was weaned from sedation, awoke
neurologically intact and was extubated without complication.
Post operative day one he was started on betablockers and lasix
for diuresis. All tubes lines and drains were removed per
cardiac surgery protocol.
.
During his post-operative recovery he developed acute kidney
injury with peak creatinine increasing to 1.9 with baseline 1.1.
This was trending down at the time of discharge.
.
He also had post-operative thrombocytopenia (his pre-op platelet
count was 100K), a heparin dependent antibody was sent. It was
was inconclusive on [**2121-5-27**] and repeated [**2121-5-28**] which was weakly
positive. Hematology was consulted and based on the optical
density did not believe this to be a true heparin induced
thrombocytopenia so a serotonin release assay was sent which
eventually came back as negative.
.
The patient also had post-operative atrial fibrillation.
Amiodarone was started with conversion back to normal sinus
rhythm. Given postop atrial fibrillation and possibility of
HITT, he was started on Argatroban and Coumadin therapy.
Warfarin was dosed for a goal INR between 2.0 to 2.5. Prior to
discharge, arrangements were arranged and confirmed with Dr.
[**Last Name (STitle) 32496**] phone who will monitor prothrombin time as an
outpatient. At discharge, he was in a normal sinus rhythm.
.
Patient also experienced urinary retention. Foley was
re-inserted and patient started on Flomax. At discharge, foley
catheter will remain and prophylactic antibiotics should be
continued given recent valve surgery. Prior to discharge,
arrangements were made with a local urologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
Finally the patient had sternal drainage that appeared to be old
blood, which resolved over a few days following several
additional doses of Cefazolin. He was eventually cleared for
discharge to home with VNA services on postoperative day eight.
Medications on Admission:
Atenolol 25mg daily
Aspirin 81mg daily
Zocor 20mg QHS
Lisinopril/HCTZ 20/12.5mg daily
Multivitamins
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: with am lasix.
Disp:*5 Tablet(s)* Refills:*0*
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
5. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: please have INR checked [**6-5**] for further dosing - please
take 1 tablet [**6-3**] and [**6-4**] then VNA to check INR [**6-5**].
Disp:*60 Tablet(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0*
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
please take 400 mg once a day for seven days on tuesday [**6-10**]
reduce to 200 mg - 1 tablet until follow up with cardiologist .
Disp:*37 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): dose reduced due to amiodatone .
Disp:*30 Tablet(s)* Refills:*0*
15. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for
10 days: until foley removed - follow up with urology on [**6-11**].
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic stenosis s/p Aortic valve replacement
Thrombocytopenia - hitt negative by serotonin
Post operative atrial fibrillation
Post operative urinary retention with catheter placement x2
Hypertension
Hyperlipidemia
Colonic polyps
Gastric Ulcer
Hepatitis A
Obesity
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram and Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
+2 lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Foley to leg bag until follow up with urologist on [**6-11**] due to
failure to void
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2121-6-19**] at 1:30pm
Cardiologist: Dr [**Last Name (STitle) 8579**] [**2121-6-26**] at 3:15 pm
Urology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2121-6-11**] at 10:15 am - [**Telephone/Fax (1) 88631**] (this
is the urology practice recommended by your PCP office [**Name Initial (PRE) **] please
continue antibiotics and foley to leg bag
***Wound check: [**6-10**] at 10:45 AM [**Hospital Ward Name **] 2A***
Please call to schedule appointments with:
Primary Care Dr [**Last Name (STitle) 32496**] in [**4-29**] weeks ([**Telephone/Fax (1) 42946**])
Labs: PT/INR for Coumadin ?????? indication A fib
Goal INR 2.0-2.5
First draw [**2121-6-5**]
Results to phone fax Dr. [**Last Name (STitle) 32496**] phone [**Telephone/Fax (1) 42946**]/fax
[**Telephone/Fax (1) **]
**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:[**2121-6-3**]
|
[
"427.31",
"287.5",
"272.4",
"788.20",
"997.1",
"278.01",
"401.9",
"E878.2",
"584.9",
"V85.41",
"424.1",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9328, 9377
|
4577, 7045
|
299, 426
|
9684, 9878
|
2001, 4554
|
10804, 11918
|
1175, 1194
|
7196, 9305
|
9398, 9663
|
7071, 7173
|
9902, 10781
|
1209, 1982
|
240, 261
|
454, 859
|
881, 1003
|
1019, 1159
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,337
| 137,476
|
40096
|
Discharge summary
|
report
|
Admission Date: [**2108-11-22**] Discharge Date: [**2108-12-3**]
Date of Birth: [**2073-7-11**] Sex: F
Service: SURGERY
Allergies:
Prozac
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
abdominal pain and rectal bleeding
Major Surgical or Invasive Procedure:
[**2108-11-23**]
Sigmoidoscopy
[**2108-11-26**]
Sigmoid colectomy.
History of Present Illness:
35 yo F with no significant past medical history originally
presented to [**Hospital3 **] on [**2108-11-21**] after an episode of
LLQ abdominal pain, syncope, and bright red bloody diarrhea
while at daughter's cheeleading practice at approximately 8PM on
[**11-21**]. She notes that she was additionally having nausea without
vomiting while in the bathroom with her BRBPR. Prior to her
syncope and bloody diarrhea, patient had been feeling well
without and fevers. She did have about 4 days of upper
respiratory infectious symptoms prior to presentation here,
including right sided sinus congestion and some sore throat.
Denied odynaphagia or dysphagia. Denies ingestion of any raw
seafood or undercooked meats. Denies sick contact with anyone
with infectious diarrhea symptoms.
.
In the emergency department, vitals at presentation were: T
afebrile, HR 104, BP 102/70, HR R4, O2Sat 100% RA. Had been
transferred from [**Hospital3 **] ED and was reported to have
BRBPR immediately upon arrival to the ED. Was crying from severe
abdominal pain and received dilaudid IV. CT abd/pelvis which
showed sigmoid bowel wall thickening and stranding. Was
subsequently started on ciprofloxacin and metronidazole.
Additionally had pantoprazole IV bolus as well as a drip that
was started. HCT was 34.4 at presentation down from 37 at [**Hospital1 **] and patient was transfused 2 units PRBC. Coags were
stable in the ED. She had hypotension in the ED with BP down to
80/40s. She received 4L of NS IVF. HR fell to 88. GI was
consulted in the ED and advised an NG lavage, though this was
not performed prior to transfer. Vitals prior to transfer to the
ICU were: T afebrile, HR 88, BP 89/54, O2Sat 100% RA.
.
Past Medical History:
1) Pyelonephritis
2) s/p appendectomy
Social History:
Single mother with 3 children aged 16, 12, and 8. Reports that
her primary job is taking care of her children and attending the
multitude of extracurricular activities.
TOBACCO: Currently 5 cigarettes daily and attempting to quit.
ETOH: Rare
ILLICITS: Distant marijuana use, no IVDU history.
Family History:
Patient does not know history of her father.
Mother generally well.
Denies any family history of diarrhea or inflammatory bowel
disease.
Physical Exam:
VS: T 97, HR 97, BP 95/63, RR 18, O2Sat 100%
GEN: Appears to be in extreme discomfort, clutching left lower
abdomen
HEENT: PERRL, EOMI, oral mucosa moist, sclera anicteric, no
conjunctival pallor
NECK: Supple, JVP flat
PULM: CTAB
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+ (hypoactive), soft, local press and rebound tenderness
and guarding in left flank and LLQ, denies tenderness of RUQ or
RLQ, bed sheets visibly soiled with maroon stool and blood clots
EXT: no C/C/E
SKIN: no rashes
NEURO: Oriented x 3, moving all extremities, non-focal
PSYCH: Tearful, admits to anxiety and fright regarding clinical
staus
Pertinent Results:
Admission Labs
[**2108-11-22**] 10:11PM HCT-31.7*
[**2108-11-22**] 05:47PM LACTATE-0.8
[**2108-11-22**] 05:47PM freeCa-1.14
[**2108-11-22**] 05:40PM WBC-5.8 RBC-4.05* HGB-12.1 HCT-35.5* MCV-88
MCH-29.9 MCHC-34.1 RDW-14.4
[**2108-11-22**] 05:40PM PLT COUNT-129*
[**2108-11-22**] 02:35PM HCT-32.9*
[**2108-11-22**] 11:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG
[**2108-11-22**] 11:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.034
[**2108-11-22**] 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2108-11-22**] 10:37AM GLUCOSE-86 UREA N-13 CREAT-0.7 SODIUM-137
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-10
[**2108-11-22**] 10:37AM CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-1.6
[**2108-11-22**] 10:37AM WBC-6.7 RBC-4.11* HGB-12.3 HCT-36.1 MCV-88
MCH-29.9 MCHC-34.0 RDW-14.3
[**2108-11-22**] 10:37AM NEUTS-63.6 LYMPHS-27.9 MONOS-4.8 EOS-2.9
BASOS-0.8
[**2108-11-22**] 10:37AM PLT COUNT-133*
[**2108-11-22**] 10:37AM PT-13.1 PTT-25.3 INR(PT)-1.1
[**2108-11-22**] 06:03AM LACTATE-1.7
[**2108-11-22**] 06:03AM HGB-13.0 calcHCT-39
[**2108-11-22**] 05:57AM GLUCOSE-92 UREA N-13 CREAT-0.7 SODIUM-137
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-19* ANION GAP-12
[**2108-11-22**] 05:57AM ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-136 ALK
PHOS-47 TOT BILI-0.7
[**2108-11-22**] 05:57AM ALBUMIN-3.3*
[**2108-11-22**] 05:57AM WBC-8.9 RBC-4.16* HGB-12.6 HCT-36.1 MCV-87
MCH-30.4 MCHC-35.0 RDW-13.9
[**2108-11-22**] 05:57AM PLT COUNT-144*
[**2108-11-22**] 01:00AM LACTATE-0.9
[**2108-11-22**] 01:00AM HGB-12.1 calcHCT-36
[**2108-11-22**] 12:47AM HCG-<5
[**2108-11-22**] 12:47AM WBC-6.5 RBC-3.81* HGB-11.8* HCT-34.4* MCV-90
MCH-31.0 MCHC-34.3 RDW-12.4
[**2108-11-22**] 12:47AM PT-14.9* PTT-28.4 INR(PT)-1.3*
[**2108-11-30**] 06:33 4.9 3.40* 10.3* 29.9* 88 30.4 34.6 13.1 147*
Source: Line-rt portacath
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2108-11-23**] 10:25 66.5 25.2 4.3 3.2 0.7
Source: Line- PIV
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2108-11-30**] 06:33 147*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2108-11-30**] 06:33 711 5* 0.6 137 4.0 104 24 13
[**2108-11-22**] CT Abd/pelvis : Segment of sigmoid colon demonstrating
mild hyperenhancement of the mucosa and internal high density
material that may represent hemorrhage, may represent the
earliest signs of colitis, infectious or inflammatory in
etiology. No evidence of associated abscess, perforation or
venous thrombosis.
[**2108-11-23**] CTA Pelvis :
Abnormal area of colon at level of proximal sigmoid - distal
descending colon cocerning for intra-luminal hematoma or mass.
No evidence of microperforation or abscess.
[**2108-11-23**] Proximal sigmoid colon, mass, biopsy (A):
Adenocarcinoma, submucosa not present to evaluate for invasion.
Additional levels examined.
[**2108-11-26**] :
Sigmoid colon, segmental resection:
Invasive adenocarcinoma; see synoptic report.
Colon and Rectum: Resection Synopsis
(Includes Transanal Disk Excision of Rectal Neoplasms)
Staging according to American Joint Committee on Cancer Staging
Manual -- 7th Edition, [**2107**]
MACROSCOPIC
Specimen Type: Sigmoidectomy.
Specimen Size: Greatest dimension: 15.2 cm. Additional
dimensions: 5.1 cm x 2.1 cm.
Tumor Site: Sigmoid colon.
Tumor configuration: Exophytic (polypoid). Infiltrative.
Tumor Size:Greatest dimension: 5.4 cm. Additional dimensions:
3.4 cm x 2.2 cm.
Macroscopic Tumor Perforation: Not identified.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: Low-grade (moderately differentiated).
Histologic Features Suggestive of Microsatellite Instability
Intratumoral Lymphocytic Response
(tumor infiltrating lymphocytes): Mild.
Peri-tumoral Lymphocytic Response
(tumor infiltrating lymphocytes): Mild.
Extent of Invasion
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 33.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
margin 1:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 21 mm.
margin 2:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 77 mm.
Circumferential (radial) margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 38 mm.
Treatment Effect:
No prior treatment.
Lymphatic Small Vessel Invasion: Present (focal); intramural.
Venous (large vessel) invasion: Absent.
Perineural invasion: Present.
Tumor Deposits (discontinuous extramural extension): Not
identified.
Type of Polyp in which Invasive Carcinoma Arose:
Adenoma.
Brief Hospital Course:
35 yo F with no significant past medical history presented on
[**2108-11-21**] to [**Hospital3 **] after an episode of LLQ abdominal
pain, syncope, and bright red bloody diarrhea of acute onset.
Her hematocrit was 38.7. She was transferred to [**Hospital1 18**] for
further management.
Ms. [**Known lastname 1557**] was admitted to the MICU for close monitoring and
serial hematocrits. Given CT findings of sigmoid thickening and
stranding, was intially concerning for infectious or
inflammatory cause of her lower GI bleeding. She was being
treated for bacterial causes with ciprofloxacin and
metronidazole initially. A flexible sigmoidoscopy was performed
and revealed a mass in descending colon that was friable and
bleeding. The Surgical service was consulted for further
evaluation. Her hematocrit remained stable during her ICU stay.
CEA level was elevated at 8.3.
Based on her sigmoidoscopy results she was taken to the
Operating Room on [**2108-11-26**] and underwent a sigmoid colectomy.
She tolerated the procedure well with minimal blood loss and
returned to the PACU in stable condition. She maintained stable
hemodynamics and her pain was controlled with an epidural
catheter infusion of Bupivicaine and a Dilaudid PCA.
During her post-operative course, she continued to complain of
abdominal pain and was re-assessed by the Acute Pain service who
readjusted her pain medicine regimen. She had the epidural
catheter discontinued on [**11-30**] and she has continued with her
oral pain medication. Her vital signs are stable and she is
tolerating a regular diet. She was evaluated by the Physical
Therapy service for assessment with ambulation and for the
present time is more comfortable with a rolling walker. Her
pain medication was increased to every 3 hours ( Oxycodone 10mg
)and is effective. Her PICC line was removed on [**2108-12-3**] and
she will follow up in the Acute Care Clinic in 2 weeks as well
as the [**Hospital **] Clinic to discuss her pathology report.
Medications on Admission:
Takes "All-Natural Dexatrin" diet pills
Discharge Medications:
1. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 7 days.
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): as needed for pain.
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*42 Tablet(s)* Refills:*1*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Outpatient Physical Therapy
Out Patient Physical Therapy for gait training and balance
Discharge Disposition:
Home
Discharge Diagnosis:
Proximal sigmoid colon mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-21**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at your follow-up appointment.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-12-10**] 11:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7634**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-12-10**] 11:00
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-15**] weeks.
Completed by:[**2108-12-3**]
|
[
"458.9",
"153.3",
"569.3",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"45.76",
"45.94"
] |
icd9pcs
|
[
[
[]
]
] |
11152, 11158
|
8242, 10237
|
303, 373
|
11230, 11230
|
3270, 8219
|
13237, 13715
|
2485, 2623
|
10327, 11129
|
11179, 11209
|
10263, 10304
|
11381, 12839
|
12855, 13214
|
2638, 3251
|
228, 265
|
401, 2098
|
11245, 11357
|
2120, 2159
|
2175, 2469
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,617
| 162,789
|
2982
|
Discharge summary
|
report
|
Admission Date: [**2200-1-24**] [**Month/Day/Year **] Date: [**2200-2-6**]
Date of Birth: [**2123-7-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
1. Right chest tube placement
2. Right subclavian line placement
3. s/p removal of right chest tube
History of Present Illness:
76 yo male who suffered a mechanical fall down several stairs
after the lights went out in his apartment building. Multiple
rib fractures were seen on x-ray in the emergency department; he
was subsequently admitted to [**Hospital1 18**] for further management of his
injuries.
Past Medical History:
1. HTN
2. CAD, s/p cardiac stent 2 yrs ago (circumflex)
3. GERD
4. Left shoulder surgery
5. Right shoulder surgery
6. Bilateral hip replacements
Social History:
Lives at home with his wife
Employed as a Psychologist at [**Name (NI) 4700**]
Family History:
Non-contributory
Pertinent Results:
on admission:
[**2200-1-24**] 03:00PM PLT COUNT-451*
[**2200-1-24**] 03:00PM WBC-19.7* RBC-4.29* HGB-13.2* HCT-39.2*
MCV-91 MCH-30.8 MCHC-33.7 RDW-13.2
[**2200-1-24**] 03:00PM NEUTS-83* BANDS-1 LYMPHS-11* MONOS-3 EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2200-1-24**] 03:00PM GLUCOSE-149* UREA N-24* CREAT-1.6* SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-20* ANION GAP-18
pertinent imaging:
CT CHEST W/O CONTRAST
Reason: 76 year old man s/p fall down stairs
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p fall down stairs
REASON FOR THIS EXAMINATION:
76 year old man s/p fall down stairs
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 76-year-old male status post fall downstairs.
COMPARISONS: Chest radiograph performed earlier the same date at
1451 hours.
TECHNIQUE: MDCT contiguous axial images were obtained from the
thoracic inlet through the mid abdomen without administration of
intravenous contrast. Multiplanar reconstructions were
performed.
CT CHEST WITHOUT INTRAVENOUS CONTRAST: Calcifications are seen
within the coronary vessels and aortic arch. Evaluation of the
vascular structures is limited due to lack of contrast, however,
there is no evidence for aneurysmal dilatation or aortic
intramural hematoma. The esophagus is fluid filled along its
entirety and there is a moderate fluid-filled hiatal hernia. No
pathologically enlarged mediastinal, hilar, or axillary lymph
nodes are noted. There are multiple fractures involving the
right lateral fifth, sixth, seventh, eighth, ninth, tenth and
eleventh ribs. The six, seventh, eighth and ninth rib fractures
are moderately displaced. There is a small amount of right
basilar pneumothorax, with a moderate high-attenuation right
pleural effusion consistent with a hemopneumothorax. The lungs
demonstrate mild focal pleural thickening and a small thin-
walled bulla at the right apex. Moderate ground-glass and
nodular opacification at the right lung base may represent
aspiration versus atelectasis. No pericardial effusion is seen.
In the upper imaged abdomen, displaced eighth, ninth and tenth
rib fractures appear to contact the lateral margin of the liver
and underlying hepatic laceration cannot be excluded on this
study. There is moderate hyperdense stranding in the
retroperitoneum surrounding the inferior liver edge and right
kidney consistent with retroperitoneal hematoma, incompletely
assessed. There is significant distention of the fluid filled
stomach. The imaged spleen appears grossly unremarkable. There
is a trace amount of free air inferior to the right liver
(series 2, image 47).
BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are
identified. In addition to the numerous right-sided rib
fractures described above, there are minimally displaced
fractures involving the right transverse processes of the T3,
T6, T7, T8, vertebral bodies. Vertebral body and disc space
heights are preserved.
IMPRESSION:
1. Multiple right-sided rib fractures, several displaced, with a
moderate right hemothorax. Small anterior pneumothorax at the
right lung base. Right basilar ground- glass and nodular opacity
may represent aspiration versus atelectasis.
2. Small-to-moderate amount of right retroperitoneal hematoma in
the imaged portion of the upper abdomen. Displaced rib fractures
abut the lateral margin of the right hepatic lobe. Hepatic
laceration cannot be excluded on this study.
3. Massive fluid distention of the stomach and esophagus.
Decompression with a nasogastric tube is recommended.
4. Minimally displaced fractures involving multiple right
transverse processes as described above.
CT HEAD W/O CONTRAST
Reason: ?ICH
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with fall down stairs and retrograde amnesia and
nausea & head lac
REASON FOR THIS EXAMINATION:
?ICH
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 76-year-old male status post fall presenting with
retrograde amnesia and nausea.
COMPARISONS: None.
TECHNIQUE: MDCT contiguous axial images were obtained through
the head without intravenous contrast. Multiplanar
reconstructions were performed.
CT HEAD WITHOUT INTRAVENOUS CONTRAST: There is no evidence of
intra- or extra-axial hemorrhage, shift of normally midline
structures, mass effect or hydrocephalus. No major or minor
vascular territorial infarct is identified. The ventricles and
sulci are normal in caliber and configuration. The basal
cisterns are not effaced. No fractures are identified on the
bone algorithm windows. Soft tissue irregularity, subcutaneous
emphysema and subgaleal hematoma along the right convexity at
the vertex. There is a small fluid level with mucosal thickening
in the right maxillary antrum. Mild mucosal thickening is also
present within the ethmoid air cells. The remainder of the
visualized paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
1. No evidence for acute intracranial pathology including
hemorrhage or mass effect.
2. Evidence of scalp laceration and subgaleal hematoma along the
vertex. No radiopaque embedded foreign bodies are seen.
3. Mucosal thickening and air-fluid level in the right maxillary
sinus without evidence for fracture, likely reflecting
sinusitis.
CHEST (PA & LAT)
Reason: assess lung expansion, for post pull PTX
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with R. chest tube removed now
REASON FOR THIS EXAMINATION:
assess lung expansion, for post pull PTX
CHEST X-RAY
HISTORY: Chest tube removal. Check for pneumothorax.
Three views. Comparison with the previous study done [**2200-1-30**].
The patient is status post trauma with multiple right rib
fractures. A right chest tube has been removed. There are tiny
circumscribed lucencies at the periphery of the right lung that
may represent minimal pleural air. Significant pneumothorax is
identified, however. Pleural thickening and/or fluid is again
demonstrated laterally on the right. There is subsegmental
atelectasis or scarring in the right lung. The left lung appears
clear except for blunting of the costophrenic sulcus. The
cardiomediastinal silhouette is unchanged. Degenerative
arthritic changes are again noted in the spine. There is a small
amount of subcutaneous emphysema on the right, as before.
IMPRESSION: No evidence of significant right pneumothorax post
chest tube removal. Small lucencies noted in the right chest may
represent minimal pleural air on that side. There is evidence
for pleural thickening and/or fluid on the right and a small
left pleural effusion. There is persistent mild subcutaneous
emphysema on the right.
Brief Hospital Course:
He was admitted to the trauma ICU, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Attending
Physician. [**Name10 (NameIs) **] respiratory status was monitored closely and
serial hematocrits were followed. On the morning of HD 2, he was
noted to have difficulty maintaining his O2 saturation. A chest
x-ray was performed, and an ABG was obtained. Tension
pneumothorax was suspected. He was intubated and needle
decompression followed by chest tube placement was performed. A
central line was placed and he was placed on the ventilator.
Subsequent investigations suggested that most of the acute
problem had been pulmonary collapse and or pneumonia. On HD 3,
Acute Pain Service was consulted for epidural catheter
placement; attempts at placement were unsuccessful. He was
placed on Ketamine drip for pain control. On HD 4, Zosyn was
started for presumed pneumonia and tube feeds were initiated.
Urology was consulted because he was noted to have bright red
blood from his Foley catheter. A three-way catheter was placed
for irrigation and he was treated empirically with antibiotics.
Urine culture on [**1-27**] was negative. On HD 5 he remained
intubated, with aggressive pain control; his sedation was
decreased. He was extubated on HD 6, and continued to make
progress. He began to work with PT and it was determined that he
would need a rehab facility upon [**Month/Year (2) **]. He was eventually
transferred to the regular nursing unit where he continued to
progress. He was noted to have increased loose stools; a stool
culture was obtained and was positive for C. difficile; Flagyl
was then initiated. He is now having regular formed bowel
movements. His chest tube was removed; respiratory effort was
much improved with adequate pain control. A standing dose of
Ultram was initiated and prn Oxycodone. He was placed on a bowel
regimen as well.
He did have some issues with lower extremity edema and was
started on a low dose Lasix 20 mg daily; [**Male First Name (un) 14261**] were also
ordered. The edema has improved and Lasix was stopped. He also
had complaints of urinary "dribbling"; reports some problems
with this prior to his trauma, but has noted increase during his
hospital stay. A post void residual was checked and hid did have
approximately 250 cc's remaining. It is being recommended that
he have PVR checks along with intermittent straight
catheterization. At follow up with Dr. [**Last Name (STitle) **] it will be
determined if a Urology consult is warranted.
He has been evaluated by Physical and Occupational therapy and
has been recommended for short term rehab.
Medications on Admission:
Lisinopril 20', Simvastatin 40', Lexapro 10', Buspar 10', ASA
325'
[**Last Name (STitle) **] Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP<110; HR<60.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) for 3 days: total of 7 days (started on [**1-31**]).
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
[**Month/Year (2) **] Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
[**Location (un) **] Diagnosis:
s/p Fall
Right hemothorax
Multiple rib fractures (right [**5-18**])
Liver laceration (Grade I)
Perinephric hematoma
C. difficile colitis
Urinary retention
[**Month/Year (2) **] Condition:
Good
[**Month/Year (2) **] Instructions:
It is important that you continue to take deep breaths, cough
and deep breath at least every hour during the day while you are
awake.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in 1- 2 weeks. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2200-2-12**]
|
[
"008.45",
"866.01",
"807.07",
"788.29",
"864.05",
"E880.9",
"868.04",
"518.81",
"530.20",
"873.8",
"V43.64",
"482.0",
"860.4",
"E849.0",
"V58.66",
"401.9",
"535.60",
"530.81",
"V45.82",
"553.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"86.59",
"96.04",
"96.72",
"99.04",
"34.04",
"45.16",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7682, 10305
|
334, 435
|
1059, 1059
|
11895, 12163
|
1022, 1040
|
6395, 6442
|
10331, 11472
|
11504, 11872
|
286, 296
|
6471, 7659
|
463, 742
|
1074, 1553
|
764, 910
|
926, 1006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,670
| 132,221
|
8068
|
Discharge summary
|
report
|
Admission Date: [**2135-11-26**] Discharge Date: [**2135-12-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Cholangitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 28825**] is a [**Age over 90 **] year-old man with history of atrial
fibrillation on coumadin, hypertension, and remote history of
partial gastrectomy and cholecystectomy who presented on the day
of admission to [**Hospital6 1597**] with right upper quadrant
pain, nausea, vomiting, diarrhea, and fevers. At the OSH he was
found to have a temperature of 97 with blood pressures in the
mid 80s. His liver enzymes were elevated with a predominantly
obstructive pattern; he underwent RUQ ultrasound that showed
intrahepatic biliary dilatation. The patient was volume
rescucitated with 4L of intravenous saline, and he was then
transferred to [**Hospital1 **] for ERCP evaluation.
At [**Hospital1 **], he was noted to be hypotensive and hypoxic with initial
vitals T 100.8, HR 80, BP 90/45, RR 16, and satting 94% on 6L.
Labs were notable for ALT of 228, AST of 338, AP of 225, and
Tbili of 2.9. White count was 17 with 8% bands. Hematocrit was
29, and platelets were 145. INR was 5.8. Lactate was 4. Blood
cultures were drawn. The patient had already received
ciprofloxacin and Flagyl at [**Hospital3 2568**], and he was given
additional Zosyn at [**Hospital1 **] ED. He got 10 mg IV vitamin K, but FFP
was held due to concern of volume overload. In addition, due to
persistent hypotension and concern of pulmonary edema with more
fluids, a groin line was placed and norepinephrine was started.
ERCP had been contact[**Name (NI) **] and will see the patient either in the
ED or when he reaches [**Hospital Unit Name 153**].
His vital signs at time of transfer were BP 101/58, satting 100%
on BiPAP, HR 110-120 (atrial fibrillation), T 101 rectally.
REVIEW OF SYSTEMS: currently, patient denies abdominal pain or
nausea. He says he does not have any discomfort.
Past Medical History:
PAST MEDICAL HISTORY:
--systolic congestive heart failure, EF 40%
--atrial fibrillation on coumadin
--hypertension
--peptic ulcer disease
--s/p partial gastrectomy in [**2080**]
--s/p cholecystectomy
--osteoarthritis
Social History:
Mr. [**Known lastname 28825**] lives with his wife. [**Name (NI) **] family, he is
increasingly dependent for most ADLs and IADLs. He can feed
himself, but generally requires assistance with bathing and
clothing. He does not walk due to very poor vision.
Family History:
nc
Physical Exam:
General: somnolent, elderly man in no acute distress, responds
to simple questions but generally appears confused and tired.
Vitals: T 96.4, BP 99/61, HR 112-120, sat 100% on NRB
Neck: jugular venous distention to just under level of mandible
Heart: irregularly irregular
Lungs: coarse inspiratory sounds diffusely
Abdomen: no guarding or rebound, soft, hypoactive bowel sounds
Extremities: cold feet distally, legs non-edematous
Pertinent Results:
Admission Labs:
[**2135-11-26**] 09:10PM BLOOD WBC-17.0* RBC-3.49* Hgb-9.7* Hct-29.0*
MCV-83 MCH-27.8 MCHC-33.4 RDW-15.7* Plt Ct-145*
[**2135-11-26**] 09:10PM BLOOD Neuts-76* Bands-8* Lymphs-8* Monos-7
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2135-11-26**] 09:10PM BLOOD PT-52.8* PTT-38.0* INR(PT)-5.8*
[**2135-11-26**] 09:10PM BLOOD Glucose-93 UreaN-22* Creat-0.8 Na-139
K-3.7 Cl-106 HCO3-21* AnGap-16
[**2135-11-26**] 09:10PM BLOOD ALT-228* AST-338* AlkPhos-225*
TotBili-2.9* DirBili-2.6* IndBili-0.3
[**2135-11-26**] 09:10PM BLOOD Lipase-25
[**2135-11-26**] 09:10PM BLOOD cTropnT-<0.01
[**2135-11-26**] 09:10PM BLOOD Albumin-2.9* Calcium-8.2*
[**2135-11-26**] 09:19PM BLOOD Lactate-4.0*
.
Admission CXR: Moderate cardiomegaly but no evidence of focal
airspace
consolidation to suggest pneumonia.
ERCP [**2135-11-27**]:
Findings: Esophagus: Limited exam of the esophagus was normal
Lumen: Evidence of a previous sub-total gastrectomy was seen in
the stomach body with Billroth II anastomosis.
Duodenum/jejunum: Limited exam of the duodenum / jejunum was
normal
Major Papilla: A single diverticulum with large opening was
found with the major papilla located inside the diverticulum.
Cannulation: Cannulation of the biliary duct was unsuccessful
using a free-hand technique despite multiple attempts with
multiple catheters. Contrast medium injection was not attempted.
Impression: Previous sub-total gastrectomy of the stomach body
with Billroth II anastomosis
Papilla located inside a large diverticulum.
Despite multiple attempts, biliary cannulation was unsucessful.
Recommendations: Return to ICU.
Consider PTC for biliary decompression.
Additional notes: The procedure was done by Dr. [**Last Name (STitle) **] and the
GI Fellow. Estimate blood loss = 0 cc. No specimens were
obtained. See impression for final diagnosis.
[**2135-11-27**] 12:26AM BLOOD WBC-26.0*# RBC-3.56* Hgb-9.5* Hct-29.4*
MCV-83 MCH-26.8* MCHC-32.4 RDW-15.6* Plt Ct-171
[**2135-11-27**] 05:00PM BLOOD WBC-18.0* RBC-3.36* Hgb-9.1* Hct-27.3*
MCV-81* MCH-27.1 MCHC-33.4 RDW-15.7* Plt Ct-125*
[**2135-11-28**] 03:12AM BLOOD WBC-16.1* RBC-3.24* Hgb-8.9* Hct-26.9*
MCV-83 MCH-27.6 MCHC-33.3 RDW-16.1* Plt Ct-114*
[**2135-11-29**] 11:55AM BLOOD WBC-11.7* RBC-3.27*# Hgb-8.9*# Hct-26.7*#
MCV-82 MCH-27.2 MCHC-33.3 RDW-15.5 Plt Ct-112*
[**2135-12-1**] 05:30AM BLOOD WBC-10.4 RBC-3.29* Hgb-9.1* Hct-26.5*
MCV-81* MCH-27.5 MCHC-34.1 RDW-15.5 Plt Ct-133*
[**2135-11-30**] 06:40AM BLOOD PT-12.8 PTT-25.4 INR(PT)-1.1
[**2135-11-29**] 02:52AM BLOOD Glucose-87 UreaN-15 Creat-0.5 Na-144
K-4.2 Cl-111* HCO3-27 AnGap-10
[**2135-12-1**] 05:30AM BLOOD UreaN-8 Creat-0.3*
[**2135-11-27**] 12:26AM BLOOD ALT-210* AST-296* LD(LDH)-214
AlkPhos-209* TotBili-3.4*
[**2135-11-27**] 07:25AM BLOOD ALT-191* AST-244* LD(LDH)-163
AlkPhos-196* TotBili-3.5*
[**2135-11-28**] 03:12AM BLOOD ALT-138* AST-139* LD(LDH)-141
AlkPhos-148* TotBili-1.5
[**2135-11-29**] 02:52AM BLOOD ALT-111* AST-78* LD(LDH)-152 AlkPhos-137*
TotBili-1.1
[**2135-11-30**] 06:40AM BLOOD ALT-84* AST-41* LD(LDH)-172 AlkPhos-143*
TotBili-0.8
[**2135-11-30**] 06:40AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.1
[**2135-11-26**] 09:10PM BLOOD Albumin-2.9* Calcium-8.2*
[**2135-11-27**] 07:35AM BLOOD Lactate-2.0
[**2135-11-27**] 09:57PM BLOOD Lactate-1.4
Blood Cultures at [**Hospital1 18**]:
[**2135-11-26**] - 4 of 4 no growth
[**2135-11-27**] - 4 of 4 no growth
[**2135-11-28**] - 2 of 2 no growth to date
UCx at [**Hospital1 18**]: No growth
Brief Hospital Course:
A/P: a [**Age over 90 **]-year-old man with remote history of partial
gastrectromy and cholecystectomy who presents with abdominal
pain and hypotension, and labs suggestive of acute cholangitis.
# Cholangitis: Given his septic presentation, he was initially
started on empric Zosyn. He was fluid resusictated with 4 L IVF
and required placement on pressors for his hypotesnion. After
much discussuion between the ICU, team, the ERCP team, and Mr.
[**Known lastname 28826**] family, it was decided that he should undergo ERCP.
He was temporarily intubated for the procedure. However, given
his history of Biliroth II gastrectomy, the CBD could not be
canulated. He was successfully extubated shortly after returning
to the ICU. Percutaneous biliary drain placement was discussed,
but patient improved clinically on abx, and family was not in
favor of further invasive procedures. Pt was continued to
empiric Zosyn with improvement in WBC count. Pressors were able
to be weaned off sucessfully. [**Hospital6 1597**] cultures came
back as pansensitive E. coli and Klebsiella (resistant to
ampicillin), and abx were narrowed to ceftriaxone. In order to
better evaluate cause of obstruction, MRCP was done which showed
choledocholithiasis. Discussion was had with Interventional
Radiology and ERCP teams, and future consideration will be given
to PTC with rendesvouz. Both teams agree for now that he should
recover from current episode, however, GI wishes to discuss with
he and HCP on [**2135-12-6**] whether to move forward soon with stone
retrieval intervention. Daughter (HCP) is aware.
.
# Hypoxia: Suspected to be secondary to pulmonary edema s/p 4L
volume rescucitation. CXR was without focal infilration. Patient
with known systolic CHF and ejection fraction of 40% in [**2130**].
IVF fluids were used sparingly to maintain BP. Diuresis was
avoided given boarderline blood pressures. Infiltrates improved
on CXR, but B/L effusions were demonstrated on [**2135-11-29**]. Oxygen
requirements were weaned to 3L NC. Sputum cultures was sent and
was negative. He was weaned to room air.
.
# Atrial fibrillation: Coumadin held initially given procedures.
Patient recieved 10 mg vitamin K in the emergency [**Hospital1 **]. Beta
Blockade was held initally. Pt did have afib with rates in the
100s. Metorpolol was re-started when BP improved with
improvement in HR to 70s-80s. Coumadin was held, and was NOT
restarted. Discussed with Daughter HCP that short term risk of
stroke is low (not nothing) and that would recommmed
re-anticoagulation only if intervention in next few weeks was
not planned for. I recommend to reasses appropriateness of
restarting warfarin AFTER [**2135-12-6**] GI followup procedure.
.
#Thrombocytopenia: Likely infection related. Stable, mild.
.
# CODE: DNR/DNI - but would want reversed for any interventional
procedure for removal of gallstones
.
# HCP = Daughter = [**First Name5 (NamePattern1) **] [**Name (NI) 28825**] [**Telephone/Fax (1) 28827**]
Medications on Admission:
--coumadin
--metoprolol 50 mg [**Hospital1 **]
--digoxin 0.125 mg qday
--citalopram dose unclear
--folic acid 1 mg qday
--Aricept dose unclear
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. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for Constipation.
4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Fever, pain.
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for Hypoxia, shortness of breath.
6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gm Intravenous Q24H (every 24 hours): continue through
[**2135-12-9**] then stop and discontinue PICC thereafter.
Discharge Disposition:
Extended Care
Facility:
Windgate of [**Location (un) 583**], MA
Discharge Diagnosis:
Bacteremia - sepsis
Cholangitis
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with septicemia from cholangitis -- an
infection of the bile system -- due to gall stones. You will
need to complete 2 weeks of antibiotics at rehab. The GI-ERCP
team would like to see you on Tuesday [**12-6**] at 4pm to discuss
future procedure to remove the gallstones if possible.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Name (STitle) **]
[**2135-12-6**] (Tuesday)
14:00 PM
[**Location (un) **]., [**Location (un) 86**] [**Numeric Identifier 718**]
[**Hospital Ward Name 452**]-Rose 101
[**Telephone/Fax (1) 13246**]
|
[
"038.9",
"V58.61",
"576.1",
"428.0",
"V49.86",
"574.50",
"427.41",
"V45.75",
"287.49",
"428.20",
"401.9",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.97",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10991, 11057
|
6602, 9591
|
275, 281
|
11153, 11153
|
3117, 3117
|
11616, 11849
|
2647, 2651
|
9785, 10968
|
11078, 11132
|
9617, 9762
|
11288, 11593
|
2666, 3098
|
2022, 2117
|
224, 237
|
309, 2003
|
3133, 6579
|
11168, 11264
|
2161, 2358
|
2374, 2631
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,741
| 115,846
|
47418
|
Discharge summary
|
report
|
Admission Date: [**2128-6-8**] Discharge Date: [**2128-6-24**]
Date of Birth: [**2073-7-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
shortness of breath; transfer from OSH
Major Surgical or Invasive Procedure:
1) Tracheostomy
2) PEG tube placement
History of Present Illness:
This is a 54 year old woman with past medical history
significant for multisystem atrophy, previously thought to have
Parkinson's Disease, but found to have rapidly progressing
symptoms and autonomic phenomena, followed by Dr. [**Last Name (STitle) **] for her
movement disorder, who has had several major hospitalizations in
the past including hospitalization earlier this year in [**State 108**]
for urosepsis, intubated, and transferred up to [**Hospital1 18**] for
continuity of care and had failure to wean from the vent,
eventually transferred to [**Hospital **] Rehab facility and weaned
successfully, who presents as a transfer from [**Hospital **] Hospital
where she had presented with two days of shortness of breath.
The patient is nonverbal, but her husband provides the history
of two days of upper respiratory symptoms including coughing,
wheezing, sounding congested but with no sputum production. She
was advised by her primary care physician's coverage to try
mucinex for secretions, but this did not help, and she developed
a low grade temperature to 99 or 100 at home. She became more
short of breath as noticed by her husband, and was seen by [**Name (NI) 269**]
on [**6-7**] and advised to go to the ER. She was taken by rescue to
[**Hospital **] Hospital ER, where she received one dose each of Vanco,
Azithro, Levaquin, and two doses of Zosyn before being
transferred to [**Hospital1 18**] the following day for continuity of care;
she was accepted to a neurology stepdown bed.
She was at [**Hospital **] Rehab after her last [**Hospital1 18**] discharge until
[**3-2**]. At baseline, she is wheelchair-bound over the past year
and one half, and nonverbal except for an occasional word (ie,
saying "okay.")
Past Medical History:
Hx C/S (G2P2)
1) MSA, originally diagnosed with PD in [**2120**]
- followd by Dr [**Last Name (STitle) **] for movement disorder
2) Hx C/S (G2P2)
3) ? pituitary adenoma
4) Osteoporosis
5) Admit [**1-2**] urosepsis c/b respiratory failure with prolonged
wean requiring tracheostomy
Social History:
The patient lives at home with her husband, who is her primary
caretaker. She has two children. She has a distant smoking
history but does not drink alcohol.
Family History:
Father with myocardial infarction.
Mother with [**Name2 (NI) 499**] cancer at age 80.
Physical Exam:
Physical Exam:
Vitals: T: P: R: BP: SaO2:
General: Awake, alert, and cooperative with exam in no acute
distress.
HEENT: Normocephalic, no scleral icterus noted, clear oropharynx
with moist mucus membranes
Neck: supple, with no JVD or carotid bruits appreciated
Pulmonary: Lungs clear to auscultation bilaterally without
wheezes, rhonchi or rales
Cardiac: regular rate and rhythm, with no murmurs
Abdomen: soft, nontender, with normoactive bowel sounds, no
masses or organomegaly noted.
Extremities: Warm with no edema and good pulses throughout
Skin: no rashes or lesions noted.
Neurologic:
Mental status: Nonverbal, able to close and open eyes on command
and can open/close eyes to denote "yes" or "no" (with number of
blinks). Moans once during exam. Awake and attentive.
Cranial Nerves: Olfaction not tested. Pupils equal, round and
reactive to light bilaterally, 4->3 mm bilaterally; visual
fields intact by blink to threat from lateral and medial
directions (both eyes). No ptosis is noted, extra-ocular
muscles were intact with saccadic movements; 3-4 beats nystagmus
bilaterally far gaze. Sensation was intact to light touch over
face. No facial asymmetry was noted, and hearing was intact to
voice bilaterally. Unable to assess SCMs and traps. Unable to
assess uvula, tongue if midline.
Motor: bilateral hand tremor and left leg tremor visible when
limbs lifted by observer. Unable to assess for drift.
Bilateral deltoid atrophy. Left hand dystonia, in flexor
position (wrist, elbow), adducted; right leg flexed at knee and
foot dorsiflexed at rest, with upgoing toe. Unable to lift
hands against gravity but is able to hold them up for 1 second
before dropping. Legs held up for split second before dropping,
unable to lift on her own against gravity. No obvious
fasiculations.
Sensory: Patient winces and blinks eyes once (meaning "yes") to
pain in all four extremities
Coordination: Normal finger to nose and heel to shin, with no
dysmetria. No dysdiadochokinesia noted on rapid alternating
hand movements or finger tapping.
Reflexes: 2+ biceps, triceps, brachioradialis, 3+ left patellar
2+ right patellar and 2+ ankle jerks bilaterally. The patient
had bilaterally upgoing toes on plantar response.
Gait: Unable to assess
Pertinent Results:
[**2128-6-24**] 04:07AM BLOOD WBC-6.7 RBC-3.13* Hgb-9.0* Hct-27.5*
MCV-88 MCH-28.8 MCHC-32.8 RDW-13.6 Plt Ct-311
[**2128-6-23**] 04:06AM BLOOD WBC-8.4 RBC-3.68* Hgb-10.6* Hct-32.8*
MCV-89 MCH-28.8 MCHC-32.3 RDW-13.8 Plt Ct-396
[**2128-6-22**] 04:00AM BLOOD WBC-8.1 RBC-3.44* Hgb-10.2* Hct-30.6*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.5 Plt Ct-332
[**2128-6-21**] 04:15AM BLOOD WBC-9.9 RBC-3.53* Hgb-10.4* Hct-31.8*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.8 Plt Ct-336
[**2128-6-20**] 04:12AM BLOOD WBC-9.0 RBC-3.43* Hgb-10.0* Hct-30.7*
MCV-90 MCH-29.2 MCHC-32.6 RDW-13.6 Plt Ct-297
[**2128-6-19**] 04:55AM BLOOD WBC-8.5 RBC-3.49* Hgb-10.2* Hct-31.0*
MCV-89 MCH-29.3 MCHC-33.0 RDW-13.5 Plt Ct-263
[**2128-6-8**] 11:29PM BLOOD WBC-9.1 RBC-3.79* Hgb-10.9* Hct-36.1
MCV-95 MCH-28.9 MCHC-30.3* RDW-13.1 Plt Ct-189
[**2128-6-9**] 03:57AM BLOOD Neuts-78.2* Lymphs-15.7* Monos-4.5
Eos-1.3 Baso-0.2
[**2128-6-24**] 04:07AM BLOOD Plt Ct-311
[**2128-6-13**] 02:58AM BLOOD Plt Ct-171
[**2128-6-8**] 11:29PM BLOOD Plt Ct-189
[**2128-6-8**] 11:29PM BLOOD PT-12.3 PTT-26.8 INR(PT)-1.0
[**2128-6-24**] 04:07AM BLOOD Glucose-98 UreaN-12 Creat-0.4 Na-136
K-4.1 Cl-102 HCO3-29 AnGap-9
[**2128-6-23**] 04:06AM BLOOD Glucose-109* UreaN-11 Creat-0.4 Na-141
K-4.4 Cl-101 HCO3-31 AnGap-13
[**2128-6-21**] 04:15AM BLOOD Glucose-103 UreaN-14 Creat-0.5 Na-138
K-4.9 Cl-98 HCO3-35* AnGap-10
[**2128-6-8**] 11:29PM BLOOD Glucose-112* UreaN-7 Creat-0.5 Na-138
K-5.2* Cl-100 HCO3-33* AnGap-10
[**2128-6-15**] 02:26PM BLOOD ALT-14 AST-20 LD(LDH)-233 AlkPhos-78
Amylase-70 TotBili-0.2
[**2128-6-15**] 02:26PM BLOOD ALT-14 AST-20 LD(LDH)-233 AlkPhos-78
Amylase-70 TotBili-0.2
[**2128-6-18**] 04:10AM BLOOD Lipase-84*
[**2128-6-15**] 02:26PM BLOOD Lipase-75*
[**2128-6-24**] 04:07AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.8
[**2128-6-15**] 05:38PM BLOOD Vanco-10.6*
.
EMG IMPRESSION:
.
Limited, abnormal study. There is electrophysiologic evidence
for a
generalized dysfunction of motor fibers but this limited study
cannot
adequately discriminate between a process involving motor nerves
or muscles.
.
CT IMPRESSION:
1. Probable inflammatory/allergic abnormalities in paranasal and
mastoid sinuses, as noted above.
2. Soft tissue density in the nasopharynx and oropharynx,
probably representing secretions. Clinical correlation is
recommended.
NOTE: There is prominent cerebellar and brainstem atrophy.
The prominent electromyographic finding is one of generalized
poor activation, consistent with the patient's known central
nervous system disorder. The limited neuromuscular transmission
studies were normal.
CXR ([**6-23**]): Bilateral moderate pleural effusions that are
stable.
Brief Hospital Course:
CC:[**CC Contact Info 100324**]
HPI: 54 yoF w/ for multisystem atrophy transferred from OSH with
pneumonia and hypoxia, admitted to Neuro step dow unit. The
patient is nonverbal, but her husband provides the history of
two days of upper respiratory symptoms including non-productive
cough and wheezing, followed by low grade fever (99-100). On
[**6-7**] she developed worsening shortness of breath and was advised
by [**Month/Year (2) 269**] to go to ED, where T 102.1 EMS took her to [**Hospital 100325**]
hospital, where she received Vanco, Azithro, Levaquin, and two
doses of Zosyn before being transferred to [**Hospital1 18**] [**6-8**]. At
baseline, she is wheelchair-bound for the past year and one
half, and nonverbal except for an occasional word (ie, saying
"okay."). On the neurolofy floor, T 97, bp 100/57, HR 111, resp
31, 95% 10 L FM. She became progressively hypoxic to 88% on 10 L
FM. ABG 7.14/111/76. She was intubated for hypercarbic
respiratory failure and transferred to the MICU.
The patient was transferred to the neurology floor and was
initially noted to be in no acute distress, on 10L O2 FM but
with O2 sats in the high 90s. Her respiratory rate was in the
18 range. She was not noted to be particularly sleepy or
agitated. One hour later, her sats were dropping and she was
tachypneic. She was placed on 100% nonrebreather and ABG was
performed with the following results: PH 7.14; PCO2 111, PO2 40
O2 Sats 76%; Temp noted to be 99.5. Code status readdressed
with husband who confirmed Full Code. MICU notified. Patient
continued to deteriorate and a code was called. Anesthesia
intubated her and she was transferred to the MICU.
PROBLEM LIST:
1. MRSA PNA
2. ESBL KLEB PNEUMONIAE UTI
3. RECURRENT FEVERS
4. MASTOIDITIS
5. FUNGURIA
MICRO: CDIF (-) X 1, SPUT [**6-14**], [**6-19**] (mrsa), [**6-21**] (GPC 2+), BLD
7/16/17/18 (-), URINE >100K YEAST)
RAD ([**6-22**]): CXR slight decrease in left pleural effusion, right
stable. no new inflitrate
SUMMARY: 15 DAY hospital course, 54 yoF w/ multisystem atrophy
presents with hypercarbic respiratory failure likely secondary
to multifocal pneumonia superimposed on chronic respiratory
acidosis in the setting of hypoventilation. Stabilized early in
course put proved difficult to wean from mechanical ventilation
secondary to periodic apnea and indicated by poor NIF scores.
.
1) Hypercarbic respiratory failure: likely [**12-31**] multifocal
pneumonia (CAP vs aspiration) superimposed on chronic
respiratory acidosis in the setting of hypoventilation. Given
neuromuscular weakness, patient proved difficult to wean and
underwent a tracheostomy and PEG tube placement on HD 14.
- ceftriaxone/azithromycin/clindamycin initially administered
for CAP/aspiration pna. Changed to vancomycin with MRSA
positive sputum.
- Urinary legionella Ag negative; blood, urine clx negative
- alb/atr MDI standing and PRN throughout hospitalization
- Vancomycin-> completed 10 day course for MRSA pneumonia
.
2) Fevers: Persistent fevers despite meropenem and vancomycin.
Resolved on [**2128-6-21**]. [**Month (only) 116**] be component of Shy [**Last Name (un) **] Syndrome,
however, patient worked up and treated for multiple other
potential etiologies. Sinus CT [**6-15**] with fluid in mastoids
bilaterally, potential for mastoiditis; Treated per ENT
recommendations with meropenam x 7 days.
- concern for loculated pleural effusions; unable to find
tappable pocket
- bilateral LENI negative
- [**6-9**] ucx grew resistant klebsiella pneumoniae; although
subsequent ucx have been negative. Completed 7 day course of
meropenam.
.
3) Multisystem atrophy: Initially methylphenidate, Midodrine,
carbidopa/levodopa, fludrocort for now. Restarted
carbidopa/levodopa and methylphenidate per neuro. Added back
fludrocrot given postural hypotension. EMG c/w shy-[**Last Name (un) **], no
other abnormalities seen. Neurology followed closely throughout
hospitalization.
.
4) Chronic constipation: large amount of stool in bowel. Chronic
constipation in setting of Shy [**Last Name (un) 16294**]. C. diff neg.
Aggressive bowel regimen resulted in acceptable stool output.
[**Month (only) 116**] need to consider home bowel regiment.
Medications on Admission:
Sinemet, Ritalin, florinef, methylphenidate, zoloft, proamatine,
macrobid, ambien, atrovent and albuterol nebs, nasonex (recently
d/c'ed).
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q2H PRN ().
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-30**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
constipation.
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO every other
day.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
10. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Please give doses at 7am, 10am, 1pm, and 4pm
daily. .
11. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please give doses at 7am and 10pm daily. .
12. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
5X/D (5 times a day): Please give doses at 7am, 10am, 1pm, 4pm,
and 7pm daily. .
13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
14. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please give at 7am daily. .
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
16. Famotidine in Normal Saline 20 mg/50 mL Piggyback Sig:
Twenty (20) mg Intravenous Q12H (every 12 hours).
17. Lorazepam 1-2 mg IV Q4H:PRN
18. Morphine Sulfate 1-3 mg IV Q4H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
HYPERCARBIC RESPIRATORY FAILURE
PNEUMONIA
Discharge Condition:
STABLE/GOOD
Discharge Instructions:
FOLLOW UP WITH PRIMARY CARE PHYSICIAN AND NEUROLOGIST
CARE PER [**Hospital1 **] GUIDELINES- TRACHEOSTOMY CARE,
PHYSICAL/OCCUPATIONAL THERAPY
PEG CARE- PER PROTOCOL
Followup Instructions:
Please call your PCP (Dr. [**First Name (STitle) 1313**] [**Telephone/Fax (1) 7318**]) for a follow up
appointment after discharge from rehab.
|
[
"482.41",
"V09.0",
"276.2",
"599.0",
"041.3",
"383.9",
"285.9",
"518.81",
"333.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"31.1",
"96.6",
"34.91",
"96.04",
"96.05",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
13789, 13868
|
7690, 9357
|
352, 392
|
13953, 13966
|
5031, 7667
|
14178, 14324
|
2654, 2741
|
12088, 13766
|
13889, 13932
|
11925, 12065
|
13990, 14155
|
2771, 3348
|
274, 314
|
420, 2156
|
3550, 5012
|
9371, 11899
|
3363, 3534
|
2178, 2461
|
2477, 2638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,574
| 179,700
|
48209
|
Discharge summary
|
report
|
Admission Date: [**2133-11-26**] Discharge Date: [**2133-11-29**]
Date of Birth: [**2084-6-14**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
L ureteral stricture
Major Surgical or Invasive Procedure:
L nephrectomy
History of Present Illness:
49yF with history of left ureteral disruption s/p
ureteroscopy being managed with left percutaneous nephrostomy
tube as well as history of ESBL E Coli UTI presents to ED with
four day of increasingly foul-smelling, green urine with left
flank pain, low-grade temperatures with chills and nausea.
Patient describes symptoms as becoming progressively worse since
[**Month (only) **]. Visit to ED in late [**Month (only) **]. She is voiding per
urethra without LUTS, hematuria. She denies abdominal pain,
emesis or change in bowel habits.
Past Medical History:
PMH: nephrolithiasis, diabetes, hypertension
PSH:
1. Left ureteral stent for stone obstruction, [**3-26**].
2. Left ureteroscopy with laser lithotripsy, complicated by
ureteral disruption and percutaneous nephrostomy tube, [**4-25**].
3. Antegrade and retrograde attempt at recannulization of
ureter, [**5-26**],
4. Second attempt at antegrade and retrograde recannulization,
[**6-25**] (short defect seen approximately 0.5 cm).
5. cysto. RPG: total length of ureteral disruption well over 6
to 8 cm.
6. s/p ovarian cyst removal through her lower midline
incision
Social History:
non contributory
Family History:
non contributory
Physical Exam:
HEENT no abnormalities
CV: RRR no MRG
RESP: lungs CTA b/l no RRW
ABD: obese, soft, NT, ND, BS+
Incision: CDI, staples
EXT: no CCE
Pertinent Results:
[**2133-11-29**] 05:10AM BLOOD WBC-5.8 RBC-3.40* Hgb-9.7* Hct-28.7*
MCV-84 MCH-28.5 MCHC-33.8 RDW-14.5 Plt Ct-362
[**2133-11-29**] 05:10AM BLOOD Plt Ct-362
[**2133-11-28**] 03:22AM BLOOD Glucose-186* UreaN-3* Creat-0.6 Na-136
K-3.9 Cl-102 HCO3-29 AnGap-9
[**2133-11-27**] 05:10AM BLOOD CK(CPK)-543*
[**2133-11-27**] 05:10AM BLOOD CK-MB-9 cTropnT-<0.01
[**2133-11-27**] 02:49AM BLOOD TSH-1.5
[**2133-11-27**] 02:49AM BLOOD T4-4.1* T3-55* Free T4-0.98
Brief Hospital Course:
Pt admitted post operatively from Nephrectomy. Pt had episode
intra op of AFib nearing the conlusion of operation. Pt was
cardioverted at the time with good result. Taken to ICU post op
for observation. No Neo needed. Pt did well, began to mobilize
fluid POD 1. WAs cleared from ICU POD 1, but remained because
of lack of beds available. PT [**Name (NI) 101613**], tolerated diet, passing
flatus. Foley removed on POD 2 and pt voided without
difficulty. Pt cleared for discharge POD 3.
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L uretral stricture
Discharge Condition:
stable
Discharge Instructions:
Return to ER if:
- persistent Temperature > 101.4
- severe abdominal or pelvic or flank pain
- persistent low urine output
- blood or pus from urine
Followup Instructions:
Dr. [**Last Name (STitle) 3748**] is 2 weeks - call for an appointment [**Telephone/Fax (1) 3752**]
|
[
"427.31",
"997.1",
"E878.6",
"401.9",
"593.3",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
3186, 3192
|
2218, 2714
|
338, 354
|
3256, 3265
|
1744, 2195
|
3462, 3565
|
1561, 1579
|
2737, 3163
|
3213, 3235
|
3289, 3439
|
1594, 1725
|
278, 300
|
382, 923
|
945, 1511
|
1527, 1545
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,936
| 172,983
|
49463+49464
|
Discharge summary
|
report+report
|
Admission Date: [**2129-3-18**] Discharge Date: [**2129-3-24**]
Service: MEDICINE
Allergies:
Levofloxacin / Macrobid / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
abdominal pain and cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89yo woman with pmh sig for atrial fibrillation, with
supratherapuetic INR, presenting with abdominal pain and cough.
Regarding abdominal pain, this has been present for 2 days, is
epigastric and "burning." No
diarrhea/constipation/fever/melena/hematochezia/vomitting. No
history of alcohol use or gallstones. Cough has been present
for one week, productive of whitish sputum, no sob, no fever.
Past Medical History:
atrial fibrillation
OA
pancreatitis
Social History:
Lives at [**Hospital3 **] center.
Physical Exam:
98.9 116/80 68 16 95%RA
NAD
No JVD, No LAD
RRR nl s1s2 2/6 SEM loudest at apex
Lungs with decreased BS b/l
Abd soft with very mild tenderness in epigastric area, no
distension, no [**Doctor Last Name **]
Increased Pain and crepitus at right knee, no erythema or calf
tenderness
Pertinent Results:
[**2129-3-18**] 06:35PM WBC-14.1* RBC-4.47 HGB-13.6 HCT-40.0 MCV-89
MCH-30.4 MCHC-34.0 RDW-13.6
[**2129-3-18**] 06:35PM ALBUMIN-4.3 CALCIUM-9.1 PHOSPHATE-2.9
MAGNESIUM-1.9
[**2129-3-18**] 06:35PM LIPASE-1847*
[**2129-3-18**] 06:35PM ALT(SGPT)-65* AST(SGOT)-62* ALK PHOS-63
AMYLASE-2623* TOT BILI-0.5
Triglycerides 97
U/S:Isolated slightly dilated extrahepatic duct, with no
evidence of acute cholecystitis. Visualization of the distal
most common hepatic duct, and pancreatic head is slightly
obscured by overlying bowel gas, and mass or stone cannot be
excluded. Correlation with subsequent CT is recommended for
further evaluation.
.
CT Abd
1) No pancreatic mass was identified. Small cyst with punctate
calcification in the anterior pancreatic head, most probably
post-pancreatitis changes. Pancreas otherwise, normal and normal
pancreatic duct.
2) Small duodenal diverticulum.
3) Small amount of ascites and bilateral pleural effusions.
.
Right knee- Severe demineralization, degenerative disease,
chondrocalcinosis, loose bodies within the joint.
.
Right hip- Severe degenerative disease with associated avascular
necrosis of the right hip. No evidence for fracture or other
indications of inflammatory arthropathy.
.
CXR- right lower lobe infiltrate or atelectasis and right
pleural effusion.
Brief Hospital Course:
1)Pneumonia: CXR infiltrate v. atalectasis. Pt with a cough but
afebrile, treated with 5 days azithro. Pt was also initially on
ceftriazxone but this was stopped. After stopping the
ceftriaxone she spiked fever and repeat CXR showed RLL
infiltrate. She was restarted on ceftriaxone and remained
afebrile on combination of ceftriaxone/azithromycin. Plan to
complete standard course. She had swallowing study to rule out
aspiration which found her to have no difficulties swallowing.
She remained afebrile and with good sats on the ceftriaxone and
azithromycin. This will be completed for [**6-12**] day course.
.
2)Pancreatitis: Ultrasound and enzymes consistant with
pancreatitis. Etiology was unclear passed stone vs meds. Her
amylase and lipase peaked and remained stable. Her diet was
slowly advanced and her pain diminished. Patient with poor
appetite but tolerating PO'son discharge.
.
3)Knee and hip pain: Per family pt has chronic arthritis and
pain. Uses walker "poorly" to get around at nursing home. Knee
and hip films showed no evidence of fracture. She has severe
right hip/knee degenerative disease.
.
4)Coagulopathy: In past her INRs have been difficult to control.
On admission INR was 6.3. Her coumadin was held and she was
given 5mg of VitK. There were no signs of active bleeding.
After she was started on her antibiotics the INR continued to
remain high and then began to rise along with her PTT. Liver
enzymes were normal. DIC panel negative. She was given
additional 10mg of Vit K which had good effect as INR decreased
to 1.4. It was felt that her coagulopathy was likely secondary
to poor nutrition adn her antibiotics.
.
5)[**Name (NI) 39621**] Pt was in sinus on admission. She was continued on
metoprolol for rate control. Coumadin was held secondary to
elevated INR. It was ultimately decided due to her history of
GI bleed and sensitivity to coumadin to not resume at this time.
Pt will be kept on aspirin for now.
Medications on Admission:
Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO
Q4-6H (every 4 to 6 hours) as needed.
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Valacyclovir HCl 500 mg Tablet Sig: One (1) Tablet PO bid ().
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8
hours) as needed.
Discharge Medications:
1. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Valacyclovir HCl 500 mg Tablet Sig: One (1) Tablet PO bid ().
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days.
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Pancreatitis
Community acquired PNA
Atrial Fibrillation
Coagulopathy
Discharge Condition:
stable, afebrile, tolerating PO's
Discharge Instructions:
Return to the emergency room with fever, difficulty breathing,
or increased abdominal pain.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2129-5-10**] 1:30.
Pt will follow up with Dr. [**Last Name (STitle) **] at rehab.
Admission Date: [**2129-3-25**] Discharge Date: [**2129-3-30**]
Service: MEDICINE
Allergies:
Levofloxacin / Macrobid / Sulfa (Sulfonamides) / Opioid
Analgesics
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Melena, coffee-ground emesis
Major Surgical or Invasive Procedure:
EGD on [**2129-3-25**]
GDA embolectomy by interventional radiology on [**2129-3-27**]
History of Present Illness:
The patient is an 89 year old female with a history of PAF off
of coumadin recently secondary to elevated INR, dementia, HTN,
and OA who presented 1 day after recent discharge for
pancreatitis with watery diarrhea and coffee-ground emesis x 2
with a 10 point Hct drop from 34 to 24 in 1 day on [**2129-3-25**]. NG
lavage cleared with 500 ccs.
As a result, the patient was transferred to the MICU where she
was evaluated by GI with an EGD and found to have multiple
ulcers in the duodenum and antrum which were cauterized and
given epinephrine injections. She was transfused a total of 7
units in the MICU. However, her bleeding recurred and
interventional radiology performed an angiogram and subsequent
gastroduodenal artery embolization which resulted in arrest of
her GI bleed. However, the plan was that if further bleeding
occurred, the patient would need surgical involvement.
On [**2129-3-28**], the patient was transferred from the MICU to the
floor after her hematocrit remained stable for 24 hours
post-embolectomy with no further episodes of
emesis/nausea/bloody diarrhea. The patient states that she has
chronic epigastric pain. She denies any
dizziness/lightheadedness/CP/SOB/cough.
However, her main complaint on transfer is bilateral knee pain
which she has had in the past secondary to osteoarthritis.
Past Medical History:
atrial fibrillation
OA
pancreatitis
Dementia
HTN
Depression
Diverticulitis
?GIB in past
Social History:
Lives at [**Hospital3 **] center.
Family History:
Noncontributory.
Physical Exam:
Tc=97.6 P=81 BP=132/56 RR=21 100% on RA I/O = [**Telephone/Fax (1) 103516**]
Gen - Lethargic, in no apparent distress
Heart - Grade II/VI holosystolic murmur at LSB, regular rate and
rhythm
Lungs - CTAB (anteriorly)
Abdomen - Soft, nontender, nondistended, active BS, no
rebound/guarding
Ext - SCD bilaterally, bilatral knee pain, +2 pulses bilaterally
Skin - At times confluent macular, erythematous, pruritic rash
on neck, trunk, back and bilateral upper extremities (first
noted [**3-26**])
Pertinent Results:
CHEST (PORTABLE AP) [**2129-3-25**] 5:09 PM
IMPRESSION:
1) Interval decrease in size of right-sided pleural effusion.
Persisting patchy opacification at the right base, consistent
with atelectasis/consolidation. Stable cardiomegaly.
2) Possible hiatal hernia.
Brief Hospital Course:
The patient is an 89 year old female with dementia, PAF now off
of coumadin, HTN, and OA who presented with GIB and 10 point Hct
drop secondary to gastric/duodenal ulcers.
.
# [**Name (NI) 4056**] Pt presented with melena times one day. She had just
recently been admitted to the hospital for pancreatitis and PNA.
During her prior stay she did have guaiac positive [**Doctor Last Name 3945**] but
this was in the setting of a supratherpeutic INR to 7 and her
Hct remained stable throughout around 34-36. This time she
presented with several eipsodes of melena. Her Hct dropped from
34-24. She was seen by GI, started on IVF, transfused, started
on IV protonix and sent to the MICU. In the MICU they did EGD
which found numerous antrum/duodenal ulcers (H.pylori neg) one
of which had visible vessel. They attemted to clip this vessel
but were unable to do, therefore they used epi to slow the
bleeding. Pt was monitored and had another 10 point Hct drop
after the procedure and receiving blood. This time IR was
consulted and they embolized the GDA artery. After this
procedyure Hct remained stable around 38-39. She continued to
have some guaiac positive stools but Hct was stable. She was
started on clear diet and switched back to PO meds. Per GI,
will require PPI [**Hospital1 **] for two months and then plan to change to
daily.
.
# Diffuse rash- The rash was first noted on [**3-26**] in the MICU. It
was attributed to morphine which the patient was receiving for
her bilateral knee pain. However she had also received other new
meds that could have been the causative [**Doctor Last Name 360**]. She was started
on IV benadryl and fexofenadine 60 [**Hospital1 **] and ranitidine 150 mg [**Hospital1 **]
with some improvement per the patient's grand-daughter. We
stopped the benadryl due to concerns for anti-cholinergic
effects.
.
# Paroxysmal atrial fibrillation- Pt was in NSR on tele
throughout her stay. Coumadin had been stopped during her last
admission. She was only on aspirirn which was stopped. She had
no episodes of Afib on tele. She was continued on BB for rate
control.
.
# [**Name (NI) 12329**] Pt was somewhat hypertensive after MICU stay so her
metoprolol was titrated with good effect.
.
# Joint pain- The patient had imaging of her right hip and knees
during her last admission. Her knees showed extensive DJD and
her right hip showed avascular necrosis. However, the patient's
family opted not to pursue surgical intervention at the time.
Had PT work with the patient. She will need further rehab after
discharge. Continued tylenol and vicoden for pain.
.
7. FEN - Advanced as toelrated to cardiac diet and encouraged
boost.
.
9. Code- DNR/DNI
Medications on Admission:
Pantoprazole 40 mg PO Q12H
Fexofenadine 60 mg PO BID
Ranitidine 150 mg PO BID
Metoprolol 50 mg PO BID
Dolasetron Mesylate 12.5 mg IV Q8H:PRN
Hydrocodone-Acetaminophen 1 TAB PO Q6H:PRN pain
Acetaminophen 325-650 mg PO Q4-6H:PRN
Multivitamins 1 CAP PO DAILY
Paroxetine HCl 20 mg PO DAILY
Donepezil 5 mg PO HS
Discharge Medications:
1. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
9. Fexofenadine HCl 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 5 days.
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day: Please give twice
a day for two MOnths and then once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Duodenal Ulcers
UGIB
Paroxysmal A.fib
HTN
Discharge Condition:
Stable, afebrile, Hct stable
Discharge Instructions:
If the patient experiences any bloody stools, melena, passing
out lightheadedness, chest pain, shortness of breath,
fevers/chills, they should seek medical attention immediately.
Followup Instructions:
Pt will be followed by physicians at [**Hospital 100**] Rehab.Pt
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2129-5-10**] 1:30
|
[
"294.8",
"733.42",
"427.31",
"693.0",
"532.40",
"401.9",
"E935.2",
"715.36"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"44.44",
"44.43",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
13268, 13341
|
9229, 11924
|
6775, 6862
|
13427, 13457
|
8943, 9206
|
13684, 13960
|
8392, 8410
|
12282, 13245
|
13362, 13406
|
11950, 12259
|
13481, 13661
|
8425, 8924
|
6707, 6737
|
6890, 8213
|
8235, 8325
|
8341, 8376
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,375
| 108,385
|
29562
|
Discharge summary
|
report
|
Admission Date: [**2148-5-1**] Discharge Date: [**2148-5-9**]
Date of Birth: [**2089-12-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
G tube clogged
Major Surgical or Invasive Procedure:
port-a-cath placed
G tube placed by IR
Suprapubic cath replaced
History of Present Illness:
58 M c quadriplegia [**2-23**] C4/C5 fracture [**2130**] and vent dependent c
PEG tube [**2-23**] massive thalamic bleed in [**2133**] who presents for
evaluation of clogged G tube. Noted on Saturday to have sluggish
passage of feeds through G tube. This morning, noted to have no
passage through G tube and sent to [**Hospital1 18**]. On discussion with RN
at rehab facility, pt c no obvious grimacing to abdominal
palpation, no aberrations of vital signs. Of note was recently
started on cefepime --> transitioned to zosyn for elevated WBC
and + sputum ctx. Also of note, recently had suprapubic catheter
replaced and has had intermittent leakage of urine via penis
over last several days.
.
In ED, VS - 98.0, 62, 108/64, 100% RA, rectal exam performed but
stool not felt and unable to be disimpacted. CT abdomen showed
multiple abdominal wall abscesses, no evidence for obstruction.
Recevied vancomycin, ceftazidime, and blood cultures drawn. Had
episode of bradycardia to 30 in ED for which pt. received
atropine once with rise in HR to 90s
.
Currently pt minimally responsive as his baseline per rehab
staff. Cannot answer questions re: pain, discomfort.
Past Medical History:
1. Recent hospitalization for sepsis at [**Hospital1 18**] thought [**2-23**] ESBL
Klebsiella osteomyelitis of L ischium vs. decubiti ulcers
2. Candidal fungemia [**8-26**] at [**Hospital1 2177**] tx c imipenem, vanc, caspo.
3. Quadriplegia s/p C4/C5 fracture [**2-23**] MVA [**2130**]
4. Thalamic hemorrhage [**2133**]
5. Diabetes
Social History:
lives at rehab, unclear [**Name2 (NI) **]/ETOH history
Family History:
Noncontributory
Physical Exam:
GEN- middle aged man lying supine, arms in flexed position.
VS- 96.1, 108, 208/122, 14, 100% RA
HEENT- Op clear, MMM. Moves eyes spontaneously
LUNGS- Coarse rhonchi diffusely. No wheeze
HEART- RRR, S1, S2, no murmur
ABDOM- G tube in place. + Erythema around site of G tube entry.
Abdomen distended mildly but not tender. Hypoactive BS.
EXTRE- wwp, no edema; denuded and atrophic muscles over legs,
clubbing
NEURO- quadriplegic. Occasional will respond to commands such as
closing eyes, showing teeth.
Pertinent Results:
CT abdomen:
1. Extensive fecal material extending from the rectum throughout
the entire colon with rectal wall thickening and likely edema in
association with fecal impaction. These findings raise the
question of stercoral colitis.
2. Probable osteomyelitis of the left ischium and ilium
secondary to a large left sacral decubitus ulcer.
3. No evidence for small bowel obstruction, however, there is
fecalization of small bowel which suggests a functional
obstruction.
4. Multiple anterior abdominal wall abscesses as described
above. Cholelithiasis without evidence for cholecystitis.
5. Gastrostomy tube, IVC filter, and suprapubic catheter
identified.
.
MICRO:
Blood cultures - 2/4 Bottles with GNR's, likely Klebsiella
AEROBIC BOTTLE (Final [**2148-5-6**]):
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. FINAL
SENSITIVITIES.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
NON-FERMENTER, NOT PSEUDOMONAS
AERUGINOSA
|
CEFEPIME-------------- 16 R
CEFTAZIDIME----------- =>16 R
CEFTRIAXONE----------- =>32 R
CIPROFLOXACIN--------- =>2 R
GENTAMICIN------------ =>8 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 4 R
MEROPENEM------------- 1 S
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ =>8 R
ANAEROBIC BOTTLE (Final [**2148-5-7**]): NO GROWTH.
.
Port a cath placement:
TECHNIQUE/FINDINGS: After informed consent was obtained, the
patient's left upper chest was prepped and draped in a sterile
fashion. Lidocaine with Epinephrine was used to anesthetize the
skin, tract and eventual location of this patient's port. The
subclavian vein was entered with a microcatheter system after
which a tract was made and a port reservoir created within the
subcutaneous tissue. The port was then sutured in place using a
zero-silk suture. The catheter was then measured so the eventual
length would place it in the distal SVC. The vascular entrance
site was then dilated to 9 French after which a peel-away sheath
was placed and the catheter advanced. The catheter was then
joined to the subcutaneous port without incident.
Final chest x-ray demonstrates no kinks in the catheter,
catheter tip in the distal SVC. The catheter was accessed within
the angiography Suite to ensure appropriate infusion and
aspiration. It was then flushed with heparinized saline.
Throughout the procedure, the tract and subcutaneous port
location were irrigated with orthopedic solution.
The overlying skin was closed with a running 2-0 Vicryl suture
(absorbable and no need to remove).
IMPRESSION: Placement of an 8 French subcutaneous port via the
left subclavian vein with the tip in the right atrium. No
complications. The catheter is ready for use.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Brief Hospital Course:
Pt was [**Hospital 70882**] transferred to [**Hospital1 18**] only to have his G tube
replaced by IR as it had become clogged. Given that he was
chronically vented, he was admitted to the ICU.
His G tube was replaced successfully by IR. There was
difficulty obtaining consent. If he is transferred from your
facility again, please document who to contact for consent, and
correct phone numbers for this person.
In anticipation of fixing the clogged G tube, he had a CT scan
in the emergency room which showed mutiple fluid filled pockets
in the abdominal wall. One of these pockets was aspirated and
showed only clotted blood. It was felt that these were most
likely due to his heparin injections and so heparin sc was
discontinued.
In the emergency room, upon seeing the abdominal wall pockets of
fluid, the emergency room staff were concerned that these could
be abscesses. Blood cultures were obtained and 2 out of 4
bottles grew gram negative rods. He was initially treated with
Zosyn, but once the culture demonstrated that it was unlikely to
be pseudomonas, and the resistance pattern was consistent with
an ESBL resistant Klebsiella, Pt was switched to Meropenem.
Meropenem was started on [**5-7**] for a 10 day course. Last day of
Meropenem is [**2148-5-16**]. it was presumed that his PICC line was
the source. This was removed and a port-a cath was placed by
IR.
Pt has a history of autonomic dysregulation, this was treated by
continuing his regimen of metoprolol.
Of note, pt was maximally impacted and constipated on arrival,
he required an [**First Name9 (NamePattern2) 70883**] [**Last Name (un) 49666**] regimen.
Medications on Admission:
Insulin - lantus 38 u qhs
Nystatin 1000 u 5cc susp. qid PO for thrush
Senna/Colace
Nexium 40 mg qd
Zinc 220 mg qd
Vitamin C 500 mg [**Hospital1 **]
Lopressor 25 tid
Lipitor 80 mg qd
Heparin SC tid
Cefepime [**4-21**] --> changed to IV Zosyn to continue until [**5-9**]
Discharge Medications:
1. Meropenem 500 mg IV Q6H
2. Heparin Flush (100 units/ml) 2 ml IV DAILY:PRN
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
4. Combivent 103-18 mcg/Actuation Aerosol Sig: Four (4)
Inhalation four times a day.
5. Novolin R Sliding Scale
FSBG 150-200 give 2 units
FSBG 201-250 give 4 units
FSBG 251-300 give 6 units
FSBG 301-350 give 8 units
FSGB 351-400 give 10 units
FSBG > 401 [**Name8 (MD) 138**] MD
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
7. Tylenol elixer
650 mg q4:prn
8. Fleet enema
PR QD
9. Dulcolax Suppository
PR QD
10. Lantus
38units QHS
11. Vitamin C
500 mg [**Hospital1 **] per GT
12. Zinc
220 mg qd per GT
13. Colace liquid
100 mg [**Hospital1 **] per GT
14. Senokot
5ml [**Hospital1 **] per GT
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Rehab
Discharge Diagnosis:
Line infection with gram negative rod bacteremia
Discharge Condition:
stable
Discharge Instructions:
The physician at the rehab facility needs to be made aware of
any fevers, changes in vital signs. Please also monitor the
surgical site on his chest for signs of bleeding or infection.
G tube has been replaced and may be used. Suprapubic catheter
has been replaced.
Followup Instructions:
Monitoring by physician at long term care facility
Completed by:[**2148-5-9**]
|
[
"996.62",
"518.83",
"560.39",
"482.1",
"996.76",
"V46.11",
"682.2",
"038.9",
"599.0",
"707.03",
"E878.3",
"337.3",
"E879.6",
"401.9",
"458.9",
"V44.0",
"427.89",
"536.49",
"995.91",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"86.07",
"97.02"
] |
icd9pcs
|
[
[
[]
]
] |
8409, 8461
|
5623, 7269
|
328, 394
|
8554, 8563
|
2590, 5600
|
8879, 8960
|
2034, 2051
|
7588, 8386
|
8482, 8533
|
7295, 7565
|
8587, 8856
|
2066, 2571
|
274, 290
|
422, 1589
|
1611, 1945
|
1961, 2018
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,917
| 130,518
|
3347
|
Discharge summary
|
report
|
Admission Date: [**2119-9-18**] Discharge Date: [**2119-9-20**]
Date of Birth: [**2046-3-14**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Senna / Iodine
Attending:[**Location (un) 1279**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
1. Placement of temporary pacing wire through a right internal
jugular catheter on [**2119-9-18**].
2. Placement of a permanent pacemaker through left subclavian on
[**2119-9-19**].
History of Present Illness:
73 year-old female with coronary artery disease status post CABG
times one and aortic valve replacement with a porcine valve,
Diabetes type II, and hypertension who presents with complete
heart block. She had a syncopal episode while doing PT
excercises. The event was not witnessed, but her husband heard
her fall and called EMS. In the ED, she was found to be in
complete heart block. She has never had any previously
documented conduction abnormalities. She denies any chest pain,
shortness of breath, palpitations or lightheadedness before or
after her syncopal episode. She does complain of an
intermittent headache for the past several months.
Past Medical History:
1. Coronary artery disease status post coronary artery bypass
graft times one, saphenous vein graft to posterior descending
coronary artery, aortic valve replacement with a porcine valve
on [**2119-1-31**]. Coronary catheterization from [**Month (only) 956**]
[**2118**] showed a 70% right coronary artery occlusion.
2. Diabetes mellitus type 2.
3. Hypertension.
4. History of severe aortic stenosis with a valve area of 0.7
status post AVR with a porcine valve.
5. Hypercholesterolemia.
6. T11 to T12 paravertebral mass.
7. Anemia.
8. Bilateral subclavian stenosis.
9. History of subdural hemorrhage after motor vehicle
accident.
Social History:
She is primarily Russian speaking although she does understand
some English. She lives with her husband. She does not smoke
or drink.
Family History:
Family history is significant for a brother who died of an MI at
the age of 65.
Physical Exam:
VITALS: Temperature: 99.4, Pulse: 44, Blood pressure: 175/43,
Respiratory rate: 19, Oxygen saturation: 93% on room air. She
was awake, alert and oriented times [**Last Name (un) 15526**], and appeared very
anxious. She had moist mucous membranes. Cardiac exam was a
regular rate, S1, S2, III/VI crescendo/decrescendo systolic
murmor best heard at base with radiation to carotids, no rubs or
gallops; JVD was elevated to 10 cm; [**Doctor Last Name **] A-waves were present.
Pulmonary exam was clear to auscultation bilaterally. Abdomen
was soft, nontender, nondistended with bowel sounds present.
Extremeties were warm without cyanosis or edema and had weakly
palpable distal pulses.
Pertinent Results:
[**2119-9-18**] 01:10PM WBC-8.1 RBC-4.40 HGB-12.9 HCT-36.5 MCV-83
MCH-29.4 MCHC-35.5* RDW-13.6
[**2119-9-18**] 01:10PM PLT COUNT-193
[**2119-9-18**] 01:10PM NEUTS-76.5* LYMPHS-19.3 MONOS-2.5 EOS-1.4
BASOS-0.3
[**2119-9-18**] 01:10PM GLUCOSE-353* UREA N-20 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2119-9-18**] 01:10PM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.0
[**2119-9-18**] 01:10PM PT-12.3 PTT-21.9* INR(PT)-1.0
[**2119-9-18**] 01:10PM CK(CPK)-37
[**2119-9-18**] 01:10PM cTropnT-<0.01
[**2119-9-18**] 01:10PM CK-MB-NotDone
[**2119-9-18**] 01:10PM SED RATE-5
[**2119-9-18**] 04:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2119-9-18**] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2119-9-18**] 04:00PM URINE RBC-<1 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
EKG: Normal sinue, left axis deviation, complete heart block
with rare captured beats.
Chest x-ray: No evidence of CHF or PNA, mild atelectasis in left
lower lobe.
Brief Hospital Course:
1. Complete Heart Block (CHB): She presented in CHB with rare
captured beats. Her CHB was thought to be due to either
ischemia, infection, or fibrosis from her aortic valve
replacement. Cardiac enzymes times three were negative and an
infection work-up was negative including urinalysis, urine
culture, blood culture, sedementation rate, and echocardiogram.
Therefore her conduction abnormality is likely secondary to
fibrosis. A temporary pacing wire was placed through a right
internal jugular catheter on the day of admission. A permanent
pacemaker was placed through the left subclavian once all
sources of infection were ruled out. She was maintained on all
of her regular medications with the exception of atentolol and
nifedipine, which were held until after the pacemaker was
placed.
2. Heart Failure: After the placement of the temporary pacing
wire, she had an increased oxygen requirement. A chest x-ray
showed new onset pulmonary edema consistent with heart failure
secondary to CHB. She was diuresed with furosemide and her
oxygen requirement decreased. She was maintained on her
outpatient dose of furosemide.
3. Coronary Artery Disease: Her cardiac enzymes were negative
times three. She had no evidence of ischemia.
4. Hypertension: On admission, her blood pressure reached 200
systolic. She required a nitroglycerin drip to maintain her
pressures around 120-140 systolic. After her permanent
pacemaker was place, she was hypertensice to 200 systolic. Her
atenolol and nifedipine were restarted and blood pressures were
maintained between 130-150 systolic.
5. Diabetes Mellitus Type 2: Her blood glucose levels were
elevate to over 300 on admission. She was maintained on an
insulin sliding scale; however, her sugars still remained
elevated.
6. Psychiatry: The patient was maintained on clonazepam,
mirtazipine, and paroxetine for anxiety.
7. Fluids, electrolytes, and nutrition: The night of admission,
she was diuresed 1300 cc with IV lasix for heart failure. She
still had evidence of heart failure after the initial day of
diuresis and required more diuresis with IV lasix. Her
potassium and magnesium were repleted. She was maintained on a
diabetic low sodium diet.
8. Prophylaxis: She received subcutaneous heparin for DVT,
Colace as a bowel regimen, pantoprazole for gastric ulcers, and
ambiem for sleep.
Medications on Admission:
1. Atenolol 50 mg po bid
2. Aspirin 325 mg po qd
3. Valsartan 160 mg po qd
4. Isosorbide dinitrate 20 mg po tid
5. Nifedipine 60 mg po tid
6. Furosemide 40 mg po qd
7. Atorvastatin 20 mg po qd
8. Glipizide 10 mg po bid
9. Ferrous sulfate 325 mg po qd
10. Mirtazipine 15 mg po qhs
11. Paroxetine 10 mg po qd
12. Clonazepam 0.5 mg po qAM
13. Zolpidiem tartate 10 mg po qhs
14. Protonix 40 mg po qd
15. Potassium chloride 10 meq po qd
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QD (once a day).
12. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
13. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
15. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 6 doses.
Disp:*6 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Complete heart block.
Heart failure.
Hypertension.
Discharge Condition:
Good.
Discharge Instructions:
Please take all of your normal medications as prescribed. You
are also prescribed an antibiotic Keflex that you should take 4
times a day for 6 doses. Please keep your follow-up appointment
in the device clinic for your new pacemaker.
Followup Instructions:
Please follow-up in the device clinic to check you pacemaker at
the following time:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2119-9-28**] 11:00
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**],
in [**12-16**] weeks.
You also have the following appointments:
Provider: [**Name Initial (NameIs) **] Where: [**Hospital6 29**] SURGICAL SPECIALTIES
Phone:[**Telephone/Fax (1) 15527**] Date/Time:[**2119-10-6**] 10:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2119-11-1**] 1:00
Completed by:[**2119-9-29**]
|
[
"426.0",
"V45.81",
"414.00",
"428.0",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
8032, 8107
|
3910, 6267
|
300, 483
|
8202, 8209
|
2806, 3887
|
8494, 9295
|
2002, 2083
|
6750, 8009
|
8128, 8181
|
6293, 6727
|
8233, 8471
|
2098, 2787
|
253, 262
|
511, 1168
|
1190, 1833
|
1849, 1986
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,124
| 163,944
|
40779
|
Discharge summary
|
report
|
Admission Date: [**2165-5-31**] Discharge Date: [**2165-6-5**]
Date of Birth: [**2091-5-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right middle lobe carcinoid
Major Surgical or Invasive Procedure:
[**2165-5-31**]: Right thoracotomy and right middle lobe sleeve
lobectomy (anastomosis of right lower lobe bronchus to
bronchus intermedius) intercostal muscle flap buttress,
mediastinal lymph node dissection and bronchoscopy with
bronchoalveolar lavage.
History of Present Illness:
The patient is a 74-year-old woman who was found to have a right
middle lobe carcinoid which was endoscopically resected. She
was admitted for surgical resection.
Past Medical History:
Thyroidectomy for fetal adenoma [**2127**]
Hyperlipidemia
Asthma
GERD
Osteoporosis
Social History:
Married lives with spouse. Children. [**Name2 (NI) 1139**] never. ETOH social.
Family History:
Mother COPD died age 84
Father died of MI at age 48 [**2114**]
Siblings MI younger brother died age 60
Physical Exam:
VS on discharge:
T 98.3, HR 77, BP 120/60, RR 18, O2 sats 96% RA resting and
94-96% ambulating
General: 74 year-old female in no apparent distress
Card: RRR normal S1,S2
Resp: clear b/l
GI: soft, NT, ND
Extr: warm without edema
Incision: Right thoracotomy site clean dry intact margins well
approximated no erythema
Neuro: awake, alert oriented.
Pertinent Results:
CXR:
[**2165-6-4**]: There is no change in the right apical pneumothorax.
Continued right effusion with minimal atelectatic changes at the
bases.
[**2165-6-3**]: there is minimal increase in right still
small pneumothorax. The lung is well aerated on the right and on
the left. There is no change in basal atelectasis. There is no
appreciable increase in pleural effusion which is currently
present on the right, small. Surgical clips appear to be
unremarkable.
[**2165-6-2**]: Following removal of one of two chest tubes, a small
right apical pneumothorax is again visualized but has slightly
decreased in size in the interval. Appearance of the chest is
otherwise without change since the recent study except for
decrease in degree of subcutaneous emphysema in the right
supraclavicular area.
[**2165-6-1**]: Small amount of right pneumothorax restricted to the
apex is unchanged. The position of two right chest tubes is
unchanged. There is small amount of pleural effusion. Lungs are
well aerated. Cardiomediastinal silhouette is stable.
[**2165-5-31**]: Two right chest tubes are in place. There is small
apical pneumothorax on the
right. Overall, the extension of the right lung is preserved. No
appreciable pleural effusion is seen. The left lung is well
aerated. Mediastinal contour is stable. Mild mediastinal shift
to the right is expected due to surgery.
Labs:
[**2165-6-1**] 07:10AM BLOOD Hct-31.5*
[**2165-5-31**] 09:44PM BLOOD WBC-12.5*# RBC-3.56* Hgb-11.2* Hct-31.9*
MCV-90 MCH-31.6 MCHC-35.2* RDW-13.5 Plt Ct-255
[**2165-6-3**] 11:15AM BLOOD Glucose-125* UreaN-10 Creat-0.8 Na-135
K-3.9 Cl-96 HCO3-30 AnGap-13
[**2165-6-3**] 11:15AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.7
Brief Hospital Course:
Mrs. [**Known lastname **] was taken to the operating [**2165-5-31**] by Dr.
[**Last Name (STitle) **] for a right thoracotomy and right middle lobe sleeve
lobectomy (anastomosis of right lower lobe bronchus to bronchus
intermedius) intercostal muscle flap buttress, mediastinal lymph
node dissection and bronchoscopy with bronchoalveolar lavage.
She was extubated in the operating room, and monitored in the
PACU. While in the PACU she was hypotensive which responded to a
fluid challenge and decrease titration of Bupivacaine Epidural
and phenylphrene. Once stable she transfer to the floor
hemodynamically stable.
Respiratory: Pulmonary toilet with incentive spirometery was
encouraged throughout her stay. She was titrated off oxygen with
ambulatory saturations of 93% on room air.
Chest tubes: 2 [**Doctor Last Name 406**] drains anteriorly and posteriorly over the
apex were removed once pleural drainage decreased on [**2165-6-2**] and
[**2165-6-3**] with stable postpull film revealing right apical
pneumothorax, which is unchanged on followup CXR's.
Cardiac: The patient had an episode of atrial fibrillation
[**2165-6-2**] which converted to Sinus rhythm with 10 mg IV
Lopressor. Her home dose Lopressor was continued and she
remained in sinus rhythm 60-70's with blood pressures 110-120
systolic.
GI: PPI and bowel regime continued. The patient was passing gas
on discharge but due for BM. Diet was advanced and tolerated.
Renal: The patient had normal renal function with good urine
output. Electrolytes were replete as needed.
Pain: Bupivacaine Epidural with split dilaudid PCA was used for
intitial pain management with good effect. [**2165-6-3**] PCA was dc'd
with po vicodin ordered and managed by the acute pain service.
The epidural was removed on [**2165-6-4**] and PO dilaudid, tylenol,
ibuprofen and neurontin were given with positive affect.
Disposition: She was seen by physical therapy and deemed safe
for home with PT. She continued to make steady progress and was
discharged to home with her family and VNA on [**2165-6-5**].
Medications on Admission:
ALBUTEROL SULFATE, ATORVASTATIN 40 mg daily, EZETIMIBE 10 mg
daily, FENOFIBRATE NANOCRYSTALLIZED 48 mg daily, HCTZ 25 mg
daily, LEVOTHYROXINE 125 mcg daily, METOPROLOL TARTRATE 50 mg
[**Hospital1 **], SINGULAIR 10mg daily, OMEPRAZOLE 20 mg daily, RALOXIFENE 60
mg daily, CALCIUM CARBONATE 600(1,500)[**Hospital1 **], FISH OIL
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Three (3) Tablet, Chewable PO BID (2 times a day).
8. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
13. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
14. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
15. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day.
16. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours.
17. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
18. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times
a day: Increase to 200mg po tid in 3 days, then 300mg po tid in
a week. .
Disp:*130 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Right middle lobe carcinoid
hyperlipidemia
asthma
GERD
osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath cough or chest pain
-Right thoracotomy incision develops drainage
-Chest tube site cover with a bandaid until healed
-Should chest tube site drain cover with a dry dressing and
change as needed
Pain:
-Acetaminophen 650 mg every 8 hrs as needed for pain
-Dilaudid 2-4 mg every 4-6 hours as needed for pain
-Ibuprofen 400-600 mg every 8 hours for pain. Take with food and
water
-Take stool softeners while on narcotics
Acvitity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes Daily
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2165-6-18**] 3:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**]
Chest X-Ray [**Location (un) **] radiology 30 minutes before your
appointment
Completed by:[**2165-6-5**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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7345, 7408
|
3205, 5269
|
337, 594
|
7520, 7520
|
1493, 3182
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8553, 8881
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1007, 1112
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5645, 7322
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7429, 7499
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5295, 5622
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7671, 8530
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1127, 1130
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1144, 1474
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269, 299
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622, 788
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7535, 7647
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810, 895
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911, 991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,142
| 188,462
|
49555
|
Discharge summary
|
report
|
Admission Date: [**2132-2-16**] Discharge Date: [**2132-3-11**]
Date of Birth: [**2056-4-5**] Sex: F
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 1557**] is well known to the
Transplant Surgery Service. She presented on [**2-17**] with
nausea and vomiting and dehydration. She had a recent
admission with similar symptoms in [**Month (only) 958**]. At the end of
[**Month (only) 958**], roughly 22 to 31, with fever and abdominal pain, where
she was evaluated with multiple tests including cholangiogram
and carotid arteriogram and improved on discharge and now
represents with similar type symptoms but worsening with the
vomiting being a new complaint. She has a past medical
history significant for an orthotopic liver transplant
secondary to end stage liver disease secondary to primary
sclerosing cholangitis, ulcerative colitis. She had a
postoperative course which was complicated by hepatic artery
thrombosis where she underwent emergent thrombectomy and
recurrent cholangitis and also multiple hepatic abscesses.
She also had metastatic colon cancer. She underwent a right
colectomy and stated that the colon cancer had metastases and
she had received some treatments with chemotherapy, but a
full course was not able to be completed. Past medical
history was also significant for hepatitis B, anemia, PTC
tube placement and multiple infections in the bile including
yeast, enterococcus. which were treated with a variety of
antibiotics over her postoperative course. Also of note in
the medical history is at the time of the orthotopic
cadaveric liver transplant she also had a Roux-en-Y
hepaticojejunostomy.
ADMISSION MEDICATIONS: Neoral 50 mg p.o. b.i.d., Prednisone
5 q.d., Actigall 300 t.i.d., Bactrim one q. day, Vitamin D,
Iron, Protonix q. day.
