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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
56,070
| 132,251
|
38095
|
Discharge summary
|
report
|
Admission Date: [**2102-6-13**] Discharge Date: [**2102-6-20**]
Date of Birth: [**2077-3-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Gunshot wound to abdomen
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Exploratory laparotomy.
2. Evacuation of 1 liter hemoperitoneum.
3. Small-bowel resection with stapled side-to-side
functional end-to-end anastomosis, 12 cm.
4. Exploration of retroperitoneum.
History of Present Illness:
25 y.o. male transfer from OSH with GSW to back with exit wound
abdomen. Patient reportedly shot in back tonight while walking
down the street trying to break up an altercation, taken to [**Hospital6 **] where he received ancef, zosyn, 2 units PRBC's,
and medflighted to [**Hospital1 18**]. Pt taken directly to the OR for
exploratory laparotomy.
Past Medical History:
None
Family History:
Noncontributory
Pertinent Results:
[**2102-6-13**] 09:30PM PO2-420* PCO2-41 PH-7.37 TOTAL CO2-25 BASE
XS--1 INTUBATED-INTUBATED
[**2102-6-13**] 09:30PM GLUCOSE-150* LACTATE-1.0 NA+-138 K+-3.8
CL--110
[**2102-6-13**] 09:20PM WBC-28.8* RBC-4.27* HGB-12.5* HCT-36.1*
MCV-85 MCH-29.3 MCHC-34.7 RDW-12.9
[**2102-6-13**] 09:20PM PLT COUNT-200
[**2102-6-13**] 09:20PM PT-13.3 PTT-23.2 INR(PT)-1.1
Brief Hospital Course:
He was admitted to the surgery service and taken directly to the
operating room for exploratory laparotomy. Postoperatively he
was taken to the trauma ICU where he remained sedated and
vented. His sedation was eventually weaned and he was extubated
on POD2. For pain control he was started on methadone 10 mg
daily, PCA Dilaudid and clonidine patch while in the ICU. He
was kept NPO awaiting return of bowel function with NGT in
place. Once transferred to the regular nursing unit his NGT was
removed he was changed to oral narcotics which provided adequate
relief; he was also started on a regular diet. At time of
discharge he was tolerating his regular diet and ambulating
independently.
He was seen by Social work given the nature of his traumatic
injuries.
He is being discharged to home with instructions for follow up
in Acute surgery clinic.
Medications on Admission:
Denies
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 3-4 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. Simethicone 80 mg Tablet, Chewable Sig: [**12-17**] Tablet, Chewables
PO QID (4 times a day) as needed for gas pain.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Gunshot wound to abdomen
Multiple small bowel enterotomies
Zone 3 non-expanding retroperitoneal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized following gunshot wound to your abdominal
region where you sustained injuries to your bowel. An operation
had to be performed to search for further internal injuries
which were repaired. You have staples that will stay in place
for 10-14 days and will be removed when you return to the clinic
next week.
Take your medication as prescribed and take a stool softener and
laxative to avoid becoming constipated while on the narcotics.
DO NOT drive, operate heavy machinery, drink alcohol or take
illicit drugs while on the narcotics.
No heavy lifting greater than 10 lbs for 6 weeks, avoid bending
for any extended period of time. No tub baths, you may shower.
Followup Instructions:
Follow up next week in Acute Surgery clinic; call [**Telephone/Fax (1) 600**]
for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2102-6-20**]
|
[
"868.14",
"863.39",
"E965.0",
"868.13",
"782.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"45.91"
] |
icd9pcs
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[
[
[]
]
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1401, 2255
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342, 556
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2915, 2915
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1012, 1378
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274, 304
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,929
| 184,389
|
45231
|
Discharge summary
|
report
|
Admission Date: [**2201-2-24**] Discharge Date: [**2201-3-5**]
Date of Birth: [**2124-3-12**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 28286**]
Chief Complaint:
3VD with chestpain awaiting CABG
Major Surgical or Invasive Procedure:
IABP
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 96672**] is 76 year-old man with a history of HTN who
presents with intermittent, stuttering chest pain for 2 days. He
describes this as reflux pain with intermittent chest pressure
on top. He increased his cimetidine and tums without
improvement. He went to his PCP and was given compazine and
prilosec prior to discharge home. Review of EKG later was
concerning so patient was called to go to the ED. EMS gave him
ASA 325mg en route in addition to nitroglycerin with some
improvement. In the ED, initial vitals were: T 100.5, P 68, BP
100/60, RR 14, O2sat 96%. He was still having CP. No N/V but
+diaphoresis. He was given one SL NTG with resolution of chest
pressure but continuation of heartburn-like pain. Exam notable
for atrophied LLL d/t polio; no concern for DVT. EKG showed SB @
57. LAD, Q III,aVF. STD V2-V3, TWI v4-v6; no prior for
comparison. CXR clear. Labs notable for trop 2.51. Pt stared on
heparin gtt. Repeat EKG with resolution of STD V2-V3 but
otherwise unchanged. On transfer to floor, VS: P 57, BP 113/74,
RR 13, O2sat 97% RA. He was chest pain free upon transfer to
floor, with no shortness of breath, nausea, or diaphoresis.
Review of systems negative for orthopnea, paroxsymal nocturnal
dyspnea, lower extremity edema. No syncope or lightheadedness.
Review of systems otherwise negative.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
hypertension
hypothyroidism
gout
depression
GERD
BPH
Mitral Valve prolapse.
Social History:
Patient is an artist who recently had his own show [**Location (un) 81267**]. He remains socially active despite having lost his wife
recently.
-[**Name2 (NI) 1139**] history: None
-ETOH: rare
-Illicit drugs: None
Family History:
Mother had multivessel coronary disease with first MI at age 63
requiring CABG
Physical Exam:
VS: BP 115/70, HR 70, RR 12, 98% RA
GENERAL: Pleasant Caucasian male in no apparent distress
HEENT: PERRL, EOMI
NECK: Supple with JVP < 8 cm
CARDIAC: RRR, nl s1/s2, no S3,S4 noted, no appreciable murmurs
LUNGS: clear bilaterally with no rales or rhonchi
ABDOMEN: Soft, NTND. normoactive bowel sounds
EXTREMITIES: no edema noted, pulses 2+ throughout
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
1. Admission Labs:
[**2201-2-24**] 04:30PM BLOOD WBC-10.6 RBC-4.44* Hgb-13.7* Hct-39.1*
MCV-88 MCH-30.8 MCHC-35.0 RDW-13.7 Plt Ct-179
[**2201-2-24**] 04:30PM BLOOD PT-14.0* PTT-27.8 INR(PT)-1.2*
[**2201-2-27**] 05:39AM BLOOD Ret Aut-1.4
[**2201-2-24**] 04:30PM BLOOD Glucose-115* UreaN-19 Creat-1.2 Na-131*
K-4.0 Cl-99 HCO3-23 AnGap-13
[**2201-2-24**] 11:10PM BLOOD CK(CPK)-1300*
[**2201-2-25**] 06:35AM BLOOD ALT-40 AST-178* LD(LDH)-683*
CK(CPK)-1006* AlkPhos-55 TotBili-1.2
[**2201-2-24**] 04:30PM BLOOD cTropnT-2.51*
[**2201-2-24**] 11:10PM BLOOD CK-MB-66* MB Indx-5.1 cTropnT-3.38*
[**2201-2-25**] 06:35AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8 Cholest-227*
[**2201-2-27**] 05:39AM BLOOD calTIBC-98* Hapto-30 Ferritn-277 TRF-75*
[**2201-2-25**] 06:35AM BLOOD Triglyc-116 HDL-54 CHOL/HD-4.2
LDLcalc-150* LDLmeas-160*
.
2. Labs on discharge:
<<<<<<<<<<<<<<<<<<<<<<<<< >>>>>>>>>>>>>>>>>>>
------------
Microbiology:
[**2201-2-28**] 11:06 am BLOOD CULTURE SIDE PORT IABP.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2201-3-1**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 9-0936 1/330/11 12:25PM.
GRAM POSITIVE COCCI IN CLUSTERS.
------------
Imaging:
ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to akinesis of the posterior
wall and severe hypokinesis of the inferior and lateral walls.
The right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
1st Cardiac Cath:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated 3 vessel coronary artery disease. The LMCA had 20%
ostial
stenosis. The LAD had 90% stenosis proximal to D1. There was
60%
stenosis in a Ramus. The LCx was totally occluded and a large
OM1
filled via left-to-left collaterals. The RCA was totoally
occluded at
mid-vessel and filled via left-to-right collaterals.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal systemic arterial pressures.
3. CT Surgery consulted for CABG.
.
2nd cardiac cath:
Interventional details
Change for 6 French XB3.5 guide. Crossed with ChoICE PT XS wire
into the upper pole of the OM. Then a 2.5 mm balloon was was
used to perform inflations. A 2.5 x 24 mm Endeavor stent was
deployed.
Attention was then turned to the LAD. The ChoICE PT XS [**Name (NI) **] was
redirected into this vessel without difficulty and placed in the
distal LAD. A 2.5 x 24 mm Endeavor stent was deployed. Final
angiography of this vessel revealed normal flow, no dissection
and 0% residual stenosis. At this point, a small distal edge
dissection of the Cx was noted as well as occlusion of a lower
pole of this vessel which could not be appreciate previously
because the vessel was totally occluded proximally. The ChoICE
PT XS wire was redirected into the distal OM upper pole and a
2.5
x 12 mm Endeavor stent was deployed completely covering the
dissection. A Pilot 50 wire was directed into the lower tiny
pole of the OM, restoring flow and PTCA with a 2.0 mm balloon
was
performed restoring TIMI 2 flow in a 2.0 mm vessel. The wire
was
withdrawn from the lower pole and the Stents in the OM were
postdilated with a 2.5 x 15 mm Quantum Apex balloon. Final
angiography revealed normal flow in the LAD, Cx and Upper pole
OM
in the stented portion. The lower pole OM had TIMI 2 flow.
COMPLICATIONS: None
Assessment & Recommendations
1. Plavix 75 mg PO QD x 12 months uninterrupted
2. Successful PTCA and stenting of the OM and LAD with DES
3. Successful IABP insertion
4. ASA indefinitely
5. Secondary prevention CAD
6. Heparin to maintain PTT 50-70 sec while IABP in place.
.
- carotid ultrasound ([**2201-2-26**]): There is less than 40% stenosis
within the internal carotid arteries bilaterally.
.
- CT abdomen/pelvis ([**2201-2-26**]):
1. No evidence of retroperitoneal bleed.
2. Moderate-sized hiatal hernia.
3. Multiple large renal cysts with ill defined small region of
hyperdensity that could represent calcium within cysts.
Recommend ultrasound for further characterization.
Brief Hospital Course:
This is a 76 year old male with a history of intermittent chest
pain over the past 2 days associated with epigastric pain and
mild nausea, relieved with nitroglycerin, and EKG changes
consistent with anterolateral ischemia and elevated troponins
suggestive of NSTEMI who underwent Cath and had 3 vessel
coronary artery disease.
.
# Non-ST elevation myocardial infarction (NSTEMI): Patient was
found on cardiac catheterization to have 3 vessel disease (LAD,
LCx, RCA). The original plan was to pursue CABG however patient
developed hypotension on the morning after catherterization and
was unresponsive to fluids. He had an immediate ECHO which
showed a non-compressable IVC, and a moderately reduced EF with
3+ MR. A CT of the abd/pelvis did not reveal a retroperitoneal
bleed. He was transferred to the CCU. Repeat catheterization was
performed with placement of drug-eluting stents (DES) to the
obtuse marginal(OM) and left anterior descending (LAD) arteries,
as well as an intra aortic ballon pump (IABP). Patient was
weaned off the ballon pump prior to discharge. Low dose ace
inhibitor and beta blocker were re-started. He was discharged on
daily high dose aspirin and plavix, low dose lisinopril and
metoprolol.
.
# Fever/bacteremia: Blood culture was positive for Gram positive
cocci in clusters, 1 out of 4 bottles from side port of IABP,
likely a contaminant. Patient was treated with IV Vancomycin,
which was discontinued when his surveillance cultures were
negative for > 48 hours. He was afebrile for 24 hours prior to
discharge. Two sets of blood culutres were pending at time of
discharge, but remained no growth to date. These should be
followed up on by his Primary Care Physician.
.
# Respiratory distress: CXR was suggestive of pulmonary
congestion and patient had desaturation in oxygen level after
small (250cc) boluses. He was gently diuresed with IV lasix with
improvement of respiratory function. He was transitioned to oral
Lasix after balloon pump discontinued, and started on Lasix 20
at discharge. He was restarted on home advair.
.
# Acute renal failure: On admission, Cr was 1.2, which peaked at
1.6, likely due to dye from cardiac catheterization. Patient was
able to maintain good urine output throughout. Prior to
discharge, Cr trended down and was 1.2 on discharge.
.
# Hypertension: Patient remained hypo- to normotensive
throughout the hospital course. Lisinopril and metoprolol were
initially held, then re-started at Lisinopril 5 daily and
Metoprolol SR 25 daily.
.
# Depression: Continued on home lorazapem and trazadone PRN
.
# Hypothyroidism : Continued on levothyroxine 50 mcg po qd.
.
# Gout: Allopurinol was held due to acute renal failure. This
was re-started on discharge, as renal function improved to
baseline.
.
# Other: The patient was evaluated by Physical Therapy, and
discharged home with a cane for ambulation.
Medications on Admission:
MEDICATIONS (on transfer):
Allopurinol 100 mg PO/NG DAILY
Aspirin 325 mg PO/NG DAILY
Citalopram 60 mg PO/NG DAILY
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Heparin IV per Weight-Based Dosing Guidelines
Levothyroxine Sodium 50 mcg PO/NG DAILY
Lisinopril 40 mg PO/NG DAILY
Lorazepam 0.5 mg PO/NG Q8H:PRN anxiety
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Mupirocin Nasal Ointment 2% 1 Appl NU [**Hospital1 **]
Omeprazole 20 mg PO DAILY
Rosuvastatin Calcium 10 mg PO DAILY
traZODONE 50 mg PO/NG HS:PRN
.
MEDICATIONS (home):
lorazepam 0.5 mg [**Hospital1 **] PRN anxiety
lisinopril 40 mg daily
levothyroxine 50 mcg daily
ranitidine 150 mg [**Hospital1 **]
tamsulosin 0.4 mg daily
allopurinol 100 mg daily
omeprazole 20 mg daily
fluticasone 50 mcg nasal spray [**Hospital1 **]
citalopram 60 mg daily
trazadone 50 mg qhs
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for anxiety.
4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
puff Inhalation twice a day.
7. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes as needed for chest pain.
Disp:*25 tablets* Refills:*0*
14. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Hypertension
Acute Systolic Dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a heart attack and required two drug eluting stents in
the your heart arteries to keep them open and restore blood flow
to the heart muscle. You developed fevers after the procedure
but all of the cultures were negative. The fevers went away on
their own and antibiotics were discontinued. You will need to be
on some new medicines to help your heart work better as it is
somewhat weak after the heart attack. You will need to take
Aspirin and Plavix every day for at last one year to prevent the
stents from clotting off and causing another heart attack. Do
not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) 1923**]
tells you it is OK. You had some fluid retention during your
hospital stay that is related to your weaker heart. Please watch
for swelling in your legs and follow a low sodium diet.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 1923**] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
We made the following changes to your medicines:
1. Start taking aspirin 325 mg and Plavix 75 mg to prevent the
stent from clotting off
3. Stop taking Omeprazole, it interferes with the Plavix, you
can continue to take ranitidine
4. Decrease the Lisinopril to 5 mg daily
5. Start taking Metoprolol Succinate to slow your heart rate and
help your heart recover from the heart attack
6. Start taking nitroglycerin as needed if you have chest pain
at home. Take up to 3 tablets 5 minutes apart. Please call Dr.
[**Last Name (STitle) 1923**] if you take this medicine and call 911 if you still
have chest pain after 3 [**Last Name (STitle) 4319**].