HOSPITAL COURSE: She was admitted to her floor and her
drains were opened and irrigated. She was given intravenous
fluids, antibiotics, Linezolid and Zosyn. Cultures were
obtained. Her temperature initially was 96.5, heart rate
107, blood pressure 128/80. Her abdomen was soft and
nondistended and nontender with a well-healed abdominal scar
with a bile drain in place, and warm extremities without
edema. Infectious Disease was consulted and their
recommendations were for Linezolid and Zosyn. Abdominal
imaging first with x-rays showed some distended bowel pattern
and temperature curve increase to 101 range. Nasogastric
tube was placed given that it was believed that she was
experiencing a bowel obstruction. She had pretty mild output
but her abdominal x-rays never improved, and the computerized
tomography scan showed dilated bowel, so on [**2-21**], after
discussion with the family and the Transplant Team, the
patient was taken to the Operating Room for exploratory
laparotomy for small bowel obstruction unresolving. Upon
opening the abdomen, the findings were that of diffuse
carcinomatosis including frozen section, consistent with
carcinomatosis. Estimated blood loss was 150. The procedure
performed was limited by the degree of recurrent metastatic
colon cancer, so she underwent an ileotransverse colon bypass
with a primary anastomosis, also the patient had a
gastrostomy tube and biopsies of the peritoneal implants.
She tolerated the procedure, although she was tachycardiac
with low urine output initially postoperatively. However,
with blood products and resuscitation she improved.
She was sent to the Transplant Surgery Floor where she
continued to make a slow recovery. Given the findings in the
Operating Room, Dr.[**Name (NI) 71453**] Team was contact[**Name (NI) **] with these
findings. A family meeting was set up between the Transplant
Surgery, attending staff and the patient's family and they
desired to proceed full course with further chemotherapy as
well as hyperalimentation as necessary with the plans of
getting Mrs. [**Known lastname 1557**] to a point where she would be safe to go
home and continue treatment. She had a gradual return of
bowel function and her gastrostomy tube was kept open for
several days until she had a resumption of flatus. She was
continued on her immunosuppressive medications and she was
followed by physical therapy and now postoperative day #19,
[**3-11**], it was deemed she was strong enough to go home with
adequate calories. She was taking oral diet and moving her
bowels with plans to gastrostomy but open PCT tube, and the
patient is discharged to home, in improved clinical
condition.
PAST MEDICAL HISTORY: Past medical history included all of
the above as well as all of the above in the history of
present illness. In addition, 1. Small bowel obstruction;
2. Ongoing cholangitis; 3. Exploratory laparotomy; 4.
Dehydration; 5. Diffuse carcinomatosis for metastatic colon
adenocarcinoma; 6. Status post cholangiogram; 7. Status
post intravenous and oral antibiotics courses; 8. Status
post postoperative oliguria resolved; 9. Status post anemia,
improved with blood products; 10. Status post
hyperalimentation, resolved; 11. Status post gastrostomy tube
administration of medicine, now resolved with a clamp of the
gastrostomy tube.
DISPOSITION: To home with services.
FOLLOW UP: Transplant Surgery, the oncology attending as
well as her regular doctors. Weekly blood draw is per the
Transplant Surgery Service.
DISCHARGE MEDICATIONS: Her usual immune medicine regimen.
The only additional medicines she will be going home with are
Percocet and Simethicone.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2132-3-11**] 18:40
T: [**2132-3-11**] 19:12
JOB#: [**Job Number 103656**]
|
[
"E878.0",
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"E878.2",
"998.12",
"276.5",
"560.9",
"996.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"54.11",
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"99.04",
"54.23",
"54.12",
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] |
icd9pcs
|
[
[
[]
]
] |
5380, 5769
|
1847, 4512
|
1708, 1829
|
5222, 5356
|
179, 1684
|
4535, 5210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,346
| 159,127
|
8615
|
Discharge summary
|
report
|
Admission Date: [**2167-12-10**] Discharge Date: [**2167-12-11**]
Date of Birth: [**2108-4-9**] Sex: M
Service: MEDICINE
Allergies:
Iron Dextran Complex / Bupropion
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
dyspnea, volume overload
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
59 M c hx of systolic CHF, DM2, HTN, Hep C, ESRD on
HD(tuthrsat), who p/w shortness of breath to ED on [**12-9**].
Patient was subsequently found to be severely hypertensive to
220s, started on nitroglycerin gtt, and transfered to MICU for
planned HD.
He had HD on [**12-7**], instead of [**12-8**] this week due to the
holiday. Subsuquently he became more progressively dyspneic
starting on noon. Patient reports his symptoms worsening at
dinner and especially become very orthopnic when he laid down.
He also reported chest tightness and wheezing. His chest
tightness was diffuse, brought on with exertion at home, lasting
few minutes. It was non radiating, he denies any arm
involvement, no lightheadedness, no nausea. He did report
significant gasping for air with chest tightness. The last time
it occured was in ED when he was moving around and the symptoms
were relieved with SLNTG. It has not recurred since. Patient
also reported an episode of chills with T of 100.2 @ noon on
[**12-9**], that has not since recurred. NO cough, no abdominal
pain, diarrhea x 3 days, once a day. Minimal urine. Also
reports increased LE swelling. Patient reports this is similar
to his prior volume overload episodes.
In ED, his VS were O2 Sats 91% RA, unable to talk in full
sentences. Given lasix 80 IV (no UO, due to HD) , nebs. K= 6.1,
given kayexalate. He also had brief episode of CP in ED,
resolved with SL nitro. Given ASA 325. No EKG changes. CXR with
overload. He was started on nitro paste with nitro gtt that
brought his BP to 160s. He also had a RIJ placed in ED [**1-16**] to
difficult access. Patient was hypertensive to 220s in AM still
on nitroglycerin gtt, and due to need for HD while on
nitroglycerin gtt was transfered to ICU.
Past Medical History:
- ESRD: on HD (since '[**64**]) Tu/Th/Sat; failed kidney [**Year (2 digits) **]
attempted [**Year (2 digits) **] [**4-20**] from Hep C positive donor but aborted
[**1-16**] hypoxia
- Diabetes type 2: followed by [**Last Name (un) **]
- Hep C: genotype 1 c hepatitis C viral load of 18,400,000 I.U.
- Diastolic CHF: last ECHO [**4-20**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA
moderately dilated; LVEF>55%
- GERD
- Former Substance Abuse: alcohol, cocaine, heroine; clean since
'[**64**], 1 relapse with cocaine in '[**65**]; attends [**Hospital1 **] and NA
- Renal cell carcinoma: s/p removal [**2162**] followed w/o recurrence
- Pericardial effusion [**2165**], presumed viral; s/p
pericardiocentesis for tamponade physiology
- Depression: no suicide attempts, +passive thoughts about
suicide with no plan
- Barrett's Esophagus
- Carpal Tunnel Syndrome: used wrist slints
- Sleep Apnea: on CPAP
Social History:
Mr. [**Known lastname 30197**] previously worked at Sheraton Hotel, retired in
[**2164**]. Currently lives with his sister
[**Name (NI) 1139**]: 80 pack-year history, quit [**2165-5-15**]
ETOH: history of 1 pint per week, quit [**2165-5-15**]
Illicits: Previous crack cocaine use, quit [**2165-5-15**].
Previous heroin use, quite 5-6 years ago. Member of NA, in
therapy for substance abuse.
Family History:
Father-died at age 52 from stroke
Mother-died in her 50s from cirrhosis
[**Name (NI) 12408**] DM
[**Name (NI) 30204**] addict
[**Name (NI) 30205**] at unknown age, due to problems with kidney and
pancreas
Physical Exam:
Vitals: T 98.0 BP 156/96 HR 76 RR 12 O2sat 96% 3L
General: African American male, NAD, comfortable, speaking full
sentences, alert and oriented x 3
HEENT: unable to appreciate JVD, anicteric
Neck: RIJ in place
Chest: CTAB, crackles at bases, no wheezes
Cor: RRR, normal S1/S2, no m/r/g
Abdomen: obese, soft, moderately distended, non-tender, well
healed RLQ surgical scar
Ext: no pitting lower extremity edema, no calf tenderness
LUE: graft for dialysis, no warmth, no induration, no signs of
infection
Pertinent Results:
[**2167-12-10**] 01:59AM WBC-13.7* RBC-3.42* HGB-9.7* HCT-31.7* MCV-93
MCH-28.4 MCHC-30.6* RDW-21.9*
[**2167-12-10**] 01:59AM PLT COUNT-421
[**2167-12-10**] 01:59AM PT-14.2* PTT-30.2 INR(PT)-1.2*
[**2167-12-10**] 01:59AM GLUCOSE-86 UREA N-43* CREAT-11.2*# SODIUM-138
POTASSIUM-6.1* CHLORIDE-100 TOTAL CO2-24 ANION GAP-20
[**2167-12-10**] 01:59AM CK(CPK)-96
[**2167-12-10**] 01:59AM cTropnT-0.04*
[**2167-12-9**]: EKG - Sinus rhythm. Consider left ventricular
hypertrophy by voltage. Prolonged QTc interval is non-specific
[**2167-12-10**]: chest xray - Pulmonary vascular engorgement and
perihilar haziness as well as fluffy opacities throughout the
lung fields are consistent with moderate CHF. Cardiomediastinal
silhouette is normal. There is no effusion or pneumothorax.
[**2167-12-10**]: TTE - The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
In brief, the patient is a 59 year old man with hx of diastolic
CHF, DM2, HTN, Hep C, ESRD on HD, p/w shortness of breath likely
due to volume overload due to extra day without HD.
Acute on chronic diastolic CHF exacerbation: This was felt
likely due to extra day without HD due to holidays worsened by
hypertension. Patient denies any medication indescretion, likely
diet nonadherence. There was no evidence of cardiac ischemia.
There was no evidence of infection. His TTE was notable for
normal systolic function without significant valvular pathology.
He was dialysed without incident and was able to wean down on
his supplemental oxygen. At the time of discharge he was
breathing comfortably on room air.
Chest pain: The patient had transient chest pain on admission
that resolved with control of his blood pressure and fluid
removal via ultrafiltration. As above, there was no sign of
acute cardiac ischemia. He continued on his home dose
metoprolol.
End-stage renal disease: On HD T-Th-Sa hemodialysis via a left
arm AV graft. He was dialyzed as above. His phos-binder
regimen was increased. His initial hyperkalemia was corrected
with kayexalate and dialysis. He will resume his regular
dialysis schedule upon discharge.
Diabetes mellitus: He continued on his home insulin regimen.
Diarrhea secondary to c. dif colitis: The patient had been
having loose stools ever since his last hospitalization. A c
dif toxin was positive and he will complete a 10 day course of
metronidazole.
Depression: He continued his home dose of celexa.
Gout: There were no signs of acute flare and he continued on his
home dose of allopurinol.
FEN: - Diabetic low salt diet
Access: HD access via AV graft. had RIJ placed w/o complication
on admission, removed before discharge
Ppx: - SC heparin, PPI, bowel regimen
CODE: - Full
DISPO: - to home with previously scheduled HD follow-up
Medications on Admission:
Aspirin 81 mg
Citalopram 20 mg
Pantoprazole 40 mg
Cinacalcet 30 mg
Gabapentin 300 mg post HD
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Pramipexole 0.25 mg QHS
Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY
Metoclopramide 10 mg daily
Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS
Metoprolol 75 mg daily
Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS
Glargine 30units at night
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qHS ().
8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a day
as needed.
10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute on chronic diastolic congestive heart failure
End-stage renal disease
Clostridium deficile colitis
Secondary:
Diabetes type 2 with complication
Obstructive sleep apnea
Discharge Condition:
good. ambulating without assist. normal oxygenation on room air.
Discharge Instructions:
You have been evaluated and treated for shortness of breath and
fluid overload. This was most likely related to not having
enough dialysis to match you intake. As you had dialysis you
improved your breathing significantly.
You were also found to have an infectious diarrhrea. This can
be treated with oral antibiotics. It is important not to drink
any alcohol as the combination of alcohol and this antibiotic
can make you very nauseated and feel uncomfortable.
Please resume your regular dialysis session on Saturday
([**2167-12-12**]).
If you have any concerning symptoms such as chest pain,
shortness of breath, palpitations, or severe abdominal pain;
please seek medical attention.
Followup Instructions:
Cardiology Clinic:
[**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2167-12-30**] 9:00
Primary Care physician:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2168-1-1**] 10:00
Pulmonary clinic:
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2168-1-8**] 8:50
[**Hospital **] Clinic: [**Location (un) **] dialysis clinic on Saturday [**2167-12-12**]
|
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icd9cm
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[
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icd9pcs
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[]
]
] |
9283, 9289
|
5642, 7526
|
319, 333
|
9517, 9584
|
4242, 5619
|
10324, 10899
|
3497, 3703
|
8038, 9260
|
9310, 9496
|
7552, 8015
|
9608, 10301
|
3718, 4223
|
255, 281
|
361, 2116
|
2138, 3072
|
3088, 3481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,873
| 137,360
|
21860
|
Discharge summary
|
report
|
Admission Date: [**2170-3-12**] Discharge Date: [**2170-3-20**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
progressive DOE
Major Surgical or Invasive Procedure:
s/p AVR [**85**] mm (CE pericardial)/stapling of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**]
History of Present Illness:
Mr. [**Known lastname 57351**] is an 81 yo with known AS/CAD who underwent PTCA in
[**2163**], now he presents with worsening DOE and fatigue. Cardiac
catheterization showed severe AS. He was refered to Dr. [**Last Name (STitle) **]
for AVR
Past Medical History:
AS
CAD-s/p PTCA [**2163**]
AS
hypercholesterolemia
asthma
lower facial neuron disease
sinus polyps
prostate CA s/p XRT
radiation proctitis
PAF
lumber disk disease
cervical sipnal stenosis w/chronic back pain
ideopathic neuropathy of feet
s/p DDD pacer
s/p TURP
s/p appy
s/p mastoid surgery
Social History:
works part time as a judge/lawyer, lives in [**Name (NI) 108**] with wife
2 alcoholic drinks/day
Pertinent Results:
[**2170-3-17**] 04:50AM BLOOD WBC-8.9 RBC-2.86* Hgb-8.3* Hct-25.4*
MCV-89 MCH-29.1 MCHC-32.8 RDW-14.0 Plt Ct-201
[**2170-3-17**] 04:50AM BLOOD Plt Ct-201
[**2170-3-17**] 04:50AM BLOOD UreaN-19 Creat-0.8 K-3.9
[**2170-3-17**] 04:50AM BLOOD Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 57351**] was admitted to [**Hospital1 18**] on [**2170-3-9**] and taken to the
operating room with Dr. [**Last Name (STitle) **], where he underwent an AVR w/21mm
CE tissue valve. In the operating room his ejection fraction
was found to be 55%, with preserved biventricular systolic
funciton. He tollerated the procedure well and was transfered
to the ICU in stable condition. He was weaned and extubated from
mechanical ventillation without difficulty. His pacer was
interrogated by the EPS service and was found to be functioning
properly. Postoperatively he had a moderate ammount of
confusion which gradulally resolved. He was restarted on his
sotalol for beta blockade, and he was not restarted on his
coumadin as Dr. [**Last Name (STitle) **] thought if he remained in sinus rhythm
post operatively, it would not be needed. His telemetry
consistently showed AV pacing with a variable rate. He was
transfered from the ICU to the regular floor on POD#6. On POD#7
the EP service increased the lower rate of his pacer to 80. It
was determined by the cardiac surgery team and physical therapy
that he would benifit from a stay at a short term rehab and on
POD#10, he was cleared for discharge to rehab.
Medications on Admission:
uroXartal qd
aciphex 20mg qd
ambien 5mg qd
betapace 80mg [**Hospital1 **]
coumadin
cozaar 50mg qd
demadex 20mg qd
potassium 10mEq qd
zocor 20mg qd
zyrtec 10mg qd
flonase qd
ventolin qd
aerobid qd
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-24**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Sotalol HCl 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
10. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
One (1) Spray Nasal [**Hospital1 **] (2 times a day).
11. Psyllium 58.6 % Packet Sig: One (1) Packet PO TID (3 times a
day) as needed.
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed for constipation.
13. Metamucil 0.52 g Capsule Sig: One (1) Capsule PO qam ().
14. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
15. Ventolin HFA 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed.
16. Aerobid 250 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
17. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
AS
s/p AVR
post op confusion-resolved
hyperlipidemia
asthma
lower facial neuron disease
R facial droop
prostate Ca-s/p XRT
PAF
radiation proctitis
s/p pacer insertion
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
do not drive for 1 month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 57352**] in [**12-24**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**12-24**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**2-23**] weeks
Completed by:[**2170-3-20**]
|
[
"V10.46",
"V45.01",
"414.01",
"427.31",
"428.0",
"293.0",
"272.0",
"424.1",
"493.90",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"37.99"
] |
icd9pcs
|
[
[
[]
]
] |
4430, 4500
|
1385, 2620
|
284, 397
|
4711, 4717
|
1115, 1362
|
5025, 5258
|
2867, 4407
|
4521, 4690
|
2646, 2844
|
4741, 5002
|
229, 246
|
425, 669
|
691, 982
|
998, 1096
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,174
| 102,106
|
2817
|
Discharge summary
|
report
|
Admission Date: [**2194-9-9**] Discharge Date: [**2194-9-11**]
Date of Birth: [**2133-7-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Right suboccipital craniotomy with excision of mass
History of Present Illness:
: 61 y/o woman with PMH significant for DCIS in right breast
(s/p lumpectomy [**2183**]), bronchoalveolar carcinoma [**2190**] and [**2193**]
(s/p thorascopic resection of lesions), melanoma of left eye
(follwed my [**Hospital **], has proton therapy Q6 months),
melanoma in right ankle (s/p wide local excision with
reconstruction), and squamous cell CA in left hand. Presents
with
HA for last month, increasing in severity in past 48 hours.
+nausea, no vomiting, no visual changes, no dizziness, no
difficulty ambulating. Given 10 of decadron x1 in ED.
Past Medical History:
: HTN, chronic sinus congestin, obesity, depression, ductal
carcinoma in situ, bronchoalveolar carcinoma, melanoma of left
eye and right ankle, squamous cell ca.
Social History:
no smoking, no alcohol, no I.V. drug use
Family History:
M- dx'd with breast Ca at 39 s/p mastectomy. Died at 83 yo
Maternal aunts/uncles - [**10-23**] have died of cancer (lung, liver,
melanoma, stomach)
Brothers - 2 have died of melanoma, both started in the eye and
spread to the liver.
Physical Exam:
PHYSICAL EXAM:
O: T:97.3 BP:165 / 83 HR: 72 R 16 O2Sats 100 RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: left pupil larger than right pupil (has had this
finding since the [**2168**]'s), reactive to light L 4mm-3mm, R 3mm to
2mm EOMs: no nystagmus, intact bilaterally.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-14**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils round and reactive to light. Left pupil larger than
right pupil. Left pupil 4mm to 3mm, right pupil 3mm to 2mm
(stable finding since [**2168**]'s). Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical, uvula midline.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-16**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pin prick
bilaterally.
Reflexes: biceps, triceps brisk and equal bilaterally
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.
Pertinent Results:
[**2194-9-8**] 07:00PM GLUCOSE-95 UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2194-9-8**] 07:00PM WBC-10.3 RBC-4.29 HGB-13.3 HCT-38.5 MCV-90
MCH-31.0 MCHC-34.6 RDW-13.2
[**2194-9-8**] 07:00PM NEUTS-64.2 LYMPHS-29.3 MONOS-3.8 EOS-2.3
BASOS-0.4
[**2194-9-8**] 07:00PM PLT COUNT-333
[**2194-9-8**] 07:00PM PT-12.2 PTT-28.3 INR(PT)-1.0
CT: Enhancing hyperdense mass within the right cerebellum
producing mass effect on the fourth ventricle. The other
ventricles appear prominent in this patient, though there are no
prior studies for comparison.
Brief Hospital Course:
Pt was admitted to the ICU for close neurologic monitoring, she
was intact and remained so. She was taken to the OR [**9-9**] where
under general anesthesia she underwent right suboccipital
craniotomy with excision of mass. She tolerated this procedure
well, was extubated and returned to the SICU for recovery and
monitoring. Post op she remained neurologically intact. Her
vital signs were stable. Post op CT showed : Postoperative
changes of the right cerebellar hemisphere with a small amount
of hemorrhage in the resection bed. Unchanged appearance of the
ventricles compared to yesterday. She also underwent post op
MRI which was reveiwed by Dr. [**Last Name (STitle) 739**] which showed no
residual tumor. She was also seen in consult by Dr. [**Last Name (STitle) 4253**]
from neurooncology. Foley was removed.Her diet and activity
were advanced. She was evaluated by PT and found to be safe for
home.
Medications on Admission:
HCTZ 12.5mg qd
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
take while on steroids.
Disp:*60 Tablet(s)* Refills:*2*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebellar mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
Keep incision dry until staples removed. Call for fever or any
signs of infection - redness, swelling or drainage from wound.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 4253**] in Brain [**Hospital 341**] Clinic - [**Hospital Ward Name 23**] 8
[**2194-9-22**] at 2:30pm. You need to have bone scan prior to this
appt - Dr[**Name (NI) 4674**] office will schedule this - call
[**Telephone/Fax (1) 1669**] for appt time.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2194-9-11**]
|
[
"V10.11",
"V10.84",
"V10.82",
"E878.8",
"401.9",
"998.11",
"197.7",
"V10.3",
"E849.7",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.14"
] |
icd9pcs
|
[
[
[]
]
] |
5286, 5292
|
3740, 4659
|
283, 336
|
5351, 5374
|
3120, 3717
|
5548, 5965
|
1181, 1415
|
4724, 5263
|
5313, 5330
|
4685, 4701
|
5398, 5525
|
1445, 1852
|
235, 245
|
365, 920
|
2145, 3101
|
1867, 2129
|
943, 1106
|
1122, 1165
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,633
| 181,802
|
4219+55555
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-7-10**] Discharge Date: [**2160-7-21**]
Date of Birth: [**2098-12-27**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Right parotid mass
Major Surgical or Invasive Procedure:
[**2160-7-10**]: Right parotidectomy with right supra-omohyoid
modified neck dissection with nerve monitoring and right
abdominal fat grafting.
[**2160-7-13**]: Evacuation of right neck hematoma.
[**2160-7-15**]: Re-exploration of right neck with evacuation of neck
hematoma.
History of Present Illness:
This is a 61 year-old Caucasian male who intially presented to
clinic on [**2160-6-13**] because for the past 1-2 years he had noted a
swelling in the right pre-auricular region. He noted that the
swelling had significantly enlarged, and a CT scan was obtained.
A prior CT scan on [**2160-6-6**] revealed a 2.3 x 2.6 x 3 cm mass
within the superficial portion of the parotid tail. At that
time, there were no characteristics of malignancy. On [**2160-6-20**],
a fine-needle aspiration biospy was performed showing malignant
cells consistent with mucoepidermoid carcinoma. On [**2160-6-24**] an
MRI neck showed a T2 hypointense lesion in the right parotid
gland at the junction of the superficial and deep lobes
measuring approximately 3 x 2.7 cm-- appearance was concerning
for malignant neoplasm versus adenopathy from overlying skin
malignancy. There was no enhancement in the mastoid segment of
the facial nerve and the lesion did not appear to extend into
the stylomastoid foramen. In clinic, he denied history of
chronic skin problems or skin malignancy. He is a non-smoker and
denies alcohol use.
He presented on [**2160-7-10**] and underwent right parotidectomy with
supra-omohyoid modified neck dissection with nerve monitoring
and with right abdominal fat graft.
Past Medical History:
History of atrial fibrillation status post ablation five
years ago, depression, asthma, arthritis. Denies past surgical
history.
Social History:
He is a non-smoker and denies alcohol use. He is employed in the
real estate industry. He is married with a son.
Family History:
Significant for cancer and heart disease. Primary lung
malignancy in his immediate family.
Physical Exam:
PHYSICAL EXAM (UPON DISCHARGE): [**2160-7-21**]
VITALS: 99.2/98.8 BP 98/52 HR 57 RR 20 O2SAT 99%RA
HEENT: Normocephalic. Atraumatic. Extraocular muscles intact
with bilaterally symmetric and equally reactive pupils. Nares
clear. OC/OP: Moist mucous membranes without evidence of lesions
or exudates. Neck supple. Right parotid incision is clean, dry
and well-approximated with sutures and staples in
place--bacitracin on incision line. Improving ecchymosis at
distal flap edge infra-auricular region with no evidence of
erythema, infection. No hematoma or collection. No
lymphadenopathy.
CVS: Regular rate and rhythm. No murmur, rub or gallop.
RESP: Clear to auscultation anteriorly, bilaterally with no
adventitious sounds. No wheezing, rhonchi or rales.
GI: soft, non-tender. Non-distended. Normoactive bowel sounds.
Right sided 3-4 cm abdominal fat graft incision is
well-approximated, healing without evidence of erythema or
infection. Steristrips in place.
EXTR: No cyanosis, clubbing or edema. 2+ peripheral pulses
bilaterally.
Pertinent Results:
[**2160-6-24**] MR IMAGING OF THE NECK
There is a heterogeneously-enhancing predominantly T2
hypointense lesion in the right parotid gland at the junction of
the superficial and deep lobes measuring approximately 3 x 2.7
cm. Appearance is concerning for malignant neoplasm versus
adenopathy from overlying skin malignancy. There is no
enhancement in the mastoid segment of the facial nerve and the
lesion does not appear to extend into the stylomastoid foramen.
[**2160-7-13**] CTA CHEST
There are numerous filling defects within the pulmonary arterial
vasculature, notably in the right upper pulmonary artery
extending into the segmental branches. A filling defect is also
noted in the left lingular branches and subsegmental branches of
the left lower and upper
lobes. There is flattening of the intraventricular septum and
enlargement of the right ventricle relative to the left
suggestive of right ventricular heart strain.
[**2160-7-13**] BILATERAL LOWER EXTREMITY ULTRASOUND
No evidence of deep venous thrombosis in bilateral common
femoral vein,
superficial femoral vein, and popliteal veins. The veins of the
calf bilaterally were not seen, unable to image, given
suboptimal evaluation.
[**2160-7-14**] CXR, COMPARISON: [**2160-7-12**].
FINDINGS: As compared to the previous radiograph, the patient
has been
intubated. The tip of the tube projects 6 cm above the carina,
the tube could be advanced by 1-2 cm.
Unchanged retrocardiac atelectasis, unchanged right perihilar
lower lobe
opacity. Unchanged size of the cardiac silhouette. The presence
of minimal
overhydration cannot be excluded.
[**2160-7-15**] CXR, COMPARISON: [**2160-7-14**].
In comparison with the study of [**7-14**], the endotracheal tube has
been
removed. Elevation of the right hemidiaphragmatic contour
persists. There
appears to be some decrease in the perihilar lower lobe opacity
on the right. On the left, the hemidiaphragm is well seen with
some continued retrocardiac and infrahilar opacification that
most likely represents some atelectasis. No evidence of
pulmonary vascular congestion at this time.
[**2160-7-17**] CXR, COMPARISONS: Comparison is made to prior
radiograph from [**2160-7-15**].
FINDINGS: Left subclavian PICC with the catheter tip at the body
of the right atrium. Repositioning via retraction by 4 cm is
recommended. Otherwise, lung fields, cardiomediastinal
silhouette, hilar silhouette, and pleural surfaces remain
unchanged. There are no pleural effusions. There is no
pneumothorax.
[**2160-7-20**] 01:43PM BLOOD WBC-7.4 RBC-3.63* Hgb-11.2* Hct-32.6*
MCV-90 MCH-30.7 MCHC-34.2 RDW-14.4 Plt Ct-258
[**2160-7-21**] 06:10AM BLOOD PT-23.8* PTT-29.2 INR(PT)-2.3*
[**2160-7-20**] 01:43PM BLOOD Glucose-140* UreaN-13 Creat-0.7 Na-140
K-4.2 Cl-101 HCO3-28 AnGap-15
[**2160-7-19**] 02:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2160-7-20**] 01:43PM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
[**2160-7-10**] PATHOLOGY, PAROTIDECTOMY
Non-invasive carcinoma ex pleomorphic adenoma, 3 cm in maximum
dimension. See synoptic report. One lymph node, negative for
carcinoma. All other neck lymph nodes negative for carcinoma,
see report.
Brief Hospital Course:
NEURO/PAIN: Mr. [**Known lastname 17881**] was admitted post-op from right
parotidectomy and right neck dissection with right abdominal fat
grafting performed. His post-op pain was controlled initially
with Acetaminophen and Percocet, then he was switched to PO
Dilaudid with more adequate control achieved. Unfortunately, he
developed some hallucinations with his pain medication on HOD#8
requiring a switch to Propoxyphene, without issue. His home dose
of Citalopram 30 mg PO daily was resumed on HOD#7. His home dose
of Trazadone was held post-operatively.
CARDIOVASCULAR: He remained hemodynamically stable immediately
post-operatively. We restarted his home blood pressure
medication, Toprol XL 25 mg PO daily on POD#0. On HOD#1 a rapid
response/trigger was called in the AM given that the patient's
blood pressure was in the 70s/40s range and he complained of
being lightheaded when he attempted to stand-up or ambulate. He
denied cardiac symptoms. He was placed on telemetry monitoring,
given three 500 mL fluid boluses with adequate response (blood
pressure increased to 100s/60s). His EKG was unchanged from
[**2-/2160**], with some residual evidence of P-R interval elongation.
His beta-blocker was discontinued due to orthostatic
hypotension. The medicine team was consulted to evaluate, and
they agreed this was related to dehydration/orthostatic
hypotension.
RESPIRATORY: The patient was extubated at the end of the
operative procedure and maintained his oxygen saturations
without issue. He was encouraged to use incentive spirometry to
prevent atelectasis or PNA. We also prescribed Albuterol nebs
PRN given his mild asthma history. On HOD#2, the patient acutely
developed tachypnea to the 30s and desatted to 74% on 5L O2
nasal cannula, and eventually required a non-breather without
improvement in his oxygen saturations. A cardiac workup revealed
a troponin of 0.07, his EKG showed some right heart strain, and
a CTA was obtained showing multiple pulmonary arterial filling
defects compatible with acute pulmonary
embolus--with evidence of right heart strain and patchy
consolidation at the lung
bases. The medical ICU resident was called to evaluate the
patient and accepted his care. The patient also had a CT head
which showed no evidence of intracranial hemorrhaging. He was
given a loading dose of Heparin at 5000 U and a [**2149**] U/hr gtt
was maintained. The patient's oxygen requirements decreased, his
tachypnea resolved, and he was maintained in the MICU for close
monitoring and heparinized for acute PE. On HOD#3 the patient
had rapid accumulation of a right neck hematoma attributed to
leaky vasculature in the setting of heparinization for acute PE
treatment. He was intubated in preparation for the OR, and was
successfully extubated on HOD#4 without issue. The patient was
again intubated in preparation for the OR on HOD#5, in
preparation for a re-exploration of the right neck with hematoma
evacuation. He was kept intubated for airway protection and
successfully extubated on HOD#6 without issue. He was weaned
from nasal cannula to room air on HOD#7.
FEN/GI: Immediately post-op/extubation (from his second hematoma
evacuation) the patient was started on clear liquids and
advanced, without issue, to regular diet as tolerated by HOD#7.
He was maintained on NS @ 100 cc/hr until he was tolerating PO
intake and his IV was hep-locked. He had no issues with nausea
or vomiting. On HOD#8 he experienced some epigastric disomfort
most consistent with reflux esophagitis/GERD, and he was started
Famotidine and TUMS/calcium carbonate. This discomfort resolved.
GENITOURINARY: The patient had a Foley placed intra-operatively,
which was subsequently removed HOD#8 and he successfully voided
without issue. His post-labs revealed a creatinine of 0.7 which
remained stable. His urine output was adequate throughout his
hospital course. There was some note of a greenish hue of his
urine in the MICU around HOD#[**4-17**], which was thought to be
attributed to a porphyria. There was no evidence of rash or
abdominal discomfort which would suggest a more worrisome
porphyria diagnosis. His urine color restored to normal on
HOD#7.
ENDOCRINE: No active issues. Patient remained euglycemic.
Sliding scale insulin was maintained while on steroids post-op.
HEME/ID: Two right neck [**Location (un) 1661**]-[**Location (un) 1662**] drains were placed
intra-operatively and maintained adequate drainage until
heparinization on HOD#3 when he was heparinized for acute
pulmonary emboli, at which time the output of the drains
increased substantially (> 300 mL per day). Given the need for
anticoagulation in the setting of acute PE, the drains were
monitored closely. Repeat hematocrits were checked. The
patient's incision initially was with mild ecchymosis at the
flap border, which increased minimally by HOD#3. There was no
evidence of hematoma, although the drains had substantial output
during heparinization. On [**2160-7-13**] (HOD#3), the patient was
continued on 1400 U/hr of unfractionated heparin for acute
pulmonary embolus. It was noted that his drains had substantial
sanguinous output, and that a right neck hematoma was rapidly
collecting, without evidence of airway compromise. He was
brought to the OR emergently on [**2160-7-13**] (HOD#3) for evacuation
of the right neck hematoma, after two sucessful attempts of
bedside hematoma evacuation (350 mL total removed) with a
pressure dressing applied. Heparinization was continued during
the OR procedure at a rate of 1400 U/hr. The patient did well
post-op, but was noted on HOD#5 ([**2160-7-15**]) to have increased
output from both [**Location (un) 1661**]-[**Location (un) 1662**] necks drains once again. He again
returned to the OR on [**2160-7-15**] for re-exploration of the right
neck with evacuation of the right neck hematoma. He had no
compressive respiratory compromise during either episode of
hematoma, albeit the collection onset was rapid.
Intraoperatively, no identifiable source of bleeding was noted,
but diffuse leaky vasculature in combination with heparinization
was the likely etiology of the bleeding. See operative
dictations for details. Post-op on (HOD#6) [**2160-7-16**], the patient
appeared to have minimal residual serosanguinous output from
both [**Location (un) 1661**]-[**Location (un) 1662**] drains, he remained intubated for 48 hours
given some intraoperative supraglottic edema. Decadron was
administered post-operatively for 3 days. He was heparinized at
a rate of 1200-1450 U/hr, without heparin boluses, for a goal
PTT of 50 to 70. Upon floor transfer, the medicine team was
consulted to assist in management of the acute PE and
heparinization. PTT draws were performed Q6-8 hours, and
adjustments to the heparin gtt were maintained. On HOD#9 his
heparin gtt was discontinued. Coumadin 5 mg PO daily was
administered on HOD#8 and HOD#9, at which time his INR was
maintained in the 2.0 to 3.5 range, with a goal of [**1-15**].5. On the
date of discharge, HOD#11, the patient was given Coumadin at 2.5
mg PO daily, which will be recommended as the home dose, per
medicine.
The patient's post-op hematocrit dropped after his first
evacuation of right neck hematoma. He had received a total of 4
units of packed red cells throughout his hospital course. His
hematocrit responded appropriately to transfusion each time, for
a goal Hct > 25. Upon discharge, his hematocrit had been stable
at 32.6%. His WBC remained within normal limits throughout his
hospitalization. The patient was maintained on Clindamycin 600
mg IV Q8 while the right neck drains were in place to bulb
suction. He is being discharged with 5 more days of PO
Clindamycin.
PROPHYLAXIS: Pneumatic compression boots were maintained in the
post-op period to prevent DVT/PE initially. The patient was
encouraged to ambulate twice daily. Famotidine was administered
for GI prophylaxis given the steroid treatment.
Medications on Admission:
Home Medications:
- Citalopram 20 mg PO daily
- Trazadone 50 mg PO HS
- Metoprolol succinate 25 mg PO daily
- ASA 325 mg PO daily
Medication on Transfer to MICU:
- Furosemide 20 mg IV ONCE
- Nitroglycerin SL 0.3 mg SL ONCE
- Chloraseptic Throat Spray 1 SPRY PO Q8H:PRN sore throat
- Acetaminophen 650 mg PO/NG Q6H:PRN pain
- Citalopram Hydrobromide 20 mg PO/NG DAILY
- Clindamycin 600 mg IV Q8H JP drain
- Trazadone 50 mg PO/NG HS
- Dilaudid 1-2mg PO Q4H:PRN pain
Discharge Medications:
1. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain: Do NOT take
narcotic pain medication with alcohol or if you anticipate
driving.
Disp:*30 Tablet(s)* Refills:*0*
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*10 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO twice
a day for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right parotid tumor, non-invasive carcinoma ex pleomorphic
adenoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Seek immediate medical attention for fever >101.5, chills,
increased redness, swelling or discharge from incision, chest
pain, shortness of breath, or anything else that is troubling
you. It is OK to shower but do not soak incision until follow up
appointment, at least. No strenuous exercise or heavy lifting (>
15 lbs) until follow up appointment, at least. Do not drive or
drink alcohol while taking narcotic pain medications. Narcotic
pain medications may cause constipation, if this occurs take an
over the counter stool softener. Resume all home medications.
You may apply bacitracin as needed to the incision site until
your follow-up appointment. Please take the Clindamycin
antibiotic for 5 days upon discharge, as prescribed. Please take
Coumadin 2.5 mg by mouth daily upon dsicharge, as prescribed.
You have been scheduled with four follow-up appointments, as
indicated below: Dr. [**Last Name (STitle) 1837**] (ENT surgery), Dr. [**Last Name (STitle) **]
(Cardiology), Dr. [**Last Name (STitle) 3060**] (Hematology) and the [**Hospital **].
Call your primary care provider to make [**Name Initial (PRE) **] follow up appointment
in [**12-15**] weeks for a follow-up appointment.
Followup Instructions:
Provider: [**Known firstname **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**2160-8-20**] 3:40
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:
[**2160-8-29**] 9:00
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**] Date/Time:
[**2160-8-1**] 4:40
The [**Company 191**] ([**Hospital3 **]) will call you with an
appointment time after your discharge, for you to be seen in [**12-15**]
days. Please call [**Telephone/Fax (1) **] if you do not receive an
[**Hospital3 **] appointment.
Name: [**Known lastname 2967**],[**Known firstname **] L. Unit No: [**Numeric Identifier 2968**]
Admission Date: [**2160-7-10**] Discharge Date: [**2160-7-21**]
Date of Birth: [**2098-12-27**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1065**]
Addendum:
After speaking with the medicine consult team one last time, it
was determined that given the patient's acute pulmonary embolus
and after reviewing his history, an INR goal of 2 to 3 is more
appropriate (previously 2 to 2.5 was cited) per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
We will still discharge Mr. [**Known lastname **] on Coumadin 2.5 mg PO daily
with [**Hospital3 **] follow-up.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1067**] MD [**MD Number(1) 1068**]
Completed by:[**2160-7-21**]
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53,716
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414
|
Discharge summary
|
report
|
Admission Date: [**2182-6-23**] Discharge Date: [**2182-6-28**]
Date of Birth: [**2119-7-11**] Sex: F
Service: MEDICINE
Allergies:
Atenolol / Vasotec
Attending:[**First Name3 (LF) 3574**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 yo F with h/o, HTN, hypertensive heart disease, who presents
with two days of fever, nausea, vomiting and mental status
changes. Patient is confused and has poor insight into her
recent symptoms and reasons for presentation to the hospital. "I
felt like I had a cold... my son brought me in, you should talk
to him." The following was obtained from discussions with family
and EMS. Over the last 4 days, patient has become increasingly
confused. She also has had fever, vomiting, and diarrhea over
last 2 days. She lives at home, with her son who called EMS and
she was brought in by ambulance.
On presentation to the ED, VS were T 99.1, HR 106, BP 127/78,
SpO2 98% on 2L. Labs were significant for WBC count of 17, K of
2.9 and ALT/AST of 185/225. CXR demonstrated L hilar opacity
suspicious for PNA. Head CT showed no acute bleed. EKG showed
sinus tachycardia with lateral ST depressions. She was given 2L
NS, azithromycin, ceftriaxone, IV and PO potassium, ibuprofen
and tylenol. She was admitted to the medicine service for
further management of PNA and transaminitis. On transfer VS were
T 99.1, HR 101, BP 102/57, RR 17, SpO2 95/4L (89 on RA)
ROS: Denies night sweats, vision changes, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- Hypertension
- Hypertensive Heart Disease - cardiomyopathy/CHF, EF improved
from 15->50% in last year with medical managment.
- S/p Tubal ligation, [**2139**]
Social History:
SOCIAL HISTORY:
She smokes 5 cigarettes per day x 12 years, occ ETOH use. No
drug use.
Family History:
Father died of pancreatic cancer. Brother w/ a stroke in his
60s. No other cancers, no premature CAD.
Physical Exam:
On Admission:
VS - Temp 99.5 F, BP 104/61, HR 96, R 18, O2-sat 96% 4L NC
GENERAL - obese AAF in no acute distress, lying in bed
HEENT - NC/AT, PERRLA, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - Rales on left, no wheezing, no crackles.
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - Awake, A&O to self, place, season, year. mild R facial
droop. no pronator drift, speech fluent, sensation grossly
intact b/l.
Pertinent Results:
Admission labs:
[**6-25**]: wbc:10.9 hgb:10.9* Hct:31.8* plt: 231
[**6-25**]: glu:123 bun:21 Cr:1.1(from 1.6) Na:144 K:3.3 Cl:107
Bicarb:26
[**6-25**]: ALT:210* AST:260* LD:558* AP:157* TB:2.1*
[**6-25**]: INR: 1.1
[**6-25**]: ABG: Po2:105 Pco2: 36 Ph:7.44 Bicarb:25
.
Discharge labs:
[**2182-6-28**] 06:10AM BLOOD WBC-6.6 RBC-3.60* Hgb-10.8* Hct-31.9*
MCV-89 MCH-30.0 MCHC-33.8 RDW-15.1 Plt Ct-314
[**2182-6-26**] 05:55PM BLOOD Neuts-72.0* Lymphs-24.0 Monos-2.6 Eos-1.1
Baso-0.4
[**2182-6-28**] 06:10AM BLOOD Plt Ct-314
[**2182-6-28**] 06:10AM BLOOD PT-13.7* PTT-25.2 INR(PT)-1.2*
[**2182-6-28**] 06:10AM BLOOD Glucose-110* UreaN-15 Creat-0.6 Na-143
K-3.4 Cl-104 HCO3-26 AnGap-16
[**2182-6-28**] 06:10AM BLOOD ALT-126* AST-142* CK(CPK)-193
AlkPhos-161* TotBili-0.8
[**2182-6-28**] 06:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.6
[**2182-6-24**] 01:15PM BLOOD %HbA1c-7.8* eAG-177*
[**2182-6-26**] 04:30AM BLOOD TSH-1.2
[**2182-6-25**] 06:50AM BLOOD IgM HAV-NEGATIVE
[**2182-6-24**] 07:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2182-6-26**] 05:55PM BLOOD HIV Ab-NEGATIVE
Bcx from [**6-23**]: GRAM POSITIVE ROD(S) CONSISTENT WITH CLOSTRIDIUM
OR BACILLUS SPECIES.
Bcx from [**6-24**]: Gram neg rods (prelim)
CXR from [**6-25**]: In comparison with the study of [**6-24**], there is
little overall changein the extensive left-sided pneumonia that
involves much of this side of the lung. Widespread
air-bronchograms are again seen. Retrocardiac atelectasis or
consolidation is again noted. Mild blunting of the costophrenic
angles again seen.
CT head from [**6-23**]: no intracranial pathology
RUQ US fro [**6-23**]: Coarsened and echogenic liver with probable
focal areas of focal fatty sparing. Please note, while the
appearance is in part due to fatty deposition,more advanced
forms of liver disease such as cirrhosis or fibrosis cannot be
excluded. Clinical correlation is advised and consideration may
be given to MRI if clinically indicated.
.
CHEST (PA & LAT) Study Date of [**2182-6-26**] 4:38 PM
Large consolidation in the left upper and mid lung, consistent
with infectious process appears to be minimally different from
the prior study with no obvious evidence of improvement. There
is unchanged cardiomegaly with small amount of left pleural
effusion that appears to be unchanged as well. The overall
appearance has progressed compared to [**2182-6-23**]. No
appreciable evidence of volume overload is demonstrated. The
findings, although consistent with infectious process might
obscure underlying mass. Followup until resolution is highly
recommended with
reevaluation of the patient in two to four weeks after
completion of antibiotic therapy. If no clinical symptoms of
improvement are present,
evaluation with chest CT, preferably after injection of IV
contrast might be considered to exclude the possibility of
post-obstructive pneumonia.
.
Brief Hospital Course:
#Bacteremia: On HOD 1, pt was found to grow g+ rods c/w
clostridium or bacillus. at this time the ceftriaxone/azithro
which she was started on was d/c'd and she was started on a
course of vanc/zosyn/clinda (for possibility of clostridium
toxin). Pt was spiking fevers persistently throughout the day
of [**6-24**](as high as 104.4), and was receiving tylenol and
continous IVF. By the following morning, her fevers had
improved, but she was significantly hypotensive (SBP in 80s),
and was satting in the low 90s on 4L NC. At this point a 1L
bolus was started and she was put on a NRB and her O2 responded
well. BP also came up to SBP 104 after half of her bolus.
However, given the concern for septic shock, a trigger and MICU
consult was called. Pt was transported to MICU where her
pressures improved with fluids without a pressor requirement.
#. Pneumonia: Initial CXR in ED showed left perihilar opacity
consistent with pna. with continued fevers, we obtained a
repeat the next evening which showed worsening of her pna to
include upper and lower lobes. It is unclear at this point
whether the pna was seeded by the bacteremia or a separate
issue. However, she was being covered for her pna with her
bacteremic management. Patient transferred to the MICU on [**6-25**]
for hypoxia requiring a nonrebreather. Vanc and zosyn were
continued and she was able to quickly wean her oxygen
requirements and was transferred back to the floor the next day.
On the floor pt had a urine culture that was positive for
legionella; after consultation with ID, the pt was switched to
Levofloxacin 750 mg daily for an abiotic course of 10days. This
was completed in the outpat setting. Pt was discharged on home
oxygen while she completed her recover.
.
#AMS: Per pt report, she had been feeling ill in the days
leading up, and her family says she was not her baseline and
that something was "off". The pt's change in MS [**First Name (Titles) **] [**Last Name (Titles) 2771**]
to her bacteremia. Her head CT was negative. [**Name (NI) 3575**] pt was
mostly A/Ox3 but would occasionally forget the date. She was
mentating well and answered questions, and carried on
conversations. Even with her episode of hypotension prompting
the MICU transfer on [**6-25**] she didn't have any acute MS changes.
As she recovered on the floor, her MS continued to improve and
returned to baseline.
.
#. Transaminitis: Unclear etiology but were initially thought to
be related to hypoperfusion state vs. hepatitis or possible
rhabdo given elevated CK. We ordered hep serologies which were
negative and trended the LFTs which generally improved over time
but findings on US were suggestive of chronic liver diases.
Follow-up was arranged in the outpt setting with a hepatologist.
Of note, LFT elevations are also common with Streptococcal
pneumonia and legionella; given the positive legionella urine
test this was likely the cause.
.
#. Acute Renal Failure: Pt came in with Cr 1.6, and this began
trending down with hydration. We believe this was of pre-renal
eitology from likely hypoperfusion state. We held her [**Last Name (un) **] and
thiazide, Cre was improved at the time of transfer out of the
MICU.
.
# Migraine headaches: Patient continued on her amitriptyline but
had positive serum tox for TCAs consistent with chronic overdose
(no signs of toxicity.) Her home dose was decreased by half.
.
# Hyperglycemia: During admision the pt was found to have high
glucose levels w/ elevated HgA1C 7.8. Outpt follow-up was
arranged with the pt's PCP for further evaluated and managed.
.
Pt was full code during her admission.
Medications on Admission:
Amitriptyline 100mg daily
Amlodipine 10 mg PO daily
Carvedilol 25 mg PO daily
Hydrochlorothiazide 25 mg PO daily
Simvastatin 20 mg PO daily
Valsartan 320 mg PO daily (not on list but patient states takes
and confirmed with pharmacy)
Acetaminophen/codeine Q6-8H prn
Aspirin 325mg daily
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
2. Supplemental Oxygen
O2 at 4lpm continuous. Pulsed dose for portability
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
8. Outpatient Lab Work
Check CBC, Chem 7, LFTs
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Mental status changes
Pneumonia
Bacteremia
Acute Renal Failure
.
Secondary:
Respiratory failure
Elevated transaminases and bilirubin (liver function tests)
Hyperglycemia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 1968**],
You were admitted to the hospital on [**2182-6-24**] because you were
having some increased confusion, and you were found to have a
blood-stream infection on admission and severe pneumonia. You
were given multiple antibiotics to treat this, in addition to
fluids to help keep your blood pressure up. However, the next
morning your blood pressure and oxygen levels dropped low, and
you were transferred to the intensive care unit for further
management. You improved with supportive oxygen therapy, IV
fluids and continued antibiotics. You were able to be
transferred to the regular medical floor on [**2182-6-25**] where you
continued to receive antibiotics. Test showed that you had
bacteria in your blood and urine. Bacteria can cause all of the
symptoms that you experienced including fever, cough, pneumonia
and stomach upset. One of the bacteria found (called legionella)
often grows in anything contain old, stagnant water such as an
old air conditioner which you stated that you had. It will be
very important that you get rid of your old air conditioner and
replace it with a new one as the old air conditioner may have
been the source of your infection.
.
Although you initially continued to have fevers and sweating on
antibiotics you tempature slowly returned to [**Location 213**] and your
need for supplamentary oxygen decreased. However, because of the
severity of the pneumonia which you had, you will need to remain
on home oxygen for a short time while you finish your
antibiotics and recover. It will be very important that you
complete the entire coures of antibiotics as prescribed to
ensure that the infection is completely treated and your
symptoms do not return. It will also be very important to
follow-up with your PCP (see appointment scheduled below) and to
have a repeat chest xray in [**1-24**] weeks to ensure that your
pneumonia has resolved.
.
While you were in the hospital, it was found that tests of your
liver function were abnormal and an ultrasound showed changes in
your liver that were suggestive of chronic liver disease. It is
very important the your liver function tests be checked to
ensure that they return to normal. Also, we have scheduled an
appointment for you to see a liver specialist (hepatologist) to
determine why there are these chronic changes seen in your liver
on ultrasound.
.
Also, it was found that you blood sugar was high and a test over
you blood showed that your hemoglobin A1C (which is a measure of
chronic high glucose in your blood) was elevated. This suggests
that you may have abnormally high glucoses levels chronically
which could suggest you might be at risk for diabetes. You will
need to follow-up with your regular doctor to have this further
evaluated and managed.
.
Blood tests also showed that the number of red bloods was low
and that you had anemia. This should be further evalutated by
your regular doctor to ensure that you red blood cell count
returns to normal after you recover from your pneumonia.
.
The following changes were made to your medications:
- Start taking Levofloxacin 750 mg daily; please be sure to
complete the entire course of your antibiotic which will end on
[**7-7**] for a total course of 10 days begun on [**2182-6-27**].
- Stop taking amlodipine; you will need to speak with your
doctor regarding whether or not you should continue taking this
medication.
- Reduce your dose of Amitriptyline 25 mg PO daily instead of
75mg given that your levels were found to be high while in the
hospital; you will need to discuss with your PCP whether to
resume your previous dose.
- Stop taking your simvastatin; please discuss with your PCP
whether this can be restarted once your liver function tests are
normal again.
- Please use your home oxygen to ensure that the level of oxygen
in your blood is >93%.
.
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your PCP
and liver doctor.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP
and liver doctor.
.
Name: [**Last Name (LF) 3576**],[**First Name3 (LF) 3577**] R.
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Appointment: Tuesday [**2182-7-2**] 11:00am
.
We are working on a follow up appointment in the Liver Center
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 9-15 days. The office will contact
you at home with an appointment. If you have not heard or have
any questions please call [**Telephone/Fax (1) 2422**].
.
Completed by:[**2182-7-14**]
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10489, 10489
|
2717, 2717
|
14718, 15414
|
2013, 2117
|
9640, 10228
|
10278, 10468
|
9331, 9617
|
10640, 14695
|
3039, 5659
|
2132, 2132
|
240, 263
|
335, 1706
|
2733, 3023
|
2147, 2698
|
10504, 10616
|
1728, 1891
|
1923, 1997
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,991
| 159,124
|
15262
|
Discharge summary
|
report
|
Admission Date: [**2193-1-4**] Discharge Date: [**2193-1-11**]
Date of Birth: [**2145-10-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 year-old male with a history of metastatic melanoma who
presents with neck pain. Patient presented to [**Doctor Last Name **]-[**Doctor Last Name 7796**] today
for enrollment in a clinical trial and was referred to our ED
for compliant of chest and neck pain. Patient reports
significant left neck pain of 2 days duration, worse with
movement. Also describes associated chest pain but this is much
less in severity and only associated with exertion. Denies
associated shortness of breath with the chest pain. Patient
describes feeling "hot, cold sensation" but denies fever or
chills. Describes mild non-productive cough of 2 days duration.
Also describes mild sore throat but no difficulty swallowing,
mild headache and dizziness. Denies rhinorrhea. Denies nausea,
vomiting or abdominal pain. Denies diarrhea. Denies upper or
lower extremity swelling. Other than concern regarding his
diagnosis has been feeling well at home.
.
Patient presented to ED VS T 100.4, HR 107, BP 123/64, RR 16, O2
Sat 98% RA. Tmax 100.4, HR 96-106. Patient was given 4 L NS, 1 L
LR, dilaudid 1 mg IV, Ativan 1 mg po, Cefeprime 2 mg IV,
Vancomycin 1 gram. Due to left neck and arm pain ultrasound was
preformed which demonstrated thrombus in one of two visualized
left brachial veins, basilic vein, axillary vein, subclavian
vein, and internal jugular vein. He has had multiple central
venous lines for he chemotherapy, specfically bilateral
subclavian and a LUE PICC line twice. He has not used his right
arm for access secondary to his previous surgical lymph node
dissection. CT scan neck confirmed left upper extremity thrombus
with complete obliteration of the left internal jugular vein and
its distal branches as well as progression of his melanoma.
Following discussion with his Heme Onc PICC pulled and patient
was started on a heparin drip.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, orthopnea, PND, lower extremity edema,
cough, urgency, dysuria, gait unsteadiness, focal weakness,
vision changes, rash or skin changes.
Past Medical History:
1. Metastatic Melanoma: Please refer to prior Onc note for full
history but in brief - Diagnosis [**10/2191**], INF [**2-/2192**], [**2192-11-29**]
cisplatin, dacarbazine, interferon, aldesleukin - failed both
therapies last Heme Onc note [**2192-12-28**] reports consideration of
compassionate use ipilimumab on trial 07-350 at [**Doctor Last Name **]-[**Doctor Last Name 7796**].
2. Pulmonary embolism diagnosed [**2192-11-2**], stable.
3. Gout, worse
4. Depression, stable
Social History:
Lives alone. Per OMR supportive family. He previously smoked 1
pack per week x 15 years. Quit smoking in the early [**2181**]. No
current alcohol or recreational drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 100.1 BP: 160/66 HR: 107 RR: 16 O2Sat: 96% RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, + tenderness of left IJ.
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: + left upper extremity swelling > right upper extremity.
Mild erythma of entire left upper - no localized tracking or
exudate. No palpable cords.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission labs:
[**2193-1-4**] 01:25PM BLOOD WBC-16.6* RBC-3.61* Hgb-10.6* Hct-31.1*
MCV-86 MCH-29.3 MCHC-34.0 RDW-17.5* Plt Ct-458*#
[**2193-1-4**] 01:25PM BLOOD Neuts-81* Bands-2 Lymphs-4* Monos-12*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2193-1-4**] 01:25PM BLOOD PT-13.2 PTT-23.6 INR(PT)-1.1
[**2193-1-4**] 01:25PM BLOOD Glucose-91 UreaN-18 Creat-0.8 Na-127*
K-7.1* Cl-89* HCO3-22 AnGap-23*
[**2193-1-4**] 04:00PM BLOOD ALT-21 AST-70* AlkPhos-312* TotBili-0.4
[**2193-1-4**] 04:00PM BLOOD Albumin-2.7*
[**2193-1-5**] 12:09AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.2*
.
Other labs:
[**2193-1-4**] 01:29PM BLOOD Lactate-6.4* Na-130* K-6.0*
[**2193-1-5**] 04:35PM BLOOD Type-ART pO2-69* pCO2-32* pH-7.45
calTCO2-23 Base XS-0
[**2193-1-6**] 05:33PM BLOOD Vanco-5.7*
[**2193-1-5**] 03:56AM BLOOD Osmolal-273*
[**2193-1-8**] 05:00AM BLOOD calTIBC-156* Hapto-556* Ferritn-838*
TRF-120*
[**2193-1-5**] 12:09AM BLOOD CK-MB-1 cTropnT-<0.01
[**2193-1-5**] 11:37AM BLOOD cTropnT-<0.01
[**2193-1-8**] 05:00AM BLOOD Ret Aut-2.1
.
.
Urine:
[**2193-1-4**] 04:30PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.025
[**2193-1-4**] 04:30PM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-15 Bilirub-SM Urobiln-1 pH-6.5 Leuks-TR
[**2193-1-4**] 04:30PM URINE RBC-0-2 WBC-[**2-16**] Bacteri-MOD Yeast-NONE
Epi-0
[**2193-1-4**] 04:30PM URINE CastHy-[**5-24**]*
[**2193-1-6**] 04:58PM URINE Osmolal-745
[**2193-1-4**] 04:39PM URINE Hours-RANDOM Creat-206 Na-110 K-100
Cl-130
[**2193-1-6**] 04:58PM URINE Hours-RANDOM Creat-71 Na-212 K-37 Cl-239
[**2193-1-4**] 04:30PM URINE Mucous-MOD
[**2193-1-5**] 04:55PM URINE Mucous-RARE
[**2193-1-5**] 04:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2193-1-5**] 04:55PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2193-1-5**] 04:55PM URINE RBC-5* WBC-4 Bacteri-FEW Yeast-NONE Epi-0
Brief Hospital Course:
47 M with metastatic melanoma presenting with L neck pain, found
to have diffuse recurrent venous thromboembolic disease, likely
LMWH failure, also fever and elevated lactate. Initially
admitted to the [**Hospital Unit Name 153**], started on heparin drip, and transferred
to the OMED service for continued management.
.
# Recurrent venous thromboembolic disease: The patient had
thrombus formation in his Left Internal Jugular, Left
Subclavian, Right Common Femoral, and Left Internal Iliac veins.
The patient has a history of bilateral pulmonary embolisms for
which he had been on Lovenox 90 mg [**Hospital1 **] (1mg/kg [**Hospital1 **]) for months.
He had a left upper extremity PICC line, which was pulled on
admission. His CT Head was negative for obvious brain
metastases, so he was started on a Heparin drip, then bridged to
Lovenox 120 mg [**Hospital1 **], as one study has shown that a 20-25%
increase in dose may prevent future recurrences in patients with
LMWH failure. He will follow up with Dr. [**First Name (STitle) **] as an
outpatient.
.
# Fever: Initially concerning for septic thrombophlebitis;
however, admission cultures were negative, and his fever curve
trended down as his pain from the clots improved. We initially
started him on Vancomycin, but this was discontinued on [**1-8**]
after cultures had been negative for 48 hours. His PICC catheter
tip was cultured and had no growth. We believe his fevers were
likely secondary to his clots and tumors. He was afebrile >24
hours prior to discharge.
-F/U pending cultures
.
# Leukocytosis: Chronic, and likely secondary to his underlying
malignancy. His white count remained relatively stable. He had
no localizing signs or symptoms of infection, and his culture
data was negative.
.
# Hyponatremia: Resolved with free water fluid restriction.
Urine lytes suggested SIADH.
.
# Metastatic melanoma: Unfortunately, his melanoma is
progressing based on recent scans. The patient was to start
compassionate Ipilimumab at the [**Hospital3 328**] when he was sent to
our Emergency Room for evaluation of his left neck pain. We
continued to control his pain and anxiety while in house. He
will follow up with his Primary Oncologist, and at the Farber to
hopefully begin Ipilimumab in the near future.
.
# Anemia: Normocytic. Fe studies reflect chronic inflammation.
.
# Hypertension: We continued lisinopril 10 daily, then increased
his lisinopril to 20 mg daily to help better control his blood
pressure.
.
# Gout: No evidence of active disease during this admission.
Medications on Admission:
COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth as directed as
needed for gout flare
ENOXAPARIN - (Dose adjustment - no new Rx) - 100 mg/mL Syringe -
90 Syringe(s) every twelve (12) hours - per patient 80 [**Hospital1 **]
HYDROMORPHONE - (Prescribed by Other Provider) - 2 mg Tablet -
[**12-16**] Tablet(s) by mouth every four (4) hours as needed for pain
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
LORAZEPAM - (Dose adjustment - no new Rx) - 1 mg Tablet - 1
Tablet(s) by mouth three times a day as needed for nausea,
vomiting, anxiety or insomnnia
MORPHINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by mouth
every eight (8) hours
ONDANSETRON HCL - (Prescribed by Other Provider) - 8 mg Tablet -
1 Tablet(s) by mouth twice a day
PROCHLORPERAZINE MALEATE - (Dose adjustment - no new Rx) - 10 mg
Tablet - 1 Tablet(s) by mouth four times a day as needed for
Nausea
Discharge Medications:
1. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
twice a day.
Disp:*60 syringes* Refills:*0*
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO as directed
as needed for gout flare.
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for nausea, anxiety.
6. morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
7. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
-recurrent venous thromboembolic disease- thrombi in the left
internal jugular, left subclavian vein, right common femoral,
and left internal iliac vein
-metastatic melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were recently admitted to [**Hospital1 18**] Medicine Oncology service
for treatment of the blood clots found in many of your veins,
including your left neck, left upper arm, and right groin area.
We started you on a heparin drip (blood thinner) and you
improved. We have started you on a higher dose of Lovenox, which
you will need to continue as outpatient. Please contact your
Primary Oncologist with any questions that you have.
.
We have made the following changes to your outpatient medication
regimen:
-Please START Lovenox at 120 mg twice daily
-Please INCREASE Lisinopril to 20 mg daily (you may take two 10
mg tabs until you are able to fill this prescription)
-Please continue all other medications as prior
Followup Instructions:
We are making you a follow up appointment with Dr. [**First Name (STitle) **].
Please call his office at [**Telephone/Fax (1) 44403**] later today or tomorrow
to find out the exact date and time.
Department: PSYCHIATRY
When: WEDNESDAY [**2193-1-9**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23908**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"453.81",
"453.82",
"285.9",
"453.86",
"453.89",
"311",
"453.85",
"401.9",
"198.5",
"453.84",
"416.2",
"197.0",
"274.9",
"276.1",
"276.2",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10219, 10225
|
5867, 8402
|
314, 320
|
10442, 10442
|
3938, 3938
|
11372, 12040
|
3164, 3182
|
9371, 10196
|
10246, 10421
|
8428, 9348
|
10592, 11349
|
3197, 3919
|
265, 276
|
348, 2460
|
3955, 4506
|
10457, 10568
|
2482, 2959
|
2975, 3148
|
4519, 5844
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,693
| 105,902
|
16659
|
Discharge summary
|
report
|
Admission Date: [**2193-1-12**] Discharge Date: [**2193-1-14**]
Date of Birth: [**2148-10-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is a 44 y.o. female with history of 1 vessel CAD s/p MI and
placement of DES to LAD in [**2186**], insulin dependent DM, and
Polysubstance abuse who presented with 3-4 days of crescendo
chest pain. The patient complained of 2 weeks of SOB with
exertion and talking that worsened over time. Three days prior
to presentation this was accompanied by chest pain that felt
like substernal chest pressure; she took sl nitro on two
occasions to good effect. On the day prior to admission, she
took 3 sl NTG. Then, at 0400 on [**2193-1-12**], she awoke from sleep
with a 10/10 chest pain/pressure that radiated to both arms and
her back. It was accompanied by an inability to move or talk and
lasted 30 minutes. She stood up, went to the bathroom, and then
went back to sleep. She awoke in the later AM, felt [**4-13**] Chest
pressure, arranged a babys[**Name (NI) 1786**] for her child, and asked her
ex-husband to take her to the [**Name (NI) 487**] [**Name (NI) **] (11:15 AM).
.
At [**Hospital1 **], pt presented with ST Elevation in 2,3, aVF, V5 and
V6. received ASA 324, Heparin Drip, Nitro drip, Plavix (600mg),
and 10u Regular insulin (bg 417). Transfered to [**Hospital1 **] with VSL
104/70, HR 76, RR 18.
.
At [**Hospital1 **], patient straight to cath lab. RCA with 95% distal
stenosis, received IC ntg, balloon angioplasty, Endeavour stent
with 2nd Endeavour to repair proximal edge restenosis. 105 ml
Omnipaque given.
.
Cardiac review of systems is notable for presence of:
DOE (walking, talking), chest pain as above.
absence of:
chest pain (at present), paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
On other review of systems:
+ occ. nausea, occ. nightsweats (when sugar low), menorrhagia,
calf pain ("charleyhorse") with ambulation, leaning on shopping
cart, numb toes, tingling fingers. All of the other review of
systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: IDDM, Dyslipidemia, Hx of Hypertension
2. CARDIAC HISTORY:
[**2186**] - Lateral NSTEMI; Single vessel disease
- PTCA to D1, Dx w/ Severe Diastolic Dysfunction
- EF 45;Anterior, mid and distal septal, apical akniesis
[**2186**] - Cath: CYPHER stent to mid-LAD, D1 subtotal occlusion
[**2187**] - negative ETT
[**2188**] - Nuclear Stress: ECG changes at 64% HR; mod perfusion
deficit
[**2188**] - Cath: Moderate Single Vessel disease
- Left Sublclavian stenosis with Bare Metal Stent
[**2190**] - Cath: 40% in-stent stenosis of LAD; no RCA disease
- LCX had mild diffuse disease and was also small
-PERCUTANEOUS CORONARY INTERVENTIONS: 4 previous caths
3. OTHER PAST MEDICAL HISTORY:
A. IDDM: a1c 13.3% in [**6-/2191**]
B. Hyperlipidemia
C. Polysubstance Abuse: Heroin (years sober), Cocaine (year
sober), Tobacco
D. Hepatitis C Ab, Negative Viral Load in [**2186**]
E. Obesity.
F. Breast Abcess [**2189**]
G. History of tuberculosis exposure s/p 9 months of tx ([**2173**]'s)
Social History:
-Tobacco history: smoked since age 12, [**2-6**] ppd --> 4 cigs/day x
6months
-ETOH: none
-Illicit drugs: hx of heroin, cocaine (Intranasal)
Lives in basement apartment of in-laws house with 7 year old
son. Trying to achieve rapprochement with seperated husband.
Subsists on $700/month. Not on MassHealth
Family History:
Major FHx of CAD; father with MI at 38, mother, uncle and
brother with CAD/MI. Father died of Esophageal Ca
Physical Exam:
VS: T= 97.1 BP=104/72 HR=70 RR=18 O2 sat= 99 on 2L
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-9**] crescendo/decrescendo murmur in
LLSB that is slightly better with valsalva and worse with hand
grip, no r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. No
splinters, [**Last Name (un) **] or oslers.
PULSES:
Right: Carotid 2+ Femoral 2+ Radial 2+ Popliteal 1+ DP 2+
Left: Carotid 2+ Femoral 2+ Radial 1+ Popliteal 1+ DP 2+
Pertinent Results:
ADMISSION LABS:
[**2193-1-12**] 03:49PM BLOOD WBC-10.9 RBC-4.22 Hgb-12.2 Hct-37.1
MCV-88 MCH-28.9 MCHC-32.8 RDW-12.8 Plt Ct-271
[**2193-1-12**] 03:49PM BLOOD Neuts-69.6 Lymphs-26.5 Monos-2.4 Eos-1.0
Baso-0.5
[**2193-1-12**] 03:49PM BLOOD Glucose-275* UreaN-11 Creat-0.7 Na-133
K-3.8 Cl-100 HCO3-26 AnGap-11
[**2193-1-12**] 03:49PM BLOOD CK(CPK)-1430*
[**2193-1-13**] 05:32AM BLOOD CK(CPK)-1147*
[**2193-1-12**] 03:49PM BLOOD CK-MB-170* MB Indx-11.9* cTropnT-4.16*
[**2193-1-13**] 05:32AM BLOOD CK-MB-112* MB Indx-9.8* cTropnT-3.38*
[**2193-1-12**] 03:49PM BLOOD Mg-1.7 Cholest-266*
[**2193-1-12**] 03:49PM BLOOD Triglyc-323* HDL-41 CHOL/HD-6.5
LDLcalc-160*
Urine tox positive for methadone, cocaine and benzodiazepines
--------------
DISCHARGE LABS:
--------------
STUDIES:
Cardiac catheterization [**2193-1-13**]:
1. Selective coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had no
angiographically apparent disease. The LAD had a patent stent
and no angiographically apparent disease. The Cx had no
angiographically apparent disease. The RCA had a distal 95%
stenosis with TIMI 2 flow into the more distal branches.
2. Limited resting hemodynamics revealed an elevated left sided
filling pressure of 30 mmHg (LVEDP). The central aortic pressure
was 97/58 mmHg. There was no transaortic gradient on pullback
from the LV to the aorta.
3. Left ventriculography revealed a calculated LVEF of 34%.
There was hypokinesis of the posterobasal, inferior, apical and
anterolateral walls.
Qualitative wall motion:
1. Antero basal - normal
2. Antero lateral - hypokinetic
3. Apical - hypokinetic
4. Inferior - hypokinetic
5. Postero basal - hypokinetic
Final DX
1. One vessel coronary artery disease.
2. Moderate left ventricular diastolic dysfunction.
.
Brief Hospital Course:
Ms. [**Known lastname 27534**] was admitted to the hospital s/p STEMI. Hospital
course by problem:
.
1. ST-ELEVATION MI
She presented with worsening chest pain and was found to have
RCA disease on cath. She received a DES to the RCA during cath.
Tox screen was positive for cocaine which likely contributed to
coronary vasospasm and cause the MI. She was given Integrilin
for 18 hours post-cath. She was started on Atorvastatin and
Lisinopril while in the hospital as well as Plavix. Due to
difficulty paying for medication, the Atorvastatin and
Lisinopril were not continued on discharge. She worked with
physical therapy prior to discharge and was chest pain free.
She was discharged only on aspirin and Plavix to facilitate
medication compliance. She has follow-up with cardiology and
her PCP.
.
2. CONGESTIVE HEART FAILURE
She has both systolic and diastolic dysfunction. Preliminary
Echo showed EF of 40-45%. She had no symptoms of decompensated
heart failure during this admission and did not require
diuretics. She was counseled on limiting her salt intake. She
has cardiology follow-up. She was not discharged on an ACE due
to inability to pay for medications.
.
3. DIABETES
Blood sugars were difficult to control. She was continued on
NPH 28 units [**Hospital1 **] as per her home regimen and was given a humalog
sliding scale. She has an appointment with [**Last Name (un) **] to follow-up
on blood sugar management as an outpatient. She was not given
an ACE due her inability to pay for medications.
.
4. SUBSTANCE ABUSE
She denied cocaine use despite urine tox screen result which was
positive for cocaine. When confronted about this she continued
to denies using cocaine and became tearful. Social work met
with her for substance abuse counseling. An HIV test was sent
and she will follow-up with her PCP for these results.
.
5. HYPERLIPIDEMIA
Cholesterol panel revealed elevated total cholesterol of 266 and
LDL of 160. She was given Atorvastatin while in-house but was
not discharged on this due to her difficulty paying for
medications.
.
6. TOBACCO USE
She was given a Nicotine patch while in house and counseled on
tobacco cessation.
.
7. FEN: Cardiac Heart Healthy, Diabetic diet.
.
FOLLOW-UP
She has an appointment to see [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks and will
follow-up on diabetic control, medication compliance and further
symptoms. She will obtain her results of her HIV test. She can
also receive the final read of her echo at that time. If she is
able to get Mass Health and pay for her medications, we would
recommend adding Pravastatin 40mg (on the [**Company **] $4 drug use)
and Lisinopril 5mg daily. She will follow-up with Dr. [**Last Name (STitle) **]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**] of [**Last Name (un) **].
Medications on Admission:
Lipitor 80 (not taken for > 1 month)
Aspirin (not taken for > 1 year)
Humulin 28 [**Hospital1 **]
Humulog 6 qMeal
Metformin 500 TID
Lisinopril 5 qd (not taken for > 1 yr).
Methadone 75 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
1. ST-Elevation MI
Secondary Diagnoses:
2. Cocaine Use
3. Systolic Congestive Heart Failure
4. Medication Non-compliance
Discharge Condition:
clear mental status, chest pain free.
Discharge Instructions:
You were admitted to the hospital after having a heart attack.
You had a procedure to place stents into the arteries that
supply your heart. It is extremely important that you take
PLAVIX (CLOPIDIGREL) to prevent these stents from closing. You
need to take this medication for the next year.
The following medications were added:
PLAVIX 75mg by mouth once a day
ASPIRIN 81mg by mouth once a day
Please continue to take your Humalin twice a day and Humalog
with meals. Please continue to take your Flovent and Albuterol
inhalers.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Please call your doctor or come to the emergency
room if you experience chest pain, shortness of breath, arm or
back pain, sweating, nausea or vomiting. Avoid salty foods such
as soups, lunch meats and canned food.
Followup Instructions:
APPOINTMENTS:
PRIMARY CARE:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP - [**2193-1-25**] at 10:00am. She is the Nurse
Practitioner who works with Dr. [**Last Name (STitle) 483**]. [**Telephone/Fax (1) 250**]
CARDIOLOGY:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - [**2193-2-4**] at 3:20pm. [**Hospital Ward Name 23**] Building, [**Location (un) 3971**]. [**Telephone/Fax (1) 62**]
DIABETES AT [**Last Name (un) **]:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**] - [**2193-1-18**] 3:30pm. One [**Last Name (un) **] Place. ([**Telephone/Fax (1) 17256**]. Please bring your meter and insurance card to the
appointment.
|
[
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"305.1",
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icd9cm
|
[
[
[]
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] |
[
"00.66",
"88.53",
"88.55",
"36.07",
"37.22",
"00.46",
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icd9pcs
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[
[
[]
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9737, 9743
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326, 351
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9909, 9949
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4817, 4817
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,197
| 122,688
|
3672
|
Discharge summary
|
report
|
Admission Date: [**2160-5-11**] Discharge Date: [**2160-5-15**]
Date of Birth: [**2090-5-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 year old woman with type 1 diabetes mellitus (insulin pump),
chronic lumbar disk disease, hypertension, hyperlipidemia,
severe peripheral [**First Name3 (LF) 1106**] disease with right BKA ([**6-/2159**],
chronic pain from PVD and phantom limb pain on narcotics),
orthostatic hypotension (was on salt tabs) who presents with
hypertension and hyperglycemia. Reportedly [**Year (4 digits) 269**] saw her today and
found her with altered mental status(confirmed with husband) and
with SBP>220. No focal numbness, weakness, tingling. Denies
fevers, chills, nausea/vomiting, abdominal pain, headache,
visual changes.
.
The patient did call [**Company 191**] today as she was discharged yesterday
without new MS [**First Name (Titles) **] [**Last Name (Titles) 16615**] and she is out at home. She
was concerned about withdrawal but her pain was well controlled
with oxycodone. Plan was for to pick up her [**Last Name (Titles) 16615**] on
[**Last Name (Titles) 766**] morning, but to present to the ED with any concerning
signs or symptoms in the interim.
.
Of note, the patient was recently admitted 6/4-9/[**2159**] for
nausea/vomiting/diarrhea felt possibly due to withdrawal (from
MS contin). She was briefly in the MICU for hypertensive
emergency (altered mental status) and mild DKA. She was treated
with aggressive insulin, IVF, pain control, anti-emetics and
labetalol gtt. Cardiology was also consulted for new RBBB that
they felt was rate related (not due to acute myocardial
ischemia). She was ultimately transitioned to Labetalol 400mg
[**Year (4 digits) **] and then to Lisinopril 5mg --> 2.5mg upon discharge (given
history of orthostatic hypotension with frequent SBP drops by 40
points). She was instructed to discontinue salt tabs which she
previously took at home. Metanephrines were also sent given ?why
she only recently became so hypertensive yet orthostatic, and so
difficult to control.
.
In the ED, initial VS were: T98.2, HR81, BP178/68, RR18, 98% on
RA. The patient was alert and oriented X3 but sleepy (easily
aroused). She was started on IVF (2L NS) and labs notable for
hyperglycemia (BS 358), otherwise stable Chem 7 without anion
gap, stable CBC, normal coags. CXR and CT head were
unremarkable. The patient was given morphine 10mg IV and then
Metoprolol 5mg X1 IV, Labetalol 10mg X1 IV, Lisinopril 5mg PO.
Her blood pressures remained elevated and infact, continued to
climb into the SBP190s-200s. Her finger stick was critically
high at 8pm and the patient gave herself 10.7 units of her
humalog insulin pump. On repeat ~two hours later, her finger
stick remained critically high and thus she was given regular
insulin 10 units SQ. On recheck, her blood sugar remains
critically high. Given her recent admission with immediate
transfer to MICU for SBP220s and anion gap acidosis (mild), she
was admitted to the MICU this time also. Repeat chem 10 showed
gap 12. She was started on a labetalol gtt and on transfer her
vitals were 97.8po 88 23 195/60 99%ra.
On arrival to the [**Name (NI) 332**] MICU, pt is alert and oriented. She
reports that she just doesnt feel right and endorses polyuria.
She denies any fevers, chills. No chest pain, palpitations,
changes in vision, sob, headache, dizziness. No diarrhea or
flushing. Vital signs were afebrile, 177/81, 82, 13, 90% RA.
Past Medical History:
- h/o DVT, unknown when
- DMI on insulin pump, patient unable to say dose. Followed by
[**Last Name (un) **].
- Peripheral neuropathy
- h/o gastroparesis
- Chronic LBP/sciatica
- HTN
- Hyperlipidemia
- Hypothyroidism
- PVD/PAD
- Autonomic dysfunction, orthostatic hypotension
- History of seizure [**2158-1-19**] characterized by becoming less
responsive, oriented to name only, gaze deviation and left arm
shaking. FS 297 and was in the setting of receiving cipro, Neuro
felt [**1-3**] infection vs PRES.
- Barretts Esophagus on EGD [**2155**]
- Depression
- MI [**2157**], no stents
PAST SURGICAL HISTORY:
[**2159-3-30**] - Malunion right intertrochanteric hip fracture with
protrusion of screw s/p revision arthroplasty
[**2159-1-7**] Comminuted right intertrochanteric hip fracture s/p right
hip fracture open reduction internal fixation (intramedullary
nail)
[**3-21**] RLE angiography
RLE SFA-AT BPG with NRSVG [**2157-9-6**]
Angioplasty of vein graft [**2158-10-4**]
[**2158-5-30**], L hip hemiarthroplasty
- Hiatal hernia
- s/p laminectomy
- s/p hysterectomy
Social History:
The patient lives with her husband. She is a former secretary.
Former tobacco use, quit in [**8-10**], previous 60 pack/yr history.
No history of EtOH or IVDU.
Family History:
Mother - coronary artery disease with MI in her 50s, died at age
84. Father - coronary artery disease with MI in her 60s, died at
age 82.
Physical Exam:
ADMISSION EXAM
General: No acute distress, alert and oriented X3, conversant,
pleasant
HEENT: Sclera anicteric, moist mucus membranes, [**Last Name (un) **]/oropharynx
clear, EOMI, PERRL
Neck: Soft, supple, JVP not elevated, Left EJ in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no bruits
Ext: Warm, no edema/ecchymosis/cyanosis. s/p right BKA well
healed and palpable popliteal pulse. No ulcers.
Neuro: Strength and sensation grossly intact, CN2-12 intact
Pertinent Results:
ADMISSION LABS
[**2160-5-10**] 07:10AM BLOOD WBC-6.8 RBC-3.71* Hgb-11.0* Hct-34.8*
MCV-94 MCH-29.6 MCHC-31.5 RDW-14.4 Plt Ct-169
[**2160-5-11**] 05:55PM BLOOD WBC-6.6 RBC-3.76* Hgb-11.5* Hct-35.1*
MCV-94 MCH-30.6 MCHC-32.7 RDW-14.4 Plt Ct-172
[**2160-5-11**] 05:55PM BLOOD Neuts-78.0* Lymphs-15.0* Monos-5.4
Eos-1.1 Baso-0.5
[**2160-5-11**] 05:55PM BLOOD PT-10.5 PTT-30.2 INR(PT)-1.0
[**2160-5-10**] 07:10AM BLOOD Glucose-164* UreaN-24* Creat-1.1 Na-137
K-4.3 Cl-103 HCO3-28 AnGap-10
[**2160-5-12**] 01:29AM BLOOD ALT-18 AST-20 LD(LDH)-197 AlkPhos-114*
TotBili-0.3
[**2160-5-11**] 10:55PM BLOOD CK-MB-3
[**2160-5-12**] 09:16AM BLOOD CK-MB-2 cTropnT-<0.01
[**2160-5-11**] 05:55PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
DISCHARGE LABS
[**2160-5-15**] 01:56AM BLOOD WBC-4.8 RBC-3.44* Hgb-10.3* Hct-31.5*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.0 Plt Ct-213
[**2160-5-15**] 01:56AM BLOOD Glucose-165* UreaN-21* Creat-1.1 Na-138
K-4.3 Cl-102 HCO3-30 AnGap-10
.
URINE
[**2160-5-12**] 09:43AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2160-5-12**] 09:43AM URINE Blood-SM Nitrite-POS Protein-100
Glucose->1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2160-5-12**] 09:43AM URINE RBC-5* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
.
MICROBIOLOGY
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
.
IMAGING
EKG
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy. Left
axis deviation consistent with left anterior fascicular block.
Compared to the previous tracing of [**2160-5-8**], there is no
diagnostic interim change.
.
CXR
The cardiac, mediastinal and hilar contours appear unchanged.
The
heart is at the upper limits of normal size. Bilaterally,
nipple shadows are visualized. The lungs appear clear. The
interstitium was more prominent on the prior examination than
now. There are no pleural effusions or pneumothorax. Mild
hyperinflation is noted. Severe degenerative changes are partly
visualized along the right shoulder.
.
HEAD CT
IMPRESSION: No evidence of acute process. Stable small
hypodense areas in the pons suggesting prior infarcts.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
69 yo female with T1DM (insulin pump), chronic lumbar disk
disease (chronic narcotics), hypertension, hyperlipidemia,
severe peripheral [**Date Range 1106**] disease with right BKA ([**6-/2159**]),
orthostatic hypotension (on salt tabs) recently admitted for
hypertensive emergency (altered mental status), mild DKA and now
presents with poorly controlled hypertension and hyperglycemia.
.
# Hyptertensive urgency: SBP >200s with mental status changes
concerning for poor perfusion. CT head did not show any acute
changes. She does not have any other signs of end organ
failure. She has had an extensive workup for her HTN including
urine metanephrines (pending), protein electropheresis wnl,
serum and urine tox recently neg for cocaine/amphetamines, no
signs of hyperaldosteronism, no h/o OSA and normal renal US
recently. It is likely that her hx of DM has led to some renal
parechymal vs microvascular disease leading to progressive HTN.
HTN has not been aggressively controlled as outpt because of
severe autonomic dysfunction resulting in orthostasis. She was
initially admitted to the MICU where she was started on
labetalol 400 [**Year (4 digits) **]. She remained hypertensive with BP in the
180s. Therefore lisinopril was increased to 20 mg daily. On
this regimen she was noted to be orthostatic so labetalol was
decreased to 200 [**Year (4 digits) **]. Prior to discharge she was able to
ambulate with PT without feeling dizzing, and with adequate
control of her BP. The patient will follow-up with her PCP. [**Name10 (NameIs) **]
is also recommended she see [**Name10 (NameIs) 878**] for evaluation of
autonomic instability.
.
# Altered mental status: Given sedation in the setting of
hypertension there was intial concern for hypertensive
emergency. Head CT showed no acute process and ultimately AMS
was felt to be due to sedation from medication as well as
possibly due to her UTI. Mental status greatly improve in the
MICU and she was at her baseline when she was transferred to the
floor.
.
# Diabetes/ r/o DKA: On admission she was noted to have
hyperglycemia in the setting of a malfunctioning insulin pump.
She did not have an anion gap to suggest DKA. UTI also likely
contributing to hyperglycemia. [**Last Name (un) **] was consulted and the
patient was maintained on lantus and HISS until mental status
improved and she was able to manage her pump.
.
# UTI- UA was grossly positive. Patient was started on
ceftriaxone. Urine culture grew pan-sensitive E.coli. She was
transition to cipro to complete a 7 day course.
.
STABLE ISSUES
.
# Chronic pain: Patient endorses [**Last Name (un) 9140**] RLE pain,
predominantly in her toes (s/p BKA). RLE warm and well perfused
with palpable pulses. ?[**Last Name (un) **] peripheral [**Last Name (un) 1106**] disease.
She was continued on her home gabapentin, oxycodone and MScontin
with holding parameters. Peripheral [**Last Name (un) 1106**] disease was managed
as below.
.
# Peripheral [**Last Name (un) **] Disease: Patient was continued on her home
plavix and zocor
.
# Depression: Patient was continued on her home citalopram
..
# Hypothyroidism: Patient was continued on her home
levothyroxine
.
TRANSTIONAL ISSUES
Full Code
monitor for orthostatic hypotension
Patient might benefit from evaluation by [**Last Name (un) **] for autonomic
instability
Medications on Admission:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Travatan Z 0.004 % Drops Sig: One (1) Ophthalmic once a day:
both eyes.
5. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Contact your PCP if you feel more lightheaded or dizzy.
7. sennosides 8.6 mg Tablet Sig: Two (2) Tablet PO once a day.
8. Humalog 100 unit/mL Cartridge Sig: 100 units/mL Subcutaneous
on insulin pump basal rate.
9. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. morphine 15 mg Tablet Extended Release Sig: Three (3) Tablet
Extended Release PO qAM (morning).
11. morphine 15 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO at bedtime.
12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
13. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO [**Last Name (un) **] (3
times a day).
14. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
18. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. oxycodone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for pain.
20. gabapentin 400 mg Capsule Sig: One (1) Capsule PO [**Last Name (un) **] (3
times a day).
21. Restasis 0.05 % Dropperette Sig: Two (2) Ophthalmic three
times a day.
22. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
24. Refresh Celluvisc 1 % Dropperette Sig: One (1) Ophthalmic
once a day as needed for dry eyes.
25. Glucagon Emergency 1 mg Kit Sig: One (1) Injection once a
day as needed for low sugar.
26. Citracal + D Maximum 315-250 mg-unit Tablet Oral
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Hyperglycemia
Urinary Tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms [**Known lastname 5936**],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because your blood pressure and blood sugar
was elevated. We started you on new medications to help with
your blood pressure. There was some concern that your insulin
pump was not working correctly. You were given insulin shots
until your pump could be replaced. You blood sugars were
improved.
We made the following changes to your medications
1. START Labetalol 200 mg three times a day
2. INCREASE lisinopril 20 mg daily
3. START Ciprofloxacin twice a day for 4 more days
You should continue to take all other medications as instructed.
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP
Location: [**Last Name (un) **] DIABETES CENTER [**Hospital 16616**] Clinic
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appt: [**Last Name (LF) 766**], [**5-19**] at 12:30pm
Department: [**Hospital3 249**]
When: FRIDAY [**2160-5-23**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
****It is recommended you follow up with our Autonomic [**Hospital Ward Name 878**]
Department. Please discuss with your primary care doctor
getting an appointment. The department can be reached at ([**Telephone/Fax (1) 16617**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"E879.8",
"311",
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"276.8",
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"250.63",
"440.20",
"V49.75",
"244.9",
"401.9",
"357.2",
"V58.67",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13566, 13572
|
8003, 9691
|
317, 323
|
13675, 13675
|
5768, 7082
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265, 279
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7117, 7980
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351, 3664
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13690, 13834
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3686, 4272
|
4773, 4935
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,741
| 162,753
|
28646
|
Discharge summary
|
report
|
Admission Date: [**2130-1-19**] Discharge Date: [**2130-1-31**]
Service: CARDIOTHORACIC
Allergies:
Codeine / Dilaudid
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pressure, syncope, mobile echodensity on anterior mitral
leaflet on ECHO [**2130-1-17**]
Major Surgical or Invasive Procedure:
[**2130-1-23**] AVR ([**First Name8 (NamePattern2) 6158**] [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] porcine valve)
History of Present Illness:
Pt is an 86 yo woman with PMH HTN, hyperlipidemia, aortic
stenosis, h/o chest pain and syncope, who presents after having
ECHO on [**2129-1-17**] that demonstrates mitral valve mass.
Patient has been seeing Dr. [**Last Name (STitle) **] in Cardiology clinic for a
2nd opinion (she is generally followed in [**State 108**], initially saw
Dr. [**Last Name (STitle) **] in [**7-21**]) for c/o two- to three-year history of
exertional and one-year history of rest chest discomfort, as
well as episodes of syncope. Due to these complaints, a cardiac
cath was perfomed here in [**8-21**] that showed normal coronary
arteries along with moderate mitral regurgitation and
mild-to-moderate aortic stenosis with a mean gradient of 20 mmHg
(Aortic valve area = 0.6cm2). She also had mildly elevated wedge
pressures to 19 and her overall ejection fraction was 53%. It
was thought, therefore, that the patient did not have a cardiac
cause for her chest discomfort.
However, the patient had some continued episodes of chest
discomfort over the next 4-5 months, worsening over the past
month to the point where the episodes were accompanied by
shortness of breath that severely limited her functional
capacity (she could hardly walk a block without stopping to
catch her breath), and substantial weakness. She also had a
couple episodes of syncope during this time. These complaints
were evaluated in [**State 108**] where the patient had a repeat ECHO
and was told that she would need to have an aortic valve
replacement. She again returned to Dr. [**Last Name (STitle) **] for a 2nd
opinion, and her follow up appointment with him was [**2130-1-17**].
Preceeding the appointment, the patient had a repeat ECHO
([**2130-1-17**]) that demonstrated a new mitral valve (anterior leaflet)
mobile mass, aortic stenosis unchanged. Per Dr.[**Name (NI) 15020**] note
from the visit that day, he believed her symptoms were unlikely
due to critical aortic stenosis and were instead likely due to a
combination of poorly controlled hypertension, diastolic
dysfunction, mild anemia, mild-moderate mitral regurgitation,
and mild-moderate aortic stenosis. She was treated with
increasing the HCTZ from 12.5mg daily to 25mg daily and adding
back nifedipine for improved blood pressure control. He also
stated that he would carefully review the ECHO and the mass that
it demonstrated, as well as the prior cardiac catheterization to
determine whether or not the patient should get a repeat
catheterization.
Upon review, demonstrates 1.5 x 1.5cm mobile mass/vegetation.
The mass prolapses into the LVOT without evidence of
obstruction. The patient was sent to the hospital for admission
for further w/u of the mitral valve mobile mass, and repeat
cardiac catheterization in AM.
Past Medical History:
Syncope [**12-21**], prior + TILT table
Aortic stenosis - mean gradient of 20 mmHg (Aortic valve area =
0.6cm2
Pacemaker approximately 5-6 years ago for ?SSS vs vagal reaction
Diastolic dysfunction
Hypertension
Hyperlipidemia
Mild anemia, ?early MDS
Osteoporosis
Urinary urgency
Cosmetic surgery many years ago
Social History:
Patient lives alone in [**State 108**]. She is currently staying with
her daughter and son in law in [**State 2748**]. Her son
in law, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] did his training at NEDH many years
ago.
Family History:
Mother had multiple [**Name (NI) 5290**] at a young age. Father had sudden death
in his 50's-unclear source.
Physical Exam:
Vitals - 98.4 120/70 60 18 97% RA
General - pleasant younger than stated age, NAD, full sentences
HEENT - NC, AT, anicteric, clear OP
Neck - JVP @ 5 cm, no carotid bruits, radiation of the AS b/l.
CVS - rrr, [**4-21**] loud ejection murmur at RUSB with clear S2.
Lungs - ctab/l no w/r/r
Abd - + BS, SNT/ND
Ext - no edema, no cyanosis, + 2 femoral + 2 DP pulses b/l, no
femoral bruits b/l
Pertinent Results:
[**2130-1-30**] 06:50AM BLOOD WBC-8.2 RBC-3.17* Hgb-9.9* Hct-28.5*
MCV-90 MCH-31.3 MCHC-34.9 RDW-15.0 Plt Ct-187
[**2130-1-31**] 09:00AM BLOOD PT-23.1* INR(PT)-2.3*
[**2130-1-31**] 09:00AM BLOOD Glucose-138* UreaN-56* Creat-2.1* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
CHEST (PORTABLE AP)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p AVR and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
PORTABLE CHEST, 9:40 A.M., [**1-25**].
INDICATION: Status post AVR with chest tube removal.
FINDINGS: Compared with [**2130-1-23**], multiple tubes and catheters
have been removed. No pneumothorax is seen.
There are small bilateral pleural effusions and patchy
atelectasis at the left base medially.
The lungs are otherwise grossly clear. No CHF.
IMPRESSION: No pneumothorax seen.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
RADIOLOGY Final Report
UNILAT UP EXT VEINS US LEFT [**2130-1-27**] 9:41 AM
UNILAT UP EXT VEINS US LEFT
Reason: evaluate for clot in LUE
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p AVR
REASON FOR THIS EXAMINATION:
evaluate for clot in LUE
INDICATION: Status post aortic valve repair, evaluate for upper
extremity clot.
COMPARISON: None.
LEFT UPPER EXTREMITY ULTRASOUND: [**Doctor Last Name **]-scale, color, and pulse
Doppler evaluation of the left internal jugular, left
subclavian, left axillary, left brachial veins were performed.
Eccentric nonocclusive thrombus is demonstrated within the left
axillary and one of the left brachial veins containing a
punctate focus of echogenicity suggestive of calcification.
These findings are likely representative chronic nonocclusive
thrombus. Left subclavian and left internal jugular veins
demonstrate normal color flow and waveforms. Normal
compressibility is present within the left internal jugular
vein. The left cephalic and basilic veins were not visualized.
IMPRESSION: Non-occlusive thrombus within the left axillary and
left brachial veins, likely chronic.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**First Name8 (NamePattern2) 8843**] [**Location (un) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Cardiology Report ECHO Study Date of [**2130-1-23**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Intra-op TEE for AVR
Height: (in) 63
Weight (lb): 130
BSA (m2): 1.61 m2
Status: Inpatient
Date/Time: [**2130-1-23**] at 10:21
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW06-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aorta - Arch: 2.5 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: *3.1 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 39 mm Hg
Aortic Valve - Mean Gradient: 29 mm Hg
Aortic Valve - LVOT Peak Vel: 0.78 m/sec
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT Diam: 1.9 cm
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
Mitral Valve - Peak Velocity: 1.3 m/sec
Mitral Valve - Mean Gradient: 5 mm Hg
Mitral Valve - Pressure Half Time: 47 ms
Mitral Valve - MVA (P [**1-17**] T): 4.7 cm2
Mitral Valve - E Wave Deceleration Time: 162 msec
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or
color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Low normal
LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Focal calcifications in ascending aorta. Normal aortic
arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe
mitral annular
calcification. Calcified tips of papillary muscles. No MS. Mild
(1+) MR.
TRICUSPID VALVE: Mild to moderate [[**1-17**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. Overall left ventricular
systolic function
is low normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. There is
severe mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
POST-BYPASS: Pt is being AV paced and is on an infusion of
phenylephrine
1. A bioprosthesis is well seated in the aortic position. Trace
central AI is
seen. A mean gradient of 30mm of Hg is seen. No evidence of a
subvalvular
gradient.
2. Biventricular systolic function is preserved.
3. Aorta is intact post decannulation
4. Other findings are unchanged
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2130-1-25**] 11:32.
Brief Hospital Course:
She was taken to the operating room on [**2130-1-23**] where she
underwent an AVR with a #21 St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] porcine valve. She
was transferred to the ICU in critical but stable condition. She
was extubated later that same day. Her vasoactive drips were
weaned by POD #2. Her pacer was interrogated by EP, they found
no sensing or pacing from the A lead. She was transferred to the
floor on POD#2. She continued to progress and was
anticoagulated with coumadin. She was found to have a
non-occlusive thrombus in the L axillary and brachial veins
which are stable and likely chronic. EP felt that she did not
need a revision of her atrial lead unless she becomes
symptomatic. She had issues with constipation which were
relieved with enemas. She also had urinary retention and had a
foley catheter placed on the PM of [**1-30**] for 775 cc of post void
residual. She continued to improve and was discharged to rehab
in stable condition on POD#8.
Medications on Admission:
ASA 81
Detrol LA 4 mg
Toprol XL 50
Lisinopril 40
Trimaterine 37.5/HCTZ 25 QD
Nifedipine XL 30
Lipitor 20
Aricept 10
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
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:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: Take as directed for INR goal of [**2-17**].5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Health Care, [**Location (un) 8447**]
Discharge Diagnosis:
AS
LVOT Mass
PMH:
Syncope with + tilt table
PPM for ? SSS vs. vagal rxn
Diastolic dysfunction
HTN
hyperlipidemia
anemia
mild proctitis
osteoporosis
urinary urgency
cosmetic surgery many years ago
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2130-1-31**]
|
[
"401.9",
"427.31",
"453.8",
"396.2",
"429.9",
"788.20",
"428.0",
"272.0",
"584.9",
"996.01",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"37.34",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12928, 13011
|
10510, 11523
|
327, 476
|
13251, 13259
|
4403, 4706
|
13558, 13703
|
3868, 3978
|
11690, 12905
|
5489, 5515
|
13032, 13230
|
11549, 11667
|
13283, 13535
|
6788, 10487
|
3993, 4384
|
193, 289
|
5544, 6762
|
504, 3252
|
3274, 3588
|
3604, 3852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,320
| 185,050
|
42577
|
Discharge summary
|
report
|
Admission Date: [**2197-9-20**] Discharge Date: [**2197-9-22**]
Date of Birth: [**2146-9-18**] Sex: M
Service: NEUROSURGERY
Allergies:
Celebrex
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
basilar tip aneurysm recannulization
Major Surgical or Invasive Procedure:
[**2197-9-20**]: Cerebral angiogram with stent assisted coiling of
aneurysm
History of Present Illness:
Mr [**Known lastname 92127**] is approximately 11 months status post subarachnoid
hemorrhage from a basilar tip aneurysm. This aneurysm was
coiled and he subsequently had
vasospasm which resulted in a small occipital infarct and had
homonymous hemianopsia. He has been unable to go back to work
because of his hemianopsia involving the left occipital lobe. He
had an MRI recently. This shows a
small area of the aneurysm filling at the base. This may be the
residual that was present at the end of the last coiling. At
this point, it was recommended that he return for a diagnostic
angiogram under anesthesia, so that any residual can be
retreated. He was started on Plavix for five days prior
to the procedure in the eventuality of a stent being placed. He
[**Male First Name (un) **] electively presents for this procedure.
Past Medical History:
vocal cord polyps, denies hx of HTN
PSH: L inguinal hernia repair, multiple procedures for vocal
cord
polyps (including trach)
Social History:
disabled, lives at home alone, denies smoking or drinking
Family History:
No family hx of aneurysms
Physical Exam:
Upon Discharge:
Unchanged neuro exam, nonfocal except for baseline right
homonymous hemianopsia.
Pertinent Results:
ANGIOGRAPHY FINDINGS: Initial images demonstrate a previously
placed coil mass at the basilar tip within the known aneurysm.
The previously placed coil mass extends superiorly from the
basilar tip and to the right of midline. Angiography of the left
vertebral artery demonstrated some recanalization with contrast
filling at the broad base of the aneurysm and to the left aspect
of the aneurysm sac. The size of residual aneurysm appeared
increased from post-coiling angiography of [**2197-1-11**].
A Neuroform stent was successfully deployed spanning the
aneurysm with distal portion in the left PCA and proximal
portion in the distal basilar artery. A total of four coils were
deployed into the aneurysm sac. Post-coiling angiography
demonstrated minimal residual stagnant flow in the neck of the
aneurysm sac. There was appropriate filling of the posterior
circulation post-embolization with no evidence of vascular
occlusion.
Right common carotid angiography was grossly unremarkable with
note made of filling of the posterior circulation via right
posterior communicating artery.
Left common carotid angiography was grossly unremarkable with
note made of a relatively diminutive left [**Name (NI) **] as compared to
the right.
Brief Hospital Course:
Pt electively presented and underwent a cerebral angiogram and
stent assisted coiling of the recannulized basilar tip aneurysm.
Procedure was without complication and he tolerated it well. He
was extubated and transferred to the ICU for close neurological
monitoring. He was kept on bedrest for 3 hours post angioseal.
He was started on a Heparin drip overnight and discontinued in
the AM. His labs remained stable on POD 1, and his angio site
remained soft with no signs of a hematoma. His foley was removed
and his diet was advanced. He was transferred to the floor on
[**9-21**] for overnight monitoring. He was OOB ambulating steadily.
He was discharged home on [**2197-9-22**], without any symptoms
overnight, good pulses distally palpated, and no collection,
hematoma, or drainage at site.
Medications on Admission:
plavix, lisinopril and omeprazole
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Lisinopril 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) [**12-12**] TAB PO Q4H:PRN severe
biopsy site pain Duration: 24 Hours
do not give together with tylenol
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-12**] tablet(s) by mouth
every four (4) hours Disp #*60 Tablet Refills:*0
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Senna 1 TAB PO BID:PRN Constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
basilar tip aneurysm recannulization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily for one month
?????? Take Plavix (Clopidogrel) 75mg once daily for one month
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks, no imaging is needed
at that time. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2197-9-22**]
|
[
"V45.89",
"368.46",
"437.3",
"E878.8",
"478.4",
"438.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
4591, 4597
|
2912, 3710
|
308, 386
|
4678, 4678
|
1649, 2889
|
6007, 6204
|
1490, 1517
|
3795, 4568
|
4618, 4657
|
3736, 3772
|
4829, 5984
|
1532, 1532
|
232, 270
|
1548, 1630
|
414, 1246
|
4693, 4805
|
1268, 1398
|
1414, 1474
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,433
| 191,469
|
46441
|
Discharge summary
|
report
|
Admission Date: [**2205-3-6**] Discharge Date: [**2205-3-12**]
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient was an 83-year-old
female with a past medical history notable for ischemic bowel
status post total colectomy and resection of one-third of her
small bowel in [**2200-3-25**], cholecystectomy for acute
cholecystitis in [**2200-9-25**], VRE UTI, coronary artery
disease status post RCA stent x 2, and a non-ST elevation MI
in [**2203**], with a recent hospitalization in [**2204-10-25**].
In [**2204-11-25**], the patient had urosepsis and pneumonia. She
presented on the day of admission to the [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] after being found unresponsive to
the nursing home. Per EMS records, she was found lethargic
and cyanotic with cold extremities on rounds there. Her heart
rate was in the 40s. Respiratory rate was in the 30s. Blood
pressure was in the 50s systolic.
Upon presentation to the [**Hospital6 2018**], she received approximately 9 L of intravenous fluids,
3 units of packed red blood cells and was placed on Levophed
drip. She was also started on broad-spectrum antibiotics in
the form of vancomycin, imipenem and Flagyl. She was sedated,
intubated and transferred to the surgical ICU with 500 cc of
red brown output.
PAST MEDICAL HISTORY: Ischemic bowel, short-gut syndrome,
acute cholecystitis, VRE UTI, Klebsiella UTI, hypertension,
COPD, CAD status post 2 stents to the RCA, non-ST elevation
MI in [**2203**].
PAST SURGICAL HISTORY: Total colectomy, cholecystectomy,
thyroidectomy.
ALLERGIES: ACE inhibitor.
MEDICATIONS: Aspirin 325, Lipitor 10 mg p.o. daily,
Lopressor 25 mg p.o. b.i.d., Atrovent nebulizers, albuterol
nebulizers, Prilosec, ranitidine, Ambien, Maalox, Flovent.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.8, the
lowest being 90, heart rate 144, blood pressure 99/43 on
Levophed and Pitressin drips, respiratory rate 12, 92% on
maximal ventilator support, FIO2 100% assist-control
ventilation. General: She was minimally responsive. Abdomen:
Ostomy had dark red blood. The abdomen itself was soft,
distended and relatively firm.
LABORATORY DATA: White blood cell count 32,000, hematocrit
40.9, 93% neutrophils; creatinine 1.5.
HOSPITAL COURSE: The patient was admitted to the intensive
care unit. The remainder of this dictation will be presented
in a system space format.
Neurologic: She was sedated using Fentanyl. Head CT scan was
obtained which revealed a questionable small frontal infarct
but no other mass or lesion.
Cardiovascular: She required maximal support with Levophed
and Pitressin throughout the intensive care unit admission to
maintain her support.
Respiratory: She required assist-control ventilation. She
developed an ARDS picture with an FIO2 requirement of 100%.
This was gradually weaned through her intensive care stay.
GI: She was maintained NPO and started on total parenteral
nutrition.
GU: In consultation with the renal service, the patient's
renal status was reasonable. Initially she had some polyuria,
but her urine status seemed to normalize. She also had a
significant lactic acidosis which only mildly improved.
Hematologic: The patient required transfusions of platelets
for a low platelet count. Hematology/oncology service was
also consulted for her thrombocytopenia. FFP was given for a
mild coagulopathy with elevated PT and INRs.
Infectious disease: She was kept on vancomycin, Imipenem and
Flagyl. She had no obvious source of infection, although her
urine did have E. Coli. The ostomy output continued to be
slightly bloody throughout the admission.
Tubes, lines and drains: She had a central catheter inserted
by the surgical intensive care team.
Prophylaxis: She was placed on Protonix. A HIT panel was sent
which was negative, although her platelets remained low
throughout the admission.
Endocrine: She was maintained on insulin drip for proper
glycemic control. The patient's electrolytes were followed
closely, and she maintained on maintenance fluid for
hydration.
The patient's status did not improve as the admission
progressed despite maximal vasopressor support. After a
detailed discussion between the attending surgeon and the
[**Hospital 228**] healthcare proxy, it ws decided to make the patient
comfort measures only.
On [**3-12**], the vasopressor support was stopped. The patient
was made comfortable with morphine and Fentanyl. She expired
at 1:13 p.m. on [**3-12**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2205-3-12**] 13:33:55
T: [**2205-3-12**] 15:01:06
Job#: [**Job Number 98656**]
|
[
"785.59",
"557.9",
"496",
"038.9",
"V45.3",
"578.9",
"579.3",
"428.0",
"041.4",
"995.92",
"V45.82",
"412",
"599.0",
"V44.2",
"286.6",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"88.67",
"96.72",
"99.04",
"99.15",
"38.93",
"99.07",
"00.17",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2308, 4763
|
1564, 1815
|
1838, 2290
|
135, 1342
|
1365, 1540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,081
| 103,931
|
7445
|
Discharge summary
|
report
|
Admission Date: [**2138-3-11**] Discharge Date: [**2138-8-25**]
Date of Birth: [**2079-8-15**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 27294**] was admitted to [**Hospital1 1444**] on [**2138-3-11**], for
recurrent bleeding in his left pelvis. He had a hip
replacement done almost 20 years ago in [**Country 6171**] for a hip
infection he developed as a child. Mr. [**Known lastname 27294**] did well with
his original hip replacement until [**2134**] when he was seen at
[**Hospital1 69**], at which time he was
found to have a loose prosthesis with extensive osteolysis.
He attempted a reconstruction in [**2136-8-8**]. However,
he had extensive bone loss and reconstruction was not
possible. He was left with a resection arthroplasty.
Over the ensuing months Mr. [**Known lastname 27294**] had recurrent collections
of fluid of his left thigh. These were initially drained
successfully. He was also on Coumadin therapy for deep
venous thrombosis. He was seen at [**Hospital6 1130**] by Oncology Service for recurrent collection of
seroma in his left thigh. He was also seen by an orthopaedic
oncologist. Neither of these workups revealed any cause of
the recurrent left thigh collection.
HOSPITAL COURSE: On [**2138-3-20**], at [**Hospital1 190**], the patient had a left hip exploration with
placement of Hemovac. On [**2138-4-1**], he had a left hip
exploration and a femur resection. On [**4-21**] and [**2138-4-25**],
he went to Interventional Radiology to have embolization of two
vessels off the superficial femoral artery and embolization
of two distal branches of the deep femoral artery. On
[**2138-5-6**], he had a left hip disarticulation. On [**2138-5-30**], a Plastic Surgery consultation was obtained. They said
there was no role for flap. On [**2138-5-12**], a Vascular
Surgery consultation was obtained stating that bleeding was
most likely venous, and embolization had no further role. On
[**5-15**], a PICC line was placed. On [**5-15**], a Medication
consultation for tachycardia was obtained, and a beta blocker
was started. On [**5-21**], and echocardiogram revealed normal
left ventricular function and an ejection fraction of 55%.
From the period of [**5-27**] to [**7-7**], the patient had 12
incision and drainages of left thigh/groin wound. The
patient had chest pain on [**7-13**] and was ruled out for a
myocardial infarction. The patient had a spiral CT done on
[**7-13**] as well which revealed multiple emboli in the left
and right pulmonary arteries. At that time [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter was placed. A chest tube was also placed for
hemothorax which had an initial output of 1200 mL.
The patient was transferred to the floor on [**2138-7-18**].
Total parenteral nutrition was started on approximately
[**2138-7-20**]. The patient was transferred back to the
Surgical Intensive Care Unit in respiratory distress on
[**2138-7-29**]. At that point he was intubated, and the
chest tube had an output of 1 liter. Repeat embolizations
were attempted of the superior gluteal artery on [**2138-8-6**].
Throughout the admission, the patient received approximately
110 units of packed red blood cells. Two more dressing
changes were performed in [**2138-8-9**]. Consultations
obtained during admission were as follows: Pain Service.
Plastic Surgery revealed no role for flap.
Hematology/Oncology workup including factor VIII [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] factor bleeding time was completely normal.
Vascular Surgery consultation revealed that most likely the
bleeding was venous in nature. Interventional Radiology
performed embolization on several occasions. Medicine
consultation was obtained. Infectious Disease consultation
was also obtained. The patient had vancomycin-resistant
osteomyelitis, and candidal line infection. He was initially
started on ampicillin, ceftriaxone, and Flagyl. These were
discontinued. He was then placed on cefepime and vancomycin.
These were then discontinued, and he was started on
piperacillin and gentamicin, and these were discontinued. He
was then started on imipenem and linezolid which were both
discontinued on [**8-16**]. He was also started on Bactrim,
levofloxacin, and fluconazole. Blood cultures obtained on
[**8-14**] also showed stenotrophomonas mysophilia
bacteremia.
The patient was made comfort measures only on [**2138-8-25**]. This was done with the help of the Ethics Committee.
All other services including Hematology/Oncology,
Orthopaedic/Oncology, Pulmonary, Medicine, Vascular, Plastic,
and Surgical Intensive Care Unit team all agreed there were
no other medical actions which could be taken. The patient
deceased at 11:40 a.m. on [**2138-8-25**].
CAUSE OF DEATH: Respiratory failure, sepsis, pelvic
osteomyelitis, bleeding diathesis of unknown cause.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 27295**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2138-8-25**] 12:51
T: [**2138-8-29**] 13:54
JOB#: [**Job Number 27296**]
|
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icd9cm
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41,144
| 178,765
|
35184
|
Discharge summary
|
report
|
Admission Date: [**2138-9-8**] Discharge Date: [**2138-9-25**]
Date of Birth: [**2056-8-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
1. Removal of hardware (old gamma nail)
2. Acetabuloplasty with girdlestone procedure, debridment of
nounion-malunion callous and debridment of psudoacetabulum and
true acetabulum superior dome.
3. Acetabular reconstruction with femoral head autograft with
ORIF of superior acetabular dome using the autograft and pelvic
plates along the posterior wall and column
4. Excision of heterotopic ossification from gluteal muscle
5. Right cemented total hip arthroplasty
.
IVC FILTER PLACEMENT
1. Ultrasound-guided puncture of right common femoral vein.
2. Placement of Bard G2 IVC filter.
3. Inferior venacavogram.
Colonoscopy
History of Present Illness:
Pt is an 82 yo F with a R hip fracture in [**6-27**] s/p failed ORIF
c/b LE DVT now on coumadin who presents with anemia noted on
routine lab draws and guaiac positive brown stool. Pt's fall
and surgery occured in FL where she lived; she moved to [**Location (un) 86**]
after the surgery failed for further medical care and to be
closer to her [**Location (un) 802**].
.
Pt reports constipation when she was in FL, but she relates this
to her percoset use post-op. Pt had several days of n/v/d one
week prior to admission, which pt relates to "food poisoning"
which has now resolved. In general over past several months, pt
denies change in weight, change in bowel movements, n/v/d,
melena, bloody stool, abdominal pain, bloating, vaginal
bleeding, tea colored urine or pale stool. She has never had a
colonoscopy; her last mamogram was years ago.
.
Over the past month pt's Hct has trended 32->26->24. At [**Location (un) **]
on the day of admission, her INR was >5, so she received 5 mg PO
vitamin K and was transferred to the [**Hospital1 18**] ED.
.
In the ED, she was hemodynamically stable: 97.3, 82, 109/45,
18,97% RA.
.
On the floor, she has no complaints. She denies CP, SOB,
palpitations, abdominal pain, dysuria, fever, night sweats,
fatigue, poor energy, or any other symptoms.
Past Medical History:
Dementia
Hyperchol
R hip fx s/p ORIF [**6-27**] in FL, c/b post-op DVT, on coumadin. Seen
here by ortho, Dr. [**Last Name (STitle) 1005**], with planned repair and ?IVC prior
to surgery
"murmur"
"mild CHF"
Social History:
Pt lived in FL, now moved to [**Hospital1 **] Home for the Aged, an
[**Hospital3 **] facility. She normally walks with a cane, but
has been bedbound due to her non-healed ORIF. She has a 40
pack-year smoking history but quit 20 years ago. She denies ETOH
or drug use. Her [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 80291**] is her HCP [**Telephone/Fax (1) 80292**].
Family History:
no hx of colon ca, ovarian ca, breast ca
Physical Exam:
On admission::
VS: 98.8, 108/60, 73, 18, 94%RA
Gen: obese elderly woman, hard of hearing, NAD
HEENT: OP clear, EOMI
Neck: No JVD, no thyromegaly, no LAD
Cor: RR, nS1 S2, II/VI holosystolic murmur
Pulm: CTAB anteriorly
Abd: +BS, NTND, No HSM. No CVAT. No spinal tenderness
Extrem: large legs, no pitting edema, R leg shorter and
internally rotated. No tenderness to palpation at wound site.
Rectal: G+ in the ED
Neuro: A&O x 3
.
At discharge::
97.8 / (129/61) / 84 / 97% on room air
-I/VI holosystolic murmur
-lungs clear bilaterally, poor effort, distant
-abdomen obese, soft, nontender
-scar on right hip with staples, minimal erythema, overlying
sheets stained with yellow serous fluid
-legs are obese and symmetrically large. unclear how much of leg
distension is a result of fluid overload vs obesity. non
pitting.
Pertinent Results:
[**2138-9-8**] 08:53PM BLOOD WBC-6.1 RBC-2.79* Hgb-7.6* Hct-23.3*
MCV-83 MCH-27.1 MCHC-32.5 RDW-16.0* Plt Ct-376
[**2138-9-23**] 05:50AM BLOOD WBC-9.1 RBC-3.22* Hgb-9.2* Hct-28.1*
MCV-87 MCH-28.6 MCHC-32.8 RDW-16.7* Plt Ct-181
[**2138-9-24**] 05:45AM BLOOD WBC-11.1* RBC-3.48* Hgb-9.9* Hct-30.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.1* Plt Ct-239
[**2138-9-25**] 05:35AM BLOOD WBC-10.9 RBC-3.65* Hgb-10.1* Hct-31.5*
MCV-86 MCH-27.7 MCHC-32.1 RDW-16.1* Plt Ct-308
[**2138-9-9**] 06:30AM BLOOD Ret Aut-2.2
[**2138-9-8**] 08:53PM BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-139
K-3.3 Cl-103 HCO3-28 AnGap-11
[**2138-9-24**] 05:45AM BLOOD Glucose-65* UreaN-10 Creat-0.6 Na-140
K-4.0 Cl-105 HCO3-25 AnGap-14
[**2138-9-25**] 05:35AM BLOOD Glucose-76 UreaN-10 Creat-0.6 Na-139
K-3.8 Cl-103 HCO3-26 AnGap-14
[**2138-9-22**] 02:41AM BLOOD Calcium-7.5* Phos-2.2* Mg-1.9
[**2138-9-10**] 04:28AM BLOOD VitB12-933*
[**2138-9-9**] 06:30AM BLOOD calTIBC-250* Hapto-313* Ferritn-19
TRF-192*
[**2138-9-13**] 06:30AM BLOOD CEA-4.4* CA125-11
=====================
CXR ([**9-23**]): improving retrocardiac density and small left
effusion.
=====================
Distal sigmoid, biopsy: Adenocarcinoma
=====================
Cardiac ECHO: Normal global and regional biventricular systolic
function. Moderate pulmonary artery systolic hypertension. Mild
aortic stenosis.
=====================
CT of chest abdomen pelvis:
1. Thickening of the mid segment of the sigmoid colon with no
proximal
obstruction is compatible with the patient's known sigmoid
cancer.
2. 7-mm right lower lobe pulmonary nodule. Considerations
include
metastatic focus or inflammatory/infectious process. FDG- PET
can be obtained for further evaluation but lesion is borderline
in size for detection by FDG-PET. Pulmonary edema and
atelectasis limits evaluation for pulmonary nodules; dedicated
repeat chest CT could be obtained after optimization of
pulmonary status for better assessment.
2. Colonic diverticulosis with no evidence of diverticulitis.
3. Cholelithiasis. Dilated CBD and possible focal pancreatic
ductal
dilation (vs small pancreatic cystic lesion). MRCP could be
obtained for
further evaluation.
4. Relative enlargement of the right ovary which is unusual for
the patient's age. This can be further evaluated by pelvic
ultrasound.
5. Large axial hiatal hernia.
6. Bilateraly hypodense renal lesions, too small to
characterize, and 31-mm right renal lesion possibly representing
a hyperdense cyst but indeterminate.
MR of the abdomen can be obtained for further characterization.
9. Chronic fracture of the right femoral neck which is
associated with
displacement of the femoral neck and head fracture fragments,
not in
contact with the dynamic hip screw.
Brief Hospital Course:
82 yo F with hx of CHF, dementia and hip fx s/p ORIF on Coumadin
presented with asymptomatic anemia and supratherpeutic INR,
found to have 6 cm fungating mass in sigmoid colon on
colonoscopy. Pt underwent substantial surgery of the right hip
(description attached). Surgical and medical oncology agreed
that the pt must recover functional status (ie be able to walk)
in order to be a candidate for surgical resection of her colonic
mass and subsequent chemotherapy. Repeat LENIS sowed no remaing
DVT. Coumadin was discontinued and the pt was stater on lovenox
(prophylactic dose) prior to discharge. Hospital course by
problem:
.
# Anemia: Pt's HCT was in the 30s 1 mo ago; on admission, HCT
was 23 and dropped to 21 with guaiac positive stool but no frank
blood in stool. EGD was performed which showed large hiatal
hernia but no source of bleed. Colonoscopy was performed, which
showed a 6 cm fungating mass in the sigmoid colon which was the
likely source of the pt's anemia. Pt was also found to be iron
deficient and she was started on supplemental iron. B12 was WNL.
Pt's Hct in 30-31 range and stable on day of discharge.
Reccommened checking CBC at least twice per week or more often
if grossly bloody bowel movements present.
.
# Colon Cancer: Adenocarcinoma by biopsy. General surgery and
oncology were consulted. Per oncology, pt is unable to receive
chemotherapy until she can walk. chemo should be done approx 1
mo after surgery. Pt has follow-up with surgical oncology
scheduled.
==CT chest/abdomen/pelvis was done for staging.
--7mm RLL nodule noted; FDG-PET can be obtained for further
evaluation.
--Relative enlargement of the right ovary which is unusual for
the patient's age. This can be further evaluated by pelvic
ultrasound (US showed complex cyst which should be followed in
[**1-23**] months).
--31-mm exophytic cyst of the lower pole of the right kidney,
does not have
the complete appearance of the simple cyst. MR of the abdomen
can be obtained
for further characterization.
.
# Hx of DVT: LENIs were negative for DVT. Given pt's recent DVT
and high risk for thrombosis given malignancy, she was started
on lovenox at prophylactic dose (30 subQ [**Hospital1 **]). IVC filter also
placed.
.
# Hip repair: Surgical intervention is outlined in "major
surgical procedures" section. At time of discharge, scar has
minimal erythema, staples are in place, there is no overt sign
of infection. Overling sheets become damp with serous
discharge--this is expected to the current degree. Pt has
follow-up scheduled with orthopedics. Requiring rehab as per
Physical Therapy reccomendations.
.
# Hx of "mild CHF": pt was on Lasix at home, but this was held
on admission due to GI bleed. She received 20 IV Lasix and O2
sats improved. Pt also had TTE which showed nl EF, mild AS, mild
TR, mod PAH, and some signs of early diastolic CHF. Given good
response to Lasix IV, would dose on a prn basis for low 02
saturation and dyspnea.
Medications on Admission:
Warfarin 2.5 mg daily
Simvastatin 40 mg qhs
Aspirin 81 daily
lasix 20 mg QD
KCL 10 mEQ QD
Acetaminophen-oxycodone prn
Acetaminophen prn
MVI
Bisacodyl prn
Docusate
Senna
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Pain.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours). mg
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO qhs prn as needed
for sleep.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] HOSP. AT [**Location (un) **]
Discharge Diagnosis:
1. COLON CANCER
2. Failed gamma nail fixation with cutout and acetabular
destruction.
3. Deep Vein Thrombosis
4. Dementia
Discharge Condition:
medically stable for transfer to rehab
Discharge Instructions:
Dear Ms. [**Known lastname 40553**],
You were admitted to the hospital initially because you were
loosing significant amounts of blood in your stool. A work-up
revealed that you have colon cancer. While you were here, your
hip was repaired. The surgical and medical cancer specialists
agree that you have to regain your strength before proceeding
with removal of the mass in your colon and the chemotherapy
which is required after surgery. For this reason, you will be
going to a facility where you will receive physical
rehabilitation.
Your medications have changed substantially during your recent
hospitalizations. An updated list will be available to you and
the rehabilitation facility where you will be.
If you note significant blood in your stool or if the scar on
hip appears to be infected please return to the hospital. Please
note the follow-up appointments that have been scheduled for you
below. You should also try to see your primary care physician
[**Name Initial (PRE) 176**] 2-3 weeks. You have not been scheduled for an
appointment with medical oncology, this is because this will be
arranged for you after you have been seen by surgical oncology.
Followup Instructions:
ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2138-9-30**] 2:55
Orthopedics: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2138-9-30**] 3:15
SURGICAL ONCOLOGY: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**]
Date/Time:[**2138-10-14**] 1:00
Completed by:[**2138-9-25**]
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24,807
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9842+56071
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Discharge summary
|
report+addendum
|
Admission Date: [**2145-4-7**] Discharge Date:
Date of Birth: [**2104-11-11**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 40 year old woman,
quadriplegic, status post cervical spine injury in a motor
vehicle accident five years ago, who also has a history of
heavy tobacco use with multiple episodes of aspiration
pneumonia, who is admitted with hypercarbic respiratory
failure.
She most recently was admitted to the [**Hospital 882**] Hospital
[**2145-2-28**], to [**2145-3-10**], with a fever, hypotension and
productive cough. She was intubated at that time and treated
with Levofloxacin, Clindamycin and Vancomycin for right lower
lobe pneumonia. She briefly required Dopamine for a period
of time. She was eventually changed to Ciprofloxacin, Flagyl
and Vancomycin for a fourteen day course. Her sputum from
that admission showed Methicillin resistant Staphylococcus
aureus and resistant Klebsiella as well as yeast. The
Klebsiella and yeast were felt to be colonizers at that time.
During that admission, she was intubated for seven days. A
tracheostomy and percutaneous endoscopic gastrostomy were
offered to the patient but adamantly refused. She was
treated with stress dose steroids for history of adrenal
insufficiency, and discharged on [**2145-3-10**], to [**Hospital3 20374**] on
maintenance dose of 5 mg Prednisone per day, as well as the
above antibiotics.
The patient was then reportedly in her usual state of health
in [**Month (only) 116**], however, she was found hypotensive with systolic
blood pressure in the 60s and room air oxygen saturation of
59%. That day she had been noticed to have progressive
shortness of breath and a productive cough. She was also
very lethargic.
In the Emergency Department, her chest x-ray was consistent
with a right lower lobe and retrocardiac infiltrate which
were possibly new, although it is difficult to know whether
this showed much change from her prior films at [**Hospital 882**]
Hospital. Her temperature was 93 degrees orally. She did not
have an increased white count but she did have nine bands on
her differential. Arterial blood gases was pH 7.28, pCO2 60
and pO2 133.
She was then intubated and admitted to the Intensive Care
Unit. She was started on Vancomycin, Flagyl and Levofloxacin
for presumed aspiration pneumonia and coverage for
Methicillin resistant Staphylococcus aureus.
PAST MEDICAL HISTORY:
1. C3-C4 spinal cord lesion after a motor vehicle accident
in [**2139**], leaving her quadriplegic. She is status post
tracheostomy.
2. History of anemia.
3. Heel osteomyelitis.
4. Gastroesophageal reflux disease.
5. Depression and anxiety which dates to before the
accident.
6. Adrenal insufficiency with chronic steroid use.
7. Multiple aspiration pneumonias with four intubations in
the last seven months and Methicillin resistant
Staphylococcus aureus in her sputum in the past.
ALLERGIES: Penicillin and Sulfa.
MEDICATIONS ON ADMISSION:
1. Oxycodone 5 mg p.o. q4hours p.r.n.
2. Zinc.
3. Vitamin C.
4. Scopolamine patch q72hours for increased secretions.
5. Albuterol MDI.
6. Klonopin 0.5 mg b.i.d.
7. M.S. Contin 15 mg b.i.d.
8. Zoloft 25 mg q.d.
9. Iron 325 mg t.i.d.
10. Dulcolax and Lactulose as needed.
11. Prilosec 20 mg p.o. q.d.
12. Atrovent MDI.
13. Estraderm patch 0.05 every third day.
14. Baclofen 38 mg every six hours.
15. Neurontin 900 mg t.i.d.
16. Reglan 10 mg q.i.d.
17. Ditropan 5 mg b.i.d.
18. Valium 5 mg b.i.d.
19. Prednisone 5 mg per day.
She recently completed a fourteen day course of Flagyl and
Vancomycin on [**2145-3-22**], as well as a total fourteen day
course of a combination of Ciprofloxacin and Levofloxacin
ending [**2145-3-22**].
SOCIAL HISTORY: The patient is a resident at [**Hospital3 20374**]
Rehabilitation. Her mother and father are involved in her
car. Her mother is [**Name (NI) 2048**] [**Name (NI) 33086**] at [**Telephone/Fax (1) 33087**], her
sister is [**Name (NI) **] at [**Telephone/Fax (1) 33088**]. She also has a history
of heavy smoker.
PHYSICAL EXAMINATION: Temperature on examination was 94.5
p.o., heart rate 72, blood pressure 102/47, respiratory rate
12, oxygen saturation 98 to 100%, intubated. In general, she
was intubated and sedated. Head, eyes, ears, nose and throat
- anicteric sclera. The pupils are equal, round, and
reactive to light and accommodation. Dry mucous membranes.
The neck revealed some nuchal rigidity due to prior cervical
fixation. Cardiovascular - tachycardic, normal S1 and S2, no
murmurs, rubs or gallops. The lungs revealed rancorous
breath sounds, right greater than the left, upper and lower
zones anteriorly. The abdomen is obese, soft, slightly
distended, nontender, diminished bowel sounds. Extremities -
trace to 1+ pretibial edema bilaterally, no cords palpable.
Skin - no rashes, grade III ulcer on her buttocks.
LABORATORY DATA: On admission, white count 6.7, hematocrit
35.5, platelets 113,000. INR 0.9. Chem7 was unremarkable.
White blood cell count differential revealed 71% neutrophils
and 9% bands. Urinalysis is nitrite positive with moderate
leucocyte esterase, [**10-6**] white blood cells. Urine culture
showed mixed bacterial flora consistent with fecal
contamination. Sputum culture showed greater than 25 polys
and less than 10 epithelial cells, beta Streptococci not
group A and Staphylococcus species as well as yeast.
Her electrocardiogram showed normal sinus rhythm, no axis
deviation, normal intervals, T wave flattening in lead III,
no other ST-T wave changes. No Q waves. No
electrocardiogram to compare. Chest x-ray showed a rotated
film of poor quality, air bronchograms at the right lower
lobe, and a retrocardiac infiltrate.
HOSPITAL COURSE: This is a 40 year old woman who is
quadriplegic, status post motor vehicle accident with C3-C4
spinal cord injury, with a history of heavy tobacco use and
multiple aspiration pneumonias requiring intubations in the
past year, most recently one month ago at the [**Hospital 882**]
Hospital, who presents with sepsis likely from a pulmonary
source.
In the Emergency Department, she was intubated for
hypercarbic respiratory failure. She was given three liters
of crystalloid and broad spectrum antibiotics to stabilize
her blood pressure.
Infectious disease - The patient was thought to likely have
another aspiration pneumonia with associated shortness of
breath, hypoxia and productive sputum with probable sepsis
causing hypotension. It is unclear from her chest x-ray on
admission whether infiltrates were new or old. A report from
the [**Hospital 882**] Hospital has been requested and has not been
received as of this dictation.
She has a history of Methicillin resistant Staphylococcus
aureus in her sputum in the past. She was therefore started
on Vancomycin to cover this and was additionally started on
Levofloxacin for gram negative coverage and Flagyl for
anaerobes associated with aspiration.
Blood culture, urine culture and sputum cultures were done.
Urine culture showed contamination. Sputum culture showed
Staphylococcus species and beta Streptococcus initially. The
final culture was pending at the time of this dictation.
Blood cultures showed no growth to date at the time of this
dictation.
Because the patient is on chronic steroids for history of
adrenal insufficiency, she was given stress dose steroids in
the Intensive Care Unit which were then tapered down quickly
with a goal of reaching her baseline dose of 5 mg Prednisone
each day.
Pulmonary - The patient had hypercarbic respiratory failure
and was intubated for approximately 36 hours. It was unclear
whether her multiple narcotics may have contributed to her
respiratory failure. It is unclear what the indication is
for her many narcotics. These were initially held and added
back as needed.
On transfer from the Intensive Care Unit to the floor, she
has stable oxygen saturation of 98% on six liters. She was
continued with chest physiotherapy initiated in the Intensive
Care Unit and with Albuterol and Atrovent nebulizers as
needed.
Cardiovascular - The patient was initially hypotensive likely
due to sepsis. She received three liters of intravenous
fluid in the Emergency Department and was briefly on
Dopamine. This was weaned off and the patient was then
briefly hypertensive, however, this resolved on its own and
the patient was normotensive on the floor. She had no acute
electrocardiographic changes on admission.
Endocrine - The patient has a history of adrenal
insufficiency. She will be continued on Prednisone 5 mg p.o.
q.d. on discharge. She received stress dose steroids which
were tapered as described in the infectious disease section.
Wound care - We had a wound care nurse evaluate the patient's
heel ulcers and sacral ulcer. They recommended that the
sacral wound be dressed with normal saline wet to moist
dressing every day and that the heels be dressed with
Duoderm. A plastic surgery consultation for the sacral ulcer
was pending at the time of this dictation.
Prophylaxis - The patient was continued on subcutaneous
Heparin 5000 units b.i.d. to prevent deep vein thrombosis and
she was given Protonix while on stress dose steroids. She
will be continued on her usual Prilosec 20 mg per day as an
outpatient.
Fluids, electrolytes and nutrition - The patient was
initially volume depleted and was hydrated with approximately
four liters of intravenous fluid. She was initially NPO and
then had her diet gradually advanced and the patient again
confirmed that she refuses placement of a gastric feeding
tube despite her ongoing risk for aspiration pneumonia. Her
electrolytes were monitored and repleted as necessary.
Communication was with the patient's mother primarily who is
[**Name (NI) 2048**] [**Name (NI) 33086**] at [**Telephone/Fax (1) 33087**].
CODE STATUS: Full.
This represents a partial discharge summary. A discharge
addendum will be dictated upon discharge with final
medications and discharge status and follow-up.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 7896**]
MEDQUIST36
D: [**2145-4-10**] 11:03
T: [**2145-4-10**] 11:42
JOB#: [**Job Number 29338**]
Name: [**Known lastname 5761**], [**Known firstname 4377**] Unit No: [**Numeric Identifier 5762**]
Admission Date: [**2145-4-7**] Discharge Date: [**2145-4-13**]
Date of Birth: [**2104-11-11**] Sex: F
Service:
ADDENDUM: This addendum is covering dates [**4-10**], through
[**4-13**].
CONTINUATION OF HOSPITAL COURSE:
1. Pulmonary: On [**4-10**], the patient acutely desaturated to
81% on her baseline six liter oxygen by nasal cannula.
Respiratory Therapy was called for chest Physical Therapy and
suctioning. Approximately 10 cc of brown thick secretions
were suctioned with relief of the patient's respiratory
status. Her breathing became more comfortable and her oxygen
saturation improved to 98% on five liters of oxygen by nasal
cannula. The patient had a chest x-ray done at the time
which was stable and an arterial blood gas which showed
decrease pO2 with stable compensated elevation in bicarbonate
and pCO2, thought to be secondary to the patient's baseline
neuromuscular compromise.
The patient had one more episode of decreased oxygenation on
the night of [**4-10**]. This time, solid food was actually
suctioned from the patient. The patient was then improved
similar to the prior episode. The patient was advised that a
G-tube or tracheostomy would benefit her and that we expected
that she would continue to aspirate as she has in the past.
However, the patient is adamant that she does not need and
does not want any G-tube and refused to discuss the matter
further. As the patient is followed primarily at the
[**Hospital 5763**] Hospital we will leave further discussions of this
matter to her primary care providers there. Of note, the
patient has had a swallowing evaluation at the [**Hospital 5763**]
Hospital so, therefore, this will not be pursued further at
this time.
2. Infectious Disease: The patient is being treated for
pneumonia, most likely aspiration pneumonia, with Vancomycin
to cover Methicillin resistant Staphylococcus aureus from her
sputum as well as Levofloxacin and Flagyl for aspiration
pneumonia. These antibiotics will continue until [**2145-4-20**].
3. Wound Care: The patient will have an outpatient
evaluation by Plastic Surgery as follow-up to the wound care
and nursing evaluation received while in-house. The Plastic
Surgery Clinic is at [**Telephone/Fax (1) 5721**]. Alternatively, the
patient can follow-up through the [**Hospital 5763**] Hospital which is
probably preferable because she has routine care at the
[**Hospital 5763**] Hospital. The Plastic Surgery Service recommended
that the patient follow-up in one to two weeks after
discharge, approximately mid-[**Month (only) **].
4. Pain Control: The patient will continue on her pain
medications as discussed in the previous discharge summary.
5. Endocrine: The patient is continuing on her Prednisone
taper with a goal of 5 mg p.o. per day of Prednisone which is
her baseline for adrenal insufficiency. The patient will be
at this goal starting the [**5-15**].
DISCHARGE MEDICATIONS:
1. Prednisone 5 mg p.o. q. day.
2. Scopolamine patch every 72 hours.
3. Prilosec 20 mg p.o. q. day.
4. Ditropan 5 mg p.o. twice a day.
5. Iron Sulfate 325 mg p.o. three times a day.
6. Multivitamin Elixir each day.
7. Lactulose 30 cc p.o. q. day.
8. Zoloft 50 mg p.o. q. day.
9. Nystatin swish and swallow, 5 cc four times a day.
10. Tylenol 650 mg p.o./p.r. q. four to six hours p.r.n.
11. Atrovent MDI q. four hours.
12. Albuterol MDI q. four hours.
13. Regular insulin sliding scale.
14. Heparin 5000 units subcutaneously twice a day.
15. Estraderm patch 0.05 mg q. three days.
16. Reglan 10 mg p.o. four times a day.
17. Neurontin 900 mg p.o. three times a day.
18. Baclofen 30 mg p.o. q. six hours.
19. Magnesium citrate one bottle p.o. q. day p.r.n.
20. Morphine sulfate, immediate release, 5 to 10 mg p.o. q.
four to six hours p.r.n.
21. Klonopin 0.5 mg p.o. twice a day.
22. Flagyl 500 mg intravenously three times a day to stop
[**2145-4-20**].
23. Levofloxacin 500 mg intravenous q. day to stop [**4-20**].
24. Vancomycin one gram intravenously q. 12 hours, stop [**4-20**].
25. Colace 100 mg p.o. twice a day.
26. Dulcolax suppository p.r. q. day.
27. MS Contin 15 mg p.o. twice a day.
28. Albuterol/Atrovent nebulizers q. four hours p.r.n.
DISCHARGE INSTRUCTIONS:
1. Wound care: Sacral wound should be dressed with wet to
moist dressing changes each day.
2. She will require follow-up with Plastic Surgery either
here at [**Hospital1 5764**] Clinic number
[**Telephone/Fax (1) 5721**], the second week of [**Month (only) **], or through [**Hospital 5763**]
Hospital where she receives her regular care.
3. Duoderm should be placed on her heel ulcers.
4. Follow-up will be with her primary care provider, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 5765**], at [**Hospital 5763**] Hospital.
DISCHARGE STATUS: To [**Hospital3 5766**] where she permanently lives.
CONDITION AT DISCHARGE: Improved.
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**]
Dictated By:[**Last Name (NamePattern1) 5767**]
MEDQUIST36
D: [**2145-4-13**] 11:03
T: [**2145-4-13**] 11:50
JOB#: [**Job Number 5768**]
|
[
"038.9",
"255.4",
"518.81",
"344.09",
"507.0",
"305.1",
"707.0",
"530.81",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13346, 14608
|
2976, 3715
|
10639, 12438
|
14632, 14636
|
4069, 5720
|
15274, 15546
|
14649, 15258
|
143, 2401
|
2423, 2950
|
3732, 4046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,829
| 147,697
|
38574
|
Discharge summary
|
report
|
Admission Date: [**2190-3-18**] Discharge Date: [**2190-3-24**]
Date of Birth: [**2128-3-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2190-3-18**] Pericardial Stripping
History of Present Illness:
This is a 61 year old female complaining of chest pain referred
for pericardial stripping.
Past Medical History:
Hepatitis B Carrier(
Hypertension
Dyslipidemia
Chronic Bronchitis
Gastroesophageal Reflux Disease
Sleep Apnea-no device used
Osteoarthritis Right knee
Peripheral Vascular disease
Uterine Leiomyoma
Stress Incontinence
Constipation
Uterovaginal Prolapse with complete Rectocele
Depression
Cataracts
s/p Dilation & Curettage
Social History:
Race: Caucasian
Last Dental Exam: [**12-23**]
Lives alone
Occupation: retired
Tobacco: current smoker 1.5 ppd; 45 PY Hx
ETOH: none in 5 yrs
Family History:
Father died of Myocardial Infarction at 67. Sister with
rheumatic heart disease.
Physical Exam:
Admission:
Pulse:77 reg Resp: O2 sat: 98% RA
B/P Right: Left: 115/71
Height: 65in Weight: 168 #
General: Well-developed female in no acute distress with tobacco
smell
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] anicteric sclera
Neck: Supple [X] Full ROM [X] -JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X] -HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 1+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: none
Pertinent Results:
[**2190-3-18**] Echo: Pre-pericardial stripping: A patent foramen ovale
is present. 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. The aortic valve
leaflets (3) are mildly thickened. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is a moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.
There is no evidence of pericardial constriction (abnormal
septal motion, LV inflow pattern abnormalities), however tissue
Doppler and Vp suggest (borderline) abnormal diastolic function.
Post effusion drainage/pericardial stripping showed a change of
E:A ratios from near 2:1 toward 1:1. No other changes were
observed.
[**2190-3-23**] 05:15AM BLOOD WBC-6.7 RBC-4.68 Hgb-14.2 Hct-42.2 MCV-90
MCH-30.3 MCHC-33.5 RDW-12.7 Plt Ct-304
[**2190-3-23**] 05:15AM BLOOD Glucose-86 UreaN-8 Creat-0.6 Na-142 K-4.1
Cl-106 HCO3-28 AnGap-12
Brief Hospital Course:
Ms. [**Known lastname 45736**] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**3-18**] she was brought directly to
the Operating Room where she underwent pericardial stripping.
Please see operative report for surgical details. Following
surgery she was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours she was weaned from
sedation and extubated.
She does have a psychiatric history including [**Hospital1 **]-polar disease.
She experienced post-operative delerium. Narcotics and
benzodiazepines were minimized. Psychiatry was consulted and
her mental status cleared. Beta blocker was initiated and the
patient was gently diuresed toward her preoperative weight. The
patient was transferred to the telemetry floor for further
recovery.
The patient was noted to have a lower extremity tremor.
Neurology was consulted. The tremor did resolve prior to
discharge. Neurology recommended an MRI for evaluation,
however, the patient was unable to tolerate this. It will be
scheduled as an outpatient, and the patient will follow up with
neurology following discharge.
Chest tubes 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 [**3-24**]
the patient was ambulating without assistance, the wound was
healing [**Last Name (un) 35099**] pain was controlled with oral analgesics.
Rheumatology was consulted for evaluation of a possible auto
immine etiology of the pericarditits and [**Doctor First Name **] an drheumatoid
factor assays were sent. Arrangements were made for outpatient
follow up with them at the time of her return surgical visit.
The patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
Albuterol prn
Amlodipine 10 qd
Vitamin D
Calcium
Advair 250/50 [**Hospital1 **]
Lisinopril 40 qd
Lithium 300 [**Hospital1 **]
Paxil 60 qd
Pravachol 20 qd
Detrol LA 4 qd
Ultram 50mg tabs(1 qAM, 2 qPM)
Trazodone 50mg qhs
Psyllium fiber qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
3. Paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO once a day.
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
BUN, Creatinine
draw 1-2 days prior to MRI
16. Radiology
MRI brain with and without contrast
dx: post-operative bilateral lower extremity tremor
this should be scheduled at [**Hospital1 **] for prior to appointment with Dr.
[**First Name (STitle) 951**] on [**2190-4-6**] 4pm
17. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily) as
needed for constipation.
18. Ibuprofen 200 mg Tablet Sig: Three (3) Tablet PO q 8hrs prn
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Constrictive pericarditis
s/p Pericardial Stripping
Past medical history:
Hepatitis B Carrier
Hypertension
Dyslipidemia
Chronic Bronchitis
Gastroesophageal Reflux Disease
Sleep Apnea-no device used
Osteoarthritis Right knee
Peripheral Vascular disease
Uterine Leiomyoma
Stress Incontinence
chronic Constipation
Uterovaginal Prolapse with complete Rectocele
Depression
Cataracts
s/p Dilation & Curettage
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with ultram prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] [**Name (STitle) **]. [**4-13**] at 1 pm ([**Telephone/Fax (1) 170**])
Primary Care: Dr. [**Last Name (STitle) **] in [**1-16**] weeks [**Telephone/Fax (1) 85764**]
Cardiologist: Dr. [**Last Name (STitle) 55499**] ([**Telephone/Fax (1) 84379**] in 4 weeks
Neurology: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 31415**]
Date/Time:[**2190-4-6**] 4:00
Rheumatology at [**Hospital1 18**] on [**4-13**] at 11am
Completed by:[**2190-3-24**]
|
[
"588.89",
"305.1",
"618.3",
"401.9",
"788.30",
"780.57",
"301.83",
"564.09",
"272.4",
"490",
"443.9",
"530.81",
"423.2",
"296.80",
"425.4",
"349.82",
"285.9",
"715.36"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.25",
"37.31"
] |
icd9pcs
|
[
[
[]
]
] |
6948, 6978
|
3031, 4870
|
331, 370
|
7426, 7520
|
1852, 3008
|
8143, 8748
|
1009, 1092
|
5157, 6925
|
6999, 7052
|
4896, 5134
|
7544, 8120
|
1107, 1833
|
281, 293
|
398, 491
|
7074, 7405
|
852, 993
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,543
| 198,034
|
52395
|
Discharge summary
|
report
|
Admission Date: [**2190-10-20**] Discharge Date: [**2190-10-25**]
Date of Birth: [**2129-8-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tegretol / Dilantin / Penicillins / Sulfonamides
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
sternal wound drainage
Major Surgical or Invasive Procedure:
PICC Line placement [**2190-10-22**]
History of Present Illness:
Underwent CABG on [**9-21**] with Dr. [**Last Name (STitle) **]. He admits to feeling
weak and having some pain. He presented to his medical doctor
and wa started on abx for a sternal wound infection. Admitted
for evaulation and management of wound.
Past Medical History:
CABG x 3 on [**10-1**]
##Diabetes
##Coronary disease
--ETT [**10-17**] 9.5" on [**Doctor First Name **] w/o ECG/sx. Mild, fixed defect of the
distal inferior and lateral walls. Ejection fraction of 57%.
--Cath: [**2188-5-6**]:
RCA: p30%, d95% (DES placed)
LMCA: 20-30%
LAD: non-flow limiting stenoses
LCX: Nl
##Hypertension, well controlled
##Hyperlipidemia, on statin therapy.
## MR: of varying degrees depending on the echo.
--Echo [**7-17**]: Overall left ventricular systolic function is
normal (LVEF> 55%). Mild inferoapical hypokinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No AR. Trivial
MR.
##Seizure Disorder: On Lamictal 300 [**Hospital1 **] and Plavix 75 daily.
Followed by Dr. [**Last Name (STitle) **] in neurology
## Actinic Keratoses removed from back
Social History:
2 cigars per week (equivalent to a 25 py hx). EtOH 1 drink with
dinner. Retired H.S. English teacher. Lives with wife. [**Name (NI) **]
6x/week.
Family History:
Father: MI @40
Sister: MI @50
Physical Exam:
NAD
PERRLA
neck has some midline swelling and tenderness
S1 S2 no murmur, rub or gallop RRR
CTAB
alert and oriented x 3
extrems with no c/c/e, warm and well-perfused
2x3 cm area above sternal notch has some fullness; erythema 4x2
cm to left of superior aspect of sternal incision
Pertinent Results:
[**2190-10-19**] 12:30PM BLOOD WBC-14.4*# RBC-3.26* Hgb-10.6* Hct-32.7*
MCV-100* MCH-32.5* MCHC-32.5 RDW-15.2 Plt Ct-363
[**2190-10-24**] 04:30AM BLOOD WBC-11.7* RBC-2.93* Hgb-9.3* Hct-28.5*
MCV-97 MCH-31.8 MCHC-32.7 RDW-14.8 Plt Ct-493*
[**2190-10-21**] 03:40AM BLOOD Neuts-81.1* Lymphs-10.5* Monos-7.1
Eos-1.0 Baso-0.2
[**2190-10-21**] 03:40AM BLOOD Hypochr-2+ Macrocy-1+
[**2190-10-24**] 04:30AM BLOOD Plt Ct-493*
[**2190-10-20**] 10:50PM BLOOD PT-15.2* PTT-29.0 INR(PT)-1.6
[**2190-10-22**] 06:25AM BLOOD ESR-51*
[**2190-10-24**] 04:30AM BLOOD UreaN-10 Creat-0.7 K-4.5
[**2190-10-19**] 12:30PM BLOOD ALT-20 AST-21 TotBili-0.5
[**2190-10-23**] 06:17AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0
Brief Hospital Course:
Admitted [**10-20**] to CSRU as there were no beds available on [**Hospital Ward Name 121**] 2.
Started on broad spectrum abx and wound/blood cultures sent. CT
scan of chest shows a normal postop exam per Dr. [**Last Name (STitle) **]. Foley
was reinserted after retention was seen on CT. Urology was
consulted. He was transferred to the floor when a bed became
available.
Sternum was intact and cultures were negative with a low grade
temp. Plan is for IV vancomycin for 2 weeks total. PICC line was
placed by the access team. Josiln consult was also obtained for
glucose management. Foley was DCed for a voiding trial on [**10-23**].
Flomax was started per GU. Patient is to follow up with Dr.
[**Last Name (STitle) **] from urology in 4 weeks.
Echo obtained showed no effusion. Sternal wound final culture
showed MRSA. Patient to be discharged with VNA services today
for continued IV vancomycin for 10 days. He should continue on
his insulin regimen as designed by the [**Last Name (un) **] team.
98 T HR 79 NSR RR 20 97% RA sat. 122/55 64.8 kg
Medications on Admission:
Lantus insulin 24-25u Q AM
SS humalog
lamictal 150 mg [**Hospital1 **]
lipitor
metoprolol
ASA 81 mg daily
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 10 days.
Disp:*20 g* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
10. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
Disp:*7 ML(s)* Refills:*0*
Insulin fixed dose and sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations:
humalog slding scale and lantus 25 units QHS
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sternal Wound Infection
Coronary Artery Disease s/p Coronary Artery Bypass Graft on
[**2190-10-1**]
Diabetes Mellitus IDDM
Seizures
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on incisions
[**Last Name (un) **] lifting greater than 10 pounds for another month
no driving for one week
Followup Instructions:
Dr. [**Last Name (STitle) **] in 3 weeks.
Follow-up with PCP/Cardiologist as recommended in previous
discharge in [**11-15**] weeks
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from urology in 4 weeks.
Completed by:[**2190-10-25**]
|
[
"780.39",
"401.9",
"682.2",
"998.59",
"V45.81",
"600.01",
"272.4",
"E878.2",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5829, 5887
|
2771, 3835
|
340, 379
|
6063, 6070
|
2058, 2748
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6256, 6529
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1757, 2039
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278, 302
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407, 658
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680, 1528
|
1544, 1695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,273
| 188,483
|
6644
|
Discharge summary
|
report
|
Admission Date: [**2133-7-6**] Discharge Date: [**2133-7-12**]
Date of Birth: [**2065-12-31**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
shortness of breath
Hypoxia
Hypercapneic respiratory failure
Pulmonary hypertension
Major Surgical or Invasive Procedure:
[**2133-7-6**] Cardiac Catherization
History of Present Illness:
67yo male with h/o liver transplant [**2126**], severe OSA, pulmonary
hypertension, and progressively worsening dyspnea over the last
two weeks, admitted for diuresis after elective cardiac cath
revealed biventricular elevated filling pressures, and now
transferred to CCU in setting of acute on chronic respiratory
acidosis requiring treatment with BiPAP.
.
Patient has had mild dyspnea on exertion at baseline for approx.
last 1-2 years, but over past several weeks has noted
progressively worsening dyspnea. He has been unable to eat for
the last few days seocndary to dyspnea while eating. Recent
work-up by his pulmonologist, including PFTs, indicated severe
restrictive pulmonary dysfunction with reduced lung volumes, but
normal DLCO when calculated for lung volumes. His pulmonologist
also felt there may be a component of diastolic heart failure
contributing to his worsening dyspnea, and he was referred for
an elective right cardiac cath which was performed earlier
today. Cath revealed severely elevated biventricular filling
pressures, as well as severe pulmonary arterial hypertension
with only moderate elevation of pulmonary vascular resistance.
PCWP was 38, PASP was 96.
After cath, patient was admitted to the cardiology service for
diuresis, as it was felt his dyspnea was primarily related to
cardiac etiology vs. a pulmonary etiology. He received
furosemide 40mg IV once (home dose furosemide 20mg PO daily).
On arrival to floor, he appeared lethargic and was difficult to
arouse. An ABG revealed a respiratory acidosis: 7.23/70/73/31.
Of note, he had taken Benadryl 75mg PO at home prior to the
procedure, and also received Fentanyl 25 mcg while in the the
cath lab. Respiratory therapy [**Name (NI) 653**], and patient
transferred to CCU for BiPAP. On arrival to CCU, vitals were:
95.5 100 176/86 32 100% on 5L NC. He had been started on a
nitro gtt in the cath lab after SBPs noted to be elevated to
200s, and after arrival in CCU his nitro gtt was titrated to
keep SBP <160.
Patient denied any chest pain, abdominal pain or nausea. He was
unable to fully answer questions secondary to his lethargic
state, and a full review of systems could not be obtained. Per
medical records, no prior history of stroke, TIA, DVT, or known
PE. No recent fevers, chills, or rigors. No history of asthma
or COPD, but patient does have h/o smoking 1-1.5 PPD for 45
years. He has a h/o OSA and has been non-adherent to using CPAP
in the past. However per family report he has been using CPAP
consistently at night over past several months, and has also
been using for several hours a day.
.
Of note, patient has hematoma in right neck after failed right
IJ placement for procedure; procedure performed through left
femoral.
Past Medical History:
Morbid Obesity
Tobacco Dependence (quit 1 yr ago, now using e-cigarettes)
EtOH Cirrhosis and portal hypertension; s/p liver transplant
[**4-/2127**]
Splenorenal shunt
Renal Insufficiency
Restrictive pulmonary dysfunction
Pulmonary Hypertension
Obstructive Sleep Apnea
DM Type 2 - resolved, occurred after OLT in setting of steroids
s/p incisional, ventral hernia repairs c/b infection
Social History:
Married but currently separated from his wife for 15 years. He
has 2 grown children. Per notes, he attended [**Location (un) **] Business
School and has been involved in a number of businesses including
owning a bank. He lives in [**Hospital1 **]. Tobacco: 1-1.5 PPD since age
20, quit one year ago (45 year history) and currently uses
e-cigarettes. EtOH: previous heavy EtOH use, no current use.
Family History:
Positive for cirrhosis, otherwise non-contributory.
Physical Exam:
VS: T=95.5 BP=176/86 HR=100 RR=32 O2 sat=100% on 5L NC
GENERAL: Lethargic appearing, awakes to voice, but falls back to
sleep within sevearl minutes. Oriented to name, hospital
setting, and year.
HEENT: NCAT. Sclera anicteric. Pupils constricted but reactive.
EOMI.
NECK: Right sided hematoma at site of attempted right IJ,
dressing stained with blood but no evidence of active bleeding,
hematoma has not increased in size since markings previously
drawn. Unable to assess JVD given body habitus.
CARDIAC: RRR, normal S1 S2, ? slight systolic murmur but
difficult to assess as heart sounds distant
LUNGS: Slightly labored breathing, but no significant accessory
muscle use. Poor airmovement bilaterally with decreased breath
sounds at bases. ?Scattered crackles.
ABDOMEN: Obese. Soft, NTND. Abdominal incisional scars.
EXTREMITIES: Bilateraly lower ext edema 3+ to level of knees.
SKIN: Chronic venous stasis changes with brawny discoloration
and verrucous appearing areas, more notable on left.
PULSES: PT, DP 1+ bilaterally
Pertinent Results:
Admission Labs:
[**2133-7-6**] 10:54PM LACTATE-1.1
[**2133-7-6**] 08:38PM GLUCOSE-126* UREA N-34* CREAT-2.0* SODIUM-141
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-30 ANION GAP-10
[**2133-7-6**] 08:38PM CALCIUM-8.8 PHOSPHATE-5.7*# MAGNESIUM-2.0
[**2133-7-6**] 01:00PM PT-15.6* INR(PT)-1.4*
[**2133-7-6**] 06:17PM ABG: PO2-73* PCO2-70* PH-7.23* TOTAL CO2-31*
BASE XS-0
[**2133-7-7**]: WBC 4.9, Hgb 12.3, HCT 37.1, Plt 91
.
Pertinent Labs:
[**2133-7-7**]: Cyclosporine level 262
[**2133-7-8**]: Cyclosporine level 70
[**2133-7-9**]: Cyclosporine level 100
.
[**2133-7-10**]: LDH 267
[**2133-7-9**]: Albumin 3.1
[**2133-7-8**]: Ammonia 63
.
[**2133-7-9**]: pH 7.30 / pCO2 70 / pO2 79 / HCO3 36
[**2133-7-8**]: pH 7.31 / pCO2 72 / pO2 77 / HCO3 38
[**2133-7-8**]: pH 7.30 / pCO2 68 / pO2 57 / HCO3 35
[**2133-7-7**]: pH 7.31 / pCO2 61 / pO2 73 / HCO3 32
[**2133-7-7**]: pH 7.29 / pCO2 64 / pO2 76 / HCO3 32
[**2133-7-6**]: pH 7.30 / pCO2 63 / pO2 66 / HCO3 32
[**2133-7-6**]: pH 7.23 / pCO2 70 / pO2 73 / HCO3 31
.
Discharge Labs:
[**2133-7-11**]: WBC 4.0, Hgb 11.1, HCT 34.6, Plt 93
[**2133-7-11**]: Na 143, K 3.7, Cl 99, HCO3 38, BUN 46, Cr 2.8, Glu 71
[**2133-7-11**]: Ca 8.3, Mag 2.1, Phos 3.5
[**2133-7-11**]: PT 16.7, INR 1.5
[**2133-7-11**]: ALT 19, AST 21, AlkPhos 79, TBili 1.1
[**2133-7-11**]: CK 71
.
Microbiology: MRSA negative, urine culture [**2133-7-8**] negative
.
Reports:
TTE [**2133-7-7**]
This study was compared to the prior study of [**2132-10-2**].
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
CONCLUSIONS:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The right ventricular free wall is
hypertrophied. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits). The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2132-10-2**], there is no definite change.
Unable to compare pulmonary artery systolic pressure estimates.
.
[**2133-7-6**] CXR: In comparison with the study of [**6-8**], the patient
has taken a
somewhat better inspiration. There is again enlargement of the
cardiac
silhouette with worsening pulmonary vascular congestion and
bilateral pleural effusions. Atelectatic changes are seen at the
left base, and the possibility of supervening pneumonia cannot
be definitely excluded (especially in the absence of a lateral
view).
.
[**2133-7-8**] CXR:
1. New right lower lobe and middle lobe atelectasis.
2. Improvement of degree of vascular congestion in both lungs.
3. Stable moderate cardiomegaly and right pleural effusion
.
[**2133-7-10**] CXR: Moderate cardiomegaly, widened mediastinum, right
middle lobe and left lower lobe atelectasis are unchanged.
Moderate right pleural effusion.
.
EKG [**2133-7-8**]: Sinus rhythm and atrial ectopy, atrial bigeminy.
The atrial ectopy is new as compared with previous tracing of
[**2133-7-6**]. The T wave inversion previously recorded in leads I and
aVL persist and the T waves are now biphasic to inverted in
leads V3-V6 and the ST segments are downsloping in lead II with
associated T wave inversions. These findings raise question of
active anterolateral and apical ischemic process. Followup and
clinical correlation are suggested.
.
[**2133-7-6**] Cardiac Catherization
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.53 m2
HEMOGLOBIN: 12.0 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 24/22/20
RIGHT VENTRICLE {s/ed} 96/24
PULMONARY ARTERY {s/d/m} 96/51/72
PULMONARY WEDGE {a/v/m} 42/43/38
**CARDIAC OUTPUT
HEART RATE {beats/min} 97
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 32
CARD. OP/IND FICK {l/mn/m2} 9.9/3.9
**RESISTANCES
PULMONARY VASC. RESISTANCE 275
**% SATURATION DATA (NL)
SVC LOW 73
PA MAIN 75
AO 95
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 33 minutes.
Arterial time = 0 minutes.
Fluoro time = 3.5 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 0 ml
Premedications:
Fentanyl 25 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Furosemide 40 mg IV
TNG 20 mcg/min IV gtt
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, RIGHT HEART KIT
7.5FR [**Doctor Last Name **], SWAN-GANZ VIP
COMMENTS:
1. Resting hemodynamics revealed elevated right and left heart
filling
pressures with RVEDP 24 mmHg and PCWP 38 mmHg. There was severe
pulmonary arterial hypertension with PASP 96 mmHg. The cardiac
index was
preserved at 3.9 L/min/m2. The pulmonary vascular resistance was
elevated at 275 dyn-sec/cm5.
FINAL DIAGNOSIS:
1. Severely elevated biventricular filling pressures.
2. Severe pulmonary arterial hypertension with only moderate
elevation
of pulmonary vascular resistance.
3. No evidence for intracardiac shunt.
Brief Hospital Course:
67yo male with h/o liver transplant [**2126**], severe OSA, and
pulmonary HTN, admitted after elective right cardiac cath
revealed severely elevated biventricular filling pressures as
well as severe pulmonary artery HTN, and who was transferred to
CCU in setting of acute on chronic respiratory acidosis.
.
# Acute on chronic respiratory acidosis - After cardiac cath,
patient noted to be lethargic, and ABG revealed pH 7.23, pCO2
70. This acid-base disturbance was thought to be an acute on
chronic respiratory acidosis, most likely due to increased
sedation in setting of cardiac cath with underlying obesity
hypoventilation syndrome and pulmonary HTN. COPD seemed less
likely given recent outpatient pulmonary work-up, which was more
consistent with restrictive physiology, however the patient does
have a significant smoking history. Respiratory therapy was
consulted, and the patient was placed on BiPAP overnight.
Repeat ABGs showed a persistent acidosis, with mild improvement
in hypercapnia following BiPAP. The patient was prescribed
nebulizers with some symptomatic improvement, and these were no
longer needed prior to discharge. He was continued on BiPAP at
night when tolerated, but generally he complied with CPAP. He
became more drowsy and disoriented at times, and this was
thought to be due to his respiratory status - his ammonia was
only mildly elevated at 63 and there were no indicators of
infection. Repeat ABGs revealed a similar respiratory acidosis
profile despite therapy, but he improved clinically. He was
noted at times to be hypoxic on O2 sats and was given
supplemental oxygen. Prior to discharge, he was able to ambulate
without oxygen (did not meet criteria for long-term O2 therapy
on ABG) and his respiratory status had improved following
diuresis.
#) Pulmonary HTN - Patient noted to have severe pulmonary HTN
during cardiac cath, which was likely contributing to his
dyspnea. The differential diganosis for the cause of his
pulmonary HTN is broad, and includes left heart diastolic
failure, severe OSA, obesity hypoventilation syndrome,
autoimmune causes, neuromuscular disease, and liver disease.
Outpatient pulmonary work-up revealed severe restrictive
pulmonary dysfunction with reduced lung volumes, but normal DLCO
when calculated for lung volumes, suggesting pulmonary HTN not
related to a primarily pulmonary vascular etiology. Per liver
team, his graft function has been normal, and hepatopulmonary
syndrome not playing a role in his pulmonary HTN. A TTE was
performed on [**2133-7-7**], but given suboptimal image quality, was
unable to better characterize pulmonary artery systolic
pressures. A pulmonary consult was called, and the team felt
the patient would not be an ideal candidate for a vasodilator
challenge at this time, but that the issue could be re-addressed
once the patient had undergone diuresis for his diastolic heart
failure exacerbation. The patient was treated for his dCHF with
aggressive diuresis (including furosemide drip), and BiPAP/CPAP
for his OSA at night. Ultimately, the patient would benefit
most from lifestyle changes including weight loss, smoking
cessation, and increased physical activity, and he is aware of
these recommendations. Could consider autoimmune work-up and
evaluation for neuromuscular disease (note normal CK 71),
however dCHF and OSA are most likely etiologies of his pulmonary
HTN. He will follow-up with Dr. [**Last Name (STitle) 575**] for further
outpatient pulmonary care.
.
# Diastolic Heart Failure - Biventricular elevated filling
pressures demonstrated on cardiac cath c/w diastolic heart
failure. These elevated pressures are significantly elevated
from previous cardiac cath in [**2125**] which showed mildly elevated
right sided filling pressures and mild/moderately elevated
left-sided filling pressures. Echo obtained [**9-/2132**]
demonstrated normal ventricular systolic function with LVEF>55%,
and moderate pulmonary HTN. Repeat echo this admission again
revealed LVEF >55%, RV free wall hypertrophy, and increased LV
filling pressures, but could not compare pulmonary artery
systolic pressures to previous studies given suboptimal image
quality of echo. Patient was aggressively diuresed following
his cath. His fluid balance was difficult to monitor, as the
patient refused a Foley catheter and was frequently incontinent.
Daily weights were monitored, and repeat CXR showed improvement
in pulmonary vascular congestion. He was also started on a beta
blocker, to allow for increased filling time. His respiratory
status had improved prior to discharge, and his weight was down
4.8kg since admission (discharge weight 130kg). He was
discharged on a regimen that includes metoprolol succinate 150mg
PO daily and torsemide 80mg PO daily. He was not started on an
ACE inhibitor in the setting of his liver transplant and
impaired renal function. He will follow-up with Dr.[**Name (NI) 3733**]
as an outpatient.
.
#) Renal insufficiency - Cr 2.0 on presentation, and had been
1.8-2.0 over past several months prior to admisison. Cr trended
up as patient as aggressively diuresed, and reached level of 3.0
on [**2133-7-9**]. Urine electrolytes obtained, and were consistent
with a pre-renal etiology. Liver team did not feel cyclosporine
toxicity was responsible for the acute rise in Cr, however his
cyclosporine dose was decreased and his levels were monitored.
His Cr and electrolytes were closely monitored, and electrolytes
were repleted as necessary. His Cr on discharge was 2.8 and
decreasing, and will be further monitored in the outpatient
setting. The patient was noted to have taken NSAIDs prior to
admission, which may also have contributed to acute kidney
injury. The patient was encouraged to not take NSAIDs following
discharge.
.
#) Hypertension - Patient hypertensive with SBP in 200s in cath
lab, was started on nitro gtt, and had SBP in 170s on arrival to
CCU. He was started on metoprolol and aggressively diuresed,
with resultant improvement in his BP. He was able to be weaned
off the nitroglycerin drip within the first day of admission.
Per the liver team, he should not be started on an ACE inhibitor
in the community, but he might benefit from the addition of
amlodipine if he becomes increasingly hypertensive on his
current regimen. His discharge medications include metoprolol
succinate 150mg PO daily and torsemide 80mg PO daily.
.
# s/p Liver Transplant: He was continued on cyclosporine,
although the dose was decreased from twice daily dosing to once
daily dosing after cyclosporine level noted to be elevated. He
was continued on his home dose of mycophenalate mofetil, as well
as prophylactic Bactrim. Both the transplant team and liver
team were aware of the admission. The liver team recommended
checking daily LFTs and INR to monitor his graft function. In
general LFTs were normal and stable throughout admission (LDH
and T bili somewhat elevated).
.
# Chronic venous stasis changes - Patient seen by wound care
nurse, who recommended aloe vesta be applied to bilateral lower
extremity venous stasis lesions twice daily. He may also
benefit from a dermatology consult in the outpatient setting.
Medications on Admission:
CYCLOSPORINE MODIFIED - (Dose adjustment - no new Rx) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day No Substitutions
DIPHENHYDRAMINE HCL - (Prescribed by Other Provider) - 25 mg
Capsule - 1 Capsule(s) by mouth as needed
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
MYCOPHENOLATE MOFETIL [CELLCEPT] - (Prescribed by Other
Provider: [**Last Name (NamePattern4) **]. states he takes this once daily) - 250 mg Capsule
-
1 Capsule(s) by mouth twice a day
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - (Prescribed by
Other Provider: [**Name Initial (NameIs) 3390**]) - 500 mg (1,250 mg)-400 unit Tablet - 1
Tablet(s) by mouth twice a day
MULTIVITAMIN - (OTC) - Capsule - 1 Capsule(s) by mouth qam
NAPROXEN SODIUM - (Prescribed by Other Provider) - 220 mg Tablet
- 1 Tablet(s) by mouth as needed
Discharge Medications:
1. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
2. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
7. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet
Sig: One (1) Tablet PO twice a day.
8. Outpatient Lab Work
Blood test (to be drawn [**2133-7-13**]): Na, K, Cl, HCO3, BUN, Cr, Glu,
Ca, Mag, Phos
Please fax results to [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], MD
Fax: [**Telephone/Fax (1) 25380**]
9. Outpatient Physical Therapy
Patient can walk with a walker or other assistance.
10. Outpatient Occupational Therapy
Please assist patient with developing strategies to complete
activities of daily living.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
PRIMARY:
Pulmonary hypertension
Diastolic heart failure
Acute on chronic renal failure
SECONDARY:
Hypertension
Obstructive sleep apnea
s/p liver transplant on longterm immunosuppression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert but sometimes drowsy
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure looking after you during your stay at the [**Hospital1 1535**]. You presented on [**2133-7-6**] for
an elective right heart catheterization following workup by your
pulmonologist, who had found abnormalities on your pulmonary
function tests. The concern was that a degree of heart failure
was contributing to your underlying chronic lung problems, most
likely due to smoking and being overweight, which can make
breathing more difficult. Prior to admission you had noticed
worsening shortness of breath especially in the past 2 weeks,
and this was severely limiting you even with eating. The
catheterization revealed high pressures in both sides of the
heart and severe pulmonary hypertension (see explanation below).
Pulmonary hypertension is the progressive constriction of blood
vessels supplying the lungs, which leads to progressive
stiffening of these blood vessels. As a result, the heart must
work harder to pump blood through the lungs, and the right side
of the heart becomes strained. The fact that less blood is able
to be pumped through the lungs means that less blood can reach
the left side of the heart (which pumps the oxygenated blood
through the body). Therefore less oxygen is available to the
body, especially during exercise, which leads to shortness of
breath.
Following your catheterization you were admitted to the CCU as
you were having difficulty breathing, and you were put on the
BiPAP machine to help your breathing. It was felt that the [**Last Name 16423**]
problem leading to your shortness of breath was heart failure
causing fluid build-up in the lungs. We therefore started you on
medications to help remove some of the water, called diuretics,
and your breathing improved as a result. Your kidney function
has been previously impaired, and it worsened somewhat during
this admission. This can be an effect of diuretics with you
becoming dryer and therefore slightly dehydrating the kidneys.
We carefully monitored your kidney function with regular blood
tests, and it was improving at the time you were discharged. You
were also drowsy and at times disoriented, and we felt that this
was because your oxygen levels were low and your carbon dioxide
levels were high. The reason for this is likely a combination
of your obstructive sleep apnea, heart failure and pulmonary
hypertension. We regularly tested your oxygen and CO2 levels by
taking blood from the artery at the wrist. You used the CPAP
machine and at times the BiPAP machine in order to help your
breathing. The pulmonology and liver transplant teams saw you
during this admission, and based on their advice we changed the
dose of your cyclosporine. On [**2133-7-10**] you had an episode of
worsening shortness of breath, but your chest X-ray showed
improvement and there were no abnormalities on the heart tracing
(ECG). We started you on a beta-blocker called metoprolol which
takes some of the strain off the heart by slowing the heart beat
and we changed you from intravenous to an oral diuretic called
torsemide. Your shortness of breath improved as did your
disorientation. You were seen by physical therapy and able to
walk holding onto a wheelchair, without requiring additional
oxygen therapy. You were stable for discharge and you were
discharged home on [**2133-7-12**] with outpatient physical therapy,
occupational therapy, and a nurse to see you in your house.
CHANGES TO MEDICATIONS:
1) Your Cyclosporine dose was REDUCED to 100mg ONCE DAILY
2) We STOPPED your diphenhydramine
3) We STARTED metoprolol succinate 150mg once daily
4) We STARTED torsemide 80mg once daily
DISCHARGE INSTRUCTIONS:
1) You will be seen by Dr[**Doctor Last Name 3733**] as an outpatient in
addition to pulmonology follow-up with Dr [**Last Name (STitle) 575**]
***It is very important that you keep all of your doctor's
apointments.***
2) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Your weight on day of discharge was 130kg (286 lbs).
3) You should try and keep to a low salt diet (2g sodium) and a
restricted fluid intake of 1.5 liters per day to stop further
fluid overload
4) Continue using your CPAP machine
5) You will have physical therapy see you as an outpatient in
addition to occupational therapy who will assess you and your
home to see if there are any adjustments necessary to make your
life easier
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Date: Tuesday [**2133-8-18**] at 1PM
Location: [**Hospital Ward Name 23**] Building [**Location (un) 436**]
Phone Number: [**Telephone/Fax (1) 62**]
PULMONOLOGY:
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.
Date: [**Last Name (LF) 2974**], [**7-17**] at 12:00
Location: E/KSB-23
Division: Pulmonary and Critical Care
Phone:[**Telephone/Fax (1) 612**]
PULMONARY FUNCTION:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB
Date/Time: [**Last Name (LF) 2974**], [**7-17**] at 11:40
Location: [**Hospital1 69**] - [**Hospital Ward Name 2104**]-7
Phone:[**Telephone/Fax (1) 609**]
CARDIOLOGY:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (STitle) **]
Date: Please call to make appointment
Location: [**Hospital Ward Name 23**] Building [**Location (un) 436**]
Telephone Number: [**Telephone/Fax (1) 62**]
|
[
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"327.23",
"459.81",
"416.0",
"287.5",
"428.0",
"305.1",
"278.01",
"584.9",
"276.2",
"585.9",
"V42.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
20258, 20309
|
10881, 18067
|
355, 393
|
20540, 20540
|
5123, 5123
|
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|
4007, 4060
|
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|
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|
18093, 19031
|
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|
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|
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|
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|
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|
232, 317
|
421, 3166
|
5139, 5548
|
20555, 20703
|
5564, 6137
|
3188, 3576
|
3592, 3991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,803
| 182,686
|
19605
|
Discharge summary
|
report
|
Admission Date: [**2140-6-28**] Discharge Date: [**2140-7-6**]
Date of Birth: [**2072-5-31**] Sex: F
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Afib w/ RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient states she was in usual state of health recently, but
noted to have generalized weakness and c/o abdominal pain at NH,
noted to have a low Hct and directed to come to the ED for
additional evaluation.
No n/v/d. The patient denies any shortness of breath or chest
pain. In the emergency department she had a CT Abd/Pelvis which
did not reveal any acute abdominal process, but there were b/l
effusions with possible PNA on the right. She was started on a
dilt drip due to her persistent tachycardia. She was guaiac
negative. She was transfused a unit of PRBCs due to the
persistent tachycardia unresponsive to diltiazem.
In the ED, initial VS were:
Temp: 97.9 HR: 174 BP: 143/105 Resp: 16 O(2)Sat: 97
On arrival to the MICU, the patient was tachycardic, on 3L NC,
but in no distress and without any complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-Atrial Fibrillation (on ASA)
-Microcytic Anemia - extensive recent GI wkup at [**Hospital1 112**] unrevealing
-Schizophrenia - diagnosed age 23
-Eczema
Social History:
Living in a nursing home. However brother is trying to have her
move in with him in [**Doctor First Name 5256**].
Family History:
Mother with ETOH abuse, no FH of heart
disease, HTN, DM or malignancy.
Physical Exam:
Vitals: T: 37.9 BP: 111/63 P: 140 R: 14 O2: 97% 3L NC
General: Alert, oriented to person and place, no acute distress,
looks older than stated age
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, slightly elevated JVP, not elevated, no LAD
CV: Tachycardic, irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Bilateral crackles to the mid-lung fields, no wheezes,
poor excursion
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
there is 2+
Neuro: CNII-XII intact, moves all extremities spontaneously
Prior to Discharge:
VS - Tc 98.7, BP-130/80, HR- 108 RR 18 97%RA
GENERAL - Alert, interactive, very pleasant chronically ill
appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no LAD
HEART - PMI non-displaced, irregularly irregular, 1/6 SEM
LUNGS - Crackles at the bases R>L, no wheezes/ronchi, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, trace bilateral LE edema, 2+ peripheral
pulses
Pertinent Results:
On admission:
[**2140-6-28**] 06:10PM BLOOD WBC-12.4*# RBC-3.12* Hgb-7.5*# Hct-24.8*
MCV-79* MCH-24.1* MCHC-30.4* RDW-16.4* Plt Ct-621*
[**2140-6-28**] 06:10PM BLOOD PT-16.1* PTT-32.7 INR(PT)-1.5*
[**2140-6-28**] 06:10PM BLOOD Glucose-127* UreaN-24* Creat-0.8 Na-135
K-4.4 Cl-98 HCO3-21* AnGap-20
[**2140-6-28**] 06:10PM BLOOD ALT-35 AST-42* LD(LDH)-232 AlkPhos-232*
TotBili-0.4
[**2140-6-28**] 06:10PM BLOOD proBNP-4799*
[**2140-6-28**] 06:22PM BLOOD Lactate-2.8*
.
CT Abd/Pelvis:
IMPRESSION:
1. Small right pleural effusion with adjacent right lower lobe
consolidation,
possibly reflecting compressive atelectasis though infectious
process cannot
be excluded.
2. Congestive heart failure with evidence of volume overload
including
hepatic congestion, small amount of perihepatic ascites and
anasarca.
3. Small amount of free fluid within the pelvis.
4. Subtle areas of hypoenhancement within the right kidney,
which raise
concern for pyelonephritis. Correlate clinically with UA.
5. Top normal appendix measuring 6-7 cm; however, no
inflammatory change and
air present within the appendix.
.
TTE:
IMPRESSION: Preserved left ventricular regional and global
systolic function. Moderate-severe tricuspid regurgitation with
right ventricular dilatation and moderate pulmonary artery
systolic hypertension.
.
LIVER OR GALLBLADDER US (SINGL Clip # [**Clip Number (Radiology) 53146**]
Reason: explanation for elevated alk phos?
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with elevated alkaline phosphatase and GGT
REASON FOR THIS EXAMINATION:
explanation for elevated alk phos?
Final Report
INDICATION: Patient with elevated alkaline phosphatase.
FINDINGS:
The liver demonstrates normal echotexture without focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary
ductal dilatation. The CBD is of normal caliber measuring 2 mm.
The portal vein is patent demonstrating hepatopetal and
pulsatile flow. Hepatic veins are prominent, which signify
underlying heart failure. The gallbladder is incompletely
distended. The gallbladder wall edema likely reflects
congestive heart failure. A 3 mm polyp is seen in the
gallbladder wall. The right kidney appears echogenic.
The pancreas is unremarkable, its tail obscured by overlying
bowel gas. The spleen measures 8.2 cm and is normal in
appearance. There is no ascites. Imaged intra-abdominal aorta
and IVC are normal in caliber. Small riht pleural effusion is
noted.
IMPRESSION:
1. Normal liver echotexture without focal lesions.
2. Gallbladder wall edema, prominent hepatic veins and
pulsatile portal
venous flow signify underlying congestive heart failure.
3. Small right pleural effusion.
4. Echogenic right kidney, may represent chronic parenchymal
disease,
correlate clinically.
Labs Prior to discharge:
============================
[**2140-7-6**] 11:05AM BLOOD WBC-10.9 RBC-3.65* Hgb-9.2* Hct-29.6*
MCV-81* MCH-25.2* MCHC-31.0 RDW-17.5* Plt Ct-615*
[**2140-7-5**] 08:04AM BLOOD PT-13.0* PTT-32.5 INR(PT)-1.2*
[**2140-7-4**] 08:00AM BLOOD ESR-100*
[**2140-7-5**] 08:04AM BLOOD Ret Aut-2.2
[**2140-7-6**] 11:05AM BLOOD Glucose-138* UreaN-15 Creat-0.7 Na-138
K-4.3 Cl-104 HCO3-23 AnGap-15
[**2140-7-5**] 08:04AM BLOOD LD(LDH)-157
[**2140-7-4**] 08:00AM BLOOD GGT-109*
[**2140-7-6**] 11:05AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0
[**2140-7-4**] 08:00AM BLOOD TotProt-6.3* Calcium-9.4 Phos-3.5 Mg-1.9
Iron-20*
[**2140-7-5**] 08:04AM BLOOD Hapto-327*
[**2140-7-4**] 08:00AM BLOOD calTIBC-259* VitB12-338 Ferritn-320*
TRF-199*
[**2140-7-4**] 08:00AM BLOOD CRP-116.8*
[**2140-7-4**] 08:00AM BLOOD PEP-NO SPECIFI
[**2140-7-5**] 08:04
ERYTHROPOIETIN
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
------------ERYTHROPOIETIN 30.9
H 2.6-18.5 mIU/mL
LABS PENDING AT DISCHARGE: MMA, Anti Mitochondrial Antibody,
Copper Level, Lead Level
Brief Hospital Course:
Primary Reason for Hospitalization:
====================================
68 y/o female with history of A fib w/ difficult to control
rates, hypertension, DMII, anemia, and schizophrenia presenting
from nursing home in afib RVR and with anemia.
ACTIVE ISSUES:
================
# Atrial fibrillation w/ RVR: Rates were initially in the 170s
on arrival to the ER. Patient was given IV diltiazem and IV
metoprolol in the ER with little effect and was eventually
started on a diltiazem infusion at 15 mg/hr in the ICU. She
continued to have rates in the 140s and blood pressures in the
80s to 90s. Cardiology recommended Digoxin loading. She was
briefly on an Esmolol infusion as well to help control rates and
was able to be weaned from this with oral Diltiazem and
Metoprolol. According to her last Cardiology note, the patient
was to be on diltiazem as an outpt but nursing home records did
not show this medication - she was solely on metoprolol. This
may have been the provoking reason for the rapid ventricular
response and/or catecholamine surge from symptomatic anemia. Her
rates came down to the normal range on the above regimen.
Aspirin was continued. Cardiac enzymes were negative and EKG
showed no signs of ischemia. On transfer to the medicine floor,
she was started on diltiazem 60mg q6hr but metoprolol dose was
decreased due to relative hypotension. As pressures improved,
we uptitrated metoprolol and switched diltiazem to extended
release 240mg daily. She remained asymptomatic with HR in 80s on
discharge.
# Anemia: Patient has chronic microcytic anemia, the origin of
which has never been clearly elucidated. On arrival, her Hct was
24.8 (down from a baseline of 31-34). Stool/rectal was guaiac
negative. She was transfused 2U PRBCs and later settled at 29.
No signs of active bleeding were seen. Hemolysis labs were
negative. Her corrected reticulocyte count was low. Iron studies
were consistent with anemia of chronic inflammation but could
also be masking a concurrent iron deficiency (although she takes
iron chronically). She has had chronically elevated inflammatory
markers of uncertain etiology.
- The patient will likely need colonoscopy as outpatient.
- The patient will need Hematology follow-up. It does not appear
that she has had a bone marrow biopsy, so this may be considered
by her outpatient providers.
# Pneumonia: CT Abd/Pelvis done in the ER for complaints of
abdominal pain showed no acute abdominal process but did show
R-sided effusion with possible consolidation. She was initially
treated with vancomycin and zosyn in the ER and subsequently
switched to levofloxacin in the ICU. She ultimately completed 8
total days of antibiotics (Vancomycin was later stopped when
MRSA swab was found to be negative. She remained afebrile.
CXR/CT showed small R-sided pleural effusion as above.
CHRONIC ISSUES:
=================
#Chronic Diastolic CHF(EF > 55%):
- Lasix was held at discharge to avoid hypotension. She may need
it resumed at a later date. Patient should be weighed daily. MD
should be notified if weight increases or decreases by more than
3 lbs.
#DM: well-controlled on oral medications. Continued metformin.
#Seizure disorder: stable. Continued Keppra 500mg [**Hospital1 **].
#Psych: hx schizophrenia, denies hallucinations, SI/HI.
Continued zyprexa 10mg [**Hospital1 **].
TRANSITIONAL ISSUES:
======================
# Patient had lasix stopped during this admission to avoid
hypotension. She may need it resumed at a later date. Patient
increases or decreases by more than 3 lbs.
# Titrate Metoprolol and Diltiazem as needed for rate control as
BP permits.
# Consider outpatient bone marrow biopsy to work-up anemia.
# Communication was with HCP (brother [**Name (NI) **] [**Name (NI) 31**], w
[**Telephone/Fax (1) 53147**], c [**Telephone/Fax (1) 53148**]) plans to bring her to North
[**Doctor First Name **] after discharge where he lives and establish new
doctors for [**Name5 (PTitle) **]. He was recommended to wait until after the
patient has the scheduled follow-up visits before she is moved
to ensure a safe transition.
Medications on Admission:
-Metformin 1000mg [**Hospital1 **]
-Metoprolol tartrate 75mg q6h
-Keppra 500mg [**Hospital1 **]
-Vitamin C 500 [**Hospital1 **]
-ASA 325
-colace 100 [**Hospital1 **]
-iron 325 daily
-folate 1mg daily
-lasix 20mg daily
-zyprexa 10mg [**Hospital1 **]
Discharge Medications:
1. diltiazem HCl 120 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. olanzapine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
Roscommon on the Parkway - [**Location 1268**]
Discharge Diagnosis:
Primary- Anemia
Atrial Fibrillation with Rapid Ventricular Response
Pneumonia
Secondary- Elevated liver enzymes
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:
Ms. [**Known lastname 31**], it was a pleasure taking care of you here at
[**Hospital1 18**].
You were admitted to the hospital for feeling unwell. While
here, you were found to have worsened anemia, which was treated
with a blood transfusion. You were also diagnosed with a
pneumonia and were treated with antibiotics. Your atrial
fibrillation was active but was treated with medication and you
did well. You are being discharged back to your skilled nursing
facility. You need to follow-up with your primary care doctor as
well as your specialists before you move to [**Doctor First Name 5256**].
The following changes were made to your medications:
1. CHANGE Metoprolol Tartrate to 25mg by mouth every 8 hours
2. STOP digoxin
3. STOP lasix 20mg daily
4. START Diltiazem Extended Release 240mg daily
Followup Instructions:
Please call Dr.[**Name (NI) 39312**] clinic and make an appointment with her
within 2-4 weeks.
The following appointments have been made for you.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2140-7-18**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2140-7-20**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2141-4-24**] at 3:00 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2141-5-2**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Test for consideration post-discharge: Methylmalonic Acid
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
[
"428.0",
"250.00",
"280.9",
"785.0",
"428.33",
"790.5",
"427.31",
"295.90",
"692.9",
"345.90",
"401.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12364, 12437
|
7181, 7426
|
281, 287
|
12612, 12612
|
3184, 3184
|
13626, 15130
|
1918, 1991
|
11571, 12341
|
4658, 4720
|
12458, 12591
|
11297, 11548
|
12795, 13603
|
2006, 3165
|
7097, 7158
|
10533, 11271
|
1160, 1592
|
229, 243
|
4752, 7083
|
7441, 10011
|
315, 1141
|
3198, 4618
|
12627, 12771
|
10027, 10512
|
1614, 1770
|
1786, 1902
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,663
| 134,734
|
31412
|
Discharge summary
|
report
|
Admission Date: [**2172-6-13**] Discharge Date: [**2172-6-20**]
Date of Birth: [**2112-1-8**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
This 60 year old male was in a MVC where his car was struck from
behind. He was transferred to [**Hospital1 18**] complaining of back pain and
loss of sensation below the waist.
Major Surgical or Invasive Procedure:
T8-T10 decompression with T3-T12 posterior instrumentation and
fusion with iliac crest bone graft, right chest tube, [**Location (un) **]
inferior vena cava filter
History of Present Illness:
60 year old male was driver in MVC, was hit from behind.
Prolonged extrication, no loss of conciousness, no sensation
from hips down.
Past Medical History:
L4-L5 laminectomy, appendectomy, DM, HTN, hypercholesterolemia
Social History:
Has fiancee and brother is primary contact
Family History:
Non-contributory
Physical Exam:
Vitals: HR 79, BP 120/70, RR 18, Sat 97% on RA
HEENT: PERRL 3-2 mm bilaterally, collar in place, no facial
trauma
Pulm: CTA no trachael deviation, chest stable
Abd: NT, ND, pelvis stable, penile prosthesis
Neuro: moving upper extremeties, no movement of lower
extremeties, no sensation below umbilicus.
Rectal: moderate tone, guiac negative
Ext: no deformities, pulses throughout
Pertinent Results:
[**2172-6-13**] 02:05AM WBC-11.9* RBC-3.61* HGB-11.3* HCT-31.2*
MCV-86 MCH-31.2 MCHC-36.1* RDW-14.7
[**2172-6-13**] 02:11AM GLUCOSE-225* LACTATE-3.2* NA+-140 K+-3.7
CL--104 TCO2-27
[**2172-6-13**] 02:05AM UREA N-32* CREAT-1.4*
[**2172-6-13**] 06:14AM PT-12.4 PTT-24.8 INR(PT)-1.1
[**2172-6-13**] 02:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT HEAD W/O CONTRAST [**2172-6-13**] 2:02 AM
IMPRESSION:
1. No hemorrhage, mass effect or edema.
CT C-SPINE W/O CONTRAST [**2172-6-13**] 2:03 AM
IMPRESSION: No fracture or subluxation. Extensive degenerative
changes as described above.
CT ABDOMEN chest pelvis W/CONTRAST [**2172-6-13**] 2:03 AM
1. Moderate right-sided hemothorax.
2. T8 vertebral body fracture with severe narrowing of the
spinal canal.
3. Left tenth rib fracture, posteriorly. Right 4th rib deformity
likely represents a fracture.
4. L2, L3, and L4 left transverse process fracture.
5. Bilateral renal cysts some of them hyperdense. If clinically
indicated, ultrasound could be performed for further
characerization.
6. Nonobstructive small right renal stone.
7. Tiny scattered lung nodules in the range of [**1-5**] mm,
statistically most likely benign. If warranted 1 year follow-up
could be performed
Brief Hospital Course:
Mr. [**Known lastname **] was brought to the ER by [**Location (un) **] from the scene of
an MVC. On arrival he was resuscitated and noted to have no
sensation or motor function below the umbilicus. CT scans were
obtained of the head, c-spine, and torso which revealed a T8
vertebral body fracture/dislocation, a left tenth rib fracture,
right sided moderate hemothorax, and L2-L4 left transverse
process fractures. From the ER he was brought to the TSICU for
further care. A chest tube was placed on the right for the
hemothorax. He was taken to the OR on [**2172-6-14**] by the
orthopaedic spine surgery service for a T3-T12 fusion with iliac
bone grafting. Post operatively he was returned to the TSICU for
further care. His ICU stay was notable for a confusion likely
due to sedation and ICU psychosis. On [**6-17**] he was given a TLSO
brace for times when he is out of bed. His chest tube was
removed on [**6-17**] and a post pull chest x-ray showed no
pneumothorax. On [**2172-6-18**] he was taken back to the operating
room for placement of an inferior vena cava filter ([**Location (un) 260**]
Type) for pulmonary embolism prevention. After this procedure
he was transferred to the floor. On the floor he remained in
stable condition and his pain was well controlled on an oral
regimine. He was seen by both physical and occupational therapy
and social work for coping issues with his injury. On [**2172-6-20**]
he was discharged to a rehab facility for further care and
[**Date Range **] in stable condition. He was instructed to follow
up with the orthopaedic spine attending and in general surgery
trauma clinic.