7. Start taking furosemide to prevent fluid retention.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 28551**]
When: Tuesday, [**3-10**], 1PM
Department: Cardiology
Location: [**Location (un) 2274**]-[**Location (un) 2277**]
Phone: [**Telephone/Fax (1) 2258**]
[**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 2564**], NP
Date/time: [**3-25**] at 1:00pm
|
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icd9cm
|
[
[
[]
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[
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|
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233, 267
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4039, 4182
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363, 2052
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3219, 4020
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13450, 13595
|
2236, 2314
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2074, 2112
|
2330, 2546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,868
| 169,973
|
52924+52925
|
Discharge summary
|
report+report
|
Admission Date: [**2164-9-29**] Discharge Date: [**2164-9-30**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
Ms. [**Known lastname 1007**] is a 74 yo woman with a history of ESRD on
hemodialysis, DM, HTN, PVD, afib, and hyperlipidemia who
presents to ED with respiratory distress. Of note, patient was
discharged on [**9-27**] by this ICU team. That admission she was
treated for acute CHF as well, requiring Bipap, which resolved
with dialysis. That admission she was noted to have
tacharrhythmia to 150s briefly during HD which improved
spontaneously and the decision was made to given verapamil prior
to dialysis. Also here INR was supratherapeutic and her [**Month/Day (4) **]
was held. This was thought to be [**1-23**] increased dose of
amiodarone. That admission was after being discharged from [**Hospital1 18**]
hours prior in which she was treated for hypotension with
dialysis, a typical presentation for her on multiple admission
in the past.
.
In the ED, thought to be in heart failure based on tachypnea to
the 40s. She was given 2 sprays of nitro and cpap. Dialysis
session completed today per resident but [**Name8 (MD) **] RN endorsed that she
had not completed dialysis. No CP or fevers. Admission vitals
98.1 106 159/93 30 30 100%. CXR wet. She was given nitro gtt,
enalapril 0.625mg, and asa 325mg. Her trop was at [**Name8 (MD) 5348**].
Weaned off bipap. Recent vitals 84 141/7 20 100%4L. 20G EJ was
placed.
.
Currently, the patient was in no distress. She described going
home and feeling fine. She went to dialysis the day before
admission but it was stoppped early due to the fact she was
having diarrhea. She says the diarrhea has since resolved. She
denied N/V, abd pain, fever, chills or cough. Per patient she
denied chest pain and her blood pressure did not drop during
dialysis. After dialysis she went home and played cards with her
friends, ate a hot saugage and layed down. Upon doing so, she
felt acutely short of breath and called 911. No associated
symtoms with this episode.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Hypertension.
2. Atrial flutter, status post ablation with recurrent atrial
fibrillation.
3. Significant left ventricular hypertrophy with LVOT gradient
and severe diastolic dysfunction.
4. End-stage renal disease on hemodialysis.
5. Diabetes.
6. COPD - home O2, 2-3L
7. Hyperlipidemia
8. PVD s/p bilateral BKAs
9. glaucoma, left eye blindness
10. GERD
Social History:
-EtOH: Denies use
-Tobacco: 30 pack year history, now smokes about 6 cigarettes
per day, re-lighting the butts intermittantly throughout the
day.
-Drugs: IV drug use.
She lives alone in [**Hospital3 **], has once weekly [**Location (un) 86**] [**Location (un) 269**]
and 5 days a week home health aide. Is mobile with prostheses
and walker or her wheelchair.
Family History:
Father with DM2, Mother deceased of stroke. Siblings died of
cancer (unknown type), stroke and brain cancer. Seven health
children. Extended family history positive for CAD, cancer and
DM.
Physical Exam:
Tmax: 36.9 ??????C (98.5 ??????F)
Tcurrent: 36.9 ??????C (98.5 ??????F)
HR: 83 (83 - 86) bpm
BP: 154/83(101) {135/65(78) - 154/83(101)} mmHg
RR: 23 (14 - 23) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: Well nourished, No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), S4, (Murmur:
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : B/L)
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender:
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, b/l BKA
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Not assessed
Pertinent Results:
[**2164-9-29**] 01:20AM BLOOD WBC-10.9 RBC-3.21* Hgb-9.2* Hct-31.3*
MCV-97 MCH-28.7 MCHC-29.5* RDW-19.0* Plt Ct-287
[**2164-9-29**] 09:55AM BLOOD WBC-10.0 RBC-3.13* Hgb-8.8* Hct-30.7*
MCV-98 MCH-28.2 MCHC-28.8* RDW-18.9* Plt Ct-274
[**2164-9-30**] 08:45AM BLOOD WBC-9.9 RBC-3.71* Hgb-10.8* Hct-36.3
MCV-98 MCH-29.2 MCHC-29.8* RDW-18.7* Plt Ct-242
[**2164-9-30**] 11:00PM BLOOD WBC-10.8 RBC-3.82* Hgb-10.9* Hct-37.1
MCV-97 MCH-28.6 MCHC-29.5* RDW-17.8* Plt Ct-294
[**2164-9-29**] 01:20AM BLOOD Neuts-86.1* Lymphs-7.0* Monos-4.3 Eos-2.2
Baso-0.5
[**2164-9-30**] 11:00PM BLOOD Neuts-84.2* Lymphs-9.2* Monos-3.4 Eos-3.0
Baso-0.3
[**2164-9-28**] 06:00AM BLOOD PT-24.5* INR(PT)-2.3*
[**2164-9-29**] 01:20AM BLOOD PT-21.7* PTT-29.0 INR(PT)-2.0*
[**2164-9-29**] 01:20AM BLOOD Plt Ct-287
[**2164-9-29**] 09:55AM BLOOD PT-25.2* PTT-45.6* INR(PT)-2.4*
[**2164-9-29**] 09:55AM BLOOD Plt Ct-274
[**2164-9-30**] 08:45AM BLOOD PT-29.0* PTT-33.4 INR(PT)-2.9*
[**2164-9-30**] 08:45AM BLOOD Plt Ct-242
[**2164-9-30**] 11:00PM BLOOD PT-31.1* PTT-31.0 INR(PT)-3.1*
[**2164-9-30**] 11:00PM BLOOD Plt Ct-294
[**2164-9-29**] 01:20AM BLOOD Glucose-137* UreaN-27* Creat-4.2* Na-146*
K-3.9 Cl-106 HCO3-30 AnGap-14
[**2164-9-29**] 09:55AM BLOOD Glucose-100 UreaN-32* Creat-4.7* Na-145
K-4.0 Cl-104 HCO3-32 AnGap-13
[**2164-9-30**] 08:45AM BLOOD Glucose-114* UreaN-45* Creat-5.9*# Na-139
K-5.0 Cl-102 HCO3-23 AnGap-19
[**2164-9-30**] 11:00PM BLOOD Glucose-176* UreaN-56* Creat-7.0*# Na-140
K-5.0 Cl-101 HCO3-23 AnGap-21*
[**2164-9-29**] 01:20AM BLOOD CK(CPK)-58
[**2164-9-29**] 09:55AM BLOOD CK(CPK)-47
[**2164-9-29**] 09:00PM BLOOD CK(CPK)-65
[**2164-9-30**] 11:00PM BLOOD CK(CPK)-57
[**2164-9-29**] 01:20AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 109115**]*
[**2164-9-29**] 01:20AM BLOOD cTropnT-0.09*
[**2164-9-29**] 09:55AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2164-9-29**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2164-9-30**] 11:00PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier **]*
[**2164-9-30**] 11:00PM BLOOD cTropnT-0.09*
[**2164-9-29**] 01:20AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7
[**2164-9-29**] 09:55AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.6
[**2164-9-30**] 08:45AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
[**2164-9-30**] 11:00PM BLOOD Calcium-9.1 Phos-5.1*# Mg-2.2
[**2164-9-29**] 01:32AM BLOOD Lactate-1.0
[**2164-9-30**] 11:04PM BLOOD Glucose-174* K-5.0
[**2164-9-29**] 01:32AM BLOOD Type-ART pO2-215* pCO2-48* pH-7.43
calTCO2-33* Base XS-7
[**2164-9-30**] 11:43PM BLOOD Type-ART pO2-55* pCO2-42 pH-7.38
calTCO2-26 Base XS-0
Chest X-ray ([**9-29**])- IMPRESSION: Findings consistent with
pulmonary edema.
Chest X-ray ([**9-30**])- IMPRESSION: Moderate pulmonary edema is
perhaps slightly improved compared to one day prior, but
persistent. Probable bilateral tiny pleural effusions
Brief Hospital Course:
MICU COURSE:
Ms. [**Known lastname 1007**] was admitted to the medical ICU for acute diastolic
CHF. The preceeding day she had dropped her blood pressures at
HD and had some fluid returned. She was managed with
nitroglycerin drip briefly and then underwent hemodialysis in
the morning. She required noninvasive ventilation in the ED
though this weaned down to nasal cannula with the interventions.
ECG did not suggest pneunomia, only volume overload. Her
symptoms improved and she was transferred to the floor.
FLOOR COURSE:
# Hypoxia/respiratory distress: Patient did well on the floor.
Her exacerbation most likely was due to dietary indiscretion as
she reports additional salt load (ate sausage recently) in
combination with underdiuresis in dialysis. She was
fluid-overloaded on exam (rales on lung exam, overload on CXR
and elevated BNP). She required CPAP while in ED but was easily
weaned to nasal cannula. Patient did not complain of chest pain
and EKG changes were absent. PE was low on the differential as
she was therapeutic on [**Known lastname **] and CXR was consistent overload.
She does have a history of COPD and requires 2L of NC oxygen at
home. She underwent dialysis here and had fluid removed. Her
blood pressures tolerated the procedure well and her shortness
of breath resolved. After dialysis she was back at her [**Known lastname 5348**]
oxygen requirement. Upon discharge, patient was heomdynamically
stable and asymptomatic.
# Hypertension- Patient has history of [**Last Name (un) 15970**] blood pressures.
She was hemodynamically stable while here. Continued her on her
home metoprolol, lisinopril, and verapamil. She denied chest
pain and her cardiac enzymes were at patient's [**Last Name (un) 5348**]. EKGs
were unchaged.
# ESRD: Patient was volume overloaded on exam. She received HD
with UF x 1 and fluid status improved. She did well and was
stable on discharge. Renal was following patient throughout
admission. She is to continue her outpatient dialysis schedule
(M, W, F).
# Afib: She was found to be in a tachyarrhythmia with rates into
150 on admission. She was given an increased dose of amiodarone
(400mg daily) and converted into sinus with a normal rate. Her
INR was therapeutic on admission so her [**Last Name (un) **] was continued
at home doses. Upon discharge, she is to continue amiodarone
400mg PO daily for rhythm control with plans to taper to 200mg
PO daily on [**10-7**]. She will also continue home verapamil and
metoprolol for rate control.
# COPD: See above. Shortness of breath improved after HD with
UF. Patient does require oxygen at home. She was continued on
home PRN albuterol with standing [**Month/Year (2) 35480**] and fluticasone.
# DM2: continued on NPH 4 units [**Hospital1 **], add on RISS with QID FS
with good control of her sugars. She was also continued on home
aspirin and statin
# Glaucoma: continued home eye drops
# GERD: continued home PPI and H2 blocker
# FEN: no IVFs / replete lytes with dialysis / regular diet
# PPX: home PPI, therapeutic on [**Hospital1 **], bowel regimen
# CODE: full
# CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DAUGHTER Phone: [**Telephone/Fax (1) 109114**]
Medications on Admission:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for cough,
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 * Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours). Disp:*90 Tablet(s)* Refills:*2*
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
13. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 1 bottle* Refills:*2*
14. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical ASDIR (AS DIRECTED).
Disp:*1 1* Refills:*2*
15. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): 1 DROP LEFT EYE HS . Disp:*1 1 bottle* Refills:*2*
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
18. Acetaminophen 500 mg Capsule Sig: One (1) Capsule PO once a
day as needed for headache.
Disp:*30 Capsule(s)* Refills:*0*
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: After 2 weeks, please decrease back to 200mg daily.
Disp:*14 Tablet(s)* Refills:*0*
21. Warfarin Oral
22. Novolin N 100 unit/mL Suspension Sig: Four (4) unit
Subcutaneous twice a day.
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for cough.
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
13. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
14. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical ASDIR (AS DIRECTED).
15. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Acetaminophen 500 mg Capsule Sig: One (1) Capsule PO once a
day as needed for headache.
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
20. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day:
for 2 weeks (day 1- [**9-27**]): After 2 weeks, please decrease back
to 200mg daily. .
21. Warfarin Oral
22. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
23. Novolin N 100 unit/mL Suspension Sig: Four (4) units
Subcutaneous twice a day: subcutaneous twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Primary:
Acute Diastolic CHF
Supratherapeutic INR
Tachyarrhythmia
Secondary:
ESRD on dialysis
Diabetes
Discharge Condition:
Good. Vital signs stable.
Discharge Instructions:
You were admitted to the hospital with a heart failure
exacerbation. While here, you received dialysis and your
symptoms improved dramatically. You were transferred to the
floor and did well.
No changes were made to your medications. Please resume them as
prescribed by your outpatient physicians.
If you experience any fevers, chills, chest pain, shortness of
breath, or any other medically concerning symptoms, please
contact your primary care physician or go to the emergency
department immediately.
You should continue taking the amiodarone 400mg by mouth daily
until [**10-7**] at which point you should start taking 200mg
daily.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L per day
Followup Instructions:
Continue your dialysis every Monday, Wednesday, Friday. You are
scheduled to get dialysis on [**2164-10-1**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-24**]
1:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2164-10-29**] 9:00
Completed by:[**2164-11-7**] Admission Date: [**2164-9-30**] Discharge Date: [**2164-10-6**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 1007**] is a 74 y.o. F with ESRD on HD, DM, HTN, atrial
fibrillation on [**Known lastname **], and diastolic CHF ([**Known lastname 113**] [**1-/2164**]), who
presents with shortness of breath after a discharge earlier in
the day. The patient noted that she had shortness of breath at
home after trying to take her medications. She then called an
ambulance. Per ED resident, pt was given 20 sprays of NTG in
the field and arrived on CPAP.
.
In the ED, initial VS: T 97.5 HR 115 BP 171/100 RR 34 100%
CPAP.
Labs, including cardiac enzymes, were drawn. Nitro gtt was
started as sbp in 180s. BP trended to 164/90 and NTG increased
to 4.4 ml/hour. Given Captopril 25 mg po x 1. ABG sent on CPAP.
Vent settings on transfer PS 15/PEEP 5/ O2 24%.
.
Currently, the patient feels much better and her SOB is much
improved.
Past Medical History:
1. Hypertension.
2. Atrial flutter, status post ablation with recurrent atrial
fibrillation.
3. Significant left ventricular hypertrophy with LVOT gradient
and severe diastolic dysfunction.
4. End-stage renal disease on hemodialysis.
5. Diabetes.
6. COPD - home O2, 2-3L
7. Hyperlipidemia
8. PVD s/p bilateral BKAs
9. glaucoma, left eye blindness
10. GERD
Social History:
- EtOH: Denies use
- Tobacco: 30 pack year history, now smokes about 6 cigarettes
per day, re-lighting the butts intermittantly throughout the
day.
- Drugs: IV drug use. She lives alone in [**Hospital3 **], has
once weekly [**Location (un) 86**] [**Location (un) 269**] and 5 days a week home health aide. Is
mobile with prostheses and walker or her wheelchair.
Family History:
Father with DM2, Mother deceased of stroke. Siblings died of
cancer (unknown type), stroke and brain cancer. Seven healthy
children. Extended family history positive for CAD, cancer and
DM.
Physical Exam:
Vitals - T: 95.5 BP: 94/56 HR: 82 RR: 11 02 sat: 100% on
CPAP 30% PEEP 5
GENERAL: elderly malaised appearing female on NC
HEENT: EOMI, anicteric, no cervical LAD
CARDIAC: RRR, nl S1, S2, no m/r/g
LUNG: bibasilar crackles to mid lung fields, no wheezes/rhonchi
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e, bilateral BKAs
NEURO: A&O
DERM: no rashes noted
Pertinent Results:
[**2164-9-30**] 11:43PM TYPE-ART PO2-55* PCO2-42 PH-7.38 TOTAL CO2-26
BASE XS-0
[**2164-9-30**] 11:04PM GLUCOSE-174* K+-5.0
[**2164-9-30**] 11:00PM GLUCOSE-176* UREA N-56* CREAT-7.0*#
SODIUM-140 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-21*
[**2164-9-30**] 11:00PM CK(CPK)-57
[**2164-9-30**] 11:00PM cTropnT-0.09*
[**2164-9-30**] 11:00PM CK-MB-6 proBNP-[**Numeric Identifier **]*
[**2164-9-30**] 11:00PM CALCIUM-9.1 PHOSPHATE-5.1*# MAGNESIUM-2.2
[**2164-9-30**] 11:00PM WBC-10.8 RBC-3.82* HGB-10.9* HCT-37.1 MCV-97
MCH-28.6 MCHC-29.5* RDW-17.8*
[**2164-9-30**] 11:00PM NEUTS-84.2* LYMPHS-9.2* MONOS-3.4 EOS-3.0
BASOS-0.3
[**2164-9-30**] 11:00PM PLT COUNT-294
[**2164-9-30**] 11:00PM PT-31.1* PTT-31.0 INR(PT)-3.1*
[**2164-9-30**] 08:45AM GLUCOSE-114* UREA N-45* CREAT-5.9*#
SODIUM-139 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-19
[**2164-9-30**] 08:45AM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2164-9-30**] 08:45AM WBC-9.9 RBC-3.71* HGB-10.8* HCT-36.3 MCV-98
MCH-29.2 MCHC-29.8* RDW-18.7*
[**2164-9-30**] 08:45AM PLT COUNT-242
[**2164-9-30**] 08:45AM PT-29.0* PTT-33.4 INR(PT)-2.9*
[**2164-9-29**] 09:00PM CK(CPK)-65
[**2164-9-29**] 09:00PM CK-MB-NotDone cTropnT-0.09*
[**2164-9-29**] 09:55AM GLUCOSE-100 UREA N-32* CREAT-4.7* SODIUM-145
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-32 ANION GAP-13
[**2164-9-29**] 09:55AM CK(CPK)-47
[**2164-9-29**] 09:55AM CK-MB-NotDone cTropnT-0.09*
[**2164-9-29**] 09:55AM CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-1.6
[**2164-9-29**] 09:55AM WBC-10.0 RBC-3.13* HGB-8.8* HCT-30.7* MCV-98
MCH-28.2 MCHC-28.8* RDW-18.9*
[**2164-9-29**] 09:55AM PLT COUNT-274
[**2164-9-29**] 09:55AM PT-25.2* PTT-45.6* INR(PT)-2.4*
[**2164-9-29**] 01:20AM PT-21.7* PTT-29.0 INR(PT)-2.0*
[**2164-9-29**] 01:20AM PLT COUNT-287
[**2164-9-29**] 01:20AM NEUTS-86.1* LYMPHS-7.0* MONOS-4.3 EOS-2.2
BASOS-0.5
[**2164-9-29**] 01:20AM WBC-10.9 RBC-3.21* HGB-9.2* HCT-31.3* MCV-97
MCH-28.7 MCHC-29.5* RDW-19.0*
[**2164-9-29**] 01:20AM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2164-9-29**] 01:20AM CK-MB-NotDone proBNP-[**Numeric Identifier 109115**]*
[**2164-9-29**] 01:20AM cTropnT-0.09*
[**2164-9-29**] 01:20AM CK(CPK)-58
[**2164-9-29**] 01:20AM GLUCOSE-137* UREA N-27* CREAT-4.2*
SODIUM-146* POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-30 ANION GAP-14
[**2164-9-29**] 01:32AM LACTATE-1.0
EKG [**2164-9-30**]: sinus tach at 100 bpm, nl axis, nl intervals, no Q
waves, no acute ST changes (no changes compared to prior on
[**2164-9-26**])
Chest X-ray ([**2164-9-29**])- IMPRESSION: Findings consistent with
pulmonary edema. Repeat radiograph after treatment is
recommended.
Chest X-ray ([**2164-10-1**]) : IMPRESSION: Improved pulmonary edema,
with unchanged cardiomegaly and tiny bilateral pleural
effusions.
Chest X-ray ([**2164-10-4**])- IMPRESSION: Further improvement and
practical normalization of chest findings in patient who
suffered from advanced pulmonary edema on multiple previous
chest examinations.
Brief Hospital Course:
****MICU course****
Admitted with shortness of breath, with increased pulm edema on
CXR, responsive to nitro gtt and CPAP which was discontinued
upon arrival to the ICU. She was dialyzed and 1.5L was removed
but she dropped her pressure and had some substernal chest
discomfort. EKG showed Afib/flutter at the time. CP resolved
with 500cc fluid given back.
****Floor course*****
That patient was transferred to the floor after doing well in
the unit. While on the floor, she denied any shortness of
breath. She was comfortable and did well on RA. She had an
[**Month/Day/Year **] on [**10-2**] which showed an EF of >55% and "severe symmetric
left ventricular hypertrophy with small cavity and hyperdynamic
systolic function. Moderate mitral stenosis from mitral annular
calcifications. At least mild mitral regurgitation. Mild
pulmonary hypertension". Her verapamil dose was increased from
40mg to 60mg Q8hr to improve ventricular filling. Due to the
high volume of admissions in the last week or so, the decision
was made to monitor her overnight and on a second session of
dialysis before considering discharging her. Overnight on
[**10-2**], she developed flash pulmonary edema with elevated
pressures so she was transferred to the MICU. Shortness of
breath resolved after receiving BiPAP and patient stablized in
the unit. She was transferred back to the floor on [**10-3**].
Course is as below.
# Hypoxia/respiratory distress: Given recent admissions,
patient kept and dialyzed daily while here. Fluid was removed
each day and patient tolerated it well. She has a history of
[**Last Name (un) 15970**] blood pressures but her BP's remained stable during this
admission. Fluid status improved and shortness of breath
resolved. She returned to [**Last Name (un) 5348**] oxygen requirements and was
asymptomatic. She was weaned off nitro drip in ICU. No signs
of pneumonia (afebrile, no cough, normal WBC). INR therapeuatic
at 3.1 making PE unlikely. Denied any chest pain, dizziness,
headaches, or syncopal-like events. Ruled out for MI (cardiac
enzymes negative x 3, no EKG changes).
- continue home metoprolol, lisinopril, verapamil
# ESRD: Patient mildly volume overloaded on admission. Renal
followed patient throughout stay. She was dialyzed daily and
fluid was removed each time. Patient remained hemodynamically
stable and symptoms resolved by discharge. She is to continue
outpatient dialysis schedule on discharge.
# Atrial fibrillation: She was in sinus rhythm and
rate-controlled on transfer to the floor. Her INR was slightly
supratherapeutic on admission. [**Last Name (un) 197**] was held on admission
but was resumed prior to discharge. She was continued on
amiodarone 400mg PO daily for rhythm control as well as her rate
control medications (verapamil and metoprolol). Patient
monitored on telemetry. On discharge, her amiodarone was
decreased to 200mg daily.
# Hypertension: SBP [**Last Name (un) 5348**] 140-160s. She was on nitro drip in
ICU, which was weaned. She remained hemodynamically stable on
the floor. She was continued on home verapamil, lisinopril and
metoprolol. She was taking verapamil 60mg TID. In order to
simply her medication regimen, we switched her to verapamil SR
180mg daily.
# COPD: She requires oxygen at home. She was continued on PRN
albuterol and standing [**Last Name (un) 35480**], fluticasone
# DM2: Continued on regimen of NPH 4 units [**Hospital1 **], add on RISS with
QID FS as well as daily aspirin and statin. Sugars
well-controlled.
# Glaucoma: continued on home eye drops
# GERD: Patient on both PPI and H2 blocker. H2 blocker was
discontinued on this admission per pharmacy recs.
# FEN: no IVFs / replete lytes with dialysis / NPO except meds
overnight
# PPX: home PPI / ranitidine, supratherapeutic on [**Hospital1 **],
bowel regimen
# CODE: FULL
# CONTACT: [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) 10123**] (daughter) Phone: [**Telephone/Fax (1) 109114**]
Medications on Admission:
Albuterol Sulfate 90 mcg 1-2 puffs inhlation q6 hours prn cough
B Complex-Vitamin C-Folic Acid 1 caposule po daily
Brimonidine 0.15% 1 drop opth [**Hospital1 **]
Pantoprazole 40 mg po daily
Ranitidine 150 mg po [**Hospital1 **]
Simvastatin 40 mg po daily
Tiotropium bromide 18 mcg 1 capsule INH daily
Verapamil 40 mg po q8 hours
Calcium Acetate 667 mg po TID
Colace 100 mg po BID
Lisinopril 5 mg po daily
Fluticasone 50 mcg 1 spral nasal [**Hospital1 **]
Dorzolamide-Timolol 2-0.5% 1 drop opth [**Hospital1 **]
Lidocaine-Prilocaine 2.5-2.5% 1 applicaiton topical ASDIR
Latanoprost 0.005% 1 drop opth [**Hospital1 **]
Folic acid 1 mg po daily
Metoprolol Tartrate 25 mg po BID
Acetaminophen 500 mg po daily prn headache
Aspirin 81 mg po daily
Amiodarone 400 mg po daily for 2 weeks (day 1 [**9-27**]), after 2
weeks decrease back to 200 mg daily
[**Month/Day (4) 197**]
Novolin 4 units SQ [**Hospital1 **]
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for cough.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) APP
Topical ASDIR.
18. Acetaminophen 500 mg Capsule Sig: One (1) Tablet PO once a
day as needed for headache.
19. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day:
Take up to 4 tablets daily.
20. Novolin N 100 unit/mL Suspension Sig: Four (4) units
Subcutaneous twice a day.
21. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Primary:
Acute Diastolic CHF
Tachyarrhythmia
Secondary:
ESRD on dialysis
Diabetes
Discharge Condition:
Good. Vital signs stable.
Discharge Instructions:
You were admitted to the hospital because of shortness of breath
that required noninvasive ventilation to support your breathing.
We felt that this was most likely because of not getting enough
dialysis. You were dialyzed here daily and your breathing
improved. Upon discharge, you were stable and doing well.
The following changes were made to your medications:
1. Please take amiodarone 200mg by mouth ONCE per day
2. Please resume your [**Location (un) **] as prescribed by your primary
care physican (4mg per day on Sunday, Tuesday, Thursday and
Saturday/ 3mg per day on Monday, Wednesday and Friday)
3. Please take verapamil SR 180mg by mouth ONCE per day. You
were taking the immediate release form three times a day, but we
want you to now take the sustained release form ONCE per day.
STOP taking the 60mg tablets of verapamil three times per day.
If you experience any chest pain, shortness of breath, fevers,
chills, abdominal pain or any other medically concerning
symptoms, please contact your primary care physician or go to
the emergency department immediately.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-24**]
1:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2164-10-29**] 9:00
Completed by:[**2164-11-7**]
|
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icd9cm
|
[
[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,840
| 176,678
|
940
|
Discharge summary
|
report
|
Admission Date: [**2110-6-3**] Discharge Date: [**2110-6-8**]
Date of Birth: [**2047-4-24**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: Briefly, this is a 63 year old
male with a history of alcoholism, insulin dependent diabetes
mellitus, pancreatitis status post partial pancreatectomy who
presented with abdominal pain, decreased p.o., vomiting,
diaphoresis on [**2110-6-4**]. The patient was found to be in
ketoacidosis with low bicarb. He was admitted to [**Hospital Ward Name 517**]
and then transferred to medical ICU on the day of admission
secondary to EKG changes and alcohol withdrawal symptoms.
The patient subsequently ruled in for a small MI and was
admitted to the medicine floor from the MICU on [**2110-6-7**].
PAST MEDICAL HISTORY:
1. Alcohol abuse. The patient reports drinking one pint per
night with a history of morning tremors.
2. Hypertension.
3. History of pancreatitis status post partial
pancreatectomy.
4. Gastritis.
5. Coronary artery disease with history of RCA occlusion, EF
of 25% to 30%. The patient had cath in [**2-20**] which showed
hypokinetic anterior basal, anterior lateral, inferior and
posterior basal walls.
MEDICATIONS ON ADMISSION: NPH 8 units in the a.m. and 6
units in the p.m., Prilosec 20 mg p.o. q.d., Captopril 50 mg
p.o. t.i.d., folic acid 1 mg q.d., Wellbutrin SR 100 mg q.d.,
metoclopramide 10 mg q.i.d.
ALLERGIES: Morphine and Motrin.
SOCIAL HISTORY: The patient is married. Positive tobacco
and alcohol history as previously mentioned.
PHYSICAL EXAMINATION: On transfer to the floor from MICU the
patient was a well appearing, black male in no apparent
distress. Answered questions, but not very conversant.
Appropriate. Cardiovascular exam revealed regular rate and
rhythm, no murmurs, rubs or gallops. Respirations were clear
to auscultation bilaterally. Abdomen was soft, nontender,
nondistended with positive bowel sounds and old scars.
Extremities showed no clubbing, cyanosis or edema.
LABORATORY DATA: On admission hematocrit was 40.4; by
discharge it had dropped to 33.4. White blood cell remained
stable throughout admission at 6. Platelet count went from
255 to 154. INR was normal on check at 1.1. Sodium on
admission was 134 and went down to 127 on discharge. ALT and
AST remained in the 20s. Amylase was initially 175 and went
down to 50 prior to discharge. Lipase was 207 and went down
to 18 by discharge. Troponin on [**6-5**] was elevated at 6.7 and
subsequently dropped to 3.7. MB peak was 8. The patient did
have large acetone on [**6-3**] was repeated and normal on [**6-5**].
Negative tox screen. Chest x-ray during admission showed
COPD, left ventricular hypertrophy, but no CHF or pneumonia.
HOSPITAL COURSE:
1. Gastrointestinal. The patient initially had pancreatitis
which resolved by enzymes. He also had little p.o. intake on
admission, but his diet was eventually advanced to full with
minimal abdominal pain. The patient was maintained on Reglan
and given Zantac during admission. He was kept on aspirin
because of coronary artery disease, but ideally that would be
discontinued.
2. Endocrinology. The patient was initially on an insulin
drip which was able to be weaned and the patient was on his
outpatient regimen of NPH with regular insulin sliding scale
for coverage by discharge. The patient also had pretty good
blood sugars prior to discharge.
3. Cardiovascular. The patient suffered a small myocardial
infarction as seen by increase in MB as well as troponin.
Cardiology followed the patient throughout his admission and
recommended medical management only. The patient was maxed
on Lopressor and ACE inhibitor.
4. Fluids, electrolytes and nutrition. The patient
developed low sodium during his admission. This was felt
secondary to low p.o. intake and the patient has been
encouraged to free water restrict, but eat a regular diet and
drink salty type fluids. The patient will need this checked
as an outpatient.
5. Renal. The patient initially had respiratory alkalosis
which resolved, followed by metabolic acidosis which also
resolved.
6. Psych. The patient was initially on the CIWA scale with
Ativan coverage, but little Ativan was needed and the patient
was weaned off CIWA after several days. The patient did
receive thiamine, folate, multivitamin for his history of
alcoholism.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Alcohol withdrawal.