Medications on Admission:
HCTZ, Norvasc, lipitor, metformin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on narcotic pain medications.
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day:
please resume home dose.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day:
please resume home dose.
7. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
please resume home dose.
8. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous twice
a day. Disp:*30 * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] and Islands
Discharge Diagnosis:
T8 vertebral fracture and spinal cord injury
Discharge Condition:
Stable
Discharge Instructions:
You had a fracture of your thoracic spine with spinal cord
injury.
Please report to your [**Hospital 62799**] [**Name10 (NameIs) **] facility, or the
nearest ER any increased pain uncontrollable on your pain
medications, shortness of breath, change in sensation or
movement, or any other symptom that is concerning to you. The
TLSO needs to be worn when out of bed. Please resume all home
medications.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1352**] in 1 week. Call [**Telephone/Fax (1) 1228**] for an
appointment.
Follow up in trauma clinic in [**1-4**] weeks. Call [**Telephone/Fax (1) 6429**] for
an appointment.
|
[
"278.01",
"860.2",
"401.9",
"250.00",
"293.9",
"E812.0",
"733.99",
"272.0",
"807.01",
"805.4",
"806.26"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"34.09",
"38.7",
"81.05",
"03.09",
"03.53",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
5195, 5282
|
2672, 4310
|
457, 623
|
5371, 5380
|
1381, 2649
|
5830, 6049
|
948, 966
|
4394, 5172
|
5303, 5350
|
4336, 4371
|
5404, 5807
|
981, 1362
|
240, 419
|
651, 786
|
808, 872
|
888, 932
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,424
| 146,533
|
239
|
Discharge summary
|
report
|
Admission Date: [**2188-5-9**] Discharge Date: [**2188-5-14**]
Date of Birth: [**2121-7-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Direct transfer from [**Hospital3 417**] Hospital for STEMI, cath and
now stablized hct and transfered out of CCU
Major Surgical or Invasive Procedure:
Cardiac catheterization
Blood transfusion
History of Present Illness:
Mr. [**Known lastname 2391**] is a 66-year-old male with hx HIV on HAART,
lymphoma, LUL lung adenocarcinoma s/p resection, hx CAD s/p PCI
with DES in [**5-17**] to proximal circumflex artery. In [**11-16**] he had
elective cath showing 90% restenosis at proximal edge of
previously placed stent, treated with overlapping Cyper stent.
Mid-RCA was 80% occluded and treated with DES as well. In [**2-18**]
pt had a left femoral artery to dorsalis pedis artery bypass
graft with an in situ greater saphenous vein graft. His plavix
was discontinued at that time. He was recently admitted on
[**2188-4-30**] w/ STEMI over III, F, taken to cath, where he had a DES
placed in the LCX for the vessel being occluded by a thrombus
proximally. Of note, at cath [**4-30**], he had a totally occluded
right external iliac artery. The pt was discharged home [**2188-5-3**].
Since that time, per the pt, he felt at baseline, with the
exception of intermittent left leg pain (s/p vascular surgery,
bypass) that would occasionally awaken him at night. He stated
he was up this morning at 4am b/c of this left leg pain, when he
developed a "cold rough" feeling in his esophagus similar to his
pain that he had with all of his prior MIs. He states it was a
[**5-24**] in severity. He took 1 nitro, and it resolved. He reports
he did not take his plavix yesterday and today. He noted
intermittent right sided chest pain as well last night, which
felt like "gas pain", + SOB, no diaphoresis, + nausea, no
vomiting. He states the feeling returned and then persisted,
took a 2nd nitro but it only decreased the pain to a [**2192-2-16**]. He
called 911.
.
In the ambulance, the pt's pain decr to [**1-25**] and he received
ASA, another nitro en route. His pain, however, only resolved
completely on nitro gtt at OSH where he was given ASA, IV
integrillin, IV heparin, started on nitro drip with full
resolution of pain, transferred to [**Hospital1 18**] for emergent cath. His
initial BP at OSH 130/75, down to 93/63 after nitro. Outside
labs with CK 60, other ezymes pending at time of transfer, BNP
17.
.
At [**Hospital1 18**], he was given plavix 600mg load prior to cath. In the
cath lab: LCX was totally occluded within proximal stents. A
wire was passed and flow was reestablished (likely development
of blood clots). 1 additional bare metal stent (no DES since he
had questionable compliance w/ plavix) placed distal to last
stent. Some non-occluding stenosis in the distal branches. Cath
was performed via radial artery (per lower ext arterial
disease). His right groin (femoral vein) developed a hematoma.
His left groin was not accessed given his c/o left leg pain post
surgery 2 months ago. He was subsequently transferred to the
floor. He then had BP drop to 90s/40s-50s and a pm HCT was found
to be 27.7 (6 point drop from pre-cath HCT). He is being
transferred to the CCU for unstable HCT and hematoma with labile
BP s/p catheterization today.
.
Brief CCU event: CT scan of abd neg for RP bleed. Neg groin for
psuedoaneurysm. Stable hct. Received total of 3 units of blood.
2 unit pRBC for hct 27 ([**5-9**]) -> 31.6 ([**5-10**] Am)-> 29.5-> 28.2
([**5-10**] 1pm)->32.3 ([**5-10**] 12pm)-> 31.8 ([**5-11**] 4am)
Past Medical History:
S/p left VATS and wedge biopsy of the left upper
lobe [**4-18**] for adenocarcinoma.
Non-hodgkins lung lymphoma
HIV
CAD
Bladder Ca, s/p resection
S/p bowel resection
Claudication
Social History:
Pt lives alone, formed smoker 1ppd has cut down significantly
since lung operations, but smoked for 40 years 1ppd, still
smokes a cigarette ocasionally, no EtOH. No IVDA.
Family History:
N/C
Physical Exam:
T: 98.2 BP: 111/67 P: 100 RR: 18 O2sat: 100% 2L NC
Gen: WNWD man in NAD. Breathing comfortably on RA lying flat.
Speaking in full sentences. Pleasant and cooperative.
HEENT: PERRL, no scleral icterus. MM dry. OP clear
Neck: JVD to mid neck lying flat
Resp: CTAB anteriorly (lying flat)
CV: RRR S1 and S2 audible w/o m/r/g
Abd: Soft, NT, ND, No hepatomegaly. no masses.
Extr: 1+ DP pulses bilaterally. No edema.
Groin: R sided hematoma well circumscribed with some ecchymosis,
site c/d/i
R Wrist: Site of cath with pressure band over insertion site and
some leaking of blood on gauze. Good cap refill on right hand.
Warm.
Pertinent Results:
CATH [**2188-5-9**]
LMCA: nl
LAD: 50% mid disease
LCX: Total occlusion within proximal stents
RCA: not injected
Abdominal aortography: mild left common femoral disease. femoral
graft patent with no signficant disease seen in graft or native
vessels to above the knee.
Intervention: Successful treatment of IPMI with BMS. Using right
radial approach, LCA engaged with AL2 guide. Stent occlusion
crossed with wire and bballoon with restoration of flow showing
progressed diesase to 80% just distal to stents. PTCA with
suboptimal result so 2.5X18 minivision stent placed into larger
upper pole which had multiple moderate lesions. prior stents
redilated with 3.0 balloon. No residual, normal flow in all
branches.
.
92
7.0 \ 9.4 / 325
-----
27.7
.
136 103 23 / 199 AGap=16
-------------
4.3 21 0.8 \
CK: 60
91
5.7 \ 11.4 / 338
--------
33.6
N:63.7 L:30.4 M:3.6 E:1.8 Bas:0.5
PT: 18.1 PTT: 150 INR: 1.7
Brief Hospital Course:
66 year old male with HIV, CAD, recently admitted for STEMI
found to have 100% LCX lesion and stented w/ DES, who presented
with STEMI to OSH, and found to have total occlusion of proximal
LCX stent, now s/p bare metal stent placement. Pt was then found
to have a hematocrit drop and hypotension necessitating
transfuse to CCU, now stabilized.
.
Blood loss: Pt was s/p catheterization with R wrist for arterial
access and R groin for venous access. CT scan was performed, and
ruled out RP bleed and U/S ruled out AV fistula and
pseudoaneurysm. He received a total of 3 units PRBCs in CCU, and
his hct has been stable. Pt likely had blood loss during cath,
and in groin hematoma. After being transferred back to the floor
from the CCU, his Hct was stable. Low-dose metoprolol was
started the night before discharge, and he tolerated this with
SBP in the 100s to 110s.
.
Cardiac. Patient was admitted with a repeat STEMI secondary to
instent thrombosis. He had placement of a bare metal stent, and
was started on higher doses of plavix at 150 mg daily. He was
continued on aspirin and a high dose statin as well. His
antihypertensives were held due to hypotension, and restarted
prior to discharge.
He was not diuresed further, despite an elevated PCWP of 28 at
catheterization, due to hypotension. He remained in normal sinus
rhythm.
.
Hyperbilirubinemia: the pt was noted to have mild jaundice and
scleral icterus on [**5-12**]. LFTs were checked and his total
bilirubin was 6.6, direct bili was 0.2. His other LFTs were
normal. His hemolysis labs were normal. The hyperbilirubinemia
was felt to be most likely due to either reabsorption of the
large hematoma or a side effect from one of his HIV meds, most
likely atazanavir. His bilirubin continued to climb but he was
otherwise asymptomatic. A RUQ U/S showed small gallstones but no
evidence of cholecystitis or obstruction. His statin and HIV
meds were stopped on discharge.
.
HIV: Patient was continued on his outpatient HIV medications. He
was continued on prophylactic bactrim. He was continued on his
antidepressants.
.
Dispo. Patient was discharged to home with a stable hematocrit.
Medications on Admission:
Aspirin 325 mg Tablet daily
Plavix 75 mg daily
Toprol XL 25 mg daily
Atorvastatin 80 mg daily
Trimethoprim-Sulfamethoxazole 80-400 mg daily
Fluoxetine 20 mg daily
Oxycodone 5-10 mg q6h prn
Viread 300 mg daily
Trizivir 300-150-300 mg [**Hospital1 **]
REYATAZ 300 mg daily
Norvir 100 mg daily
Gabapentin 300 mg Q12H
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. STEMI with in stent thrombosis
2. Hypotension
3. Groin hematoma
4. Acute blood loss anemia
5. Medication noncompliance
6. hyperbilirubinemia from hematoma reabsorption vs. HAART
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted because you had another heart attack, from a
clot in the stent in your blood vessel. This happens when you do
not take your medications regularly.
It is very important to take all your medications. Your dose of
Plavix was increased to 150 mg daily.
If you develop chest pain, nausea, vomiting, throat tightness,
clamminess or shortness of breath, call your PCP or go to the
emergency room.
If the bruise in your groin gets larger or more tender, or if
you become lightheaded on standing, you should call your doctor
and let him know.
Do not take your anti-retroviral medications until directed by
your PCP. [**Name10 (NameIs) **] medications you should not be taking are abacavir,
ritonavir, atazanavir, tenofovir, and Combivir. Keep taking your
Bactrim.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2392**] on Thursday [**2188-5-13**] at
10:20am; at that time you will have your blood drawn to check
your liver function tests. You may call his office at
[**Telephone/Fax (1) 2393**] with any questions.
Please follow up with Dr. [**Last Name (STitle) **] on [**2188-5-28**] at 10:30am. He will
adjust your blood pressure medications as necessary. You may
call his office at [**Telephone/Fax (1) 2394**] with any questions.
Follow up with Dr. [**Last Name (STitle) **] (vascular surgery) as scheduled on
[**2188-5-28**] at 2:30pm. You may call her office at [**Telephone/Fax (1) 2395**]
with any questions.
Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**]
Date/Time:[**2188-8-14**] 2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-8-14**] 1:00
Completed by:[**2188-5-16**]
|
[
"V10.11",
"410.31",
"V08",
"V10.51",
"440.21",
"414.01",
"428.0",
"785.51",
"782.4",
"V15.81",
"285.1",
"E879.0",
"202.80",
"996.72",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.52",
"99.20",
"37.23",
"00.45",
"88.56",
"00.66",
"99.04",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
8877, 8932
|
5728, 7871
|
428, 471
|
9157, 9166
|
4770, 5705
|
10087, 11014
|
4108, 4113
|
8236, 8854
|
8953, 9136
|
7897, 8213
|
9190, 10064
|
4128, 4751
|
275, 390
|
499, 3702
|
3724, 3904
|
3920, 4092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,125
| 101,573
|
829
|
Discharge summary
|
report
|
Admission Date: [**2140-3-15**] Discharge Date: [**2140-3-18**]
Date of Birth: [**2082-7-23**] Sex: M
Service: CCU
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 57 year old male with
hypercholesterolemia and known coronary artery disease status
post coronary artery bypass graft in [**2130**] with quiescent
disease since then, not requiring sublingual Nitroglycerin;
chest pain either. He presented with one day of chest pain
that began this morning while putting up wallpaper. The
patient noted ten out of ten chest pain, substernal chest
pain with no radiation with associated diaphoresis but no
shortness of breath, lightheadedness, nausea or vomiting.
The patient took three sublingual Nitroglycerin that had
already expired without effect, called Emergency Medical
Services where he received Nitroglycerin spray times two
without effect as well.
At the outside hospital, he was noted to have ST elevations
in leads II, III and F plus reciprocal ST depressions in
leads V1 through V2. The patient received ReoPro and
Retavase at full dose as well as Nitroglycerin and aspirin at
the outside hospital. There was no change in his chest pain,
therefore, the patient was transferred to [**Hospital1 346**].
In the Catheterization Laboratory here, he was noted to have
a pulmonary arterial pressure of 38/21 with a pulmonary
arterial mean of 26. A PCWP of 19. All grafts were found to
be open. The right coronary artery was noted to have a 30%
proximal stenosis and a mid-99% stenosis which was stented.
After catheterization, the patient was made chest pain free.
Note: The patient may have become transiently hypotensive at
the outside hospital after Nitroglycerin.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Coronary artery disease status post myocardial infarction
in [**2128**] and [**2130**]; coronary artery bypass graft in [**2130**] where
he underwent three grafts including a left internal mammary
artery to the left anterior descending, saphenous vein graft
to obtuse marginal 1 and saphenous vein graft to D1.
MEDICATIONS:
1. Accupril 10 q. day.
2. Aspirin 325 mg q. day.
3. Lipitor 10 q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Distant tobacco history. Currently no
alcohol. He denies drug use. He is married with four
children and he lives in [**Hospital1 **].
PHYSICAL EXAMINATION: Temperature 97.7 F.; blood pressure
113/75; heart rate of 76; O2 saturation of 100%. In general,
alert and oriented times three in no acute distress. HEENT:
Normocephalic, atraumatic. Pupils are equal, round and
reactive to light. Extraocular motions are intact.
Oropharynx is clear. Pulmonary clear to auscultation
bilaterally, anteriorly. No wheezes. Cardiovascular:
Regular rate and rhythm; no murmurs, rubs or gallops.
Abdomen nontender, nondistended, normoactive bowel sounds.
No hepatosplenomegaly. Extremities with no cyanosis,
clubbing or edema.
LABORATORY: White blood cell count of 9.4, hematocrit 35.2,
platelets 174. INR of 1.4. Sodium of 141, potassium of 4.4,
chloride 111, bicarbonate of 24, BUN of 11, creatinine of
0.7, glucose of 107.
CK 1345. Arterial blood gases 7.31, 46, 120.
EKG post catheterization revealed elevations in T and F, poor
R wave progression, and T wave inversions in V5 through V6,
II, III and F.
ASSESSMENT: This is a 57 year old male with coronary artery
disease, now with new right coronary artery disease,
plus/minus inferior myocardial infarction.
HOSPITAL COURSE:
1. CARDIAC: Status post right coronary artery intervention.
The patient is now made chest pain free and was
hemodynamically stable. He was continued on aspirin and
Plavix and ReoPro for twelve hours. A beta blocker was
started at low dose and his ACE inhibitor was continued.
Fasting lipids were checked and were found to be a total
cholesterol of 114, HDL of 41, LDL of 58 and triglycerides of
73. He was continued on his Lipitor. He was continued on
Telemetry and his CKs were cycled and were found to be
trending down.
Nitroglycerin and morphine was avoided given possible right
ventricular involvement. He underwent an echocardiogram the
next morning which revealed an ejection fraction of 35 to
40%, a normal left atrium and left ventricle and right
ventricle. Moderate left ventricular systolic dysfunction,
mild mitral regurgitation; akinesis in the basal inferior,
mid to distal anterior and apical areas.
He also underwent an electrophysiology consultation in order
to do a single average EKG to assess his sudden risk for
death and this was positive; therefore, as an outpatient he
will complete this work-up by undergoing a T wave alternans
test as well as a Holter Monitor.
The patient was transferred to the Floor on [**3-17**] and
was doing well. His beta blocker was titrated up, his ACE
inhibitor was continued, and he was doing well and was stable
for admission on [**3-18**].
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE INSTRUCTIONS:
1. He will be following up with Dr. [**Last Name (STitle) **].
2. He will be returning for a T wave alternans test and a
likely electrophysiology study.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Toprol XL 25 q. day.
2. Lipitor 10 q. day.
3. Quinapril 10 q. day.
4. Plavix 75 q. day for a total of nine months.
5. Aspirin 325 q. day.
6. Multivitamin.
DISCHARGE DIAGNOSES:
1. Inferior myocardial infarction status post stent to the
right coronary artery.
2. Positive single average Electrophysiology test.
3. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2140-6-17**] 16:01
T: [**2140-6-17**] 17:23
JOB#: [**Job Number 5814**]
|
[
"410.71",
"401.9",
"285.9",
"272.0",
"414.01",
"V45.81",
"786.3",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.78",
"36.06",
"88.56",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
5410, 5834
|
5224, 5389
|
3524, 4988
|
5012, 5168
|
2398, 3507
|
155, 168
|
198, 1727
|
1749, 2218
|
2236, 2374
|
5194, 5201
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,753
| 149,781
|
2562
|
Discharge summary
|
report
|
Admission Date: [**2169-4-5**] Discharge Date: [**2169-4-12**]
Date of Birth: [**2096-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Pneumovax 23
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
72 year old Female with history of CAD, CVA, and siezure
disorder presents to ED after witnessed seizure activity.
Daughter said pt slumped in chair, was nonresponsive, had right
sided facial droop, and was diaphoretic. She was post-ictal
afterwards. Pt has history of had seizure disorder secondary to
stroke in [**2164**]. Prior to neuro event patient c/o crampy lower
abd pain, after eating lunch. EMS called, initially vitals bp
90/40s, diaphoretic, postictal. C/o crampy abd pain, having to
go to bathroom in ambulance. In [**Name (NI) **] pt had 3 bed pans of BRBPR.
BP 160s-170s, pulse 50s (beta blocked), mentating well. No CP,
no sob. Complaining of intermittent crampy lower abdominal pain.
Received 300 NS, dilantin 500 mg IV, protonix 40 mg IV, and was
ordered for a head CT (neg). She had 750 cc NG lavage which was
all negative. No n/v/d, no melena prior to this. She was
admitted to the MICU, where she received several liters NS,
changed to dilantin, underwent colonoscopy.
Past Medical History:
seizures [**12-21**] hemorrhagic stroke, CAD s/p CABG, alzheimer's,
subtotal gastrectomy [**2158**] secondary to NHL (causing b12 def),
CVA, TIA, HTN, hyperlipidemia, B12 deficiency, hypothyroidism
Social History:
daughter is HCP #[**Telephone/Fax (1) 12955**], remote smoking, no etoh, no
drugs, lives on her own, family is looking for [**Hospital1 1501**].
Physical Exam:
Temp 99.8/100.1 at 4pm BP 125/65 (100's-130's/40s-60s) HR 85
(60s-80s) RR 17 (14-26) I/O: 1800/1530 (los +5499)
GEN: NAD pleasantly demented female
HEENT: NCAT, PERRL, EOMI, MMM, no nystagmus
CV: RRR S1 S2 II/VI SM at LSB no r/g
RESP: CTABL no r/r/w
ABD: soft, +NABS, LLQ tenderness to mild palp, no r/g, ND
EXT: no cyanosis clubbing or edema
NEURO: CN 2-12, AAOx3, strength 5/5 b/l UE and LE and sensation
to LT grossly intact, 2+ DTR biceps (not able to elicit at
knees)
Skin: warm, dry
Pertinent Results:
[**2169-4-5**] 03:25PM BLOOD WBC-8.0# RBC-4.09* Hgb-13.3 Hct-39.2
MCV-96 MCH-32.6* MCHC-34.0 RDW-12.8 Plt Ct-169
[**2169-4-5**] 03:25PM BLOOD Neuts-76.0* Lymphs-17.0* Monos-5.6
Eos-1.2 Baso-0.3
[**2169-4-5**] 03:25PM BLOOD PT-12.7 PTT-24.8 INR(PT)-1.1
[**2169-4-5**] 03:25PM BLOOD Glucose-142* UreaN-21* Creat-1.2* Na-138
K-3.7 Cl-104 HCO3-23 AnGap-15
[**2169-4-5**] 03:25PM BLOOD ALT-16 AST-23 CK(CPK)-128 AlkPhos-69
Amylase-197* TotBili-0.3
[**2169-4-5**] 03:25PM BLOOD Lipase-54
[**2169-4-5**] 03:25PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.3
[**2169-4-7**] 06:35AM BLOOD Triglyc-39 HDL-54 CHOL/HD-1.9 LDLcalc-38
[**2169-4-5**] 03:25PM BLOOD Carbamz-5.7
[**2169-4-6**] 04:45AM BLOOD Lactate-2.3*
.
micro: negative blood and stool culture
.
tagged RBC scan [**2169-4-5**]: Focus of tracer accumulation in the
pelvis does not change over 90
minutes of imaging and is most likely located in the rectum.
This finding can be seen with hemorrhoids. No site of active
hemorrhage is seen in the small or large bowel. If clinically
indicated, additional imaging can be performed with a 12 hour
delay.
.
CTH [**2169-4-5**]: : No evidence of acute intracranial hemorrhage.
Unchanged right frontal encephalomalacia and evidence of chronic
microvascular ischemia.
.
[**2169-4-5**] EKG: Sinus bradycardia at 53 bpm with first degree A-V
block (PR 220) Left atrial abnormality, Long QTc interval 463ms,
Extensive ST-T changes are nonspecific Since previous tracing of
[**2165-10-29**], no significant change
.
colonoscopy [**4-6**]: Erythema, friability and ulceration in the
sigmoid colon compatible with likely ischemic colitis. Erythema
in the rectum. Otherwise normal colonoscopy to sigmoid colon
.
CTA ABD W&W/O C & RECONS [**2169-4-7**]:
1) Diffuse mild-to-moderate bowel wall edema, particularly in
the rectosigmoid region, with suggestion of inflammation in the
sigmoid, but without discrete fluid collection. This is
consistent with the clinical diagnosis of ischemic colitis,
particularly in the rectosigmoid region. No evidence of
obstruction or perforation.
2) Patent major branches, with vascular calcifications. Patency
of superior mesenteric vein and portal vein also demonstrated.
No intraluminal filling defects identified, however, ischemia is
not definitively excluded on the basis of this study.
3) Cyst in right kidneys; low-density lesions in left kidney and
liver, too small to fully characterize, but also probably
representing cysts.
4) Bilateral small pleural effusions.
Brief Hospital Course:
A/P: 72 y/o F w/dementia, CAD, CVA, p/w seizures and BRBPR:
1. GI bleed: She was followed by GI and surgery and had a tagged
RBC scan which was consistent with a rectosigmoid bleed. She
then underwent colonoscopy which showed ischemic colitis in that
area while in the MICU. She was placed on prophylactic GI
antimicrobial coverage while in the ICU. She did not require a
blood transfusion and as she was stable, was transferred after
colonoscopy to the floor. On the floor, CT angiogram of the
abdomen was done to evaluate her bowel wall and vasculature was
done as she was still having pain. This was again consistent
with rectosigmoid ischemic colitis with significant bowel wall
edema. Her abdominal pain slowly resolved. Her hematocrit did
trend down slowly from 37-39 on the day of admission to 32 at
discharge but she did not meet our criteria for blood
transfusion. She has a baseline b12 deficiency for which she
takes supplements, however, this anemia was thought to be from a
slow GI ooze. Her reticulocyte count was at 1.6. Her diet was
slowly advanced, and she tolerated this without difficulty. We
placed her on a low dose aspirin instead of her prior full
strength, weighing the risk of bleeding with the opposing risk
of her significant underlying ischemic arterial disease. Her
antibiotics were discontinued. She was started on protonix IV
and discharged on po protonix for GI prophylaxis. She will need
a repeat colonsocopy or flexible sigmoidoscopy in [**4-26**] weeks to
assess for complete resolution.
.
2. Seizures: Head CT ruled out bleed and she had no residual
neurologic defects. Given her history, and as she had a
witnessed seizure she was loaded with IV dilantin 500 IV x1,
then placed on standing dilantin IV while she was NPO. Once she
was eating, tegretol was restarted and once the tegretol level
was at goal ([**3-8**]), the dilantin was discontinued. Her nightly
tegretol dose was increased.
3. ARF: Her creatinine peaked at 1.2 at admission. This
resolved to baseline ~0.8, with hydration and was thought to be
secondary to prerenal azotemia.
.
4. CAD: her ASA was initially held, and her beta blocker was
initially dosed at 1/2 her home dose in the MICU. The beta
blocker was eventually resumed at her full dose but her ASA was
restarted at 81mg instead on the floor, as discussed above. We
continued her lisinopril and resumed her statin at transfer to
the floor.
.
5. PPX: maintained on protonix IV and then switched to po,
pneumoboots
.
6. Adverse pneumococcal vaccine reaction: After receiving the
pneumococcal vaccine, per hospital protocol for all patients in
her age group who have not been previously immunized, the
patient developed erythema, induration, and pain at the
injection site in her Right deltoid consistent with an adverse
vaccine reaction. Prior to receiving this vaccination, the
patient's daughter and HCP had specifically been questioned
about her mother's vaccination history and she denied that her
mother had received the pneumoccocal vaccine in the past. The
patient received standing tylenol, and prn ibuprofen, and ice
packs for pain with improvement. The adverse reaction was duly
reported to appropriate hospital and federal authorities.
.
7. Hypothyroidism: we continued her home dose of synthroid.
.
8. Alzheimers: she was mostly pleasantly demented, but
sundowned with agitation and wandering requiring frequent
redirection. Her living situation was discussed with her
children, and per her daughter and HCP, her children will
personally provide 24 hour monitoring for her at the patient's
home, with eventual plans to find a [**Hospital1 1501**]. They deffered our
offer to help provide them with this service at discharge. She
was continued on exelon once taking po's.
.
9. Glaucoma: she was continued on her home medications
.
10. Code: full
.
11.Communication:
Daughter [**First Name8 (NamePattern2) 501**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 12956**] (H) [**Telephone/Fax (1) 12957**] (c)
[**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) 12958**] Cell [**Telephone/Fax (1) 12959**] (cell) Son
[**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 12960**] cell daughter [**Telephone/Fax (1) 12961**] (w)
Medications on Admission:
tegretol 200", lisinopril 20', b12 1000', toprol XL 50', EC ASA
325', synthroid 25', Exelon 1.5", lipitor 40', traratan 1gtt ou,
azopt 1gtt tid, mvi, Calcium "
*
Meds on transfer to floor:
Levofloxacin 500 mg IV Q24H ischemic colitis
1000 ml D5 1/2NS Continuous at 125 ml/hr for [**2163**] ml
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4-6H:PRN pain
Azopt *NF* 1 % OU tid
Metoprolol 12.5 mg PO BID
Metronidazole 500 mg IV Q8H ischemic colitis
Pantoprazole 40 mg IV Q24H
Exelon *NF* 1.5 mg Oral [**Hospital1 **]
Phenytoin 150 mg IV Q8H
Levothyroxine Sodium 12.5 mcg IV
Discharge Medications:
1. Brinzolamide 1 % Drops, Suspension Sig: One (1) gtt
Ophthalmic tid (): OU.
2. Rivastigmine Tartrate 1.5 mg Capsule Sig: One (1) Capsule PO
bid ().
3. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. 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*
8. 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*
9. Tegretol 200 mg Tablet Sig: 1.5 Tablets PO at bedtime: 1 and
1/2 tablets every evening.
Disp:*60 Tablet(s)* Refills:*0*
10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain for 2 days: as needed for R arm pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
ischemic colitis
lower gastrointestinal bleed
Blood loss anemia
seizure
adverse reaction to pneumovax
Coronary artery disease, s/p CABG
hypothyroidism
Discharge Condition:
stable and improved with improved abdominal tenderness. Stable
hemtocrit for nearly 1 week, tolerating regular diet.
Discharge Instructions:
Please seek immediate medical attention if you experience
further episodes of blood in your stool, or have worsening
abdominal pain, or if you experience fever, shaking chills,
chest pain, shortness of breath, or other symptoms concerning to
you.
It is very important that you follow up with gastroenterology
(see below).
Continue to take your medications as directed. We recommend
that you increase you continue taking your usual 200mg Tegretol
every morning (1 tablet), but increase your Tegretol dose
slightly in the evening --you should now take 300mg (1 and [**11-20**]
tabs). Your aspirin dose has been decreased to 81mg/day (a baby
aspirin). [**Name2 (NI) **] have also been started on an medication called
protonix for reducing stomach acid (reflux).
Continue to apply ice packs to your right arm to reduce the
inflammation from the vaccine, and take tylenol as needed for
pain. The redness and pain should resolve over the next [**11-20**]
days. Please phone your PCP if the redness and pain in the
right arm has not resolved by Friday.
PLease do not drive or use the stove.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2169-4-27**] 9:30
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D., [**2169-5-1**]
12:30 in the [**Hospital Unit Name 12962**] Suite, which is
located at [**Location (un) 12963**]. Please
Phone:[**Telephone/Fax (1) 1983**] with questions about your appointment.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] within the next [**11-20**]
weeks. Call [**Telephone/Fax (1) 1713**] to make an appointment.
|
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"285.1",
"E879.8",
"557.9",
"294.10",
"780.6",
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
10773, 10822
|
4739, 8980
|
290, 303
|
11017, 11136
|
2235, 4716
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12276, 12991
|
9606, 10750
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10843, 10996
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9006, 9583
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11160, 12253
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1721, 2216
|
247, 252
|
331, 1323
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1345, 1544
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1560, 1706
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,031
| 127,931
|
1974+55338
|
Discharge summary
|
report+addendum
|
Admission Date: [**2148-6-13**] Discharge Date: [**2148-6-25**]
Date of Birth: [**2092-11-2**] Sex: M
Service: MEDICINE
Allergies:
Albumin Products / Lipitor / Mevacor / Ace Inhibitors /
Amiodarone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath with progression over the past 3 days
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
55M with CHF who is admitted from Dr.[**Name (NI) 3536**] clinic for
diuresis.
Mr. [**Known lastname **] has h/o AFIB, CAD s/p MI [**2132**] and CABG + MVR [**2140**],
re-do MVR [**2142**] and most recently in [**4-/2148**] underwent tricuspid
valvuloplasty + MVR + [**Hospital1 **]-atrial MAZE. Subsequently had worsening
fluid retention and admitted to cardiac [**Doctor First Name **] [**5-10**] for
exacerbation of congestive heart failure. Echo revealed normal
working bioprosthetic mitral valve and no TR. Was gently IV
diuresed with lasix gtt and discharged home after 6 day hospital
course. Subsequently underwent successful cardioversion on [**6-4**]
for his AF followed by a plasmapheresis for his high LDL [**6-5**].
Over the past week has noticed worsening leg edema, increased
abdominal girth and decreased exertional tolerance - short of
breath at twenty paces. He increased lasix from 40 to 60 on [**6-3**]
then 60 to 80mg [**Hospital1 **] 4 days ago without improvement. He is
currently 217lb and says his dry weight is 205.
This morning felt especially weak and malaised, had trouble
sleeping at night. Saw Dr. [**First Name (STitle) 437**] in clinic who referred him to
the CCU for further treatment.
He denies any recent symptom of febrile/infectious illness.
Denies food indiscretion. He has been taking his medications w/o
fail. He denies recent chest pain.
He denies orthopnea, PND. Reports nocturia X1.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
denies recent fevers, chills or rigors. denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence syncope or
presyncope. See HPI otherwise.
Past Medical History:
- Mitral valve regurgitation s/p Mitral valve replacement in
[**2142**], [**4-/2148**]
- Tricuspid valve regurgitation s/p Tricuspid annuloplasty in
[**4-/2148**]
- Chronic Systolic Congestive Heart Failure
- Coronary Artery Disease, s/p MI in [**2132**], s/p s/p CABG (LIMA to
LAD, SVG to OM, SVG to PDA to PLV) [**2140**] ,RCA and LAD PCI's
- Paroxysmal/Persistent atrial fibrillation s/p five prior
cardioversions, ablation in [**2146**] and biatrial MAZE in [**4-/2148**]
- History of NSVT s/p AICD implant in [**2142**], VT ablations [**10/2146**]
- Moderate Pulmonary artery hypertension, AICD reimplant in
[**4-/2148**]
- Severe Hyperlipidemia(intolerant of statins, undergoes
plasmapheresis every two weeks at [**Location (un) 5450**] Kidney Center with
AV graft in the left arm [**2141**]
- Mild Anemia
- Obstructive sleep apnea (CPAP)
- Chronic Renal Insufficiency
- Carotid Disease
- Chronic renal insufficiency
Social History:
The patient is married and has two children 14 y/o girl, 17 y/o
boy. He is a substitute teacher in a local elementary school
and is currently not working. He was a salesman in the past. He
quit tobacco over 20 years ago and had prior 20 pack year
history, occasional beers but not for the past 2 months. .
Family History:
Father - healthy
Mother - atrial fibrillation + CAD.
4 brothers, 1 sister healthy.
Physical Exam:
ON ADMISSION:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Jugular veins are prominent to earlobe, JH reflux
positive.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: minimal [**Hospital1 **]-basilar crackles, no wheezes or rhonchi.
ABDOMEN: Distended but soft, NT. there is flank dullness and
shifting dulness. No HSM or tenderness. Abd aorta not enlarged
by palpation. No abdominal bruits.
EXTREMITIES: No femoral bruits. Edema + 4 to thighs, minimal
pitting edema on sacrum.
SKIN: stasis dermatitis on shins, no ulcers, AV fistula on his
left forearm
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
On discharge:
Dry weight 83kg, on room air, JVD to ~4cm above sternal notch
Lungs clear bilaterally
Ext with 1+ pitting edema
Pertinent Results:
ADMISSION LABS:
[**2148-6-13**] 03:27PM GLUCOSE-118* UREA N-35* CREAT-1.7*
SODIUM-130* POTASSIUM-9.8* CHLORIDE-95* TOTAL CO2-30 ANION
GAP-15
[**2148-6-13**] 03:27PM CK(CPK)-178
[**2148-6-13**] 03:27PM CK-MB-2 cTropnT-0.03* proBNP-[**Numeric Identifier 10864**]*
[**2148-6-13**] 03:27PM CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.2
[**2148-6-13**] 03:27PM WBC-4.3 RBC-2.84* HGB-9.0* HCT-27.3* MCV-96
MCH-31.6 MCHC-32.9 RDW-16.4*
[**2148-6-13**] 03:27PM PLT COUNT-181
[**2148-6-13**] 03:27PM PT-20.8* PTT-28.8 INR(PT)-1.9*
MICRO:
[**2148-6-16**] 9:31 pm URINE Source: CVS.
**FINAL REPORT [**2148-6-20**]**
URINE CULTURE (Final [**2148-6-20**]):
ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
STUDIES:
[**6-13**] EKG: Marked baseline artifact. Normal sinus rhythm
alternating with an atrial paced, ventricular sensed and atrial
paced, ventricular paced rhythm alternating with one hundred
percent ventricular paced rhythm. Frequent ventricular premature
beats and one ventricular couplet is noted. In the leads which
are comparable to tracing performed on [**2148-6-4**] there is no
diagnostic interval change. Several leads cannot be compared
because all the beats are paced.
[**6-14**] CXR: Current study demonstrates interval progression of
interstitial pulmonary edema currently moderate in severity
associated with small bilateral pleural effusions. Pacemaker
defibrillator leads are unchanged. Replaced valve, most likely
mitral appears to be in unchanged position. No pneumothorax is
seen.
[**6-15**] TTE: The left atrium is moderately dilated. The left
ventricular cavity is moderately dilated. LV systolic function
appears moderately-toseverely depressed (on milrinone), left
ventricular ejection fraction = 30%. However, the stroke volume
and cardiac index are preserved (due to the fact that the left
ventricle is dilated). The right ventricular free wall thickness
is normal. Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The gradients are higher than expected
for this type of prosthesis. The tricuspid valve leaflets are
mildly thickened. A tricuspid valve annuloplasty ring is
present. There is mild tricuspid stenosis due to the
annuloplasty ring. [Due to acoustic shadowing, the severity of
tricuspid regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
During transient total occlusion of the patient's arteriovenous
fistula there was no change in left ventricular stroke volume.
IMPRESSION: dilated left ventricle; reduced left ventricular
ejection fraction with preserved cardiac index; no change in
stroke volume during temporary occlusion of arteriovenous
fistula
[**6-20**] EKG: Artifact is present. Probable atrial pacing with
native ventricular conduction. Ventricular ectopy. There is a
non-specific intraventricular conduction delay. Non-specific
ST-T wave changes. Compared to the previous tracing of [**2148-6-13**]
ventricular pacing is no longer present.
[**6-21**] TTE: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= 15-20%). There is a mild resting
left ventricular outflow tract obstruction. The right
ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The gradients are higher than expected for this type
of prosthesis. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. A tricuspid valve
annuloplasty ring is present. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2148-6-15**],
left ventricular systolic function appears similar to slightly
more vigorous. QRS appears slightly narrower and wall motion
appears slightly more synchronous.
Brief Hospital Course:
55M with chronic systolic CHF EF 20%, h/o AFIB, CAD s/p MI [**2132**]
and CABG + MVR [**2140**], re-do MVR [**2142**]; tricuspid valvuloplasty +
MVR + [**Hospital1 **]-atrial MAZE [**4-/2148**], s/p successful cardioversion 8 days
prior to admission for AF who is admitted with worsening heart
failure evidenced by significant fluid retention. Diuresed 20L
with iv medication and discharged home in stable condition.
# Acute on Chronic Systolic Heart Failure: Patient was s/p
recent surgery with mitral + tricuspid annuloplasty with post
surgical course notable for worsening fluid retention. On
admission weight was up approximately 20L of fluid. Echo was
unchanged from prior. He was aggressively diuresed with iv
lasix, dopamine and milrinone which initially he did not respond
to. Renal was consulted for UF and he underwent one treatment
through is AV fistula with marked improvement in his reponse to
the iv medications. He was negative 19L for his length of stay.
He was transition to oral diuresis of metolazone and torsemide
and stopped his lasix as it had been ineffective as an
out-patient. Additionally, his heart rate was not well
controlled on his home cardevilol and heart rate control was
felt to be important to maintain adequate cardiac filling time.
His carvedilol was stopped and metoprolol succinate 200mg once a
day was started.
# Acute on Chronic Kidney Injury: Felt to be pre-renal in
setting of poor forward flow from acute CHF. Initally required
UF once with renal and then responded well to iv diuresis.
Creatinin returned to baseline.
# Hypokalemia: Required twice daily repletion in setting of
aggressive diuresis and discharged home on home oral potassium
# Coronary Artery Diease: Asymptomatic throughout hospital
stay. Continued on home medications except cardvedilol change
to metoprolol succinate as above. He receives [**Hospital1 **]-monthly
plasmapheresis for LDL as he has experienced significant side
effects from statin therapy.
# Atrial Fibrillation: Long history of AF s/p PVI and most
recently cardioversion prior to admission. Rate control was not
adequate on carvedilol and changed to metoprolol as above.
Patient was continued on digoxin and warfarin.
# Urinary Tract Infection: Postive UA and culture grew out
enterobacter. He was treated initially with ceftriaxone and
changed to po bactrim and completed a 7 day course on [**6-24**].
# Chronic Back pain: Treated with standing tylenol. No focal
deficits on neuro exam and was consistent with musculoskeletal
strain.
# OSA: Patient was offered CPAP at home settings, initially
continued but then refused.
# Chronic normocytic anemia: Multifactorial in setting of CKD
and acute and chronic illness. Remained at baseline.
# CODE: Full (discussed with patient)
Medications on Admission:
carvedilol 25 mg [**Hospital1 **]
digoxin 125 mcg daily
furosemide 80 mg Tablet
potassium chloride 10 mEq Tablet daily
spironolactone 25 mg daily
warfarin 3 mg Tablet daily
zolpidem 5-7.5mg daily
aspirin 81 mg Tablet daily
Discharge Medications:
1. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
6. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on 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 congestive heart failure.
20 L of water were removed with a lasix infusion.
The following medication changes were made:
***STOPPED: Lasix, please stop taking this medication.
***STOPPED: Carvedilol, you should stop taking this medication.
***STARTED: Torsemide 60mg once a day (a total of three 20mg
tablets). This is a medication that will help your body get rid
of the extra fluid in your body and it replaces the lasix.
***STARTED: Metolazone 2.5mg once a day. This medication will
also help your body get rid of fluid.
***STARTED: Metoprolol Succinate 200mg once a day, this replaces
the carvediolol.
No other medication changes were made, you should continue all
your other home medications as previously directed.
Please be sure to weigh yourself every morning, [**Name8 (MD) 138**] MD if your
weight goes up more than 3 lbs.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2148-7-15**] at 3:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2148-7-17**] at 4:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 1516**],[**Known firstname 389**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 1517**]
Admission Date: [**2148-6-13**] Discharge Date: [**2148-6-25**]
Date of Birth: [**2092-11-2**] Sex: M
Service: MEDICINE
Allergies:
Albumin Products / Lipitor / Mevacor / Ace Inhibitors /
Amiodarone
Attending:[**Last Name (NamePattern1) 915**]
Addendum:
Patient with systolic heart failure is not on ACE-I/[**Last Name (un) **] on
discharge due to acute kidney injury. He will follow up with
[**First Name8 (NamePattern2) 1518**] [**Last Name (NamePattern1) 1519**] in heart failure clinic on [**2148-7-2**] when she can
restart him on ACE-I/[**Last Name (un) **] if his creatinine is around his
baseline.
He was also called this afternoon to instruct him that he shoul
take 60 meq of potassium instead of 20 mg eq of potassium which
was written in his discharge worksheet.
Discharge Disposition:
Home
[**First Name4 (NamePattern1) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 916**]
Completed by:[**2148-6-25**]
|
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"276.8",
"285.21",
"585.9",
"427.31",
"428.0",
"414.00",
"V42.2",
"272.1",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16658, 16834
|
10068, 12856
|
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|
13900, 13900
|
4613, 4613
|
15014, 16635
|
3568, 3653
|
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13826, 13879
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|
14051, 14991
|
3668, 3668
|
4481, 4594
|
296, 355
|
435, 2280
|
4630, 10045
|
3682, 4467
|
13915, 14027
|
2302, 3226
|
3242, 3552
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,317
| 128,577
|
31806+57765
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-12-1**] Discharge Date: [**2174-12-21**]
Date of Birth: [**2098-6-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin Er / Lisinopril / Diovan
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic with heart murmur
Major Surgical or Invasive Procedure:
[**2174-12-5**] Aortic Valve Replacement (21mm CE pericardial),
Coronary Artery Bypass Graft x 2 (LIMA to LAD, Free RIMA to OM)
History of Present Illness:
73 y/o asymptomatic female who was incidently found to have
heart murmur on exam. Workup revealed severe aortic stenosis and
coronary artery disease.
Past Medical History:
Hypertension, Hyperlipidemia, CLL, s/p T&A, s/p Umbilical Hernia
repair, s/p Cholecystectomy, s/p total hip replacement, s/p
varicose vein ligation, s/y hysterectomy
Social History:
Quit smoking 44 years years ago (15yr smoking hx). Denies ETOH.
Family History:
Non-contributory
Physical Exam:
Skin: Unremarkable
HEENT: EOMI, PERRL NCAT
Neck: Supple, FROM -JVD, -bruit
Chest: CTAB -w/r/r
Heart: RRR 3/6 SEM
Abd: Soft NT/ND +BS
Ext: Warm, well-perfused, very tortuous varocosities b/l
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**12-5**] Echo: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post_Bypass: Preserved biventricular systolic function,. LVEF
55% Mild MR. [**First Name (Titles) 5544**] [**Last Name (Titles) **]. There is a bioprosthesis seen well
seated in the native aortic position and functioningn well.
Thoracic aortic contour is intact
[**12-1**] CNIS: Bilateral less than 40% carotid stenosis.
[**12-1**] LE vein mapping: No suitable lower extremity venous
conduit identified.
[**12-7**] CXR: Small left apical pneumothorax status post chest tube
removal. Interval improvement in volume status with decreased
pulmonary vascular congestion.
[**2174-12-1**] 07:45PM BLOOD WBC-15.3* RBC-4.03* Hgb-12.6 Hct-37.0
MCV-92 MCH-31.2 MCHC-34.0 RDW-14.4 Plt Ct-231
[**2174-12-8**] 07:55AM BLOOD WBC-17.5* RBC-3.59* Hgb-10.9* Hct-32.3*
MCV-90 MCH-30.3 MCHC-33.7 RDW-15.1 Plt Ct-127*
[**2174-12-3**] 04:45AM BLOOD PT-11.8 PTT-25.9 INR(PT)-1.0
[**2174-12-7**] 02:30AM BLOOD PT-13.2* PTT-33.1 INR(PT)-1.2*
[**2174-12-1**] 07:45PM BLOOD Glucose-185* UreaN-15 Creat-0.7 Na-143
K-3.9 Cl-104 HCO3-27 AnGap-16
[**2174-12-7**] 02:30AM BLOOD Glucose-142* UreaN-14 Creat-0.8 Na-136
K-4.3 Cl-107 HCO3-24 AnGap-9
Brief Hospital Course:
Ms. [**Name13 (STitle) **] was transferred from OSH after findings of severe
aortic stenosis and 80% left main coronary artery disease. Upon
admission at [**Hospital1 18**] she underwent pre-operative work-up which
also included carotid u/s and lower ext. vein mapping. She also
had mild left lower extremity cellulitis which was treated with
antibiotics. Following medical management for several days, she
was brought to the operating room on [**12-5**] where she underwent a
coronary artery bypass graft x 2 and aortic valve replacement.
Please see operative report for surgical details. Within 24
hours she was weaned from sedation, awoke neurologically intact
and extubated. By post-op day two pressors were weaned off.
Chest tubes were removed and she was transferred to the SDU for
further care later this day. On post-op day three her epicardial
pacing wires were removed. Beta blockers and diuretics were
started and she was gently diuresed towards her pre-op weight.
Physical therapy worked with patient during post-op period for
strength and mobility. She continued to make steady progress and
on post-op day 5 she was discharged home with vna.
Medications on Admission:
Norvasc 10mg qd, Lipitor 10mg qd, Triamterene, Aspirin 81mg qd,
Coreg CR 10mg qd, Fish Oil, Vit C, Aleve prn, Flexeril prn,
Niferx 150mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*1*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
10. Triamterene 50 mg Capsule Sig: One (1) Capsule PO once a
day.
11. Niferex 60 mg Capsule Sig: One (1) Capsule PO once a day.
12. Flexeril 10 mg Tablet Sig: One (1) Tablet PO prn.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH: Hypertension, Hyperlipidemia, CLL, s/p T&A, s/p Umbilical
Hernia repair, s/p Cholecystectomy, s/p total hip replacement,
s/p varicose vein ligation, s/y hysterectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 6254**] in [**3-19**] weeks
Dr. [**Last Name (STitle) 7640**] in [**2-15**] weeks
Completed by:[**2174-12-10**] Name: [**Known lastname **],[**Known firstname 5473**] J Unit No: [**Numeric Identifier 12293**]
Admission Date: [**2174-12-1**] Discharge Date: [**2174-12-21**]
Date of Birth: [**2098-6-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin Er / Lisinopril / Diovan
Attending:[**First Name3 (LF) 674**]
Addendum:
She was not discharged as planned.
Major Surgical or Invasive Procedure:
[**2174-12-5**] Aortic Valve Replacement (21mm CE pericardial),
Coronary Artery Bypass Graft x 2 (LIMA to LAD, Free RIMA to OM)
[**2174-12-16**] bedside sternal wound debridement
[**2174-12-19**] bedside sternal wound debridement
[**12-13**] PICC line placement
Physical Exam:
Sternal wound - open with adipose tissue and pink tissue
measures 13cm length, Top - Width 3cm depth 2cm - mid incision
width 5.5cm depth 3.5 cm - bottom width 1cm depth 1.5 cm
Pertinent Results:
RADIOLOGY Final Report
CHEST (PA & LAT) [**2174-12-18**] 9:35 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 5**] MEDICAL CONDITION:
76 year old woman s/p CABG/AVR
REASON FOR THIS EXAMINATION:
r/o inf, eff
PA AND LATERAL CHEST FROM [**12-18**]
HISTORY: Status post CABG and AVR.
IMPRESSION: PA and lateral chest compared to [**12-13**]:
Small bilateral pleural effusions increased, moderate bibasilar
atelectasis is stable. Upper lungs clear. Postoperative widening
cardiomediastinal silhouette unchanged. No pneumothorax. Tip of
the left PIC catheter passes as far as the low SVC.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12294**]
Approved: MON [**2174-12-19**] 4:48 AM
Cardiology Report ECG Study Date of [**2174-12-13**] 9:23:54 AM
Sinus rhythm. Non-specific ST-T wave changes. Left atrial
abnormality.
Non-diagnostic Q waves in lead III. Compared to previous tracing
of [**2174-12-12**]
atrial fibrillation has converted to sinus rhythm.
Read by: [**Last Name (LF) 12295**],[**First Name3 (LF) **] L.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 168 82 390/411 0 12 53
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2174-12-13**] 9:25 AM
CHEST PORT. LINE PLACEMENT
Reason: please check placement l bas picc(46 cm) call beeper
[**Numeric Identifier **] a
[**Hospital 5**] MEDICAL CONDITION:
76 year old woman s/p AVR/ cabg x2
REASON FOR THIS EXAMINATION:
please check placement l bas picc(46 cm) call beeper [**Numeric Identifier **] asap
thanks
PORTABLE CHEST
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2174-12-12**]. In the interim
since the prior examination a left-sided PICC line has been
placed which terminates within the expected region of the
cavoatrial junction. The patient is status post median
sternotomy and prosthetic aortic valve placement. A calcified
aorta is again noted. The cardiomediastinal silhouette is within
normal limits and stable. There is improved aeration of the lung
bases with residual left basilar atelectasis. There is a left
basilar haziness noted likely reflects underlying small
effusion.
IMPRESSION:
1. Improved aeration of the lung bases with residual left
basilar atelectasis and likely small effusion.
2. Left-sided PICC line in satisfactory position.
DR. [**First Name (STitle) **] [**Doctor Last Name 12296**]
Approved: TUE [**2174-12-13**] 10:14 AM
[**2174-12-21**] 05:23AM BLOOD WBC-16.8* RBC-3.29* Hgb-9.5* Hct-29.4*
MCV-89 MCH-28.7 MCHC-32.2 RDW-14.3 Plt Ct-357
[**2174-12-20**] 09:09AM BLOOD WBC-25.7* RBC-3.70* Hgb-10.8* Hct-33.4*
MCV-90 MCH-29.2 MCHC-32.4 RDW-14.7 Plt Ct-449*
[**2174-12-12**] 10:35AM BLOOD WBC-32.5*
[**2174-12-6**] 04:17AM BLOOD WBC-14.6* RBC-3.26* Hgb-9.9* Hct-29.2*
MCV-90 MCH-30.5 MCHC-34.0 RDW-15.4 Plt Ct-157
[**2174-12-1**] 07:45PM BLOOD WBC-15.3* RBC-4.03* Hgb-12.6 Hct-37.0
MCV-92 MCH-31.2 MCHC-34.0 RDW-14.4 Plt Ct-231
[**2174-12-21**] 05:23AM BLOOD Neuts-44.2* Lymphs-47.8* Monos-3.9
Eos-3.8 Baso-0.3
[**2174-12-12**] 10:35AM BLOOD Neuts-44* Bands-3 Lymphs-44* Monos-4
Eos-0 Baso-0 Atyps-4* Metas-1* Myelos-0
[**2174-12-19**] 05:22AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2174-12-12**] 10:35AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-NORMAL
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
[**2174-12-21**] 05:23AM BLOOD Plt Ct-357
[**2174-12-14**] 07:27AM BLOOD PT-12.9 PTT-25.5 INR(PT)-1.1
[**2174-12-3**] 04:45AM BLOOD PT-11.8 PTT-25.9 INR(PT)-1.0
[**2174-12-1**] 07:45PM BLOOD Plt Ct-231
[**2174-12-7**] 02:30AM BLOOD Fibrino-624*#
[**2174-12-21**] 05:23AM BLOOD Glucose-101 UreaN-22* Creat-1.0 Na-141
K-3.8 Cl-100 HCO3-34* AnGap-11
[**2174-12-1**] 07:45PM BLOOD Glucose-185* UreaN-15 Creat-0.7 Na-143
K-3.9 Cl-104 HCO3-27 AnGap-16
[**2174-12-19**] 10:21AM BLOOD ALT-16 AST-14 LD(LDH)-324* AlkPhos-77
Amylase-37 TotBili-0.4
[**2174-12-1**] 07:45PM BLOOD ALT-14 AST-17 LD(LDH)-192 AlkPhos-70
Amylase-55 TotBili-0.4
[**2174-12-19**] 10:21AM BLOOD Lipase-25
[**2174-12-19**] 10:21AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.4 Mg-2.1
[**2174-12-1**] 07:45PM BLOOD %HbA1c-5.8
[**2174-12-20**] 07:19PM BLOOD Vanco-23.9*
[**2174-12-18**] 06:40AM BLOOD Vanco-19.1
Brief Hospital Course:
She developed atrial fibrillation and remained in the hospital.
She was started on amiodarone and eventually converted to NSR.
She then developed sternal drainage and was also found to have a
small erythematous neck mass with purulent drainage at the site
of her right IJ catheter. She was started on antibiotics for
both and was seen by infectious diseases. She was also seen by
vascular surgery to evaluate the neck mass which did not require
drainage. She remained on IV antibiotics, vancomycin and
ceftazidime. Bedside debridement of sternal wound was performed
on [**12-16**] and wet to dry dressings started. Ceftazadime was
discontinued on [**12-19**] per ID recommendations. Sternal wound was
debrided at bedside [**12-19**] and VAC dressing was applied. She
continues on vancomycin being followed by [**Hospital **] clinic. VAC
dressing removed [**12-21**] with wet to dry placed for VAC dressing to
be applied at home [**12-22**]. She was discharged home with services
on POD 16.
Medications on Admission:
Norvasc 10, lipitor 10, triamterene, EC ASA 81, Niferex 150,
Flexeril 10 PRN, Coreg CR 10
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:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
6. PICC line
PICC line per NEHT protocol
7. Outpatient Lab Work
Weekly lab draws
Vancomycin CBC with differential and chem 7, vancomycin trough
Results to [**Hospital **] clinic [**Hospital1 8**] fax # ([**Telephone/Fax (1) 3790**]
Attn Dr [**Last Name (STitle) **]
8. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
Disp:*30 Wafer(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: please check with cardiologist in 2 weeks regarding
continued use.
Disp:*14 Tablet(s)* Refills:*0*
13. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
14. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO three times a
day.
Disp:*45 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks: please check with cardiologist in 2 weeks regarding
continued use.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
16. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 2238**]y (750)
mg Intravenous every twelve (12) hours for 5 weeks: completes
[**1-23**].
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Post operative atrial fibrillation
Sternal wound infection
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH: Hypertension, Hyperlipidemia, CLL, s/p T&A, s/p Umbilical
Hernia repair, s/p Cholecystectomy, s/p total hip replacement,
s/p varicose vein ligation, s/y hysterectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
any changes in sternal wound, please contact the [**Name2 (NI) 4294**] at
([**Telephone/Fax (1) 2092**].
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 near or on incision
5) No bathing or swimming until sternal wound healed. NO shower
until cleared by [**Telephone/Fax (1) 4294**]
6) No lifting greater then 10 pounds until wound healed.
7) No driving until cleared by [**Telephone/Fax (1) 4294**]
8) VAC dressing change every Monday and Thursday with VNA.
9) Call with any questions or concerns. [**Telephone/Fax (1) 1477**]
[**Last Name (NamePattern4) **]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks [**Telephone/Fax (1) 1477**]
Dr. [**Last Name (STitle) 12297**] in [**3-19**] weeks [**Telephone/Fax (1) 5412**]
Dr. [**Last Name (STitle) 12298**] in [**2-15**] weeks [**Telephone/Fax (1) 12299**]
Wound check appointment [**Hospital1 **] [**Telephone/Fax (1) 5412**]
Already scheduled appointments:
Provider: [**Name10 (NameIs) 12300**] CARE ID Phone:[**Telephone/Fax (1) 496**] Date/Time:[**2174-12-23**]
2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12301**],MD MPH[**MD Number(3) **]:[**Telephone/Fax (1) 496**]
Date/Time:[**2175-1-24**] 10:00
Labs Weekly CBC with differential, Chem 7, and Vanco trough
please fax results to [**Hospital **] clinic Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 1021**]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2174-12-21**]
|
[
"458.29",
"401.9",
"999.31",
"424.1",
"427.31",
"785.6",
"276.2",
"041.11",
"E879.8",
"204.10",
"272.0",
"493.90",
"414.01",
"998.59",
"682.6",
"682.2",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"35.21",
"88.72",
"36.16",
"86.22",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
15657, 15715
|
12378, 13374
|
7558, 7822
|
16095, 16102
|
8037, 8146
|
931, 949
|
13514, 15634
|
15736, 16074
|
13400, 13491
|
16126, 17850
|
6929, 7520
|
7837, 8015
|
267, 299
|
9493, 12355
|
9429, 9464
|
494, 645
|
667, 834
|
850, 915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,144
| 159,362
|
33069
|
Discharge summary
|
report
|
Admission Date: [**2186-1-29**] Discharge Date: [**2186-2-4**]
Date of Birth: [**2112-7-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percodan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2186-1-30**] 1. Aortic valve replacement with 21-mm St. [**Hospital 923**] Medical
Biocor tissue valve. 2. Coronary artery bypass grafting x1 with
reverse saphenous vein graft to the right coronary artery.
History of Present Illness:
73 year old female with aortic stenosis, COPD, hypertension and
dyslipidemia complaining of dyspnea with very minimal exertion.
She was admitted to OSH on [**12-8**] with CHF and excessive ETOH
intake; she was diuresed and d/c to home. Echo on [**2185-12-9**] shows
EF 45-50%, mild inferior wall hypokinesis, grade 1 diastolic
dysfunction, moderate mitral regurgitation, moderate mitral
annular calcification, severe aortic stenosis, moderate aortic
regurgitation. Pt presented on [**1-3**] for cardiac catheterization
as part of pre op evaluation for aortic valve repair. Cath
revealed coronary artery disease in addition to aortic stenosis
and surgery was planned for [**2186-1-21**].
Past Medical History:
Aortic stenosis
Chronic obstructive pulmonary disease
Hypertension
Paroxysmal atrial fibrillation
Dyslipidemia
Deep Vein Thrombosis (20 years ago)
Spinal stenosis/ bulging discs
Breast lumpectomy (benign)
Fatty tumors removed from thigh/ buttocks
Social History:
Race:caucasian
Last Dental Exam: endentulous
Lives with: alone, sister and daughter will stay with patient
post-op
Occupation: retired
Tobacco:quit 6-7 months ago, history of 52 years x1ppd
ETOH:quit 2 months ago, drank a fifth of vodka every 2-3 days x1
year, she is in rehab currently
Family History:
CAD, brother with [**Name (NI) 1291**] in his 40s
Physical Exam:
Pulse: 89 Resp: 16 O2 sat: 96%RA
B/P Right: 139/67 Left:
Height:5'2" Weight:129 lbs
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur II/VI SEM RUSB
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm, well-perfused [x] Edema/Varicosities [-]
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 1+ Left: np
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit (-)
Pertinent Results:
[**2186-1-30**] Echo: PRE-BYPASS: The left atrium is normal in size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Moderate to severe (3+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is severe mitral annular
calcification. There is moderate thickening of the mitral valve
chordae. Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.
POST CPB: 1. Preserved LV systolci function. 2. Bioprosthetic
valve in aortic positiion. Well seated and mechanically stable.
Trace AI. 3. No significant gradient.
[**2186-1-29**] 04:48PM BLOOD WBC-7.9 RBC-3.42* Hgb-9.5* Hct-28.8*
MCV-84 MCH-27.8 MCHC-33.0 RDW-16.6* Plt Ct-274
[**2186-2-1**] 04:24AM BLOOD WBC-18.1*# RBC-4.30 Hgb-12.0 Hct-36.5
MCV-85 MCH-28.0 MCHC-33.0 RDW-16.4* Plt Ct-140*
[**2186-2-4**] 06:02AM BLOOD WBC-9.4 RBC-3.89* Hgb-11.0* Hct-33.8*
MCV-87 MCH-28.4 MCHC-32.6 RDW-16.5* Plt Ct-152
[**2186-1-29**] 04:48PM BLOOD PT-14.2* PTT-25.0 INR(PT)-1.2*
[**2186-2-2**] 10:57AM BLOOD PT-15.1* PTT-30.4 INR(PT)-1.3*
[**2186-2-3**] 04:52AM BLOOD PT-18.7* PTT-29.5 INR(PT)-1.7*
[**2186-2-4**] 06:02AM BLOOD PT-30.2* INR(PT)-3.0*
[**2186-1-29**] 04:48PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-138
K-3.4 Cl-100 HCO3-27 AnGap-14
[**2186-2-1**] 04:24AM BLOOD Glucose-105* UreaN-11 Creat-0.7 Na-137
K-4.4 Cl-106 HCO3-26 AnGap-9
[**2186-2-4**] 06:02AM BLOOD UreaN-16 Creat-0.5 Na-138 K-4.0 Cl-97
[**2186-1-29**] 04:48PM BLOOD ALT-10 AST-14 LD(LDH)-189 AlkPhos-47
TotBili-0.2
[**2186-2-2**] 03:24AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
[**2186-1-29**] 04:48PM BLOOD %HbA1c-6.1* eAG-128*
Brief Hospital Course:
Mrs. [**Known lastname 76883**] was admitted one day before surgery due to being
on Coumadin for atrial fibrillation. Her last dose of Coumadin
was [**1-24**] and on admission she was started on IV Heparin and
underwent usual pre-operative work-up. On [**1-30**] she was brought
to the operating room where she underwent an aortic valve
replacement and coronary artery bypass graft x 1. Please see
operative report for surgical details. Following surgery she was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. She did however require IV
anti-hypertensives during the first several days of post-op and
was eventually transitioned to PO beta-blockers. In addition,
diuretics were started and she was diuresed towards her pre-op
weight. In the CVICU should has slight mental status changes
along with agitation which cleared by post-op day [**3-24**]. Post-op
she remained in atrial fibrillation and required a diltiazem gtt
and was started back on Coumadin. Chest tubes and epicardial
pacing wires were removed per protocol. She was transferred to
the stepdown for on post-op day three. Physical therapy worked
with patient during post-op course for strength and mobility. On
post-op day 2 and 3 her WBC increased to a peak of 20.5 but
trended back down on day of discharge to 9.4. There were no
signs of infection on her incision. On post-op day five she
appeared ready for discharge home with VNA services and the
appropriate medications and follow-up appointments. Her first
INR draw will be on Sunday [**2186-2-5**], with results to called to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP. Next draw on Tuesday [**2-7**] and then every
Monday, Wednesday and Friday in future. Her cardiologist, Dr.
[**Last Name (STitle) 11493**] will resume INR/Coumadin follow-up like he has done
pre-op.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 2.5 mg/0.5
mL Solution for Nebulization - 2.5 mg neb q 6 hours
BUDESONIDE-FORMOTEROL [SYMBICORT] - (Prescribed by Other
Provider) - 160 mcg-4.5 mcg/Actuation HFA Aerosol Inhaler - 1
puff INH twice a day
FUROSEMIDE [LASIX] - (list) - 40 mg Tablet - 1 Tablet(s) by
mouth 1 po qd
IPRATROPIUM-ALBUTEROL [COMBIVENT] - (Prescribed by Other
Provider) - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - [**1-22**]
puffs INH PRN as needed for SOB, wheezing
OLMESARTAN [BENICAR] - (Prescribed by Other Provider) - 20 mg
Tablet - 0.5 (One half) Tablet(s) by mouth daily
ROSUVASTATIN [CRESTOR] - (list) - 10 mg Tablet - 1 Tablet(s) by
mouth 1 po qd
WARFARIN - (list) - 5 mg Tablet - 1 Tablet(s) by mouth daily,
last dose 12/09
Crestor 10mg daily
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*2*
11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
12. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): No Coumadin needed [**2186-2-4**]. Please take dose amount as
directed in future. INR to be drawn tomorrow with results called
to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] at [**Telephone/Fax (1) 170**]. Future dosage recommendations
per cardiologist Dr. [**Last Name (STitle) 11493**].
Disp:*90 Tablet(s)* Refills:*2*
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
all care vna
Discharge Diagnosis:
Aortic stenosis and Coronary artery disease s/p Aortic valve
replacement and coronary artery bypass graft x 1
Past medical history
Chronic obstructive pulmonary disease
Hypertension
Paroxysmal atrial fibrillation
Dyslipidemia
Deep Vein Thrombosis (20 years ago)
Spinal stenosis/ bulging discs
Breast lumpectomy (benign)
Fatty tumors removed from thigh/ buttocks
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg 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 with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**3-2**] at 1pm
Cardiologist: Dr. [**Last Name (STitle) 11493**] on [**2-17**] at 10:30am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 19960**] in [**4-25**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Atrial fibrillation
Goal INR 2-2.5
First draw Sunday [**2186-2-5**], then Tuesday [**2-7**] and every Monday,
Wednesday and Friday in future.
Results from Sunday [**2186-2-5**] should be called to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP[**Telephone/Fax (1) 76884**]. Then results to be called to Dr. [**Last Name (STitle) 11493**] at
[**Telephone/Fax (1) 11650**].
Completed by:[**2186-2-4**]
|
[
"285.9",
"V58.61",
"V45.89",
"272.4",
"428.30",
"414.01",
"427.31",
"305.03",
"496",
"424.0",
"V12.51",
"401.9",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9320, 9363
|
4624, 6556
|
294, 504
|
9768, 9994
|
2503, 3410
|
10917, 11851
|
1810, 1861
|
7395, 9297
|
9384, 9747
|
6582, 7372
|
10018, 10894
|
1876, 2484
|
235, 256
|
532, 1220
|
1242, 1490
|
1506, 1794
|
3420, 4601
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,487
| 199,591
|
14079
|
Discharge summary
|
report
|
Admission Date: [**2136-12-22**] Discharge Date: [**2136-12-27**]
Date of Birth: [**2069-5-26**] Sex: F
Service: MEDICINE
Allergies:
Rofecoxib
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
LGIB, radiation proctitis
Major Surgical or Invasive Procedure:
flexible sigmoidoscopy
History of Present Illness:
67 y/o F w/ hx of CAD and radiation proctitis (s/p XRT 02 and 03
for uterine CA). Pt presented with BRBPR. She is s/p argon
laser tx 3 wks ago ([**Date range (1) 41988**]). Pt was transferred to
[**Hospital1 18**] for another argon laser treatment 12/08-15/04 due to
recurrent bleeding. Bleeding recurred [**12-21**] when she had three
profuse episodes and went to [**Location (un) **] where her Hct was seen to
drop from 34 to 28.5. She was subsequently transferred back to
[**Hospital1 18**] where she complained of lightheadedness and sob on
admission and was transferred to the [**Hospital Unit Name 153**].
.
FLex sig showed abnormal vascularity in the rectum compatible
with radiation proctitis and a clip was placed and cauterization
performed.
Past Medical History:
Uterine cancer- s/p XRT '[**34**]
Radiation proctitis
Hyperlipidemia
HTN
DM type 2
CAD s/p CABG '[**35**]
GERD
s/p appy/ccy
CHF
AF
s/p pacemaker
CRF baseline cr 1.2-1.8
Social History:
Lives alone, denies T/A/D. Widowed.
Family History:
Father passed away in 50's from CAD. Siblings with early CAD
Physical Exam:
98.9, 175/44, 53 paced, 100%3L
GEN: nad
CHEST: CTAB
CV: 2/6 sem, best heard at bases, rrr
ABD: obese soft nt, well healed surgical scar
EXT: positive pulses, no edema
RECTAL: liquid brown/red, heme positive
Pertinent Results:
[**2136-12-21**] 11:15PM BLOOD WBC-4.7 RBC-3.71* Hgb-11.0* Hct-33.0*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.3 Plt Ct-264
[**2136-12-21**] 11:15PM BLOOD Neuts-72.8* Lymphs-16.8* Monos-7.4
Eos-2.6 Baso-0.5
[**2136-12-21**] 11:15PM BLOOD PT-12.6 PTT-21.0* INR(PT)-1.0
[**2136-12-21**] 11:15PM BLOOD Glucose-342* UreaN-67* Creat-1.8* Na-141
K-3.9 Cl-102 HCO3-30* AnGap-13
[**2136-12-21**] 11:15PM BLOOD Calcium-9.0 Phos-4.1 Mg-2.5
##########################################
PORTABLE CHEST: Comparison is made to prior study dated
[**2136-12-2**]. The current study is limited by significant patient
rotation. Changes of prior median sternotomy are again noted. A
dual-chamber transvenous cardiac pacer is without change. The
cardiac and mediastinal contours are not well evaluated, but
appear grossly unchanged. Evaluation of the lung parenchyma is
also limted. Diffuse indistinctness of vessel and hilar outlines
may reflect mild CHF. Relative haziness of the hemithorax may be
an artifact of rotation. No frank air-space infiltrate is seen.
IMPRESSION: Limited study; cannot rule out mild CHF.
##########################################
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There is pleural
thickening identified at bilateral lung bases. There are
scattered pleural calcifications seen. The patient is status
post cholecystectomy. The liver, spleen, pancreas, and adrenal
glands are unremarkable. There is a focal area within the mid
pole of the right kidney without cortical enhancement, which
likely represents an aread of prior infarction or inflammation.
The kidneys are otherwise unremarkable.
CT OF THE PELVIS WITH IV CONTRAST: There is no free air, fluid,
or significant lymphadenopathy within the pelvis. There is
atherosclerotic disease within the aorta and iliac vessels with
wall calcifications. Note is made of diffuse, circumferential
thickening of the rectum and sigmoid colon consistent with the
patient's history of radiation proctitis/colitis. There is also
thickening of the bladder wall. The rest of the bowel loops are
unremarkable.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1) No abnormal masses or lymphadenopathy in the abdomen and
pelvis to indicate metastatic disease.
2) Bibasilar pleural thickening with pleural calcifications seen
on limited views of the lungs consistent with asbestos exposure.
3) Circumferential wall thickening of the rectum and sigmoid
colon consistent with the patient's history of radiation. There
is also bladder wall thickening.
Brief Hospital Course:
ANEMIA: Pt was transferred to the [**Hospital Unit Name 153**] for hemodynamic control.
She received 1 unit of PRBCs for a Hct drop from 31 to 27. Her
Hct remained stable throughout the rest of her hospitalization.
.
PROCTITIS: Pt now with multiple episodes of BRBPR secondary to
proctitis. A non-emergent diverting colectomy is recommended.
.
CHF: not an active issue on this admission
.
HTN: managed well on current regimen
.
DM: FSG and ISS, controlled throughout hospitalization
.
ARF: Cr 1.2 to 1.7, possibly secondary to prerenal, Pt was
hydrated, but insisted on leaving. Will have PCP measure Cr and
suggest rehospitalization if increasing Cr.
Medications on Admission:
amiodarone 200 mg
cardizem
compazine
iron
nph 34am/10pm
humalog ss
toprol xl
nitro patch
lasix 80 [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Radiation proctitis
Discharge Condition:
Stable hct, no further bleeding episodes following argon therapy
Discharged to home
Discharge Instructions:
1) Please go to [**Hospital3 7571**]to recheck your creatinine (lab
request provided) on [**12-28**] and on [**12-29**]. Please have lab call
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 26677**])- he is on call over the holidays.
2) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
3) Please follow up with appointmets at GI and surgery as below
3) Please continue taking your medications as prior to admission
3) Please return to the Emergency room for any recurrent
episodes of bleeding
Followup Instructions:
Please go to [**Hospital3 7571**]for creatnine check on [**12-28**] and
[**12-29**] and please have lab call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 26677**]
with results
1) [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2137-1-16**]
9:00
2) E SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2137-1-16**] 9:00
3) Please call Dr.[**Name (NI) 1482**] office ([**Telephone/Fax (1) 2981**]) for a
surgery appointment after the [**Holiday **] holidays
|
[
"285.1",
"276.5",
"V10.42",
"427.31",
"V45.81",
"569.49",
"584.9",
"250.00",
"V45.01",
"909.2",
"E879.2",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
5064, 5070
|
4235, 4899
|
298, 322
|
5133, 5218
|
1682, 4212
|
5817, 6490
|
1369, 1432
|
5091, 5112
|
4925, 5041
|
5242, 5794
|
1447, 1663
|
233, 260
|
350, 1108
|
1130, 1300
|
1316, 1353
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,363
| 135,535
|
52356
|
Discharge summary
|
report
|
Admission Date: [**2174-12-25**] Discharge Date: [**2174-12-30**]
Date of Birth: [**2108-12-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
? sepsis, shortness of breath and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 66 yo man with hx of CAD s/p CABG [**2174-9-27**] for 3VD and Left
main disease, CHF, severe COPD and hx of lung cancer here after
recent hospitalization for CABG c/b sternal dehisance and then
dehisance of pec flaps s/p VAC dressing placement with wound cx
c/w MRSA and acitenobacter, multi-drug ressistant pseudomonas
pna(only cipro [**Last Name (un) 36**]) which [**Doctor Last Name **] resulted in failure to wean and
trached on [**11-4**]. At rehab overall was doing well except pt had
panic attacks while on trach collar and could not tolerate being
off vent. Continued to have some pain at wound site and
otherwise well until noted to be increasing dyspnea, temp and
SBP to 70's per report. Was started on solumedrol 60mg IV for
COPD flare, imipenum and vanc for hx of pseudomonas and MRSA.
Also noted to have prurulent drainage from wound and sent here
for further eval for possible sepsis.
Past Medical History:
CAD - s/p PCI, CHF, HTN, Hypercholesterolemia, Severe COPD, Lung
CAncer - s/p RLL lobectomy, GERD and PUD, BPH, Anemia,
Depression, History of Shingles, s/p Appy, s/p chole, s/p
cataract surgery, s/p Nissen
Social History:
160 pack year history of tobacco - quit 3 years ago. Admits to
occasional ETOH. He lives with his wife. Former [**Name2 (NI) 86**] Globe
worker. He requires home oxygen and is on chronic steroids.
Family History:
Significant for premature coronary artery disease. Father and
brothers were diagnosed in their 30's.
Physical Exam:
VS T 97.1/98.4 P 98(81-115) BP 142/66 RR 15 Sat 99%RA I/O
1888/2330 and 592/360-- [**Location 10226**]662 PS 12/5--> 650TV, RR 20 ABG
7.41/46/124 and 99%RA
GEN aao, nad
HEENT PERRl, MMM
CHEST CTAB occaional crackles and exp wheezes, +right VAC
dressing in place
CV RRR no murmurs, occasional extra beats
ABD soft NT/Nd, +BS
EXT no edema, [**2-3**]+reflexes bilaterally
Pertinent Results:
S&S eval
SUMMARY / IMPRESSION:At this time, the pt is not demonstrating
any s&s of aspiration with any of the PO boluses administered.
Given that no green residue was suctioned from pt's airway and
that pt was eating safely at rehab, it is recommended that he be
placed on a PO diet of ground solids and thin liquids. PO meds
may be taken whole. In addition, the cuff on the pt's trach may
be left inflated during meals, as long as the Passy Muir Valve
is
NOT placed. Although the RN reported suctioning some green
residue from pt's trach yesterday, it is likely that this was
due
to green dye from oral cavity mixing in with saliva, as this can
commonly occur after green dye swallow evaluations.
RECOMMENDATIONS:
1. PO diet consistency of ground solids and thin liquids
2. PO meds may be taken whole
3. The cuff on trach tube may be left inflated during meals.
HOWEVER, if Passy Muir Valve is placed on pt, the the cuff
should
be DEFLATED.
.........
CHEST (PORTABLE AP) [**2174-12-28**] 12:30 PM
CHEST (PORTABLE AP)
Reason: please assess for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with s/p cabg, s/p trach with pseudomonas in
sputum and infiltrate
REASON FOR THIS EXAMINATION:
please assess for infiltrate
INDICATION: 65-year-old status post trach with pseudomonas in
the sputum, assess for infiltrate.
COMPARISON: [**2174-12-25**].
SEMI-ERECT CHEST RADIOGRAPH: This film is suboptimal obscuring a
portion of the left hemithorax and the lung apices. Tracheostomy
tube, nasogastric tube and surgical clips in the abdomen are
again seen. There is no change in the increased interstitial
markings bilaterally, likely secondary to a nonspecific chronic
lung disease. Superimposed acute process is difficult to
exclude.
.......
[**2174-12-30**] 04:19AM BLOOD WBC-19.8* RBC-3.43* Hgb-9.4* Hct-28.0*
MCV-82 MCH-27.3 MCHC-33.4 RDW-15.5 Plt Ct-465*
[**2174-12-29**] 02:51AM BLOOD WBC-21.6* RBC-3.50* Hgb-9.9* Hct-29.0*
MCV-83 MCH-28.3 MCHC-34.2 RDW-15.8* Plt Ct-489*
[**2174-12-25**] 10:30PM BLOOD WBC-41.9*# RBC-3.19* Hgb-9.0* Hct-26.2*
MCV-82 MCH-28.1 MCHC-34.2 RDW-15.9* Plt Ct-469*
[**2174-12-25**] 10:30PM BLOOD Neuts-91* Bands-4 Lymphs-2* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2174-12-30**] 04:19AM BLOOD Plt Ct-465*
[**2174-12-30**] 04:19AM BLOOD PT-13.5* PTT-25.9 INR(PT)-1.2
[**2174-12-26**] 05:05AM BLOOD PT-12.6 PTT-23.8 INR(PT)-1.1
[**2174-12-30**] 04:19AM BLOOD Glucose-70 UreaN-29* Creat-1.3* Na-133
K-4.4 Cl-98 HCO3-22 AnGap-17
[**2174-12-29**] 02:51AM BLOOD Glucose-128* UreaN-25* Creat-1.2 Na-132*
K-4.0 Cl-95* HCO3-25 AnGap-16
[**2174-12-26**] 05:05AM BLOOD Glucose-122* UreaN-38* Creat-1.2 Na-137
K-4.3 Cl-101 HCO3-23 AnGap-17
[**2174-12-25**] 10:30PM BLOOD Glucose-198* UreaN-40* Creat-1.2 Na-134
K-4.6 Cl-100 HCO3-22 AnGap-17
[**2174-12-26**] 03:46PM BLOOD ALT-25 AST-11 AlkPhos-123* Amylase-32
TotBili-0.4
[**2174-12-28**] 03:28AM BLOOD CK-MB-2 cTropnT-0.06*
[**2174-12-25**] 10:30PM BLOOD cTropnT-0.05*
[**2174-12-30**] 04:19AM BLOOD Calcium-7.9* Phos-4.7* Mg-1.9
[**2174-12-29**] 02:51AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8
[**2174-12-26**] 05:05AM BLOOD Calcium-9.0 Phos-5.0* Mg-1.9
[**2174-12-30**] 04:19AM BLOOD Vanco-22.3*
[**2174-12-29**] 07:47PM BLOOD Tobra-3.1*
[**2174-12-30**] 04:50AM BLOOD Type-ART pO2-125* pCO2-47* pH-7.36
calHCO3-28 Base XS-0
[**2174-12-26**] 12:45AM BLOOD Type-ART pO2-431* pCO2-46* pH-7.31*
calHCO3-24 Base XS--3
[**2174-12-25**] 10:33PM BLOOD Lactate-1.2
[**2174-12-29**] 12:52PM BLOOD freeCa-1.02*
Micro
[**2174-12-25**] 10:30 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2174-12-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2174-12-29**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SECOND COLONY
TYPE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| PSEUDOMONAS AERUGINOSA
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- 16 I 16 I =>64 R
CEFTAZIDIME----------- =>64 R =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R 1 S 1 S
GENTAMICIN------------ 2 S =>16 R =>16 R
IMIPENEM-------------- =>16 R =>16 R =>16 R
LEVOFLOXACIN---------- 4 I
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- =>128 R =>128 R
TOBRAMYCIN------------ <=1 S =>16 R =>16 R
[**2174-12-26**] 8:12 am SWAB Source: sternal wound.
GRAM STAIN (Final [**2174-12-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2174-12-28**]):
ACINETOBACTER BAUMANNII. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- 4 I
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Briefly 66 yo man with complex hx of CAD s/p CABG, CHF, severe
COPD and hx of lung cancer read,itted from rehab with concerns
for worsening dyspnea and leukocytosis.
.
# ID: Complicate infectious disease history as indicated in HPI
and previous d/c summaries. Orginially admitted to CTSURG
service who felt sternal wound was healing well and cotinued Vac
dressings. Leukocytosis likely [**2-2**] stress dose steorids prior
to presentation. No obvious source of infection other than
wound; CXR without PNA< U/A clean, BCx negative. Seen and
followed by infectious disease service. Pt continued on
Vanc/Cip/Flagyl/Imipenum initially. Culture data from wound and
secretions with pseudomanas and actinobacter. Pt remined
afebrile and all survalliance blood cultures without growth. Pt
remained hemodynamically stable. Under recommendation of ID,
Abx tailered to Tobramycin and Ciprofloxacin which Pt did well
with. Levels followed and Tobra dosed accordingly. Pt to
continue on current antiobiotic regimen for at least 6 weeks.
Pt needs to be followed closely in the interim with close
infectious disease follow up.
.
# Resp: Pt s/p trach with PSV requirement prior to admission.
Pt stable during hopsitalization. Initially placed on AC but
quickly changed to PSV. Pt continued to require PSV overnight
but tolerated trach mask with PMV. Pt tolerated addition of PMV
by speech and swallow service. [**Name (NI) 108229**] Pt tolerating PO and
speach. Pt to continue steroids at current dose with
instructions to follow up with his primary pulmonologist in [**1-2**]
weeks.
.
# Pain: Pt with continued sternal pain secondary to wound. Pt
controlled with SR morphine and short acting for break through.
.
# CAD s/p CABG: Non specific EKG changes at presentation with
increased ectomy. Pt ruled out by cardiac enzymes for acute MI.
Pt continued on asa, plavix, statin and metoprolol. BB
uptitrated as tolerated by HR. HTN relativel well controlled.
.
# COPD: History of moderate COPD by last PFTs [**5-5**], followed by
Dr [**Last Name (STitle) 217**], has been steroid dependent for some time and
on 20mg prednisone except one time dose of solumedrol prior to
transfer. Continued inhalers, singulair and prednisone at 20mg.
Would benefit from decrease of steroids as to promote wound
healing but unable to at this time. Recommend f/u with Dr
[**Last Name (STitle) 217**].
.
# sternal dehisance: stable with VAC dressing in place. Wound
care as per pg 3.
.
# Panic attacks: stable with klonopine 0.5mg [**Hospital1 **], with few prn
doses of ativan.
.
# CKD: appears to have new baseline creatinine 1.4 after CABG
c/b ATN. Renally dose meds for clearance of 64ml/min.
.
# Dispo: Pt discharged back to NE [**Hospital1 **] for continuation of
care.
Medications on Admission:
NTP, ASA 325, Plavix, Toprol XL 25 qAM, 50 qPM, Zocor 20,
Decadron, Theophylline 400 [**Hospital1 **], Singulair 10 qD, Protonix 40 qD,
Flomax, Claritin, Serax prn anxiety, Effexor, Wellbutrin,
Pamelor, Atrovent inhaler, Albuterol, Xopenex neb tid (w/ resp
dept).
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
14. Acetaminophen 160 mg/5 mL Solution Sig: [**1-2**] PO Q4-6H (every
4 to 6 hours) as needed.
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
Fifteen (15) ML PO QID (4 times a day) as needed.
16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
18. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
21. Insulin Lispro (Human) 100 unit/mL Solution Sig: [**1-10**] unites
Subcutaneous ASDIR (AS DIRECTED): as per attached sliding scale.
22. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours).
23. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
24. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
25. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
26. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
27. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 14 days.
28. Metoclopramide 10 mg IV Q8H:PRN nausea
29. Tobramycin Sulfate 40 mg/mL Solution Sig: Four [**Age over 90 1230**]y
(450) mg Injection Q48H (every 48 hours): start [**2174-12-31**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CAD
Sternal Wound
tracheobronchitis
HTN
hyperlipidemia
respiratory failure
Discharge Condition:
stable, afebrile
Discharge Instructions:
take all medications as instructed
make all follow up appointments
Call your PCP or return to ED if you have: chest pain, fever
>101.4, rigors, worsening shortness of breath, increased wound
pus, or any other concern.
Followup Instructions:
Please follow up with PCP [**Last Name (NamePattern4) **] [**1-2**] weeks
Please call Dr [**Last Name (STitle) 217**] and follow up in [**1-2**] weeks.
You will need close infectious disease follow up, please call
the [**Hospital **] clinic at ([**Telephone/Fax (1) 4170**] and make an appointment to see
Dr [**First Name4 (NamePattern1) 4333**] [**Last Name (NamePattern1) 4334**] in [**2-4**] weeks. They will determine the length of
anti-biotics.
Please follow up with your cardiac surgeon as per their
recommendations.
|
[
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"401.9",
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"491.22",
"V10.11",
"600.00",
"V46.11",
"998.59",
"272.0",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13801, 13873
|
8167, 10927
|
343, 349
|
13992, 14011
|
2251, 3313
|
14279, 14808
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1744, 1846
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11241, 13778
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3350, 3433
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1529, 1728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,835
| 105,494
|
4520+4562
|
Discharge summary
|
report+report
|
Admission Date: [**2194-1-21**] Discharge Date:
Date of Birth: [**2164-5-10**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 19280**] is a 29 year old
white male admitted on [**2194-1-21**] with increased
abdominal pain and associated nausea and vomiting. The
patient has a long history of alcohol abuse, pancreatitis,
status post recent alcohol binge with 12 to 15 beers per day
with occasional shots of alcohol. The patient's last drink
was three days ago by report. The patient was transferred to
the Medical Intensive Care Unit service from the floor with
clinical and CT evidence of pancreatitis with no fluid
collection. The patient was initially on nothing by mouth
and given aggressive fluid resuscitation on the floor, but
became hypoxic on [**2194-1-22**] and warranted Medical
Intensive Care Unit evaluation. We were called to see the
patient when he was hypoxic and tachycardiac and
normotensive. The patient was started on ampicillin,
gentamicin and Flagyl in the Emergency Room. The patient has
a history of adult respiratory distress syndrome in the
setting of pancreatitis.
At baseline, the patient is seen in pain clinic for chronic
abdominal pain. He reports that he awoke on [**2194-1-20**]
with abdominal pain that was different from his chronic pain.
He came to the Emergency Room and reported episodes of nausea
and vomiting. He denied melena, bright red blood per rectum
or hematuria. The patient states he has had no
hallucinations. He feels tremulous and is diaphoretic. He
denies palpitations and has had no bowel movement since two
days prior to admission. The patient denies orthopnea or
paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY: 1. Alcoholic pancreatitis with
several admissions for the above; history of adult
respiratory distress syndrome in the setting of pancreatitis,
for which he was treated in the Surgical Intensive Care Unit
approximately two years ago; at that time, the patient had a
splenic hematoma and underwent a splenectomy with a distal
pancreatectomy. 2. History of gastroesophageal reflux
disease. 3. History of hypertension. 4. Sleep apnea. 5.
Hypercholesterolemia. 6. Chronic pain in left side of
abdomen and left shoulder, seen in pain clinic, on Oxycontin
30 mg twice a day. 7. Alcohol withdrawal; long history of
alcohol abuse and has been admitted to the hospital several
times for delirium tremens; patient reports approximately two
to three episodes of intubation in the Intensive Care Unit in
the setting of alcohol withdrawal. 8. Right upper quadrant
abscess, status post percutaneous catheter drainage in [**2192-5-5**]. 9. Distal pancreatectomy and splenectomy, as above.
MEDICATIONS ON ADMISSION: Oxycontin 30 mg p.o.b.i.d.,
albuterol meter dose inhaler p.r.n.; on transfer to Medical
Intensive Care Unit, patient was on Dilaudid 2 to 4 mg
i.v.q.4-6h.p.r.n., nicotine patch, Valium, thiamine 100 mg
p.o.q.d., folate 1 mg p.o.q.d. and Zantac.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient has been abusing alcohol since
the age of 15 or 16. He has a history of detoxification
times one which was unsuccessful. He denies intravenous drug
use but does have a 17 pack year smoking history. He has no
history of illicit drug use. He is unemployed and currently
lives with his mother.
FAMILY HISTORY: There is a history of alcoholism in the
patient's father.
PHYSICAL EXAMINATION: Physical examination on admission to
the Intensive Care Unit revealed a temperature of 101.4,
pulse 74 to 164, respiratory rate 20 to 28, blood pressure
108 to 132/70 to 100 and oxygen saturation 90% in room air.
General: Pleasant male with mild abdominal distress. Head,
eyes, ears, nose and throat: Normocephalic, atraumatic,
pinpoint pupils, anicteric sclerae, oropharynx clear, no
jaundice. Cardiovascular: Tachycardiac, no murmur, rub or
gallop. Lungs: Clear to auscultation bilaterally. Abdomen:
Distended with epigastric to periumbilical pain, hepatomegaly
with liver approximately 3 to 4 cm below costal margin.
Extremities: No cyanosis, clubbing or edema. Skin: Spider
angiomata on anterior chest. Neurologic examination: Alert
and oriented times three, not tremulous, 2+ reflexes
throughout, motor [**5-10**] in bilateral upper and lower
extremities.
LABORATORY DATA: At the time of transfer, white blood cell
count was 18.1, hematocrit 47.3, platelet count 308,000,
sodium 135, potassium 3.5, chloride 96, bicarbonate 16, BUN
9, creatinine 0.5, glucose 100, amylase 405, lipase 1,685;
white blood cell count later in the day had increased to 23
with 82% neutrophils, 3% bands, 12% lymphocytes and 3%
monocytes. Amylase was subsequently found to be 212 with a
lipase of 522. Electrocardiogram at the time of transfer:
Sinus rhythm at 159 with no ischemic changes; no change from
[**2192-4-12**], rate 142, QRS 471 at this time.
RADIOLOGIC DATA: Right upper quadrant ultrasound: Fatty
infiltration of the liver. Abdominal CT on [**2194-1-21**]:
Pancreatitis, no pseudocyst or fluid collection; status post
partial pancreatectomy and splenectomy; fatty liver
infiltration, inflammation of duodenum near the pancreatic
head. Chest x-ray: Residual minor atelectasis, right lower
lung zone greater than left lower lung zone.
HOSPITAL COURSE: The patient was subsequently transferred to
the Medical Intensive Care Unit for further evaluation and
treatment. At that time of transfer, he was on two liters of
nasal cannula and was moderately agitated with abdominal
pain.
1. Pancreatitis: The patient was admitted to the Medical
Intensive Care Unit with acute alcoholic pancreatitis. His
amylase and lipase at the time of transfer were 212 and 522
respectively. His amylase went from 212 down to 26 on
[**2194-2-3**] with lipase going from 1,620 at the time of
admission to 522 at the time of transfer to the Medical
Intensive Care Unit, 45 on [**2194-1-28**] to 28 on [**2194-2-3**]. The patient's ALT remained in the 20 to 60 range
with an AST in the same range. His alkaline phosphatase was
102 at the time of admission and 373 on [**2194-2-2**].
Bilirubin was stable at 0.3 to 0.7.
The patient was treated with aggressive fluid hydration in
the setting of acute pancreatitis. He was given fluid
boluses of 250 to 500 cc initially and was put on normal
saline at 250 cc/hour for the first 12 to 24 hours. The
patient ended up receiving a large normal saline load of
approximately 16 liters during the hospitalization. The
patient continued to have temperatures throughout the
hospitalization, with a maximum temperature of 104.2 on
several occasions. The patient is currently febrile to 102.
We have done multiple blood, urine and sputum cultures and
all cultures have remained negative. His sputum culture on
[**2194-1-27**] grew two colonies of coagulase positive
Staphylococcus aureus, which was not aggressively treated.
At this point, an infectious source of his fevers is thought
to be unlikely as the patient has persistently had culture
negative samples. The patient is thought to have elevated
temperatures in the setting of severe acute pancreatitis and
cytokine release.
At the beginning of the hospitalization, the patient became
progressively more hypotensive. He was on a propofol and
Ativan drip at this time. On [**2194-1-26**], the patient
was started on Neo-Synephrine as his blood pressure had
dipped down in the high 70s to low 80s systolic and he was
found to be unresponsive to fluid boluses. The patient was
on 26.7 of Neo-Synephrine at this time. This was
subsequently weaned off on [**2194-1-27**] and the patient
did not require any further pressors throughout the
hospitalization.
The patient continued to be aggressively fluid resuscitated
for the first seven to days of the hospitalization. He
underwent a repeat abdominal CT on [**2194-1-29**] due to
the fact that the patient had been hypotensive, had evidence
of adult respiratory distress syndrome on chest x-ray and, by
physical examination and ventilator numbers was not making
any progress. Furthermore, the patient continued to be
febrile despite multiple negative cultures. A CT scan of the
chest was done at the same time as a CT of the abdomen and
the impression was: (1) extensive areas of patchy
consolidation with confluence at bilateral bases which are
worrisome for infection; (2) interval increase in the extent
of fluid and peripancreatic stranding, now with
loculation/pseudocyst formation and no evidence of
pancreatitis necrosis. Given the presence of a
peripancreatic fluid collection, we had a CT guided fluid
aspiration of this region. The fluid from this aspiration
had negative polymorphonuclear neutrophils, negative Gram
stain and culture negative.
On [**2194-1-27**], the patient was empirically started on
Imipenem despite the absence of necrosis by subsequent CT
scans. The patient was continued on Imipenem for a total of
seven days, however, he continued to spike fevers through
this intervention and, given the negative cultures and
negative evidence for futility of continuing this medication,
it was discontinued on [**2194-2-1**].
Throughout the course of the last week, the patient has
slowly gotten better. His abdomen is slightly less distended
with quiet, but positive, bowel sounds on the day of
dictation, [**2194-2-5**]. He continues to be on nothing
by mouth and has been fed via total parenteral nutrition
since the day of transfer to the Medical Intensive Care Unit.