3. Pancreatitis.
4. Non-Q wave MI.
DISCHARGE MEDICATIONS:
1. NPH 8 units in the morning, 6 units in the evening.
2. Thiamine 100 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Multivitamin p.o. q.d.
5. Folate 1 mg p.o. q.d.
6. Captopril 12.5 mg t.i.d.
7. Lopressor 75 mg p.o. t.i.d.
8. Prilosec 20 mg p.o. q.d.
9. Neutra-Phos one pack p.o. t.i.d.
10. Reglan 10 mg p.o. q.i.d.
11. Magnesium oxide 800 mg p.o. b.i.d.
12. Tylenol 650 mg p.o. q.four hours p.r.n.
13. Oxycodone 5 mg q.six p.r.n.
FOLLOWUP: The patient should follow up with Dr. [**Last Name (STitle) **], his
primary care, within the week for repeat blood work. The
patient needs chem-10 to make sure his cal, mag and phos are
staying stable and that his sodium has also recovered.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 6269**]
MEDQUIST36
D: [**2110-6-8**] 14:30
T: [**2110-6-10**] 16:25
JOB#: [**Job Number 6270**]
|
[
"250.10",
"276.3",
"577.1",
"414.01",
"303.91",
"291.81",
"410.71",
"414.8",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
4425, 4514
|
4537, 5496
|
1216, 1432
|
2751, 4370
|
1560, 2734
|
164, 758
|
780, 1189
|
1449, 1537
|
4395, 4404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,299
| 124,775
|
43769+58655
|
Discharge summary
|
report+addendum
|
Admission Date: [**2163-9-15**] Discharge Date: [**2163-10-1**]
Date of Birth: [**2107-10-21**] Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Abacavir / Furosemide / Hayfever /
Iodine / Ziagen
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Diarrhea, altered mental status
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
55yo M with HIV (recent CD4 count 492, VL undetectable [**2163-8-18**]),
HTN, HLD, presenting for abdominal pain, transferred to the MICU
for acute renal failure, anemia, altered mental status.
The patient was seen recently in [**Company 191**] on [**8-18**] for right third toe
cellulitis which was treated with a 14 day course of Bactrim.
At that time, the patient had labs drawn which was significant
for Hct 27.4, Cr 1.9, as well as a CD4 count of 492 and an
undetectable viral load. The patient reports full compliance
with the full Bactrim course. He reports that his current
symptoms began 2 weeks ago with copious diarrhea which occurs
twice daily, associated with diffuse lower abdominal pain in a
band-like distribution. He denies hematochezia, melena, and
denies history of GI bleeds in the past. He subsequently
reports developing dyspnea which is worse with exertion over the
past week, but denies orthopnea and denies increased lower
extremity edema. He is unable to give further details in his
history due to somnolence. His partner thought he looked much
worse today so decided to take him in. His partner reports the
patient has been "sleeping for 20 hrs/day and has had diarrhea
for a week. He is incontinent of stool every time he stands up.
He is drinking fluids. He describes episodes of 'collapsing'
for the past 2-3 weeks with no other focal neuro symptoms."
Of note, the patient does have a history of polysubstance abuse,
and has been taking 2 Percocet 4 times a day. He reports a
history of crystal meth use last use was within last week, and
denies use of ADHD/ADD medications.
In the ED, initial VS were: 97.4 92 86/47 22 97%
He was found to have anemia of 18.5 and was guiac negative with
initial labs negative for hemolysis. He was given 2 units PRBC.
He also was found to have a BUN 141 and Cr 9.0 and was given 2L
NS with an increase of his SBP to the 110's. Given his diarrhea
and recent antibiotic use, he was given empiric Flagyl and stool
was sent for C. diff. CT abdomen/pelvis was ordered and showed
persistent chronic L UPJ obstruction with mild to moderate
hydronephrosis but no acute abnormalities. Serum tox and urine
tox was significant for Acetaminophen level of 11 and positive
urine amphetamines. Given his somnolence, CT head was ordered
which was negative. Per ED report, EKG showed sinus tach at 90,
it N8, QRS 116, QTC 422.
Upon arrival to the MICU, the patient was appropriate but
somnolent and A&Ox2-3 (oriented to person, place, but knew the
year but not the month). He otherwise reported improvement of
his symptoms and denied abdominal pain, nausea/vomiting, chest
pain, shortness of breath, or other complaints.
On review of systems, he reports an occipital headache radiating
to his neck but denies vision changes including blurry vision,
double vision, and denies significant neck stiffness or fevers.
He denies cough, chest pain, shortness of breath,
nausea/vomiting, or rash.
Past Medical History:
HIV(+)[**2141**]
peripheral neuropathy
CKD
chronic anemia
HTN
depression
s/p multiple hip replacements inc left total hip arthroplasty,
acetabular component only on [**2162-10-19**], L hip replacement
[**2162-10-6**] c/b septic arthritis
hx of spinal meningitis
hx of seizures s/p MVA
R rotator cuff surgery
Recently seen in [**Company 191**] for right third toe cellulitis, which was
treated per OMR notes with a 14 day course of Bactrim. Labs
drawn at that time were unremarkable, notable for a Cr 1.9 and
Hct 27.4 as well as Na 137, CD4 count 492, undetectable viral
load. The patient reports compliance with the full course of
Bactrim, which was scheduled to complete [**8-31**].
Social History:
Lives with his partner. Former cigarette smoker quit 2 yrs ago.
Drinks socially. Reports hx of crystal meth use, denies current
use.
Family History:
Mom HTN hip replacement
Dad HTN hip replacement
Reports that multiple members of family have had hip
replacements for arthritis at young age, attributes this to
heavy manual labor in family bakery.
Denies family history of renal disease including polycystic
kidney disease.
Physical Exam:
Admission Physical Exam:
Vitals: T:95.8 BP:95/48 P:90 R:16 O2:93%
General: Alert, no acute distress,Oriented but very lethargic,
responds to verbal stimuli and falls back to sleep mid-sentence
HEENT: Sclera anicteric,left ear lobe piercing with blood, dry
oral mucosa, black lesion on R edge of tongue, healing bite
marks on L side of tongue, dried blood on healing lesion on
inside of lower lip
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1, physiologic splitting of
S2, LLSB holosystolic murmur, crescendo-decrescendo murmur at
RUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft,+BS, non-distended, tender to deep palpation in
bilateral lower quadrants, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no cyanosis or edema, LLE
thinner than R, tattoos on RLE and RUE, several small lesions on
hands, healing scab over 3rd right toe, missing several toenails
Discharge PE:
VS: Tm 99.4 Tc 98.1 104/68 97 18 95 on RA
Gen: NAD, pleasant and conversational, AAO x3, alert and
appropriate
CV: RRR, nml S1/S2, no murmurs/rubs/gallops
lungs: CTAB, no wheezes/crackles appreciated
abdomen: soft, nondistended, nontender, +BS
GU: erythematous fine rash in distribution of diaper; extending
across upper thigh to buttock
extremities: 2+ DP pulses, no LE edema, R leg tatoo all the way
up to the hip
Neuro: no asterixis, [**5-12**] UE and LE strength b/l
Pertinent Results:
Admission Labs:
[**2163-9-15**] 12:00PM WBC-5.7 RBC-1.55*# HGB-6.4*# HCT-18.5*#
MCV-120* MCH-41.5* MCHC-34.6 RDW-14.4
[**2163-9-15**] 12:00PM NEUTS-92* BANDS-1 LYMPHS-7* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2163-9-15**] 12:00PM PLT SMR-NORMAL PLT COUNT-314
[**2163-9-15**] 12:00PM GLUCOSE-128* UREA N-141* CREAT-9.0*#
SODIUM-126* POTASSIUM-4.5 CHLORIDE-90* TOTAL CO2-16* ANION
GAP-25*
[**2163-9-15**] 12:00PM ALT(SGPT)-13 AST(SGOT)-11 LD(LDH)-172 ALK
PHOS-83 TOT BILI-0.3
[**2163-9-15**] 12:00PM LIPASE-36
[**2163-9-15**] 12:00PM HAPTOGLOB-327*
[**2163-9-15**] 12:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-11 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2163-9-15**] 12:17PM LACTATE-1.1
[**2163-9-15**] 01:52PM PT-12.6 PTT-25.2 INR(PT)-1.1
Discharge labs:
[**2163-9-30**] 06:43AM BLOOD Vanco-21.1*
[**2163-9-29**] 08:40AM BLOOD CRP-16.3*
[**2163-10-1**] 06:15AM BLOOD WBC-3.7* RBC-2.38* Hgb-7.9* Hct-22.9*
MCV-96 MCH-33.2* MCHC-34.5 RDW-19.2* Plt Ct-141*
[**2163-10-1**] 06:15AM BLOOD Glucose-85 UreaN-22* Creat-1.4* Na-138
K-4.8 Cl-105 HCO3-24 AnGap-14
[**2163-10-1**] 06:15AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
Studies:
.
CXR [**2163-9-15**]: Cardiac, mediastinal and hilar contours are normal.
The lungs are clear. There is no pleural effusion, pneumothorax,
or focal consolidation.
.
CT Head [**2163-9-15**]: No intracranial hemorrhage or other acute
intracranial process.
.
CT abd/pelvis [**2163-9-15**]: 1. No nephrolithiasis. Findings compatible
with chronic left UPJ obstruction, with minimal cortical
thinning of the left kidney, unchanged from prior studies. 2.
Diffusely fluid-filled right colon, likely reflecting patient's
provided history of diarrhea. Mild adjacent fat stranding and
prominent lymph nodes, likely reactive, are nonspecific.
Clinical correlation is advised. 3. Bowel-containing left
inguinal hernia, without complication.
.
TTE: [**2163-9-20**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Physiologic mitral regurgitation is seen (within normal limits).
There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2162-10-11**],
trace aortic regurgitation is now detected.
.
TEE: [**2163-9-22**]
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
.
IMPRESSION : No vegetation/mass seen.
Lumbar Spine MRI:
IMPRESSION:
1. Multilevel abnormal bone marrow signal likely representing
bone marrow
replacement as seen in anemic/HIV disorders. An infiltrating
process cannot be completely excluded.
2. L4-5 enplate changes with abnormal disc signal likely
degenerative in
nature. Discitis osteomyelitis less likely but cannot be
completely excluded in this noncontrast study. Contrast MRI is
suggested if clinically warranted.
3. Multilevel degenerative changes as described in detail above,
worse at L4-5 level.
.
b/l hip xray: [**2163-9-28**]
IMPRESSION: Bilateral total hip arthroplasties without hardware
loosening or
fracture. If there is high clinical concern for septic arthritis
ultrasound
to assess for the presence of an effusion, should be performed.
Bilateral hip US:IMPRESSION: No fluid identified in either hip.
Brief Hospital Course:
55M with PMH of HIV, recent CD4 492 and viral load of less than
48 copies/ml, CKD, admitted with diarrhea, abdominal pain,
sepsis, severe anemia, and acute renal failure. His course was
notable for slow to clear Staph aureus bacteremia and persistent
fever felt to be due to PICC line which was placed with negative
cultures, but have been placed with low grade bacteremia that
was not picked up on usual surveillance cultures.
.
#Staph aureus bacteremia:
Patient was admitted with sepsis, hypotensive requiring ICU
admission. Pt did not require pressors but was aggressively
fluid resuscitated. His initial blood cultures had no growth but
repeat cultures a few days later, drawn because of persistent
fever, grew MRSA. His cultures were slow to clear prompting
TTE/TEE and spine MRI (he developed new low back tenderness
during admission) which were all negative for vegetation,
abscess, diskitis, or osteomyelitis. Given that his cultures
were slow to clear the decision was made to continue Vancomycin
for a total course of 6 weeks from his date of discharge. This
date was determined because despite clearing his blood cultures
he continued to have low grade fevers. Workup for this including
Hip X-ray and ultrasound (looking for septic joint as cause;
[**Month/Day/Year 1957**] consulted and felt joint infection unlikely) was negative
and it was ultimately felt that low grade fevers were due to
PICC placement when cultures were no growth, but there may have
been some low grade bacteremia still present. After PICC was
removed the patient was afebrile for >48 hours and discharged to
rehab. He will be continued on Vancomycin for 6 weeks from day
of discharge. He was seen by Infectious Disease and the patient
will fu in outpatient [**Hospital **] clinic. Rifampin will most likely be
added for 2 weeks in the outpatient setting given his indwelling
hardware. It was ultimately felt that MRSA bacteremia was likely
from his previous toe ulcer.
.
#. Acute on Chronic Renal Failure due acute tubular necrosis:
He had a creatinine of 9.0 on admission, increased from his
baseline of 1.7-1.9. Muddy brown casts were seen on sediment
c/w acute tubular necrosis which was felt to be due to poor
renal perfusion in the setting of profuse diarrhea, hypotension,
and sepsis. He was hydrated and his renal function returned to
[**Location 213**] over the course of the hospitalization.
.
#Anemia: He had a new anemia with Hct of 17 from a baseline of
27-30. He had a macrocytosis felt to be due to his chronic
alcohol use plus ARV therapy. In addition, his reticulocyte
count was suppressed and he could potentially have marrow
suppression from Bactrim or from Etoh. His Hct increased
appropriately after 3 units PRBC transfusion. During his
hospital course, the patient received multiple units of blood.
It was unclear why his crits kept trending down. The patient
was guaic positive one time, but the rest of his stools were all
guaic negative. External rectal exam did not demonstrate any
hemorrhoids or possible bleeding source. Looking back through
OMR notes, the patient has been anemic for some time, but not it
has been thought to be mostly due to his ART/etoh use, given his
macrocytosis. The patient had a colonoscopy last year that was
normal. Although the patient required PRBCs over course of
hospital stay, his Hct was relatively stable and therefore the
patient was discharged to LTAC with instructions to check hct
periodically and transfuse as necessary. His PCP was made aware
of potential need for outpatient endoscopy should he continue to
require transfusions once his acute illness resolves.
.
#Diarrhea: Given that staph aureus bacteremia is well known to
cause diarrhea and patients diarrhea improved with treatment of
MRSA it is felt that diarrhea was due to MRSA bacteremia.
Additional stool studies were sent and were negative. He was
transiently on empiric flagyl which was discontinued when C.
diff PCR was negative. It was not felt he had an opportunistic
infection given his preserved CD4 count.
.
#Encephalopathy:
He was admitted with encephalopathy that was most likely due to
a combination of uremia and sepsis. He had asterixis that
improved with improvement in his infections and renal function
returning back to normal. It was also felt possible that some of
his encephalopathy could have been related to the build up of
psychiatric medications in the setting of acute renal failure
and these were held until his mental status improved to
baseline, which it did prior to discharge. His home psychiatric
medications were restarted at this time.
.
#. Hyponatremia: He had a Na of 126 on admission felt to be
related to hypovolemia. It improved to normal with IV
hydration. We aggressively hydrated the patient and repleted
his electrolytes as needed. Sodium 138 at time of discharge.
.
# ETOH abuse: The reports having a significant drinking history
prior to hospitalization (3 pitcher sized cocktails daily). He
was placed on CIWA on the medicine floor. He never scored high
enough on CIWA to get Lorazepam and it was eventually
discontinued.
.
#Lumbar low back pain: The patient was complaining of low back
pain and given his bacteremia, we wanted to rule out a source of
infection like epidural abscess. The patient had an L-spine MRI
that showed degenerative changes. Although no contrast was used
in this study, further study was not pursued as the patient will
be treated for 6 weeks with antibiotic therapy which would be
the treatment for low level diskitis or osteomyelitis.
.
Transitional Issues:
# Gabapentin: Please uptitrate the patient's Gabapentin dose as
tolerated as a outpatient.
.
# anemia: consider hematology outpatient visit to further
investigate the etiology of his anemia. Based on his
macrocytosis, his ART therapy and etoh abuse certainly
contribute to this anemia, but there still might be an
underlying contributing factor.
.
# bacteremia: The patient should follow up with ID re:
bacteremia and fax his weekly blood work to OPAT.
.
# fevers: If the patient spikes fevers again, consider IR guided
aspiration of hip joints to further evaluate for septic joints.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs(s) by mouth every four (4) to six (6) hours as needed for
cough/wheezing
ARIPIPRAZOLE [ABILIFY] - 2.5mg one tablet qhs
BUPROPION HCL - 150 mg Tablet Extended Release - One Tablet(s)
by mouth every day
CEPHALEXIN [KEFLEX] - 500 mg Capsule - 4 Capsule(s) by mouth
ONCE
Please 30 minutes prior to any dental procedure for the next 2
years
DARUNAVIR [PREZISTA] - 600 mg Tablet - Take one Tablet(s) by
mouth twice a day
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
FOLIC ACID - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day
GABAPENTIN [NEURONTIN] - 600 mg Tablet - 1 Tablet(s) by mouth
twice a day and two by mouth at bedtime
LAMIVUDINE [EPIVIR] - 150 mg Tablet - Take one Tablet(s) by
mouth
once a day
MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 to 2 Tablet(s)
by mouth four times a day as needed
PAROXETINE HCL [PAXIL] - 20 mg Tablet - 1 Tablet(s) by mouth
twice a day
QUETIAPINE [SEROQUEL] - 100 mg Tablet - one Tablet(s) by mouth
twice a day and 2 tablets by mouth at bedtime
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - Take one Tablet(s) by
mouth twice a day
RITONAVIR [NORVIR] - 100 mg Capsule - Take one Capsule(s) by
mouth twice a day
ZIDOVUDINE - 300 mg Tablet - Take one Tablet(s) by mouth twice a
day
LORATADINE - 10MG Tablet - TAKE ONE BY MOUTH EVERY DAY
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
cough/wheeze.