Furthermore, the gastroenterology and surgery services
continue to follow the patient along with us and leave
recommendations on a daily basis.
2. Respiratory: The patient was admitted to the Medical
Intensive Care Unit for closer monitoring. He required
intubation on MICU day number one in the setting of hypoxemia
despite a 100% non-rebreather. The patient has had evidence
of adult respiratory distress syndrome on chest x-ray, with
bilateral opacification. Furthermore, the patient has
required FiO2 of 1 at several points throughout the
hospitalization to maintain oxygen saturation of
approximately 90%. He has also required pronation on several
occasions to facilitate oxygenation given his clinical
picture and diagnosis of adult respiratory distress syndrome
in the setting of pancreatitis.
On [**2194-1-29**], the patient underwent bronchoscopy in
the setting of increased respiratory secretions.
Bronchoscopy showed purulent material in the bronchioles and
had a Gram stain with 3+ polymorphonuclear neutrophils and no
organisms. The culture was negative. Given the history of
bilateral consolidation on the chest CT on [**2194-1-29**],
the patient was started on Levaquin, which he remains on to
this date, [**2194-2-5**]. We are continuing to attempt a
decrease in ventilatory support. The patient was on pressure
control ventilation throughout the majority of his
hospitalization.
The patient is currently on pressure control ventilation with
a driving pressure of 20 and a PEEP of 12. Tidal volumes are
approximately 600 with FiO2 0.5, respiratory rate 20 and I to
E ratio of 1:1.5. The last gases on these settings have been
37/46/72. We will attempt to decrease the respiratory rate
on pressure control ventilation and then ultimately try to
change the pressure support ventilation to determine how the
patient will do with less support. Throughout the
hospitalization, the patient's chest x-rays have gradually
gotten better. His last chest x-ray on [**2194-2-4**]
showed an improvement in the bilateral opacification.
3. Sedation: The patient has been on Ativan and morphine
drips throughout the majority of this hospitalization. His
Ativan and morphine drips were at 25 and 80 per hour
respectively. We have had addiction consults and pain
management consults to aid in dealing with this difficult
patient. Currently, the patient's Ativan and morphine are
being decreased by 10% per day. He has been started on
Haldol 4 mg four times a day and is intended to get Haldol 10
mg intravenously as needed for agitation as opposed to
bolusing with Ativan. The psychiatry consult has been
helping us with weaning guidelines. Given the patient's
chronic pain history, and his baseline 30 mg twice a day of
Oxycontin as an outpatient, it will likely take several days
to decrease his dose of these agents now that the patient is
off cisatracurium which he had been on for approximately one
and one-half weeks of the hospitalization.
4. Nutrition: The patient has been receiving total
parenteral nutrition throughout the entire hospitalization.
This is dictated by the nutrition recommendations on a daily
basis.
5. Lines: The patient has a left internal jugular which is
day number 12 on [**2194-2-5**]. He also has an arterial
line which is day number 11 on [**2194-2-5**]. The
arterial line will be discontinued today as we are planning
to follow oxygen saturations as opposed to arterial blood
gases.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 16512**]
MEDQUIST36
D: [**2194-2-5**] 14:37
T: [**2194-2-5**] 15:45
JOB#: [**Job Number 19281**]
Admission Date: [**2194-1-21**] Discharge Date: [**2194-3-7**]
Date of Birth: [**2164-5-10**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM:
He did well after transfer to the Medical Floor from the
Intensive Care Unit. His Haldol was tapered to 5 mg po
t.i.d. with the eventual plan to taper off as per Psychiatry.
The Valium was also tapered to 5 mg po b.i.d. The eventual
goal is to discontinue both medications over the next one to
two weeks. He otherwise remains stable, increasing mobility
and strength as per physical therapy. His sinus pain
secondary to feeding tube placements, however, resolved with
no fever or worsening pain. He continues to have a Foley
secondary to poor mobility. This can probably be
discontinued as his mobility improves. He continues to
tolerate his tube feeds at a goal rate of 70 cc an hour. His
subcutaneous heparin can be discontinued with improved
mobility as well. Likely, it should be monitored while on
tube feeds.
DISCHARGE STATUS: Stable vital signs. Still improving
strength and mobility.
DISCHARGE MEDICATIONS: Please disregard discharge
medications list on previous summary. Current discharge
medications will be:
1. Heparin 5000 units subcutaneous b.i.d.
2. Topamax 100 mg po q.h.s.
3. Fentanyl patch 75 mcg td q. 72 hours.
4. Haldol 5 mg po t.i.d.
5. Valium 5 mg po b.i.d.
6. Motrin 200 mg q. 6.
7. Tylenol 650 mg po q. 8.
8. Dulcolax 10 mg po q.d. prn.
9. Tube feeds, Peptamen at 70 cc an hour.
FOLLOW-UP: Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] from
Gastroenterology regarding pancreatitis.
[**First Name8 (NamePattern2) 312**] [**Name8 (MD) 313**] M.D. [**MD Number(1) **]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2194-3-9**] 11:29
T: [**2194-3-9**] 11:29
JOB#: [**Job Number 19405**]
|
[
"780.57",
"272.0",
"401.9",
"276.0",
"577.0",
"291.81",
"458.9",
"486",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"99.15",
"33.22",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
3389, 3448
|
14305, 15093
|
2747, 3047
|
5343, 14281
|
3471, 4190
|
149, 1707
|
4215, 5325
|
1730, 2720
|
3064, 3372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,555
| 174,692
|
54148
|
Discharge summary
|
report
|
Admission Date: [**2104-6-26**] Discharge Date: [**2104-7-2**]
Date of Birth: [**2044-5-25**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 60-year-old white
female patient with no previous history of coronary artery
disease who presented after approximately 12 hours of
intermittent stuttering chest pain radiating to bilateral
arms. She did also have shortness of breath and nausea. She
presented to an outside hospital emergency department with
chest pain. Her electrocardiogram showed ST elevations in
the lateral leads with associated ST depression inferiorly.
She was treated with nitroglycerin as well as a heparin drip
and IV beta-blockers and was transferred to the [**Hospital1 346**] on [**2104-6-26**], for cardiac
catheterization. This revealed right dominant system with a
tight osteal left main lesion of 80 to 90 percent as well as
90 percent occlusion at the mid LAD. She had an intra-aortic
balloon pump placed at that time due to her anatomy and the
cardiothoracic surgical consult was obtained. She was
admitted to the Coronary Care Unit over night and
preoperatively prior to coronary artery bypass graft.
PAST MEDICAL HISTORY: Glaucoma.
MEDICATIONS PRIOR TO ADMISSION: Timolol.
ALLERGIES: Keflex and Percodan.
SOCIAL HISTORY: The patient denies alcohol or tobacco intake
and exercises regularly.
Physical examination preoperatively was unremarkable as were
preoperative laboratory values.
She was taken to the Operating Room on [**2104-6-26**], where
she underwent coronary artery bypass graft times 3 with the
LIMA to the LAD, saphenous vein to the OM and saphenous vein
to the diagonal. Postoperatively, she was transported from
the Operating Room to the Cardiac Surgery Recovery Unit in
good condition. The patient was transported from the
Operating Room on Neo-Synephrine with an intra-aortic balloon
pump intact. She was successfully weaned from mechanical
ventilation and extubated later the day of surgery. Her Neo-
Synephrine was weaned off the following day. Her intra-
aortic balloon pump was discontinued. She was started on
beta-blocker and transferred out of the Intensive Care Unit
to the Telemetry Floor on postoperative day 1. On
postoperative day 2, the patient remained hemodynamically
stable in sinus rhythm with a rate in the 80s. Her chest
tubes were discontinued. She was begun with diuretics. On
postoperative day 3, the patient continued to progress from a
physical therapy standpoint. She began ambulation. Her
epicardial pacemaker wires were discontinued on postoperative
day 3. She had not had arrhythmias and was tolerating her
beta-blocker and diuretic regimen.
On postoperative day 4, she continued to progress and
completed physical therapy level 5. She also had her beta-
blocker increased. However, the following day on
postoperative day 5, the patient had a syncopal event upon
getting out of the hot shower. She said that she felt
lightheaded and was helped down to the ground. She denies
any loss of consciousness and no hitting her head at all.
She was alert and oriented upon examination. At that time,
she denied any chest pain and was able to stand and ambulate
to bed without any difficulty. For that reason, her
Lopressor was discontinued and her diuretics were
discontinued as well. Although her blood pressure was 102/42
at the time of the event and her heart rate was 83 and normal
sinus rhythm, it was felt prudent to decrease her beta-
blocker as well as discontinue her Lasix and keep her in the
hospital for another 24 hours. She remained monitored for
the following 24 hours with no further events and no further
syncope and no further lightheadedness and is stable and is
being discharged home today.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Ranitidine 150 mg p.o. b.i.d.
3. Methazolamide 50 mg p.o. b.i.d.
4. Timolol eye drops 0.5 percent b.i.d.
5. Dilaudid 2 mg p.o. one-half to one tablet p.o. q. 4 to 6
hours p.r.n. pain.
6. Plavix 75 mg p.o. q.d.
7. Aspirin 81 mg p.o. q.d.
8. Lopressor 12.5 mg p.o. b.i.d.
9. Vitamin C 500 mg p.o. b.i.d.
10. Folic acid 1 mg p.o. q.d.
11. Niferex 150 mg p.o. q.d.
The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in
approximately 5 weeks. She is to follow up with Dr. [**Last Name (STitle) **] in
one to two weeks as well as with her primary care physician.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft
DISCHARGE CONDITION: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2104-7-2**] 14:52:46
T: [**2104-7-2**] 15:43:56
Job#: [**Job Number **]
|
[
"410.11",
"365.9",
"276.5",
"780.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"88.56",
"39.61",
"36.12",
"36.15",
"99.20",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
4538, 4809
|
3769, 4427
|
4449, 4516
|
1234, 1278
|
164, 1167
|
1190, 1201
|
1295, 3746
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,021
| 139,587
|
27182
|
Discharge summary
|
report
|
Admission Date: [**2164-5-14**] Discharge Date: [**2164-7-6**]
Date of Birth: [**2097-1-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Left Hydonephrosis; Ventral hernia; Sigmoid stricture
Major Surgical or Invasive Procedure:
Cystoscopy, left retrograde pyelogram, attempted
left stent placement.
Exploratory laparotomy, lysis of adhesions (3
hours), rectosigmoid resection and coloproctostomy,
mobilization of the splenic flexure, repair of ventral
hernia, post colostomy.
History of Present Illness:
67F with h/o obstructing sigmoid mass of indeterminant pathology
s/p chemo/rads and resection of mass with transverse colostomy
([**9-20**]). Since this time she has been relatively stable. She
has developed a ventral hernia at the site of her old diverting
colostomy. Routine CT scan on [**4-21**] showed new onset left
hydronephrosis. Presented for left ureteral stent placement
(which was unsuccessful) and elective resection of strictured
sigmoid.
Past Medical History:
Obstructing Rectosigmoid Mass
Emphysema
PSH:
Colostomy/[**Doctor Last Name **]/Jejunostomy Tube [**2163-5-19**]
Open Cholecystectomy
Social History:
+ETOH (~2/day)
+tobacco (50+ pk/yr history)
No recreational drugs
Family History:
Mother died in late 70s of CVA
Father died in mid 60s of "hiatal hernia" (?strangulated hernia)
Physical Exam:
Admission PE- [**2164-5-14**]
96.5 84 102/58 18 97%RA
Gen: alert and in NAD. OX3
Heent: PERRL. Neck supple. OP clear
CV: RRR no m/g/r
Resp: CTAB. good inspiratory effort
Abd: soft, ND, NT (+)transverse colostomy with loose brown
stool. +left side ventral hernia, soft. +BS
Ext: MAE. no c/c/e
Pertinent Results:
PROCEDURE: Cystoscopy, left retrograde pyelogram, attempted
left stent placement.
ASSISTANT: [**First Name4 (NamePattern1) 11894**] [**Last Name (NamePattern1) **], MD.
COMPLICATIONS.: None.
ANESTHESIA: General.
INDICATIONS: The patient is a 67-year-old woman with a
recent CT scan in [**Location (un) 620**] showing a chronically obstructed
left kidney. There is a possible calculus along the route of
the left distal ureter, however, this is beyond the level of
obstruction.
PROCEDURE: The patient was prepped and draped in lithotomy
position. A #22 French cystoscope was inserted into the
urethra which was normal. The bladder mucosa appeared
slightly atrophic, and the ureteral orifices were, however,
normal size and slightly laterally positioned.
A #8 French tapered catheter was gently inserted into the
left distal ureteral orifice and 5 cc of contrast dye was
injected which revealed a distal ureter with complete
retrograde obstruction. Beyond the level of obstruction,
was a very faint calcification, roughly 5-
8 mm in diameter, possibly consistent with the calcification
seen on CT scan. A straight sensor wire was attempted to be
placed beyond the strictured area but was unable. We then
moved to an angled Glidewire and multiple attempts at passing
the Glidewire beyond the area of stricture were unsuccessful.
At this point the decision was made to abort the stent
placement rather than continued attempts at the wire
placement or ureteroscopy without wire access which can result
in
ureteral rupture.
The bladder was emptied and the patient was transferred to
the PACU stable.
PLAN: The patient will likely require a left percutaneous
nephrostomy tube and possible antegrade wire access which may
allow retrograde access to the stricture and possibly the
stone.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 66700**]
PROCEDURE: Exploratory laparotomy, lysis of adhesions (3
hours), rectosigmoid resection and coloproctostomy,
mobilization of the splenic flexure, repair of ventral
hernia, post colostomy.
INDICATIONS: This patient had either diverticulitis or an
obstructing carcinoma of the rectum which we could never get
close enough to do a valid biopsy. She underwent radiation
which remedied whatever the lesion was. We never found any
carcinoma in the specimen and she did have evidence of
diverticular disease. She underwent resection and then a
protective colostomy because of the fact that the anastomosis
never seemed to heal and indeed the most recent barium enema
revealed that she did not have adequate healing and as a
matter of fact had several leaks, probably disruptive of the
anastomosis either because of tension, which I had doubted,
or because of the previous radiation. After preparation the
following procedure was carried out.
PROCEDURE IN DETAIL: Under satisfactory general anesthesia
the patient was placed supine and prepped and draped in the
usual manner. We opened up the left paramedian incision and
were able to free-up of lysis of adhesions in the pelvis
which were extensive and which required extensive revision
starting with the ligament Treitz taking down the previous
feeding jejunostomy, but in fact we were able to get the
entire pelvis freed up without any difficulty. Upon entering
the pelvis there were a number of adhesions that were quite
dense. These were taken down. We actually were able to take
down the small bowel. There was only one area where there was
ballooning out of the serosa which was later repaired with
interrupted 5-0 Prolene and we were then able to go to work
on the previous rectosigmoid which required rectosigmoid
resection in order to get an adequate connection with the
anastomosis on the bottom. There was a stricture at the
previous anastomosis. Initial attempt at irrigation did not
pass any fluid into the pelvis, only later when we mobilized
the colon and had a hole in it was there any irrigation that
came through. We mobilized the small bowel extensively in a
number of areas that were adherent to the pelvis. There was
an abscess which was then drained and irrigated with
gentamicin. We then cultured it as well prior to irrigating
with gentamicin. Finally after mobilizing the splenic
flexure, a 2-layer silk anastomosis was carried out with some
difficulty but finally a good anastomosis was obtained and
reinforced with the appendices epiploica.
In the meantime trying to mobilize the rectum I believe we
injured a branch of the internal iliac and we lost about 750
cc, controlling this with 5-0 Prolene; 2 units were given.
After this and the anastomosis we then changed gowns and
gloves for closure, irrigated and then checked for hemostasis
in the left upper quadrant, as well as around in the pelvis.
A closure of the hernia was done internally first with
approximating the fascia from within with interrupted 0
Vicryl sutures and then closing the peritoneum under it with
a #1 Vicryl suture. The wound was closed in layers. We
decided not to do a feeding jejunostomy because there was no
anastomosis between the mouth and the transverse colostomy.
The wound was closed in layers with #1 chromic catgut on the
peritoneum. Taking the rectus, which previously had been
separated and sewing it over the midline, #1 Vicryl on the
fascia, 3-0 Vicryl on the subcutaneous tissue and 4-0
Monocryl subcuticular closure. Two sponge counts and needle
counts were reported as correct by the nurse in charge. The
patient tolerated the procedure well. Estimated blood loss
was 750 cc. Urine output was scanty at about 60 cc for the
entire case but it picked up as soon as we took her out of
Trendelenburg. She may need some more volume and we did keep
her dry. It should be pointed out that we looked at the area
of the left ureter and indeed it looked like it was stenotic
right at the area with a large ureter above and may have been
radiated.
SECOND ASSISTANT: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**]
Brief Hospital Course:
[**Known firstname 1743**] [**Known lastname 54371**] underwent cystoscopy, left retrograde
pyelogram, and attempted
left stent placement. After the procedure she was admitted to
the surgery service under the care of Dr. [**Last Name (STitle) 957**]. The following
day she underwent exploratory laparotomy, lysis of adhesions,
rectosigmoid resection and coloproctostomy,
mobilization of the splenic flexure, and repair of ventral
hernia. She tolerated the procedure well and was returned to
the floor after recovery in the PACU. Postoperatively she was
afebrile. Hct was stable at 30. Urine output was marginal, but
WNL. Pain was well controlled via epidural. At POD 2 she began
to mobilize fluid. She was tachycardic and had periods of O2
desaturation. ECG was WNL. Troponin was negative. Chest xray
showed bibasilar atelectasis and small pleural effusions. Lasix
was provided. At POD 4 she had return of bowel function. Diet
was advanced. She remained tachycardic despite beta blockade.
She was afebrile. WBC remained elevated at 19.9. AT POD 6 she
was made NPO due to nausea and +gastric distention per KUB. PICC
line was placed and TPN started. NGT was placed. Cardiology was
consulted for persistent tachycardia. She was transferred to the
ICU. Repeat ECG, cardiac enzymes, and echo were WNL. TSH was
WNL. Lactate was 2.1. A moderate amount of clear-amber fluid
was found draining from her rectum and was +creatinine at 32.
CT cystogram and CT urogram were completed which showed large
left retroperitoneal uroma which appeared to leak from distal
left ureter. Significant right hydronephrosis was noted. CT
scan of abdomen/pelvis/chest showed moderate bilateral pleural
effusions and bibasilar atelectasis; abdominal and pelvic
ascites and focal fluid collections in the left abdominal and
pelvic retroperitoneal regions; and active extravasation of
contrast suspicious for ureteral injury. There was no evidence
of pulmonary embolism. There was no evidence of communication
of the fluid collections and the bowel. Fluconazole/Flagyl were
added to the abx regimen. Later in the evening she was intubated
for respiratory distress. At POD 9 she underwent percutaneous
drain placement in the retroperitoneal fluid collection. A left
nephrostomy tube was placed with antegrade nephrostogram showing
probable transected left ureter with free extravasation of
contrast into the pelvis. At POD 10 she remained intubated. She
was transfused for a Hct of 24.5. Abdominal drain began to
appear bilious. Fluid was +Amylase. At POD 11 she was extubated.
She was hemodynamically stable. WBC count was 20.5 from 27. At
POD 14 she was febrile to 101.7. Peritoneal fluid was negative
for growth. Blood and urine cultures were sent. CXR showed
bibasilar pleural effusions and linear opacities. She was
hemodynamically stable. WBC count was 14.7 At POD 15 a repeat CT
scan was completed showing continued abdominal fluid collection.
The pigtail catheter was exchanged. The scan did not reveal a
communication between the collection and bowel. At POD 16 she
was afebrile and doing well. WBC count was down to 9.9. She
continued to have a moderate amount of biliious drainage from
the pigtail drain. At POD 29 she was transferred to the floor.
She was receiving CBI for hematuria. Nephrostomy continued to
drain clear urine. Urine cytology was sent which was negative
for malignant cells. At POD 31 an interval CT scan was performed
to evaluate abdominal fluid collection, as drain output had
greatly decreased. The scan showed no new fluid collection with
marked resolution of drained collection. The urinary catheter
was discontinued. At POD 36 she was afebrile and doing well. The
hematuria was much improved since removal of the catheter. She
had no problems with voiding independently. The pigtail
catheter drainage was decreased to ~50ml per day with increased
ostomy output. She remained NPO with TPN for nutritional
support. At POD 44 the fistula output had dropped off
significantly to about 40ml per day. A repeat CT scan showed no
residual fluid in the area of the pigtail catheter. Her diet
was advanced to clear liquids. By HD 51 she was tolerating a
regular diet, but was not eating adequate calories per calorie
count. Megace was started. TPN was continued and cycled over
night. The pigtail continued with low output. Nephrostomy
remained in place and draining adequately. She was afebrile and
ambulatory. WBC was 12.6, but repeat CT scan showed no new
fluid collection and no interval change in the drain site. A
PICC line was placed and the CVL was removed. On [**7-6**] she was
discharged home. A PICC line was placed prior to discharge for
TPN, as she was not taking in adequate calories. The pigtail
and nephrostomy tubes remained. She was to follow up with Dr.
[**Last Name (STitle) 957**] in clinic in [**1-17**] weeks.
Medications on Admission:
Metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) ml PO DAILY
(Daily).
Disp:*qs * Refills:*0*
3. Megestrol 40 mg/mL Suspension Sig: Ten (10) ml PO Q24H (every
24 hours).
Disp:*qs * Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*0*
6. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
7. Pigtail Flush
Normal Saline 0.9% 10ml syringe. Flush pigtail abdominal drain
with 10ml NS daily.
Disp: 40
Refills: 0
8. PICC Line Care
PICC line care per protocol. Monitor for signs of infection or
misplacement.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Sigmoid Stricture
Hydronephrosis
Ureteral injury s/p attempted stent placement
Post-op urinoma
Post-op abdominal fluid collection
Enteric Fistula w/ drain
Post-op Pneumonia
Post-op Anemia
Discharge Condition:
Stable
Discharge Instructions:
Please return or contact for:
* [**Hospital1 **] (>101 F) or chills
* Nausea or vomiting
* Abdominal Pain
* Increased output of pigtail drain
* Decreased or no output from ostomy
* Misplacement of drains
* Increased redness or drainage from around tube sites
* Chest pain or shortness of breath
* Any other concerns
No showering or tub baths with drains in place. No lifting over
10 pounds or abdominal stretching exercises for 4 weeks.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] in clinic in 2 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:[**2164-7-8**]
|
[
"E878.8",
"596.7",
"401.9",
"V10.06",
"998.59",
"553.21",
"569.81",
"568.0",
"997.4",
"567.38",
"V55.3",
"V15.3",
"518.81",
"305.1",
"593.3",
"593.89",
"492.8",
"591",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"99.04",
"99.15",
"53.51",
"45.76",
"54.59",
"87.74",
"54.91",
"96.48",
"55.03",
"38.93",
"97.29",
"96.71",
"45.94",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13760, 13815
|
7938, 12798
|
366, 617
|
14047, 14056
|
1789, 7915
|
14543, 14788
|
1359, 1456
|
12881, 13737
|
13836, 14026
|
12824, 12858
|
14080, 14520
|
1471, 1770
|
273, 328
|
645, 1102
|
1124, 1259
|
1275, 1343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,036
| 132,480
|
26508
|
Discharge summary
|
report
|
Admission Date: [**2165-3-18**] Discharge Date: [**2165-4-12**]
Date of Birth: [**2086-3-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG x 3 (LIMA->LAD, saphenous vein -->OM, saphenous
vein-->distal RCA) on [**2165-3-27**]
History of Present Illness:
This is a 79 year old female who was transfered from an outside
hospital where she presented 1 day ago in the emergency room
with chest pain and dyspnea on exertion. She has a history of
coronary artery diseas status-post catheterization on [**2-18**]-elevation MI with 3 vessel disease seen and stenting of her
left circumflex coronary. She was found to have EKG changes at
the outside hosptial and elevated cardiac enzymes and was
transferred here. She has no chest pain since admission. She has
a history of diabetes and hypertension. On review of systems she
has no fevers, abdominal pain, or cough.
Past Medical History:
s/p TAH/BSO
s/p cholecystectomy
type 2 DM
status-post R fem->ant tibial bypass [**1-18**] complicated by wound
infection
Anxiety
Retinopathy
Hypertension
Coronary Artery disease
GERD
ST-elevation MI in [**2-18**] w/ catheterization and stenting of left
circumflex
Constipation
Social History:
The patient lives with her grandson. She is non-english
speaking. She has a history of tobacco use and occasionally
drinks alcoholic beverages.
Family History:
non-contributory
Physical Exam:
On admission:
97.6, 60 sinus, 174/73, 20, 96 % room air
Gen: no acute distress, comfortable
HEENT: moist mucous membranes
Neuro: non-focal
CV: regular rate and rhythm, no murmur
Pulm: bilateral basilar rales
Abd: soft, non-tender
Extr: absent palpable peripheral pulses in LLE, RLE with splint
Pertinent Results:
[**2165-3-18**] 12:35PM BLOOD WBC-7.7 RBC-3.88* Hgb-11.7* Hct-35.6*
MCV-92 MCH-30.1 MCHC-32.8 RDW-16.3* Plt Ct-254
[**2165-3-18**] 06:22PM BLOOD WBC-7.0 RBC-3.86* Hgb-11.7* Hct-35.1*
MCV-91 MCH-30.3 MCHC-33.4 RDW-16.3* Plt Ct-253
[**2165-3-18**] 12:35PM BLOOD Neuts-57.7 Lymphs-32.9 Monos-7.0 Eos-2.2
Baso-0.3
[**2165-3-18**] 12:35PM BLOOD PT-15.6* PTT-41.0* INR(PT)-1.4*
[**2165-4-8**] 05:32AM BLOOD PT-26.1* INR(PT)-2.7*
[**2165-4-9**] 04:15AM BLOOD PT-39.7* INR(PT)-4.4*
[**2165-4-10**] 10:05AM BLOOD PT-25.5* INR(PT)-2.6*
[**2165-4-11**] 05:00AM BLOOD PT-21.5* INR(PT)-2.1*
[**2165-4-11**] 05:00AM BLOOD WBC-11.5* RBC-3.60* Hgb-10.6* Hct-31.1*
MCV-86 MCH-29.4 MCHC-34.1 RDW-15.2 Plt Ct-327
[**2165-3-18**] 12:35PM BLOOD Glucose-177* UreaN-15 Creat-1.0 Na-145
K-3.2* Cl-106 HCO3-32 AnGap-10
[**2165-4-10**] 10:05AM BLOOD Glucose-146* UreaN-38* Creat-1.5* Na-142
K-3.8 Cl-100 HCO3-33* AnGap-13
[**2165-4-11**] 05:00AM BLOOD Glucose-49* UreaN-31* Creat-1.2* Na-141
K-3.3 Cl-99 HCO3-34* AnGap-11
[**2165-3-18**] 06:22PM BLOOD ALT-80* AST-58* CK(CPK)-19* AlkPhos-186*
TotBili-0.4
[**2165-3-28**] 02:58AM BLOOD ALT-33 AST-161* LD(LDH)-481* AlkPhos-83
Amylase-69 TotBili-0.4
[**2165-3-30**] 12:52PM BLOOD ALT-38 AST-98* LD(LDH)-477* AlkPhos-244*
Amylase-71 TotBili-1.1
[**2165-3-18**] 12:35PM BLOOD CK-MB-2 cTropnT-0.02*
[**2165-3-18**] 06:22PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2165-3-19**] 05:57AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2165-3-26**] 09:08PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2165-3-27**] 04:22AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2165-3-18**] 12:35PM BLOOD Calcium-8.4 Phos-3.2 Mg-1.7
[**2165-3-28**] 02:58AM BLOOD Albumin-1.9* Phos-2.9 Mg-3.0*
[**2165-3-31**] 03:26PM BLOOD Albumin-2.7*
[**2165-3-18**] 06:22PM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE
[**2165-3-19**] 06:12PM BLOOD Vanco-16.1*
[**2165-3-23**] 08:02PM BLOOD Vanco-16.2*
[**2165-3-25**] 04:39AM BLOOD Vanco-24.4*
[**2165-4-1**] 08:52AM BLOOD Vanco-12.6*
MICROBIOLOGY: [**3-29**] blood culture: negative, [**3-29**] c. diff:
negative, [**4-4**] c. diff: negative
RADIOLOGY:
[**2165-3-18**] CXR: There are small bilateral pleural effusions and
associated bibasilar opacities consistent with atelectasis
and/or consolidation, especially in the left lower lobe,
essentially unchanged. No definite new lung lesions. No
pneumothorax.
[**2165-3-27**] CXR: Patient is status post interval median sternotomy
and coronary artery bypass surgery. An endotracheal tube is
present, terminating in the right main bronchus. Swan-Ganz
catheter terminates in the distal right pulmonary artery, right
PICC line terminates in the superior vena cava, nasogastric tube
terminates below the diaphragm, and mediastinal drains and
left-sided chest tube are present. Cardiac and mediastinal
contours are stable compared to the preoperative radiograph.
There is mild interstitial pulmonary edema present, note is made
of patchy atelectasis in left lower lobe and lingula as well as
a probable small left pleural effusion.
[**2165-4-10**] CXR: 1. Left PICC terminating in the distal SVC without
evidence of pneumothorax.
2. Continued bilateral pleural effusions and left basilar
atelectasis
CARDIOLOGY:
[**2165-3-18**] TTE: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed with global hypokinesis and akinesis of the basal to
mid inferior wall . Tissue velocity imaging E/e' is elevated
(>15) suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal. Right
ventricular systolic function is borderline normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2165-2-19**], the
overall LVEF is similar and the degree of mitral regurgitation
appears slightly less.
[**2165-3-27**] TEE: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Left ventricular wall thicknesses
and cavity size are normal. Overall left ventricular systolic
function is moderately depressed. Resting regional wall motion
abnormalities include akinetic basal inferior which is also
aneurysmal; mid and apical anteroseptal and anterior hypokinetic
walls; basal inferoseptal hypokinetic wall. Right ventricular
chamber size and free wall motion are normal. .
Mitral valve: The mitral valve leaflets are mildly thickened
with no prolapsing or flail segments. Evaluation by color flow
doppler (vena contracta 4-5mm), pulmonary venous inflow (no
systolic reversal or blunting of pulmonary veins of both sides),
mitral annulus (30mm), dilated left atrium (4.7cm) and normal
sized left ventricle in diastole (5.6 cm), a central regurgitant
jet is visualized which is consistent with moderate (2+) mitral
regurgitation under anesthesia and with provocative measures
like trendelenburg position.
POSTBYPASS:
Mild improvement in the wall motion abnormalities of the
previously hypokinetic areas. LVEF 40% with epinephrine running
at 0.05mcg/kg/min. Mitral regurgitation is mild to moderate.
Ascending aorta looks okay without any evidence of dissection.
Brief Hospital Course:
This is a 79 year old female who was admitted with unstable
angina on [**2165-3-18**]. This was in the setting of cardiac
catheterization with stenting. She was hemodynamically stable on
admission and was admitted to the floor for close monitoring.
Cardiology was [**Date Range 4221**] upon admission for pre-operative
planning and a preoperative echo was obtained. She was continued
on lasix and beta-blockade preoperatively but plavix (for her
recent lower extremity bypass) was held. Vascular surgery
consultation was obtained given her recent bypass procedure and
history of groin infection and she was started on pre-operative
antibiotics. [**Last Name (un) **] consultation was also obtained for
assistance with blood sugar control. She was taken to the
operating room for a CABG x3 on [**2165-3-27**] (please see the
operative note of Dr. [**Last Name (STitle) **] for full details). She was
extubated without complication early in her post-operative
course but required re-intubation for respiratory compromise.
She had acute oliguric renal failure post-operatively which
improved with hydration and diuretics. She also had acute atrial
fibrillation post-operatively which was treated with amiodarone;
she did, however require cardioversion for unstable Afib on
post-operative day 6. She was started empirically on vancomycin
and meropenum for leukocytosis post-operatively in the setting
of her known groin infection, as per Infectious Disease
department recommendations. Wet to dry dressings were continued
to these incisions. Of note, she developed what appeared to be a
sternal wound infection vs partial dehiscence around one week
post-operatively and vancomycin was continued. Betadine
occlusive dressings were applied daily to her sternum with
improvement. From a nutritional standpoint, given her prolonged
intubation she required some tube feeding post-operatively;
eventually she was able to tolerate a regular diet. After her
first re-intubation she was again extubated on post-operative
day 6 without complication. She was transferred out of the
intensive care unit on post-operative day 10. Rehab screening
was obtained. She was gently diuresed towards her preoperative
weight. Physical therapy worked with her daily for assistance
with her postoperative strength and mobility. The wound care
nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for some mild pressure ulcers. Her coumadin
was titrated for her target INR of 2.0-2.5. A PICC line was
placed for her intravenous antibiotics. Vancomycin and
levofloxacin were continued per the infectious disease and
vascular surgery service. She will remain on one additional week
of vancomycin and levofloxacin from her date of discharge. The
[**Last Name (un) **] diabetes service continued to adjust her diabetes
medications to ontain tight control of her blood suagrs. Ms.
[**Known lastname **] continued to make steady progress and was discharged to
rehabilitation on [**2165-4-12**]. She will follow-up with Dr. [**Last Name (STitle) **],
her cardiologist, the vascular surgery service and her primary
care physician as an outpatient. Dr. [**First Name (STitle) **] will manage her
coumadin dosing and blood work when she is discharged from
rehabilitation.
Medications on Admission:
On admission:
Lopressor 200 po bid
Protonix 40 po qdaily
Percocet prn
Ambien 5 mg po qhs
lipitor 80 mg po qdaily
aspirin 325 mg po qdaily
plavix 75 mg po qdaily
colace 100 mg po bid
lasix 40 mg po qdaily
insulin
glyburide 5 mg po qdaily
Lisinopril 20 mg po qdaily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
adjust dosage based on INR goal 2.0-2.5
.
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*240 Tablet(s)* Refills:*0*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*qs ML(s)* Refills:*0*
8. 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 Daily and PRN. Inspect site every shift
9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*120 Tablet(s)* Refills:*0*
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs qs* Refills:*0*
15. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. 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*
18. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 days.
Disp:*2 Tablet(s)* Refills:*0*
19. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs qs* Refills:*0*
21. Insulin Glargine 100 unit/mL Solution Sig: Three (3) units
Subcutaneous at bedtime.
Disp:*qs units* Refills:*2*
22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
23. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: See Regular Insulin sliding scale
qachs.
Disp:*qs qs* Refills:*2*
24. Vancomycin in Normal Saline 1 g/250 mL Solution Sig: One (1)
Intravenous q48hrs for 7 days: please check Vanc trough with
3rd dose.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
CAD
PVD
HTN
hypercholesteremia
MI [**2-18**]
TAH/BSO
CCY
DM
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever >101, redness or drainage from incision, or
weight gain more than 2 pounds in one day or five pounds in one
week.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Hospital Ward Name 121**] 2 wound clinic on [**2165-4-19**] between 11-1PM
follow up with Dr. [**Last Name (STitle) **] in two weeks [**Telephone/Fax (1) 170**]
follow up with PCP or [**Hospital1 18**] primary care center [**Telephone/Fax (1) 65485**] in [**1-14**] weeks.
follow up with Dr. [**First Name (STitle) **] in two weeks [**Telephone/Fax (1) 4022**]
Completed by:[**2165-4-12**]
|
[
"707.19",
"424.0",
"V45.82",
"411.1",
"428.0",
"707.14",
"041.4",
"584.5",
"998.32",
"682.2",
"427.31",
"250.00",
"410.72",
"518.5",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"38.93",
"96.6",
"39.61",
"36.12",
"96.72",
"36.15",
"88.72",
"99.04",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
14250, 14330
|
7521, 10764
|
325, 417
|
14434, 14441
|
1875, 7498
|
14811, 15206
|
1527, 1545
|
11079, 14227
|
14351, 14413
|
10790, 10790
|
14465, 14788
|
1560, 1560
|
275, 287
|
445, 1050
|
10805, 11056
|
1072, 1350
|
1366, 1511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,565
| 176,687
|
6011+6012
|
Discharge summary
|
report+report
|
Admission Date: [**2198-11-11**] Discharge Date: [**2198-11-11**]
Service: PURP [**Doctor First Name 147**]
NOTE: The patient was admitted to the Purple Surgery Service
on [**2198-11-11**], and transferred to the Cardiology Service on
[**2198-11-16**].
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
male with a history of abdominal pain times three days and a
left inguinal hernia. The patient's family reports that the
hernia has increased in size in the last three weeks. There
has been no nausea or vomiting. The patient did have flatus
on the day of admission, but decreased bowel movements in the
past week. The hernia was reported to the primary care
physician. [**Name10 (NameIs) **] patient has no history of incarceration, and
no fever or chills. The patient has been tolerating an oral
diet.
The patient is deaf and mute and illiterate; however, the
patient does understand sign language.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Large B-cell lymphoma, status post CHOP.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lopressor 50 mg twice a day.
2. Nifedipine XL 60 mg q. day.
3. Accupril 20 mg twice a day.
4. Hydrochlorothiazide 20 mg three times a day.
LABORATORY: White blood cell count 13.5, hematocrit 38.5,
platelets 118, 70% neutrophils, 22% lymphocytes. Sodium 125,
potassium 3.2, chloride 90, HCO3 22, BUN 36, creatinine 1.6,
glucose 113.
KUB: Dilated loops of bowel with air fluid levels.
EKG with left bundle branch block.
PHYSICAL EXAMINATION: Vital signs with temperature at 95.9
F.; 66; 100/47; 10; 100% on two liters. Respiratory: Rales
left lung base. Cardiovascular: Regular rate and rhythm.
Abdomen soft, nontender, slightly distended. Rectal with no
masses, heme negative. Groin: Large left inguinal hernia,
nonreducible; no skin changes. Extremities warm.
HOSPITAL COURSE: On [**2198-11-11**], the patient was taken to the
Operating Room for repair of an incarcerated left inguinal
hernia. As part of the procedure the patient underwent an
ileocecectomy and a left [**Doctor Last Name 11455**] hernia repair.
Intraoperatively, the inguinal hernia was found to be
strangulated. Please see dictated Operative Note for further
details.
The patient came from the Operating Room with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**]
drain routed to the left scrotum and a second [**Location (un) 1661**]-[**Location (un) 1662**]
drain to the right pelvis. The [**Location (un) 1661**]-[**Location (un) 1662**] drain that went
to the right pelvis was removed on postoperative day four.
Postoperatively, the patient was found to be in atrial
fibrillation and an EKG showed T waves in V2 and V3, lead III
and lead AVF. Because of this and the patient's electrolyte
abnormalities, the patient was sent to the Unit for a day.
The patient was placed on Cefazolin and Flagyl, both of which
were continued throughout the patient's stay on the Purple
Surgery Service.
Postoperatively, the patient had three sets of cardiac
enzymes and ruled out for a myocardial infarction; however,
the patient continued in ventricular fibrillation. He was
placed on Metoprolol and the dose was gradually increased for
rate control. At the end of postoperative day one, the
patient was transferred to the floor.
The following day, the patient appeared to be in moderate
distress; he had end expiratory wheezes and a tender abdomen
with voluntary guarding. The [**Location (un) 1661**]-[**Location (un) 1662**] in his scrotum
put on two ml and the [**Location (un) 1661**]-[**Location (un) 1662**] in his abdomen put out 30
ml. Because of the patient's pain, the patient was changed
to an intravenous PCA machine.
By postoperative day two, the patient's sodium had risen to
132 with an ongoing infusion of normal saline. His potassium
continued to drop periodically, being 3.4 on postoperative
day two, for which he was repleted. His BUN was 25 and his
creatinine was 1.1.
A Cardiology consultation was obtained and they found that
the atrial fibrillation and left bundle branch block were new
on this admission. They recommended oral anti-coagulation
when consistent with surgery and rate control. Cardioversion
was anticipated when the patient had a therapeutic INR. They
suggested an increase in beta blockers and a TSH level and
Coumadin with a goal INR of 2.0 to 3.0 when safe.
The patient's TSH came back at 6.1 and the patient was
therefore started on oral Levothyroxine.
An echocardiogram was also obtained which showed an left
ventricular ejection fraction of 25 to 30% with hypo and
akinesis of several walls, suggestive of coronary artery
disease. The patient also had a three plus mitral
regurgitation, a four plus tricuspid regurgitation and
probably mild aortic stenosis. They felt that this
represented a case of ischemic cardiomyopathy with severe
systolic heart failure and severe valvular disease added to
the atrial fibrillation.
They suggested that the Metoprolol be increased, that an ACE
inhibitor be started, and that digoxin be added to the
patient's regimen. All of these were done.
On postoperative day three, the patient continued to have
voluntary guarding of his abdomen but his pain appeared to be
brief. Later on postoperative day three, the patient
reported a large amount of flatus and was therefore begun on
a clear diet. His intravenous was Hep-locked and he
continued to require repletion for low potassium.
On postoperative day five the patient had a benign abdominal
examination and reported flatus. He tolerated his liquid
diet the previous day very well and therefore he was advanced
to a full diet which he again tolerated well.
On postoperative day five, the patient was transferred to the
Cardiac Service for further work-up of his ischemic
cardiomyopathy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], M.D. [**MD Number(1) 23652**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2198-11-18**] 10:54
T: [**2198-11-18**] 19:49
JOB#: [**Job Number 23653**]
Admission Date: [**2198-11-11**] Discharge Date: [**2198-12-9**]
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23654**] is an 81 year old
male with a history of non Hodgkin's lymphoma, status post
radiation chemo treatment and hypertension. He is deaf. He
presented with a three day history of abdominal pain. He was
found to have an incarcerated hernia and was admitted to the
surgery service for successful repair. See surgery dictation
and operating room note for further details regarding his
surgery. After the surgery, he was found to be in atrial
fibrillation with a left bundle branch block on his
electrocardiogram. He was ruled out by cardiac enzymes. He
denies any chest pain or shortness of breath. At home, the
patient is very functional. He does not complain of chest
pain or shortness of breath. He denies any orthopnea,
paroxysmal nocturnal dyspnea, leg swelling.
Surgery service requested an echocardiogram which showed an
ejection fraction of 25%, normal left ventricular wall
thickness and severe regional wall motion abnormalities;
akinesis of the inferior septal wall; hypokinesis of the
septal wall. 3+ mitral regurgitation, 2+ mitral
regurgitation, moderate pulmonary hypertension. MRA
moderately dilated.
He was seen in consultation by our EP service who recommended
rate control, anticoagulation and follow-up for D-C
cardioversion. The patient was admitted to the C-Med service
for cardiac catheterization.
PAST MEDICAL HISTORY: Non Hodgkin's lymphoma in [**2185**], status
post radiation treatment, status post CHOP chemotherapy in
[**2186**] and [**2187**], currently in remission. Hypertension.
Deafness.
MEDICATIONS ON TRANSFER:
Mucomyst.
Magnesium oxide.
Lasix 20 mg p.o. twice a day.
Coumadin 2.5 mg p.o. q. day.
Lopressor 150 mg intravenous three times a day.
Percocet 1 mg p.o. four times a day prn.
Digoxin 0.125 mg p.o. q. day.
Captopril 12.5 mg p.o. three times a day.
Levothyroxine 100 mg p.o. q. day.
Flagyl 500 mg p.o. three times a day.
Kefzol 1 mg p.o. three times a day.
SOCIAL HISTORY: The patient is deaf. He lives with his
wife. His daughter interprets for him. Denies smoking or
alcohol use. Interestingly, the patient was institutionalized
as a child and has wariness for medical care. No known drug
allergies.
PHYSICAL EXAMINATION: On examination, the patient was
afebrile; heart rate of 102 and irregular; blood pressure
104/76; respiratory rate of 18; 99% on room air. In general,
he is in no apparent distress. HEAD, EYES, EARS, NOSE AND
THROAT: Extraocular movements intact. MMI. Sclera
anicteric. Right orbit sunken. Has a glass eye in the right
orbit. Neck: Some jugular venous distention, no carotid
bruits. Chest: Mild crackles at bases. CV: Irregularly
irregular, no murmurs appreciated. Abdomen: Soft, nontender,
nondistended. Normoactive bowel sounds. Midline incision was
[**Location (un) 1661**]-[**Location (un) 1662**] drain, clean, dry and intact. Extremities:
Trace to 1+ edema bilaterally. 1+ femoral pulses
bilaterally. 1 to 2+ dorsalis pedis pulses bilaterally. No
femoral bruits.
LABORATORY DATA: On admission, white count was 14.3;
hematocrit of 32.9; potassium of 3.2; BUN 42; creatinine 1.4;
magnesium 1.6.
Electrocardiogram showed left bundle branch morphology and
irregularly irregular rhythm.
HOSPITAL COURSE: 1.) Incarcerated hernia: Please see
surgery operative report and dictation for further details
regarding his surgery during the course of his time on the
C-Med service. His midline incision healed. He had a
dehiscence of the lower groin incision; however, the wound
was clean and did not have any drainage. At the time of
discharge, both incisions were clean, dry and intact.
2.) Coronary artery disease: The patient had an
echocardiogram on [**2198-11-14**] which showed a moderately dilated
left atrium. Severe regional left ventricular systolic
dysfunction with inferior akinesis, septal hypokinesis,
apical hypokinesis/akinesis and hypokinesis elsewhere. Right
ventricular chamber size and free wall motion are normal. 3+
mitral regurgitation. 2+ tricuspid regurgitation. 4+ CR.
Moderate pulmonary artery systolic hypertension.
The patient was then taken for a cardiac catheterization on
[**2198-11-16**] where he was found to have a diffuse 30% stenosis of
the proximal right coronary artery, 30% stenosis at the mid
right coronary artery and 60% stenosis at the distal right
coronary artery. He had discrete 30% stenosis of the left
main, discrete 50% stenosis of the mid left anterior
descending and a 90% stenosis of the diffusely diseased left
circumflex. Final diagnoses were as follows:
One vessel coronary artery disease.
Mildly elevated LVEDP.
No aortic stenosis.
Mitral regurgitation.
Atrial fibrillation.
Successful stenting of the mid left circumflex.
The patient was started on Plavix. He was continued on
aspirin and beta-blocker during the course of his
hospitalization. He complained of no further chest pain.
However, during the course of subsequent events in the
hospital and stresses, it was noted that when the patient had
an increased heart rate, he had mildly elevated troponin
2.05, believed to be related to elevated heart rate.
Subsequent electrocardiograms throughout his hospitalization
showed no changes compared to previous electrocardiograms.
Atrial fibrillation: The patient was seen in consultation by
Dr. [**Last Name (STitle) 284**] in the EP service. He was rate controlled
with beta-blocker and was started on Coumadin for
anticoagulation. One attempt at cardioversion was made;
however, he spontaneously reverted back to atrial
fibrillation. At the time of this dictation, the patient is
continued on heparin for anticoagulation, being rate
controlled with a beta blocker. Eventually, he will be
transitioned back to Coumadin after his hospitalization.
Congestive heart failure: The patient was transferred to the
Intensive Care Unit for acute congestive heart failure
exacerbation during the course of the hospitalization. He
was diuresed with Lasix. He has an ejection fraction of 25%.
He was continued on a beta-blocker, Ace inhibitor and Lasix.
At the time of this dictation, he is well compensated without
signs or symptoms of congestive heart failure.
Mental status change: After the time of the patient's DC
cardioversion, the patient was noted to have some mental
status changes. He became agitated, was intermittently
staring off into space and was not responding appropriately
to his sign language interpreter or family. At that time, he
had a CT scan and MR which were both negative for acute
bleed. However, the MR was poor study because of his
movement. He was also seen in consultation by the neurology
service and an EEG was obtained which showed diffuse
encephalopathy but no focal seizure activity. It was felt
that his change in mental status was secondary to delirium
which could be caused by a multiple of factors including
changes in electrolytes. At the time of the change in mental
status, the patient was noted to be hypernatremic. He also
had a chest x-ray which showed a right lower lobe infiltrate,
believed to be an aspiration pneumonia. At that time, he was
placed on Ceftriaxone and Flagyl to treat the aspiration
pneumonia. He completed a 14 day course of antibiotics.
Around the time that his mental status began to change, he
also stopped swallowing.
Swallowing: When he had mental status changes, he stopped
swallowing. He had a total of two speech and swallow
evaluations during his hospitalization, both of which showed
contrast slipping into the trachea and not prompting a
swallow reflex. The cause of his decline in swallowing is
thought to be secondary to his mental status changes and
delirium. Nasogastric tube was placed and tube feeds were
started during the course of his admission. At the time of
this dictation, gastroenterology service has seen the patient
in consultation and is planning for percutaneous endoscopic
gastrostomy placement prior to discharge to a rehabilitation
facility.
Mental status changes: The patient's mental status changes
could be due to a number of causes during this
hospitalization but, at the time of this dictation, his
mental status has improved to the point where he is
appropriately responding to sign language interpreters and
his family, although he is extremely fatigued and weak and is
not able to be attentive for more than a few minutes at a
time.
Hypothyroidism: The patient was continued on Levothyroxine.
He did have his TSH checked during this hospitalization. At
one point, it was borderline high; however, considering his
medical issues, it was recommended that after discharge he
have his thyroid function tests rechecked and his medications
adjusted accordingly.
DISCHARGE DIAGNOSES:
Deafness.
Coronary artery disease.
Congestive heart failure, Ejection fraction of 25%.
Atrial fibrillation.
Status post hernia repair and right colectomy.
Hypothyroidism.
DISCHARGE MEDICATIONS:
Dictation will be amended at the time of discharge to include
discharge medications.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**]
Dictated By:[**Last Name (NamePattern1) 2706**]
MEDQUIST36
D: [**2198-12-7**] 03:21
T: [**2198-12-7**] 17:08
JOB#: [**Job Number 23655**]
|
[
"507.0",
"562.12",
"557.0",
"518.81",
"584.9",
"550.10",
"428.0",
"202.80",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.72",
"45.72",
"99.62",
"96.6",
"45.93",
"99.04",
"53.03",
"88.56",
"36.07",
"37.23",
"47.19",
"36.01",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
14927, 15099
|
15122, 15500
|
9464, 14906
|
8441, 9446
|
6232, 7584
|
7812, 8168
|
7606, 7787
|
8185, 8418
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,192
| 152,949
|
28345+28346
|
Discharge summary
|
report+report
|
Admission Date: [**2177-11-6**] Discharge Date: [**2177-11-14**]
Date of Birth: [**2113-10-26**] Sex: M
Service: [**Last Name (un) 7081**]
CHIEF COMPLAINT: Shortness of breath.
DIAGNOSIS: Right lung mass.
HISTORY OF PRESENT ILLNESS: This 64-year-old gentleman with
02 requirement at home who has had several months of dyspnea
on exertion. The patient says he has been unable to walk out
of his bedroom without feeling shortness of breath. He denies
any chest pain, palpitations, lightheadedness. He denies any
other weight loss and has been seen by Dr. [**Last Name (STitle) 952**] and comes
to the [**Hospital1 18**] for a thoracotomy and segmentectomy for his lung
mass that was seen on CT.
PAST MEDICAL HISTORY: Notable for COPD and BPH.
PAST SURGICAL HISTORY: Notable for left knee replacement,
left distal interphalangeal index finger amputation, left
carpal tunnel release.
SOCIAL HISTORY: The patient has a longstanding smoking
history; 1 pack per day for 40 years. Occasional EtOH use. No
illicit drug use. The patient is married with children and
grandchildren.
FAMILY HISTORY: Father and brother died of bladder cancer.
Mother died of MI and gastric carcinoma.
MEDICATIONS AT HOME: Include albuterol, Flomax, lorazepam
and Spiriva.
ALLERGIES: The patient has no known allergies.
PHYSICAL EXAMINATION: On presentation to the hospital was
98.6, 116, 146/84, 18, 93% on 2 liters. The patient was
pleasant. In no acute distress. He was awake and oriented x
3. Lungs were decreased over the bilateral bases. He was a
regular rate and rhythm, plus S1/S2 with no murmurs, rubs or
gallops. The patient was obese, soft, distended, but
nontender abdomen. No clubbing, cyanosis or edema noted on
the lower extremities.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 18**] on
[**2177-11-6**] and was admitted under endothoracic surgery
service under Dr. [**Last Name (STitle) 952**]. Upon presentation, the patient was
sent for a CT scan with contrast; which was notable for a 5.2-
x 5-cm right lung mass with several small adjacent satellite
nodules. Emphysema was noted. A 3-cm cyst at the upper pole
of the right kidney was also seen. The patient was then
preoperatively prepared. An EKG which showed normal sinus
rhythm with no signs of ischemia. An x-ray was also obtained
on the 17th which showed a large right hilar mass. No
evidence of acute cardiopulmonary process. The patient was
scheduled to go for an operation on the 17th; however, he was
rescheduled for [**11-8**] for his operation of a right
thoracotomy and right segmentectomy. Pathology was sent,
which is still pending. The patient tolerated the procedure
well without any real complications. A chest tube was
inserted into the right thorax. Postoperative chest x-ray was
noted which showed a posterior section of atelectasis of the
remnant upper lung with a 17-mm apical pneumothorax and an
indwelling chest tube x 2. The patient was sent to the
cardiac service ICU postoperatively. He received Ancef. His
left chest showed decreased breath sounds with a faint
wheeze. The right chest was coarse to the apex with decreased
sounds at the base. Chest tube put out 250 cc for one and 100
cc for the other. They were both to suction with no air leak
seen, and they were pulling serosanguineous material.
On postoperative day #2, the patient continued to do well. A
chest x-ray was obtained on the 20th which again - compared
to the 19th - showed a small right apical pneumothorax which
had a slight increase in size. There was a new right
streaking mid lung field opacity; which was probably due to
atelectasis.
On postoperative day #3, the patient did well. He did become
anxious and agitated overnight, and causing him to remove his
[**Doctor Last Name 406**] chest tube and his peripheral IV. The [**Doctor Last Name 406**] put out 180
cc before it was pulled. On the 21st, as well, the apical
chest tube was also removed and an x-ray was also obtained
which showed a moderate hydropneumothorax which was
relatively unchanged from previous exams.
On the 22nd, the patient again underwent another chest x-ray
which showed a slightly increased pneumothorax with a
significantly pleural effusion which was possibly loculated.
Later in that afternoon he underwent another chest x-ray
which showed an interval decrease in the size of the right
apical pneumothorax. His right lung mass and superimposed
mild edema were also seen. On the 23rd, the patient underwent
another which showed little interval from prior examination.
A pneumothorax was again. There was also a right lung mass
resection with postoperative clips seen.
Upon discharge, the patient is sent for an x-ray which shows
no change from previous exams with the left lung being clear.
The patient is doing well today, and he is no acute distress.
Alert and oriented x 3. His lungs are clear. He is regular
rate and rhythm. Positive S1/S2. He has a soft, obese,
distended but nontender belly. No clubbing, cyanosis or edema
is noted. A PT evaluation was obtained on the 20th, which
said the patient would probably need pulmonary rehab for his
pulmonary issues and for pulmonary PT.
RELATIVE SIGNIFICANT RESULTS IN LABORATORIES: Upon
admission, the patient had a white count of 10.4, with
hematocrit 35.5, a platelet count of 291. He also had a
sodium of 143, a potassium of 4.3, a chloride of 101, with a
bicarbonate of 34, his BUN was 14, with a creatinine of 1.1,
and a glucose of 109, and a calcium of 9.7, a phosphorous of
3.4, and a magnesium of 2.1. Immediately postoperatively, the
patient had a white count of 7.9 with a hematocrit of 29.3, a
platelet count of 267. The patient did not require any
transfusions during this admission. Postoperatively, he had a
sodium of 139, a potassium of 4.1, a chloride of 92, a
bicarbonate of 43, a BUN of 11, a creatinine of 0.7, with a
glucose of 128. He also had a calcium of 8.3, a phosphorous
of 2.7 and a magnesium of 2.0. Upon discharge, the patient
has a white count of 6.6, a hematocrit of 33.3 and a platelet
count of 437. He has a sodium of 138, a potassium of 4.0,
chloride 91, bicarbonate 40, BUN 13, creatinine 0.8, and
glucose of 172. He has a calcium of 9.3, a phosphorous of
3.7 and a magnesium level of 2.2.
DISCHARGE STATUS/INSTRUCTIONS: The patient is status post a
segmentectomy for a right upper lobe lung mass. He was
instructed that he had this operation, that he is going to
be discharged on pain medication. He was told not to drive or
operate heavy machinery. He is going to be sent to a rehab
facility for pulmonary toilet and postoperative care. The
facility was told that he should come back to the [**Hospital1 18**] for
the following reasons: Temperature greater than 101.5,
increasing pain, nausea or vomiting which may be noted,
increased shortness of breath above the 2-liter oxygen
requirement that the patient maintains at home, increasing
pain or any shortness of breath that the patient may
experience.
MAJOR INVASIVE PROCEDURE: The patient is status post a right
posterior and apical segmentectomy.
DISCHARGE FOLLOWUP: He is to follow up with Dr. [**Last Name (STitle) 952**] in 2
to 3 weeks for a postoperative care evaluation and monitoring
of his pulmonary status.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 29268**]
MEDQUIST36
D: [**2177-11-14**] 09:38:34
T: [**2177-11-14**] 10:42:47
Job#: [**Job Number 68811**]
Admission Date: [**2177-11-6**] Discharge Date: [**2177-11-14**]
Date of Birth: [**2113-10-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
right lung mass
Major Surgical or Invasive Procedure:
Right muscle sparing thoracotomy with posterior and
apical segmentectomy of the right upper lobe.
Right thoracoscopy diagnostic.
Flexible bronchoscopy.
History of Present Illness:
The patient had is a delightful
64-year-old gentleman with severe COPD with oxygen dependent.
He is on supplemental oxygen of 2.0 liters. Found to have a
non-small cell lung cancer of the right upper lobe in the
posterior and apical segment. He underwent extensive staging
including cervical mediastinoscopy with biopsy and was found
to have no evidence of metastatic disease.
Past Medical History:
COPD-O2 dependent, BPH
Social History:
Long-standing smoking history (1 PPD x 40 yrs), occasional
EtOH use. No illicit drug use. Pt is married with children and
grand-children
Family History:
Father and Brother died of bladder CA, Mother died of MI and
Gastric CA
Physical Exam:
98.6-116-146/64-18-93% 2L
Pleasant and in no acute distress. Awake alert and oriented
RRR +S1/S2 with no murmurs, rubs, gallops
Decreased breath sounds over bilateral bases
Obese, Soft, distended, NT
No clubbing, cyanosis, edema of lower extremities
Brief Hospital Course:
refer to medical record for hospital course
Medications on Admission:
Albuterol, Flomax, O2 2L
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) **]
Discharge Diagnosis:
right posterior and apical upper lobe segmentectomy-pathology
pending
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 64878**] if you develop, fevers,
chills, chest pain, shortness of breath, redness or drainage
from your chest incisions.
You may shower on thursday. After showering, remove your chest
tube dressing and cover the site with a clean bandaid daily
until healed.
Followup Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for a follow up
appointment
Completed by:[**2178-2-19**]
|
[
"512.1",
"518.81",
"162.3",
"E878.6",
"276.2",
"600.00",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.3"
] |
icd9pcs
|
[
[
[]
]
] |
9361, 9425
|
9026, 9071
|
7877, 8038
|
9539, 9555
|
9919, 10042
|
8662, 8736
|
9146, 9338
|
9446, 9518
|
9097, 9123
|
1777, 7079
|
9579, 9896
|
1228, 1328
|
794, 911
|
8751, 9003
|
1351, 1759
|
7822, 7839
|
7100, 7805
|
8066, 8445
|
8467, 8491
|
8507, 8646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
735
| 127,633
|
55896
|
Discharge summary
|
addendum
|
Name: [**Known lastname 5005**], [**Known firstname 647**] Unit No [**Unit Number 5006**]
Admission Date: [**2120-2-9**] Discharge Date: [**2120-2-17**]
Date of Birth: Sex:
Service:
ADDENDUM:
HOSPITAL COURSE: This is a 51-year-old female admitted after
undergoing right radical nephrectomy for renal cell
carcinoma. She was left with a chest tube and on [**2120-2-10**]
was hemodynamically stable. Later that day she developed
acute shortness of breath requiring transfer to the SICU.
She was thought to have a high probability of pulmonary
embolism complicated with congestive heart failure.
She was observed and eventually anticoagulated. The patient
was heparinized and eventually changed to Coumadin. She was
seen by her primary care doctor who was to follow her
postoperative for management of her anticoagulants.
DR.[**Last Name (STitle) 117**],[**First Name3 (LF) 116**] 12-988
Dictated By:[**Last Name (NamePattern1) 5007**]
MEDQUIST36
D: [**2120-10-31**] 16:55
T: [**2120-11-4**] 09:52
JOB#: [**Job Number 5008**]
|
[
"414.01",
"997.1",
"189.0",
"428.0",
"285.9",
"E878.8",
"415.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"55.51",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
246, 1095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,717
| 182,165
|
8034
|
Discharge summary
|
report
|
Admission Date: [**2145-9-4**] Discharge Date: [**2145-9-4**]
Date of Birth: [**2094-10-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Ms. [**Doctor Last Name 28727**] is a 50F with a PMH s/f ESRD on HD, HTN, DM
type II who presented to the ED with 12-16 hrs of nausea and
vomiting. Initially her emesis was reportedly clear, and then
became "like coffee grounds". Per the patient her fingerstick
prior to coming to the ED was 400. Of note the patient
freqently vomits black material at home.
Review of systems is otherwise negative for fevers, chills,
night sweats, HA, confusion, changes in vision, cough, diarrhea,
or dysuria.
In the emergency department her initially vital signs were 98.5,
229/119, 104, 14, 100%RA. The patient was initially thought to
have complications of gastroparesis. Hematocrit was stable at
38-40. She was given her home blood pressure regimen,
anti-emetics, and 10 units of SC insulin for a blood sugar of
339. Her fingerstick was checked one hour later, and noted to
be 482, with an anion gap of 13. She was given 10 units of IV
insulin and started on an insulin gtt at 8units/hr. She has
recieved a total of 1.5L, as she has ESRD.
Past Medical History:
1. Poorly controlled DM type 1, diagnosed in [**2117**]. Followed at
the [**Last Name (un) **] (Dr. [**Last Name (STitle) 14116**]. Last HbA1c 9.8 in [**2-16**] at [**Last Name (un) **]. AV
fistula on [**2145-1-20**], currently seeing Dr.[**Doctor Last Name 4849**] for
evaluation of kidney transplant
2. Severe gastroparesis
3. Diabetic neuropathy, with Charcot joints
4. Chronic renal insufficiency baseline Cr ~4 .Started dialysis
in [**2-16**]
5. Hypertension
6. Non-healing left foot ulcer with several foot surgeries
7. Hx. of MRSA
8. h/o UGIB
9. peripheral neuropathy
10. Diabetic retinopathy s/p laser surgery (blind right eye)
Social History:
Lives with her husband and two sons, remote smoking history and
occasional ETOH. Currently unemployed.
Family History:
NC
Physical Exam:
T=98.0 BP=123/75 HR=82 RR=13 O2=99RA FS: 276
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. 3/6 SEM at RUSB. Mild JVD
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2145-9-3**] 11:50PM BLOOD WBC-10.7 RBC-4.36 Hgb-13.6 Hct-41.0
MCV-94 MCH-31.2 MCHC-33.2 RDW-14.6 Plt Ct-312
[**2145-9-3**] 11:50PM BLOOD Neuts-79.7* Lymphs-13.8* Monos-4.1
Eos-1.8 Baso-0.5
[**2145-9-3**] 11:50PM BLOOD PT-11.8 PTT-21.8* INR(PT)-1.0
[**2145-9-3**] 11:50PM BLOOD Glucose-339* UreaN-33* Creat-6.1*# Na-133
K-4.7 Cl-93* HCO3-28 AnGap-17
[**2145-9-4**] 07:24AM BLOOD Glucose-260* UreaN-37* Creat-6.2* Na-136
K-4.7 Cl-98 HCO3-26 AnGap-17
[**2145-9-3**] 11:50PM BLOOD ALT-21 AST-21 CK(CPK)-126 AlkPhos-105
TotBili-0.3
[**2145-9-4**] 07:24AM BLOOD Lipase-28
[**2145-9-3**] 11:50PM BLOOD Lipase-41
[**2145-9-3**] 11:50PM BLOOD cTropnT-0.08*
Relevant Imaging:
1)CT head ([**9-3**]): No evidence of acute intracranial
abnormalities.
2)Cxray ([**9-3**]): Mild stable cardiomegaly. No acute pulmonary
process. No evidence of pneumoperitoneum.
Brief Hospital Course:
Ms. [**Doctor Last Name 28727**] is a 50yo female with PMH significant for
IDDM c/b ESRD on HD and gastroparesis. Presented to the ED with
vomiting and hyperglycemia.
1)Hyperglycemia/Diabetes: Patient presented with blood sugars in
500's in the ED. Her anion gap was 12 with very little ketones
in her urine. She was briefly started on an insulin gtt but upon
transfer to the MICU the drip was stopped since this was thought
not to be DKA. She received IVFs. [**Last Name (un) **] was consulted and felt
that this was not DKA and recommended that she continue her home
regimen with close carbohydrate counting. At time of discharge,
her blood sugars had normalized and she was tolerating all
meals.
2)Gastroparesis: Continued on Metaclopramide.
3)Hematemesis: The patient reports chronic hematemesis at home,
with "coffee grounds" in her emesis frequently. Hematocrit
remained stable. Started on H2 blocker at time of discharge.
4)HTN: Continued on home regimen of Metoprolol and Amlodipine.
5)Hyperlipidemia: Continued on Pravachol.
Medications on Admission:
Amitriptyline 25mg qhs
Norvasc 5mg [**Hospital1 **]
Lantus 30 units at bedtime
Humalog sliding scale
Metoclopramide 5mg [**Hospital1 **]
Metoprolol succinate 25mg daily
Pravachol 40mg daily
Aspirin 81mg daily
Discharge Medications:
1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Insulin
Please resume home insulin regimen: Lantus 30 units at night;
humalog I:C 1:8 with sensitivity factor of 1:40 correcting to
150 mg/dL.
8. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Hyperglycemia
Insulin dependent diabetes mellitus
End stage renal disease
Secondary diagnoses:
Hypertension
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
1)You were admitted to the hospital with high blood sugars. The
cause of the high blood sugars was unclear. There were no signs
of an infection. You may have had a viral gastrointestinal
illness that is now resolving.
2)Please take all medications as listed in the discharge
instructions. You were seen by one of the [**Last Name (un) **] physicians
during your hospital stay. You should continue the Lantus 30
units at night along with humalog I:C 1:8 with sensitivity
factor of 1:40 correcting to 150 mg/dL.
3)You are also being started on a medication for your acid
reflux called Zantac. Please take one tablet twice daily.
4)Please schedule a follow-up appointment with your primary care
physician [**Name Initial (PRE) 176**] 1 week after being discharged from the
hospital. You should also attend the appointments as listed
below.
5)If you experience any fevers, chills, chest pain, shortness of
breath, dizziness, or any other concerning symptoms, please
return to the emergency room.
Followup Instructions:
1)Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2145-9-8**]
2:00
2)Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2145-9-17**] 9:50
3)Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2145-9-20**] 10:30
|
[
"V45.1",
"707.14",
"V58.67",
"250.52",
"362.01",
"578.0",
"536.3",
"250.42",
"272.4",
"250.62",
"357.2",
"403.91",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5765, 5771
|
3687, 4727
|
327, 342
|
5958, 5967
|
2811, 3463
|
7011, 7417
|
2206, 2210
|
4986, 5742
|
5792, 5886
|
4753, 4963
|
5991, 6988
|
2225, 2792
|
5907, 5937
|
274, 289
|
3481, 3664
|
370, 1408
|
1430, 2070
|
2086, 2190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,576
| 195,819
|
35914
|
Discharge summary
|
report
|
Admission Date: [**2100-9-18**] Discharge Date: [**2100-9-20**]
Date of Birth: [**2037-12-7**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Compazine
Attending:[**First Name3 (LF) 69160**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
fiberoptic examination or airway in the OR
History of Present Illness:
HPI: 62 yo female who presents to the ED with stridor 1 day
after
undergoing an esophageal dilation. She has a history of
radiation
induced esophageal strictures related to breast cancer treatment
requiring multiple dilations. She also has a history of a right
vocal cord paralysis relating to a prior esophageal perforation
in [**2098**]. During the procedure yesterday, the case was aborted
because the patient experienced laryngospasm. She required
intubation with some diffulty per anesthesia reports. She is
followed by Dr. [**Last Name (STitle) 1837**] for her right cord paralysis. The
ORL service is consulted for assistance with an airway
evaluation.
Past Medical History:
Esophageal stricture [**3-3**] radiation therapy s/p multiple
dilitations, last on [**2100-7-23**]
Breast Cancer s/p right mastectomy [**2091**], s/p chemo/XRT [**2092**]
Hypertension
Hypothyroidism
Benign spinal tumor s/p resection [**2092**]
Social History:
Woked as [**Name8 (MD) **] RN in special needs nursery at [**Hospital **] hospital x27
years, married, lives with husband. [**Name (NI) 1139**]: none, ETOH: social
Family History:
Diabetes, lung cancer, and CHF
Physical Exam:
At the time of discharge
AVSS
NAD
no stridor, no retractions
FOE performed: 4 mm airway, bilateral vocal cord paralysis
no pooling of secretions
no airway edema
voice strong
Brief Hospital Course:
Following evaluation in the ED, the patient was brought to the
ORL for evaluation of the airway in a controlled environment.
Fiberoptic exam showed bilateral vocal cord paralysis. 2
additional exams confirmed this observation. Tracheostomy was
recommended but declined by the patient. She elected for further
observation despite knowing the risks of observation without a
definitive airway.
Decadron 10 mg X3 doses was utilized. Airway edema improved and
stridor resolved. She was admitted to the MICU for observation.
Breathing improved and the patient was transferred to the floor
on hospital day 2. No stridor occurred after transfer. Tube
feeds were restarted. Nutrition assisted with tube feed
recommmendations which were well tolerated
On hospital day 3, the team and Dr. [**First Name (STitle) **] agreed that the patient
was appropriate for discharge. She will follow-up on Thurs [**9-23**] for evaluation.
Medications on Admission:
lansprazole, levothyroxine, verapamil, metoclopramide, docusate,
nutren 2.0, oxycodone, lorazapam
Discharge Medications:
1. senna 8.6 mg Tablet [**Month (only) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 50 mg/5 mL Liquid [**Month (only) **]: One (1) PO BID (2
times a day).
3. levothyroxine 50 mcg Tablet [**Month (only) **]: One (1) Tablet PO 3X/WEEK
([**Doctor First Name **],TU,TH).
4. levothyroxine 25 mcg Tablet [**Doctor First Name **]: One (1) Tablet PO 4X/WEEK
(MO,WE,FR).
5. verapamil 40 mg Tablet [**Doctor First Name **]: 1.5 Tablets PO Q12H (every 12
hours).
6. metoclopramide 10 mg Tablet [**Doctor First Name **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. lorazepam 0.5 mg Tablet [**Doctor First Name **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral vocal cord paralysis
Discharge Condition:
stable
Discharge Instructions:
Please return to the ED for any noisy breathings, shortness of
breath or anything that concerns you.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] Thursday [**9-24**]. Call to
schedule [**Telephone/Fax (1) 2349**].
Completed by:[**2100-9-20**]
|
[
"V85.0",
"276.50",
"909.2",
"530.3",
"478.6",
"786.39",
"997.39",
"478.33",
"V45.71",
"244.9",
"799.4",
"V44.1",
"786.1",
"401.9",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3732, 3738
|
1747, 2667
|
298, 343
|
3813, 3822
|
3971, 4123
|
1499, 1532
|
2815, 3709
|
3759, 3792
|
2693, 2792
|
3846, 3948
|
1547, 1724
|
238, 260
|
371, 1033
|
1055, 1301
|
1317, 1483
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,477
| 154,902
|
10655
|
Discharge summary
|
report
|
Admission Date: [**2162-5-5**] Discharge Date: [**2162-5-11**]
Date of Birth: [**2129-4-17**] Sex: M
Service: PURPLE SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 33 year-old
male status post gastric bypass surgery for morbid obesity on
[**2162-5-5**].
PAST MEDICAL HISTORY: Obesity, degenerative joint disease,
heartburn, headache.
PAST SURGICAL HISTORY: Orchiectomy in [**2152**], because of an
undistended right testicle.
MEDICATIONS AT HOME: Advil.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Blood pressure 120/70. Pulse 82.
Respiratory rate 16. Heart regular rate and rhythm. Lungs
clear to auscultation bilaterally. Abdomen was soft, obese,
nontender with bowel sounds. Extremities had no edema.
Electrocardiogram was normal sinus rhythm.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2162-5-5**] for a Roux-en-Y gastric bypass. There were no
complications. Estimated blood loss was 150 cc.
On postoperative day number one there was increased blood
from the nasogastric tube approximately 150 cc. The patient
was noted to be diaphoretic, lightheaded and nauseous without
complaints of chest pain or shortness of breath. At that
point he was transferred to the Intensive Care Unit where his
hematocrit continued to fall. He was transfused 6 units of
packed red blood cells in total and 2 units of fresh frozen
platelets. His hematocrit dipped to a low of 18%, but then
after the transfusions stabilized at around 28%. On [**5-8**] the
patient's hematocrit was stable and there was no bleeding
from the nasogastric tube. He was then transferred back to
the floor on [**5-9**] in stable condition. Since then his
hematocrit has continued to remain stable at approximately
28%.
On discharge the patient has a stable hematocrit. He is
tolerating a stage three diet well.
DISCHARGE MEDICATIONS: Roxicet po for pain one to two
teaspoons q 4 hours, Ranitidine, Actigall 300 mg b.i.d. for
six months, vitamin B-12 1000 micrograms po q day times two
months.
The patient will follow up in surgical nutrition clinic and
follow up with Dr. [**Last Name (STitle) **] in two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Last Name (NamePattern1) 34958**]
MEDQUIST36
D: [**2162-5-11**] 10:12
T: [**2162-5-12**] 07:23
JOB#: [**Job Number 34959**]
|
[
"997.4",
"998.11",
"278.01",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.31"
] |
icd9pcs
|
[
[
[]
]
] |
1888, 2449
|
820, 1864
|
477, 523
|
385, 455
|
546, 802
|
171, 279
|
302, 361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,195
| 121,208
|
32212
|
Discharge summary
|
report
|
Admission Date: [**2164-9-10**] Discharge Date: [**2164-9-19**]
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CHF; Critical AS
Major Surgical or Invasive Procedure:
[**2164-9-12**] AVR (25 mm [**Company 1543**] Mosaic Ultra porcine))/Coronary
Artery Bypass Grafting x 2 (LIMA to LAD, SVG to PDA)
[**2164-9-14**] Mediastinal exploration for bleeding
History of Present Illness:
[**Age over 90 **]yo male with known critical AS(0.6cm2) known to service since
[**Month (only) **]. Scheduled for AVR later this month, admitted to [**Location (un) **]
with CHF, diuresed with good
resolution SOB.
Past Medical History:
Critical AS,Coronary artery disease
s/p AVR (25 mm [**Company 1543**] Mosaic Ultra porcine)/Coronary Artery
Bypass Grafting x2
CHF,Hyperlipidemia,
small bowel AVMs
,[**Company **] in [**2158**],Anemia requiring blood transfusions [**2163**],
? CAD,PAF,s/p colonscopy approximately [**2161**],BPH,s/p Bilateral
knee replacement [**2157**]. MRSA of LT knee subsequently
Social History:
Retired farmer
- Widower, wife died last year.
- Lives alone in the in-law apt at his son's house
- Has a very supportive family.
- Quit smoking 50 years ago (<5 pack year history)
- No EtOH
- No illicit drug use
Family History:
- Mother: Died at 72 secondary to an MI.
- Father: Died at 83 of old age.
Physical Exam:
Admission Physical Exam
Pulse: Resp:16 O2 sat:
B/P Right:136/82 Left:130/82
Height: Weight:
General:WDWN in NAD
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [n]few crackles at bases
Heart: RRR [x] Irregular [] Murmur4/6 SEM base
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right: 2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
PREBYPASS
The left atrium is mildly dilated. The left atrium is elongated.
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45%) with global
mild hypokinesis and severe hypokinesis of the inferolateral
septum.
Right ventricular systolic function is normal with good free
wall contractility.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta.
The aortic valve leaflets are severely thickened/deformed.
Number of leaflets cannot be determined. There is critical
aortic valve stenosis (valve area <0.5 cm2). Moderate (2+)
aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. Moderate (2+) mitral
regurgitation is seen.
There is no pericardial effusion.
POSTBYPASS
The patient is AV-paced on a phenylephrine infusion.
Left ventricular systolic function is slightly improved (LVEF =
50-55%) with some septal dyskinesis consistent with ventricular
pacing.
The new bioprosthetic aortic valve is well-seated without
perivalvular leaks or aortic regurgitation. Peak/mean gradients
across the new valve are 14/9 mmHg.
Mitral regurgitation is now mild (1+).
The thoracic aorta is intact.
Dr. [**Last Name (STitle) **] was informed of the results at the time of the
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
[**2164-9-18**] 04:50AM BLOOD WBC-6.7 RBC-3.19* Hgb-9.8* Hct-27.8*
MCV-87 MCH-30.6 MCHC-35.1* RDW-16.7* Plt Ct-207
[**2164-9-17**] 01:18AM BLOOD WBC-9.6 RBC-3.31* Hgb-10.3* Hct-29.0*
MCV-88 MCH-31.1 MCHC-35.4* RDW-16.7* Plt Ct-184
[**2164-9-17**] 01:18AM BLOOD PT-13.4 PTT-28.9 INR(PT)-1.1
[**2164-9-15**] 03:14AM BLOOD PT-15.1* PTT-38.9* INR(PT)-1.3*
[**2164-9-18**] 04:50AM BLOOD Glucose-97 UreaN-35* Creat-1.3* Na-132*
K-3.6 Cl-96 HCO3-27 AnGap-13
[**2164-9-17**] 01:18AM BLOOD Glucose-103* UreaN-26* Creat-1.5* Na-132*
K-3.7 Cl-96 HCO3-25 AnGap-15
[**2164-9-16**] 03:08AM BLOOD Glucose-103* UreaN-24* Creat-1.4* Na-132*
K-4.2 Cl-100 HCO3-25 AnGap-11
[**2164-9-18**] 04:50AM BLOOD Mg-2.3
[**2164-9-17**] 01:18AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.9
[**2164-9-10**] 07:20PM BLOOD TSH-46*
[**2164-9-11**] 09:25PM BLOOD Free T4-0.56*
Brief Hospital Course:
Admitted on [**9-10**] to complete pre-op w/u.Underwent surgery with
Dr. [**Last Name (STitle) **] on [**9-12**]. transferred to the CVICU in stable
condition on titrated phenylephrine and propofol drips. Low dose
epinephrine drip started that evening. Extubated on POD #1. Had
significant amount of bloody chest tube output and was taken
back to the OR on POD 2 for mediastinal exploration. He
remained hemodynamically stable and tolerated the procedure
well. He was again transferred to CVICU for recovery.
POD 1 from re-exploration found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. Labs demonstrated
hypothyroidism, endocrine consult was called and the patient was
started on levothyroxine. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 7 and 5, the wound
was healing and pain was controlled with oral analgesics. He
was deconditioned and it was decided to send him to rehab on
discharge. The patient was discharged to [**Hospital3 **] in
good condition with appropriate follow up instructions.
Medications on Admission:
AMIODARONE 200mg once a day
LASIX 20mg in AM and at noon
KCL 10mEq daily
IRON 325mg daily
pravachol 10 mg daily
Multivitamin daily
FINASTERIDE 20mg daily
omperazole 20 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q8H (every 8 hours).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
16. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
17. Outpatient Lab Work
Draw TSH, free T3 and free T4 on [**2164-9-26**], copy results to Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 11376**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 68789**] ([**Last Name (un) 16844**]) - [**Location (un) 1157**]
Discharge Diagnosis:
Critical AS,Coronary artery disease
s/p AVR /cabg x2
CHF,Hyperlipidemia,h/o esophageal
[**Last Name (LF) 75319**],[**First Name3 (LF) **] in [**2158**],Anemia requiring blood transfusions [**2163**],
? CAD,PAF,s/p colonscopy approximately [**2161**],BPH,s/p Bilateral
knee replacement [**2157**]. MRSA of LT knee subsequently
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.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:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Thursday [**10-11**] @ 1:00 pm
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] in [**1-28**] weeks [**Telephone/Fax (1) 11376**]
Cardiologist Dr.[**Last Name (STitle) 41990**] on [**10-4**] at 10:00 AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Draw TSH, free T3 and free T4 on [**2164-9-26**], results to Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 11376**]
Completed by:[**2164-9-19**]
|
[
"E942.0",
"V12.04",
"285.9",
"427.31",
"E878.8",
"244.3",
"511.9",
"456.1",
"424.1",
"428.0",
"428.43",
"998.11",
"414.01",
"458.29",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.93",
"35.21",
"39.61",
"36.11",
"36.99"
] |
icd9pcs
|
[
[
[]
]
] |
8110, 8214
|
4757, 6230
|
240, 427
|
8585, 8796
|
2079, 4734
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9722, 10370
|
1311, 1387
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6457, 8087
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8235, 8564
|
6256, 6434
|
8820, 9699
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1402, 2060
|
183, 202
|
455, 672
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694, 1064
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1080, 1295
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20,754
| 182,710
|
51132
|
Discharge summary
|
report
|
Admission Date: [**2122-4-15**] Discharge Date: [**2122-5-4**]
Date of Birth: [**2037-3-4**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins / Darvon
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Black stools
Major Surgical or Invasive Procedure:
EGD
colonoscopy x2
Small bowel enteroscopy
History of Present Illness:
85 y.o. female with hx GERD, hiatal hernia, thoracoabdominal
aneursym (last 5.5cm) who presents to the [**Hospital1 **] ED with black
stools for three days associated with weakness, SOB, DOE. The
patient states that she has been living in [**State 108**] for the last
3 months with her husband. She states that on Sunday she was
preparing to return, when she noted headache, lightheadedness,
and dizziness. She states that her "good old fashioned
tummyache" was at her baseline but she developed new
constipation. On Monday prior to leaving [**State 108**] she had one
black bowel movement, however she decided to wait to come to the
[**Hospital1 **] for her treatment. She stayed home yesterday, but today her
lightheadedness was too much and she came to the ED.
.
Of note patient self tapered steroids for PMR in [**Month (only) **] and
admits to very little ETOH intake, last drink was sunday on the
plane, a tomato juice and vodka. She has taken no more than 81mg
of ASA daily. No excess NSAIDS.
.
In the ED, initial vs were 98.6 86 76/47 24 93%. She refused NG
lavage. Her HCT was 17.7 from a baseline of She was started on a
protonix drip and given 2 units PRBC. She was crossed for 2
more. Vitals at the time of transfer 88 144/62 18 100. Stool
Guaiac was + and black
.
GI is aware. CTA showed no leak from her AAA and showed its
enlarged. Vascular is aware. c/o crampy abdominal pain. 2 18 G
IVs placed. Rectal revealed black guaiac positive stools.
Past Medical History:
PMH: DM2, COPD, HTN, PVD, CAD, gout, venous insufficiency, PMR
PSH: thoracoabdominal aneurysm repair [**Hospital1 2025**] '[**10**], emergent R
fem-[**Doctor Last Name **] [**Hospital1 2025**] '[**10**], removal for infection, R fem-[**Doctor Last Name **] with NRSVG
[**5-10**], removal L frontotemporal meningeoma [**5-10**], incisional
hernia repair with mesh [**8-11**]
Social History:
Lives with husband. Significant tobacco history - smoked x45
years, up to 2ppd. Quit in [**2109**] has been on and off since.
Intermittent EtOH or IVDU. Retired; worked as a waitress,
teacher, and in the mayor's office. Active in community.
Family History:
Mother with HTN
Sisters with HTN
Brother: pancreatic CA, died at 64y/o
no h/o lung disease in family
no diabetes/early MI
Physical Exam:
Admission Physical Exam:
Vitals: T:98.2 BP:132/55 P:66 R:18 O2:96% RA
General: Alert, oriented female, no acute distress
HEENT: +Conjunctival pallor, DryMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, SEM heard best at LUSB,
Abdomen: soft, some tenderness to palpation in the umbilical
region, non-distended, multiple scars, no palpable pulsatile
mass. bowel sounds present, no rebound tenderness or guarding,
no organomegaly
GU: no foley
Ext: warm, well perfused, palpable pulses
.
Discharge Physical Exam:
Vitals: T: 97/99.4 BP: 119/61 (90s-150s/40s-70s) HR: 88
(80s-90s) RR: 20 O2: 99%RA
General: Alert, oriented female, no acute distress
HEENT: Dry MM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: CTAB
CV: Regular rate and rhythm, systolic murmur [**2-15**] throughout
Abdomen: soft, +BS, Moderate tenderness to palpation diffusely
over abdomen
Ext: warm, well perfused, chronic R>L swelling
Pertinent Results:
admission labs
[**2122-4-15**] 04:15PM BLOOD WBC-6.0 RBC-2.32*# Hgb-5.8*# Hct-17.7*#
MCV-76* MCH-24.9* MCHC-32.7 RDW-16.6* Plt Ct-195
[**2122-4-15**] 04:15PM BLOOD Neuts-73.8* Lymphs-19.3 Monos-5.1 Eos-1.3
Baso-0.5
[**2122-4-15**] 04:15PM BLOOD PT-13.5* PTT-26.8 INR(PT)-1.2*
[**2122-4-15**] 04:15PM BLOOD Glucose-144* UreaN-53* Creat-1.2* Na-137
K-4.0 Cl-102 HCO3-26 AnGap-13
[**2122-4-15**] 04:15PM BLOOD ALT-10 AST-12 AlkPhos-70 TotBili-0.2
[**2122-4-15**] 04:15PM BLOOD Lipase-31
[**2122-4-15**] 04:15PM BLOOD Albumin-3.5 Calcium-8.3* Phos-4.0 Mg-2.1
[**2122-4-15**] 05:46PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2122-4-15**] 05:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
discharge labs:
[**2122-5-4**] 07:50AM BLOOD WBC-7.9 RBC-2.95* Hgb-8.9* Hct-25.4*
MCV-86 MCH-30.1 MCHC-35.0 RDW-14.9 Plt Ct-187
[**2122-5-4**] 07:50AM BLOOD PT-13.9* PTT-25.3 INR(PT)-1.2*
[**2122-5-4**] 07:50AM BLOOD Glucose-138* UreaN-42* Creat-0.9 Na-137
K-4.8 Cl-103 HCO3-28 AnGap-11
[**2122-5-4**] 07:50AM BLOOD Calcium-8.1* Phos-4.5 Mg-2.1
.
([**4-20**]) CT COLONOGRAPHY: There is adequate distention of the
colon between the three positions. There are no strictures,
masses, or polyps. A moderate amount of fluid is seen throughout
the colon; however, this displaces with repositioning and does
not interfere with interpretation. There are a few scattered
diverticula are noted at the splenic flexure, the descending
colon and the cecum.
CT OF THE ABDOMEN [**4-24**]: The liver is without focal lesions. The
spleen, pancreas, adrenal glands and right kidney are
unremarkable. There is a low-density lesion in the left kidney,
which on prior CT examination has been demonstrated to represent
a cyst. There is an aortic aneurysm, better evaluated on the
recent CT scan.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is no free fluid in
the pelvis. No pelvic lymphadenopathy is noted. The small bowel
is unremarkable.
On bone windows, there are no concerning osteolytic or
osteosclerotic lesions.
IMPRESSION:
1. Normal CT colonography. No evidence for masses or polyps.
Scattered
sigmoid diverticulosis. Please note that the sensitivity of CT
colonography for polyps greater than 1 cm is over 90%.
Sensitivity for polyps 5-9 mm is 70-80%. Flat lesions may be
missed.
2. Fusiform aneurysm of the thoracic and abdominal aorta, better
evaluated on the recent CTA of the torso.
([**4-22**]) ECG: Normal sinus rhythm. Q waves in leads III and aVF.
Poor R wave progression. Consider prior inferior myocardial
infarction. Compared to the previous tracing of [**2122-4-15**] no
diagnostic interval change.
([**4-15**]) CTA: The aortic arch measures 3.1 cm in transverse
dimension, stable. The mid descending thoracic aorta measures
3.9 x 3.9 cm, stable from prior exam. Starting at the distal
descending thoracic aorta and extending through the abdominal
aorta to just distal to the level of the renal arteries is
fusiform dilation of the aorta with maximal dimension of 6.6 x
7.0 cm at the level of the origin of the SMA. Above this level,
there is complex septation along the aorta with mural thrombus
and areas of presumed ulcerative plaque. Given the lobulated
margins of the descending thoracic aorta, specifically seen on
series 3, image 65, the possibility of a penetrating
atheromatous ulcer cannot be excluded though overall
configuration is stable. There is no periaortic hematoma or
evidence of aortic rupture. No evidence of aortoenteric fistula.
The celiac, SMA, and renal arteries opacify normally. There is
tortuosity of the distal abdominal aorta with ectasia of the
common iliacs and areas of atherosclerotic plaque noted
primarily involving the left common iliac artery. Also noted is
a right superficial femoral artery aneurysm which measures up to
1.8 cm in dimension, similar to prior exam. There is thrombosis
of the right CSA stent seen on series 3, image 225, unchanged.
CHEST: Nodular enlargement of the thyroid, left greater than
right, is
unchanged and compatible with a goiter. There is associated mass
effect on
the proximal segment of the esophagus. There is no mediastinal,
hilar, or
axillary lymphadenopathy. The esophagus is moderately distended
containing
fluid, mid and distally. Heart size is stably enlarged. No
pleural or
pericardial effusion is seen. Coronary artery calcification and
calcification of the mitral annulus and aortic valve is also
noted. Central pulmonary arterial tree opacifies normally.
Lung windows are notable for mild apically predominant
centrilobular
emphysema. Scattered areas of atelectasis is noted. There is a
nodule in the right upper lobe seen on series 3, image 28, which
measures 9 mm in maximal dimension. This nodule appears stable
in size compared with the [**2121**] CT scan. Aside from this, no
worrisome nodules are seen within either lung. No pleural
effusion or pneumothorax is seen.
ABDOMEN: The liver appears normal. Gallbladder is not
visualized, likely
surgically absent. The spleen, adrenal glands, and pancreas
appear
unremarkable. The kidneys enhance symmetrically and excrete
contrast
promptly. A left renal hypodensity is noted arising
exophytically in the
interpolar region measuring 2.6 x 4.5 cm, most likely a simple
cyst and
grossly stable from prior exam.
The stomach and duodenum appear unremarkable. Again, there is no
sign of
aortoenteric fistula. No retroperitoneal lymphadenopathy or
hematoma is seen.
No abdominal free air or free fluid.
PELVIS: Loops of small bowel demonstrate no evidence of ileus or
obstruction. Colonic diverticulosis is noted without evidence of
diverticulitis. Uterus is grossly unremarkable. No adnexal
masses are seen. Urinary bladder is normal.
BONES: Left posterior rib cage deformity is again noted.
Bilateral
sacroiliac sclerosis and vacuum disc phenomena likely reflect
sacroiliitis, chronicity unclear. [**Name2 (NI) **]-containing ventral
abdominal hernias are noted on series 401B, image 36 and image
41.
IMPRESSION:
1. Massive fusiform aneurysm of the thoracic and abdominal
aorta, up to 7 cm in diameter, increased from prior CT scan
without signs of rupture or
aortoenteric fistula. Complex septation and lobulation of this
fusiform
aneurysm is again noted with gross stability.
2. Right upper lobe pulmonary nodule which bears monitoring on
followup
imaging.
3. Additional incidental findings as detailed above with
stability from prior exam.
.
KUB [**5-1**]: Previously seen radiopaque capsule presumed to be
lodged within the region of the terminal ileum is no longer
visualized on the current study. There is a nonspecific bowel
gas pattern seen with non-distended air-filled loops of large
and small bowel. The enteric tube is seen projecting in location
likely consistent with the body of the stomach. There is no
evidence of any intra-abdominal free air. There is no evidence
to suggest small bowel obstruction or ileus.
IMPRESSION:
1. Radiopaque capsule no longer seen within the abdomen.
2. Nonspecific bowel gas pattern with no evidence to suggest
obstruction or ileus.
.
COLONOSCOPY [**2122-5-1**]:
Red blood and clots was seen in the entire colon. Fresh blood
was noted accumulating in the cecum. No mucosal lesions could be
identified. This suggests small bowel source of bleeding.
Multiple attempts to intubate the terminal ileum were
unsuccessful. Excavated Lesions Multiple diverticula were seen
in the whole colon. Diverticulosis appeared to be of moderate
severity.
.
Impression: Red blood and clots was seen in the entire colon.
Fresh blood was noted accumulating in the cecum. No mucosal
lesions could be identified. This suggests small bowel source of
bleeding.
Blood in the colon
Diverticulosis of the whole colon
Otherwise normal colonoscopy to cecum
.
CTA [**2122-5-2**]:
LUNG BASES: There is bibasilar atelectasis without pleural or
pericardial
effusion. Note is made of coronary arterial calcification.
ABDOMEN: The liver, spleen, bilateral adrenals, and pancreas
appear normal. The kidneys demonstrate a stable-appearing cyst
emanating from the left upper pole and are otherwise normal in
appearance. There is a left extrarenal pelvis incidentally
noted.
The aorta is markedly irregularly aneurysmal with chronic
dissection. It is unchanged in caliber when compared with 4/15.
There is no sign of aortic rupture. The celiac axis is tightly
stenotic and appears to fill by
retrograde direction. The SMA, and bilateral renal arteries are
patent. The right femoral artery also demonstrates an irregular
aneurysmal dilation of the common femoral, with occlusion of the
superficial femoral artery, which is not fully evaluated but
appears unchanged.
The stomach is collapsed. Loops of small bowel are normal in
caliber and
enhancement. There is no contrast filling small bowel to suggest
acute GI
bleed. Multiple foci of [**Month/Day/Year **]-containing anterior abdominal
hernias are seen.
PELVIS: The bladder, uterus and adnexae, and rectum appear
normal. There is no pelvic side wall pathologic lymphadenopathy.
The colon is largely
collapsed and demonstrates diverticula, but no evidence of
diverticulitis.
BONE WINDOWS: There is multilevel degenerative change without
concerning
lytic or blastic osseous lesions.
IMPRESSION:
1. No CT evidence of acute gastrointestinal hemorrhage.
2. Redemonstration of markedly irregular thoracic and abdominal
aortic
aneurysm with probable retrograde filling of the celiac axis.
3. Multiple [**Month/Day/Year **]-containing abdominal hernias.
.
GI BLEEDING STUDY [**2122-5-3**]:
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for minutes were obtained.
Blood flow images show a tortuous aorta and iliac vessels.
Dynamic blood pool images show bleeding at 5 minutes in the left
lower quadrant, with blood accumulating slowly for approximately
20 minutes before bleeding ceased. The luminal blood then moved
in a serpentine pattern across the abdomen toward the left lower
quadrant. Imaging for up to 90 minutes showed no other bleeding
activity.