2. bupropion HCl 150 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
3. Keflex 500 mg Capsule Sig: Four (4) Capsule PO as directed:
please take 4 capsules by mouth once 30 minutes prior to any
dental procedure for the next 2 years.
4. darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. quetiapine 100 mg Tablet Sig: One (1) Tablet PO three times
a day: please take one tablet by mouth in AM, afternoon, and 2
tablets at bedtime.
11. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. zidovudine 100 mg Capsule Sig: Three (3) Capsule PO Q 12H
(Every 12 Hours).
14. loratadine 10 mg Tablet Sig: One (1) Tablet PO once daily
().
15. aripiprazole 5 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime): please take 2.5 mg before bedtime.
16. Outpatient [**Location **] Work
please check weekly CBC, BMP, and vancomycin troughs. Please
fax results to ID nurses [**Telephone/Fax (1) 1419**]
17. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours): please take vancomycin until
[**11-3**] .
18. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
19. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
q4h PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
primary diagnosis:
Staph aureus bactermia
human immunodeficiency virus
status post hip replacements bilaterally
acute tubular necrosis
diarrhea
secondary diagnosis:
anemia
high blood pressure
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 9499**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you had bad
diarrhea. In the emergency room, your blood pressures were low
and your kidney function was very bad and you were admitted to
the intensive care unit. Because your kidneys were not
filtering your blood properly, many toxins built up in your body
and your mental status was affected. In the intensive care
unit, you were given fluids and your blood pressures and kidney
function improved. Your mental status also began improving.
Once you were stable, you were transferred to the general
medicine floor.
On the floor, we continued to hydrate you and your mental status
and kidney functioned continued to improve. However, you were
having some fevers and we sent blood and urine samples and found
that there was bacteria growing in your [**Last Name (un) 22761**] and urine.
We consulted the infectious disease doctors and started [**Name5 (PTitle) **] on
antibiotics to treat the blood infection. We also talked to the
orthopedic surgeons to let them know what was going on just
because you have hip replacements and sometimes the bacteria can
invade hardware. We did some imaging of your hips (xray and
ultrasound) and both were normal. We also did imaging of your
feet, as before you were first admitted you had a cellulitis on
your toe and this may have been an entry point for bacteria;
this imaging also did not suggest any bone infection.
Because you were still having diarrhea, we started you on
antibiotics just in case you had another type of infection in
your intestines. Your diarrhea has since resolved, and you are
having hard bowel movements now.
You are still on antibiotics for the bacteria in your blood. We
are discharging you this antibiotic, Vancomycin, and you should
continue this medication until [**11-3**]. In order to take this
medication outside of the hospital, we needed to put a line in
your arm that gives us access to your veins. You will have to
get blood work done one time/week and fax the results to the
infectious disease clinic ([**Telephone/Fax (1) 1419**].
We made some changes to your medications:
START Vancomycin 750 mg intravenously every 12 hours until
[**2163-11-3**].
CHANGE Gabapentin to 300 mg by mouth two times per day
Followup Instructions:
** You missed your previously scheduled dermatology appointment
because you were still in hospital; please call ([**Telephone/Fax (1) 45763**]
to make appointment
.
** Please call [**Telephone/Fax (1) 457**] to make appointment with the
infectious disease doctors for [**Name5 (PTitle) **]-hospitalization follow up
within 2 weeks of discharge
.
Department: [**Hospital3 249**]
When: TUESDAY [**2163-10-4**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2163-11-4**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: [**Hospital3 249**]
When: THURSDAY [**2163-11-24**] at 2:20 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2163-10-1**] Name: [**Known lastname 14868**],[**Known firstname **] Unit No: [**Numeric Identifier 14869**]
Admission Date: [**2163-9-15**] Discharge Date: [**2163-10-1**]
Date of Birth: [**2107-10-21**] Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Abacavir / Furosemide / Hayfever /
Iodine / Ziagen
Attending:[**First Name3 (LF) 14870**]
Addendum:
Spoke with [**Hospital1 1238**] Attg after d/c that patient will need q3days
to qweek Hct checks. Will need to be transfused for Hct < 21.
Confirmed Vanco dose of 750mg q12.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 14871**] MD [**MD Number(2) 14872**]
Completed by:[**2163-10-1**]
|
[
"272.4",
"311",
"276.8",
"305.70",
"275.2",
"584.5",
"038.12",
"285.9",
"724.2",
"356.9",
"276.1",
"V08",
"787.91",
"995.91",
"599.0",
"348.31",
"305.01",
"276.2",
"V15.82",
"585.4",
"V43.64",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
24448, 24662
|
10174, 15716
|
370, 377
|
19930, 19930
|
5985, 5985
|
22505, 24425
|
4242, 4517
|
17796, 19586
|
19703, 19703
|
16350, 17773
|
20113, 22320
|
6766, 10151
|
4557, 5478
|
15737, 16324
|
22349, 22482
|
5492, 5966
|
299, 332
|
405, 3367
|
19869, 19909
|
6001, 6750
|
19722, 19848
|
19945, 20089
|
3389, 4076
|
4092, 4226
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,676
| 160,005
|
2016+55341
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-2-17**] Discharge Date: [**2200-3-8**]
Date of Birth: [**2138-2-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Protonix / Codeine / Venomil Honey Bee Venom /
Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
3 vessel CABG on [**2-24**]
History of Present Illness:
HPI: Mr. [**Known lastname **] is a 61 yo M with h/o HTN, hyperlipidemia, PVD,
and CKD who presented to [**Location (un) **] at 3 am with chest pain. 1 day
PTA, patient experienced a chest tightness and pressure while
working at his computer. He denied having sharp radiating pain,
SOB, palpitations, dizziness, headache, or nauseau. This
pressure had been on and off over the past 2 days, and improved
with NTG. Yesterday, the pressure was constant throughout the
day, despite taking 6 NTG sublingual tablets. Pt presented to
[**Hospital1 **] ED for evaluation. Pt was afebrile, HR 50's
sinus, BP 157/83, RR 18-20, Sat 95% 2L NC. He was admitted to
the CCU, where second set of cardiac enzymes ruled in with
troponin of 19.2 and CK of 544. Monitor showed runs of
nonsustained VT at approximately 100 bpm, with the longest being
12 beats. Had a 2nd episode of chest pain at 12 noon with no EKG
changes per report. Pt was pain free after SL nitro x 2.
.
Transfered to [**Hospital1 18**] cath lab for evaluation. Will undergo
cardiac catheterization tomorrow AM. Pt is currently pain free
and anxious about tomorrow's procedure. EKG shows no changes. Pt
is currently on heparin, but off NTG. ROS is positive for 1
month of fatigue, rhinorrhea, and nasal congestion. He denies
fevers, chills, dyspnea on exertion (prior to admission could
climb 2 flights of stairs easily without pain). Denies PND,
ankle edema, palpitations, syncope, changes in bowel or urinary
function.
Past Medical History:
-HTN
-Hyperlipidemia
-AAA 4.7 cm (followed by Dr. [**Last Name (STitle) **]
-Renal Artery Stenosis s/p L stent in [**2195**]
-PVD s/p PTA to Left Leg
-CKD (baseline creatinine 2.0) with 1 functioning kidney (Right)
followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) **]/Anxiety/PTSD
-Restless Leg Syndrome
-Tobacco use
-Back fusion surgery
-Osteoporosis
Social History:
Smokes [**12-6**] ppd, 70 pack-year history. Former heavy alcohol use
([**3-10**] whiskeys per day), reports quitting 2 yrs ago; **per wife,
patient still drinks at least 2 martinis every evening**.
Denies any drug use. Retired police officer. [**Country 3992**] veteran.
Family History:
No history of cardiac disease
Physical Exam:
VS - 98.0 136/80 57 20 99% RA
Gen: overweight middle aged male in NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. has upper and
lower dentures
Neck: Supple with no JVD
CV: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Obese, soft, NTND. No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers
.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
OSH labs:
Na 140, K 4.4, Cl 105, Co2 27, Creat 2.0-> 1.8, Bun 18, Calcium
8.7, Ionized calcium 1.07, Trig 357, Mg 2.0, INR 1.0, PTT 77,
Trop 19.2, Ck 544, Wbc 6.5, Hgb 11, Hct 32, Plt 205
Cxr: linear scarring at left base. no acute disease
.
Admission labs:
[**2200-2-18**] 06:20AM BLOOD WBC-6.4 RBC-3.41* Hgb-10.5* Hct-31.1*
MCV-91 MCH-30.8 MCHC-33.8 RDW-15.2 Plt Ct-208
[**2200-2-18**] 06:20AM BLOOD PT-14.7* PTT-53.4* INR(PT)-1.3*
[**2200-2-18**] 06:20AM BLOOD Glucose-94 UreaN-13 Creat-1.7* Na-138
K-4.7 Cl-106 HCO3-24 AnGap-13
[**2200-2-18**] 06:20AM BLOOD CK-MB-18* MB Indx-6.6* cTropnT-1.78*
[**2200-2-18**] 06:20AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8 Cholest-163
[**2200-2-18**] 06:20AM BLOOD Triglyc-216* HDL-31 CHOL/HD-5.3
LDLcalc-89
.
Imaging:
- Cardiac catheterization ([**2200-2-18**]): Selective coronary
angiography revealed diffuse three vessel coronary artery
disease. The LMCA was short without disease. The LAD had
diffuse 70-80% stenosis at the proximal segment through to the
mid segment. There was a small first diagonal with a 90%
stenosis and a second diagonal with a 90% stenosis. The mid to
distal LAD was a large vessel with a 40-50% stenosis in its mid
portion. The LCX had a 90% stenosis in the proximal segment and
the distal LCX terminated in a small to medium sized LPL branch.
The OMB1 had no angiographically apparent disease. The OMB2
was large and had an 80% stenosis in its proximal segment
followed by an 80% stenosis in the mid segment. The OMB3 had an
80% stenosis at its origin and was overall a large caliber
vessel. The RCA was occluded at the mid segment and the distal
RCA was filled by left to right collaterals. The distal RCA
terminated in a small RPDA and a larger RV marginal branch
supplied the inferior wall and RV apex.
- Cardiac echo ([**2200-2-19**]): The left atrium is elongated. There is
mild regional left ventricular systolic dysfunction with
inferior akinesis and inferolateral hypokinesis. The remaining
segments contract normally (LVEF = 45-50 %). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. The
mitral valve leaflets are structurally normal. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventriculkar systolic dysfunction
with inferior akinesis and inferolateral hypokinesis c/w CAD.
Moderate pulmonary hypertension.
- CXR ([**2200-2-20**]): 1. Mild CHF with minimal interstitial edema and
small right pleural effusion versus pleural thickening. 2.
Multiple compression deformities in the spine, unchanged since
recent lateral thoracic spine radiograph of [**2199-11-20**].
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 831**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 11062**]TTE (Complete) Done
[**2200-2-19**] at 1:53:09 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 11063**] Cardiology
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Street Address(2) 8667**], [**Hospital Ward Name **] 4
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2138-2-22**]
Age (years): 61 M Hgt (in): 69
BP (mm Hg): 136/80 Wgt (lb): 179
HR (bpm): 61 BSA (m2): 1.97 m2
Indication: Preoperative assessment.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2200-2-19**] at 13:53 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W007-0:12 Machine: Vivid [**6-9**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.29 >= 0.29
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Left Ventricle - Lateral Peak E': 0.13 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 10 < 15
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.57
Mitral Valve - E Wave deceleration time: 168 ms 140-250 ms
TR Gradient (+ RA = PASP): *36 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2198-11-15**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
MITRAL VALVE: Normal mitral valve leaflets. Trivial MR. Normal
LV inflow pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is elongated. There is mild regional left
ventricular systolic dysfunction with inferior akinesis and
inferolateral hypokinesis. The remaining segments contract
normally (LVEF = 45-50 %). Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. The mitral valve
leaflets are structurally normal. Trivial mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventriculkar systolic dysfunction
with inferior akinesis and inferolateral hypokinesis c/w CAD.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2198-11-15**],
findings are similar.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2200-2-19**] 16:02
Brief Hospital Course:
1. Coronary artery disease:
Patient presented with chest pain from OSH hospital. EKG was
unchanged but cardiac enzymes were elevated. Pt was diagnosed
with NSTEMI and transferred to [**Hospital1 18**] for cardiac
catheterization. Cath on [**2-18**] showed 3 vessel disease with
occlusion in the proximal RCA and stenosis in the LAD and LCx.
Pt underwent CABG on [**2-27**] due to plavix washout and slightly
elevated creatinine.
.
2. HTN:
BP was stable while in patient. Pt developed slightly elevated
creatinine levels, and diovan was held. All other home BP
medications were continued.
.
3. CKD: Basline creatinine is between 1.6 and 2.0. On admission,
creatinine was 1.6 and slowly increased. Nephrotoxic agents were
avoided and [**Last Name (un) **] was discontinued. Renal was consulted...
.
4. Depression/Anxiety/PTSD:
Pt reported feeling anxious prior to procedure. SW was
consulted. Ativan was started for anxiety and trazadone for
insomnia.
.
CODE: FULL
Mr. [**Known lastname **] was taken to cardica surgery on [**2200-2-27**] for a CABG X4
(LIMA-LAD, SVg to OM with Y to diagonal, SVG to RCA.
Post operatively Mr. [**Known lastname **] was admitted to the ICU for ongoing
postoperative care.
Over the next three post-op days he was extubated , developed
metabolic acidosis and was re-intubated.
He was extubated on on [**2200-3-4**]. His post operative course was
also complicated by confusion. His narcotics were d/c'd and his
mental status improved. Mr. [**Known lastname **] chest tubes and temporary
pacing wires were removed per protocol. He was transferred from
the ICU to the floor. He was started on lopressor and developed
bradycardia- lopressor dose was adjusted to 12.5 mg and is
tolerating well without further episodes of bradycardia. He was
diuresed to his pre-op weight and was sent home on one week of
lasix. Mr. [**Known lastname **] was cleared by physical therapy for discharge
home.
Medications on Admission:
Amlodipine 10mg daily
Valsartan 160mg [**Hospital1 **]
Simvastatin 20 mg
Aspirin 81 mg daily
Calcitriol 0.25 mcg five days a week
Alendronate 35 mg PO Qweek
Sertaline 100mg daily
Oxycodone 5mg
Ambien 10 mg qhs
Pramiprexole 0.25 1-2 tablets qhs
Esomeprazole EC 40mg daily
Omega 3 fish oil
Ferrous sulfate 325 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 5 times
per week.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 mdi* Refills:*2*
13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-8**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 mdi* Refills:*2*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 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 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease
anxiety
depression
PTSD
renal artery stent
s/p spinal fusion
chronic back pain
Abdominal aortic aneursym
peripheral vacsular disease
s/p PTA to left leg
hyperlipidemia
hypertension
restless leg syndrome
Chronic kidney disease
osteoporosis
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call for appointments
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] (cardiologist)in 2 weeks
Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] (primary care)in [**1-7**] weeks
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2200-3-8**] Name: [**Known lastname **],[**Known firstname **] R Unit No: [**Numeric Identifier 1542**]
Admission Date: [**2200-2-17**] Discharge Date: [**2200-3-8**]
Date of Birth: [**2138-2-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Protonix / Codeine / Venomil Honey Bee Venom /
Vicodin
Attending:[**First Name3 (LF) 1543**]
Addendum:
correction:
Follow up is with Dr. [**Last Name (STitle) **] who was the cardiac surgeon for
Mr. [**Known lastname **] not, Dr. [**Last Name (STitle) **].