IMPRESSION: Intermittent bleeding in the left lower quadrant of
the abdomen, in the distal jejunum or proximal ileum
.
SMALL BOWEL ENTEROSCOPY [**2122-5-4**]
Normal esophagus.
Stomach:
Mucosa: Patchy erythema and congestion of the mucosa were noted
in the antrum and stomach body. These findings are compatible
with gastritis.
Duodenum: Normal duodenum.
jejunum: Flat Lesions A single small angioectasia that was not
bleeding was seen in the mid jejunum. A gold probe was applied
successfully.
ileum: Not examined.
Other findings: Scope advanced to distal jejunum. No evidence of
fresh blood noted
.
Impression: Scope advanced to distal jejunum. No evidence of
fresh blood noted
Angioectasia in the mid jejunum (thermal therapy)
Erythema and congestion in the antrum and stomach body
compatible with gastritis
Otherwise normal small bowel enteroscopy to distal jejunum
.
Brief Hospital Course:
Summary: Ms [**Known lastname 50388**] is an 85yo female with GERD, PUD, and a
7.3cm thoracoabdominal aneurysm with a GI bleed of obscure
etiology despite extensive workup.
.
#GI bleed: Initially admitted to the ICU given hypotension in
the ED. Once stable, she was hemodynamically stable on the
floor, however she continued to bleed requiring intermittent
transfusion to keep her Hct above 25. She received a total of
18U of PRBC over her course. She continued to have melanotic,
guiac positive stools, with subsequent hematochezia. On [**4-16**]
(in the ICU) she had an EGD notable for small non-bleeding
angioectasia, which was cauterized, and gastritis. On [**4-17**],
colonscopy was performed which was notable for sessile polyps
and sigmoid diverticulosis, however it was felt to be a
difficult study most consistent with a proximal source of
bleeding. On [**4-20**], given her continued transfusion requirement,
she had a tagged RBC scan which failed to localize the bleeding.
Additionally, she had a virtual CT colonscopy which showed no
abnormality. During this time she continued to require
transfusions at a rate of about 1 unit per day. Given the
inability of these studies to localize the bleeding, a capsule
endoscopy was attempted. However, due to slow transit time
(through esophagus and stomach), the capsule was retained in the
upper GI tract for an extended period, resulting in a
nondiagnostic study. The capsule subsequently lodged in the
terminal ileum and remained there for several days, but
eventually passed as evidenced on serial KUBs. Given her
persistent GI bleeding, decison was made to re-prep for
colonoscopy on [**5-1**] which showed no colonic lesions, but
consistent pooling of blood in the cecum from likely small bowel
bleed. CTA was obtained on [**5-2**] but showed no source for the
bleed, and no sign of aortoenteric fistula. Decision was then
made to repeat tagged RBC scan on [**5-3**] which infact showed LLQ
bleed, likely distal jejunem/prox ileum. IR was reconsulted who
felt embolization would be risky given her expanding AAA and
history of repair per IR. Therefore, she underwent small bowel
enteroscopy on [**5-4**] which again showed no source of bleed. She
was therefore transferred on [**5-4**] for more advanced endocscopic
diagnostics. Of note, hematochezia had resolved on discharge.
She remained NPO throughout the majority of her course on PPN
for nutrition. Hct 25.4 on discharge
.
#Thoracoabdominal aneurysm: This was noted by CTA to have
increased in size to 7.3cm from prior size of 5.5cm. She was
seen by the vascular service who deferred repair given her
comorbidities. Per the IR team, this also preculdes her from
embolization procedure for her GI bleed
.
#Lung nodules: She was noted to have a <1cm lung nodule, stable
on current scan versus prior studies in [**2121**]. Should be
followed up in 6 months.
.
# Gout: Continued Allopurinol
.
# Back pain/shoulder pain: Back pain likely her chonic OA.
Shoulder pain seems to localize to muscle spasm on medial side
of scapula. NSAIDs contraindicated, on tylenol.
.
# Mild ARF: Cr 1.2 on admission. Clinical picture fit with
Pre-renal, and resolved with transfusions. Her diuresis was
held for majority of admission but restarted on [**4-29**] in the
setting of LE edema (home dose of 40mg daily). However this was
discontinued on the day of discharge given tachycardia and
likely volume depleted state. Cr was 0.9 on discharge
.
# COPD: Continued home albuterol, spiriva, switch symbicort to
advair in house.
.
# CAD: Held Imdur and lisinopril in setting of hypovolemia.
Lasix initially held, then restarted given LE edema. This was
again held on discharge given volume-down state.
.
# DM2: diet controlled, monitored in house.
.
# Follow up/transitional
[**Hospital 30412**] transferred to [**Hospital1 **] for further endoscopic workup
-Note that imdur, lasix, and lisinopril were being held in-house
and should be readdressed.
-Lung nodules should be followed up in 6 months
- Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1520**] at the [**Hospital1 18**] Hospitalist
office [**Telephone/Fax (1) 9472**] with any questions or concerns
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg prn wheezing
ALLOPURINOL - 150mg daily
SYMBICORT - 160 mcg-4.5 \one puff inhaled twice a day
FLUTICASONE 50 mcg Spray, 1-2 puffs once daily
FUROSEMIDE - 40 mg Tablet daily
ISOSORBIDE MONONITRATE - 120 mg Tablet daily
LISINOPRIL - 2.5 mg Tablet - daily
METOPROLOL TARTRATE - 50 mg Tablet -[**Hospital1 **]
NITROQUICK - 0.3 mg Tablet, Sublingual - prn
OMEPRAZOLE [PRILOSEC] - 40 mg Capsule, Delayed Release(E.C.) -
[**Hospital1 **]
PRAVASTATIN - 10 mg QHS
SUCRALFATE - one gram by mouth twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled Once daily
.
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet - one Tablet(s) by mouth daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
2. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation twice a day.
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Home with Service
Discharge Diagnosis:
GI bleed
Abdominal Aortic Aneurysm
Pulmonary nodule
Gout
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:
Ms. [**Known lastname 50388**],
You were admitted to the hospital because of bleeding from your
GI tract. We did several tests and endoscopic procedures, and
we were still not able to localize the bleed. Therefore, you
are being transferred to [**Hospital6 **] for further
evaluation.
We made the following changes to your medications (which may be
adjusted by your new hospital):
TEMPORARILY STOP: Lasix
TEMPORARILY STOP: Lisinopril
TEMPORARILY STOP: Imdur
STARTED: Protonix 40mg by mouth twice daily (in place of
omeprazole
.
It was a pleasure participating in your care
Followup Instructions:
please follow up as directed after discharge from [**Hospital1 **]
|
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icd9cm
|
[
[
[]
]
] |
[
"44.43",
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icd9pcs
|
[
[
[]
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20485, 20504
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302, 347
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,503
| 129,333
|
12565
|
Discharge summary
|
report
|
Admission Date: [**2164-5-7**] Discharge Date: [**2164-5-15**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Propofol
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Intubation/Mechanical ventilation
History of Present Illness:
Pt is a [**Age over 90 **]F with COPD, h/o cardiomyopathy with EF 55%,
paroxysmal afib, recently admitted to [**Hospital1 **] [**Location (un) 620**] with COPD
flare/CAP who presents with acute respiratory distress. HPI is
taken from records as patient is intubated.
.
The patient was admitted from [**Date range (1) 38893**] to [**Hospital1 **] [**Location (un) 620**] for
fever, confusion, and tachypnea. She was diagnosed with COPD
flare and PNA and treated with Solumedrol for her COPD and
CTX/Azithro/Vanco for her PNA. She improved clinically and was
switched to Prednisone and Levofloxacin. According to her most
recent D/C summary, she was due to finish Levofloxacin today and
was continuing her steroid taper. However, this AM the patient
presented with acute SOB. There was no report of CP, n/v. At
[**Location (un) 620**] she was noted to be wheezy, her skin was noted to be
clammy and was on a NRB. HR 160s. She was subsequently intubated
with propofol, which was switched to etomidate/succ after ?
rash. SoluMedrol 125mg was given. Labs at the OSH notable for
Lact 3.7, WBC 19 (no bands), Na 132, Cr 1.2, CK 26, Trop T
0.143. ABG 7.35/54/353 on PEEP5, Fi02 1. Blood cultures were
sent. There were no MICU beds available and was transferred via
med flight. In the helicopter her BP dropped and she was started
on Levophed.
.
In the ED, initial VS T 101.6, HR 144, BP 90/54, RR 13, 100%
intubated. EKG with afib with RVR and LBBB. Levophed was cont
from [**Location (un) **], 2L NS given. Pt given Digoxin 0.5mg IV x1. RIJ
CVL placed. Pt given vanco 1g IV x1, and ? CTX. Afib converted
to sinus, BP improved, levophed was stopped.
.
On arrival to the floor, patient is intubated and sedated, off
Levophed.
Past Medical History:
-h/o Non-ischemic cardiomyopathy: TTE in [**5-14**] with EF 55%, 2+
AR, 1+ MR; s/p Cath in [**4-8**] with no significant CAD
-COPD on home 02 - PFTs in [**4-13**] with FEV-1 1.02L (69%), VC 1.85L
-Hypothyroidism, s/p thyroid nodule resection
-Paroxysmal Afib
-HTN
-Depression
-CKD baseline 1-1.2
-Glaucoma
-Recent wrist fracture
Social History:
Patient currently lives in a NH ([**Location (un) 582**]). Former smoker. Quit
10yrs ago per report.
Family History:
Mother died of pancreatic cancer in her 80s. One brother died
from PNA and the other from cancer of the spinal cord.
Physical Exam:
VS: T 98.7, BP 113/65, HR 76, RR 12, 98% AC 500/12, PEEP 5, Fi02
1
Gen: Pt is intubated and sedation but opens eyes to command
HEENT: Pupils asymmetric, reactive on R only, anicteric sclera,
MMM
Neck: supple, RIJ CVL intact, no obvious JVD
Heart: RRR nl S1 S2, no m/r/g
Lungs: Bronchial BS bilat, symmetric, no wheeze, no crackles
Abd: soft, NT, ND + BS
Ext: cool, 1+ DP pulses, no pitting edema
Skin: scattered eccymoses
Neuro: Sedation but opens eyes, + corneals, gag reflex.
Occational spontaneous movements though minimal given sedation.
Pertinent Results:
Admission labs:
[**2164-5-7**] 04:57AM WBC-17.9*# RBC-3.57* HGB-10.5* HCT-33.4*
MCV-93 MCH-29.4 MCHC-31.4 RDW-15.2
[**2164-5-7**] 04:57AM NEUTS-75* BANDS-3 LYMPHS-17* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2164-5-7**] 04:57AM PLT SMR-NORMAL PLT COUNT-210
[**2164-5-7**] 04:57AM GLUCOSE-203* UREA N-23* CREAT-1.1 SODIUM-136
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
.
Studies:
CHEST (PORTABLE AP) [**2164-5-7**]
IMPRESSION: Congestive failure and probable small bilateral
pleural effusions, left basilar atelectasis. Underlying
emphysema. ETT and NGT in place.
.
ECG Study Date of [**2164-5-7**]
Irregular tachycardia - probably atrial fibrillation with rapid
ventricular response to 138. Left bundle branch block.
.
TTE (Complete) Done [**2164-5-7**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild to moderate global left ventricular
hypokinesis (LVEF = 35-40 %). Interventricular septal motion is
normal. The aortic valve leaflets (3) are mildly thickened. No
aortic stenosis is seen. Mild (1+) 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.]
The tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. The pulmonic
valve leaflets are thickened. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild-moderate global hyopkinesis.
Mild aortic regurgitation. Borderline pulmonary artery systolic
hypertension.
.
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) [**2164-5-9**]
IMPRESSION: Fractures of the left inferior and superior pubic
rami.
.
PELVIS (AP, INLET & OUTLET) [**2164-5-10**]
Three views of the pelvis are obtained and compared to the study
of the day before. Again noted are fractures of the left
inferior and superior pubic rami. The fractures are
non-displaced. Pubic symphysis is congruent. There are moderate
degenerative changes of the lower lumbar spine. Further
evaluation for occult fractures of the pelvis may be better
performed with CT.
.
CT PELVIS W/O CONTRAST [**2164-5-12**], PRELIM
IMPRESSION:
1. No significant pelvic hematoma identified.
2. Multiple left-sided pelvic fractures as noted above.
3. Cystic area seen within the pelvis dependently anterior to
the rectum. Also, soft tissue attenuation focus seen posteriorly
within the bladder. Pelvic MRI is recommended for further
characterization of these findings.
Brief Hospital Course:
[**Age over 90 **]F with COPD, cardiomyopathy, paroxysmal afib who presents with
acute respiratory distress and afib with RVR. Hospital course
was complicated by fall with resultant pelvic fracture. There
was also an incidental finding of pelvic mass.
.
COPD Exacerbation: Pt was initially hypoxic and hypercarbic at
OSH, requiring intubation overnight. She was easily extubated
and maintained adequate O2 saturation in the mid-to-high 90s on
2L NC. She received methylprednisolone in the ED, was started on
a prednisone taper in the MICU that was scheduled to end at
rehab. She was continued on her albuterol, ipratropium MDIs and
had no respiratory distress on the floor.
.
Hospital-Acquired Pneumonia: Pt was also found to have
pneumonia. Endotracheal sputum was positive for MRSA. DFA and
legionella were negative. She was initially started on
vancomycin and piperacillin-tazobactam, switched to vancomycin
and cefepime, which were discontinued by discharge after 9 days.
Blood cultures were negative. Patient was stasble
respiratory-wise by discharge.
.
Cardiogenic hypotension: Pt was hypotensive in the setting of
intubation and atrial fibrillation with RVR. Once pt returned
to NSR with digoxin given in the ED, she was quickly weaned off
of pressors.
.
Paroxysmal Atrial Fibrillation: She was in a. fib with RVR in
ED and was given digoxin with subsequent conversion. By
discharge, pt remained in NSR with home bisprolol. Pt had been
on ASA for anticoagulation with CHADS2 score of 2, but given her
risks of bleeding and reluctance for blood transfusion, aspirin
was discontinued by discharge.
.
Demand ischemia: Pt had slightly elevated troponins on
admission that trended down with time. This was likely [**3-10**]
demand ischemia during a fib with RVR as CKs are flat. Pt had
normal cath in [**2158**]. Pt was continued on lisinopril, bisprolol,
ASA.
.
Pelvic fracture s/p fall: Pt had a mechanical fall and was
found to have a pelvic fracture. She was [**Year (4 digits) 6349**] by
Orthopedics and this was found to be an nonoperative fracture.
Orthopedics recommended weightbearing as tolerated, and she will
follow up with them as outpatient. Pain was controlled with
standing acetaminophen and prn low-dose oxycodone.
.
Anemia: Iron studies suggested anemia of chronic disease. Retic
count is inappropriately low. Vitb12/folate levels were WNL.
Hemolysis labs were negative. Pt had guaiac positive stool on
[**5-13**] but is refusing colonoscopy. CT does not show bleed into
her pelvis. She was continued on iron supplements. Her Hct
dropped to 21.6 on [**2164-5-14**], and she reluctantly agreed to 2 units
of pRBCs, after which her Hct increased to 26.7.
.
Pelvic mass on CT scan: patient refused further work-up.
.
Chronic systolic congestive heart failure: Echo showed EF of
35-40%. Pt was volume resuscitated in the MICU and appeared
euvolemic on exam on the floor. She denied any SOB on the
floor. Her home dose of furosemide was resumed on the floor
along with her lisinopril, bisprolol, ASA.
.
HTN: Initially patient was actually hypotensive, leading to the
discontinuation of all her antihypertensives. Pt was then
normotensive on home lisinopril, bisprolol. Her home isosorbide
mononitrate was held and would be possibly restarted at rehab if
her BP continued to be stable.
.
Hypothyroidism: Pt was continued on Levothyroxine.
.
Glaucoma: Pt was continued on home eye drops.
.
Code: Per HCP, patient is DNR but will allow intubation.
Medications on Admission:
Prilosec 20 mg daily.
Lisinopril 30 mg daily.
Bisoprolol 10 mg daily.
Synthroid 75 mcg daily.
Blephamide eye drops, 1 drop daily twice per day both eyes.
Advair 1 puff twice per day.
Colace 100 mg twice per day.
Oyster Cal 500 mg 3 times per day.
Senna 1 tab daily.
Remeron 15 mg daily.
Neurontin 300 mg twice per day.
Lasix 40 mg daily.
Spiriva 18 mcg daily.
Aspirin 81 mg daily.'
Ferrous sulphate 325mg [**Hospital1 **]
Imdur 30mg Daily
Prednisone 20mg Daily through [**5-9**], then 10mg Daily through [**5-13**]
Vicodin 1 tab q4 prn
Immodium 2mg PRN
Duoneb q6 prn
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Bisoprolol Fumarate 5 mg Tablet Sig: Two (2) Tablet PO daily
().
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sulfacetamide-Prednisolone 10-0.2 % Drops, Suspension Sig:
One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inh Inhalation once a day.
15. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) neb Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
16. Prednisone 5 mg Tablet Sig: see comment Tablet PO once a
day: Tapering regimen: 20 mg on [**2164-5-16**]; 10 mg on [**4-15**],
[**5-19**]; 5 mg on [**5-17**], [**5-22**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary:
Hospital Acquired Pnuemonia
Chronic obstructive pulmonary disease exacerbation
Pelvic fracture
Pelvic mass
Anemia
.
Secondary:
Paroxysmal atrial fibrillation
Demand ischemia
Chronic systolic congestive heart failure
Hypertention
Hypothyroidism
Glaucoma
Discharge Condition:
stable
Discharge Instructions:
You were admitted for difficulty breathing, which required
intubation, i.e. being on a breathing tube for one day. You were
treated for pneumonia and exacerbation of chronic obstructive
pulmonary disease. You have finished a course of antibiotics.
You were started on and will finish steroids at the
rehabilitation center.
.
While you were here, you had fallen and suffered a pelvic
fracture. The Orthopedic doctors [**First Name (Titles) **] [**Last Name (Titles) 6349**] [**Name5 (PTitle) **] and you do
NOT need surgery. You will need to follow up at the Trauma
Clinic in 3 weeks. An appointment has been made for you. You
were also found to have a pelvic mass, further work-up of which
you declined.
.
Please take your medications as prescribed.
.
If you develop lightheadedness, shortness of breath, cough,
fever, chest discomfort, worsening hip pain or swelling, or any
other concerning symptoms, please call your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**] at [**Telephone/Fax (1) 5294**] or go to the Emergency
Department.
Followup Instructions:
Please follow up with the Trauma Clinic on [**2164-5-29**] on
11:00 AM. The clinic number is [**Telephone/Fax (1) **].
.
Please also follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**]
on [**2164-6-1**] at 2:00 PM. His clinic number is
[**Telephone/Fax (1) 5294**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"789.39",
"E849.7",
"244.9",
"486",
"808.2",
"491.21",
"425.4",
"428.22",
"585.9",
"403.90",
"428.0",
"E885.9",
"518.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11564, 11641
|
5919, 9410
|
258, 294
|
11947, 11956
|
3225, 3225
|
13080, 13532
|
2529, 2647
|
10028, 11541
|
11662, 11926
|
9436, 10005
|
11980, 13057
|
2662, 3206
|
198, 220
|
322, 2041
|
3241, 5896
|
2063, 2395
|
2411, 2513
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,240
| 174,171
|
43556
|
Discharge summary
|
report
|
Admission Date: [**2175-12-12**] Discharge Date: [**2175-12-16**]
Date of Birth: [**2125-2-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Spenoid [**Doctor First Name 362**] mass, Metastatic Breast Cancer
Major Surgical or Invasive Procedure:
[**2175-12-13**]: Left sided craniotomy for mass decompression
History of Present Illness:
Patient is a 50F electively admitted to the neurosurgery service
for craniotomy for mass resection
Past Medical History:
Breast CA with mets to spine and pleura
Abnormal Liver function tests
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
On Discharge:
Patient is alert, oriented to person, place and date. PERRL.
Left periorbital edema and ecchymosis, consistant with recent
left craniotomy. Face is symmetric, tongue is midline. Full
strength and sensation throughout upper and lower extremities.
Pertinent Results:
MRI(Post-op); reveals decompression of left temporal mass, and
associated post-operative changes. Stable imaging.
Brief Hospital Course:
Patient is a 50F electively admitted to the hospital on [**2175-12-12**]
for planned resection of spenoid [**Doctor First Name 362**] mass. On [**12-12**], she went
had an angiogram to attempt to embolize the blood supply to said
mass; however defined vasculature could not be identified. On
[**12-13**], she went to the OR for left sided crani. The mass was
decompressed, and frozen section pathology(intraop) identified a
metastatic carcinoma. After the OR, she was returned to the PACU
overnight for frequent neuro checks, which were uneventful. on
POD#1, she transferred from the ICU to the floor. Neuro and
Radiation oncology were consulted. PT/OT were also consutled,
and recommended she be discharged to home without services. She
was subsequently discharged on [**12-16**]
Medications on Admission:
Xeloda
Discharge Disposition:
Home
Discharge Diagnosis:
Spenoid [**Doctor First Name **] Mass
Metastatic Breast Cancer
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication(taper to 2mg
twice daily), make sure you are taking a medication to protect
your stomach (Prilosec, Protonix, or Pepcid), as these
medications can cause stomach irritation. Make sure to take
your steroid medication with meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**8-18**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-15**] 4pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization.
Completed by:[**2175-12-19**]
|
[
"197.2",
"198.3",
"198.4",
"V10.3",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"88.41",
"02.12",
"01.6",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
2015, 2021
|
1176, 1958
|
388, 453
|
2128, 2152
|
1038, 1153
|
7263, 8191
|
725, 743
|
2042, 2107
|
1984, 1992
|
2176, 2197
|
758, 758
|
772, 1019
|
5432, 7240
|
282, 350
|
2209, 5405
|
481, 581
|
603, 675
|
691, 709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,516
| 103,157
|
54133
|
Discharge summary
|
report
|
Admission Date: [**2195-7-13**] Discharge Date: [**2195-7-18**]
Date of Birth: [**2134-9-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Left lower extremity ischemia with
ulceration.
Major Surgical or Invasive Procedure:
Left SFA to TPT bypass with NRGSV
History of Present Illness:
This is a 60-year-old man who has
left leg ulceration in the heel. Arteriogram showed occlusion
of the above-knee popliteal artery with reconstitution of the
below-knee popliteal artery and a single-vessel runoff via
the peroneal which had a patent posterior tibial artery.
Given these findings, the patient was consented for a femoral
to tibial bypass to help assist him with wound healing
Past Medical History:
CHF with EF < 20%, global right and left ventricle hypokinesis
DM2 on insulin
HTN
CAD: CABG [**2187**], on asa, plavix; MIBI in [**1-31**] w/out rev [**First Name (Titles) 110951**]
[**Last Name (Titles) 110952**]
Social History:
- no current etoh
- no cigarette smoking, no illegal drug use
- blood transfusion once before, at hospitalization at [**Hospital1 18**] in
[**1-/2193**]
Family History:
non-contributory
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: 2/6 SEM
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], dop pt
lle - palp fem, [**Doctor Last Name **], dop pt, dp
ulcer on the left heel, debrided bedside
graft palp
Pertinent Results:
[**2195-7-17**] 07:10AM BLOOD
WBC-11.7* RBC-3.39* Hgb-10.3* Hct-29.2* MCV-86 MCH-30.3
MCHC-35.1* RDW-14.2 Plt Ct-276
[**2195-7-17**] 07:10AM BLOOD
Glucose-61* UreaN-32* Creat-2.4* Na-140 K-3.7 Cl-103 HCO3-25
AnGap-16
[**2195-7-17**] 07:10AM BLOOD
Calcium-8.3* Phos-4.2 Mg-2.2
[**2195-7-13**] 06:00PM BLOOD
Glucose-255* Lactate-2.2* Na-134* K-4.8 Cl-108
[**Known lastname **],[**Known firstname **] I [**Medical Record Number 110955**] M 60 [**2134-9-18**]
Cardiology Report ECG Study Date of [**2195-7-13**] 7:33:08 PM
Baseline artifact. Sinus rhythm. P-R interval prolongation. Left
bundle-branch block. Compared to the previous tracing of [**2195-7-8**]
there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 186 150 490/490 75 -26 -179
Brief Hospital Course:
Patient is a 60 year old male with multiple medical problems
including severe peripheral vascular disease and a non-healing
left foot ulcer on which an angiogram was performed on previous
admission [**2195-7-7**] without complication. Patient was scheduled
for surgery [**2195-7-13**] and discharged home. Patient was found to
have chronic renal insufficiency on previous admission and was
discharged with stable Cr.
On this admission patient underwent a Left superficial femoral
artery to
dorsalis pedis trunk bypass with reverse greater saphenous vein.
The operation was uncomplicated. Patient returned to the
floor. During his post-operative recovery patient experienced
an episode of tachycardia for which he was followed by
cardiology. ECG and cardiac enzymes were found to be negative
and the patient was asymptomatic. Cardiology was consulted and
it was determined no further workup was necessary. During his
hospital admission patient's creatinine rose to 2.5. He was
given IV bicarbonate and at discharge his creatinine has
stabilized.
Patient was discharged home on POD5 with visiting nurse to
monitor his leg incision for signs of infection and with PT to
help patient ambulate.
Medications on Admission:
xanax 1mg TID, Amlodipine 5 mg Tablet QD, Coreg 25 QD, Clonidine
0.2 mg Tablet TID, Plavix 75, Lasix 80mg [**Hospital1 **], Hydralazine 25
mg Tablet TID, Vicodin prn, Lantus 55 units in a.m., 22 units at
night, Lisinopril 2.5 mg Tablet QD, zocor
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Insulin
Sliding Scale & Fixed Dose
Fingerstick QACHS
Insulin SC
Fixed Dose Orders
Breakfast Bedtime
Glargine 55 Units Glargine 22 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-50 mg/dL 4 oz. Juice
51-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
> 400 mg/dL Notify M.D.
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a
day for 10 days: prn.
Disp:*31 Tablet(s)* Refills:*0*
11. [**Last Name (un) 1724**]
xanax 1mg TID, Amlodipine 5 mg Tablet QD, Coreg 25 QD, Clonidine
0.2 mg Tablet TID, Plavix 75, Lasix 80mg [**Hospital1 **], Hydralazine
25 mg Tablet TID, Vicodin prn, Lantus 55 units in a.m., 22 units
at night, Lisinopril 2.5 mg Tablet QD, zocor 40mg QD
12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
On Hold check with PCP before taking.
Discharge Disposition:
Home With Service
Facility:
caritas home care
Discharge Diagnosis:
Peripheral Vascular Disease
Gangrenous ulcer left heel
CRI
Low HCT post op requiring PRBC
Bedside debridement of leftheel ulcer
Diabetes mellitus type 2, HTN, coronary artery disease, CHF
Discharge Condition:
Stable
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 ([**10-8**] lbs) until your follow up appointment.
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 [**1-27**]
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:
Followup with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-8-6**] 11:30
Follow-up with Podiatry: Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name (STitle) **] for appt. Phone: ([**Telephone/Fax (1) 19882**]
|
[
"V45.81",
"428.0",
"357.2",
"250.70",
"427.1",
"440.24",
"707.14",
"250.60",
"585.9",
"428.20",
"403.90",
"997.1",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.28",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
361, 397
|
6220, 6229
|
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|
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|
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6269, 10301
|
1274, 1782
|
275, 323
|
425, 817
|
839, 1054
|
1070, 1225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,994
| 197,775
|
34485
|
Discharge summary
|
report
|
Admission Date: [**2166-8-17**] Discharge Date: [**2166-8-25**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
s/p fall, not found for 2 days, eval for LE weakness
Major Surgical or Invasive Procedure:
Spine surgery [**2166-8-20**]: T8-L2 fusion.
History of Present Illness:
88y/o RHF with PMH sig for HTN and HLD that pres from OSH
([**Hospital1 1474**]) after being foundby nephew at home on [**2166-8-13**] x48hrs
s/p fall. Pt was in normal state of health. Staying alone with
full ADLs when she awoke to go to the bathroom. Based on her
description she transferred over to a bedside commode. During
the
transfer "something happened," "I had a quick faint." She is
unsure of a LOC but think that she fainted. She did not hir her
head on the way down. Her back and buttocks hit first. She
attempted to get up using her elbows and arms but was unable to
did so. She does question if at this time she had bilateral leg
weakness.
Pt does mention that she lost her urine on the way to the
commode
and mention that she has a history of "bladder prolapse" and it
had been out over the last few days and she mentions a history
of
constipation yet worse this week than others.
Pt denies palpitations, chest pain, slipping, a loss of footing,
no numbness, tingling, slurred speech, facial droop noted.
Past Medical History:
HTN
HLD
Vertigo
Osteoporosis
NO hx of cardiac problems, strokes
Hysterectomy
R knee [**Doctor First Name **]
Social History:
Lives alone uses a walker for ADLS. ADLS Full. Has a nephew that
visits her name [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Telephone/Fax (1) 79240**] or [**Telephone/Fax (1) 79241**]. NO
EtOH,
NO Tobacco, NO Illicit drugs
Family History:
father - leukemia
brother - prostate ca
Mother died in 90s and has sister living now in her 90s
NO FMH of strokes, no cardiac issues
Physical Exam:
VS: AF T 96.6 89 124/74 20 98% glc 94
Gen: Alert, awake, cooperative in pain secondary to transferring
beds with back sores
HEENT: dry mm, NCAT no bruising or tenderness noted
Neck: Supple, FROM
CV:NSR, RRR, S1, S2 no murmurs rubs or gallops
Chest: sym chest rise, CTAB
Abd: distended, NT, +BS, healed scar, no bruising
Ext: minimally limited ROM secondary to pain,
SPINE: slight inconsistent pain to deep palp in the lower
thoracic spine, over the areas of nuded skin and early decubitus
ulcer
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, and date. For location pt states a
research bldg. Attentive, says [**Doctor Last Name 1841**] backwards only skipping
[**Month (only) 958**].
Speech is fluent with normal comprehension and repetition;
naming
intact. No dysarthria. Registers [**3-10**], recalls [**3-10**] in 5 minutes.
No right-left confusion. No evidence of apraxia or neglect.
Cranial Nerves: Pupils equally round and reactive to light, 3-2
mm bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally. Horizontal nystagmus
1-3beats. Sensation intact V1-V3. Facial movement symmetric.
Palate elevation symmetric. Sternocleidomastoid and trapezius
full strength bilaterally. Tongue midline, movements intact.
Motor: Reduced secondary to aging bulk yet symmetric and tone
bilaterally. No observed myoclonus, asterixis, or tremor. No
pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE
R 4+ 5 5 5 4+ 4+ 4+ 4+ 4+ 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, position sense. No extinction
to DSS.
Reflexes: 2+ and symmetric throughout. Toes downgoing
bilaterally.
Coordination: finger-nose-finger, finger-to-nose, Gait: not
assessed. Romberg negative.
Pertinent Results:
[**2166-8-25**] 05:59AM BLOOD WBC-10.6 RBC-2.84* Hgb-8.0* Hct-24.5*
MCV-86 MCH-28.3 MCHC-32.8 RDW-14.9 Plt Ct-175
[**2166-8-24**] 02:35AM BLOOD WBC-9.7 RBC-2.78* Hgb-7.9* Hct-23.7*
MCV-85 MCH-28.3 MCHC-33.1 RDW-15.0 Plt Ct-153
[**2166-8-23**] 01:39PM BLOOD WBC-10.2 RBC-2.76* Hgb-8.1* Hct-23.8*
MCV-86 MCH-29.3 MCHC-34.0 RDW-15.7* Plt Ct-168
[**2166-8-23**] 02:59AM BLOOD Hct-23.8*
[**2166-8-23**] 01:40AM BLOOD WBC-9.9 RBC-2.63* Hgb-7.7* Hct-22.5*
MCV-86 MCH-29.4 MCHC-34.4 RDW-15.7* Plt Ct-162
[**2166-8-22**] 02:52AM BLOOD WBC-12.1* RBC-3.02* Hgb-8.6* Hct-25.7*
MCV-85 MCH-28.4 MCHC-33.4 RDW-15.0 Plt Ct-175
[**2166-8-21**] 08:03AM BLOOD WBC-9.9 RBC-3.30* Hgb-9.5* Hct-28.2*
MCV-86 MCH-29.0 MCHC-33.9 RDW-15.2 Plt Ct-169
[**2166-8-21**] 12:55AM BLOOD WBC-9.5 RBC-3.65* Hgb-10.3* Hct-31.1*
MCV-85 MCH-28.1 MCHC-32.9 RDW-14.5 Plt Ct-145*
[**2166-8-20**] 09:00AM BLOOD WBC-10.1 RBC-3.93* Hgb-11.2* Hct-33.9*
MCV-86 MCH-28.4 MCHC-32.9 RDW-15.4 Plt Ct-152
[**2166-8-19**] 06:30AM BLOOD WBC-9.7 RBC-4.00* Hgb-11.3* Hct-34.9*
MCV-87 MCH-28.2 MCHC-32.3 RDW-15.5 Plt Ct-143*
[**2166-8-18**] 06:20AM BLOOD WBC-9.8 RBC-4.14* Hgb-12.0 Hct-36.2
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.3 Plt Ct-133*
[**2166-8-17**] 08:05PM BLOOD WBC-10.8 RBC-4.32 Hgb-12.3 Hct-36.7
MCV-85 MCH-28.5 MCHC-33.6 RDW-14.7 Plt Ct-133*
[**2166-8-17**] 08:05PM BLOOD Neuts-84.1* Lymphs-9.2* Monos-5.5 Eos-1.1
Baso-0.1
[**2166-8-25**] 05:59AM BLOOD Plt Ct-175
[**2166-8-24**] 02:35AM BLOOD Plt Ct-153
[**2166-8-23**] 01:39PM BLOOD Plt Ct-168
[**2166-8-23**] 01:40AM BLOOD Plt Ct-162
[**2166-8-22**] 02:52AM BLOOD Plt Ct-175
[**2166-8-21**] 08:03AM BLOOD Plt Ct-169
[**2166-8-21**] 12:55AM BLOOD Plt Ct-145*
[**2166-8-21**] 12:55AM BLOOD PT-14.9* PTT-37.2* INR(PT)-1.3*
[**2166-8-20**] 09:00AM BLOOD Plt Ct-152
[**2166-8-20**] 09:00AM BLOOD PT-14.3* PTT-30.9 INR(PT)-1.2*
[**2166-8-19**] 06:30AM BLOOD Plt Ct-143*
[**2166-8-19**] 06:30AM BLOOD PT-14.1* PTT-33.9 INR(PT)-1.2*
[**2166-8-18**] 06:20AM BLOOD Plt Ct-133*
[**2166-8-18**] 06:20AM BLOOD PT-13.8* PTT-33.3 INR(PT)-1.2*
[**2166-8-17**] 08:05PM BLOOD Plt Ct-133*
[**2166-8-25**] 05:59AM BLOOD Glucose-90 UreaN-9 Creat-0.3* Na-139
K-3.7 Cl-100 HCO3-38* AnGap-5*
[**2166-8-24**] 02:35AM BLOOD Glucose-100 UreaN-8 Creat-0.3* Na-139
K-3.7 Cl-102 HCO3-35* AnGap-6*
[**2166-8-23**] 01:40AM BLOOD Glucose-119* UreaN-11 Creat-0.3* Na-140
K-3.6 Cl-106 HCO3-30 AnGap-8
[**2166-8-22**] 02:52AM BLOOD Glucose-116* UreaN-12 Creat-0.4 Na-140
K-3.9 Cl-109* HCO3-27 AnGap-8
[**2166-8-21**] 12:55AM BLOOD Glucose-135* UreaN-9 Creat-0.2* Na-139
K-3.7 Cl-108 HCO3-24 AnGap-11
[**2166-8-20**] 09:00AM BLOOD Glucose-97 UreaN-12 Na-139 K-3.5 Cl-105
HCO3-28 AnGap-10
[**2166-8-19**] 06:30AM BLOOD Glucose-91 UreaN-22* Creat-0.4 Na-142
K-3.7 Cl-107 HCO3-28 AnGap-11
[**2166-8-18**] 06:20AM BLOOD Glucose-93 UreaN-31* Creat-0.4 Na-142
K-4.3 Cl-109* HCO3-25 AnGap-12
[**2166-8-17**] 08:05PM BLOOD Glucose-101 UreaN-39* Creat-0.5 Na-139
K-3.9 Cl-105 HCO3-27 AnGap-11
[**2166-8-18**] 06:20AM BLOOD CK(CPK)-266*
[**2166-8-17**] 08:57PM BLOOD CK(CPK)-408*
[**2166-8-18**] 06:20AM BLOOD CK-MB-6 cTropnT-0.02*
[**2166-8-17**] 08:57PM BLOOD CK-MB-6 cTropnT-<0.01
[**2166-8-25**] 05:59AM BLOOD Calcium-7.7* Phos-3.3 Mg-2.0
[**2166-8-24**] 02:35AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8
[**2166-8-23**] 01:40AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.7
[**2166-8-22**] 02:52AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.1
[**2166-8-21**] 10:00AM BLOOD Mg-1.9
[**2166-8-21**] 12:55AM BLOOD Phos-3.7 Mg-1.4*
[**2166-8-20**] 09:00AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.8
[**2166-8-19**] 06:30AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.1
[**2166-8-18**] 06:20AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.1 Cholest-160
[**2166-8-17**] 08:05PM BLOOD Calcium-8.2* Phos-2.7 Mg-2.2
[**2166-8-18**] 06:20AM BLOOD %HbA1c-5.6
[**2166-8-18**] 06:20AM BLOOD Triglyc-163* HDL-26 CHOL/HD-6.2
LDLcalc-101
[**2166-8-17**] 08:57PM BLOOD TSH-3.4
[**2166-8-17**] 08:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2166-8-23**] 01:54AM BLOOD Type-ART pO2-73* pCO2-47* pH-7.43
calTCO2-32* Base XS-5
[**2166-8-21**] 10:09AM BLOOD Type-ART pO2-149* pCO2-38 pH-7.42
calTCO2-25 Base XS-0
[**2166-8-21**] 05:50AM BLOOD Type-ART pO2-130* pCO2-36 pH-7.37
calTCO2-22 Base XS--3
[**2166-8-21**] 12:58AM BLOOD Type-ART pO2-136* pCO2-37 pH-7.42
calTCO2-25 Base XS-0
[**2166-8-20**] 11:07PM BLOOD Type-ART pO2-183* pCO2-40 pH-7.38
calTCO2-25 Base XS-0
[**2166-8-20**] 09:52PM BLOOD Type-ART pO2-194* pCO2-45 pH-7.37
calTCO2-27 Base XS-0 Intubat-INTUBATED
[**2166-8-20**] 08:18PM BLOOD Type-ART Temp-35.8 Rates-/8 Tidal V-500
pO2-94 pCO2-43 pH-7.44 calTCO2-30 Base XS-4 Intubat-INTUBATED
Vent-CONTROLLED
[**2166-8-23**] 01:54AM BLOOD Lactate-1.1
[**2166-8-21**] 10:09AM BLOOD Glucose-141* K-4.2
[**2166-8-21**] 05:50AM BLOOD K-3.6
[**2166-8-20**] 11:07PM BLOOD Glucose-100 Lactate-1.0 Na-138 K-3.3*
Cl-109
[**2166-8-20**] 09:52PM BLOOD Glucose-102 Lactate-1.6 Na-138 K-3.4*
Cl-103
[**2166-8-20**] 08:18PM BLOOD Glucose-90 Lactate-1.9 Na-137 K-3.4*
Cl-101
[**2166-8-21**] 10:09AM BLOOD O2 Sat-98
[**2166-8-21**] 05:50AM BLOOD O2 Sat-99
[**2166-8-21**] 12:58AM BLOOD O2 Sat-99
[**2166-8-20**] 11:07PM BLOOD Hgb-8.8* calcHCT-26
[**2166-8-20**] 09:52PM BLOOD Hgb-10.8* calcHCT-32
[**2166-8-20**] 08:18PM BLOOD Hgb-11.5* calcHCT-35
[**2166-8-23**] 01:54AM BLOOD freeCa-1.04*
[**2166-8-21**] 10:09AM BLOOD freeCa-1.12
[**2166-8-20**] 11:07PM BLOOD freeCa-1.03*
[**2166-8-20**] 09:52PM BLOOD freeCa-1.06*
Brief Hospital Course:
This 88 yo woman sustained trauma after a fall and was not found
for several days. She was evaluated at an OSH and, after being
stabilized, was thought to have some new LE weakness, and was
transferred to [**Hospital1 18**] neurology for evaluation. She arrived in
the night and was agitated/delerious, for which she was given
zyprexa, and also went into AF with RVR to the 190's. She was
given IV lopressor, IV diltiazem x 2 doses, and then a diltiazem
drip. During the night she converted to sinus rhythm and had a 6
second pause, which upon further discussion with the cardiology
team, was thought to be a conversion pause. Cardiology
recommended continuing lopressor PO, and she remained in sinus
rhythm for the remainder of her hospitalization.
The initial assessment of her neurolocigal status by the
floor team was clouded by her lethargy, suspected to be likely
secondary to the zyprexa she had received overnight.
Nonetheless, in light of her trauma, she received an MRI/MRA of
her brain, which was read as showing extensive chronic small
vessel ischemic disease, a chronic lacunar infarction in the
right thalamus without acute infarction, and apparent occlusion
versus slow flow of the left posterior cerebral artery. She
received an EEG which was read as an abnormal portable EEG due
to the slow background with occasional generalized slow
activity. This finding suggests a
widespread mild encephalopathy affecting both cortical and
subcortical
structures. There were no areas of prominent focal slowing and
no clear epileptiform features. Ultimately, her mental status
improved as the day passed, and consequently it was presumed
that her lethargy was indeed secondary to the zyprexa. The
remainder of her neurological exam was significant for a LE
paraparesis, but thought to be secondary to predominantly to
pain and perhaps old spondylosis. Cord compression was not
appreciated on imaging.
At the OSH, imaging had suggested a T11 vertebral fx with
some sort of poorly visualized anterior mass, thought to be a
hematoma. She received an MRI of her C- and T-spine here which
showed acute fracture of the anterior portion of the T11
vertebral body which was presumably an unstable fracture with
recommended spinal surgical evaluation, and no evidence for cord
compression or cord encroachment. Subsequent CT of the C- and
T-spince confirmed unstable distraction fracture of the T11
vertebral body along with disruption of the anterior
longitudinal ligament, diffuse osteopenia with scoliosis, and
diffuse multilevel degenerative joint disease.
She was transferred to the orthopedic service for spine
surgery which occurred [**2166-8-20**]. She underwent T10 to T12
posterior laminectomy decompression of T10-T11, T11-T12,
posterior spinal fusion T8-L2, posterior spinal instrumentation
segmental from T8-L2, application of local autograft, allograft
and BMP II, and open treatment of fracture dislocation T11.
She was transferred back to the neurology service on the
night of [**2166-8-24**]. On the morning of [**8-25**] she was found to be in
a grumpy mood with many complaints about her environs, which,
according to family members is consistent with her baseline. She
was oriented to self, place, and "[**2166-8-8**]." Her LE
paraparesis was essentially unchanged compared to her admission
exam. She also had some mild weakness in her deltoids
bilaterally R>L. Her reflexes were diminished at the biceps and
otherwise were absent throughout. The remainder of her
neurological exam was normal.
Per d/w orthopedics, her activity level is as tolerated and
she is able to work with PT/OT. She should continue her wound
care as prescribed, continue use of the First Step mattess, and
continue her bowel regimen as prescribed.
Medications on Admission:
Perocet 1 tab q4 PRN pain
Toradol 15mg IV q6 PRN pain
Unasyn 3gm IV q6
Nystatin powder
Lovenox 30 mg SC qday
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
6. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
grams PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
T11 vertebral fracture
Discharge Condition:
stable
Discharge Instructions:
You have sustained a T11 vertrbral fracture which was surgically
repaired via a T8-L2 fusion. Please return to the ER if you
expereince any sudden focal weakness, change in sensation,
vision, speech, or cognition, any severe headaches, vertigo, new
incontinence, or anything else that concerns you seriously.
Followup Instructions:
Orthopedic follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]: ([**Telephone/Fax (1) 2007**]
With PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10381**]
Completed by:[**2166-8-25**]
|
[
"805.2",
"707.02",
"733.00",
"707.01",
"737.30",
"E891.8",
"780.2",
"707.8",
"401.9",
"599.0",
"707.03",
"785.0",
"707.05",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"81.63",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
13907, 13979
|
9317, 13074
|
317, 364
|
14046, 14055
|
3857, 9294
|
14412, 14691
|
1817, 1951
|
13233, 13884
|
14000, 14025
|
13100, 13210
|
14079, 14389
|
1966, 2462
|
225, 279
|
392, 1417
|
2940, 3838
|
2501, 2923
|
2486, 2486
|
1439, 1550
|
1566, 1801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,205
| 118,871
|
41839
|
Discharge summary
|
report
|
Admission Date: [**2185-11-22**] Discharge Date: [**2185-12-2**]
Date of Birth: [**2123-11-12**] Sex: M
Service: SURGERY
Allergies:
morphine / Iodine
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
[**2185-11-29**] Dobhoff feeding tube placement
[**2185-11-24**] Replacement of PTBD drain
History of Present Illness:
62 year old male recently discharged after complicated ICU stay
for necrotizing pancreatitis, now presenting back from rehab
with GI bleed. Patient was initially transferred from an OSH
with severe gallstone pancreatitis and multiorgan failure with
ARDS, acute renal failure requiring dialysis and a CT showing
necrotizing pancreatitis with development of a pseudocyst. At
[**Hospital1 18**] he was managed initially in the [**Hospital Unit Name 153**], and his course was
complicated by cholangitis requiring ERCP that was unsuccessful
to cannulate the CBD given the severe inflammation compressing
the duodenum and a PTC was placed on [**2185-9-30**]. He developed a
large pancreatic pseudocyst requiring operative drainage and in
[**2185-10-18**] he underwent a RNY cyst jejunostomy, SBR,
cholecystectomy and umbilical hernia repair. Postop he required
a tracheostomy given respiratory failure and unable to wean from
the vent. He was finally discharged to rehab on [**2185-11-17**] on
trach collar, tolerating PMV, with PTBD internal/external capped
and a Dobbhoff for tube feeds, on HD Monday/Wednesday/Friday and
off antibiotics.
Past Medical History:
PMH:
- Diabetes
- Hypertension
- Hyperlipidemia
- Nephrolithiasis
- Vertebral disc disease
PSH:
- [**2185-9-30**] percutaneous biliary drain
- [**2185-10-18**] Open pancreatic debridement. Roux-en-Y pancreatic
cyst jejunostomy. Small bowel resection. Open cholecystectomy.
Umbilical hernia repair.
- [**2185-10-27**] Tracheostomy.
- [**2185-11-15**] Tunneled hemodialysis catheter placement
Social History:
Lives in [**Location **], PA. Smokes 1 cigar/day, drinks
2 drinks/night.
Family History:
non-contributory
Physical Exam:
Vitals: T 97.9 HR 97 BP 100/57 RR 20 SO2 99%
GEN: A&Ox3, NAD.
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l. Trach collar.
ABD: Soft, mildly distended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Wound clean dry intact with sterile strips placed. No
induration,
erythema or drainage
DRE: normal tone, macroscopic melena. +guaiac
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
134 98 52
-------------< 132
4.9 29 2.2
ALT: 101 AP: 852 Tbili: 2.5 Alb: 2.2
AST: 136 Lip: 18
11.8 > 25.5 < 321
N:59 Band:6 L:14 M:7 E:1 Bas:0 Metas: 7 Myelos: 5 Other: 1
NGT lavage: no evidence of blood, clear saline
Brief Hospital Course:
Patient was admitted to the West 2A surgical service in the ICU
for management of his GI bleed. Upon admission to the TSICU
patient underwent an EGD that was positive for a large gastric
ulcer with no evidence of active bleeding. She was started on a
PPI gtt and carafate standing Patient was transfused with 2
units of RBCs and remained stable with stable BP and Hct after
the transfusion. A Dobhoff feeding tube was replaced. Patient
continued on HD in his regular schedule. Patient had some
transient hypotension during his second night overnight,
responsive to fluid boluses. On [**11-24**] a Cholangiogram was
performed showing some filling defects of biliary tract,
consistent with clots, without visible communication with
hepatic arterial, venous or portal vessels. upsizing of a 10
French biliary drainage catheter to a 12 French biliary drainage
catheter. A bedside debridement of his sacral decub ulcer was
performed as well, with some necrotic tissue, but no purulent
drainage or signs of active infection. On [**11-25**] patient had an
episode of nausea/vomiting of tube feeds and so these were held.
He had frequent episodes of melena and required 2U of RBCs. His
H. Pylori serology was negative and his Gastrin level was
normal. On [**11-27**] patient had episode of mild hematemesis along
with some melena and some blood from biliary drain. An NGT was
placed with a negative NG lavage. Protonix gtt was restarted. A
CTA of abd/pelvis showed no active extravasation and some mild
thickening of the jejunum. This finding along with a Hct drop
from 30 to 25, made us ask GI to do another EGD on [**11-27**], which
showed the same large ulcer, that was actually in the duodenal
bulb with no signs of recent bleeding. The jejunojejunostomy
anastomosis looked intact with no signs of bleeding. Given
significant NGT trauma seen, this was taken out with no
nasointestinal tubes for 24 hrs. On [**11-29**] a Postpyloric feeding
tube was replaced. Given that the LFTs continued to improve and
the biliary drained started to put out minimal bilious output
and no more bloody output, the PTC was capped with normal LFTs
after that. Patient was treated with Unasyn empirically during
his hospital stay, but was stopped on [**9-30**] given normalization
of LFTs and WBC. Nephrology followed the patient because of
improved urine output and started spacing out the HD treatments.
On [**11-30**] speech and swallow cleared him for thin liquids and
puree solid diet, which was started having adequate tolerance.
On [**12-1**] he had hemodialysis and had his sacral wound debrided
at the bedside. He was hemodynamically stable and his PTBD
remained capped, which he tolerated well. At the time of
discharge he was working with physical therpay on getting out of
bed and was tolerating his soft pureed diet.
His discharge instructions included recommendations for physical
therapy to continue and for appropriate wound care for his
sarcal decubitus ulcer. He was discharged on [**Hospital1 **] pantoprazole.
Medications on Admission:
colace 100", senna prn, heparin 5000''', oxycodone [**4-26**] prn,
midodrine 2.5''', iron 325', dulcolax 10 prn, zofran prn,
collagenase ointment, lopressor 12.5''', mvi, tylenol prn pain,
folic acis 1', insulin lantus 25 units at bedtime, insulin
regular sliding scale, lidocaine patch 5% daily.
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing .
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
7. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
8. fentanyl citrate (PF) 50 mcg/mL Solution Sig: One (1)
Injection Q2H (every 2 hours) as needed for pain.
9. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
10. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
14. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
15. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: deconditioned, needs shifting assistance in
bed.
Discharge Instructions:
You were seen in the hospital for evaluation of a GI bleed. You
were given blood products and had your red blood cell count
checked regularly to make sure it stayed at an acceptable level.
You also had your biliary tract drain replaced on this
admission. By the time you were being discharged you were
starting to tolerate pureed food after nutrition saw you and
confirmed that it was ok for you to start this diet. At time of
discharge you were also stable hemodynamically.
You were seen by nutrition and wound care services who advised
on the plan for your diet and wound care respectively.
Thank you for letting us take part in your care.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) 468**] as instructed below:
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2185-12-15**] 2:00. His
office is located in the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name **]
[**Hospital1 18**], [**Location (un) 470**].
As instructed before you should follow up with your Primary Care
Physician. [**Name10 (NameIs) **] you will need ongoing management of your blood
sugars as well as your kidney function, you should continue to
see the
nephrologist and the endocrinologist. Please arrange with your
primary care physician to be followed for those conditions.
Completed by:[**2185-12-2**]
|
[
"532.90",
"285.21",
"576.2",
"578.1",
"707.25",
"585.6",
"250.00",
"584.9",
"707.03",
"578.0",
"V44.0",
"V45.11",
"862.22",
"E876.8",
"403.91",
"794.8",
"786.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.08",
"33.24",
"39.95",
"51.98",
"87.54",
"45.13",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7873, 7944
|
2840, 5849
|
287, 384
|
8011, 8011
|
2589, 2817
|
8853, 9578
|
2073, 2091
|
6197, 7850
|
7965, 7990
|
5875, 6174
|
8185, 8830
|
2106, 2570
|
239, 249
|
412, 1550
|
8026, 8161
|
1572, 1966
|
1982, 2057
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,697
| 154,107
|
5961
|
Discharge summary
|
report
|
Admission Date: [**2104-5-26**] Discharge Date: [**2104-5-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
confusion, generalized weakness
Major Surgical or Invasive Procedure:
Femoral line
Subclavian line
arterial line
OJ tube
ET intubation
History of Present Illness:
Mr. [**Known lastname 23505**] is a 82 yoM w/ metastatic prostate cancer who
presented with confusion and generalized weakness. He was
diagnosed with prostate cancer 9 years ago, at which time he
received XRT. 6 years ago, given recurrence, he was started on
Lupron; Casodex was started last year. He was followed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] at [**Hospital1 2025**], and was recently started on a new protocol
using an amidogen product for bone metastases. Given severe
progressive weakness in both lower extremities and lumbar back
pain, he had a lumbar MRI [**2104-5-15**] (ordered by his neurologist Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 23506**]), which showed a tight stenosis at L4/5 and
metastatic lesions at multiple levels, predominalty L5 and S1
with epidural metastases. He was admitted [**Date range (1) 23507**] to [**Hospital1 23508**]. There, he was started on steroids. EMG
revealed generalized neuropathy and acute severe L5-S1
radiculopathy bilaterally, consistent with known
stenosis/epidural metastases. MRI of cervical and thoracic spine
revealed multi-level sclerotic lesions suggesting metastic
disease. A bone scane demonstrated muld lumbosacral uptake,
along with uptake on left lower rib cage, left femur, and right
humerus. He was evaluated by Dr. [**Last Name (STitle) 23509**] of oncology, who
discontinued Casodex (given elevated LFTs) and referred him to
radiation oncology for radiation treatments - received [**2104-5-22**]
and [**2104-5-23**]. Pt was discharged on [**2104-5-22**] to complete 10
radiation treatments as an outpatient; he also apparently
transferred his oncologic care to Dr. [**Last Name (STitle) 23509**] and was planning
to follow-up with him as an outpatient.
.
On [**5-24**], his wife noted that the patient was more confused than
usual - having to be reminded about the date or appointments. He
also noted generalized weakness, although he cannot localize
this to specific extremities. This prompted him to present to
[**Hospital1 18**] ED, on [**5-26**] where he was noted to be febrile to 101. He
was admitted and on [**5-27**] an MRI of the L spine was obtained
showing metastasis. Steroids were increased to 4 mg
dexamethasone Q6 and XRT was continued. As he was febrile, a
course of levaquin was started for presumed CAP and UTI as he
had a positive UA. He was noted to be in renal failure on [**5-27**]
and developed an O2 requirement for which he was diuresed
without improvement. He grew staph from his blood and
antibiotics were switched to vanco and pip tazo.
.
On day of transfer to ICU, the patient was noted to be in a.fib
with rates in the 130's and hypotensive to 95/63. He continued
to be confused. He was noted to have an Aa gradient on his ABG.
He was transferred to ICU for further evaluation and management
of his hypotension.
.
ROS: Currently, patient denies any pain, but admits to shortness
of breath. He denies dysuria. Per report he has had cough,
productive of minimal sputum. No weight loss, night sweats, loss
of vision, sinus pain, sore throat, chest pain, palpitations,
shortness of breath, nausea, vomiting, abdominal pain, abdominal
swelling, melena, bleeding, dysuria, rash, headache.
Past Medical History:
1) Prostate CA:
2) Glaucoma
4) Hypertension
5) hypercholesterolemia
6) h/o colon CA s/p colectomy
7) bilateral THR
8) Status post incisional hernia repair,
9) s/p right inguinal hernia repair
Social History:
Pt denies tobacco or alcohol use. Rare alcohol, none recently
Family History:
NC
Physical Exam:
Tc 98.7, bp 118/71, HR 120, resp 28, 96% 2L NC
Gen: elderly male, lying in bed, tachypneic, using accessory
muscles to breath
HEENT: anicteric, normal conjunctiva, oral mucosa dry
Cardiac: tachycardic, no M/R/G appreciated
Pulm: dullness to percussion on right [**3-15**] way up with wheezes
and bronchial breath sounds bilaterally.
Abd: NABS, soft, obese, NT/ND. Well healed surgical incisions.
Ext: minimal edema. Right knee with well healed [**Doctor First Name **] incision.
Slightly warm. DP and radial pulses 2+ bilaterally.
Neuro: Alert, oriented to person, place, and month and year but
not date. 3+/5 strength LE bilaterally, 4+/5 UE bilaterally,
sensation intact to light touch proximally and distally in upper
and lower extremities bilaterally.
Back: No tenderness to percussion over spine
Psychiatric: confused, pleasant
GU: Foley in place
Pertinent Results:
[**2104-5-26**] 09:50AM BLOOD WBC-14.8* RBC-4.40* Hgb-12.7* Hct-36.0*
MCV-82 MCH-28.8 MCHC-35.1* RDW-15.2 Plt Ct-202
[**2104-5-26**] 09:50AM BLOOD Neuts-87* Bands-9* Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2104-5-28**] 01:46PM BLOOD PT-13.1 PTT-24.5 INR(PT)-1.1
[**2104-5-26**] 09:50AM BLOOD UreaN-70* Creat-1.9* Na-135 K-3.7 Cl-94*
HCO3-27 AnGap-18
[**2104-5-26**] 09:50AM BLOOD ALT-36 AST-39 AlkPhos-158* Amylase-52
TotBili-0.8
[**2104-5-26**] 09:50AM BLOOD Albumin-3.7 Calcium-8.9 Phos-4.3 Mg-2.5
[**2104-5-26**] 09:50AM BLOOD VitB12-890
[**2104-5-27**] 06:20AM BLOOD calTIBC-209* VitB12-893 Folate-12.8
Ferritn-1098* TRF-161*
[**2104-5-26**] 09:50AM BLOOD TSH-0.67
[**2104-5-26**] 09:50AM BLOOD Free T4-1.6
[**2104-5-26**] 09:50AM BLOOD CEA-2.0 PSA-46.3*
[**2104-5-28**] 07:42AM BLOOD Type-ART pO2-61* pCO2-35 pH-7.48*
calTCO2-27 Base XS-2
[**2104-5-28**] 07:36PM BLOOD Type-ART pO2-67* pCO2-30* pH-7.49*
calTCO2-23 Base XS-0
[**2104-5-28**] 10:49PM BLOOD Type-ART pO2-197* pCO2-47* pH-7.33*
calTCO2-26 Base XS--1 Intubat-INTUBATED
[**2104-5-29**] 12:39AM BLOOD Type-ART Temp-37.2 Rates-16/ Tidal V-500
PEEP-10 FiO2-60 pO2-99 pCO2-54* pH-7.29* calTCO2-27 Base XS--1
-ASSIST/CON
[**2104-5-29**] 01:52AM BLOOD Type-ART Temp-37.2 Rates-18/ Tidal V-500
PEEP-10 FiO2-50 pO2-100 pCO2-48* pH-7.31* calTCO2-25 Base XS--2
-ASSIST/CON Intubat-INTUBATED
[**2104-5-29**] 05:03AM BLOOD Type-ART Temp-36.7 Rates-20/ Tidal V-500
PEEP-10 FiO2-40 pO2-95 pCO2-44 pH-7.32* calTCO2-24 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2104-5-29**] 12:00PM BLOOD Type-ART Temp-36.4 Rates-/20 Tidal V-500
PEEP-5 FiO2-40 pO2-121* pCO2-37 pH-7.35 calTCO2-21 Base XS--4
-ASSIST/CON Intubat-INTUBATED
[**2104-5-29**] 01:35PM BLOOD Type-ART Temp-36.7 Rates-20/ Tidal V-500
PEEP-5 FiO2-40 pO2-97 pCO2-39 pH-7.33* calTCO2-21 Base XS--4
-ASSIST/CON Intubat-INTUBATED
[**2104-5-29**] 08:06PM BLOOD Type-MIX FiO2-40 pO2-44* pCO2-51*
pH-7.27* calTCO2-24 Base XS--3
[**2104-5-30**] 07:41AM BLOOD Type-ART pO2-135* pCO2-46* pH-7.26*
calTCO2-22 Base XS--6
[**2104-5-30**] 02:17PM BLOOD Type-ART pO2-62* pCO2-32* pH-7.40
calTCO2-21 Base XS--3
[**2104-5-30**] 04:45PM BLOOD Type-ART Temp-37.1 Rates-/17 Tidal V-700
PEEP-8 FiO2-50 pO2-81* pCO2-37 pH-7.38 calTCO2-23 Base XS--2
Intubat-INTUBATED Vent-SPONTANEOU Comment-ORAL
[**5-26**] renal u/s: Suggestion of mild left-sided collecting system
fullness, which is incompletely evaluated given suboptimal
patient positioning. Mild left sided hydronephrosis cannot be
excluded.
.
[**2104-5-26**] CXR: There is some soft tissue density on both sides of
the trachea in the superior mediastinum, with mild tracheal
deviation to the right. The lungs are clear without
consolidation. No pleural effusion is seen. There are
degenerative changes of the spine, but no sclerotic foci are
identified.
.
[**2104-5-26**] Head CT w/o contrast: No acute intracranial hemorrhage
or mass effect.
.
[**5-26**] MRI L spine: Large enhancing mass involving L5 and S1
vertebrae, with prominent compression of the thecal sac and,
less extensively, encroachment into the L5/S1 neural foramina,
compatible with metastatic disease. Additinal foci in the
vertebral body of L4 and left ilium are also concerning for
metastatic disease.
.
[**5-29**] TEE: mitral valve vegetation w/ leaflet perforation
.
NEBH
[**5-21**] CT Abd GU protocol: There are small bilateral low-density
adrenal masses, compatible with nonfunctioning adenomas. There
is mild caliectasis in the right kidney and mild hydroureter
down to the urinary bladder. There are bilateral renal cysts,
somewhat dense on the left, compatible with hemorrhagic cysts.
On the left side, there is moderate hydronephrosis and
hydroureter down to the urinary bladder. There is a very large
amount of streak artifact from the patient's bilateral THRs,
which obscures the UVJs bilaterally. I do not see any densely
calcified stones in either UVJ. Tumor cannot be excluded.
.
[**5-20**] MRI cervical and thoracic spine: Large left-sided thyroid
mass lesion, which demonstrates retrosternal extension into the
superior mediastinum and deviates the trachea to the right side.
Several small foci of decreased T2 signal are present along T6,
T7, T8 and T9 vertebrae consistent with metastatic disease.
Other smaller foci of abnormal signal are present involving the
lower thoracic vertebrae from T10 through T12 levels. There is
metastatic disease involving the upper thoracic vertebrae from
T1 through T3 levels. There is no underlying marrow edema or
compression fractures. There is no extrinsic cord compression
seen at any level.
.
Several abnormal foci of decreased T1 signal involving the
vertebral bodies of C6, C7, and T1 consistent with diffuse
metastatic disease most likely related to prostate cancer. In
addition there is also involvement of the pedicles and posterior
elements of C6 vertebra. At C3-C4 level, there is mild
degenerative anterolisthesis of C3 in relation to C4, resulting
in moderate canal stenosis with flattening of upper cervical
cord. Severe stenosis of the foramina is present due to
uncovertebral and facet hypertrophy. At C4-C5 level, there is
slight disc space degeneration and end-plate spurring. There is
mild stenosis of the canal. Moderate foraminal narrowing is
present, left more than right due to uncovertebral and facet
hypertrophy. At C5-C6 level, there is severe stenosis of the
canal produced by central herniation of the disc, end-plate
spurring, and posterior element hypertrophy encroaching and
flattening the ventral aspect of the cord. There is severe
narrowing of the foramina bilaterally due to uncovertebral and
facet hypertrophy. Diffuse metastatic involvement of C6 vertebra
is noted including the pedicles and posterior elements. At C6-C7
level, there is mild stenosis of the spinal canal produced by
central end-plate spurring. Severe foraminal stenosis is present
due to uncovertebral and facet hypertrophy. At C7-T1 level,
there is mild degenerative anterolisthesis of C7 in relation to
T1. Mild foraminal stenosis is present. The central canal is
patent. A large lobulated soft tissue mass lesion is seen
involving the left
lobe of the thyroid measuring 4.5 x 4.8 cm and has resulted in
slight deviation of the trachea to the right. The airways are
still patent.
.
[**4-15**] blood cultures on [**5-26**] + for MSSA; [**2-16**] bottle VRE
urine from [**5-26**] + for staph aureus
[**2-14**] blood cultures on [**5-27**] +MSSA
.
EKG with sinus tach in 110's. ST down on avL, left axis. Poor R
wave progression.
Brief Hospital Course:
82 yoM w/ h/o colon CA, prostate CA, known spinal metastases
undergoing radiation treatment presents with confusion, fever,
and diffuse weakness. His hospital course during this admission
is as follow, and pt died on [**2104-5-31**]:
.
# Respiratory failure: pt was initially full code per
discussion with pt's wife and developed hypoxic respitory
failure and was intubated [**5-28**]. His had pulmonary edema that
appeared to be mixed cardiac/noncardiac in etiology and so was
managed with lung-protective ventilation. Several family
meetings were held during the course of his hospitalization.
Given his metastatic prostate cancer and poor prognosis, his
family decided to make him DNR and no reintubation after
extubation on [**2104-5-29**] and comfort measure only on [**2104-5-31**]. Pt
was extubated on [**2104-5-31**], and shortly after extubation became
apenic and developed asystole in 15 minutes. He was pronouced
dead at 12:50pm on [**2104-5-31**]. Family were at the bedside and
declined autopsy, and PCP and attending were informed.
.
# Endocarditis: Given his initial positive blood cultures (MSSA
and VRE), he had TTE and TEE done, TEE was positive for
endocarditis w/ perforated leaflet with severe MR. Because of
his widely metastatic cancer and septic shock, he was not an
appropriate candidate for surgical interevention. He was
started on nafcillin/linezolid for Staph coverage and afterload
reduction w/ hydralazine and nitro drip
.
# Sepsis: Staph Aureus bacteremia and VRE in blood cx. He
became hypotensive acutely on [**2104-5-28**], and was Central line
(femoral) was place, and he was briefly on levophed and fluid
boluses; continued dexamethasone (4q6-->4q8) given bacteremia;
initially on Vanc/Zosyn, switched to nafcillin/linezolid after
sensitivity came back.
.
# A.fib with RVR. Likely secondary to stress from acute
infection, as well as direct myocardial irritation. Returned to
sinus during the hospitalization.
.
# respiratory alkalosis and hypoxia: likely secondary to
hyperventilation from sepsis. Hypoxemia due to ARDS vs
aspiration vs CHF vs PNA vs metastatic disease vs PE. He was
intubated on [**2104-5-28**]. Once his family decided to focus on
comfort care, he was extubated and died shortly after
extubation.
.
# Generalized weakness: He has known spinal canal/foraminal
stenosis (cervical and lumbar) in addition to cervical,
thoracic, and lumbar metastases, most prominent at L5/S1 with
epidural extension. given diffuse metastatic disease,
endocarditis, and sepsis, he was not felt to be an appropriate
surgical candidate.
.
# CHF, valvular: Not part of medical history, however, now
hypoxic and hypotensive and TEE w/ severe MR likely due to
endocarditis.
# NSTEMI: most likely secondary to acute infection, hypotension,
and ARF. Microemboli to coronaries also possible.
.
# Change in mental status: Per wife, baseline is A+O x 3. Likely
secondary to hypoxia/toxic metabolic from infection, although
steroids could also be contributing. Could also be mets even
though head CT normal. Meningitis less likely but possible as
he's never been instrumented. RPR, B12, calcium, TSH/Free T4
normal.
.
# Acute renal failure: likely ATN. w/ decreasing UOP and
increasing Cr. Septic emboli (MSSA in urine) and hypovolemia
possibly contributing. Repeat U/S does not show hydronephrosis.
Renally dose all meds (check vanco level)
.
# Prostate cancer/metastatic disease (spine, bilateral
adrenals). PSA 46.3 and CEA 2. Spine metastases presumed to be
secondary to prostate CA given elevated PSA, although pt also
has large thyroid lesion and a history of colon cancer. Followed
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23509**] who is considering salvage chemo with
taxotere. MRI w/ known mets to L5/S1 region.
.
# anemia: B12/folate normal. High ferritin and low iron.
Consistent with AOCD and hemolysis unlikely as his bili is
normal; transfuse for < 25
.
# thrombocytopenia: platelets at admit 202 and now trending
down. Could be from DIC and or HIT since patient has likely had
heparin before at OSH. DIC labs negative, heparin restarted
given high likelihood of PE in pt with metastatic prostate
cancer
.
# hyperglycemia: due to steroids and possibly acute infection;
he was started on insulin gtt on [**2104-5-30**]
.
# FEN: tube feeds started [**5-29**] after OJ placement; replete
lytes prn
.
# PPx: heparin SC, pneumoboots and PPI
Medications on Admission:
dexamethasone 4 mg PO BID
Finesteride
lipitor
vicodin prn
doxazosin
calcium
vitamin D
furosemide
Discharge Medications:
pt passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Mitral Valve Endocarditis, Staphylococcal
Septic shock
Congestive heart failure (valvular)
metastatic prostate cancer
respiratory failure
acute renal failure
Discharge Condition:
death
Discharge Instructions:
death
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2104-5-31**]
|
[
"486",
"458.9",
"V10.05",
"272.4",
"785.59",
"198.5",
"038.11",
"272.0",
"427.31",
"041.11",
"518.5",
"428.0",
"421.0",
"185",
"427.89",
"276.3",
"599.0",
"285.22",
"995.92",
"584.5",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.91",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
15995, 16004
|
11383, 14233
|
294, 361
|
16206, 16214
|
4837, 11360
|
16268, 16433
|
3944, 3948
|
15956, 15972
|
16025, 16185
|
15834, 15933
|
16238, 16245
|
3963, 4818
|
223, 256
|
389, 3632
|
14248, 15808
|
3654, 3848
|
3864, 3928
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,005
| 124,108
|
252
|
Discharge summary
|
report
|
Admission Date: [**2148-11-29**] Discharge Date: [**2148-12-15**]
Date of Birth: [**2085-2-10**] Sex: M
Service: SURGERY
Allergies:
Codeine / Narcotic Analgesic & Non-Salicylate Comb /
Analgesics,Narcotics Classifier / Ciprofloxacin Er / Heparin
Agents
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Leak around bilateral PTC drains
Major Surgical or Invasive Procedure:
[**2148-11-29**] CBD resection, hepaticojejunostomy, ccy, liver biopsy
[**2148-12-11**] Segment 2 left hepatic artery pseudoaneurysm coiling
History of Present Illness:
Per Dr.[**Name (NI) 1369**] note: The patient is a 63-year-old male with a
history of lymphoma diagnosed in [**2122**] for which he received
radiation therapy and CHOP. He developed paralysis of the left
leg due to radiation in [**2124**] and has been dependent on a brace
and crutches. He developed radiation colitis with periodic
rectal bleeding and incontinence of stool and urine in [**2127**]. He
developed recurrent lymphoma in the porta hepatis and was
treated with radiation therapy in [**2144-9-16**]. He also received
CHOP and RICE. He developed a biliary stricture and common
hepatic duct obstruction and underwent ERCP and stent placement
in [**2144-8-17**] and [**2145-6-17**]. Those stents were removed. In
[**2148-1-18**], he presented with fever and elevated LFTs. He had
an ERCP at that time and was subsequently referred to [**Hospital1 18**]
where he underwent an ERCP on [**2-8**]. This demonstrated the
presence of an existing plastic stent that was blocked with
sludge and was removed. He had small stone fragments and pus
that were seen extruding from the common duct once the stent was
removed. There was a long benign-appearing stricture of the
common bile duct and common hepatic duct with dilatation of the
intrahepatic ducts proximally. Cytology was negative. Since
then, he has undergone several follow-up ERCPs and dilatation.
He has also undergone repeated brushings for cytology that have
all been benign.
.
Because of recurrent stricture that has been unresponsive to
endoscopic dilatation, he was referred for consideration of
Roux-en-Y hepaticojejunostomy. We have discussed the indications
for surgical repair, the surgical procedure itself, risks,
potential complications, postoperative recovery, follow-up, and
outcomes. The patient has provided informed consent and is
brought to the operating room for cholecystectomy, common bile
duct excision, and Roux-en-Y hepaticojejunostomy.
Past Medical History:
1) Left leg paralysis from radiation to pelvic fossa in [**2122**]
2) atrial fibrillation
3) histiocytic-lymphocytic lymphoma s/p CHOP and XRT
4) large B-cell lymphoma to porta hepatis s/p XRT, CHOP and
cyclophosphamide ([**2143**]) now without evidence of disease
5) gastritis
6) history of HCV with reportedly unremarkable liver biopsy,
though pt remarks that he was told he has early signs of
cirrhosis - will attempt to get outside records
7) status post left leg fracture.
8) bilateral inguinal hernia repair
9) gastritis
10)VRE bacteremia [**2148-11-13**]
11)[**2148-11-29**] Common bile duct excision, Roux-en-Y
hepaticojejunostomy, cholecystectomy, segment IVB mass
resection, intraoperative ultrasound
Social History:
His social history is significant for the fact that he is
married and is currently employed as a psychologist. He is
currently retiring from his practice due to health reasons. He
has two adult children who are healthy.
Family History:
His family medical history is significant for his parents who
are both deceased, his mother from hypertension and father from
congestive heart failure.
Physical Exam:
97.6 57 103/49 14 97%RA 6'2" wt: 158lbs
NAD
A&O x 3, FC
RRR
CTA bilaterally
NABS, soft, ND, NT, right lateral incision open but clean, not
erythematous with moist-to-dry dressings
Pertinent Results:
ON ADMISSION:
[**2148-11-29**] 02:42PM BLOOD WBC-16.9*# RBC-2.99* Hgb-10.4* Hct-29.8*
MCV-100* MCH-34.9* MCHC-35.0 RDW-14.5 Plt Ct-342
[**2148-11-29**] 02:42PM BLOOD PT-14.9* PTT-36.0* INR(PT)-1.3*
[**2148-11-29**] 02:42PM BLOOD Glucose-125* UreaN-14 Creat-0.7 Na-133
K-4.7 Cl-106 HCO3-19* AnGap-13
[**2148-11-29**] 02:42PM BLOOD ALT-63* AST-91* LD(LDH)-176 AlkPhos-282*
Amylase-18 TotBili-2.8*
[**2148-11-29**] 02:42PM BLOOD Lipase-12
[**2148-11-29**] 02:42PM BLOOD Albumin-2.5* Calcium-7.4* Phos-2.8
Mg-1.3*
.
ON DISCHARGE:
[**2148-12-15**] 04:59AM BLOOD WBC-7.6 RBC-3.54* Hgb-10.8* Hct-32.1*
MCV-91 MCH-30.5 MCHC-33.7 RDW-16.5* Plt Ct-260
[**2148-12-15**] 04:59AM BLOOD PT-17.5* PTT-34.6 INR(PT)-1.6*
[**2148-12-15**] 04:59AM BLOOD Glucose-106* UreaN-5* Creat-0.7 Na-133
K-3.7 Cl-103 HCO3-23 AnGap-11
[**2148-12-15**] 04:59AM BLOOD ALT-33 AST-36 AlkPhos-324* Amylase-32
TotBili-2.8*
[**2148-12-15**] 04:59AM BLOOD Lipase-18
[**2148-12-15**] 04:59AM BLOOD Albumin-2.5*
Brief Hospital Course:
On [**2148-11-29**] he underwent common bile duct excision, Roux-en-y
hepaticojejunostomy, cholecystectomy, segment IVB mass resection
with intraoperative ultrasound and liver biopsy. Surgeon was Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative report for details. Two
JPs were placed. There were two PTCs. Postop, he was
comfortable on a dilaudid pca. SBP ranged between 88-90 postop
and he received 1.5 liters of fluid boluses. A CXR and EKG were
wnl. An NG was in place and he was npo.
On pod 2, Linezolid was switched to Daptomycin for h/o VRE in
blood. Cefepime continued for E.coli and pseudomonas in the
bile/blood. The NG was removed. He developed rapid afib and was
transferred to the SICU. IV diltiazem was given with conversion
back to a sinus rhythm. Heart rate decreased to the 70s. On
[**12-4**] a tube cholangiogram was performed showing good position
of the catheter with free drainage of contrast material into the
jejunem. There was no evidence of communication between the
biliary system and the vasculature. Two small dilatations of
peripheric biliary ducts in the right liver lobe.
On [**12-5**] a TTE was performed showing no endocarditis. Dapto and
cefepime were discontinue as he had received an appropriate
course of treatment.
He developed melena and hematachezia on [**12-6**]. Hct decreased to
25 from 31 and 4 PRBC, 2 FFP and 1 bag of cryo were given with
a hct increase to 32. A c.line was placed for blood products and
rapid infusion. A repeat tube cholangiogram was performed on
[**12-7**] demonstrating good position without evidence of
communication with the vasculature or extravasation. The t tube
and PTCs were opened. The left PTC and t tube were drainin
sanguinous fluid as well as the JPs. He remained NPO. A fib
recurred. A diltiazem drip was resumed and lopressor was
increased to 37.5mg [**Hospital1 **]. Dilt was eventually weaned off. On
[**12-10**] he was in rapid afib with rates into the 150-160s. IV
lopressor was given x 3 without effect. He was transferred back
to the SICU for managment. Hematocrits were cycled. Hct was
stable. He again started passing black tarry stool and the
biliary drains again started draining serosanguinous fluid. LFTs
trended up with the t.bili increasing to 6.7 and alk phos up to
300s.
On [**12-11**], a hepatic arteriogram was performed showing
approximately 2 cm pseudoaneurysm involving the left hepatic
artery in segment II. Dr. [**Last Name (STitle) 380**] successfully performed coiling
of the pseudoaneurysm as well as directly proximal and distal
branches resulting in total occlusion of the aneurysm. He spiked
a temp to 101.9. He was pancultured. ID evaluated and
recommended resuming Daptomycin and Cefepime. These antibiotics
were stopped on [**12-13**] as cultures remained negative.
On [**12-14**], the right PTC was capped. LFTs continued to improve
and on [**12-15**], the left PTC was capped. His LFTs continued to
improve with both PTC drains capped and he remained afebrile.
.
PT evaluated him and felt that he had returned to his baseline
requiring assist for transfers. Home PT was recommended. VNA
services were arranged for PT, dressing changes and monitoring.
.
Diet was slowly advanced and tolerated. He was deemed stable
for discharge home with services on [**12-15**] tolerating a regular
diet, at baseline requiring assistance for transfers, pain
well-controlled, and both PTC drains capped without pain or
fevers. He will follow-up with Dr. [**Last Name (STitle) **] in clinic. He will
follow-up with his gastroenterologists for adjustment of his GI
medications and his cardiologists for adjustment of his BP
medications.
Medications on Admission:
Aldactone, potassium, ursodiol,Protonix, Augmentin, Imodium,
calcium, multivitamin, and Metamucil.
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. Outpatient Lab Work
Please get laboratory work prior to your appointment with Dr.
[**Last Name (STitle) **] on [**2147-12-19**]. You need CBC, Chem10, LFTs, PT/INR and PTT.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Common bile duct stricture
VRE/E.coli bacteremia
Biliary pseudomonas
Atrial fibrillation
L hepatic artery pseudoaneurysm
Discharge Condition:
Good
Discharge Instructions:
.
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, increased abdominal pain,
redness/bleeding/drainage from the incision or drain sites, or
jaundice.
.
Please take medications as prescribed.
.
Please follow-up as directed.
.
No heavy lifting (> 10lbs) for 4-6 weeks or until directed. You
may shower, no baths for 4-6 weeks.
Followup Instructions:
Scheduled Appointments :
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2148-12-18**] 3:40
.
Appointments to be made:
Please follow-up with your primary care physician as soon as
possible.
.
Please call your gastroenterologists:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2495**]
[**Street Address(2) 2496**] [**Apartment Address(1) 2497**]
Gastrointestinal Specialists
[**Location (un) 2498**], MA
.
Please follow-up with your cardiologists for adjustment of your
heart rate medications.
.
Please get laboratory work prior to your appointment with Dr.
[**Last Name (STitle) **] on [**2147-12-19**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"427.31",
"576.2",
"287.4",
"E930.8",
"155.2",
"E879.2",
"070.54",
"576.1",
"344.9",
"E878.2",
"442.84",
"578.1",
"572.8",
"V10.79",
"997.4",
"790.7",
"997.79",
"909.2",
"574.10",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"38.93",
"51.37",
"00.14",
"39.79",
"50.22",
"51.22",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
9498, 9553
|
4878, 8597
|
414, 557
|
9718, 9725
|
3883, 3883
|
10157, 11014
|
3507, 3661
|
8746, 9475
|
9574, 9697
|
8623, 8723
|
9749, 10134
|
3676, 3864
|
4409, 4855
|
342, 376
|
585, 2508
|
3897, 4395
|
2530, 3251
|
3267, 3491
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,800
| 197,781
|
27727
|
Discharge summary
|
report
|
Admission Date: [**2139-6-28**] Discharge Date: [**2139-7-13**]
Date of Birth: [**2061-4-30**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Coma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78yo RH woman with recent admission for right MCA stroke,
followed by PCA infarction which led to emergent right-sided
hemicraniectomy for worsening edema and herniation, and pt was
transferred to extended care with residual eyelid apraxia,
left-sided neglect and autotopagnosia and left hemiparesis, now
readmitted to neurologic ICU in coma, due to massive left-sided
hemispheric hemorrhagic stroke.
Past Medical History:
-prior strokes: Roughly 10 years ago and again in
[**2138-1-28**] she had strokes. The first event started with
a dull headache and was followed by transient (minutes-long)
left hand clumsiness. The next episode occurred when she was
playing cards and she transiently lost vision in the right half
of space. Apparently, she was admitted to [**Hospital6 33**]
and was told she had a stroke. She was noted to have possible
cardiac source was on warfarin.
-migraine headaches: Since about the age of 30 years. Headaches
consisted of bifrontal dull aching, preceded by aura of
scintillations and sometimes by right field cut.
-hypertension
-hyperlipidemia
Social History:
The pt lived at home before her prior, recent admission for
stroke. She is a former clerical worker. She smoked roughly
[**12-29**] pack of cigarettes per day for twenty years, but quit about
40 years ago. She had an occasional glass of wine with dinner.
No history of IVDU.
Family History:
Notable for many female family members with migraine headache.
Physical Exam:
Exam:
P 65 BP 113/38 Ox: 100% R 20 on volume control to Vt 600cc Peak
pressures in
upper 20's, 20bpm, 5 peep
Gen: elderly woman unresponsive to all noxious stimuli, with no
observed spontaneous movements, intubated
CV: RRR
Abd: soft
Ext: no edema
Neuro:
CN: pupils pinpoint and unreactive to light, gaze is midline
with
no extraocular movement to oculocephalic maneuver. Corneal
reflexes not tested
Motor: no response in any extremity to sternal rub or pressure
on
nailbed
Reflexes: toes upgoing bilaterally
Brief Hospital Course:
The patient was admitted to the ICU with a very poor prognosis.
CT on admission showed "massive new areas of intraparenchymal
hemorrhage in both hemispheres causing subfalcine and
transtentorial herniation." She was intubated and, at the
family's insistence, full measures were taken to sustain her
life. This plan was altered upon the family's finding of her
will, which stated that she would not want her life prolonged in
this state, including such invasive procedures with intravenous
lines and a ventilator. At this point, she was extubated at the
family's request. Her care was focused on comfort measures.
The patient expired on [**2139-7-13**] at 10:31PM of respiratory arrest,
related to her intracranial hemorrhage. She was CMO at the
time. There were no breath sounds, heart sounds, or brainstem
reflexes, pupils were fixed and dilated.
Her son and daughter were informed and extensively involved in
the decisions of her medical care throughout her hospital
course. Extensive family meetings were held to keep them
updated and assist in medical decision making.
Medications on Admission:
Heparin 5,000 SQ, Zocor 40, Amiodarone 400 [**Hospital1 **], Lopressor
37.5 tid, ASA 325 and Senna and Colace
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired:
Respiratory arrest secondary to cerebral hemorrhage
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2139-7-14**]
|
[
"427.31",
"431",
"780.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3635, 3644
|
2367, 3446
|
321, 327
|
3748, 3757
|
3813, 3851
|
1750, 1815
|
3606, 3612
|
3665, 3727
|
3472, 3583
|
3781, 3790
|
1830, 2344
|
277, 283
|
355, 757
|
779, 1436
|
1452, 1734
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,005
| 126,862
|
23232
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 59720**]
Admission Date: [**2147-12-26**]
Discharge Date: [**2147-12-27**]
Date of Birth: [**2126-3-15**]
Sex: M
Service: TRA
This is death notification of a trauma patient.
This gentleman is a 21 year old male who was in a motor
vehicle accident and was ejected 40 feet. He was an
unrestrained driver. He was transferred in by Med Flight and
taken directly to the Operating Room. He was in PEA,
pulseless electrical activity, upon admission to the
Operating Room and ACLS protocol was initiated. Vital signs
were regained and the patient was then prepped and draped
emergently and a semi-sterile left lateral thoracotomy was
performed. The chest was opened and this was found to have
some bleeding, however no evidence of tamponade was
identified and the aorta appeared normal.
A TEE intraoperatively was done and this also showed no signs
of dissection. The patient was hypotensive and continued to
require significant fluid resuscitation. His abdomen was
opened and a large amount of abdominal blood was identified
during the packing of the patient's abdomen. The patient
again became hypotensive and lost all vital signs and became
asystolic. ACLS protocol was begun and multiple rounds of
epinephrine, bicarb, atropine as well as intracardiac massage
were all performed. The patient did not return any other
vital signs and after 40 minutes of ACLS protocol it was
decided that the patient was not going to return any vital
signs and therefore he was pronounced dead.
The patient was diagnosed dead on [**2147-12-27**] at 12:21 a.m.
Dr. [**Last Name (STitle) 519**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RES, and multiple other
assistants were present in the Operating Room when this was
done. The patient is pronounced dead and medical examiner
was identified and is accepting the case, Dr. [**Last Name (STitle) 3501**] from the
medical examiner's office. Dr. [**Last Name (STitle) 519**] then went to discuss the
case with the patient's family who was present in the waiting
area.
DISCHARGE DIAGNOSIS: Death secondary to trauma, likely
massive hemorrhage.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2147-12-27**] 00:56:13
T: [**2147-12-27**] 01:53:48
Job#: [**Job Number 59721**]
|
[
"864.14",
"807.09",
"285.1",
"458.9",
"423.9",
"805.06",
"790.92",
"E812.0",
"E849.5",
"860.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.60",
"54.11",
"37.91",
"34.09",
"37.12",
"38.91",
"88.72",
"96.71",
"99.07",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
2098, 2422
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,153
| 112,988
|
10228
|
Discharge summary
|
report
|
Admission Date: [**2185-11-29**] Discharge Date: [**2185-12-9**]
Date of Birth: [**2139-2-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor Vehicle Crash
Major Surgical or Invasive Procedure:
[**11-29**] IM nail right femur frature
[**12-2**] ORIF right tibia fracture
History of Present Illness:
46 yo restrained driver s/p motor vehicle crash; extensive front
end damage with winshield break. No LOC.
Past Medical History:
Hypertension
Hypercholesterolemia
Social History:
Lives with wife
Employed as a Housekeeper
Denies tobacco
Rare ETOH
Family History:
Noncontributory
Physical Exam:
VS upon admission:
BP 200/99 HR 80 O2 Sat 96-100% on 100% FM GCS 15
Alert, collared and boarded
CTA bilaterally
RRR S1 S2
Soft, NT, ND; guaiac negative FAST exam positive
Right thigh contusion & deformity; LLE with open deformity
Pertinent Results:
[**2185-11-29**] 06:16PM WBC-10.1 RBC-3.58* HGB-10.1* HCT-27.7*
MCV-77* MCH-28.2 MCHC-36.5* RDW-14.4
[**2185-11-29**] 06:16PM PLT COUNT-130*
[**2185-11-29**] 06:16PM PT-13.9* PTT-23.7 INR(PT)-1.3
[**2185-11-29**] 01:50PM GLUCOSE-191* UREA N-22* CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
[**2185-11-29**] 01:50PM CALCIUM-7.0* PHOSPHATE-3.9 MAGNESIUM-1.3*
[**2185-11-29**] 09:30AM TYPE-ART PO2-206* PCO2-46* PH-7.34* TOTAL
CO2-26 BASE XS--1
[**2185-11-28**] 11:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-11-28**] 11:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2185-11-28**] 11:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
TIB/FIB (AP & LAT) BILAT [**2185-11-29**] 12:12 AM
FEMUR (AP & LAT) BILAT; KNEE (2 VIEWS) BILAT
Reason: ASSESS FX
INDICATION: Evaluate for fracture.
COMPARISON: None.
RIGHT LOWER EXTREMITY, NINE RADIOGRAPHS: There is transverse
fracture through the mid portion of the right femur, with medial
angulation of the fracture fragment and posterior displacement
with bayoneting of the distal fracture fragment. Additionally,
there is a fracture of the lateral aspect of the proximal tibia,
extending to involve the lateral tibial plateau. There is
approximately 1 to 2 mm displacement at the fracture line. No
definite fracture of the fibula is identified. Limited images of
the right ankle joint demonstrate no definite effusion or
associated fracture.
LEFT LOWER EXTREMITY, FOUR RADIOGRAPHS: On these single view
images of the left lower extremity, no definite fractures are
identified. No knee joint effusion is seen. Bony mineralization
is normal.
IMPRESSION:
1. Transverse fracture of the mid portion of the right femur, as
described above.
2. Longitudinal fracture of the proximal portion of the left
tibia, extending to the lateral tibial plateau.
VENOUS DUP EXT UNI (MAP/DVT) RIGHT [**2185-12-7**] 4:09 PM
VENOUS DUP EXT UNI (MAP/DVT) R
Reason: please evaluate for DVT.
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with Right femoral and R tibial plateau fracture
s/p ORIF now with cellulitis R shin and edema of thigh and
tenderness.
REASON FOR THIS EXAMINATION:
please evaluate for DVT.
CLINICAL INFORMATION: 46-year-old man with right femoral and
right tibia plenty of fracture, cellulitis at right shin, and
edema of thigh. Evaluate for DVT.
PROCEDURE/FINDINGS: Duplex ultrasound was performed at the right
lower extremity.
The right common femoral, superficial femoral, popliteal,
anterior and posterior tibial veins are patent and compressible.
No evidence of deep venous thrombosis was identified in the
right leg venous system.
IMPRESSION: No evidence of deep venous thrombosis in the right
lower extremity venous system.
TIB/FIB (AP & LAT) RIGHT [**2185-12-7**] 8:39 AM
FEMUR (AP & LAT) RIGHT; TIB/FIB (AP & LAT) RIGHT
Reason: check hardware
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with
REASON FOR THIS EXAMINATION:
check hardware
STUDY: Right femur, two views performed on [**2185-12-7**].
HISTORY: 46-year-old man with femur and proximal tibial
fractures.
FINDINGS: Comparison is made to prior study [**2185-12-2**].
There is again seen an intramedullary rod with one proximal and
two distal interlocking screws fixating a transverse fracture
through the proximal right femoral shaft. There is anatomic
alignment of the injury. Surgical skin staples are seen
laterally. Images of the tibia and fibula demonstrates interval
placement of a lateral plate with multiple cortical screws
fixating a fracture of the right tibial plateau. Lateral
surgical skin staples are also seen. There is no evidence for
hardware complications. A brace is seen surrounding the right
knee.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedics was
immediately consulted because of patient's injuries. He was
taken to the OR on [**11-29**] for IM rodding of right femur fracture
and on [**12-2**] for ORIF of tibia fracture and closure of wound
left lower extremity.
Neurology was consulted due to finding on CT scan; tiny lacunar
infarcts noted; felt that motor vehicle crash not likely caused
by this. Recommended holding ASA until stable and to restart
patient's home antihypertensives and statin. These were
restarted. At this time his HCTZ and Atenolol have been on hold
secondary to orthostasis and dizziness. His symptoms have slowly
improved; his Hct was initially low and this has improved as
well. Most recent Hct 28.3 on [**12-5**].
On [**12-7**] patient noted with cellulitis of his RLE anterior tibia
region; he was started on Ancef 1 GM IV every 8 hours and
underwent LENIS which were negative for DVT. He is being
discharged to home on Keflex 500 mg po QID.
Physical therapy was consulted and have recommended home PT.
Medications on Admission:
HCTZ 25'
Atenolol 50'
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:*45 Tablet(s)* Refills:*0*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
once a day: Continue for 4 weeks.
Disp:*30 * Refills:*0*
6. CPM machine as directed
7. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
8. Wheelchair
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Motor Vehicle Crash
Sternal Fracture
Grade IV Liver Laceration
Right Femur Fracture
Left Anterior Tibia Fracture
Wound Cellulitis RLE
Discharge Condition:
Stable
Discharge Instructions:
*Do not bear any weight on your right leg.
*Continue to wear your [**Doctor Last Name **] brace on your right leg until you
follow up with Dr. [**Last Name (STitle) 1005**] in 2weeks.
*You will need to continue with your Lovenox injections for 4
weeks.
*Follow up with Orpthopedic Surgery in 2 weeks.
NOT take your blood pressure medications until you see Dr.
[**Last Name (STitle) 1789**].
*Return to the Emergency room if dizziness worsens.
Followup Instructions:
Call [**Telephone/Fax (1) 6439**] for follow up appointment with Trauma Clinic
in 2 weeks.
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2185-12-27**] 8:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2185-12-27**] 8:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2185-12-9**]
|
[
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"401.9",
"998.59",
"821.01",
"864.05",
"823.00",
"682.6",
"E812.0",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"79.36",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6703, 6761
|
4862, 5907
|
339, 418
|
6943, 6952
|
997, 3095
|
7443, 7964
|
710, 727
|
5979, 6680
|
4029, 4050
|
6782, 6922
|
5933, 5956
|
6976, 7420
|
742, 747
|
276, 301
|
4079, 4839
|
446, 553
|
761, 978
|
575, 610
|
626, 694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,030
| 172,599
|
49176+49177+49178+49179+49206+59151+59152
|
Discharge summary
|
report+report+report+report+report+addendum+addendum
|
Admission Date: [**2116-5-21**] Discharge Date: [**2116-6-8**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 38-year-old
woman with end-stage renal failure on dialysis with a history
of hypertension, diabetes mellitus Type I, peripheral
vascular disease, status post left below the knee amputation
and multiple digit and toe amputation. She is initially
unable to give much history and her family was not available
initially on arrival. She reportedly had a left sided
headache which started on the morning of admission and her
blood sugar was low earlier in the day but that corrected
with food although her confusion did not improve.