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2200-3-10**]
|
[
"E947.8",
"333.94",
"V45.73",
"585.3",
"V15.82",
"414.01",
"427.89",
"276.2",
"309.81",
"511.9",
"E937.9",
"293.0",
"E941.3",
"518.81",
"441.4",
"300.4",
"440.1",
"V45.4",
"733.00",
"403.90",
"584.9",
"410.71",
"458.29",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.91",
"96.04",
"96.71",
"38.93",
"88.56",
"36.13",
"96.6",
"37.22",
"39.61",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
16180, 16395
|
10321, 12236
|
344, 373
|
14647, 14654
|
3269, 3511
|
15194, 16157
|
2568, 2599
|
12603, 14261
|
14361, 14626
|
12262, 12580
|
14678, 15171
|
9178, 10298
|
2614, 3250
|
294, 306
|
401, 1874
|
3527, 9129
|
1896, 2260
|
2276, 2552
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,321
| 120,300
|
13629
|
Discharge summary
|
report
|
Admission Date: [**2108-6-25**] Discharge Date: [**2108-6-26**]
Date of Birth: [**2036-6-13**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
male with a history of hypertension, hyperlipidemia, known
coronary artery disease (status post coronary artery bypass
graft in [**2098**] and prior percutaneous coronary interventions)
who presented for elective catheterization after experiencing
increasing dyspnea and angina on exertion.
The patient had a coronary artery bypass graft in [**2098**] with a
left internal mammary artery to left anterior descending
artery, saphenous vein graft to ramus intermedius, and
saphenous vein graft to right coronary artery. The patient
had recurrence of exertional angina in [**2107-12-13**] and
went for a catheterization on [**2108-1-11**]. The
saphenous vein graft to ramus intermedius was found occluded
and was stented. His symptoms returned six weeks later, and
the patient went for re-catheterization on [**2108-3-14**].
Re-stenosis was found in the ramus intermedius stent, and the
stent was successfully reopened by angioplasty. His symptoms
improved slightly, but following catheterization the patient
states he has experienced a progressive decrease in his
exercise tolerance with frequent dyspnea and angina on
exertion that resolves with rest. The patient denies
orthopnea, paroxysmal nocturnal dyspnea, edema, claudication,
or lightheadedness. The patient is an ex-smoker who quit in
the [**2075**]; reportedly smoking half a pack per day. He has
longstanding hypertension and hyperlipidemia but denies a
history of diabetes or a family history of coronary artery
disease.
PAST MEDICAL HISTORY: As per history of present illness.
The patient also has proctitis, for which he is taking
sulfasalazine.
PAST SURGICAL HISTORY: Coronary artery bypass graft,
hemorrhoid fistula surgery, hand surgery, back surgery [**35**]
years ago, and knee surgery.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Outpatient medications included
sulfasalazine 1000 mg p.o. b.i.d., niacin 500 mg p.o. b.i.d.,
aspirin 325 mg p.o. q.d., atenolol 50 mg p.o. q.d.,
Zocor 20 mg p.o. q.d., vitamin C, and vitamin E.
SOCIAL HISTORY: An ex-smoker. A social drinker of alcohol.
He works as a limousine driver to airport. He is married.
FAMILY HISTORY: Family history was noncontributory.
REVIEW OF SYSTEMS: On review of systems, the patient denies
melena and bright red blood per rectum. He says he has never
been diagnosed with Crohn's disease.
HOSPITAL COURSE: The patient was admitted for elective
catheterization. The hemodynamic findings were a cardia
output Fick of 16.4, a cardiac index of 8.32, a capillary
wedge pressure of 13, a pulmonary artery pressure of 29/14,
right atrial pressure of 14. The left ventriculography was
not done. His left main coronary was normal. The left
circumflex with 100% intermediate in-stent restenosis with
discontinuity at the distal end consistent with spontaneous
stent fracture secondary to chronic flexion extension at the
saphenous vein graft touchdown site. The first obtuse
marginal and second obtuse marginal had mild irregularities.
The right coronary artery was totally occluded; as had
previously been observed. Saphenous vein graft to right
coronary artery had an ulcerated 50% proximal lesion;
otherwise was normal. The left internal mammary artery to
left anterior descending artery was wildly patent.
Intervention details revealed attempts were made to cross the
entire length of the stent with 0.014 PT Graphics wire.
Ultimately, the wire was passed at the distal structure, and
distal dye injection demonstrated small myocardial
perforation with connection to myocardial vein draining into
the coronary sinus. Several additional attempts to redirect
the wire into arterial lumen were unsuccessful. At this
point, the patient became severely hypotensive requiring
initiation of pressors. An emergent echocardiogram
demonstrated normal left ventricular systolic function with
no evidence of a pericardial effusion. Pulmonary artery
saturation increased to 90% on dopamine, but there was no
evidence for stepup during saturation run. The patient's
chest pain and hypotension gradually resolved, and the
patient was discontinued on dopamine. A repeat angiogram
demonstrated no further dye extravasation and persistent
occlusion of intermedius stent.
The patient was sent to the Coronary Care Unit overnight with
a Swan-Ganz catheter in place. On presentation to the
Coronary Care Unit, the patient's blood pressure was 169/75,
pulse was 61, respiratory rate was 14, pulse oximetry was 98%
on 2 liters. A pulmonary artery pressure was 22/11. The
patient was lying in bed with a hot blanket in no acute
distress. No jugular venous pressure or carotid bruits were
present. The patient had a regular rate, distant heart
sounds, first heart sound and second heart sound. No
murmurs, rubs or gallops. The lungs were auscultated
anteriorly and had good air entry and were clear to
auscultation. The patient had positive bowel sounds,
nontender and nondistended. Extremities revealed no edema,
good pulses. The femoral line was not bleeding and had no
bruit. The patient was alert and oriented times three, and
neurologic examination was grossly intact.
His echocardiogram at the time of catheterization revealed an
ejection fraction of 75% to 80%, left ventricular cavity
under filled, left ventricular systolic function was
hyperdynamic, no wall abnormalities, no aortic regurgitation,
trivial mitral regurgitation, and no pericardial effusions.
1. CARDIOVASCULAR: The patient was started on aspirin.
Heparin was held secondary to possible myocardial bleed. He
was continued on his Zocor dose and eventually restarted on a
beta blocker.
A repeat echocardiogram in the morning showed no signs of a
pericardial effusion. The patient was placed on Imdur 30 mg
p.o. q.d. to treat his anginal symptoms. Since the
percutaneous coronary intervention was unsuccessful, the
patient will require medical management for now and hopefully
self-revascularize.
Cycling of the creatine phosphokinases revealed a peak of 71
with no troponins. The patient was initially hypertensive
when he was brought to the floor, but throughout the course
of the night his blood pressure fell without medical
intervention, allowing us to put him back on his beta blocker
regimen.
The patient frequent premature atrial contractions, but no
ectopy.
2. PULMONARY: His oxygen saturations were good. His lungs
remained clear, and Lasix was not deemed necessary.
3. HEMATOLOGY: His hematocrit fell from 39.9 on [**6-20**]
to 32.3 after catheterization on [**6-25**]. This was likely
due to dilutional effects from the catheterization. Repeat
hematocrits remained stable, and the patient had no signs of
bleeding.
4. GASTROINTESTINAL: Initially, sulfasalazine was withheld,
but the next day the patient was returned to his regular
regimen of sulfasalazine.
The patient was advised to follow up with his primary care
physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) and his cardiologist (Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1391**]).
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home without
services.
DISCHARGE DIAGNOSES: Coronary artery disease.
MEDICATIONS ON DISCHARGE:
1. Sulfasalazine 1000 mg p.o. b.i.d.
2. Niacin 500 mg p.o. b.i.d.
3. Aspirin 325 mg p.o. q.d.
4. Atenolol 50 mg p.o. q.d.
5. Zocor 20 mg p.o. q.d.
6. Vitamin C.
7. Vitamin E.
8. Imdur 30 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient was advised to follow up
with his primary care physician.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 41122**]
MEDQUIST36
D: [**2108-6-26**] 16:46
T: [**2108-6-30**] 03:54
JOB#: [**Job Number 41123**]
cc:[**Apartment Address(1) 41124**]
|
[
"401.9",
"411.1",
"V45.81",
"272.4",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
2373, 2410
|
7434, 7460
|
7486, 7695
|
2039, 2235
|
2591, 7296
|
1834, 2012
|
7311, 7412
|
2431, 2572
|
7716, 8082
|
161, 1680
|
1704, 1810
|
2252, 2356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,318
| 100,638
|
13120
|
Discharge summary
|
report
|
Admission Date: [**2158-3-31**] Discharge Date: [**2158-4-19**]
Date of Birth: [**2086-2-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Location (un) 1279**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
PEG placement
Thoracentesis
Chest Tube
History of Present Illness:
The patient is a 72 year old male with a history of MI, s/p CABG
[**1-14**] followed by 5 week ICU stay notable for CHF, pericardial
effusion drainage transferred from [**Hospital **] [**Hospital **] Hospital
with shortness of breath and hypoxia. Since d/c from [**Hospital1 18**] to
[**Hospital1 **] on [**2158-2-21**], pt per family has had little imporvement in
overall condition. He is cachectic, very limited in activity
[**3-15**] fatigue, and has suffered several setbacks in his recovery
including pna and CDiff colitis. His respiratory status has
been stable until 10 days PTA when he gradually became more SOB,
orthopneic, and had PND. He had 1 day per report by family, of
CP but doctors told [**Name5 (PTitle) **] there was no evidence of MI. Over past
several days patient became more tachypneic and short of breath.
CXR showed increased bilateral effusions. He did not diurese
and became acutely worse on day of admission. He was
transferred to [**Hospital1 18**] where in the ED he was urgently intubated
for hypoxia and decreased responsiveness.
Past Medical History:
CAD, s/p MI [**2143**], angioplasties in '[**43**], '[**45**], '[**46**], '[**47**], CABG
[**2158-1-11**]
CHF, chronic afib
mild CRI
HTN
DM 2
peripheral neuropathy
prostate cancer s/p XRT '[**42**]
skin cancer, s/p multiple excisions
anxiety, depression
restless leg syndrome
gout
ingiunal hernia repair
s/p cardiac arrest [**2152**] (hyperkalemia)
Social History:
Lives in [**Hospital1 392**] with wife, retired, drives himself, quit smoking
more than 40 years ago (<20PPY hx), no ETOH
Family History:
Mother died of "CAD" in [**2137**]
Physical Exam:
Tc=100 P=84 BP=140/98 RR=18 97% on 2 liters
Gen - Flattened affect, mumbles to himself, does not answer
questions appropriately, waxes and wanes (at most, alert and
oriented x 2)
Heart - Irregularly irregular, no M/R/G
Lungs - CTAB
Chest - Small hematoma (stable) on right upper aspect of chest
wall
Abdomen - PEG tube in place, active bowel sounds, NT, ND
Ext - Left medial knee with stable, hard hematoma, no C/C/E,
with SCD bilaterally and +1 pulses bilaterally
Pertinent Results:
[**2158-4-9**] 06:00AM BLOOD WBC-13.1* RBC-3.46* Hgb-11.0* Hct-33.4*
MCV-97 MCH-31.9 MCHC-33.1 RDW-15.3 Plt Ct-188
[**2158-4-8**] 06:45AM BLOOD WBC-12.6* RBC-3.50* Hgb-11.3* Hct-34.6*
MCV-99* MCH-32.2* MCHC-32.7 RDW-15.1 Plt Ct-187
[**2158-4-7**] 07:05AM BLOOD WBC-12.3* RBC-3.37* Hgb-10.6* Hct-32.5*
MCV-97 MCH-31.6 MCHC-32.7 RDW-15.5 Plt Ct-195
[**2158-4-6**] 04:49AM BLOOD WBC-10.5 RBC-3.50* Hgb-11.0* Hct-34.5*
MCV-99* MCH-31.5 MCHC-32.0 RDW-15.7* Plt Ct-199
[**2158-4-5**] 03:58PM BLOOD WBC-10.5 RBC-2.99* Hgb-9.6* Hct-30.1*
MCV-101* MCH-32.0 MCHC-31.8 RDW-15.1 Plt Ct-233
[**2158-4-5**] 02:39PM BLOOD WBC-9.0 RBC-2.74* Hgb-8.8* Hct-28.3*
MCV-103* MCH-32.2* MCHC-31.1 RDW-14.9 Plt Ct-207
[**2158-4-4**] 05:56AM BLOOD WBC-10.7 RBC-3.13* Hgb-9.9* Hct-30.8*
MCV-99* MCH-31.7 MCHC-32.2 RDW-15.5 Plt Ct-229
[**2158-4-1**] 02:22AM BLOOD WBC-13.9* RBC-3.06* Hgb-10.3* Hct-29.5*
MCV-96 MCH-33.5* MCHC-34.8 RDW-15.9* Plt Ct-375
[**2158-3-31**] 01:15PM BLOOD WBC-13.4* RBC-3.85* Hgb-12.4* Hct-38.4*
MCV-100* MCH-32.1* MCHC-32.2 RDW-15.5 Plt Ct-443*#
[**2158-4-9**] 06:00AM BLOOD PT-16.8* PTT-38.2* INR(PT)-1.8
[**2158-4-9**] 06:00AM BLOOD Glucose-154* UreaN-57* Creat-1.1 Na-147*
K-2.5* Cl-112* HCO3-26 AnGap-12
[**2158-4-9**] 05:20PM BLOOD K-3.9
[**2158-4-8**] 06:45AM BLOOD Glucose-149* UreaN-49* Creat-1.2 Na-148*
K-2.9* Cl-114* HCO3-25 AnGap-12
[**2158-4-7**] 07:05AM BLOOD Glucose-138* UreaN-42* Creat-1.2 Na-146*
K-2.8* Cl-112* HCO3-25 AnGap-12
[**2158-4-6**] 04:49AM BLOOD Glucose-117* UreaN-35* Creat-1.2 Na-148*
K-3.1* Cl-111* HCO3-29 AnGap-11
[**2158-4-5**] 08:32PM BLOOD Glucose-144* UreaN-33* Creat-1.2 Na-145
K-3.5 HCO3-27
[**2158-4-5**] 03:58PM BLOOD Glucose-114* UreaN-32* Creat-1.2 Na-145
K-3.3 Cl-113* HCO3-26 AnGap-9
[**2158-4-5**] 02:39PM BLOOD Glucose-525* UreaN-29* Creat-1.1 Na-132*
K-3.2* Cl-102 HCO3-24 AnGap-9
[**2158-4-5**] 05:44AM BLOOD Glucose-132* UreaN-31* Creat-1.2 Na-149*
K-2.7* Cl-114* HCO3-28 AnGap-10
[**2158-4-4**] 05:56AM BLOOD Glucose-72 UreaN-32* Creat-1.3* Na-149*
K-3.0* Cl-113* HCO3-28 AnGap-11
[**2158-4-3**] 04:36AM BLOOD Glucose-87 UreaN-35* Creat-1.3* Na-144
K-3.2* Cl-104 HCO3-34* AnGap-9
[**2158-3-31**] 01:15PM BLOOD Glucose-168* UreaN-38* Creat-1.0 Na-149*
K-5.0 Cl-103 HCO3-44* AnGap-7*
[**2158-3-31**] 01:15PM BLOOD ALT-68* AST-58* LD(LDH)-320* AlkPhos-158*
Amylase-73 TotBili-0.6
[**2158-4-2**] 04:11AM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2158-3-31**] 07:59PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2158-3-31**] 01:15PM BLOOD cTropnT-0.07*
[**2158-4-9**] 06:00AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.5*
[**2158-4-1**] 02:22AM BLOOD %HbA1c-4.4
TTE: The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with focal hypokinesis of the distal septum, distal
anterior wall and apex. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. Mild (1+) 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 a trivial/physiologic
pericardial effusion. There is a large left pleural effusion.
COMPARISON: [**2158-1-24**].
TECHNIQUE: Noncontrast head CT.
HEAD CT W/O IV CONTRAST: There is no intra- or extra-axial
hemorrhage, mass effect, or shift of normally midline
structures. Differentiation of [**Doctor Last Name 352**] and white matter is
preserved. There are white matter chronic infarctions and basal
ganglia lacunes. There is prominence of the sulci and
ventricles, consistent with atrophy.