Subsequently she came into the emergency department for the
headache and had a head CT which showed a right thalamic
basal ganglia bleed with extension into the lateral and third
ventricles.
PAST MEDICAL HISTORY: Hypertension, end-stage renal disease
on dialysis. Diabetes mellitus Type I, peripheral vascular
disease, status post below the knee amputation and question
stroke and seizures in the past. Also a history of
Naphthalene induced coma from inhaling moth balls.
PAST SURGICAL HISTORY: Status post left below the knee
amputation. Status post right transmetatarsal amputation,
status post parathyroidectomy, status post renal transplant
in [**2104**], now failed. Status post tracheostomy in the past.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Labetalol which she had not been taking regularly.
2. Amitryptiline.
3. Insulin.
4. Enalapril.
5. Nifedipine.
SOCIAL HISTORY: No history of smoking or alcohol. Lives
with her daughter and granddaughter. Again, there is a
history of Naphthalene induced coma.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Unable to obtain on admission.
PHYSICAL EXAMINATION: Initially the patient is afebrile,
blood pressure 160 to 210/80 to 100. Pulse 70 to 100. In
general the patient is lying in bed, at times agitated, In no
acute distress. Head, eyes, ears, nose and throat:
Nonicteric sclera. Mucous membranes dry. Neck supple. No
lymphadenopathy, no carotid bruits. Heart: Normal S1 and
S2. Regular rate and rhythm. Pulmonary: Clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended. Extremities: Left below the knee amputation,
right toes and fingers all amputated. Left hand with three
digits amputated. Neurologic exam: Mental status: Awake,
alert, intermittently cooperative and attentive. Non-fluent
aphasia with one to two word answers, frequently becomes
frustrated an turns away. No neglecter signs. After she was
intubated she was very unresponsive for a long period of time
however, currently by [**2116-6-8**] she is now awake and alert and
does intermittently follow commands and does move all
extremities.
Cranial nerves on admission: Discs flat and sharp. Visual
fields intact to confrontation. Pupils normal round and
reactive to light, no RAPD. Pupils continue to remain
normal, round and reactive to light. Extraocular movements
full and intact without nystagmus. Normal facial sensation.
Has subtle left facial droop which now is not present.
Tongue midline without fasciculations. Sternocleidomastoids
and trapezius normal bilaterally which has not been able to
be fully tested because of intubation. Motor: Normal bulk
and tone with adventitious movements. Mild left drift and
left hemiparesis in the 4+ to 5 range, worse in the arm. The
patient has been moving all her extremities to command and
occasionally does move them all spontaneously as well by
[**2116-6-8**]. Sensory grossly intact. Reflexes symmetric
throughout.
LABORATORY: On [**2116-6-8**] white count 15.6, hematocrit 27.9, she
has been intermittently transfused throughout this hospital
course. Platelets 510, INR 1.2, PTT 28.4, Prothrombin time
13.7. Sedimentation rate 138 on [**6-3**]. Most recent
Cerebrospinal fluid sent on [**6-7**] showed a white count of 8,
RBC 1210. Glucose 166, creatinine 4.9, BUN 50, sodium 133,
potassium 4.0, chloride 94, bicarbonate 25. She did have
rising liver function tests which started to decrease
however, amylase and lipase as of [**6-8**] were still rising.
Amylase on [**6-8**] was 142. ALT 49, AST 75, LDH 168, alk phos
1102, total bilirubin 0.3. Lipase 195. She ruled out for
myocardial infarction by enzymes. CRP was 19. [**Last Name (un) **] levels
were followed and she was redosed per level. She is no
longer on Phenytoin and this level has not been checked.
Total protein was assessed 51, glucose 68. C. Diff was
positive. Second C. Diff on [**6-8**] is pending. The C. Diff on
[**5-26**] was positive. Cerebrospinal fluid on [**6-7**] negative. On
[**6-3**] negative. [**6-1**] negative. [**5-29**] negative. [**5-26**]
negative. [**5-25**] negative. Sputum sent on [**6-7**] is growing
staph aureus coag positive. On [**6-6**] growing staph aureus coag
positive. [**6-2**] growing staph aureus coag positive sensitive
to Gentamicin, Tetracycline and Vancomycin only. On [**5-29**]
sputum also growing staph aureus coag positive. On [**5-23**] also
growing staph aureus coag positive with the same
sensitivities. On [**5-22**] also growing staph aureus coag
positive.
Blood cultures [**6-7**] no growth to date. [**6-6**] no growth to date.
[**6-4**] no growth to date. [**6-3**] no growth to date. [**6-1**]
negative. [**5-28**] negative. [**5-26**] negative. [**5-23**] growing staph
coag negative in [**2-9**] bottles sensitive to Clindamycin,
Erythromycin, Rifampin, Tetracycline and Vancomycin. On [**5-22**]
1/4 bottles was growing two different strains of staph aureus
coag negative. One strain sensitive to Clindamycin,
Erythromycin, Gentamicin, Rifampin, Tetracycline and
Vancomycin. The other strain sensitive to Clindamycin,
Erythromycin, Gentamicin and Oxacillin.
CT of the abdomen which was a repeat CT from [**5-24**] was
unchanged since that date. There was small interval increase
in the small amount of ascites present, no new abscess or
inter-abdominal or inter-pelvic pathology identified. There
remained a stable appearance of a large retroperitoneal and
periportal lymph node.
The most recent head CT on [**2116-6-2**] showed stable appearance
of the brain. Original head CT revealed hemorrhage in the
right basal ganglia area and right thalamus with extension to
the right lateral ventricle with mild dilatation of the
temporal [**Doctor Last Name 534**] of the right lateral ventricle which remained
unchanged for sometime. The patient also received bilateral
upper and lower extremity Dopplers for the question of
thrombus. There was found to be a chronic, non-occlusive
thrombus in the proximal right internal jugular vein but
otherwise there were no deep vein thrombosis in any
extremities.
Chest x-ray most recently were clear. EEG on [**2116-5-22**] showed
background slowing and indicating wide spread encephalopathic
condition. There were no focal abnormalities and no
epileptiform features.
HOSPITAL COURSE: To [**2116-6-8**]
Mrs. [**Known lastname **] presented on [**2116-5-21**] with a right thalamic, right
basal ganglia bleed extending into the right ventricle. This
was felt to be due to hypertension as she came in with
systolic blood pressures above 200 and her family stated she
had been non-complication with her anti-hypertensives at
home. On the day of admission she was intubated for apneic
spells and her family decided that she would wish to be "Do
Not Resuscitate" but not DNI. Neurosurgery subsequently
placed ventricular drain and initially she was loaded on
Dilantin for a question of seizures. Renal was also
consulted to follow for her end-stage renal failure.
Neurologically did not have any seizures witnessed by any
residents or attendings and per description by the nurses had
some rhythmic eye movements however, EEG showed no
epileptiform activity and the Dilantin was very difficult to
keep at therapeutic doses given the renal failure and the
frequent dialysis. So the Dilantin was discontinued
eventually and the patient has not had any witnessed seizure
activity.
As for the ventricular drain, Neurosurgery has been managing
this. Her ventricular drain has been draining a significant
amount of fluid throughout the hospital course. When
clamping has been attempted the ICP's have increased to the
low to mid-20's and the patient has become more somnolent.
The decision has been made to place a ventriculoperitoneal
shunt this week.
Neurologically the patient has improved since she arrived in
the Intensive Care Unit. She has now become more awake and
alert and will follow both axial and appendicular commands
intermittently. She does seem to be mor somnolent prior to
dialysis and after dialysis will eventually become more
awake.
As far as her renal issues, Mrs. [**Known lastname **] has been followed by
her outpatient physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] and she has
continued regular dialysis schedule while here in the
hospital. Dialysis has continued through her Quinton
catheter.
Infectious Disease. It was felt that her bacteremia was due
to infection of the Quinton catheter. Instead of removing
this catheter, the decision was made to treat through this
infection and Vancomycin was started. The patient has been
redosed for levels less than 15 and all blood cultures have
been negative since [**2116-5-23**]. Additionally the patient has
been growing staph coag positive in her sputum and again she
is on Vancomycin for this. She did develop some loose stools
and C. diff was sent which was positive and the patient was
started on Flagyl for treatment of this. However, since the
Vancomycin and Flagyl have started, the patient has continued
to have daily fever spikes and Infectious Disease was
consulted. Infectious Disease recommended repeat CT of the
abdomen and pelvis which was not revealing for any new
pathology. They also recommended empiric treatment for gram
negative rods which was started on [**2116-6-7**] in the form of
Ceftazidime. This will be continued as a trial basis to see
if the fevers may stop. No precise cause of the fevers as of
[**2116-6-8**] has yet been identified.
Diabetes. The [**Last Name (un) 3208**] has been following and recommending
Humalog sliding scale as well as insulin in the TPN while she
was on TPN. Also to cover her with Lantis at night. Her
blood sugars have been well controlled with the [**Last Name (un) 3208**]
consulting.
Gastrointestinal: The patient has had severe gastroparesis.
She was started on Reglan as well as Erythromycin. It was
felt that Erythromycin may be contributing to worsening of
the C. Diff so this was stopped and it was unclear as to
whether the Reglan was increasing her LFTs and this was
stopped. The patient did improve eventually and a J-tube was
placed and tube feeds were then restarted after a couple of
weeks of TPN. The patient did have transient elevation of
ALT and AST which now seem to be decreasing. The alk phos is
still remaining high however as well as elevated amylase and
lipase. It is also not 100% clear what may be causing this
elevation of enzymes. However, we are following this closely
and have considered contributions from all of her
medications. Per abdominal CT there are no abscesses to
explain this and the total bilirubin has not been elevated at
all. We will continue to follow this throughout her hospital
course.
Hematologic. The patient has had guaiac negative stool but
does suffer from chronic anemia and has had intermittent
transfusions to attempt to keep her hematocrit at 30.
Cardiovascular. Mrs. [**Known lastname **] has been continued on
Nicardipine, Labetalol and Hydralazine in order to keep her
systolic blood pressure below 150. She tends to be
hypertensive on days when she is not having dialysis however,
in dialysis she does tend to become hypotensive. Now that
she has the J-tube in place she will be started on p.o.
anti-hypertensives and today has been started on Metoprolol
50 mg p.o. twice a day and the Labetalol drip has been
stopped.
Respiratory. Mrs. [**Known lastname **] remains ventilated and at some point
this week the plan is for her to receive a tracheostomy.
For now the patient remains stable condition in the
neurological Intensive Care Unit and the oncoming [**Male First Name (un) **] will
dictate the rest of the hospital course and all of the
discharge instructions and medication as well as any
follow-up that may be needed.
[**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 10034**]
MEDQUIST36
D: [**2116-6-8**] 19:11
T: [**2116-6-8**] 19:57
JOB#: [**Job Number 103157**]
Admission Date: [**2116-5-21**] Discharge Date: [**2116-6-8**]
Date of Birth: [**2078-4-17**] Sex: F
Service: NEURO MED in NEURO INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 38 year-old
woman with end stage renal failure on dialysis with a history
of hypertension, diabetes mellitus type 1, peripheral
vascular disease, status post left below knee amputation and
multiple digit and toe amputations. She is initially unable
to give much history and her family was available initially
on arrival. She reportedly had a left sided headache which
started on the morning of admission and her blood sugar was
low earlier in the day but that corrected with food although
her confusion did not improve. Subsequently she came into
the emergency department with a headache and a head CT which
showed a right thalamic basal ganglia bleed with extension
into the lateral and third ventricles.
PAST MEDICAL HISTORY: Hypertension, end stage renal disease
on dialysis, diabetes mellitus type 1, peripheral vascular
disease, status post below knee amputation and a question of
stroke and seizures in the past. Also a history of
naphthalene induced coma from inhaling moth balls.
PAST SURGICAL HISTORY: Status post left below knee
amputation. Status post right transmetatarsal amputation.
Status post parathyroidectomy. Status post renal transplant
in [**2104**], now failed and tracheostomy in the past.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: Labetalol which she had not been taking
regularly, amitriptyline, insulin, analopril, nifedipine.
SOCIAL HISTORY: No history of smoking or alcohol. Lives
with her daughter and granddaughter. Again there is a
history of naphthalene induced coma.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Unable to obtain on admission.
PHYSICAL EXAMINATION: Initially the patient is afebrile,
blood pressure 160 to 210/80 to 100, pulse 70s to 100. In
general the patient is lying in bed, at times agitated, in no
acute distress. Head, eyes, ears, nose and throat:
nonicteric sclera, mucous membranes dry. Neck supple, no
lymphadenopathy, no carotid bruits. Heart: normal S1, S2,
regular rate and rhythm. Pulmonary: clear to auscultation
bilaterally. Abdomen soft, nontender, nondistended.
Extremities: left below knee amputation, right toes and
fingers all amputated. Left hand with three digits
amputated. Neurological examination: mental status awake,
alert, intermittently cooperative and attentive. Nonfluent
and aphasia with one to two word answers, frequently becomes
frustrated and turns away. After she was intubated she was
very unresponsive for a long period of time. However,
currently by [**2116-6-8**] she is awake and alert and does
intermittently follow commands and does move all extremities.
Cranial nerves on admission: disks flat and sharp. Visual
fields intact to confrontation. Pupils normal, round and
reactive to light, no RAP. Pupils continue to remain normal,
round and reactive to light. Extraocular eye movements full
and intact without nystagmus. Has subtle left facial droop
which is now not present. Tongue midline without
fasciculations. Sternocleidomastoid and trapezius normal
bilaterally which not been able to be fully tested since
intubation. Motor normal bulk and tone without adventitious
movement. Mild left drift and left hemiparesis in the 4+ to
5 range, worse in the arm. The patient has been moving all
her extremities to command and occasionally does move them
all spontaneously as well by [**2116-6-8**]. Sensory grossly intact.
Reflexes symmetric throughout.
LABORATORY STUDIES: On [**2116-6-8**] white count 15.6, hematocrit
27.9. She has been intermittently transfused throughout this
hospital course. Platelets [**6-15**], INR 1.2, PTT 28.4, PT 13.7.
Sed rate 128 on [**6-3**]. Most recent cerebrospinal fluid sent
on [**6-7**] showed a white count of 8, RBC of 1210, glucose 166,
creatinine 4.9, BUN 50, sodium 133, potassium 4.0, chloride
94, bicarb 25. She did have rising liver function tests
which started to decrease. However, amylase and lipase as of
[**6-8**] were still rising. Amylase on [**6-8**] was 142, ALT 49, AST
75, LDH 168, alk phos 1102, total bilirubin 0.3, lipase 195.
She ruled out for myocardial infarction by enzymes. CRP was
19. Vancomycin levels were followed and she was redosed per
levels. She is no longer on phenytoin and this level is not
in the chart. The total protein in cerebrospinal fluid 51,
glucose 68. C. difficile was positive. A second C.
difficile on [**6-8**] is pending. The C. diff on [**5-26**] was
positive. Cerebrospinal fluid on [**6-7**] negative. On [**6-3**]
negative. [**6-1**] negative. [**5-29**] negative. [**5-26**] negative.
[**5-25**] negative. Sputum sent on [**6-7**] is growing staph aureus
coag positive. On [**6-6**] growing staph aureus coag positive.
[**6-2**] growing staph aureus coag positive sensitive to
Gentamicin, tetracycline and Vancomycin only. On [**5-29**] sputum
also growing staph aureus coag positive. On [**5-23**] also
growing staph aureus coag positive with the same
sensitivities. On [**5-22**] also growing staph aureus coag
positive. Blood cultures [**6-7**]: no growth to date. [**6-6**] no
growth to date. [**6-4**] no growth to date. [**6-3**] no growth to
date. [**6-1**] negative. [**5-28**] negative. [**5-26**] negative. [**5-23**]
growing staph coag negative in one out of four bottles
sensitive to Clindamycin, erythromycin, Rifampin,
Tetracycline and Vancomycin. On [**5-22**] one out of four bottles
was growing two different strains of staph aureus coag
negative. One strain sensitive to Clindamycin, erythromycin,
Gentamicin, Rifampin, Tetracycline and Vancomycin. The other
strain sensitive to Clindamycin, Erythromycin, Gentamicin and
Oxacillin. CT of the abdomen and pelvis which was a repeat
CT from [**5-24**] was unchanged from that date. There was small
interval increase in the small amount of ascites present. No
new abscess or intra-abdominal or intrapelvic pathology
identified and there remained stable appearance of a large
retroperitoneal and periportal lymph node. The most recent
head CT on [**2116-6-2**] showed stable appearance of the brain.
Provisional head CT revealed hemorrhage in the right basal
ganglia area and right thalamus with extension to the right
lateral ventricle with mild dilatation of the temporal [**Doctor Last Name 534**]
of the right lateral ventricle which remained unchanged for
some time. Patient also received bilateral upper and lower
extremity Dopplers for the question of thrombus. There was
found to be a chronic nonocclusive thrombus in the proximal
right internal jugular vein but otherwise there were no deep
venous thromboses in any extremities. Chest x-rays most
recently were clear. EEG on [**2116-5-22**] showed background
slowing indicating widespread encephalopathic condition.
There were no focal abnormalities and no epileptiform
features.
HOSPITAL COURSE: Mrs. [**Known lastname **] presented on [**2116-5-21**] with a
right thalamic right basal ganglia bleed extending to the
right ventricle. This was felt to be due to hypertension as
she came in with systolic blood pressures above 200 and her
family stated she had been noncompliant with her
antihypertensives at home. On the day of admission she was
intubated for apneic spells and her family decided that she
would wish to be Do Not Resuscitate but not Do Not Intubate.
Neurosurgery subsequently placed ventricular drain and
initially she was loaded on Dilantin for a question of
seizures. Renal was also consulted to follow up for her end
stage renal failure. She neurologically did not have any
seizures witnessed by any residents or attending per
description by the nurses had had some rhythmic eye
movements. However, EEG showed no epileptiform activity and
the Dilantin was very difficult to keep at therapeutic doses
given the renal failure and the frequent dialysis. So the
Dilantin was discontinued eventually and the patient has not
had any witnessed seizure activity. As for the ventricular
drain neurosurgery has been managing this. Her ventricular
drain has been draining a significant amount of fluid
throughout the hospital course. When clamping has been
attempted the ICPs have increased to the low to mid-20s and
the patient has become more somnolent. The decision has been
made to place a ventriculoperitoneal shunt this week.
Neurologically the patient has improved since she arrived in
the Intensive Care Unit. She has now become more awake and
alert and will follow both axial and appendicular commands
intermittently. She does seem to be more somnolent prior to
dialysis and after dialysis will eventually become more
awake. As far as her renal issues Mrs. [**Known lastname **] has been
followed by her outpatient physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**], and
she has continued her regular dialysis schedule while here in
the hospital. Dialysis has continued through her Quinton
catheter. From an infectious disease standpoint it was felt
that her bacteremia was de to infection of the Quinton
catheter. Instead of removing the catheter the decision was
made to treat through this infection and Vancomycin was
started. The patient has been redosed for levels less than
15 and all blood cultures have been negative since [**2116-5-23**].
Additionally the patient has been growing staph coag positive
in her sputum and again she is on Vancomycin for this. She
did develop some loose stools and C. difficile was sent which
was positive and the patient started on Flagyl for treatment
of this. However, since the Vancomycin and Flagyl have been
started the patient has continued to have daily fever spikes
and infectious disease was consulted. Infectious disease
recommended repeat CT of the abdomen and pelvis which was not
revealing for any new pathology. They also recommended
empiric treatment for gram negative rods which was started on
[**2116-6-7**] in the form of Ceftazidine. This will be continued on
a trial basis to see if the fevers may stop. No precise
cause of the fevers as of [**2116-6-8**] has yet been identified. In
regards to her diabetes the [**Hospital1 **] has been following and
recommending Humalog sliding scale as well as insulin in the
total parenteral nutrition while she was on TPN and also to
cover her with Lantus at night. Her blood sugars have been
well controlled with the [**Hospital1 **] consulting. From a
gastrointestinal standpoint the patient has had severe
gastroparesis. She was started on Reglan as well as
Erythromycin. It was felt that the Erythromycin may be
contributing to worsening of the C. difficile so this was
stopped and it was unclear as to whether the Reglan was
increasing her liver function tests and this was stopped.
The patient did improve eventually and a J tube was placed
and tube feeds were then restarted after a couple of weeks of
TPN. The patient did have transient elevation of ALT and AST
which now seemed to be decreasing. The alk phos is still
remaining high, however, as well as elevated amylase and
lipase. It is also not 100 percent clear what may be causing
this elevation of enzymes. However, we are following this
closely and have considered contributions from all of her
medications. Per abdominal CT there are no abscesses to
explain this and the total bilirubin has not been elevated at
all. We will continue to follow this throughout her hospital
course. Hematologically the patient has had guaiac negative
stools, does suffer from chronic anemia and has had
intermittent transfusions to attempt to keep her hematocrit
at 30. From a cardiovascular standpoint Mrs. [**Known lastname **] has been
continued on Nicardipine, labetalol and hydralazine in order
to keep her systolic pressure below 150. She tends to be
hypertension on days when she is not having dialysis.
However, in dialysis she does tend to become hypotensive.
Now that she has the G-J tube in place she will be started on
p.o. antihypertensives and today has been started on
metoprolol 50 mg p.o. b.i.d. and the labetalol drip has been
stopped. Respiratory-wise Mrs. [**Known lastname **] remains ventilated and
at some point this week the plan is for her to receive a
tracheostomy.
For now the patient remains in stable condition in the Neuro
Intensive Care Unit and the oncoming [**Male First Name (un) 1573**] will dictate the
rest of the hospital course and all of the discharge
instructions and medications as well as any follow up that
may be needed.
[**First Name8 (NamePattern2) 4224**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**]
Dictated By:[**Last Name (NamePattern1) 4525**]
MEDQUIST36
D: [**2116-6-8**] 19:10
T: [**2116-6-9**] 16:13
JOB#: [**Job Number 103158**]
Admission Date: [**2116-5-21**] Discharge Date:
Date of Birth: [**2078-4-17**] Sex: F
Service: MED
ADDENDUM: This is a stat dictation summary addendum to the
last dictation summary from [**2116-7-6**], and will encompass
the hospital course and discharge planning from [**2116-7-6**],
to [**2116-7-23**].
HISTORY OF PRESENT ILLNESS: In brief, this is a 38-year-old
female with multiple medical problems including end-stage
renal disease on hemodialysis Tuesday, Thursday, Saturday,
type 1 diabetes, hypertension, severe peripheral vascular
disease, multiple digit amputations, who initially presented
to the [**Hospital1 69**] with a right
thalamus/basal ganglia intracranial bleed status post VP
shunt with subsequent apneic/hypoxic respiratory failure with
PEG and trach placement who continues to have intermittent
fevers, has diffuse lymphadenopathy, chronically elevated
alkaline phosphatase and persistent right atrial thrombus.
HOSPITAL COURSE: Fever: The patient has had persistent
intermittent fevers to greater than 100 approximately q. 2-3
days. She has had an extensive infectious workup and is
being treated currently with vancomycin dose by level greater
than 15 for a methicillin-resistant Staphylococcus aureus
line tip infection in the setting of a known right atrial
thrombus. Length of treatment will be determined from the
time the line tip was pulled which was [**2116-6-16**]. She
will continue on vancomycin by level until [**2116-8-6**]. Since
that time the patient has had repeated blood cultures, all of
which have been negative. She has no signs of respiratory
infection. She does have multiple other potential sites
including an irritated J-tube site which was noted for
positive Klebsiella which was thought not to be a pathogen.
She has a sacral decubitus ulcer. She has multiple lines and
she has this undiagnosed diffuse lymphadenopathy. She
recently had a lymph node biopsy which was negative for
infection showing granulomatous disease with central necrosis
which was negative for special stains for organisms.
Additionally, she has a remote history of traveling to the
West Indies and is being treated empirically with doxycycline
100 mg p.o. b.i.d. for possible Klebsiella versus Brucella
infection. She will continue on doxycycline until she is
seen in Infectious Disease Clinic, time and date determined
below. The patient has been hemodynamically stable. For her
intermittent fevers she should be continued on antibiotics,
vancomycin by level and doxycycline and report if her
temperature spikes greater than 100.5 degrees Fahrenheit.
Respiratory failure: The patient was initially trached for
her apneic/hypoxic respiratory failure during her Intensive
Care Unit stay for her intracranial bleed. She had marked
improvement during the later part of her stay with removal of
the tracheostomy tube. She was evaluated by Speech and
Swallow and it was determined she was safe for p.o. intake.
She has no evidence of pneumonia or other signs of infection.
Respiratory status has been stable.
End-stage renal disease: The patient has end-stage renal
disease on hemodialysis. She receives dialysis Tuesday,
Thursday and Saturday. She is followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
of the Renal Service. She will continue to be followed by
Dr. [**First Name (STitle) 805**] and has an outpatient appointment scheduled
following discharge. Of note, the patient has a tendency to
become hypotensive following dialysis treatments which
respond effectively to intravenous fluid boluses.
Increased alkaline phosphatase: The patient has a
chronically elevated alkaline phosphatase in the range of 5-
700 without associated increase in her transaminases. She
had multiple abdominal ultrasounds and CT scans which have
shown normal liver echogenicity without mass or stones. She
has no ductal dilatation. She was unable to tolerate an MRCP
due to her inability to hold her breath and to sit still for
this study. Additionally, liver biopsy was postponed due to
the risk of infection associated with biopsy in the setting
of VP shunt. There have been discussions to consider a
transjugular approach; however, at the time of discharge,
this was deferred and will be followed up as an outpatient.
Diffuse lymphadenopathy: The patient has extensive granular
central necrosis; however, on the most recent pathology
report there seems to be some dissension as to whether it is
true central necrosis and cannot be ruled out for possible
sarcoid. The patient's serum ACE levels were negative. The
differential diagnosis for this diffuse adenopathy is
tuberculosis, Brucella, Coxiella, lymphoma and sarcoidosis,
to name a few. She has been ruled out for lymphoma by
biopsy. Sarcoid serum ACE levels were negative. Coxiella
and Brucella send out cultures are pending along with
Histoplasma. She will continued to be followed by serial CT
scans to monitor the extent of her adenopathy as an
outpatient.
Hypercalcemia: The patient has known hypercalcemia in the
setting of a relatively normal PTH with normal vitamin B25
levels with vitamin B125 levels pending. Serum ACE was
negative as stated above. The patient was treated with
pamidronate 30 mg IV times one on [**2116-7-7**]. Outpatient
________ will be followed on send-out labs to determine a
cause for her hypercalcemia.
Right atrial thrombus: The patient has a known right atrial
thrombus. Most recently assessed [**2116-7-20**], showing an
ejection fraction of approximately 60 percent with normal
left atrium with a 3-4 cm x 0.3 cm wide echodensity in the
body of the right atrium. In comparison to PTE study of [**2116-6-18**], the mass may be somewhat thinner but likely longer.
The patient will need to be followed with serial
echocardiograms to monitor clot progression. The patient at
this point has not been anticoagulated secondary to recent
history of intracranial bleed as discussed in prior discharge
summaries. The outpatient primary care physician will need
to discuss with Neurosurgery the possibility of reintroducing
anticoagulation for this known right atrial clot.
Additionally, the length of the antibiotic treatment
associated with intermittent fevers in terms of the
vancomycin therapy is due to a presumed endovascular
infection in the setting of a positive MRSA line tip with a
known right atrial thrombus.
Diabetes type 1: The patient has very labile blood sugars
depending upon her nutritional intake. Her Lentis dosing has
ranged from 10 to 30 units q. hs. with a corresponding
Humalog sliding scale. She was followed by the [**Hospital 3208**] Clinic
during her stay. Currently she is on Lentis 13 units q. hs.
with a Humalog sliding scale as we attempt to reintroduce a
p.o. diet without tube feeds. Blood sugars will need to be
followed q.i.d. and h.s. possibly up to q. 6h. to ensure
adequate glycemic control and to avoid the possibility of
hypoglycemia. The patient will be continued on the diabetic
and renal diet. She will continue to be seen at [**Last Name (un) 3208**] per
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] of Nephrology.
Hypertension: The patient came in with a significant
hypertension emergency complicated by intracranial bleed. At
the present time her blood pressures are well controlled with
hemodialysis and fluid removal. She has not been able to
tolerate additional antihypertensive at this time.
Antihypertensives should be reintroduced as needed in the
outpatient setting.
Sacral decubitus ulcer: The patient has a known sacral
decubitus ulcer. She is receiving vitamin C and zinc for
nutritional supplementation. She is using wet-to-dry
dressings with DuoDerm b.i.d. throughout her hospital stay.
She will need to have continued wound care of her sacral
decubitus ulcer.
Fluids, Electrolytes and Nutrition: The patient recently had
her tube feeds discontinued and was initiated on p.o. diet.
The patient has a poor appetite and associated nausea and
vomiting with a known history of diabetic gastroparesis. She
was started on Reglan 5 mg p.o. q.i.d. in the setting of
reduced creatinine clearance. She continues to be increasing
her p.o. intake well at the time of discharge; however, it
may be necessary to supplement her dietary needs with tube
feeds. The patient was seen by Nutrition and she will be
followed by a nutritionist at her extended care facility.
Nutrition recommended the following: Diabetic and renal
diet. [**Month (only) 116**] give Nephro p.o. supplement with meals. Encourage
calorie counting to accurately assess dietary intake and to
consider using tube feeds Nephro 45 cc plus 48 grams of
ProMod over 12 hours to meet 50 percent of patient's needs.
This will have to be reassessed at the rehabilitation
facility. Currently, the patient is off tube feeds though
she has a functioning G-tube in place.
Prophylaxis: The patient should be continued on heparin
subcu for deep venous thrombosis prophylaxis as well as
proton pump inhibitor.
Anxiety/depression: The patient has extreme anxiety. She
has been treated with Ativan 1-2 mg IV q. 4-6h. p.r.n.
Additionally, she was started on Celexa 20 mg p.o. q. day for
depression.
Cardiovascular: The patient has significant risk factors for
coronary artery disease. She is currently receiving aspirin
81 mg p.o. q. day. ______________ have been held secondary
to increase in transaminases per report. Beta blocker and
ACE inhibitor have been held secondary to hypotension.
CONDITION ON DISCHARGE: The patient is hemodynamically
stable, afebrile, breathing comfortably on room air and
tolerating p.o. The patient is eager to initiate physical
therapy and occupational therapy for continued
rehabilitation.
DISCHARGE STATUS: The patient will be discharged to an acute
level care facility.
DISCHARGE DIAGNOSES: Right thalamic/basal ganglia
intracranial bleed.
Hypertensive emergency.
Respiratory failure, central and hypoxic.
Methicillin-resistant Staphylococcus aureus line tip
infection.
Coag negative Staph bacteremia.
Clostridium difficile colitis.
Diffuse lymphadenopathy, unclear etiology.
Increased alkaline phosphatase of unclear etiology.
Failure to thrive.
Complications of diabetes.
Hypoglycemia.
Hyperglycemia.
Hypotension.
Right atrial thrombus.
Depression.
Anxiety.
DISCHARGE MEDICATIONS:
1. Dulcolax 10 mg p.o. q. day as needed for constipation.
2. Sarna lotion p.r.n. itching.
3. Heparin subcu 5000 units q. 12h.
4. Protonix 30 mg p.o. q. day.
5. Aspirin 81 mg p.o. q. day.
6. Vitamin C 500 mg p.o. b.i.d.
7. Zinc sulfate 220 mg p.o. q. day.
8. Tylenol 650 mg suppository q. 6h. as needed for fever.
9. Celexa 20 mg tablet p.o. q. day.
10. Loperamide 2 mg p.o. b.i.d. for diarrhea.
11. Doxycycline 100 mg p.o. q. 12h. continuous until
seen by Infectious Disease specialist.
12. Insulin, Glargine 13 units subcu at bedtime. Adjust
per fingerstick glucose levels.
13. Humalog sliding scale.
14. Metoclopramide 0.5 mg p.o. q.i.d. CHF
15. Zofran 2-4 mg IV as needed for nausea.
16. Lorazepam 1-2 mg IV q. 6h. as needed for anxiety.
17. Heparin flushes for line care.
FOLLOW UP: Follow up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Name (STitle) 805**], Friday, [**7-31**], at 11:00 a.m. in [**Hospital 3208**] Clinic.
Phone number [**Telephone/Fax (1) 3637**].
Scheduling Infectious Disease follow up in the week of [**8-16**]. Telephone number [**Telephone/Fax (1) 457**]. Appointment to be made
with Fellow plus attending. Service may have to call to
finalize appointment. Will be important to follow up on
Coxiella, Brucella and Histoplasma antigen send-outs as well
as antibiotic therapy in terms of doxycycline and vancomycin.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 103159**]
Dictated By:[**Last Name (NamePattern1) 13601**]
MEDQUIST36
D: [**2116-7-23**] 12:58:23
T: [**2116-7-23**] 13:48:29
Job#: [**Job Number 10221**]
Admission Date: [**2116-5-21**] Discharge Date:
Date of Birth: [**2078-4-17**] Sex: F
Service: MED
ADDENDUM: This is a stat dictation summary addendum to the
last dictation summary from [**2116-7-6**], and will encompass
the hospital course and discharge planning from [**2116-7-6**],
to [**2116-7-23**].
HISTORY OF PRESENT ILLNESS: In brief, this is a 38-year-old
female with multiple medical problems including end-stage
renal disease on hemodialysis Tuesday, Thursday, Saturday,
type 1 diabetes, hypertension, severe peripheral vascular
disease, multiple digit amputations, who initially presented
to the [**Hospital1 69**] with a right
thalamus/basal ganglia intracranial bleed status post VP
shunt with subsequent apneic/hypoxic respiratory failure with
PEG and trach placement who continues to have intermittent
fevers, has diffuse lymphadenopathy, chronically elevated
alkaline phosphatase and persistent right atrial thrombus.
HOSPITAL COURSE: Fever: The patient has had persistent
intermittent fevers to greater than 100 approximately q. 2-3
days. She has had an extensive infectious workup and is
being treated currently with vancomycin dose by level greater
than 15 for a methicillin-resistant Staphylococcus aureus
line tip infection in the setting of a known right atrial
thrombus. Length of treatment will be determined from the
time the line tip was pulled which was [**2116-6-16**]. She
will continue on vancomycin by level until [**2116-8-6**]. Since
that time the patient has had repeated blood cultures, all of
which have been negative. She has no signs of respiratory
infection. She does have multiple other potential sites
including an irritated J-tube site which was noted for
positive Klebsiella which was thought not to be a pathogen.
She has a sacral decubitus ulcer. She has multiple lines and
she has this undiagnosed diffuse lymphadenopathy. She
recently had a lymph node biopsy which was negative for
infection showing granulomatous disease with central necrosis
which was negative for special stains for organisms.
Additionally, she has a remote history of traveling to the
West Indies and is being treated empirically with doxycycline
100 mg p.o. b.i.d. for possible Klebsiella versus Brucella
infection. She will continue on doxycycline until she is
seen in Infectious Disease Clinic, time and date determined
below. The patient has been hemodynamically stable. For her
intermittent fevers she should be continued on antibiotics,
vancomycin by level and doxycycline and report if her
temperature spikes greater than 100.5 degrees Fahrenheit.
Respiratory failure: The patient was initially trached for
her apneic/hypoxic respiratory failure during her Intensive
Care Unit stay for her intracranial bleed. She had marked
improvement during the later part of her stay with removal of
the tracheostomy tube. She was evaluated by Speech and
Swallow and it was determined she was safe for p.o. intake.
She has no evidence of pneumonia or other signs of infection.
Respiratory status has been stable.
End-stage renal disease: The patient has end-stage renal
disease on hemodialysis. She receives dialysis Tuesday,
Thursday and Saturday. She is followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
of the Renal Service. She will continue to be followed by
Dr. [**First Name (STitle) 805**] and has an outpatient appointment scheduled
following discharge. Of note, the patient has a tendency to
become hypotensive following dialysis treatments which
respond effectively to intravenous fluid boluses.
Increased alkaline phosphatase: The patient has a
chronically elevated alkaline phosphatase in the range of 5-
700 without associated increase in her transaminases. She
had multiple abdominal ultrasounds and CT scans which have
shown normal liver echogenicity without mass or stones. She
has no ductal dilatation. She was unable to tolerate an MRCP
due to her inability to hold her breath and to sit still for
this study. Additionally, liver biopsy was postponed due to
the risk of infection associated with biopsy in the setting
of VP shunt. There have been discussions to consider a
transjugular approach; however, at the time of discharge,
this was deferred and will be followed up as an outpatient.
Diffuse lymphadenopathy: The patient has extensive granular
central necrosis; however, on the most recent pathology
report there seems to be some dissension as to whether it is
true central necrosis and cannot be ruled out for possible
sarcoid. The patient's serum ACE levels were negative. The
differential diagnosis for this diffuse adenopathy is
tuberculosis, Brucella, Coxiella, lymphoma and sarcoidosis,
to name a few. She has been ruled out for lymphoma by
biopsy. Sarcoid serum ACE levels were negative. Coxiella
and Brucella send out cultures are pending along with
Histoplasma. She will continued to be followed by serial CT
scans to monitor the extent of her adenopathy as an
outpatient.
Hypercalcemia: The patient has known hypercalcemia in the
setting of a relatively normal PTH with normal vitamin B25
levels with vitamin B125 levels pending. Serum ACE was
negative as stated above. The patient was treated with
pamidronate 30 mg IV times one on [**2116-7-7**]. Outpatient
________ will be followed on send-out labs to determine a
cause for her hypercalcemia.
Right atrial thrombus: The patient has a known right atrial
thrombus. Most recently assessed [**2116-7-20**], showing an
ejection fraction of approximately 60 percent with normal
left atrium with a 3-4 cm x 0.3 cm wide echodensity in the
body of the right atrium. In comparison to PTE study of [**2116-6-18**], the mass may be somewhat thinner but likely longer.
The patient will need to be followed with serial
echocardiograms to monitor clot progression. The patient at
this point has not been anticoagulated secondary to recent
history of intracranial bleed as discussed in prior discharge
summaries. The outpatient primary care physician will need
to discuss with Neurosurgery the possibility of reintroducing
anticoagulation for this known right atrial clot.
Additionally, the length of the antibiotic treatment
associated with intermittent fevers in terms of the
vancomycin therapy is due to a presumed endovascular
infection in the setting of a positive MRSA line tip with a
known right atrial thrombus.
Diabetes type 1: The patient has very labile blood sugars
depending upon her nutritional intake. Her Lentis dosing has
ranged from 10 to 30 units q. hs. with a corresponding
Humalog sliding scale. She was followed by the [**Hospital 3208**] Clinic
during her stay. Currently she is on Lentis 13 units q. hs.
with a Humalog sliding scale as we attempt to reintroduce a
p.o. diet without tube feeds. Blood sugars will need to be
followed q.i.d. and h.s. possibly up to q. 6h. to ensure
adequate glycemic control and to avoid the possibility of
hypoglycemia. The patient will be continued on the diabetic
and renal diet. She will continue to be seen at [**Last Name (un) 3208**] per
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] of Nephrology.
Hypertension: The patient came in with a significant
hypertension emergency complicated by intracranial bleed. At
the present time her blood pressures are well controlled with
hemodialysis and fluid removal. She has not been able to
tolerate additional antihypertensive at this time.
Antihypertensives should be reintroduced as needed in the
outpatient setting.
Sacral decubitus ulcer: The patient has a known sacral
decubitus ulcer. She is receiving vitamin C and zinc for
nutritional supplementation. She is using wet-to-dry
dressings with DuoDerm b.i.d. throughout her hospital stay.
She will need to have continued wound care of her sacral
decubitus ulcer.
Fluids, Electrolytes and Nutrition: The patient recently had
her tube feeds discontinued and was initiated on p.o. diet.
The patient has a poor appetite and associated nausea and
vomiting with a known history of diabetic gastroparesis. She
was started on Reglan 5 mg p.o. q.i.d. in the setting of
reduced creatinine clearance. She continues to be increasing
her p.o. intake well at the time of discharge; however, it
may be necessary to supplement her dietary needs with tube
feeds. The patient was seen by Nutrition and she will be
followed by a nutritionist at her extended care facility.
Nutrition recommended the following: Diabetic and renal
diet. [**Month (only) 116**] give Nephro p.o. supplement with meals. Encourage
calorie counting to accurately assess dietary intake and to
consider using tube feeds Nephro 45 cc plus 48 grams of
ProMod over 12 hours to meet 50 percent of patient's needs.
This will have to be reassessed at the rehabilitation
facility. Currently, the patient is off tube feeds though
she has a functioning G-tube in place.
Prophylaxis: The patient should be continued on heparin
subcu for deep venous thrombosis prophylaxis as well as
proton pump inhibitor.
Anxiety/depression: The patient has extreme anxiety. She
has been treated with Ativan 1-2 mg IV q. 4-6h. p.r.n.
Additionally, she was started on Celexa 20 mg p.o. q. day for
depression.
Cardiovascular: The patient has significant risk factors for
coronary artery disease. She is currently receiving aspirin
81 mg p.o. q. day. ______________ have been held secondary
to increase in transaminases per report. Beta blocker and
ACE inhibitor have been held secondary to hypotension.
CONDITION ON DISCHARGE: The patient is hemodynamically
stable, afebrile, breathing comfortably on room air and
tolerating p.o. The patient is eager to initiate physical
therapy and occupational therapy for continued
rehabilitation.
DISCHARGE STATUS: The patient will be discharged to an acute
level care facility.
DISCHARGE DIAGNOSES: Right thalamic/basal ganglia
intracranial bleed.
Hypertensive emergency.
Respiratory failure, central and hypoxic.
Methicillin-resistant Staphylococcus aureus line tip
infection.
Coag negative Staph bacteremia.
Clostridium difficile colitis.
Diffuse lymphadenopathy, unclear etiology.
Increased alkaline phosphatase of unclear etiology.
Failure to thrive.
Complications of diabetes.
Hypoglycemia.
Hyperglycemia.
Hypotension.
Right atrial thrombus.
Depression.
Anxiety.
DISCHARGE MEDICATIONS:
1. Dulcolax 10 mg p.o. q. day as needed for constipation.
2. Sarna lotion p.r.n. itching.
3. Heparin subcu 5000 units q. 12h.
4. Protonix 30 mg p.o. q. day.
5. Aspirin 81 mg p.o. q. day.
6. Vitamin C 500 mg p.o. b.i.d.
7. Zinc sulfate 220 mg p.o. q. day.
8. Tylenol 650 mg suppository q. 6h. as needed for fever.
9. Celexa 20 mg tablet p.o. q. day.
10. Loperamide 2 mg p.o. b.i.d. for diarrhea.
11. Doxycycline 100 mg p.o. q. 12h. continuous until
seen by Infectious Disease specialist.
12. Insulin, Glargine 13 units subcu at bedtime. Adjust
per fingerstick glucose levels.
13. Humalog sliding scale.
14. Metoclopramide 0.5 mg p.o. q.i.d. CHF
15. Zofran 2-4 mg IV as needed for nausea.
16. Lorazepam 1-2 mg IV q. 6h. as needed for anxiety.
17. Heparin flushes for line care.
FOLLOW UP: Follow up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Name (STitle) 805**], Friday, [**7-31**], at 11:00 a.m. in [**Hospital 3208**] Clinic.
Phone number [**Telephone/Fax (1) 3637**].
Scheduling Infectious Disease follow up in the week of [**8-16**]. Telephone number [**Telephone/Fax (1) 457**]. Appointment to be made
with Fellow plus attending. Service may have to call to
finalize appointment. Will be important to follow up on
Coxiella, Brucella and Histoplasma antigen send-outs as well
as antibiotic therapy in terms of doxycycline and vancomycin.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 103159**]
Dictated By:[**Last Name (NamePattern1) 13601**]
MEDQUIST36
D: [**2116-7-23**] 12:58:23
T: [**2116-7-23**] 13:48:29
Job#: [**Job Number 10221**]
Admission Date: Discharge Date:
Date of Birth: Sex: F
Service:
ADDENDUM: This is an Addendum to the dictation summary done
today.
DISCHARGE MEDICATIONS:
1. Dulcolax 5 mg by mouth once per day.
2. Sarna lotion.
3. Heparin 5000 units subcutaneously q.12h.
4. Protonix 40 mg by mouth once per day.
5. Aspirin 81 mg by mouth once per day.
6. Vitamin C 500 mg by mouth twice per day.
7. Zinc sulfate 220 mg by mouth once per day.
8. Tylenol 650-mg suppositories q.6h. as needed (for fever).
9. Celexa 20 mg once per day.
10. Loperamide 2 mg by mouth twice per day (for
diarrhea).
11. Docusate 100 mg q.12h. (until seen in Infectious
Disease Clinic - may change to intravenous at same dose
100 mg intravenous twice per day if concerned with nausea
and upset stomach).
12. Glargine 13 units subcutaneously at hour of sleep.
13. Humalog sliding scale.
14. Reglan 5 mg by mouth four times per day before meals
and at bedtime.
15. Zofran 2 mg to 4 mg intravenously q.3-4h. as needed
(for nausea).
16. Lorazepam 1 mg to 2 mg intravenously q.4-6h. as
needed (for anxiety).
17. Heparin flushes.
18. Vancomycin 1 gram intravenously for levels of less
than 15; done at hemodialysis - last dose [**2116-8-16**].
SUMMARY OF FOLLOW-UP PLANS: Primary care physician [**Name Initial (PRE) **] [**Name10 (NameIs) **]
up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] ([**Telephone/Fax (1) 3637**]) on [**Last Name (LF) 2974**], [**7-31**],
at 11:00 a.m. in the [**Hospital **] Clinic.
Infectious Disease - follow up with Dr. [**Last Name (STitle) 51426**] ([**Telephone/Fax (1) 103183**])
in the [**Hospital Unit Name **] on [**2116-8-17**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], INT
Dictated By:[**Last Name (NamePattern1) 13601**]
MEDQUIST36
D: [**2116-7-23**] 13:06:57
T: [**2116-7-23**] 13:36:09
Job#: [**Job Number **]
Name: [**Known lastname **], [**Known firstname 16672**] Unit No: [**Numeric Identifier 16673**]
Admission Date: [**2116-5-21**] Discharge Date: [**2116-6-17**]
Date of Birth: [**2078-4-17**] Sex: F
Service: MED
This is a discharge summary addendum of the dates [**6-10**]
through [**6-17**].
Patient is a 38-year-old woman with multiple medical
problems, end-stage renal disease, hypertension, type 1
diabetes, multiple digit amputations, and right below the
knee amputation, who presented with a bleed in the right
thalamus and basal ganglia extending into the right ventricle
most likely due to hypertension. She initially had
extraventricular drain that was placed. Every time the drain
was clamped, the intracerebral pressure rose to the mid 20s.
Significant events during this week of this admission were:
1. Neurologically: A ventriculoperitoneal shunt was placed
on [**2116-6-11**]. The patient tolerated the procedure well.
2. On [**2116-6-15**], the patient had a tracheostomy performed
by the Neurological SICU team. On [**6-16**], the patient had
a significant hypotensive episode where after dialysis she
became febrile, had rigors. Needed to be put on Neo-
Synephrine to maintain her blood pressures. She had systolic
blood pressures in the 80s. She was treated with IV
antibiotics, levofloxacin, and vancomycin. At this point it
was felt that the patient's neurological symptoms were stable
particularly from the right thalamus and basal ganglial
bleed.
Neurological exam at time of transfer to the Medical
Intensive Care Unit showed that she opened her eyes to exam.
She had a right gaze preference. To noxious stimuli, she
moved all of her extremities including intermittently she was
able to actually follow commands by movement of her arms.
The plan is that if she were to have a seizure, then the
patient should be loaded on Dilantin. Patient was also
started on aspirin 81 mg p.o. q.d. for stroke prophylaxis.
3. Cardiovascularly: The patient's blood pressures were well
controlled on oral antihypertensives. She was placed back
home on a home regimen of enalapril 40 mg p.o. b.i.d.,
Norvasc 10 mg p.o. q.d., and metoprolol 100 mg p.o. t.i.d.
She was weaned off of the nicardipine drip on [**6-10**] and
propofol drip on [**6-13**]. She receiving hydralazine IV prn
for blood pressure goals less than systolic blood pressure
less than 160.
4. Renally: She was continuing her hemodialysis and on [**6-17**], a new hemodialysis catheter was replaced.
5. As per her endocrine requirements, she was on Lantus 11
units q.h.s., 8 units p.o. while NPO and on a Humalog sliding
scale. She is followed by the [**Last Name (un) 616**] diabetes service. On
the day of transfer, her sugars were increasing to the 300s
and she was put on an insulin drip.
6. Hematologically, she has chronic anemia. Her stool
guaiacs have been negative. Her goals are to transfuse her
if her hematocrit is greater than 30.
7. FEN and GI wise: She has a G-J tube, and she is
tolerating full tube feeds at 30 cc an hour. She is on a
proton-pump inhibitor, lansoprazole. She had elevated
amylase, lipase into the low 100s, which will be followed
clinically and most likely has pancreatitis.
8. From an infectious disease perspective, she has a Staph
coag negative infection for which she completed the course of
vancomycin on [**2116-6-13**], and she was also being treated
with Flagyl renally dosed for Clostridium difficile. Her
repeat Clostridium difficile culture on [**2116-6-8**] was
negative, and the plan is to treat her for seven days of
Flagyl after all antibiotics were off. Because of her
pancreatitis, she had a CT of the abdomen and pelvis on [**7-5**], which was negative for abscess. She is currently on
levofloxacin and vancomycin for her recent hypotensive
episodes, fever, and rigors on [**6-16**].
The ID service is following with regards of these fevers of
unknown origin. These fevers are unlikely due to a
neurological etiology in that in [**Month (only) **] of this year, when
she was admitted, she was also noted to have fevers of
unclear origin. She did have a lymph node axillary that was
biopsied that showed on pathology to be granulomatous and AFB
staining was negative. However, further staining was not
done. She is hematologically on subQ Heparin and pneumoboots
for prophylaxis.
She was transferred to the Medical Intensive Care Unit on [**2116-6-17**]. The attending during this part of the admission up
until [**6-17**] was the Neurology service. The attending was
Dr. [**First Name8 (NamePattern2) 1060**] [**Name (STitle) **].
DR.[**Last Name (STitle) 964**],[**First Name3 (LF) 963**] 11-933
Dictated By:[**Last Name (NamePattern4) 16675**]
MEDQUIST36
D: [**2116-6-17**] 19:18:40
T: [**2116-6-19**] 05:24:31
Job#: [**Job Number 16676**]
Name: [**Known lastname **], [**Known firstname 16672**] Unit No: [**Numeric Identifier 16673**]
Admission Date: [**2116-5-21**] Discharge Date: [**2116-7-6**]
Date of Birth: [**2078-4-17**] Sex: F
Service: MED
ADDENDUM TO DISCHARGE SUMMARY TO BE DICTATED BY MEDICAL ICU
TEAM FOR THE PATIENT'S HOSPITALIZATION DURING THIS PERIOD,
AND IN PARTICULAR THE TIME POINT FROM [**6-17**] TO [**2116-6-24**]:
HOSPITAL COURSE: On [**2116-6-24**], the patient was called out
to the floor from the Medical ICU to the [**Hospital1 **] service.
The patient arrived to the floor after having been on vanco
and Flagyl for MRSA from internal jugular dialysis tip. Also
had been found recently with a right atrial thrombus and
remained on 35 percent O2 trach collar. Also had been found
to have Staph aureus in her cerebrospinal fluid. On
transfer, the patient was on subcu heparin, and was on
Lantus, and insulin sliding scale. She was on Maalox. She
was on lansoprazole. She was on Flagyl 500 po bid and then
vanco dosed by level.
STROKE: The patient was continued on supportive care with a
1:1 sitter and restraints as needed for agitation.
END-STAGE RENAL DISEASE: The patient had a temporary
hemodialysis catheter placed to allow hemodialysis.
C. DIFF INFECTION: She was continued on Flagyl 500 [**Hospital1 **].
MRSA FROM CATHETER TIP: Vanco was continued to be dosed.
NUTRITION: The patient was continued on tube feeds.
CODE STATUS: DNR, but not DNI.
DIABETES: Continued on standing and sliding scale insulin.
PROPHYLAXIS: On subcu heparin.
NEUROLOGIC: Of note, the patient was verbal during this
point but somewhat irritable and not fully able to respond to
questions, but would respond to questions about pain,
shortness of breath, and generally gave short answers for
questions.
The patient was noted during her hospital course to have
fevers, as well as elevated alkaline phosphatase, but
borderline high ALT and AST. Abdominal ultrasound was
performed on the 21 to evaluate for the elevated alkaline
phosphatase. A small amount of ascites was seen, but no
evidence of any gallbladder or biliary abnormalities to
explain the elevated AST's. A CT of the abdomen with
contrast was performed on the 22. She was found to have no
evidence of any obvious abscess. There were, however,
enlarged intra-abdominal and intrathoracic lymph nodes.
There was a large subaxillary lymph node measuring 0.7 cm in
diameter. This was, given the patient's co-morbidities,
assessed via ultrasound, and needle biopsies were obtained
for both microbiology, as well as pathology for possible
granulomatous disease to explain the patient's fevers. As of
the date of this dictation, Gram stains and AFB stains have
been negative. The cultures for AFB are still pending.
The plan now is that the patient is to undergo an MRCP to
evaluate for other causes of this elevated alkaline
phosphatase. The elevation appears to be stable and not
trending.
THROMBUS: Given the patient's recent intracranial bleed, no
anticoagulation was done at this point.
Final disposition and plans to be dictated as an addendum to
this discharge summary addendum by the team taking over for
me for the care of this patient.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 16677**]
Dictated By:[**Doctor Last Name 5951**]
MEDQUIST36
D: [**2116-7-6**] 15:12:26
T: [**2116-7-7**] 11:23:37
Job#: [**Job Number 16678**]
|
[
"331.4",
"518.81",
"250.81",
"996.62",
"403.91",
"431",
"996.81",
"707.0",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.31",
"40.11",
"44.32",
"99.15",
"38.95",
"96.6",
"38.93",
"02.34",
"02.2",
"31.1",
"39.95",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14633, 14651
|
47792, 48277
|
50203, 51328
|
57336, 60365
|
14366, 14465
|
14101, 14344
|
49137, 50180
|
14726, 15707
|
51346, 57318
|
14671, 14703
|
38282, 38885
|
15721, 19888
|
2464, 2864
|
2449, 2449
|
13815, 14077
|
14482, 14616
|
47476, 47770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,300
| 134,862
|
27296
|
Discharge summary
|
report
|
Admission Date: [**2181-4-16**] Discharge Date: [**2181-4-16**]
Date of Birth: [**2136-1-29**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45-year-old Russian speaking female c no PMH who presented with
abdominal pain and vomiting after reportedly taking some Russian
diet pills. Her history was obtained in the ED through a Russian
interpreter, and she was unable to further describe the pills.
She apparently started to menstruate on Saturday after a 8 month
hiatus. Following this, she decided to become more active and
try to improve her diet; she also took 3 Russian "diet pills,"
on Sunday afternoon. She had acquired these pills in [**Country 532**].
After taking these, she developed diffuse arm and leg spasms and
nausea followed by bilious vomiting. No blood in emesis. No
diarrhea/constipation. She felt sufficiently ill to contact her
[**Name2 (NI) 9259**] who arranged for an ambulance.
.
In the ED she was noted to be tachycardic and otherwise
completely stable. She was given activated charcoal and 3 liters
of normal saline IV. She had no concerning EKG findings and only
a mild leukocytosis without left shift. A lactate was checked
and was found to be elevated at 5. In addition, she had an ABG
done on an unknown FiO2 and that ABG revealed a respiratory
alkalosis. Toxicology was consulted and had no further
suggestions. The patient was admitted to the ICU for closer
monitoring.
.
On our exam she reported resolution of arm/leg spasms and only
complained of persistent mild nausea and fatigue.
Past Medical History:
None
Social History:
SOCHX: Trained as engineer, works as accountant in a city north
of the Ural Mountains; lives there with her husband and 2
children. Visiting a friend in the U.S. for the last few months.
.
FAMHX: Non contributory
Physical Exam:
VITALS: afebrile, 91, 120/75, 112-14, 97%
GEN: lying in bed in NAD
HEENT: OP clear, sclerae anicteric, conjunc pink
CV: RRR, S1, S2
LUNGS: CTA
ABD: soft, NT, ND
EXT: WWP, no CCE
NEURO: A*O*3; able to engage in meaningful conversation through
interpreter
Pertinent Results:
WBC 12.3 (80P, 18L), HCT 39.4, PLT 360
Na 143, K 3.6, Cl 108, HCO3 18, BUN 14, Cr 0.9, Gluc 193
CK 87, Trop T <0.01
ALT 19, AST 39, AP 56, TB 0.5, [**Doctor First Name 674**] 107, LDH 433, ALB 5.0
INR 1.0, PTT 23.7
.
ABG = 7.53/26/114
Lactate = 5.3, 5.7
.
Urine/Serum Tox Screens = Negative
.
UA: >50 RBCs, no evidence of UTI
.
EKG: Sinus tach @ 100, nl axis, nl intervals, no ST changes
.
CXR: No acute cardiopulmonary process
.
Pelvic Film: Normal pelvic ultrasound.
.
Pelvic Ultrasound: Normal pelvic ultrasound.
Brief Hospital Course:
BRIEF OVERVIEW:
45-year-old Russian speaking female who presented with
nausea/vomiting after taking "diet" pills. The pt had a friend
bring the "diet" pills to the ICU and it was found that they
were multivitamins meant to supplement her diet. Her LFTs were
normal with the exception of an elevated LDH; however, the
specimen was hemolyzed. She was thought to have gastroenteritis
resulting in nausea and vomiting. Her lactic acidosis may have
been due to her respiratory alkalosis and resolved prior to
discharge (5.7 -> 1.7). IVF hydration and anti-emetics resolved
her symptoms. Lactate normalized as noted above. HCG was
negative. The pt was discharged in stable condition with follow
up arranged through [**Company 191**].
Medications on Admission:
MVI
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
gastroenteritis
dysmenorrhagia
Discharge Condition:
good
Discharge Instructions:
please return to the Emergency Department if you have: worsening
abdominal pain, intractable nausea or vomitting, inability to
tolerate food or drink, blood or black in your stool or vomit,
persistent fever greater than 101, worsening vaginal bleeding,
or any other concern.
You should follow up with a primary care doctor as directed
below.
Followup Instructions:
You have an appointment at [**Hospital6 733**] on [**5-9**] at
2:50 with Dr [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 250**] to confirm and
to apply for free care. At this visit you should have complete
physical examination including GYN evaluation.
Provider: [**Name10 (NameIs) 62718**] [**Last Name (NamePattern4) 62719**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2181-5-9**] 2:50
Completed by:[**2181-5-3**]
|
[
"E947.8",
"728.85",
"785.0",
"995.2",
"626.4",
"787.01",
"276.2",
"789.07"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3633, 3639
|
2814, 3550
|
311, 318
|
3714, 3721
|
2274, 2791
|
4112, 4556
|
3604, 3610
|
3660, 3693
|
3576, 3581
|
3745, 4089
|
1999, 2255
|
257, 273
|
346, 1724
|
1746, 1752
|
1768, 1984
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,793
| 191,505
|
52721
|
Discharge summary
|
report
|
Admission Date: [**2133-2-6**] Discharge Date: [**2133-2-10**]
Date of Birth: [**2081-5-2**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6440**]
Chief Complaint:
prostate cancer
Major Surgical or Invasive Procedure:
Radical retropubic prostatectomy and pelvic lymph node
dissection
History of Present Illness:
Mr. [**Known lastname **] is a 51 year-old male with a history of
elevated PSA. He underwent a prostate needle biopsy which
demonstrated [**Doctor Last Name **] III plus III from the left base of the
gland. His preoperative PSA was 4.6.
Past Medical History:
chronic lymphocytic leukemia
sleep apnea, GI reflux disease, hypercholesterolemia,
hypertension, gout, scleritis and prostate cancer
Social History:
The patient continues to work in the mortgage
business.
Family History:
Non-contributory
Physical Exam:
Temperature 98.3 heart rate 106 blood pressure 116/80
respiratons 20 O2 aturation 96% on room air.
Alert and oriented. No acute distress.
Regular rhythm. Tachycardia. S1 S2 normal. No rubs, gallops
Clear to auscultation bilaterally. No wheezing
Abdomen soft, obese, non-tender.
Extremities without edema.
Pertinent Results:
[**2133-2-6**] 11:48PM TYPE-ART TEMP-38.7 O2-20 PO2-97 PCO2-51*
PH-7.35 TOTAL CO2-29 BASE XS-0 INTUBATED-NOT INTUBA
[**2133-2-6**] 10:48PM GLUCOSE-127* UREA N-11 CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12
[**2133-2-6**] 10:48PM CK(CPK)-434*
[**2133-2-6**] 10:48PM WBC-46.4* RBC-4.32* HGB-11.1* HCT-34.8*
MCV-81* MCH-25.8* MCHC-31.9 RDW-16.6*
[**2133-2-6**] 10:48PM NEUTS-18* BANDS-5 LYMPHS-70* MONOS-6 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2133-2-6**] 10:48PM PLT COUNT-287
[**2133-2-6**] 10:48PM PT-13.2 PTT-28.0 INR(PT)-1.1
[**2133-2-6**] 09:22AM TYPE-ART PO2-142* PCO2-42 PH-7.39 TOTAL
CO2-26 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2133-2-6**] 09:22AM GLUCOSE-105 LACTATE-2.8* NA+-138 K+-3.6
CL--106
[**2133-2-10**] 07:05AM BLOOD WBC-37.7* RBC-3.54* Hgb-9.2* Hct-28.7*
MCV-81* MCH-26.0* MCHC-32.0 RDW-16.8* Plt Ct-316
[**2133-2-9**] 07:10AM BLOOD WBC-43.9* RBC-3.72* Hgb-9.5* Hct-29.9*
MCV-80* MCH-25.4* MCHC-31.7 RDW-16.6* Plt Ct-320
[**2133-2-10**] 07:05AM BLOOD Neuts-12* Bands-1 Lymphs-80* Monos-3
Eos-1 Baso-0 Atyps-2* Metas-0 Myelos-0 Promyel-1*
[**2133-2-9**] 07:10AM BLOOD Neuts-17* Bands-1 Lymphs-78* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 Promyel-1*
[**2133-2-10**] 07:05AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2133-2-10**] 07:05AM BLOOD Plt Ct-316
[**2133-2-9**] 07:10AM BLOOD Glucose-101 UreaN-18 Creat-1.0 Na-141
K-4.3 Cl-105 HCO3-28 AnGap-12
[**2133-2-7**] 05:20AM BLOOD CK(CPK)-489*
[**2133-2-7**] 05:20AM BLOOD CK-MB-3 cTropnT-<0.01
[**2133-2-6**] 10:48PM BLOOD CK-MB-3 cTropnT-<0.01
[**2133-2-6**] 01:30PM BLOOD CK-MB-3 cTropnT-<0.01
[**2133-2-9**] 07:10AM BLOOD Calcium-8.4 Mg-2.1
RADIOLOGY Final Report
CHEST (PA & LAT) [**2133-2-8**] 2:36 AM
CHEST (PA & LAT)
Reason: assess for fluid/pneumonia
[**Hospital 93**] MEDICAL CONDITION:
51 year old man with evidence of failure on previous CXR
REASON FOR THIS EXAMINATION:
assess for fluid/pneumonia
This is a repeat dictation for a lost report. Study is dated
[**2133-2-8**].
COMPARISON: [**2133-2-7**].
INDICATION: Evaluate for failure.
The lung volumes are low. Allowing for this factor, the heart
size is normal but demonstrates left ventricular configuration.
Pulmonary vascularity is also within normal limits for
technique. There is a persistent patchy left retrocardiac
opacity as well as a linear opacity at the right lung base. The
linear opacity appears slightly increased but is consistent with
discoid atelectasis.
IMPRESSION:
1) Persistent patchy left retrocardiac opacity, which may relate
to patchy atelectasis. In the appropriate clinical setting,
pneumonia is also a consideration.
2) Discoid atelectasis, right lower lobe.
ECG [**2133-2-10**]:
Sinus rhythm
Normal ECG
Since previous tracing of [**2133-2-6**], QRS voltage increased and
there may be mild
ST segment elevation in leads I, aVL,V5-V6
Clinical correlation is suggested
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 142 94 376/426.71 55 13 31
Brief Hospital Course:
Patient tolerated procedure well. Post-operatively he became
hypotensive with systolic blood pressures drifting into low 70s
and briefly required neosynephrine for managment of hypotension.
He was started on diltiazam for tachycardia (120s). He also
developed progressively increasing work of breathing, requiring
CPAP.
EKG was negative, but chest radiography showed increasing
interstitial edema. While in the [**Hospital Unit Name 153**], he spiked a fever to
101.6 and was treated with levofloxacin. Repeat chest
radiography showed resolving CHF. Hypoxia progressively improved
and there were no signs of pneumonia. Patient was subsequently
transferred to the floor on telemetry. He continued to be
tachycardic on post-op day 1. His pulmonary exam progressively
improved. Levofloxacin was continued. He was transitioned to PO
pain medications on post-operative day 2 and tolerated diet
advancement well. He continued to be tachycardic but
asymptomatic and medicine consult was obtained. Flagyl was
added to antibiotic regimen on post-operative day 3. No clear
etiology for persistent tachycardia was found. He was discharged
home in stable condition on post-operative day 4 with follow-up,
including outpatient echo.
Medications on Admission:
prilosec
prednisone eye gtts
rebitussin
sudafed
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: do not exceed 4 grams of
acetaminophen per day.
Disp:*30 Tablet(s)* Refills:*0*
4. Ipratropium Bromide 0.02 % Solution Sig: [**11-23**] inhales
Inhalation Q6H (every 6 hours).
Disp:*1 inhales* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose bowel movements.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
post operative pneumonia
obesity
gastric reflux
hypertension
gout
sleep apnea
prostate cancer
Discharge Condition:
resolving pneumonia
Discharge Instructions:
Finish antibiotic as perscribed.
[**Month (only) 116**] shower tomorrow; do not soak wound and keep dry.
Call doctor or go to emergency department if develop fevers
greater than 101.5, develop difficulty breathing or blood clots
in foley.
Take tempature at home daily.
If done with antibiotics for pneumonia, also take one day of
levofloxcin one day before removal of foley and for two days
following.
Followup Instructions:
Patient to follow up with primary care provider this week to
assess futher cardiac workup.
Patient to call Dr. [**Last Name (STitle) 365**] for follow up urology appointment
[**Telephone/Fax (1) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2133-3-20**] 9:00
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2133-4-27**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2133-4-28**] 1:30
Completed by:[**2133-6-8**]
|
[
"486",
"285.9",
"200.10",
"997.1",
"602.3",
"530.81",
"185",
"493.90",
"204.10",
"997.3",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"60.5",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
6454, 6460
|
4429, 5659
|
328, 396
|
6598, 6619
|
1269, 3158
|
7070, 7907
|
908, 926
|
5757, 6431
|
3195, 3252
|
6481, 6577
|
5685, 5734
|
6643, 7047
|
941, 1250
|
273, 290
|
3281, 4406
|
424, 662
|
684, 818
|
834, 892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,085
| 132,105
|
21063
|
Discharge summary
|
report
|
Admission Date: [**2145-6-7**] Discharge Date: [**2145-6-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
bleeding from rectum along with weakness/fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 86 yo man with hx of metastatic pancreatic cancer dx'ed
in the past yr who presented to the ED with chief complaint of
fatigue and bright red blood per rectum.
Past Medical History:
metastatic pancreatic cancer
Social History:
nc
Family History:
nc
Physical Exam:
T 96 P 69 163/72 18 o2 sat 100% RA
cachexic elderly man
perrl, eomi
neck supple
cv - rrr
CTA
abd is soft and nt/nd
ext without edema
no rashes
alert and oriented
Pertinent Results:
[**2145-6-7**] 06:16PM HCT-26.7*
[**2145-6-7**] 03:28AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2145-6-7**] 03:28AM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-15 BILIRUBIN-LG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2145-6-7**] 03:27AM GLUCOSE-67* UREA N-24* CREAT-1.1 SODIUM-144
POTASSIUM-3.7 CHLORIDE-109* TOTAL CO2-24 ANION GAP-15
[**2145-6-7**] 03:27AM ALT(SGPT)-85* AST(SGOT)-101* ALK PHOS-332*
TOT BILI-5.5*
[**2145-6-7**] 03:27AM CALCIUM-7.8* PHOSPHATE-3.2 MAGNESIUM-1.9
[**2145-6-7**] 03:27AM WBC-15.5* RBC-3.11*# HGB-9.8*# HCT-30.5*#
MCV-98 MCH-31.5 MCHC-32.2 RDW-19.7*
[**2145-6-7**] 03:27AM NEUTS-80* BANDS-9* LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2145-6-7**] 03:27AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
TARGET-1+ SCHISTOCY-1+ BURR-1+
[**2145-6-7**] 03:27AM PLT COUNT-237
[**2145-6-7**] 03:27AM PT-14.9* PTT-26.1 INR(PT)-1.3*
[**2145-6-6**] 10:17PM COMMENTS-GREEN TOP
[**2145-6-6**] 10:17PM HGB-9.5* calcHCT-29
[**2145-6-6**] 03:40PM URINE HOURS-RANDOM
[**2145-6-6**] 03:40PM URINE GR HOLD-HOLD
[**2145-6-6**] 03:40PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2145-6-6**] 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.0 LEUK-NEG
[**2145-6-6**] 12:02PM GLUCOSE-83 UREA N-24* CREAT-1.4* SODIUM-142
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-24 ANION GAP-16
[**2145-6-6**] 12:02PM ALT(SGPT)-117* AST(SGOT)-222* LD(LDH)-272*
ALK PHOS-376* AMYLASE-33 TOT BILI-3.2* DIR BILI-2.2* INDIR
BIL-1.0
[**2145-6-6**] 12:02PM LIPASE-9
[**2145-6-6**] 12:02PM ALBUMIN-3.1*
[**2145-6-6**] 12:02PM WBC-20.5*# RBC-2.03* HGB-6.7* HCT-20.2*
MCV-100* MCH-33.0* MCHC-33.1# RDW-18.0*
[**2145-6-6**] 12:02PM NEUTS-93* BANDS-4 LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2145-6-6**] 12:02PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2145-6-6**] 12:02PM PLT SMR-NORMAL PLT COUNT-302
[**2145-6-6**] 12:02PM PT-13.9* PTT-28.3 INR(PT)-1.2*
[**2145-6-6**] 12:00PM GLUCOSE-79 UREA N-25* CREAT-1.4* SODIUM-143
POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
[**2145-6-6**] 12:00PM CALCIUM-7.9* PHOSPHATE-4.3 MAGNESIUM-1.9
Brief Hospital Course:
1. BRBPR: He was admitted to the ICU. His initial hct was 20 so
he was transfused. He had imaging of his abd which revealed a
large pancreatic mass encasing his celiac axis. He was treated
for pain.
2. Pancreatic mass and Prostate Cancer: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] had a
family mtn with the pt and his family and the decision was made
to make the pt comfort measures only with hopes of home hospice.
He was tx'ed to 11R on [**2145-6-8**].
3. dispo: sent to inpt. Hospice facility
Medications on Admission:
iron
pain killer
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*0 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. Morphine Concentrate Oral
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health center
Discharge Diagnosis:
Metastatic pancreatic cancer
Discharge Condition:
poor
Discharge Instructions:
Please call the hospice team and/or your primary care doctor
with any questions about your care.
Followup Instructions:
Followup with your primary care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **], if you
have any questions
|
[
"280.0",
"157.8",
"198.89",
"576.1",
"276.52",
"585.9",
"185"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4026, 4082
|
3145, 3672
|
309, 316
|
4155, 4162
|
802, 3122
|
4307, 4429
|
601, 605
|
3739, 4003
|
4103, 4134
|
3698, 3716
|
4186, 4284
|
620, 783
|
221, 271
|
344, 513
|
535, 565
|
581, 585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,725
| 173,510
|
10638
|
Discharge summary
|
report
|
Admission Date: [**2143-8-16**] Discharge Date: [**2143-8-23**]
Date of Birth: [**2114-7-27**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: A 28-year-old black male in a
car crash with extraction time of one hour, combative at the
scene, positive loss of consciousness.
PAST MEDICAL HISTORY: The patient has a past medical history
of asthma.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: No known medications currently.
PHYSICAL EXAMINATION ON ADMISSION: On initial examination
revealed he was a unrestrained driver. The patient was
complaining of numbness in his right upper extremity on
presentation. Positive alcohol on board. Generally, alert,
awake, and oriented. Pupils were equal and reactive to
light. A small superficial laceration on his forehead.
Tenderness in his left clavicle. A regular rate and rhythm
on cardiovascular. Breath sounds were good bilaterally. The
abdomen was soft. The back was without stepoff. His pelvis
was stable. There was a small puncture wound in his left
lower extremity. No deformities. Neurologically wise, the
patient was not cooperative with the examination.
LABORATORY DATA ON ADMISSION: Laboratories on arrival were
white blood cell count of 9.2, hematocrit of 34,
platelets 234. Coagulations were PT 13.1, PTT was 24.4, INR
was 1.1. Fibrinogen was 283. Ethanol was 149. Chemistry
revealed a sodium of 143, potassium 3.5, chloride 107,
bicarbonate 21, BUN 13, creatinine 1.1, glucose of 133.
Amylase was 48.
RADIOLOGY/IMAGING: Initial trauma series showed a cervical
spine that was negative to C5.
A chest x-ray which showed a fracture of the left clavicle
which was nondisplaced and of the right first rib.
Pelvis x-ray was negative.
HOSPITAL COURSE: The plan was to admit this gentleman. He
had a CT of the neck which showed a transverse process
fracture of C5 and C6, and the C6 extended into the vertebral
artery foramen. CT also showed a left clavicle fracture and
a right first rib fracture. CT of the abdomen was negative.
CT of the head was negative. There was no extravasation of
fluid, blood or contrast in the chest CT.
So, the initial assessment of this gentleman was that of a
28-year-old man with a transverse process fracture of C5-C6
extending into the vertebral artery foramen with questionable
mental status given his uncooperativeness and combative
examination. Positive alcohol. Cervical spine precautions,
cervical collar, logroll precautions. Orthopaedics
consultation for spine and pain control, and admission to
Surgical Intensive Care Unit for frequent neurologic checks.
Orthopaedics was involved and given the fact that there was a
question about extension of the fracture into the vertebral
artery foramen, Neurosurgery was consulted. A MRA was done,
per Neurosurgery, which showed a right vertebral artery
thrombosis and positive anterior longitudinal ligament
injury. Chest x-ray was repeated as well without change.
So, the patient was kept on cervical spine precautions in a
hard collar, and Neurosurgery advised anticoagulation which
was done, and an angiogram as well. The MRA could not rule
out a dissection which was another reason why the angiogram
was done for dissection of the vertebral artery. The patient
had some weakness in his right upper extremity, but the
sensation was normal to light touch and pinprick in the
bilateral upper extremities and lower extremities. The
patient was anticoagulated on heparin. Neurosurgery and
Orthopaedics was following. Orthopaedics' evaluation
resulted in agreement with the hard collar as well as a
follow-up evaluation in two weeks at the office of Dr. [**Last Name (STitle) 34920**].
They also put him in a sling for his clavicular fracture.
The angiogram showed the right vertebral artery with a low
flow state with good collateral flow and left dominant, and
heparin was continued, and eventually Coumadin was begun.
The patient was then transferred out of the unit, and his
neurologic checks were given less frequently, and the patient
was continued on Coumadin. He was also on Percocet and
Zantac. The goal of the INR per the Neurosurgery team was an
INR of 2 to 3. There were no neurologic deficits during his
hospitalization. His arm strength completely improved and
was equal bilaterally.
On hospital day eight, this was the patient's second day of
anticoagulation with an INR above 2. The patient was to be
going home with his cervical collar in place. He had
appropriate follow-up appointments. He was tolerating a
regular diet, having bowel movements, and ambulating without
difficulty. He was seen and cleared by Physical Therapy to
go home. He was to go home on Coumadin 5, Percocet, and
Colace.
DISCHARGE DIAGNOSES:
1. C5-C6 transverse process fractures.
2. Anterior longitudinal ligament injury of his neck.
3. Right vertebral artery thrombosis.
4. Status post motor vehicle crash.
5. Right clavicular fracture.
6. Right first rib fracture.
DISCHARGE INSTRUCTIONS: Continue anticoagulation with
Coumadin. Follow up with primary care physician appointment
that was arranged. Follow up with Orthopaedics. Follow up
with Neurosurgery. Follow up in the Trauma Clinic. Ambulate
and call if there were any problems.
CONDITION AT DISCHARGE: Discharge condition was stable and
improved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2143-8-23**] 12:34
T: [**2143-8-27**] 13:33
JOB#: [**Job Number 34921**]
|
[
"305.00",
"810.00",
"780.09",
"806.05",
"E812.0",
"807.01",
"873.42",
"433.20",
"891.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
4748, 4981
|
426, 480
|
1762, 4727
|
5006, 5267
|
5282, 5606
|
156, 287
|
1185, 1743
|
310, 399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,241
| 155,554
|
24245
|
Discharge summary
|
report
|
Admission Date: [**2172-7-7**] Discharge Date: [**2172-7-15**]
Date of Birth: [**2139-9-13**] Sex: M
Service: MEDICINE
Allergies:
Betadine
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
fever and tachycardia
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
32yo M w/ encephalomyelitis s/p brain bx at [**Hospital1 2025**] in [**2167**] and
eczema who presents to the ED with high grade fever, headahce
and pain in his R-shoulder.
.
The patient was in a general state of good health, works two
jobs until 3 days prior to presentation when he had a subjective
temperature, sore throat and rhinorrhea. He slept for sixteen
hours but still felt poorly upon awakening prompting hiim to
take sudafed. He then experienced some "disequilibrium" upon
standing without falling. He took some tylenol and then slep for
24 hours. Upon awakening he experienced severe [**9-8**] stabbing R
shoulder pain with sore muscles in the upper back and neck. The
pain has been dull, but at times sharp and shooting, but it does
not shout along his spine or into his arm. There is no radicular
pain. The pain in the shoulder gets worse in the morning and
gets better as the day progresses. He thinks the shoulder was
swollen initially, but not any longer. He denies trauma/other
joint involvement and has never happened before.
.
3 d ago, he also has a [**4-8**] frontal headache, grinding,
continuous, like a vice. Not positional, no photophobia,
diplopia, blurred vision. Some nausea at times,but no vomiting.
HA is worse in AM. No clear awakenings, though sleep has been
poor. No knowns triggers; no trauma that he knows of.No
weakness, numbness or tingling, bowel or bladder problems.
Claims completely different from encephalomyelitis symptos.
Tylenol provides good relief.
.
On review of systems, the pt. reports a productive cough which
began today. During the LP he had mild sob which has since
resolved. Denies CP, tightness or palpitations. Mild nausea w/o
emesis. Poor appetite for several days. DEnies sorethroat,
earache, sinus tenderness, abdominal pain, diarrhea, dysuria. +
myalgias. L leg more swollen than right which he just noticed
today and is new. He also then experienced multiple watery bms,
approximately 4/hr x 24 hours hours along with mild mid LQ
abdominal cramping. His last episode of diarrhea was on
[**2172-7-6**]. Has not been on antibiotic recently. Patient denies
recent travel/sick contact. Eczema might have worsened lately.
.
Patient did not arrive with ED records. According to Dr. [**Name (NI) 61527**] verbal sign out, his VS were T104 150/97 P90 98% on RA.
Patient had LP after negative CT head and was started on
vanco/CTX/ampicillin/acyclovir. He was also in renal failure and
has abnormal LFTs. Baseline values were unknown. He had RUQ U/S
which was did not show cholecystitis. MRI C spine did not show
epidural abscess. Orthopedic saw him in the ED, attempted
arthrocentesis but could not aspirate any fluid. Patient
received 5L fluid in ED. He was suppose to go to regular medical
floor. HOwever, nurses refuse to accept patient becuase he has
tachycardia in 110s, despite knowing that he has fever.
Past Medical History:
- h/o demyelinating encephalomyelitis - dx at [**Hospital1 2025**], p/w
photophobia and was sore from his L-ear to his scapula; s/p
craniotomy with biopsy and 5 week hospital stay, recovered
completely
- htn never treated
- [**9-3**]- with bacteremia-
per pt from eczema skin wound d/c'ed on 2 weeks po abx but
cannot remember the name of it.
- eczema
Social History:
He is from NJ. He attended [**University/College 5130**] and has a degree in
advertising and marketing. He now works as a bartender and in
security. 10 lifetime sexual partners. [**Name (NI) **] STDs. Last tattoo 4
years ago. No foregn travel or outdoor sports/camping. [**1-3**]
drinks per week. No IVDU ever. No incarcerations or periods of
homelessness. 1 ppd x 9 years. Lives with roomate. No children.
Family History:
Grandfather htn and CVAs, GM died of sepsis, mother with dm,
Father is [**Country **] vet with schizophrenia.
Physical Exam:
T99 P95 BP166/96 R17 95% on RA
GEN: NAD, sweaty, pleasant AA male
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, OP clear, neck supple, no JVD or carotid bruits
appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, obese, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: eczematous rash noted on bilateral lower extremity
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty, CN II-XII intact, normal muscle bulk, strength and
tone throughout, nml light touch throughout, Plantar response
was flexor bilaterally.
Right shoulder: no obvious swelling/redness/warmth, tender along
anterior joint line, normal range of motion
Pertinent Results:
[**2172-7-7**] 01:50PM WBC-11.5* RBC-4.42* HGB-13.7* HCT-39.3*
MCV-89 MCH-31.0 MCHC-34.9 RDW-14.5
[**2172-7-7**] 01:50PM NEUTS-87.0* BANDS-0 LYMPHS-8.1* MONOS-3.1
EOS-0.4 BASOS-1.4
[**2172-7-7**] 01:50PM PLT SMR-LOW PLT COUNT-107*
[**2172-7-7**] 01:50PM GLUCOSE-115* UREA N-28* CREAT-2.1* SODIUM-135
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-24 ANION GAP-18
[**2172-7-7**] 01:50PM ALT(SGPT)-61* AST(SGOT)-99* LD(LDH)-926* ALK
PHOS-52 AMYLASE-155* TOT BILI-2.9* DIR BILI-0.5* INDIR BIL-2.4
[**2172-7-7**] 01:50PM TOT PROT-6.6
[**2172-7-7**] 01:50PM LIPASE-195*
[**2172-7-7**] 06:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2172-7-7**] 06:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2172-7-7**] 06:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2172-7-7**] 10:15PM CEREBROSPINAL FLUID (CSF) WBC-16 RBC-562*
POLYS-26 BANDS-2 LYMPHS-45 MONOS-23 ATYPS-1 MACROPHAG-3
[**2172-7-7**] 10:15PM CEREBROSPINAL FLUID (CSF) PROTEIN-36
GLUCOSE-68
[**2172-7-7**] 06:43PM PT-12.8 INR(PT)-1.1
[**2172-7-7**] 06:43PM FIBRINOGE-770* D-DIMER-3507*
CT head w/out contrast [**2172-7-7**] - IMPRESSION:
No intracranial hemorrhage is identified. An area of subtle low
attenuation in the white matter adjacent to the right frontal
[**Doctor Last Name 534**] may reflect changes from recent biopsy, or underlying
changes from the patient's reported demyelinating
encephalomalacia.
.
MRI C-spine [**2172-7-7**] - IMPRESSION:
1. There is no evidence of an epidural abscess in the cervical
spinal canal.
2. There is an intramedullary lesion dorsally at the level of
the base of the dens with slight mass effect, the appearance of
which is suspicious for a demyelinating lesion. An ependymoma
could have an identical appearance and followup
contrast-enhanced MRIs of the brain and cervical spine are
recommended.
.
CXR [**2172-7-7**] - No acute cardiopulmonary abnormality
.
RUQ U/S - [**2172-7-7**]: The liver demonstrates no focal or textural
abnormality. There is no intra- or extra-hepatic biliary ductal
dilatation. The common duct is normal caliber measuring up to 4
mm. The pancreas is unremarkable. There is no ascites. There is
appropriate hepatopetal main portal vein blood flow. The
gallbladder contains a 1 cm shadowing stone in the fundus, which
is mobile. Also noted is a small 3 mm polyp. The gallbladder is
non-distended, and there is no wall thickening or
pericholecystic fluid. There was a negative ultrasonic [**Doctor Last Name 515**]
sign.
IMPRESSION: Cholelithiasis. However, the gallbladder is
nondistended, and there is no wall thickening or pericholecystic
fluid to suggest acute cholecystitis. No biliary ductal
dilatation.
.
X-ray R shoulder - [**2172-7-7**]:No prior studies are available for
comparison. There is no acute fracture, dislocation, or
lytic/sclerotic lesion identified. The joint spaces are well
preserved. The soft tissues are unremarkable with no effusion
identified.
Brief Hospital Course:
1) SEPSIS: [**3-3**] gram positive cocci in pairs on blood cultures
from admission-portal of entry could be chronic eczema lesions
though none obviously infected. CT head neg, MRI C spine no
cervical epidural abscess, ?demyelinating lesion, U/S show
gallstone w/ no cholecystitis, right shoulder XR unremarkable,
attempted aspiration without fluid, CXR neg, UA neg, urine tox
neg, LENI left leg neg. Patient initially started on broad
spectrum antibiotics for possible meningitis. AFter workup
related only Group G strep bacteremia, narrowed down to
Ceftriaxone 2g daily. Surveillance blood cultures remained
negative. TTE and TEE did not show any evidence of
endocarditis. The exact source of bacteremia remained unclear,
and plan was for total 2 week course of ceftriaxone.
.
2) Hemolytic Anemia:
No evidence of DIC or TTP. Likely due to sepsis. REsolved by
discharge.
.
3) Acute renal failure:
Admission creatinine 2.1, improved with hydration, treatment of
sepsis. STabilized in mid 1's which is likely baseline. Pt
should have outpatient workup of renal insufficiency.
.
4) abnormal LFTs- high ALT, AST and bili(both dir and indir),
mildly elevated pancreatic enzymes; RUQ U/S show galstone w/ no;
nml coagscholecystitis, no BD dilatation.
- hepatitis panel negative
- likely was related to hemolysis and improved with resolution
of hemolysis.
.
5) Demyelination on CT: Neuro consulted and not felt to be
acute.
.
6) HTN: Significantly hypertensive once sepsis resolved. By
discharge required 4 medications: norvasc, hydral, labetalol,
captopril. Given age, that level of hypertension should be
worked up for secondary causes after discharge.
.
Medications on Admission:
None.
Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) g Intravenous Q24H (every 24 hours) for 7 days.
Disp:*14 g* Refills:*0*
2. Saline Flush 0.9 % Syringe Sig: Three (3) ml Injection SASH
and prn for 7 days.
Disp:*30 syr* Refills:*0*
3. Heparin Flush 10 unit/mL Kit Sig: Three (3) mL Intravenous
SASH and prn for 7 days.
Disp:*60 ML* Refills:*0*
4. Outpatient Lab Work
one week after discharge, CBC, AST/ALT, alk phos, Bun,
creatinine. Fax results to [**Telephone/Fax (1) 457**] (Dr. [**Last Name (STitle) 3394**] in ID).
5. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*0*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*30 gram* Refills:*0*
9. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*30 grams* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Strep bacteremia
Hypertension
Discharge Condition:
Good--afebrile, BP well controlled.
Discharge Instructions:
Please follow up as below.
You will need lab work done in one week. You can come in to [**Hospital 191**]
clinic in the [**Hospital Ward Name 23**] building for this. I have included a
prescription.
You will continue on antibiotics for one more week.
Followup Instructions:
INFECTIOUS DISEASE: Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2172-8-11**] 9:30
Please call Find a Doc at [**Telephone/Fax (1) 5867**] to make an appointment
with a new Primary care doctor. This is very important to
manage your blood pressure as well as other issues.
|
[
"283.19",
"995.92",
"682.6",
"692.9",
"287.5",
"401.9",
"584.9",
"038.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11036, 11097
|
8109, 9773
|
290, 296
|
11171, 11209
|
5046, 8086
|
11512, 11866
|
4005, 4116
|
9829, 11013
|
11118, 11150
|
9799, 9806
|
11233, 11489
|
4131, 5027
|
229, 252
|
324, 3190
|
3212, 3565
|
3581, 3989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,683
| 192,931
|
21686
|
Discharge summary
|
report
|
Admission Date: [**2197-2-23**] Discharge Date: [**2197-3-1**]
Date of Birth: [**2173-9-6**] Sex: F
Service: MEDICINE
Allergies:
Latex / Fentanyl / Risperidone
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar puncture, blood patch [**2197-3-1**].
History of Present Illness:
This is a 23 year old biologically female who identifies as a
male, with PMH significant for HIV (recently started [**Month/Day/Year 2775**]),
untreated Hep C, recent admission to [**Hospital1 18**] for zoster, but never
filled acyclovir script after he was discharged now presents
with fever, nausea and vomiting, dizzyness and lightheadedness.
.
The pt reports that he "can't keep anything down," and feels
like head is "being squeezed," and has a history of tension
headaches and migraines. He says this head pain "does not feel
like the usual migraine." Of note, the pt started [**Hospital1 2775**]
(Truvada, Reyataz, Norvir) on [**2197-2-21**]. The pt denies
photophobia, meningismus, endorses fever to 102 at home. He
endorses cough, sore throat, no chest pain or palpitations. He
endorses diarrhea "for a long time," nausea and vomiting for the
past two days. Labs on [**2197-2-7**] showed HIV VL: 931 cd4: 318.
.
In the ED, initial vs were: T 98.1, P 71, BP 130/79, RR 16, POx
100%.
CT head was unremarkable. Patient had an LP (opening pressure
was 15) and pt received: Ondansetron, Morphine, Acetaminophen,
Lorazepam, Dilaudid, CeftriaXONE, Ibuprofen, Acyclovir,
Vancomycin. During LP pt became more tachycardic, got morphine
as HR increased to 140. Tmax in ED was 103 with rigors. EKG at
pulse of 160 showed sinus tachycardia. On transfer to the ICU
the pt had received 4L NS, with pulse in the 130's. On exam pt
has faint rash over the left deltoid. Pt still uncomfortable,
with headache.
After arriving in the ICU the patient appeared uncomfortable and
was tachycardic and tachypnic.
Past Medical History:
-Cerebral Palsy, s/p multiple achilles tendon surgeries, no
residual deficits per patient, mild urinary retentiona at times.
-HIV (not on [**Date Range 2775**]), dx approx 2 yrs ago. Took PMTCT 1 yr ago
successfully. ([**2196-10-6**]) CD4 = 412, VL 2400
-Asthma, mild intermittent: Has received FLU vaccine [**10-10**]
-Prior Thrush due to Advair for asthma
-Hepatitis C diagnosed in [**9-6**], no IFN therapy, last Hep C VL
not detected
-s/p Appendectom [**12-7**]
-Depression: Sees Dr. [**Last Name (STitle) 57035**] at [**Hospital3 55848**] Health Center,
Prozac tapered off 1 week ago, was to begin Cymbalta per her
report.
-History of Suicide Attempts: last SA was in [**10-8**], requiring
ICU admission at [**Hospital 8**] Hospital. Pt overdosed on his
medications at that point (Prozac, Trileptal, Seroquel). Pt
-reports hx of 2 SA by OD, and 2 SA by cutting. First SA at age
13-14. Self Cutting, last circa [**2191**], self reports near fatal
cut and has stopped Anorexia/bulimia, currently with active
behaviors including restricting and purging
-PTSD - rape survivor
-ADHD - on Concerta
-OCD
-Trauma/Abuse: last time this occured that patient is willing to
acknowledge is [**1-/2194**] but will not discuss incident.
h/o + UA/UTIs
Social History:
Complicated social history. Female-to-male gender, has all
female organs, does not take hormones. Currently lives in
[**Location 17065**] with 1 yo son. Hx of crystal meth per his report
today -- states has been clean for 4 years, though past records
indicate more recent use and prior use of heroin, cocaine use.
Occasional EtOH, last drink 1 wk ago (40oz beer daily). [**12-3**] PPD
tobacco.
Family History:
Grandmother: Gallbladder issues
Aunt: Diabetes
Mother Cervical, ovarian, uterine [**Last Name (un) 3711**]
Physical Exam:
Vitals: BP: 119/69 P: 106 R: 18 O2: 97% RA
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, unable to cooperate to
assess meningismus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, otherwise 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
Skin: No evidence of vesicles, erythema or crusting. Areas on
left upper extremities that may be former vesicles, now bland
appearing with no erythema
Neuro: A+Ox3, CN II-XII intact
Motor: [**4-5**] Upper and Lower extremities
Sensation: Intact
Gait assessment deferred
Pertinent Results:
LABORATORY DATA:
Complete Blood Count:
[**2197-2-23**] 03:10PM BLOOD WBC-5.0# RBC-4.46 Hgb-11.6* Hct-35.8*
MCV-80* MCH-26.1* MCHC-32.6 RDW-12.7 Plt Ct-272
[**2197-2-24**] 03:32AM BLOOD WBC-11.8*# RBC-3.93* Hgb-9.9* Hct-30.8*
MCV-79* MCH-25.2* MCHC-32.1 RDW-12.6 Plt Ct-157
[**2197-2-25**] 08:05AM BLOOD WBC-4.6# RBC-3.92* Hgb-10.0* Hct-30.9*
MCV-79* MCH-25.5* MCHC-32.4 RDW-12.9 Plt Ct-135*
[**2197-2-26**] 08:30AM BLOOD WBC-3.3* RBC-3.98* Hgb-10.0* Hct-31.3*
MCV-79* MCH-25.2* MCHC-32.0 RDW-12.8 Plt Ct-104*
[**2197-2-27**] 07:50AM BLOOD WBC-3.4* RBC-3.98* Hgb-10.1* Hct-31.6*
MCV-79* MCH-25.2* MCHC-31.8 RDW-13.1 Plt Ct-154
[**2197-2-28**] 08:05AM BLOOD WBC-3.8* RBC-4.06* Hgb-10.6* Hct-32.2*
MCV-79* MCH-26.2* MCHC-33.1 RDW-13.0 Plt Ct-215
[**2197-3-1**] 07:40AM BLOOD WBC-4.4 RBC-4.52 Hgb-11.2* Hct-35.6*
MCV-79* MCH-24.8* MCHC-31.5 RDW-13.0 Plt Ct-252
[**2197-2-23**] 03:10PM BLOOD Neuts-69.3 Lymphs-25.9 Monos-3.3 Eos-0.6
Baso-0.9
.
Coagulation Profile:
[**2197-3-1**] 07:40AM BLOOD PT-12.5 PTT-30.1 INR(PT)-1.1
.
Basic Metabolic Profile:
[**2197-2-23**] 03:10PM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-138
K-3.4 Cl-103 HCO3-26 AnGap-12
[**2197-3-1**] 07:40AM BLOOD Glucose-89 UreaN-6 Creat-0.6 Na-139 K-3.7
Cl-103 HCO3-27 AnGap-13
[**2197-2-24**] 03:32AM BLOOD Calcium-7.5* Phos-3.8 Mg-1.3*
[**2197-3-1**] 07:40AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9
.