Otherwise, paranasal sinuses and mastoid air cells are clear.
The surrounding osseous and soft tissue structures are within
normal limits.
IMPRESSION: No intracranial hemorrhage or mass effect. Chronic
microvascular and lacunar infarction.
COMPARISON: Comparison is made to [**2158-4-8**].
TECHNIQUE: Noncontrast head CT.
FINDINGS: There is no intracranial hemorrhage, mass effect,
shift of normally midline structures, major vascular territorial
infarcts. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
There are chronic periventricular hypodensities consistent with
chronic ischemic changes. There is a round hypodense area in the
left frontal lobe that is unchanged compared to the prior study
and most likely represents an old lacune. The paranasal sinuses
are normally aerated.
IMPRESSION: Stable appearance of the brain. No evidence of acute
intracranial hemorrhage.
Brief Hospital Course:
1. CHF-etiology likely inadequate afterload reduction (no ACE
inhibitor and low dose lasix.) Possible EF significantly lower
than pre-CABG LV gram indicated. He diuresed well with
nesiritide gtt accompanied by boluses of Lasix (responded to
lasix 100 mg IV). He was able to be extubated on [**4-4**] after
considerable diuresis. He also had a thoracentesis (pleural
fluid c/w transudate), which was complicated by a pneumothorax
on the right. Thoracic surgery placed a chest tube, which was
able to be discontinued 2 days later (ptx resolved).
His medical management was optimized. His ACE inhibitor was
titrated up along with his metoprolol to 100 mg TID, and he
still had relatively poor bp control, in the 130s to 150s.
Aldactone was added. He was placed on standing lasix 80 [**Hospital1 **]
which was decreased to once a day, as well as ASA and a statin.
2. Hypoxemia-likely all due to CHF but question of infiltrate on
initial CXR. His sputum grew GNR but culture negative. He was
originally placed on vanc/zosyn, but was changed to levaquin for
total 7 day course. He remained afebrile. His oxygen
saturation improved greatly with diuresis.
3. Afib-labled chronic. His coumadin was originally held, and
he was placed on a heparin gtt. This was discontinued when he
had the chest tube placed. His coumadin was restarted when the
tube was pulled, and he was not bridged with heparin given the
risk of bleeding. His INR was supratherapeutic upon discharge
and his INR should be checked by his visiting nurse the day
after discharge.
4. Metabolic Alkalosis-likely contraction from diuresis.
Improved with diamox, although not resolved. Question if pt has
hyperaldo - hypernatremia, hypokalemia, and difficult to treat
hypertension. However, he would need to have all his diuretics
stop to appropriately diagnose this, and that isn't feasible at
this time.
5. Psych: He was intermittently confused and agitated throughout
his course. He was originally kept on his outpatient regimen of
seroquel 25 qhs and zyprexa 2.5 tid. He was evaluated by
psychiatry who recommended a delirium workup. His head CT was
neg, as was his TSH. Psychiatry recommended discontinuing the
zyprexa and seroquel and instead recommended standing haldol TID
and [**Hospital1 **] prn for agitation. At times, the patient exhibited
extreme behavior by verbally attacking his nurses and
physicians.
6. Gout: He developed an erythematous, painful R MTP joint,
which was treated wiht prednisone 30 mg po qd x 2 d. Because of
his altered mental status, which became acutely worse the same
day the steroids were started, he only had 2 days of prednisone.
His toe pain resolved, and the steroids were discontinued
(?steroid psychosis).
7. Hematuria-Foley catheter was placed last admission in [**1-14**].
This was placed by urology with cystoscopy and ureteral dilation
secondary to anatomical difficulty from BPH. Foley was removed
this admission as it had been in place for three months. Due to
urinary incontinence and skin breakdown from fungal infection
the catheter was replaced by urology. It should be removed once
skin condition improves.
8. Clostridium Difficile Colitis: Patient had been started on
oral vancomycin for clostridium difficile colitis diagnosed at
[**Hospital1 **] Rehabilitation Center. (Presumably he was
started on vancomycin since had previously been treated
[**Date range (1) 40058**] for C difficile colitis with Flagyl and this was
assumed to be a relapse.) He completed his course on [**2158-4-7**],
however, continued to have diarrhea with positive C diff toxin.
Therefore, the vancomycin was restarted on [**2158-4-12**] with plan for
10 days to complete [**2158-4-21**]. Flagyl was added for a ten day
course ([**2158-4-15**] to [**2158-4-25**]).
9. Placement: Many discussions with the family were made. The
patient's wife felt that he had suffered emotionally and
physically in a rehab hospital where he recently stayed and
refused to place him in another rehab hospital. Instead, she
felt that the patient was nearing the end of his life and
preferred him to be home for his quality of life and happiness.
All those actively involved in Mr. [**Known lastname 40059**] care, including
nurses, doctors, and case managers, advised his wife that caring
for Mr. [**Known lastname 2523**] required a high degree of nursing care and were
strongly against sending the patient home as he appeared
medically unfit. However, Mrs. [**Known lastname 2523**] insisted on taking him
home. As a result, case management was involved in setting up
home VNA and maximal medical services available. In addition,
the wife met on several occasions with the nursing staff to care
for her husband under nursing supervision and guidance 5-6 days
before discharge. As the patient is at risk for aspiration and
thus must remain strictly NPO, his wife was also provided
teaching regarding tube feeding through his PEG.
10. On the day of discharge, the patient was found to have a
urinary tract infection (he has a chronic foley in place). Thus,
he was given Levaquin for 10 days for a complicated UTI.
Medications on Admission:
amlodipine 10 mg
vitamin C
Buproprion 100 mg
cholestyramine 4 mg [**Hospital1 **]
digoxin 0.125 mg
folate
lasix 20 mg daily
labetalol 200 mg [**Hospital1 **]
lansoprazole 30 mg SR
mg oxide 400 mg [**Hospital1 **]
megace 400 mg qd
neutraphos 1 pkt tid
nystatin S&S qid
seroquel 25 mg qhs
KCl 60 meq qd
aldactone 25 mg [**Hospital1 **]
thiamine
warfarin 2 mg po qd
vancomycin 125 mg po q6h through [**2158-4-7**]
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*3*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*3*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*3*
5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*3*
6. Enteral feeding pump
Enteral feeding pump with supplies
7. Nutrition
Promode with fiber at 70 cc continuous feeds
7 cans/day, 9 cases/month
8. Suction
Suction machine with yankeur tip
9. saline
Saline bullets
1 box
10. Bed
[**Hospital 485**] hospital bed
11. Mattress
Alternate pressure mattress
12. Wheelchair
Wheelchair with removable legs
13. Commode
3 in 1 commode
14. [**First Name4 (NamePattern1) 4886**]
[**Last Name (NamePattern1) 4886**]
15. oxygen
O2 at 2 liters continuous
16. Lancets Regular Misc Sig: One (1) Miscell. four times
a day.
Disp:*180 180* Refills:*3*
17. Insulin
Test strips
#180
3 refills
18. insulin
Insulin syringe 100 unit
# [**Unit Number **]
3 refills
19. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
20. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
21. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO TID (3 times a day).
Disp:*90 Packet(s)* Refills:*2*
22. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*3*
23. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*3 3* Refills:*2*
24. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*3 3* Refills:*3*
25. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
26. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*30 Tablet(s)* Refills:*3*
27. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
28. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*3*
29. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
30. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*4 4* Refills:*3*
31. Outpatient Physical Therapy
INR check on [**2158-4-20**]. Please have results faxed to Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] and have coumadin adjusted accordingly.
32. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
33. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
34. Vancomycin HCl 125 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Congestive heart failure
Atrial fibrillation
Discharge Condition:
fair
Discharge Instructions:
Please continue your current medications and tube feedings.
Please take nothing by mouth as Mr. [**Known lastname 2523**] is at risk for
aspiration.
Please return to the hospital or call your doctor if you
experience shortness of breath or chest pain or if there are any
concerns at all
Followup Instructions:
Please make an appointment in the next 2 weeks with: PCP:
[**Name10 (NameIs) **],[**First Name3 (LF) 251**] T [**Telephone/Fax (1) 4475**].
Please make an appointment in the next 2 weeks with Congestive
Heart Failure Clinic at [**Telephone/Fax (1) 3512**]
|
[
"427.31",
"518.81",
"512.8",
"285.9",
"428.0",
"599.0",
"250.80",
"294.8",
"414.00",
"996.64",
"276.0",
"008.45",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"96.72",
"99.04",
"38.91",
"34.91",
"00.13",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15852, 15903
|
7105, 12217
|
332, 372
|
15992, 15998
|
2537, 7082
|
16334, 16594
|
1998, 2034
|
12678, 15829
|
15924, 15971
|
12243, 12655
|
16022, 16311
|
2049, 2518
|
273, 294
|
400, 1471
|
1493, 1843
|
1859, 1982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,120
| 100,263
|
53969
|
Discharge summary
|
report
|
Admission Date: [**2102-4-20**] Discharge Date: [**2102-4-26**]
Date of Birth: [**2055-2-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7744**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Central venous line placement
Intubation and mechanical ventilation
Extubation
History of Present Illness:
The patient is a 47 year old with PMHx COPD who was found down
in hotel room. Per report, he had been having several days of
N/V/D with possible AMS x1 day. He was taken to [**Hospital3 **]
where he was found to be unconcious, hypotensive, altered,
mumbling, responding only to pain. He had right CVL placed,
started on levophed, and intubated. He had a difficult
intubation requiring 30 of Etomidate and 10 of Vec and 2 passes
with a glide scope. A 7.0mm tube was placed. Labs returned
with Cr 9.7, K of 7.7 with peaked T waves and widened QRS. He
was given CaCl x2, insulin/D50, 2 amps bicarb, and 3L NS. He
was started on zosyn, but this was stopped when he reached [**Hospital1 18**]
as it was discovered he has an allergy to penicillin. He was
initially difficult to ventilate at [**Hospital3 15402**] so was paralyzed
with 2 doses of vec and was given solumedrol/albuterol for
?obstructive process. Transported via [**Location (un) **] to [**Hospital1 18**] during
which time he became easier to ventilate. Labs showed K
remaining elevated at 6.8 - he got Cagluconate, amp of bicarb.
EKG improved, with slightly peaked T waves, QRS 78. CT
Head/Neck was done and was ok. CT A/P showed RLL consolidation,
confirmed on CT Chest. ABG shoed increased CO2 so his RR was
increased to 28. He was given Levaquin/flagyl/vanco as well as
lasix 40mg IV with 3L urine output while in ED.
.
On arrival to the MICU, he was intubated and sedated on
pressors.
.
Review of systems: Unable to obtain
Past Medical History:
- Stroke 6 months ago per sister
-HTN
-DM
-COPD
-migraines
-chronic LBP s/p low back surgery '[**86**] for spinal stenosis or
sciatica, on oxycodone
- muscle spasms, on valium 10 tid
-tobacco
-alcoholism, sober [**2083**]
-remote PUD [**1-26**] etoh
-insomnia on seroquel
-R index finger injury [**1-26**] tablesaw, s/p fusion [**Doctor First Name **]
-R broken jaw s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ~[**2091**]
-CCY ~[**2089**]
-appy as child
-stable vision loss since accident as a child
Social History:
Lives at home w/ common-law wife and daughter.
Disabled [**1-26**] back pain, gets SSI income.
Tob [**12-26**] ppd x 35yrs.
Etoh sober since [**2083**].
Remote marijuana habit, infrequent recreational cocaine use
remotely, none in many yrs.
From [**Doctor First Name 26692**], moved to Mass ~7-8y ago.
Monogamous w/ wife.
Family History:
mom died metastatic cancer 59yo
dad died CA unknown type
4 siblings, 1 died MVA, 1 sis diabetes/HTN
4 children healthy
Physical Exam:
Admission Physical Exam:
General: Intubated, sedated, intermittent myoclonic jerks
HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL 2-->1
Neck: supple, no LAD, difficult to appreciate JVD [**1-26**] habitus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: right sided inspiratory wheezing with markedly decreased
breath sounds at the base, CTA on left
Abdomen: soft, non-distended, obese, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place, right femoral CVL in place - dressing c/d/i
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, trackmarks along left posteromedial calf from ankle to
knee, multiple track marks and puncture wounds along both legs
Neuro: Moves all 4 extremities equally
.
Discharge Physical Exam:
Vitals: Tmax 99.0 Tc 98.8 BP 129/83 HR 83 RR 20 O2 Sat 99% on
RA; patient desaturated to 91-94% on RA during ambulation; FSBG
124, 175, 175, 142
General: Sitting up in bed eating breakfast.
HEENT: EOMI. MMM. Tongue midline.
CV: RRR. No M/R/G.
Lungs: Auscultated posteriorly. Patient diffusely wheezy
throughout the lung fields posteriorly. Nml work of breathing.
No accessory muscle use.
Abd: Overweight. NABS+. Soft. NT/ND.
Ext: WWP. Trace pitting edema bilaterally. No clubbing or
cyanosis.
Neuro: Patient very alert and interactive this AM.
Pertinent Results:
Admission labs:
[**2102-4-20**] 06:15PM BLOOD WBC-22.8* RBC-3.74* Hgb-12.2* Hct-35.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-15.0 Plt Ct-173
[**2102-4-20**] 10:57PM BLOOD Neuts-97.1* Lymphs-1.4* Monos-0.9*
Eos-0.5 Baso-0.1
[**2102-4-20**] 06:15PM BLOOD PT-11.3 PTT-26.8 INR(PT)-1.0
[**2102-4-20**] 10:57PM BLOOD Glucose-180* UreaN-68* Creat-6.0*# Na-138
K-7.3* Cl-100 HCO3-26 AnGap-19
[**2102-4-20**] 10:57PM BLOOD ALT-26 AST-21 LD(LDH)-158 CK(CPK)-151
AlkPhos-72 TotBili-2.3*
[**2102-4-20**] 10:57PM BLOOD Calcium-9.1 Phos-6.6* Mg-1.7 UricAcd-9.7*
[**Hospital3 **]:
[**2102-4-20**] 06:15PM BLOOD Fibrino-540*
[**2102-4-20**] 06:15PM BLOOD Lipase-36
[**2102-4-21**] 04:29PM BLOOD Lipase-15
[**2102-4-20**] 10:57PM BLOOD CK-MB-6
[**2102-4-21**] 11:30AM BLOOD Cortsol-8.1
Lactate trend:
[**2102-4-20**] 11:05PM BLOOD Lactate-0.8 K-6.8*
[**2102-4-21**] 08:56AM BLOOD Lactate-1.2
[**2102-4-21**] 04:01PM BLOOD Lactate-0.9
[**2102-4-22**] 04:38AM BLOOD Lactate-0.8
[**2102-4-23**] 03:01AM BLOOD Lactate-0.4*
Discharge labs:
[**2102-4-26**] 06:10AM BLOOD WBC-3.8* RBC-2.98* Hgb-9.1* Hct-28.3*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-141*
[**2102-4-26**] 06:10AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-137
K-3.6 Cl-103 HCO3-28 AnGap-10
[**2102-4-26**] 06:10AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6
Imaging:
[**2102-4-20**] Portable CXR:
FINDINGS: An endotracheal tube terminates near the thoracic
inlet, approximately 7.5 cm above the carina. An orogastric tube
passes beneath the left hemidiaphragm, its distal course not
imaged. Opacification in the right lower hemithorax suggests a
pleural effusion with volume loss including mild rightward shift
of mediastinal structures most suggestive of atelectasis. An
infectious causes is not excluded, however. The left lung
appears clear. Although the extreme left costophrenic sulcus is
partly excluded, there is no evidence for pleural effusion on
the left side. Allowing for technique, the cardiac, mediastinal
and hilar contours are unremarkable.
IMPRESSION:
1. Endotracheal tube in a somewhat high lying position,
approximately 7.5 cm above the carina. If clinically indicated,
the tube could be advanced by approximately 3 cm.
2. Right basilar opacification with volume loss including
suspicion for a
pleural effusion.
.