Liver Function Tests:
[**2197-2-23**] 03:10PM BLOOD ALT-31 AST-34 LD(LDH)-146 AlkPhos-76
TotBili-2.9* DirBili-0.4* IndBili-2.5
[**2197-2-25**] 08:05AM BLOOD ALT-21 AST-29 LD(LDH)-162 AlkPhos-67
TotBili-3.4*
.
[**2197-2-24**] 03:32AM BLOOD Hapto-143
[**2197-2-23**] 03:10PM BLOOD TSH-0.67
[**2197-2-23**] 07:05PM BLOOD Lactate-1.5
.
Urine:
[**2197-2-23**] 03:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2197-2-23**] 03:45PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2197-2-23**] 03:45PM URINE RBC-[**5-11**]* WBC-[**2-3**] Bacteri-MOD Yeast-NONE
Epi-[**5-11**]
.
MICROBIOLOGY:
[**2197-2-25**] 08:05AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
NEGATIVE
[**2197-2-25**] 08:05AM BLOOD B-GLUCAN-Test NEGATIVE
[**2197-2-24**] 10:16AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
NEGATIVE
[**2197-2-24**] 10:16AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test POSITIVE
[**2197-2-24**] 10:16AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-Test NEGATIVE
.
Blood Culture: [**2197-2-23**]: no growth to date.
.
CSF Analysis: [**2197-2-23**]:
GRAM STAIN (Final [**2197-2-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2197-2-26**]): NO GROWTH.
CRYPTOCOCCAL ANTIGEN (Final [**2197-2-24**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
CSF Viral Culture: [**2197-2-23**]: No virus isolated thus far.
.
URINE CULTURE (Final [**2197-2-25**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
.
Monospot Test: [**2197-2-24**]: MONOSPOT (Final [**2197-2-25**]): NEGATIVE by
Latex Agglutination.
.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2197-2-27**]): NEGATIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2197-2-27**]): NEGATIVE BY
EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2197-2-27**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: NO ANTIBODY DETECTED.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop 6-8 weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
.
CMV Viral Load [**2197-2-25**]: CMV DNA not detected.
.
HCV VIRAL LOAD (Final [**2197-2-27**]): 558,000 IU/mL.
.
ECG ([**2197-2-23**]): Narrow complex tachycardia which is likely sinus
tachycardia. Compared to the previous tracing of [**2194-12-31**] the
rate has increased.
.
ECG ([**2197-2-26**]): Sinus bradycardia with atrial premature beats.
Compared to the previous tracing of [**2197-2-23**] the rate has
decreased. ST-T wave changes are not seen on the current
tracing.
.
CT Head ([**2197-2-23**]): IMPRESSION: No acute intracranial process.
.
CXR ([**2197-2-23**]): IMPRESSION: No acute pulmonary process.
Brief Hospital Course:
23 year old biologically female who identifies as male gender
with a history of HIV, Hepatitis C, and recent admission for
zoster presents with fever, tachycardia and headache a few days
after initiation of [**Month/Day/Year 2775**].
.
# Headache: Presented to ED with fever, tachycardia, and mild
headache. The initial differential for headache in this patient
included viral meningitis given recent history of zoster
infection and incomplete acyclovir course, bacterial meningitis,
and reaction to [**Month/Day/Year 2775**] meds. Head CT was without acute
pathology. Patient was empirically started on vancomycin,
ceftriaxone, and acyclovir, which were discontinued after CSF
did not suggest bacterial meningitis. Acyclovir was empirically
continued due to persistent headache until CSF HSV PCR was
negative. Pain control was provided initially with IV Dilaudid
which was transitioned to PO morphine. IV caffeine and fiorocet
were both attempted without success. Due to suspicion that
worsening headache was secondary to lumbar puncture, pain
service was consulted and blood patch was placed on [**2197-3-1**] with
good effect. Patient was discharged home with short supply of
PO morphine. [**Date Range 2775**] medication was held upon admission and per
PCP, [**Name10 (NameIs) **] held at the time of discharge. PCP to have
discussions with patient in regards to her [**Name10 (NameIs) 2775**] medication.
.
# Fever: Unknown etiology, but possible secondary to to viral
syndrome, NOS. Blood, CSF and urine cultures did not yield any
organisms to date. Chest xray was unremarkable. Head CT and LP
WNL. [**Month (only) 116**] have also been a hypersensitivity reaction to [**Month (only) 2775**]
meds. Empiric antibactial antibiotics were discontinued as
fevers resolved and no clear source of infection could be
identified.
.
# Tachycardia: The patient was tachycardic on presentation.
Sinus tachycardia seen on EKG. Likely secondary to pain,
headache, or viral syndrome. Pt denied chest pain,
palpitations, shortness of breath. The patient did endorse a
fire-like pain over L UE, which may be secondary to
post-herpetic neuralgia. The patient was maintained on
telemetry overnight, given IV hydration and pain control as
above.
.
# Hyperbilirubinemia: No evidence of jaundice on exam. Mild
tenderness to palpation over abdomen on exam. LDH was normal,
and anemia was at baseline, so unlikely elevated bili due to
hemolysis. Likely due to current [**Month (only) 2775**] regimen. Possibly
secondary to [**Doctor Last Name **] Syndrome in the setting of poor PO intake.
Lactate is 1.5 which made cholangitis less likely. No further
imaging was performed.
.
# HIV: The patient was diagnosed with HIV several years ago, and
had not been on [**Doctor Last Name 2775**] until this past week. Most recent labs
showed VL: 931, CD4: 318. Given fever, tachycardia and headache,
which may all be secondary to [**Doctor Last Name 2775**] side effects, [**Doctor Last Name 2775**] was held
on admission. After discussions with PCP, [**Name10 (NameIs) 2775**] was
discontinued at the time of discharge.
.
# Hepatitis C: Never treated. Hepatology follow up is in place.
.
# History of Anorexia/Bulemia: Monitored intake and
electrolytes.
Medications on Admission:
Truvada (Emtricitabine NRTI, Tenofovir nRTI)
Reyataz (Atazanavir protease inhibitor)
Norvir (Ritonavir protease inhibitor)
Cymbalta
Adderall
Trileptal
Discharge Medications:
1. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
Disp:*15 Tablet(s)* Refills:*0*
4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Medication
Adderall - please continue taking the dose that you were
previously taking.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Viral syndrome, NOS
- Post Lumbar puncture headache
Secondary:
- Cerebral palsy
- HIV
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 because you developed a severe
headache, nausea, vomiting and fevers. We performed a lumbar
punture as we were concerned that this was due to bacterial
meningitis, however it did not appear to be the case. You were
initially started on antibiotics, but these were discontinued
after we confirmed that you did not have meningitis. Your
symptoms improved, fevers resolved and you are ready to go home.
You had a blood patch done on [**3-1**] to help relieve your
headache.
We made the following changes to your medications:
We STARTED you on Morphine 15mg every six hours as needed for
pain. Please do not drive or drink alcohol while taking this
medication. Please arrainge for assistance to care of your
child when taking this medication.
We STOPPED your medications for HIV. Please follow up with Dr.
[**Last Name (STitle) **] before resuming these medications.
Please continue to take all your other medications as
prescribed.
Please follow up with your primary care doctor as shown below.
Followup Instructions:
You have the following follow-up appointments:
Please follow up with Dr. [**First Name4 (NamePattern1) 2855**] [**Last Name (NamePattern1) **] on [**3-8**] at 2pm. His
phone number is [**Telephone/Fax (1) 43944**].
Hepatology:
Please follow up with:
Department: LIVER CENTER
When: THURSDAY [**2197-5-4**] at 9:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"349.0",
"343.9",
"300.3",
"311",
"493.90",
"284.1",
"305.1",
"079.99",
"E939.1",
"V15.41",
"302.50",
"309.81",
"277.4",
"V08",
"V13.02",
"305.01",
"314.01",
"599.0",
"070.54",
"V45.79",
"288.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.95",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
13226, 13232
|
9239, 12496
|
298, 344
|
13373, 13373
|
4634, 7539
|
14583, 14606
|
3667, 3776
|
12698, 13203
|
13253, 13352
|
12522, 12675
|
13521, 14053
|
3791, 4615
|
7572, 9216
|
14631, 15123
|
14083, 14560
|
250, 260
|
372, 1970
|
13388, 13497
|
1992, 3239
|
3255, 3651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,219
| 172,358
|
32695
|
Discharge summary
|
report
|
Admission Date: [**2191-6-2**] Discharge Date: [**2191-6-8**]
Date of Birth: [**2148-2-26**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
43F transferred from OSH with intra-abdominal abscess and fevers
s/p infected IUD removal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 yo F with no significant past medical history who was
transferred to [**Hospital1 18**] from [**Hospital1 **] on [**6-2**] for IR vs surgical
drainage of pelvic fluid collection.
Patient mentions that prior to admission starting on [**5-23**]
she had about 4 days of L hip pain. It was so severe that she
couldn't put her pants on, because it was painful to elevate
her L leg. This resolved prior to admission, and hasn't
recurred.
Approximately 3 weeks prior to admission at [**Location (un) 620**] developed
intermittent HA and low-grade fever (to 101). On [**5-26**] she saw her
PCP, [**Name10 (NameIs) 1023**] diagnosed her with an anal fissure which was
culture-positive for Group A Strep. Due to this infxn and a
clinical picture concerning for Lyme disease, doxycycline
therapy
was initiated on [**5-27**].
She subsequently presented to [**Hospital1 **]-[**Location (un) 620**] on [**5-30**] with a fever to
103.6 and a meningitis-like appearance. WBC was 14. LP attempted
in ED but unsuccessful, started on empiric
ceftriaxone/acyclovir/vancomycin/ampicillin. Repeat LP several
hours later was negative for infection; CSF glucose = 88, total
protein = 26. Her abx regimen was subsequently changed to
Pip/Tazo.
CT torso revealed malpositioned IUD w/ free fluid in pelvis and
collection in L pelvic adnexa. She was started on clindamycin on
[**6-1**]. IUD removed on [**6-2**] (had been in place for 2 years).
Abdominal MRI revealed 6 cm necrotizing LN adhering to pelvic
sidewall. Early [**6-2**] morning, Tmax 103 despite ongoing
antibiotics. She was transferred to [**Hospital1 18**] for drainage of pelvic
fluid collection.
Past Medical History:
anal fissure with + graph A strep
appendectomy
Social History:
Smokes [**11-22**] cigarettes/day. No drug abuse
Family History:
non-contributory
Physical Exam:
Gen: Young woman lying in bed, calm, NAD
Vitals: 99.1 98.7 64 100/60 16 97%RA
HEENT: NCAT OP clear
CV: rrr s1s2 no mrg
Resp: CTAB
Abd: soft ntnd bs+ no masses palpated on exam
Ext: no c/c/e
Pertinent Results:
[**2191-6-2**] 08:58PM GLUCOSE-85 UREA N-9 CREAT-0.9 SODIUM-143
POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-27 ANION GAP-11
[**2191-6-2**] 08:58PM estGFR-Using this
[**2191-6-2**] 08:58PM CALCIUM-7.8* PHOSPHATE-2.8 MAGNESIUM-2.1
[**2191-6-2**] 08:58PM WBC-4.7 RBC-3.16* HGB-9.9* HCT-29.0* MCV-92
MCH-31.4 MCHC-34.2 RDW-12.2
[**2191-6-2**] 08:58PM PLT COUNT-208
[**2191-6-2**] 08:58PM PT-14.7* PTT-31.3 INR(PT)-1.4*
[**2191-6-6**] 06:18AM BLOOD ALT-530* AST-636* AlkPhos-845*
TotBili-0.7
[**2191-6-8**] 06:02AM BLOOD ALT-328* AST-158* AlkPhos-592*
TotBili-0.5
[**2191-6-6**] 05:20PM BLOOD CRP-26.4*
[**2191-6-5**] 11:04PM BLOOD HBsAb-NEGATIVE IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
[**2191-6-3**] 04:02PM BLOOD Lactate-0.7
[**2191-6-7**] 10:10AM BLOOD Lipase-77*
[**2191-6-7**] 10:10AM BLOOD Glucose-126* UreaN-11 Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-29 AnGap-11
[**2191-6-6**] 05:20PM BLOOD ESR-80*
[**2191-6-7**] 10:10AM BLOOD Plt Ct-364
[**2191-6-7**] 10:10AM BLOOD WBC-8.6 RBC-3.40* Hgb-10.9* Hct-32.2*
MCV-95 MCH-32.0 MCHC-33.7 RDW-13.4 Plt Ct-364
[**2191-6-7**] 10:10AM BLOOD Neuts-61.6 Lymphs-30.0 Monos-3.8 Eos-3.8
Baso-0.8
Brief Hospital Course:
General Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment of her intraabdominal abscess. The
patient was transferred here on [**2191-6-2**] from [**Location (un) 620**] [**Hospital1 18**]. She
was admitted to the SICU for management. Her hospital course is
as follows:
Neuro: The patient received IV dilaudid with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: When the patient was transferred here from [**Location (un) 620**]
[**Hospital1 18**] she was on 3 L NC. vital signs were routinely monitored.
Good pulmonary toilet, early ambulation and incentive
spirrometry were encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially NPO with IV fluids. Diet
was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient was intially
started on Clindamycina and Gentamycin. The patient had blood
cultures drawn that were no growth to date, urine culture was
negative, C diff. PCR was negative, gonnococcal and chlamydia
nucleic acid probes were negative. The patient was formally
evaluated by infectious disease and was started on clindamycin
and Zosyn. Shortly after starting this antibiotic regimen the
patient became afebrile and continued to stay so for the
remainder of her stay.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 gram IV solution of
Piperacillin-tazobactam every 8 hours Disp #*176 Gram Refills:*0
2. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*28 Tablet Refills:*0
3. 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.
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
Pelvic suppurative lymphadenitis with multiple nodes containing
abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to this hospital for pelvic suppurative
lymphadenitis with multiple nodes containing abscesses
coalescing that were discovered on a CT scan at [**Location (un) 620**] [**Hospital1 18**].
You were treated with IV antibiotics and have shown improvement.
You are now ready for discharge.
Please continue your IV Zosyn until [**2191-6-21**]. At which
point you will followup with infectious disease for further
recommendations. You are to have weekly lab tests that
include:CBC with differential, BUN/Cr until you follow up with
infectious disease.
You are to resume your regular home diet, home medications, and
continue staying well hydrated at home. If your nausea is
decreasing your oral intake, you are to notify your physician.
[**Name10 (NameIs) **] at home continue taking probiotics such as yogurt products
as discussed with you.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Notify your physician if you develop fevers greater than 100.4
while at home.
Followup Instructions:
Please schedule a follow up appointment with Dr. [**First Name (STitle) 2819**] by calling
his office at the following telephone number.
Surgical Specialties
[**Street Address(2) 3001**]
[**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 2998**]
[**Hospital Unit Name 76188**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2359**]
Department: RADIOLOGY
When: MONDAY [**2191-6-13**] at 2:10 PM
With: RADIOLOGY [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital 2039**] CARE CENTER
When: MONDAY [**2191-6-13**] at 3:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 34803**], MD [**Telephone/Fax (1) 34804**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2191-6-21**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"625.4",
"305.1",
"996.59",
"E879.8",
"683",
"514",
"565.0",
"614.4",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
6710, 6766
|
3649, 6059
|
391, 398
|
6884, 6884
|
2464, 3595
|
8664, 10007
|
2221, 2239
|
6114, 6687
|
6787, 6863
|
6085, 6091
|
7035, 8641
|
2254, 2445
|
262, 353
|
426, 2068
|
6899, 7011
|
2090, 2138
|
2154, 2205
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,367
| 113,905
|
27053
|
Discharge summary
|
report
|
Admission Date: [**2165-2-3**] Discharge Date: [**2165-3-17**]
Date of Birth: [**2087-4-25**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p fall from standing
Major Surgical or Invasive Procedure:
PEG/Trach
Ex lap and liver repair for liver laceration
placement A line/central line/swan ganz
History of Present Illness:
Pt is a 77 y/o man w/ hx of CHF and hypertension who presents
from [**Hospital 1474**] hospital after falling from standing. Pt reports
that he hit his head, his rt elbow and the right side of his
abdomen. He says he was getting up out of bed when he fell. He
does not remember anything else about the fall. At the OSH, pt
denied LOC. He complained of mid back pain ([**4-8**]). His vitals on
presentation to OSH were 97.7 152/74 100 18 97%RA. Pt was pale,
alert and oriented. Hct was found to be low at 35.8, with MCV of
90.7 and RDW of 19.5. Platelets were low at 65. WBC was normal
at 7.5. Found to have SDH, transported to [**Hospital1 18**] for further
managment.
During transport, pt was slow to respond to questions. Pt had
sinus tachcardia and complained of [**4-8**] HA. He began to require
O2 and was 100% on 4L.
In the [**Name (NI) **], pt received Thiamine HCl 100mg/mL-2mL, Multivitamin
IV 10mL Vial, Folic Acid 1mg/0.2mL Syringe, Morphine Sulfate 2mg
Syringe, Furosemide 40mg/4mL Vial.
Pt is able to ambulate at baseline, but he reports that he does
not ambulate very frequently. He sometimes uses a wheelchair.
Pt reports that he has had palpitations in the past. He does not
recall getting dizzy when he stood up, however, pt's son reports
that he often does complain of dizziness when he stands up. Per
son, pt has never blacked out before. He has never had an MI.
At baseline pt reports that he has some swelling in his legs. Pt
reports that the swelling he has now is worse than usual but is
unable to say when it got worse. [**Name (NI) 1094**] son reports that the
swelling has been coming and going for years.
Pt reports that he has a cough which is new. His cough is not
productive. He denies fevers or chills. At home, never has
required O2 but now has new O2 requirement. [**Name (NI) 1094**] son reports
that he has been more tired than usual this past week. Pt has a
history of recurrent PNA.
Pt complains of headache, and low back pain. Back pain is not
new for him, but it is worse after his fall.
In the [**Name (NI) **] pt was complaining of neck pain when c-spine collar
was removed.
Pt denies SOB, chest pain, N or V.
Past Medical History:
- CHF - first diagnosed in '[**55**], Echo in [**2158**] w/ EF of 45-50%,
Echo in [**10-3**] w/EF of 60%, no WMA
- COPD - FEV1 of 0.6 L, never intubated per outside records
- Recurrent PNA - last in [**11-3**]
- Htn
- GERD
- Chronic low back pain - for many years, ?osteoarthritis
- Cancer?
- ?infected gallbladder - s/p percutaneous drainage in [**2164-10-9**],
cx grew klebsiella
- Gout
- Rheumatic fever - Echo in [**10-3**] shows nl Aortic, mitral and
tricuspid valves, trace MR, moderate TR
- Renal insufficiency with ACE inhibitor in [**10-3**], now resolved
.
Social History:
Pt lives on his own. Reports that he cares for himself, but has
3 sons who live near by.
Tob - smokes for 61 years, ? ppd, ?stopped in [**2-3**]
EtoH - denies, outside records indicate EtoH use in [**10-3**]
Family History:
5 brothers, one died, 3 healthy, not in contact with last
brother, denies heart disease and DM, 3 sons healthy
.
Physical Exam:
Vitals - T99.2 BP 156/60 HR 84 RR 16 SaO2 98% on 3L
General - pale, thin, man, lying flat on a stretcher with neck
in c-spine collar, NAD
HEENT
Eyes - conjunctiva erythematous R>L, pupils 2mm, sluggish
response, but equal, unable to test for EOM but no gross
abnormalities noted
Ears - decreased hearing especially in left ear, TMs obscurred
due to wax
Throat - red, slightly swollen tongue, dry MM, lips cracked
Neck - Unable to assess due to c-collar
Chest - speaks in full sentences, no use of accessory muscles,
anertior lung exam w/ decreased breath sounds at apices
bilaterally, otherwise good air movement, few crackles at both
bases, no wheezes
CV - RRR, nl S1 and S2 with III/VI systolic murmur best heard at
the LLSB
Abd - +BS, soft, non-distended, moderately tender to palpation
in RUQ and rt flank, no rebound or guarding, negative [**Doctor Last Name 515**]
Rectal - per ED, guiaic neg, nl tone
Extrem - rt elbow with lac and swollen, able to move normally,
2+ pitting edema bilat up to high calf, cool feet, poor distal
pulses, tender to palpation
Neuro
CN II - unable to assess
CN III, IV, VI - poor cooperation with tests of EOM, but pt
moves eyes in all directions when not instructed to
CN V - reports normal facial sensation bilat
CN VII - moves face normally
CN VIII - decreased hearing in both ears L>R
CN IX, X - gag not assessed
CN XII - tongue midline
Strength - pt reports that he "can't" lift legs off of bed, but
reports that he usualluy walks a bit at home
Sensation - reports nl sensation to light touch and vibration in
LE bilat
Reflexes - 2+ in biceps, brachioradialis, patellar reflexes
bilat, Babinski equivical
Skin - dry and flaky thoughout, worst on feet, nails extremely
long and thinkened, erosions on shins bilat
Mental status - AAOx3, pt able to answer questions when can hear
questions and wants to answer, non-cooperative with history and
physical exam
Pertinent Results:
[**2165-2-3**] 08:55AM WBC-6.9 RBC-3.21* HGB-9.1* HCT-29.5* MCV-92
MCH-28.3 MCHC-30.8* RDW-19.5*
[**2165-2-3**] 08:55AM NEUTS-69 BANDS-0 LYMPHS-14* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-5* NUC RBCS-1*
[**2165-2-3**] 08:55AM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL
TEARDROP-OCCASIONAL
[**2165-2-3**] 08:55AM PLT SMR-LOW PLT COUNT-89*
[**2165-2-3**] 08:55AM PT-13.6* PTT-25.7 INR(PT)-1.2*
[**2165-2-3**] 08:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-2-3**] 08:55AM HAPTOGLOB-323*
[**2165-2-3**] 08:55AM ALBUMIN-2.8*
[**2165-2-3**] 08:55AM CK-MB-5 proBNP-5930*
[**2165-2-3**] 08:55AM cTropnT-0.03*
[**2165-2-3**] 08:55AM LIPASE-13
[**2165-2-3**] 08:55AM GLUCOSE-99 UREA N-22* CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19
[**2165-2-3**] 05:33PM calTIBC-174* VIT B12-GREATER TH FOLATE-11.0
FERRITIN-1428* TRF-134*
[**2165-2-3**] 05:33PM IRON-19*
[**2165-2-3**] 05:33PM CK-MB-5 cTropnT-0.02*
[**2165-2-3**] 05:33PM LD(LDH)-322* CK(CPK)-183*
Brief Hospital Course:
A/P 77 y/o M w/ hx of CHF and htn, who presented to OSH after
fall from standing. Unclear if fall due to trip and fall or
other cause, as pt has no recollection of event. At OSH pt was
found to have subdural hematoma and was transferred to the [**Hospital1 **]
for further management.
On admission pt was sent to the MICU. Neurosurgery and spine
consults were obtained for recommendations regarding the
patients subdural hematoma and L1/L5 compression fractures. The
patient remained in a ccollar and on logroll precautions until
such time that spine service cleared the cspine and provided a
TLSO brace for getting out of bed. Neurosurgery followed until
the subdural was proven stable. The medical service also worked
the patient up for possible causes of syncope, none which were
proven. Not long into the patient's stay he aspirated chicken
and rice subsequently developing pneumonia requiring intubation.
His respiratory condition worsened to ARDS. He was empirically
treated with vanc, zosyn, levoflox although no clear
microorganism grew from his sputum even with good sputum samples
obtained with bronchoscopy. Pt also developed septic shock
requiring pressors to maintain blood pressure. Meanwhile, it
was noted that the patient had a R elbow laceration with leaking
bursa. The ortho service noted that the wound was not infected
and could be adequately managed with wet to dry dressings.
Also, while on the MICU service the patient suffered from anemia
and thrombocytopenia as well as mild adrenal insufficiency. Pt
was given steroids. A HIT panel was sent and returned negative.
To maintain nutritional support the pt was placed on tube
feeds. The patient also required other typical ICU
interventions for CHF, hypernatremia, hypokalemia,
hypomagnesemia. Pt was maintained on pneumoboots and heparin SQ
for DVT prophylaxis as well as protonix for GI prophylaxis.
On the [**2-20**] the patient underwent PEG and trach
placement. This unfortunately was complicated by a liver
laceration causing acute blood loss anemia and requiring
exploratory laparotomy and liver repair. The PEG was exchanged
for a GJ tube.
Post operatively the patient was transferred to the surgical
trauma service. The patient required extensive volume and blood
resussitation but did recover better than expected from this
acute event. Subsequently on the surgical trauma service, the
patient again developed septic shock from a pseudomonas,
enterobacter, and staph pneumonia with difficult sensitivity
spectrums. This continues to be treated with
Vanc/Cefepime/Zosyn/Flagyl. The patient did finally wean off
pressors successfully. The patient was also worked up for CDiff
which was negative, all line tips have been negative, and urine
has been free of bacteria. The patient did again develop
thrombocytopenia. HIT panel was now positive. All heparin
products were d/c'd, and the patient was changed to fondaparinux
for dvt prophylaxis. The patient was given cardioprotective
lopressor when tolerated. Vent weaning has been particularly
slow and diuresis particularly difficult. The patient has had
mild renal failure associated with over diuresis. Tube feeds
have been restarted and are tolerated well. The J port is used,
and the G port is clamped. Podiatry has seen the patient for
foot care. The patient has also developed a R forearm
thrombophlebitis which is improving. Due to assymmetric
swelling a dvt study was performed to r/o RUE dvt. Pt did
develop atrial fibrillation/flutter which required
cardioversion. By the time of d/c the patient has cleared
mentally only enough to track/aknowledge our presence at times,
moves 4 ext minimally, and rarely follows commands.
Interval summary completion: Before being able to be discharged
to rehab, Mr [**Known lastname 22933**] developed another episode of sepsis. He
was pancultured, with a persistent psuedomonal pneumonia. He
also developed a large sacral decubitis ulcer, which showed
significant epidermal sloughing given his markedly edematous
subcutaneous tissues. Because of constant stooling, this ulcer
became secondarily infected. He developed a septic shock
recalcitrant to broad spectrum antibiotics, pressors,
bicarbonate and steroids. He was made DNR by his health care
proxy on [**3-16**], and ultimately succumbed to his disease on [**3-17**].
Medications on Admission:
- Hydrocodone
- Lasix 20mg
- Protonix 40mg
- Lopressor 25mg
- Temozepam
- ?Nebulizer - has received Advair, Tiotropium, Duoneb,
albuterol in the past
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Subdural hemorrhage
L1/5 compression fractures
CHF
ARDS
Liver laceration
Pseudomonas and Enterobacter and Staph aureus pneumonias
HIT+
Thrombophlebitis
R olecranon bursa rupture/ulcer
Blood loss anemia
Metabolic alkylosis
Septic shock
Hyperglycemia
Hypokalemia
Hypomagnesemia
Atrial fibrillation/flutter
Hypernatremia
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
]
] |
11209, 11288
|
6637, 10980
|
297, 394
|
11650, 11660
|
5453, 6614
|
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3406, 3521
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11309, 11629
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11006, 11158
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11684, 11689
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3536, 5434
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234, 259
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422, 2574
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2596, 3164
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3180, 3390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,564
| 101,945
|
39583
|
Discharge summary
|
report
|
Admission Date: [**2119-8-3**] Discharge Date: [**2119-9-1**]
Date of Birth: [**2057-11-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Prochlorperazine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst headache of Life [**Last Name (un) **] eating dinner
Major Surgical or Invasive Procedure:
[**8-4**]: Cerebral angiogram with coiling of ACOMM Artery Aneurysm
[**8-8**]: Cerebral angiogram with intra-arterial verapamil
[**8-9**]: Cerebral angiogram with intra-arterial verapamil &
nicardipine
[**8-21**]: Trach and PEG
[**8-22**]: Cerebral angiogram with additional coiling of ACOMM
History of Present Illness:
61yoF, previously healthy, now transferred from [**Hospital6 10443**] with reported "worst headache of her life," found to
have diffuse subarachnoid hemorrhage and left ACOM aneurysm.
Reportedly, she was eating dinner at approximately 5:30pm when
she complained of a severe headache, suddenly became somnolent
and aphasic in association with acute onset of L-sided
hemiparesis. No trauma or h/o previous symptoms. She reportedly
proceeded to collapse and was brought to [**Hospital6 5016**],
where she became intubated for airway protection after witnessed
emesis. She received fentanyl and versed for sedation; no
anti-epileptics were given. Reportedly she did not follow any
commands and was observed to have decorticate posturing, left
upper extremity and withdrawal to painful stimuli, lower
extremities bilateral. At the OSH, she underwent a head CT which
revealed a large, diffuse SAH and was subsequently Medflighted
to
[**Hospital1 18**] for neurosurgical management.
Past Medical History:
Osteoporosis
Social History:
Married, works as a hair dresser, three children
Family History:
NC
Physical Exam:
O: T: 98.0 BP:114/68 HR: 79 R: 15 O2Sats: 100% on vent
Gen: NAD, intubated, sedated
HEENT: Pupils: 3->2mm bilaterally, reactive
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated and sedated on arrival; does not follow
commands.
Orientation: n/a
Recall: n/a
Language: n/a
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm b/l
III, IV, VI: not done
V, VII: not done
VIII: +gag
IX, X: not done
[**Doctor First Name 81**]: not done
XII: not done
Motor: decorticate posturing left upper extremity; unresponsive
right upper extremity; withdrawal to painful stimuli lower
extremities, bilaterally
Toes downgoing bilaterally
Upon discharge:
Alert, does say some simple words, makes eye contact, smiles
occasionally. Shows some slight finger movements to LUE.
Withdraws to noxious with BLE. Localizes with RUE. PERRL.
Pertinent Results:
[**2119-8-3**] CTA head: IMPRESSION: Recently ruptured left anterior
communicating artery aneurysm with extensive subarachnoid
hemorrhage and intraventricular extension. No evidence of
vasospasm, no other aneurysms.
[**8-4**] CT head: IMPRESSION:
1. New right frontal-approach ventriculostomy catheter
terminating in the
third ventricle.
2. Slight decrease in size of right lateral ventricle, with
bowing of the
septum pellucidum into the right lateral ventricle and unchanged
or slightly enlarged left lateral ventricle.
3. No increase in extensive subarachnoid blood.
[**8-7**] Head CT: IMPRESSION: 1. Stable size of the ventricular
system with right frontal approach ventriculostomy catheter
stably terminating in the third ventricle. 2. Stable extensive
subarachnoid hemorrhage. 3. Interval introduction of
pneumocephalus seen within the right greater than left frontal
horns and the right temporal ventricular [**Doctor Last Name 534**]. NOTE ADDED AT
ATTENDING REVIEW: The patient is now status post coiling of an
anterior cerebral artery aneurysm. There is no evidence of new
hemorrhage. The left lateral ventricle is smaller than on the
study of [**2119-8-4**]. The right frtonal [**Doctor Last Name 534**] is larger. There is a
small focus of hypodensity in the right frontal lobe, adjacent
to the hematoma and coil, new since the study of [**2119-8-4**], and
likely reflecting infarction.
[**8-8**] Head CT:IMPRESSION: 1. Unchanged appearance of subarachnoid
hemorrhage, left frontal hematoma and right frontal infarct.
2. Small amount of subdural hemorrhage along the falx
posteriorly to the
left, potentially related to the decompression from the
ventriculostomy
placement.
[**8-9**] Echo: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thicknesses and cavity size are
normal. There is severe global left ventricular hypokinesis
(LVEF = 20 %). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with severe global hypokinesis c/w diffuse process
(toxin, metabolic, etc. Multivessel CAD less likely, but cannot
be fully excluded). Pulmonary artery systolic hypertension. Mild
mitral regurgitation.
[**8-11**]: Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the findings of the prior study (images reviewed) of [**2119-8-9**], the left ventricular ejection fraction is
higher.
[**8-13**]: head CT: IMPRESSION: 1. No evidence of increase in
subarachnoid hemorrhage. Previously noted subarachnoid
hemorrhage is slightly evolved in the interval. 2. Normal
ventricular size with the drain extending to the third
ventricle. 3. Coiling in the region of anterior communicating
artery with an adjacent hypodensity as before.
[**8-7**]- pending EEG :
This EEG telemetry from [**Date range (1) 87361**] showed persistent sleep
or medication-related patterns with no major change in frequency
or
voltage over the time of the recording. There were no
epileptiform
features.
[**8-14**] EEG
This monitoring of cerebral function from [**Date range (1) 10831**]/[**2118**]
showed a profoundly suppressed background at the beginning and
throughout the recording. There was no major asymmetry in
background
voltages. There were no epileptiform features or electrographic
seizures.
[**2119-8-15**] CTA head
1. Multifocal narrowing in the proximal course of the anterior
cerebral
arteries bilaterally adjacent to the anterior communicating
artery coiling
suggestive of vasospasm. The remaining intracranial vasculature
appears
unremarkable.
2. Stable subarachnoid hemorrhage.
3. Air-fluid levels in the paranasal sinuses.
4. There is again artifact seen from the prior coiling in the
region of the anterior communicating artery. There is stable
appearance to the surrounding hypodensity, ischemic changes
cannot be completely excluded, please correlate clinicallly.
[**2119-8-16**] EEG
This monitoring of cerebral function from [**Date range (1) 61726**]/[**2118**]
showed a profoundly suppressed background throughout the
recording.
There was no major asymmetry in background voltages. There were
no
epileptiform features or electrographic seizures.
[**2119-8-18**] EEG
This EEG telemetry showed a slow and low voltage background
throughout. This indicates a widespread encephalopathy. The
record
appeared unchanged from earlier recordings in the last several
days.
There were no epileptiform features or electrographic seizures.
[**2119-8-19**] CT head
Overall unchanged appearance of the ventricles. Other findings
as described above.
[**2119-8-20**] CT head
1. Status post removal of an external ventricular drain, without
evidence of hemorrhage in the tube tract.
2. Stable changed appearance of the ventricles. No new
intracranial
hemorrhage
[**2119-8-22**]: CT head
1. Slight enlargement of the third ventricle since [**2119-8-19**].
Close follow-up is recommended.
2. Persistent scattered foci of subarachnoid hemorrhage along
the cerebral
convexities with no evidence of new intracranial hemorrhage.
[**2119-8-28**] MRI BRAIN:
IMPRESSION:
1. Multiple acute infarcts in the watershed territory between
the right
anterior cerebral and middle cerebral arteries.
2. Chronic blood products in the anterior interhemispheric
fissure, within
the sulci of both hemispheres, and in the occipital horns of the
lateral
ventricles.
3. Apparent arachnoid cyst in the left medial cranial fossa.
Review of prior studies suggests that there was prior hemorrhage
into this lesion.
[**2119-8-29**] UE Doppler:
Occlusive thrombus seen within the left basilic vein. No DVT
seen in the remainder of the veins of the left arm.
ECG [**2119-8-30**]:
Sinus rhythm and frequent atrial ectopy in a trigeminal pattern.
Compared to the previous tracing of [**2119-8-24**] no diagnostic
interim change.
Brief Hospital Course:
Ms. [**Known lastname 87362**] was admitted from the Emergency room to the
Surgical ICU. She remained intubated for airway protection. An
external ventricular drain was placed for hydrocephalus and
shortly thereafter her exam improved tremendously to the point
that she became arrousable and was following all comands and
moving all four extremities.
She was taken to Angio on [**8-4**] where she was found to have and
left ACOMM artery aneurysm. This was succesfully coiled without
complication but will require further coiling with a stent in
the near future. Post procedure she was transferred to the SICU
for close neurological monitoring including q1 neurochecks and
strict blood pressure control to less than 140 systolic. Pt was
extubated without difficulty following her procedure.
On [**8-5**] her neurological exam was good therefore [**Month/Year (2) 5041**] was raised
to 20. Continuous EEG monitoring was initiated per vasospasm
protocol. Her neurological exam remained stable.
On [**8-6**] [**Month/Year (2) 5041**] was clamped and she was started on SQH for DVT
prophylaxsis. Pt noted to have increase heart rate into 150's
and EKG showed atrial fibrilation. She was treated with
lopressor 5mg IV x2 with good resolution. Cardiac enzymes were
cycled and they were negative.
[**8-7**] Pt [**Name (NI) 5041**] opened overnight as she had increased ICP's while
clamped. The drain was left at 20cm above the tragus and she had
no further episodes of increased ICP. Her episodes of atrial
fibrilation did resolve and she had no further tachycardia and
no further treatment. She was febrile on this day and blood,
urine, sputum and CSF cultures were sent.
[**8-8**] Upon examination she was noted to be more lethargic and
oriented only to her self and not year or location. She was also
not following commands with her lower extremities and not moving
them spontaneously. A stat head ct showed no change from prior
exam and no hydrocephalus or infarct. She was taken to the neuro
interventional suite for cerebral angiogram. She did receive
intra-arterial verapmil to the left ICA for treatment of her
vasospasm. Her SBP goal was increased to 140-160 and this did
improve her mental status somewhat and she was following
commands with all extremities and oriented to year.
On [**8-9**] The patient developed garbled speech and disorientation.
She was again taken to angio and received verapamil and
nicardipine for vasospasm. It was also noticed that there was
coil migration into the parent artery. While in angio the
patient became tachycardic and developed pulmonary edema
requiring intubation. She progressed to cardiogenic shock and
cardiology was consulted for assistance with managment and
possible balloon pump. Over the next 24 hours the patient was
very unstable requiring 3 pressors (max dose), esmolol and
milrinone. The patient developed multiple arrythmias requiring
cardioversion. She was then paralyzed and heavily sedated.
[**Date range (1) 87363**] The patient remained paralyzed with pressors and
medical management. On [**8-12**] a Head CT was performed and stable.
On [**8-13**] head CT was again stable. paralytics were discontinued
and pressors were weaned.
On [**8-14**] Pt was only requiring 1 pressor. neurological exam was
hindered by sedation. LFT's were very high and elevated INR is
suspected secondary to the liver failure. It was decided at this
time not to reverse the INR.
On [**8-15**] Overnight, patient had an episode of seizure like
activity of the lower extremities. Continous EEG revealed
********
exam still hindered. CSF was sent due to longevity of [**Month/Year (2) 5041**]
catheter.
On [**8-19**] [**Month/Year (2) 5041**] was discontinued and a final set of CSF was sent
after a successful clamping trial.
[**8-21**]: Bedside trach and Peg without complication. [**8-22**] Patient
went back to the angio suite for coiling of the remainder
portion of the ACOMM aneurysm. We consulted infectious disease
for persistant fevers and nephrology for persistant respiratory
alkalosis.
On [**8-22**] she underwent a complete coiling of Acom aneurysm. She
was on a heparin drip. [**8-23**] the heparin gtt was discontinued and
the antibiotics were discontinued on [**8-24**] although she was still
febrile. The thought was that her fever was possibly related to
the Keppra.
On [**8-26**] her nimodipine was discontinued, as she was past day 21.
A rash was noted on her bilateral UE and chest. No known source
was identified. Benadryl/Sarna lotion was initiated.
on [**8-29**] patient was started on a heparin drip for stroke and a
right upper extremity DVT. Coumadin was started on [**8-30**].
Dermatology was consulted who recommended Hydrocortisone cream
which was started on [**8-30**].
On [**8-30**] she was noted to have some telemetry changes and cardiac
enzymes were done which showed a Troponin of 0.02 which repeat
Troponin was 0.08 then trended down [**Date range (1) 43500**]. ECG was
unchanged. Coumadin was started for a goal INR of [**12-27**].5.
[**8-31**] Coumadin was increased, Heparin gtt continued, PTT within
range, INR not within goal. Speech eval done and PMV placed.
[**9-1**] INR not within range. UA shows + UTI. Cipro started.
Heparin gtt continued. Rehab bed offered and accepted. Patient
was discharged.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 325 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
2. aspirin 325 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
3. camphor-menthol 0.5-0.5 % Lotion [**Month/Day (4) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for rash/itch.
4. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Hospital1 **]: 1350 (1350) units/hr Intravenous ASDIR (AS
DIRECTED): PTT 60-80
Keep until INR goal obtained. Check PTT Q 6hrs.
5. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
6. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Hospital1 **]: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for CA <
8.4.
8. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Hospital1 **]: One (1)
PO DAILY (Daily).
9. ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
10. warfarin 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4
PM: GOAL INR 2-2.5.
11. cortisone 1 % Cream [**Hospital1 **]: One (1) Appl Topical QID (4 times a
day) as needed for Rash.
12. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3
times a day).
15. sodium chloride 1 gram Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
16. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q
8H (Every 8 Hours).
17. 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.
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Subarachnoid Hemorrhage
Respiratory Failure
Cardiac arrythmias
Myocardial infarction
Pulmonary edema
Protien/Calorie malnutrition
Coma
Hydrocephalus-transient
Drug rash
Anemia requiring transfusion
DYSPHAGIA
LEFT HEMIPARESIE
UTI
Discharge Condition:
Level of Consciousness: Alert but not interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
- Continue with medications as prescribed.
- Continue with a bowel regimen.
- There is no activity restrictions. [**Month (only) 116**] advance activity as
tolerated.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2102**] 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 follow-up with Cardiology within 2 weeks. Please call
([**Telephone/Fax (1) 2037**] to make this appointment.
Completed by:[**2119-9-1**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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16873, 16920
|
9307, 14604
|
371, 665
|
17193, 17314
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2776, 3004
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17529, 18013
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1789, 1793
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14659, 16850
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16941, 17172
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14630, 14636
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17338, 17506
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1808, 2060
|
273, 333
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2580, 2757
|
693, 1671
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2195, 2564
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3013, 3359
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5904, 9284
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2075, 2179
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1693, 1707
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1723, 1773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,853
| 179,542
|
54967
|
Discharge summary
|
report
|
Admission Date: [**2185-8-4**] Discharge Date: [**2185-8-17**]
Date of Birth: [**2100-6-22**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
unresponsiveness, L sided weakness
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
Mr. [**Known lastname 112244**] is a 85-year-old right-handed man presenting with
Intracerebral hemorrhage on a background of dementia, congestive
heart failure, renal failure, prior pneumonia, prior "stroke"
(not worked-up).
He was asleep when his daughter arrived. [**Name2 (NI) **] refused to get up
for
breakfast at about 7:30 AM - this sometimes happens. He said
goodbye to his other daughter. [**Name (NI) **] then got up around 10 or 10:30
AM, walking to the bathroom without his walker. At 11 AM he was
back in bed and told his daughter to go away, he wanted to sleep
- again normal for him. At about 11:30 his daughter tried to
move
him, noted that he wasn't moving his left side and was drooling.
He was dysarthric, but able to speak and understand. 911 was
called and they were taken to [**Hospital3 **], but there was no
neurologist, per the patient's family. Head CT was performed
showing a large hemorrhage. He was intubated and transferred to
[**Hospital1 18**].
He just saw his Cardiologist and his blood pressure and
otherwise
stable - they were asked to come back in six months. Dementia
had
been diagnosed by PCP, [**Name10 (NameIs) **] an admission at [**Hospital3 **] for
pneumonia also resulted in a daignosis of Alzheimer's disease.
He
also had an AMI while there (6/[**2184**]). He has otherwise been
well,
but is eating poorly - he doesn't get out of bed as much and
seems less interested - but has eaten well for the last two
weeks.
Review of systems was negative except as above, per family. ROS
with patient limited.
Past Medical History:
- Coronary artery disease
- Dementia, provisionally Alzheimer's type
- Pneumonia
- 'TIA' - about five to six months ago, not worked up in full,
but seems to have been TIA - fluent aphasia without other
features, recovered over a few minutes.
- Congestive heart disease, likely post-infarctive and in the
setting of prerenal state and pneumonia, AMI
- Hypertension
- Hyperlipidemia
- No prior surgery
Social History:
Smoking: Smoked in youth, per daughter.
Alcohol: None.
Drugs: No.
Living Situation: Lives with daughter.
Education and Language: English.
Functional Baseline: Able to feed self, dress, and toilet
indpendently. Dependent for other ADL's.
Other: Retired mail handler.
Family History:
Mother had diabetes. Father unknown. Sibling with alcoholism.
Physical Exam:
Physical Exam on Admission:
Vitals: T afebrile F; HR 52 BPM; BP 152/64 (had been SBP ~ 100)
mmHg; O2Sat 100 % CMV 18 x 450, FiO2 0.5
General Appearance: Leaning to left, little spontaneous
movement,
but awake.
HEENT: NC, ETT in place.
Neck: Supple but reduced ROM.
Lungs: Clear within limits of exam, vent sounds.
Cardiac: Bradycardic regular. Normal S1/S2.
Abdominal: Soft, NT, BS+.
Extremities: No edema, cool (particularly right), delayed
capillary refill and trophic changes in feet.
Neurologic Examination:
Mental status:
Awake and attentive to events in room. Appropriate head shake or
nod to simple questions. Only mild behavioral discomfort given
ETT despite sedation being off. Tends to pay more attention to
right.
Cranial Nerves:
I: Not tested.
II: Pupils symmetric, round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation on right,
not left.
III, IV, VI: Extraocular movements conjugate and without
nystagmus, difficult to get over to left.
V, VII: Jaw midline, facial droop on left.
VIII: Hearing intact to voice.
IX, X: Not examinable.
[**Doctor First Name 81**]: Not examinable.
XII: Not examinable.
Tone and Bulk:
Tone is increased in legs, right arm flaccid.
Power:
Dense paresis of left arm, left leg moves to noxious stimulation
of foot.
Reflexes:
B T Br Pa Ac
R 2 1 2 0 0
L 3 2 2 1 0
Toes upgoing bilaterally.
Sensation:
Withdraws and increased arousal to painful stimulus to right,
withdraws on right (foot, not hand).
Coordination and Cerebellar Function:
Not tested.
Gait:
Not tested.
*****************
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2185-8-4**] 04:40PM TYPE-ART RATES-/16 TIDAL VOL-450 O2-100
PO2-412* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 AADO2-259 REQ
O2-51 INTUBATED-INTUBATED
[**2185-8-4**] 05:03PM GLUCOSE-147* LACTATE-2.0 NA+-136 K+-4.4
CL--102 TCO2-21
[**2185-8-4**] 05:04PM FIBRINOGE-263
[**2185-8-4**] 05:04PM PT-10.6 PTT-28.3 INR(PT)-1.0
[**2185-8-4**] 05:04PM PLT COUNT-205
[**2185-8-4**] 05:04PM WBC-8.8 RBC-4.04* HGB-12.8* HCT-38.3* MCV-95
MCH-31.7 MCHC-33.5 RDW-13.1
[**2185-8-4**] 05:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-8-4**] 05:04PM TSH-1.6
[**2185-8-4**] 05:04PM TRIGLYCER-149 HDL CHOL-42 CHOL/HDL-2.7
LDL(CALC)-41
[**2185-8-4**] 05:04PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-2.1
CHOLEST-113
[**2185-8-4**] 05:04PM CK-MB-2 cTropnT-<0.01
[**2185-8-4**] 05:04PM LIPASE-43
[**2185-8-4**] 05:04PM estGFR-Using this
[**2185-8-4**] 05:04PM UREA N-19 CREAT-1.7*
[**2185-8-4**] 05:15PM URINE HYALINE-1*
[**2185-8-4**] 05:15PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2185-8-4**] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2185-8-4**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2185-8-4**] 05:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CT head [**8-4**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage involving mainly the right
frontoparietal region with intraventricular extension, no
significant change. Mass effect on the right lateral ventricle
and unchanged midline shift to the left.
2. New increase in size of right temporal [**Doctor Last Name 534**] of the lateral
ventricle
likely due to trapping.
3. Stable subarachnoid blood in the right sylvian fissure and
new
subarachnoid blood now seen in the left temporal region.
Brief Hospital Course:
85-year-old right-handed man with a hx of dementia, CHF, renal
failure, prior stroke who was found unresponsive at home. CT
head revealed large right lobar intraparenchymal hemorrhage with
mass effect and intraventricular extension. He was admitted to
the neuro ICU initially for close monitoring, then was later
made CMO.
Neuro:
He was monitored closely with Q1hr neuro checks overnight. He
was started on a nicardipine drip for BP control with a goal <
160. Aspirin and anticoagulants were held. Neurosurgery was
consulted and declined acute surgical intervention. Per
discussion with his daughters he was made DNR/DNI and was
extubated on [**8-5**]. Palliative care was consulted and after
further discussion he was made CMO. He was put on a morphine gtt
and PRN ativan. He was transferred to the floor under inpatient
hospice. Due to continued discomfort/agitation he was
transitioned to a dilaudid drip on [**8-16**] and ativan was increased.
He passed away peacefully at 12:40am on [**2185-8-17**]. Daughters were
at the bedside and declined autopsy.
Cardiovascular:
He was maintained on telemetry monitoring. BP was monitored
closely and controlled with nicardipine and metoprolol as above
while in the ICU, but once made CMO his cardiac meds were
withdrawn.
PENDING LABS:
None
TRANSTIONAL CARE ISSUES: None, pt expired on [**2185-8-17**].
Medications on Admission:
- Aricept 2.5 mg PO QD
- Metoprolol succinate 50 mg PO QD
- ASA 325 mg PO QD
- Remeron 15 mg PO QHS
- Lipitor 40 mg PO QHS
- Trazodone 12.5 mg PO QHS
- Vitamin D
- Namenda 10 mg PO BID
- Celexa 10 mg PO QD
- Eye drops
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right lobar intraparenchymal hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname **] was admitted to [**Hospital1 69**]
on [**2185-8-4**] after he was found unresponsive at home. A CT
scan of his head showed a large bleed in the right side of his
brain. A breathing tube was placed and he was admitted to the
neuro ICU. After discussion with his family the decision was
made to remove the breathing tube the next day and not to pursue
any further aggressive interventions. Palliative care was
consulted and per his family's wishes he was made CMO on [**8-5**].
He was started on a morphine drip and transferred out of the ICU
to inpatient hospice care. He passed away peacefully at 12:40am
on [**2185-8-17**].
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"412",
"294.10",
"V15.82",
"272.4",
"V12.54",
"331.0",
"437.9",
"342.92",
"V49.86",
"277.39",
"414.01",
"585.9",
"403.90",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7921, 7930
|
6272, 7624
|
338, 361
|
8014, 8024
|
4382, 6249
|
8723, 8822
|
2660, 2723
|
7892, 7898
|
7951, 7993
|
7650, 7869
|
8048, 8700
|
2738, 2752
|
4354, 4363
|
264, 300
|
389, 1938
|
3483, 4326
|
2766, 3228
|
3268, 3467
|
3253, 3253
|
1960, 2361
|
2377, 2644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,428
| 130,408
|
30108+57677
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-2-27**] Discharge Date: [**2112-3-10**]
Date of Birth: [**2048-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Anuria
Major Surgical or Invasive Procedure:
[**2-27**] Emergent Replacement of ascending aorta and hemiarch (22 mm
gelweave)/resuspension of aortic valve.
History of Present Illness:
63 yo M with no significant PMHx who presents from [**Hospital3 **] as a transfer. Patient was found to have new onset
renal failure, with creatinine 5.8. Patient initially presented
to OSH ED after developing acute onset sharp chest and back pain
while sitting in a chair while on the computer. He noted that
with this onset of acute pain, he also developed anuria and
diffuse weakness and myalgias. He states that the pain persisted
for several hours, and he was concerned that he had an MI, and
presented to an OSH, where he was diagnosed with pneumonia and
stomach "gas bubble" and treated with ciprofloxacin and
metaclopromide. His symptoms failed to improve, and he then
presented to his urologist, who transferred him to the ED to be
seen. In the ED, patient was noted to have acute renal failure
and markedly elevated LFTs. He denies fever, chills, weight
loss, headache, vision changes, SOB, abdominal pain, flank
tenderness, dysuria, hematuria, urinary frequency. He has not
traveled recently, and denies any recent sexual exposures, blood
transfusions, IVDU, or new medications other than above.
Pt admitted to MICU, a subsequent CT scan showed Aortic
dissection and the patient underwent an emergent repair
Past Medical History:
borderline HTN
Social History:
+ alcohol use. Denies illicit drug use or tobacco. Lives at home
alone. Unemployed but has worked in past as a taxi driver.
Family History:
NC
Family history of DVT's and PE's
Physical Exam:
Admission
VS: 99.1 HR 94 BP 127/55 RR 12 O2sat 95% RA
Gen: well appearing in NAD.
HEENT: Sclera anicteric. MMM. No oral ulcers or lesions. Neck
supple.
Hrt: RRR. No MRG
Lungs: CTAB no RRW
Abd: Soft. Obese. No organomegaly. Normoactive bowel sounds.
Back: No CVAT. Foley draining clear yellow urine. No penile
lesions.
Ext: WWP. No CCE.
Skin: No jaundice.
Discharge
VS T 98.2 BP 135/50 HR78 SR RR 20 O2sat 93% RA
Gen NAD
Neuro A&Ox3, nonfocal exam
Pulm CTA bilat
CV RRR Sternum stable, incision w/steri strips CDI
Abdm soft, NT/ND/+BS
Ext warm, 1+ pedal edema bilat
Pertinent Results:
[**2112-2-27**] 07:18PM HGB-10.4* calcHCT-31
[**2112-2-27**] 02:05PM LACTATE-2.4*
[**2112-2-27**] 01:00PM GLUCOSE-143* UREA N-66* CREAT-5.6* SODIUM-133
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-18* ANION GAP-22*
[**2112-2-27**] 01:00PM CK-MB-8 cTropnT-0.58*
[**2112-2-27**] 01:00PM PLT COUNT-110*
[**2112-2-27**] 01:00PM PT-15.4* PTT-25.9 INR(PT)-1.4*
[**2112-2-27**] 07:47AM GLUCOSE-117* UREA N-64* CREAT-5.8* SODIUM-135
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-19* ANION GAP-20
[**2112-2-27**] 07:47AM ALT(SGPT)-1863* AST(SGOT)-882* LD(LDH)-881*
ALK PHOS-82 TOT BILI-0.7
[**2112-3-4**] 06:15AM BLOOD WBC-8.4 RBC-3.35* Hgb-9.5* Hct-28.3*
MCV-84 MCH-28.2 MCHC-33.5 RDW-14.3 Plt Ct-266
[**2112-3-4**] 06:15AM BLOOD Plt Ct-266
[**2112-3-1**] 02:50AM BLOOD PT-14.9* PTT-23.8 INR(PT)-1.3*
[**2112-3-4**] 06:15AM BLOOD Glucose-98 UreaN-33* Creat-1.3* Na-140
K-4.5 Cl-105 HCO3-27 AnGap-13
[**2112-3-3**] 06:20AM BLOOD ALT-177* AST-39 LD(LDH)-306* AlkPhos-100
Amylase-134* TotBili-0.5
[**2112-2-26**] 06:33PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
RADIOLOGY Final Report
CHEST (PA & LAT) [**2112-3-3**] 8:49 AM
CHEST (PA & LAT)
Reason: evaluate pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
63 year old man s/p asc aorta and hemiarch replacement
REASON FOR THIS EXAMINATION:
evaluate pleural effusions
INDICATION: Evaluate pleural effusions.
PA AND LATERAL CHEST: Comparison to two days prior reveals
increase in size of left-sided pleural effusion, which is
moderate. Right-sided pleural effusion is small and likely
decreased. Retrocardiac density persists, which likely
represents atelectasis and effusion; however, focal
consolidation cannot be excluded. Today's exam reveals multiple
predominantly upper lung field nodular densities measuring up to
approximately 4 mm in size, which likely were present on [**2-26**] and may represent multiple granulomas. The patient is status
post sternotomy, and mediastinal and hilar contours are
unchanged.
IMPRESSION:
1. Increase in size of moderate left-sided pleural effusion with
decrease in size of small right-sided pleural effusion.
2. Retrocardiac density, which likely represents a combination
of atelectasis and effusion; however, focal consolidation cannot
be excluded.
3. Multiple predominantly upper lung field small nodular
lesions, which likely represent small granulomas.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Cardiology Report ECHO Study Date of [**2112-2-27**]
PATIENT/TEST INFORMATION:
Indication: Abnormal ECG. Aortic dissection. Aortic valve
disease. Chest pain. Hypertension. Pericardial effusion.
Tamponade.
Status: Inpatient
Date/Time: [**2112-2-27**] at 19:59
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: *6.4 cm (nl <= 3.4 cm)
Pericardium - Effusion Size: 1.0 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No LA mass/thrombus (best excluded by
TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the body of the RA. A catheter or pacing wire
is seen in the RA and extending into the RV. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Normal regional LV systolic function.
Mild-moderate regional LV systolic dysfunction.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior- hypo; mid anterior - hypo; basal anteroseptal -
hypo; mid anteroseptal -hypo; basal inferoseptal - hypo; mid
inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo;
basal inferolateral - hypo; mid inferolateral - hypo; basal
anterolateral - hypo; mid anterolateral - hypo; anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Markedly
dilated ascending aorta. Focal calcifications in ascending
aorta. Markedly dilated aortic arch.
Moderately dilated descending aorta Focal calcifications in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Moderate to
severe (3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PERICARDIUM: Moderate pericardial effusion. No pericardial
thickening. Brief RA diastolic collapse.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related
complications. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. The patient was under general
anesthesia throughout the procedure.
Conclusions:
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No left atrial mass/thrombus seen (best
excluded by transesophageal echocardiography).
2. No spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. There is mild to moderate regional left
ventricular systolic dysfunction with mild global LV systolic
dysfunction.
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is markedly dilated The aortic arch is
markedly
dilated. The descending thoracic aorta is moderately dilated.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Moderate to severe (3+) aortic regurgitation is seen.
There is a dissection flap visible at the level of the RCA,
although flow is demonstrated in both the RCA and the LMCA. The
dissection flap extends into the arch and to the descending
aorta at the level above the LSCA origin.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7. There is a moderate sized pericardial effusion. There is no
pericardial
thickening. There is brief right atrial diastolic collapse.
POST-CPB and Circ Arrest: On infusions of epinephrine and
phenylephrine.
Improved aortic regurgitation, now 1+. Flow seen in both RCA and
LMCA.
Well-seated aortic tube graft in the ascending aorta. There is
still evidence for a small dissection flap in the descending
aorta at the level of the subclavian artery but there is no
lumenal compromise seen. There is preserved biventricular
systolic function on inotropic support with a LVEF = 45%.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2112-2-28**] 01:36.
RADIOLOGY Final Report
MRA CHEST W&W/O CONTRAST [**2112-2-27**] 3:26 PM
MRA CHEST W&W/O CONTRAST
Reason: eval for aortic dissection
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with recent sudden onset chest pain radiating to
back now with ATN and likely ischemic liver, please eval for
aortic dissection
REASON FOR THIS EXAMINATION:
eval for aortic dissection
MRA CHEST.
CLINICAL HISTORY: 63-year-old man with recent sudden onset chest
pain radiating to back. Now with ATN and likely ischemic liver.
Please evaluate for aortic dissection.
No prior studies available for comparison.
TECHNIQUE: Multiplanar T1- and the T2-weighted images were
acquired on a 1.5 T magnet, including dynamic 3D imaging,
obtained prior to, during, and after the intravenous
administration of gadolinium-DTPA.
Multiplanar 2D and 3D reformations and subtraction images were
generated on an independent workstation.
FINDINGS: There is aortic dissection, extending from the aortic
root through the proximal portion of the descending thoracic
aorta, distal to the great vessels. This finding is compatible
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11916**] type A/DeBakey type I aortic dissection. The
aortic root is dilated, measuring 6.2 x 6.0 cm (sequence 7,
image #90). There is a fenestration between the true and false
lumens in the proximal ascending aorta, best demonstrated on
cine series (sequence 7, image #88). Aortic regurgitation is
also appreciated on cine sequences (sequence 7, image #29). The
dissection extends into the right brachiocephalic artery, with
associated focal occlusion of the brachiocephalic artery,
however, the right carotid artery is patent and not involved by
the dissection. Note is made of a bovine arch, a normal variant.
The dissection extends into the left subclavian artery as well.
The dissection does not appear to involve the major coronary
artery branches.
There is a moderate pericardial effusion consistent with
hemopericardium. No specific MR signs of tamponade are
appreciated; notably the SVC and IVC are of normal caliber and
cine sequences demonstrate grossly normal ventricular wall
motion. This would be better assessed on echocardiography, if
clinically warranted.
There are bilateral pleural effusions, moderate on the right and
small on the left. There is mild adjacent atelectasis.
Multiplanar reformatted images were essential in the delineation
of the above findings.
Findings were discussed with the surgical team at the time the
study was being performed. The findings were subsequently
discussed with cardiothoracic surgeon, Dr. [**First Name (STitle) **], prior to
surgical intervention.
IMPRESSION:
1. Ascendnig aortic dissection originating at the dilated (6 cm)
aortic root, extending to proximal portion of the descending
thoracic aorta, consistent with [**Location (un) 11916**] type A aortic
dissection. Involvement of all great vessels, as described
above. The origin of the right coronary artery is uncertain, the
left originates from the true lumen; both are patent.
2. Moderate hemopericardium without specific MR signs of cardiac
tamponade. Aortic regurgitation.
3. Bilateral pleural effusions, right greater than left.
4. Patent SMA, Celiac, and duplicated bilateral renal arteries.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2112-2-29**] 11:00 AM
Brief Hospital Course:
Patient was transfer from So [**Hospital **] Hospital with new onset acute
renal failure. Pt states this illness began with acute onset
sharp chest and back pain that persisted for several hours,
myalgia and anuria were associated symptoms. The patient was
treated for "pneumonia and gas bubble". Symptoms did not improve
and his urologist referred him back to ER where he was noted to
have renal failure and elevate LFT's. pt was ythen transferred
to [**Hospital1 18**] for further care. He was admitted to MICU, a subsequent
CT scan showed aortic dissection and he was brought emergently
for replacement of ascending aorta and resuspension of aortic
valve on [**2-27**]. He tolerated the operation well and was
transferred to the cardiac surgery ICU, see OR report for
details. Patient did well in the immediate postop period, he
remained hemodynamically stable, was weaned from the ventilator
and extubatedon POD1. On POD2 he was weaned from all vasoactive
IV medications and on POD3 was transferred to the floor for
continued care. He continued to do well, his activity level was
increased.
His renal and hepatic function continued to improve and on POD6
it was decided he was stable and ready to discharge to
rehabilitation
Medications on Admission:
None
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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
5. Testosterone 1 % (25 mg) Gel in Packet Sig: 2.5 mg
Transdermal once a day.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Type A Aortic Dissection
HTN
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 31**] 2-3 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 170**] Call to
schedule appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2112-3-4**] Name: [**Known lastname 12032**],[**Known firstname **] Unit No: [**Numeric Identifier 12033**]
Admission Date: [**2112-2-27**] Discharge Date: [**2112-3-10**]
Date of Birth: [**2048-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
He remained in the hospital awaiting disposition. He was
discharged home to his brothers house on [**3-10**].
Discharge Disposition:
Home
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2112-3-10**]
|
[
"599.0",
"584.5",
"401.9",
"423.0",
"280.9",
"276.2",
"570",
"441.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
16541, 16667
|
13409, 14639
|
328, 441
|
15427, 15435
|
2527, 3720
|
15734, 16518
|
1884, 1921
|
14694, 15316
|
10007, 10151
|
15375, 15406
|
14665, 14671
|
15459, 15711
|
5187, 9970
|
1936, 2508
|
282, 290
|
10180, 13386
|
469, 1689
|
1711, 1727
|
1743, 1868
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,581
| 195,956
|
34607
|
Discharge summary
|
report
|
Admission Date: [**2159-6-23**] Discharge Date: [**2159-7-10**]
Date of Birth: [**2076-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Headache and gait instability
Major Surgical or Invasive Procedure:
Bilateral burr hole evacuation of subdural hematomas
History of Present Illness:
82 y/o male in previously good health who slipped in the shower
on [**2159-6-11**]. He denies loss of consciousness, but developed a
headache. He also denies weakness, numbness, tingling, visual
changes, or dizziness before or after fall. He was taken to
outside hospital where head CT revealed bilateral acute subdural
hematomas; 8mm on the right side and 7mm on the left side with
associated 2mm left to right midline shift. He was admitted to
the neurosurgery service for observation, but did not require
operative management. He was discharged to home with home PT in
place. Over the past week, his family noticed he had more
difficulty with ambulation and concentration. He was also more
lethargic, and demonstrated mild dysarthria. Upon return to
[**Hospital1 18**] ED, repeat head CT did not reveal acute bleeding, but
midline shift from left to right has increased to approximately
6mm. Bilateral frontal and parietal subdural fluid collections
are still present.
.
He underwent bilateral burr hole evacuation on [**6-24**]. His
post-operative course was complacated by lethargy, waxing/[**Doctor Last Name 688**]
mental status and difficulty following commands. He was
transferred to the MICU for worsening tachypnea and hypoxemia.
In the MICU, he was briefly intubated, treated for
hospital-acquired aspiration PNA (initially on vanomycin and
pip-tazo, but currently on pip-tazo alone). A CTA was negative
for PE. An echocardiogram demonstrated preserved LV function. He
was extubated succesfully on [**7-5**]. He passed speech and swallow
evaluation.
Past Medical History:
Hearing loss
Diverticulitis
Hyperlipidemia
.
PSHx:
Unknown surgery for diverticulitis - [**2144**]
Social History:
Married, lives with wife. Very active prior to recent fall. No
alcohol, smoking, or drug use.
Family History:
Non-contributory
Physical Exam:
Exam upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-4**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-5**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. Mild dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing to voice diminished bilaterally; hearing aid in
place.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-9**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2159-7-4**] CTA chest:
1. No evidence of pulmonary embolus.
2. Nodular and ground-glass opacities at the lung bases which
could represent sequela of aspiration or evolving infectious
process.
3. Small bilateral pleural effusions.
.
[**2159-7-4**] CT c-spine:
1. Severe degenerative changes involving the cervical spine as
described. Grade 1 anterolisthesis at the C2-3 level.
2. Opacification of the left mastoid air cells, which may
reflect
mastoiditis.
.
[**2159-7-4**] Echo:
Poor image quality. The left atrium is normal in size. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The overall LVEF is probably preserved. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are severely thickened/deformed. Significant
aortic stenosis is present (not quantified due to poor image
quality). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Calcific AS (could not quanitfy due to poor image
quality). If clincially indicated, a repeat study when extubated
is suggested.
.
[**2159-7-4**] CT head:
1. Essentially stable appearance of bilateral subdural
hematomas, without significant interval change compared to
examination six days prior. No shift of midline structures or
hemorrhage.
2. Opacification of the left mastoid air cells, which may
reflect mastoiditis.
.
[**2159-6-23**] CT head:
1. Evolving and enlarging bilateral subdural hematomas most of
which appears chronic with few scattered acute hemorrhagic foci
as described above.
2. Rightward subfalcine herniation of 7 mm, worse than prior
study.
Brief Hospital Course:
82yo M with recent SDH s/p burr hole evacuation, transferred to
MICU for hypoxemia, tachypnea likely [**1-6**] hospital-acquired
aspiration PNA and briefly intubated; now extuabted since [**7-5**].
.
# Respiratory failure: During his post op course on the
neurosurgical service on the floor, he became tachypneic and
hypoxic. Medical consult was called. CXR from [**7-3**] suggested
new RLL opacity and stable LLL opacity, a CTA (showed bilateral
opacities in lung bases suggesting PNA, likely aspiration. He
was started on vanco/zosyn on [**7-3**] for HAP. Of note, the CTA on
[**7-4**] was also negative for PE so as not to suggest acute
thromboembolism as a cause of his respiratory failure.
Additionally, he was ruled out for acute MI with cardiac enzymes
x3 and TTE showed a preserved LVEF, signifiant AS, trace AR, 1+
MR. A [**7-4**] head CT showed essentially stable appearance of
bilateral subdural hematomas, without significant interval
change compared to examination six days prior; no shift of
midline structures or hemorrhage. Thus, this finding made neuro
cause of resp failure less likely. He clinically responded well
to the vanco and zosyn and was successfully extubated on [**7-5**].
Sputum cultures grew only oropharyngeal flora and blood cultures
were negative. The patient was initially noted to have a poor
cough, therefore there was concern for continued aspiration
risk. However on [**7-6**] the pt passed speech and swallow and his
oxygen requirement continued to lessen. In light of negative
cultures vanco was d/ced on [**7-6**]. He was briefly transitioned to
levofloxacin/flagyl given most likely etiology of his
respiratory failure was an aspiration event and although
afebrile, his WBC count increased so he was changed back to
zosyn for the completion of his antibiotic course. He will
complete a 10 day course of antibiotic treatment on [**2159-7-13**]. He
should currently be maintained on aspiration precautions,
however speech and swallow reevaluation on day of discharge
advanced him to ground solids and thin liquids with PO meds
crushed; he should have 1:1 supervision with meals to maintain
standard aspiration precautions and assist with feeding.
Further diet advancement will be determined by repeat speech and
swallow evaluation upon discharge. He is maintaining oxygen
saturation in the mid to high 90s on 2L NC currently.
.
# Fever: As outlined above likely [**1-6**] pulmonary infection as he
defervesced with treatment and with concomitant improvement in
his respiratory status. Urine and blood cultures were negative
and his burr hole surgical sites were without evidence of
infection. As above, he will complete course of zosyn on [**7-13**].
.
# Somnolence/delirium: Post op course was initially complicated
by lethargy, waxing/[**Doctor Last Name 688**] mental status and attention as well
as difficulty following commands. Beginning on [**7-5**] the
patient's mental status markedly improved so that on [**7-6**] and
therafter he has been awake and alert, and able to recognize
family. He has continued to improve daily so that he is now
alert and oriented and follows commands and responds to
questions appropriately.
.
# Subdural hematoma: Patient initially presented on [**2159-6-12**] with
headache following fall on the previous day was observed and
nonsurgically managed and was discharged on [**6-13**]. He then
represented to OSH on [**2159-6-23**] with subacute difficulty
ambulating and lethargy at which time he was found to have
increasing midline shift. Thus, he was transferred to [**Hospital1 18**] for
further management and is s/p bilateral bur hole evacuation on
[**6-24**] by [**Doctor Last Name **] of neurosurgery. Post operatively he remained on
the neurosurgical service until developing respiratory distress
at which time he was transferred to the MICU and then to the
general medical service. Repeat head CTs throughout his stay
have consistently showed stability of his subdural hematomas.
He should be continued on keppra until his follow up appointment
with neurosurgery on [**2159-7-17**] at which time continuation of this
medication will be decided. Repeat CT head will be performed on
[**7-17**] prior to his follow up appointment.
.
# Aortic stenosis: "Significant AS" was called on echo while
inpatient however it was not quantified due to poor image
quality. He has been without lightheadedness, chest pain nor
evidence of CHF during his hospitalization. He should however,
have repeat TTE as an outpatient in order to further quantify
his aortic stenosis.
.
# Bradycardia and hypotension: Briefly on [**7-5**] while in the ICU,
BPs 80/30s with HR to the 30s. HR improved with stimulation and
hypotension responded to 1000cc bolus. Felt likely physiologic
given timing at night and responsive to waking. Atropine was
placed at bedside and pacer pads on patient however bradycardia
and hypotension spontaneously resolved. Following this brief
episode of hypotension he was then hypertensive around time of
extubation. Given his HR markedly improved and he became
hypertensive, he was started on metoprolol (bradycardia was
brief and resolved on its own) and received IV lasix x1 on [**7-6**]
with great response. Would continue to watch for bradycardia
with HTN as sign of increased ICP, however no sign of SDH
progression on multiple studies and is currently normotensive
with normal HR (60-80s).
.
# Hypertension: Peri-extubation, he was noted to be
hypertensive. He was started on metoprolol by the ICU team with
good response in his blood pressure. This will be continued
upon discharge.
.
# Anemia: hct on [**2159-6-11**] was normal and no prior labs in our
system prior to that. Most recently his hct has been stable in
the low to mid 30s. Likely due in part to small amount of blood
loss perioperatively. Additionally, iron studies were c/w AOCD.
B12 and folate were normal.
.
# FEN: Passed Speech and swallow [**7-6**] at which time he was
started on pureed, nectar diet which has since been advanced to
ground solids and thin liquids. Oral medications should be
crushed. He must remain on 1:1 sitter with meals to enforce
strict aspiration precautions. His diet can be further advanced
pending repeat speech and swallow evaluation. His PO intake
should be monitored as he may require supplemental nutrition if
he is unable to take in enough calories by mouth.
.
# Hematuria: Slightly blood tinged urine was noted on day of
discharge following mild foley trauma. Urine was without
evidence of infection. Foley catheter should be removed upon
arrival to rehab and voiding trial performed.
.
# Code: FULL.
Medications on Admission:
1. Acetaminophen prn
2. Docusate Sodium 100 mg [**Hospital1 **]
3. Phenytoin Sodium Extended 100 mg PO tid
4. Dilaudid 2 mg PO every four 4 hours prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Zosyn 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every
eight (8) hours for 3 days: to complete course on [**2159-7-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Bilateral subdural hematomas
Aspiration pneumonia
Delirium
Anemia
Hypertension
Discharge Condition:
Stable, maintaining normal O2 saturations on 2L NC, afebrile,
with marked improvement in mental status.
Discharge Instructions:
You were admitted with increased lethargy and gait instability
and were found to have worsening subdural hematomas. You
underwent burr hole evacuation of your subdural hematomas by
neurosurgery. During your postoperative course, you experienced
respiratory distress and required transfer to the medical
intensive care unit and intubation. You have been treated with
antibiotics (course to be completed on [**2159-7-13**]) and improved
markedly so that you were successfully extubated and transferred
to the regular medical floor.
.
You will need continued agressive physical and occupational
therapy in order to regain your strength and increase your
activity.
.
You will need to follow up with neurosurgery as an outpatient.
You will need a repeat CT scan of your head on the [**6-16**] as outlined below. You should continue keppra in the
meantime.
.
Please call your doctor or return to the emergency department if
you development headache, changes in your vision,
lightheadedness/dizziness, focal numbness/tingling/weakness,
fevers/chills, worsening cough or shortness of breath, chest
pain or any other symptoms that concern you.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] SCAN
Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2159-7-17**] 2:00
2. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD
Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2159-7-17**] 3:00
|
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"389.9",
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"562.10",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"01.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13469, 13541
|
5577, 12224
|
345, 400
|
13664, 13770
|
3621, 5034
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428, 2001
|
2777, 3602
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5337, 5554
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2306, 2504
|
2519, 2761
|
2023, 2124
|
2140, 2236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,441
| 192,410
|
16548
|
Discharge summary
|
report
|
Admission Date: [**2160-5-13**] Discharge Date: [**2160-5-30**]
Date of Birth: [**2092-10-8**] Sex: F
Service: [**Doctor First Name 147**]
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal pain, nausea vomiting and cold right lower extremity
Major Surgical or Invasive Procedure:
1. Exploratory laparatomy for perforated jejunoileal diverticula
2. Thrombectomy of Right lower extremity.
History of Present Illness:
Pt is a 67 year old female with COPD, PVD status post Right
lower extremeity bypass graft who came to the emergency
department with 3 days of nausea and vomiting with 2 days of
Right lower extremity numbness. She had been in her usual state
of health until 3 days prior to admission when she had several
episodes of nobilious emesis, was unable to tolerate food, and
had crampy abdominal pain.
Past Medical History:
COPD
Peripheral vascular disease
history of Deep vein thrombosis
s/p Right arterial bypass
Social History:
Occasional alcohol, quit tobacco
Family History:
non contributory
Physical Exam:
Exam on admission was as follows:
Temperature 97, Pulse 95, Blood pressure 145/89, Respirations
20, Oxygen saturation 20 on 4 liters nasal canula
General: alert oriented in No apparent distress
Neck supple and trachea midline with no masses or enlarged
cervical lymph nodes
Chest was clear to auscultation bilaterally
Heart: regular rate and rhythm with no murmurs rubs or gallops
Rectal exam: normal tone, guiac negative
Abdomen: Soft distended with tenderness to the lower abdomen
with guarding but no rebound
Extremities: Right lower extremeity cool to mid thigh, with
decreased capilary refil, motor and sensation were equal and
symmetric
Pertinent Results:
[**2160-5-13**]: CT abdomen: Dilated small bowel without a transition
point with some free air in the abdomen. This is concerning for
ischemic bowel considering the patient has an ischemic leg.
Bowel perforation due to other reasons cannot be ruled out but
is low in the differential list. Multiple diverticuli are seen
without acute evidence of diverticulitis.
[**2160-5-13**]: Abdominal xray-: Partial small bowel obstruction with
bowel perforation.
Brief Hospital Course:
The patient was placed in the intensive care postopertively
after undergoing an exploratory laparotomy for a perforated
diverticula and a thrombectomy in the right lower extremity.
She was extubated on [**2160-5-15**] and placed on bipap. she had
erythema around her wound and was started on vancomycin,
levofloxacin, and flagyl. the patient continued to do well. She
had wet-dry dressing changes twice daily and the wound was
checked continually for the presence of granulation. She began
tolerating regular food and began taking oral medications. Her
baseline respiratory status continued to give her some
difficulty, but she has slowly improved although she needs
pulmonary rehabilitation. She has had 10 days of antibiotics
and will continue on levofloxacin and flagyl for 4 days to
complete a 2 week course of antibiotics. she will continue wet
to dry dressing changes and will need acute rehab for her
pulmonary status as well as to help her with dressing changes
and wound care. She has been on coumadin and her last INR on
discharge was 2.4 with a coumadin dose of 5mg daily. she will
need to be followed as an outpatient for INR tracking and dose
management
Medications on Admission:
verapamil 40 tid
captopril12.5 tid
lopressor 25 [**Hospital1 **]
fluoxetine 20 qd
Mg
folic acid
asprin 325 qd
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q8H (every 8 hours).
Disp:*1 Inhanler* Refills:*2*
2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
3. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*2*
12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
also restart your medications that you were taking
preoperatively, and you can consult with your primary care
doctor about it.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
1. S/p exploratory laparotomy
2. Perforated jejunoileal diverticula
3. s/p throbectomy of Right lower extremity
4. Ischemia of Right Lower extremity
5. Chronic obstructive pulmonary disease
6. Hypertension
Discharge Condition:
Stable
Discharge Instructions:
[**Name8 (MD) **] MD [**First Name (Titles) 151**] [**Last Name (Titles) 152**] fevers, abnormal foul smelling discharge
coming from the wound, Severe pain, intractable nausea or
vomiting.
You will have assistance in changing the bandages on your wound
twice daily.
you can start medications you were on preoperatively and can
consult your primary care physician with any other questions
Continue your home medications as you were taking them
preoperatively and you can call your primary care physican with
any other questions
Followup Instructions:
Follow up in 1 week from tuesday with Dr. [**Last Name (STitle) 5182**], you can
call for an appointment [**Telephone/Fax (1) 5189**].
Follow up with Vascular surgery in 1 week [**Telephone/Fax (1) 1784**]
Follow up with Plastic surgery clinic
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"557.0",
"562.01",
"996.74",
"567.8",
"427.31",
"496",
"425.4",
"276.5",
"444.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"89.64",
"39.49",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5152, 5223
|
2264, 3440
|
378, 488
|
5473, 5481
|
1787, 2241
|
6060, 6414
|
1091, 1109
|
3600, 5129
|
5244, 5452
|
3466, 3577
|
5505, 6037
|
1124, 1768
|
276, 340
|
516, 911
|
933, 1025
|
1041, 1075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,820
| 111,639
|
41162
|
Discharge summary
|
report
|
Admission Date: [**2137-2-16**] Discharge Date: [**2137-3-3**]
Date of Birth: [**2068-5-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Rt thigh swelling and pain
Major Surgical or Invasive Procedure:
Cystoscopy
Thoracocentesis
IVC filter fixation
History of Present Illness:
68 yo male, who presented with right swollen painful thigh for 3
days. He could hardly walk due to the pain and pain is more when
he walks around otherwise while sitting there is minimal pain.
He never had similar compaint before. He was in his usual normal
state of health until [**Month (only) **] when he started to have right
lower abdominal pain and right flank pain for which he seeked
his doctor, percocet was prescribed however it worsened. He also
took Motrin for the last 3 months in addition to percocet for
the pain. In addition to this pain, he had intermittent
hematuria. For this, he had an abdominal US and CT abd/pelvis at
[**Hospital1 2177**], and according to the patient, there was a mass in the
urinary baldder and a cyst in his right kidney. He was reffered
for urology appointment, however his appoitnement was cancelled.
He also mentioned that it seems like he lost weight, however on
the scale it still shows 182, but the wife mentioned that his
arm size was bigger than what it is today. Also, the patient
mentioned that he has a new onset hypertension that started
about 3-4months ago for which he is on anti-hypertensive. In the
last 2-3 weeks, he also noted bilateral scrotal painless
swelling but no lower limb swelling bilaterally until wed. when
he started to have swelling and pain in his right thigh. No
fever or chill or sick contact. 2 years ago he had a left sided
abd pain, for which he also had a CXR that showed 3.5cm mass in
his left lung. For that mass he had an MRI, and he was told that
he doesn't need further MRI, it can be followed up by CXR. He
also mentioned shortness of breath on exertion and dry cough for
the last 3 months. 3-4 months ago he could go upstairs before he
gets SOB, however recently by minimal effort he is SOB. No
associated chest pain or dizziness or sweating or palpitations.
He uses valid-date puffer occasionally within the last few
months with minimal relief. He also described some lower chest
tightness, a few times post-meal, and not with his SOB.
In the ED, initial vs were: 98.3 118 163/72 18 95%. On exam
tender right leg, guiaic negative. Labs notable for WBC 13.3,
creatinine of 2.7 (unclear baseline). UA positive, urine culture
sent. Blood culture sent. LENI showed nonocclusive DVT of the
right distal SFV. He was started on a heparin gtt. He developed
new oxygen requirement in the ED. CXR showed RML opacity
obscuring right heart border. He was given levofloxacin 750mg
for presumed pneumonia. He was given tylenol, and morphine. He
was given 1L IVF. Vitals on transfer: 98.2 117 101/84 18 92%2L
.
On the floor, reports shortness of breath with minimal exertion.
Past Medical History:
bladder mass
Hypertension
COPD
Social History:
-married
-former construction worker
-former smoker = quit 10yrs ago, smoked 0.5ppd x40yrs
-denies IVDA
-denies ETOH
Family History:
non-significant
Physical Exam:
On admission:
-------------
Vitals: 97.4 159/96 68 20 98%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased BS right base, no wheezes, rales, ronchi
CV: S1, S2 regular rhythm, normal rate
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: oriented x3, CNII-XII intact, no gross sensory or motor
deficits, negative pronator drift, gait not assessed
The day before he decides for CMO
Vitals: 98.1, 104/64, 95 bpm, 20, sat97% on 3L O2
GEN: alert, oriented x3, sitting in bed, lethargic, Not in acute
distress. urine color is light brownish.
HEENT: Mucous membranes moist, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
LN: no axillary LN could be appreciated. A small LN is noted in
the right inguinal.
CV: normal rate and regular rhythm, no murmurs, rubs or gallops
PULM: relatively fair A/E on the Rt side. Still some crackles
are heard at mid & lower zone of Rt lung. No wheezes could be
appreciated.
ABD: Soft, slight tenderness on touching the peri-umbilical,
slightly distended, no rebound tenderness or guarding, no
organomegaly. bowel sounds positive. No CVA tenderness noted.
Spine & EXTR: right thigh looks well, no erythema at inner right
thigh, no tenderness to touch. Dorsalis pedis was felt on Lt
side, couldn't be felt on Rt side. Lt forearm's hematoma on the
medial side looks smaller. still has bilateral lower limb
pitting edema.
NEURO: Alert and oriented x3. CNII-XII grossly intact, no gross
sensory or motor deficits, gait not assessed.
Pertinent Results:
[**2137-2-16**] 09:19PM CK(CPK)-102
[**2137-2-16**] 09:19PM CK-MB-2
[**2137-2-16**] 07:35PM PT-16.8* PTT-38.5* INR(PT)-1.5*
[**2137-2-16**] 02:53PM URINE HOURS-RANDOM UREA N-618 CREAT-356
SODIUM-53 POTASSIUM-63 CHLORIDE-13
[**2137-2-16**] 10:00AM TSH-0.47
[**2137-2-16**] 10:00AM ALT(SGPT)-30 AST(SGOT)-29 LD(LDH)-283*
CK(CPK)-96 ALK PHOS-88 TOT BILI-0.6
[**2137-2-20**] 08:55AM BLOOD WBC-16.3* RBC-2.69* Hgb-7.7* Hct-23.2*
MCV-86 MCH-28.6 MCHC-33.2 RDW-13.2 Plt Ct-217
[**2137-2-28**] 06:35AM BLOOD WBC-21.0* RBC-2.86* Hgb-8.4* Hct-24.7*
MCV-87 MCH-29.3 MCHC-33.9 RDW-13.9 Plt Ct-173
[**2137-2-28**] 05:45PM BLOOD Glucose-111* UreaN-79* Creat-5.3* Na-134
K-5.2* Cl-101 HCO3-17* AnGap-21*
[**2137-2-28**] 05:45PM BLOOD Calcium-9.3 Phos-7.1* Mg-2.5
Cytology/histopathology:
[**2137-2-16**]: URINE CYTOLOGY: Very atypical urothelial cells, present
singly and in clusters, suspicious for urothelial
dysplasia/neoplasia.
[**2137-2-19**]: Pleural fluid: POSITIVE FOR MALIGNANT CELLS, Consistent
with poorly differentiated carcinoma. The neoplastic cells are
immunoreactive for keratin AE1/AE3; CAM 5.2, CK7, CK20, focally
positive for B72.3, [**Last Name (un) **]-31. They show no immunoreactivity for
calretinin, WT-1, TTF-1, P63, CK5/6, CEA, or CD15. Based on
this immunophenotypic profile, it is difficult to determine the
origin of the tumor.
[**2137-2-19**]: Bladder mass biopsy:
A. Bladder, left lateral dome, deep biopsy:
- Invasive high grade papillary urothelial carcinoma,
extensively invading lamina propria. No definitive muscularis
propria seen. Note: The invasive component is poorly
differentiated, in some areas growing in spindle cells and in
other areas in single pleomorphic cells.
B. Bladder tumor, dome, biopsy:
- High grade papillary urothelial carcinoma, suspicious for
lamina propria invasion. No muscularis propria seen.
Imaging:
--------
[**2137-2-16**]: Lower Ext. Doppler: Non-occlusive thrombosis of the
right distal superficial femoral vein.
[**2137-2-16**]: CT head without contrast: No overt intarcranial
pathology
[**2137-2-17**]: CT Chest w/o contrast:
1. Numerous multifocal pulmonary nodules several of which have a
central
solid component and peripheral ground glass component.
Additional nodules
have a more spiculated contour. Overall, the appearances are
highly
concerning for multifocal metastatic disease.
2. Abnormal soft tissue seen in the mediastinum posterior to the
esophagus
and in the superior paraaortic retroperitoneum consistent with
lymphadenopathy. In addition, there is a large soft tissue mass
in the left
supraclavicular region, likely a metastasis.
3. Bilateral pleural effusions, larger on the right. Possible
solid
components seen bilaterally as described.
4. 3.2-cm likely fat-containing mass at the left base consistent
with a
hamartoma. Stable since [**2132**].
[**2137-2-18**]: ECHO: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2137-2-20**]: ECHO: BED-SIDE:
Mildly dilated right ventricle with free wall hypokinesis,
severe pulmonary hypertension, and abnormal septal movement
consistent with acute right ventricular pressure overload.
Compared with the prior study (images reviewed) of [**2-18**]/201, the
severity of pulmonary hypertension has increased. Right
ventricle is now mildly dilated and mildly hypokinetic.
[**2137-2-20**]: Upper ext. Doppler: No evidence of left upper extremity
DVT
[**2137-2-25**]: CT Abd/Pelvis:
1. No CT evidence for bladder leak in this somewhat limited
examination
secondary to lack of ability to distend the bladder with
contrast.
2. Extensive retroperitoneal lymphadenopathy concerning for
metastatic
disease.
3. Multiple pulmonary irregular opacities at the lung bases,
incompletely
imaged, concerning for metastatic disease.
4. Evidence for volume overload, including anasarca and
bilateral moderate
pleural effusions.
[**2137-2-26**]: CYSTOGRAM: No evidence of vesicoureteral reflux
[**2137-2-28**]: Duplex/Doppler US Abd?pelvis:
1. Inferior vena cava thrombosis extending at least from the
infrahepatic
inferior vena cava to the level of the IVC filter.
2. Pleural effusion on the right.
Brief Hospital Course:
68 yo M, with recent bladder mass & renal cyst, hypertension,
scrotal bilateral swelling, SOB on exertion and new hemoptysis
presented with swollen painful Rt thigh and was admitted to
[**Hospital1 18**] for further evaluation.
.
# DVT/PE: LENI on admission showed SFV non-occlusive DVT. Given
the patient has bladder cancer, most likely with metastatic
pleural effusion, he was at high risk for hypercoagulation and
DVT. He was started on heparin infusion since his Cr on
admission was 2.8 with baseline of 1.2-1.5 per OSH records from
[**Hospital1 2177**]. Heparin infusion was discontinued prior to thoracocentesis
[**2137-2-18**] by 6 hours and restarted after the procedure by 1 hr.
Also, Heparin was discontinued prior to cystoscopy [**2137-2-19**] by 6
hours and restarted after the procedure by about 12 hr. (total
time held peri-cystoscopy ~ 24 hr). The day following cystoscopy
his renal function deteriorated (Cr up to 5.3) and he
decompensated with hypotension and hypoexemia despite being on
O2. Bedside Echo showed severe pulmonary hypertension, which was
new compared to the Echo he had 2 days prior to this event. He
was transferred to the Medical ICU, where he received total of 3
units of PRBC (had a few episodes of coffee ground vomitus) and
Heparin drip was held. He was transferred back to the medical
floor after he was stabilized during his 2 day stay in the ICU
for 2 days. His renal function gradually improved (Cr down to
~3). IVC filter was fixed without using contrast on [**2137-2-27**] with
the aim to discontinue his heparin infusion, since his urine
wasn't clearing of blood following cystoscopy despite continuous
bladder irrigation. After IVC filter was placed, his kidney
function deteriorated again. Doppler US abd/pelvis on [**2137-2-28**]
showed Inferior vena cava thrombosis extending at least from the
infrahepatic inferior vena cava to the level of the IVC filter.
.
# HYPOXIA: Most likely was due to PE given his DVT and possible
hypercoag state due to bladder cancer.Another conern was that
the Rt pleural effusion that could be causing compression
atelectasis. Thoracocentesis was done on [**2137-2-18**] and 1.2L bloody
effusion was aspirated. Repeat CXR showed increasing small
right-sided pleural effusion. Pt transferred to the MICU on
[**2137-2-20**] for episode of hypotension, hypoxia, and with signs of
RV strain on TTE. Had been off heparin drip for nearly 24 hours
the day before for cystoscopy, which could have allowed PE to
progress or for second PE to occur. He was a poor candidate for
lysis as he had hematuria from bladder mass as well as bloody
pleural effusion. Diagnosis of PE not formally made on CTA
(poor renal function) or V/Q scan (pulmonary nodules). Heparin
drip was empirically restarted but was held due to coffee ground
emesis in the ICU, then restarted and transferred back to
medical floor after he became stable.
.
#TACHYCARDIA: Most likely it was due to PE due to DVT in distal
SFV. Echo done [**2137-2-18**] was WNL. Bedside echo (after the pt's BP
dropped to 70's/50's and sat down to 89-90% on [**2137-2-20**]) showed
new onset severe pulm HTN and new Right ventr. regional
hypokinesia and mild dilatation, suggesting RV strain and
concern of PE. Pt was transferred to the MICU. After returning
to the medical floor, he was still tachycardic.
.
# BLADDER/RENAL lesion: Found to have bladder exophytic polypid
lesion on CT abd/pelvis at [**Hospital6 **] [**2136-12-10**]. CT
urography at [**Hospital1 2177**] [**2136-12-10**] showed retroperitoneal conglumerate LN
(per report: nonspecific - lymphoma,granulomatous, mets). CT
chest w/o contrast showed 1.numerous multifocal pulmonary
nodules 2.Abnormal soft tissue seen in the mediastinum posterior
to the esophagus and in the superior paraaortic retroperitoneum
consistent with lymphadenopathy. 2.large soft tissue mass in the
left supraclavicular region, likely a metastasis. Had cystoscopy
for it [**2137-2-19**]. Bladder mass pathology showed high grade
papillary urothelial carcinoma, invasive and poorly
differentiated. He continued to have bloody urine post
cystoscopy despite continuous bladder irrigation. Cystogram
showed no reflux or bladder leak. IVC filter was fixed in an
attempt to stop heparin infusion, with the aim to remove the
foley. Palliative chemotherapy was limited due to his poor
kidney function. Palliative radiotherapy was not favored by the
patient due to possible irritative bladder and rectal side
effects.
.
# RENAL INSUFFICIENCY: a likely reason could be the motrin he
took for 3 months for his abd. pain. no hydronephrosis or
obstruction was seen on the US. Intra-operatively (cystoscopy
[**2137-2-19**]) retrograde pyelogram was done which didn't reveal [**Last Name (un) **].
He might have had an intra-op hypotension, giving acute renal
injury, possibly ATN. Baseline Cr 1.2-1.5 per OSH records from
[**Hospital1 2177**]. After gradual improvement, his kidney function deteriorated
further after IVC filter was placed though contrast was not
used.
.
# Leukocytosis: Possibly secondary to stress induced
(operation). Pt remained afebrile with no signs of localized
infection.
.
# hypertension: possibly secondary to renal failure. No
antihypertensive meds given while hospitalized due to concern
that tachycardia could be due to compensatory mechanism for a
possible PE.
.
# scrotal bilateral painless swelling: Concern for compression
on IVC from possible malignancy. Scrotal US at [**Hospital1 2177**] (done mid [**Month (only) **]
[**2136**]) showed bilateral hydroceles.
.
# NORMOCYTIC ANEMIA: Hematuria due to bladder cancer, cystoscopy
and biopsy, and was on heparin drip. Also, bloody pleural
aspirate. In addition, he had coffee-ground vomitus in the ICU.
# comfort measures: on [**2137-2-28**], pt and HCP decided for comfort
measures only after having extensive family meeting.
# Mr [**Known lastname 89666**] sadly passed away on [**2137-3-3**].
Medications on Admission:
percocet
antihypertensives
Discharge Disposition:
Expired
Discharge Diagnosis:
Bladder Cancer
Malignant pleural effusion
DVT
PE
Discharge Condition:
Passed away
|
[
"197.6",
"416.0",
"300.00",
"799.02",
"453.2",
"415.19",
"584.5",
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"285.1",
"197.0",
"188.8",
"453.41",
"486",
"585.3",
"276.2",
"403.90",
"511.81",
"599.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.49",
"38.91",
"38.7",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
15920, 15929
|
9908, 15842
|
330, 378
|
16021, 16035
|
5075, 9885
|
3263, 3280
|
15950, 16000
|
15868, 15897
|
3295, 3295
|
264, 292
|
406, 3058
|
3309, 5056
|
3080, 3112
|
3128, 3247
|
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