[**2102-4-20**] Head CT: FINDINGS: There is no evidence of intracranial
hemorrhage, mass effect, shift of normally midline structures,
or vascular territorial infarct. [**Doctor Last Name **]-white matter
differentiation is preserved throughout. The ventricles and
sulci are normal in size and configuration. No fractures are
noted. Opacification within the paranasal sinuses is likely
related to recent intubation. Mastoid air cells are clear.
IMPRESSION: No evidence of acute intracranial process.
.
[**2102-4-20**] CT Chest: FINDINGS: The right middle and lower lobe are
collapsed. Bronchiectasis is mild in the segmental and
subsegmental bronchi of the middle lobe, and in the subsegmental
divisions of the superior and basal segments. There is no
central bronchial occlusion. The constellation suggests that
atelectasis may well be chronic. There is no indication of
pneumonia or pleural or pericardial abnormality. A few small
bronchi in the posterior segment of the right upper lobe are
impacted and there is mild heterogeneity in background density
of both upper lobes suggesting small airway obstruction or mild
emphysema. Mediastinal lymph nodes are not pathologically
enlarged. In the absence of contrast administration, I cannot
say that there are no enlarged right hilar lymph nodes (there
are none on the left), but even if right hilar nodes are
present, they are not contributing to the atelectasis because
there is no bronchial obstruction.
Heart is normal size and the study is notable for the virtual
absence of atherosclerotic calcification, except for small
plaques at the bifurcation of the innominate artery. ET tube is
in standard placement. Excretions are pooled above the inflated
cuff.
This study is not designed for subdiaphragmatic diagnosis except
to note there is no adrenal mass. A small Bochdalek hernia in
the posterior right hemidiaphragm transmits only subphrenic fat.
IMPRESSION:
1. Combination of mild but diffuse bronchiectasis in collapsed
right middle and lower lobes. In the absence of bronchial
obstruction, this suggests that the collapse is not acute. No
evidence of pneumonia. Minimal mucoid impaction in small bronchi
in the upper lobe.
2. Either small airway obstruction or mild emphysema.
.
CT C-spine: FINDINGS: Imaged portions of the brain are better
visualized on the concurrent head CT. Patient is intubated.
Nasogastric and endotracheal tubes are in appropriate position.
No evidence of fractures or acute alignment abnormalities. No
evidence of critical spinal canal stenosis. Visualized portions
of the lung bases show some scarring in the right upper lobe.
Left upper lobe is unremarkable.
IMPRESSION: No evidence of fracture.
.
CT Abdomen/pelvis: CT OF THE ABDOMEN: At the right lower lung
bases consolidative processes with air bronchograms and volume
loss including rightward shift. No pericardial effusion. No
pleural effusion. The left lung is clear.
Within the abdomen, the evaluation structures is limited without
IV contrast, however, with these limitations in mind, the liver
is unremarkable. The gallbladder has been surgically removed.
The spleen, bilateral kidneys and pancreas are all unremarkable.
There is some fat stranding of unclear significance around the
left adrenal. The adrenals themselves are unremarkable.
An NG tube is seen coursing into the stomach and ending at the
pylorus. The remainder of the small bowel is unremarkable. Large
bowel is also unremarkable.
No mesenteric adenopathy is appreciated.
CT OF THE PELVIS: Rectum, sigmoid colon, bladder, and prostate
are all unremarkable. The patient has a Foley catheter.
OSSEOUS STRUCTURES: The osseous structures are unremarkable. No
concerning lytic or sclerotic lesions.
IMPRESSION:
1. No evidence of acute intra-abdominal process.
2. Consolidative process in the right lower lobe consistent with
pneumonia versus atelectasis; sequelae of aspiration could also
be considered particularly noting historical circumstances.
.
[**2102-4-21**] Portable CXR: IMPRESSION:
1. Interval placement of a right internal jugular central line
with its tip in the mid superior vena cava. The endotracheal
tube has its tip approximately 5.5 cm above the carina,
unchanged. A nasogastric tube is seen coursing below the
diaphragm with the tip not identified. Patchy and linear opacity
at the right base is stable suggestive of patchy and
subsegmental atelectasis. Probable small layering right
effusion. The lungs are otherwise clear without evidence of
pulmonary edema or pneumothorax. Overall, cardiac and
mediastinal contours are stable given differences in
positioning.
.
Microbiology:
[**2102-4-20**] 6:15 pm BLOOD CULTURE TRAUMA.
**FINAL REPORT [**2102-4-26**]**
Blood Culture, Routine (Final [**2102-4-26**]): NO GROWTH.
[**2102-4-20**] 6:50 pm URINE
**FINAL REPORT [**2102-4-21**]**
URINE CULTURE (Final [**2102-4-21**]): NO GROWTH.
[**2102-4-20**] 10:57 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2102-4-22**]**
MRSA SCREEN (Final [**2102-4-22**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2102-4-21**] 1:52 am URINE Source: Catheter.
**FINAL REPORT [**2102-4-21**]**
Legionella Urinary Antigen (Final [**2102-4-21**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2102-4-21**] 1:36 am BRONCHIAL WASHINGS
**FINAL REPORT [**2102-4-23**]**
GRAM STAIN (Final [**2102-4-21**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2102-4-23**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
[**2102-4-23**] 3:53 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending) times 2
[**2102-4-25**] 5:54 am IMMUNOLOGY Source: Line-cvl.
**FINAL REPORT [**2102-4-26**]**
HCV VIRAL LOAD (Final [**2102-4-26**]):
HCV-RNA NOT DETECTED.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Rare instances of underquantification of HCV genotype 4
samples by
[**Doctor Last Name **] COBAS Ampliprep/COBAS TaqMan HCV test method used
in our
laboratory may occur, generally in the range of 10 to 100
fold
underquantitation. If your patient has HCV genotype 4
virus and if
clinically appropriate, please contact the molecular
diagnostics
laboratory ([**Telephone/Fax (1) 6182**]) so that results can be confirmed
by an
alternate methodology.
[**2102-4-25**] 12:15 pm IMMUNOLOGY Source: Line-PICC.
HBV Viral Load (Pending):
Hepatits B Ag Negative
Hepatitis B Ab Negative
Brief Hospital Course:
47 year old male with a past medical history significant for
COPD, DM, HTN who presents after being found down with hypoxic
and hypercarbic respiratory failure, RLL consolidation,
hyperkalemia, and [**Last Name (un) **].
# Hypoxic and hypercarbic respiratory failure - Patient has a
history of COPD, on admission had prolonged expiration phase,
but no expiratory wheezing on exam. CT showed large right lower
lobe consolidation concerning for pneumonia, possibly
aspiration. No evidence of fluid overload on exam. Given body
habitus, may have component of hypoventilation or OSA. Urgent
bronchoscopy in MICU showed secretions in RLL but no mass or
obstructing lesion - sample sent for culture/gram stain. He was
treated for health-care acquired pneumonia with
vancomycin/meropenem/levofloxacin for atypical coverage pending
culture results. Legionella antigen negative. The patient
self-extubated on [**4-23**] and was able to be maintained with
non-invasive ventilation thereafter.
# Aspiration pneumonia- Patient was started on vancomycin,
meropenem and levofloxacin (for atypical coverage) in the MICU.
Upon transfer to the general medicine floor, the patient was
continued on broad spectrum antibiotics. As the patient
clinically improved, the patient was transitioned to oral
antibiotics, Levofloxacin and Clindamycin (for coverage of
anaerobic bacteria). The patient remained afebrile on oral
antibiotics. The patient was discharged home with another 3 days
of Levofloxacin and Clindamycin to complete a 10-day course for
treatment of aspiration pneumonia. Supplemental oxygen was
weaned and then discontinued. The patient was saturating in the
mid to high 90s at rest on room air and had ambulatory
saturation of 91-94% on room air day prior to discharge.
# Shock - Most likely from hypovolemia and sepsis. Bedside
ultrasound showed collapse of IJ with hyperdynamic and fully
contracting ventricles consistent with hypovolemia. While EKG
showed low voltages, he did not have evidence of pericardial
effusion or low EF on bedside U/S. Per the OMR note, he was
recently on steroids for COPD so he is at risk for AI. He was
treated for pneumonia, provided aggressive fluid resuscitation,
and provided stress dose steroids. He was weaned off pressors
after 24 hours and his pressure normalized.
# Hyperkalemia - The patient exhibited persistent kyperkalemia
despite adequate treatment, and despite good renal function.
EKGs initially showed mild peaked T waves, but QRS remained
stable. Normalized after the first 24 hours.
# Acute renal failure - Likely related to hypovolemia given the
patient's admission exam. CK initially flat so the patient's
acute renal failure was not attributed to rhabdomyolysis. Serum
creatinine improved with hydration to 1.6, although there is no
clear baseline for this patient. Serum creatinine was trended
through the admission, and the patient's serum creatinine
normalized, ranging from 0.9 to 1.0.
OUTPATIENT ISSUES: Patient will need to have renal function
reassessed at his next PCP [**Name Initial (PRE) 648**].
# Pancytopenia - Upon transfer from the ICU to the floor, the
patient's cell counts were noted to be falling. Thrombocytopenia
initially was most pronounced. The patient did receive heparin
during the admission; 4T score of 4, classifying the patient's
probability of HIT as intermediate. The patient's CBC was
trended daily, and his white count and hematocrit were noted to
be falling as well. The differential included marrow suppression
secondary to sepsis or secondary to medication. On day of
discharge, the patient's blood cell lines were noted to be
uptrending.
OUTPATIENT ISSUES: Patient will need to have follow-up CBC at
next PCP [**Name Initial (PRE) 648**].
CHRONIC ISSUES:
# Hypertension - Patient with a history of hypertension; as an
outpatient, patient is maintained on amlodipine 10, HCTZ 12.5mg,
and lisinopril 20mg daily. These medications were initially held
in light of shock. Patient's blood pressure initially ran in the
150s systolic. The patient was started on amlodipine 10mg daily
initially. With a stable trend in the patient's serum
creatinine, the patient's lisinopril and hydrochlorothiazide
were restarted. With initiation of patient's full
anti-hypertensive regimen, the patient's systolic blood pressure
ranged in the 120s-130s systolic.
# Chronic Obstructive Pulmonary Disease - The patient had
albuterol and ipratropium inhalers available to him through his
admission. The patient was also given a nicotine patch through
the admission. Multiple times through the admission, the
importance of smoking cessation was emphasized to the patient.
He was also empirically started on Tiotropium inhaler once daily
on discharge. Upon discharge, the patient was provided with a
prescription for nicotine patches to aid with smoking cessation.
OUTPATIENT ISSUES: PFTs as an outpatient if not already done.
Smoking cessation counseling with the patient's primary care
provider.
# Type 2 Diabetes Mellitus - As an outpatient, the patient is on
500mg metformin [**Hospital1 **]. Upon admission, the patient was
transitioned to an insulin sliding scale for hyperglycemic
coverage. On the medicine floor, the patient's finger stick
blood glucose ranged from 125-175, and he required minimal
insulin coverage. The patient was discharged home with
instructions to continue taking 500mg metformin [**Hospital1 **].
# History of muscle spasm - Patient was continued on home dose
of standing Valium 10mg TID.
# Chronic Low Back Pain - Oxycodone was restarted when the
patient was transferred to the medicine floor. Dosing was
up-titrated to original home dose and frequency on day of
discharge.
# History of substance abuse - Through the patient's stay in the
MICU, he was placed on a CIWA scale. The patient did not score
while in the ICU. On the medicine floor, the patient did not
score, and CIWA scale was discontinued. Of note, the patient has
been sober from alcohol for the past 17 years.
OUTPATIENT ISSUES: Follow-up pending HIV serology.
# Hepatitis C - Patient serology confirmed during this
admission. Viral load negative. Patient has not pursued
treatment in the past. Hepatitis B serology and HIV were also
drawn during this admission.
OUTPATIENT ISSUES: Discussion between the patient and his PCP
regarding treatment for hepatitis C. Patient will need hepatitis
B vaccination given hepatitis B serology. Follow-up pending HIV
serology.
# History of insomnia - Patient's home Seroquel was held upon
admission in light of patient's serious illness. This was
initially held on the medicine floors as the patient still
appeared drowsy. On day of discharge, patient was instructed to
continue Seroquel at home dosing.
# Code: Full (presumed)
# Pending studies:
--Blood cultures
--Hepatitis B viral load
--HIV serology
# PCP [**Last Name (NamePattern4) 702**]:
--Repeat CBC and chemistry at patient's next PCP appointment
[**Name9 (PRE) 110669**] of COPD therapy
--Smoking cessation discussion
Medications on Admission:
lisin-HCTZ 20-12.5
amlodipine 10
metformin 500 [**Hospital1 **]
fioricet prn
valium 10 TID standing
oxycodone 30mg 5-6x/day
albuterol prn
seroquel 150 qhs
Discharge Medications:
1. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for Migraine Headache .
5. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
7. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO twice
a day for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
10. Seroquel XR 150 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO at bedtime.
11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Capsule Inhalation once a day.
Disp:*14 capsules* Refills:*0*
13. oxycodone 10 mg Tablet Sig: Three (3) Tablet PO every four
(4) hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Aspiration pneumonia
Acute renal failure
Secondary diagnosis:
Chronic Obstructive Pulmonary Disease
Hypertension
Type 2 Diabetes Mellitus
Chronic low back pain
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your hosptalization
at [**Hospital1 69**].
You were hospitalized with pneumonia and acute renal failure.
Initially you were in the ICU requirining mechanical
ventilation. Through your stay in the ICU, you were able to be
taken off the ventilator and your kidney function improved. You
were then transferred to the general medicine floor for
continued treatment of your pneumonia. You initially received IV
antibiotics for your pneumonia, and now you have been
transitioned to oral antiobitics. You will have 3 more days of
antiobitics to take once you leave the hospital.
*STOP SMOKING* This is one of the best things that you can do
for yourself. Discuss the options that are available for
quitting smoking with your primary care physician.
Take all medications as prescribed. Note the following
medication changes:
1. *ADDED* Levofloxacin 750mg daily and Clindamycin 600mg every
12 hours for the next *3* days for continued treatment of your
pneumonia
2. *ADDED* Nicotine patch apply daily; discontinue if you
continue to have bad dreams while the patch is on you.
3. *ADDED* Prednisone 40mg for one more day
4. *ADDED* Spiriva 1 capsule daily for treatment of your
underlying COPD
Keep all hospital follow-up appointments. Your [**Hospital 14776**]
hospital appointments are listed for you.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2102-5-3**] at 2:40 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 25193**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2102-5-17**] at 5:20 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 25193**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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|
17661, 20910
|
1920, 2443
|
2459, 2783
|
3770, 4316
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,708
| 117,546
|
25182
|
Discharge summary
|
report
|
Admission Date: [**2158-11-21**] Discharge Date: [**2158-12-19**]
Date of Birth: [**2118-3-25**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**Known firstname 371**]
Chief Complaint:
Trauma s/p fall
Major Surgical or Invasive Procedure:
1. T8-L2 fusion and T11-12 laminectomy on [**2158-11-25**]
2. Anterior cervical diskectomy and fusion C5-6 on [**2158-11-27**]
3. IVC filter placement on [**2158-11-28**]
4. Open gastrostomy tube placement on [**2158-12-12**]
2. Open tracheostomy [**2158-12-13**]
History of Present Illness:
HPI: The patient is a 40 yo male with unknown previous medical
history who was brought to the ED after a fall.
This evening the patient was drunk. While sitting on the rail at
[**Location (un) **] T-station, he fell backwards, about 15 feet down, onto
a
cement floor. He was found with blood on the back of his head.
In
the field he was able to say his name and address, moved his
arms
on both sides, but no movement was seen in his lower
extremities.
Per report he did not have sensation in his legs. GCS 14. A
bottle of valium was found (prescription).
Upon arrival in the ED, his breathing was shallow and he was
intubated for airway protection. He was able to follow simple
commands, but a history could not be obtained.
Past Medical History:
unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
T afebrile BP:105/60 HR88 sO298% RR16
Gen: NAD
HEENT: NC/AT. Anicteric. MMM. some blood in his mouth. Blood on
back head.
Neck: Collar
Cardiac: RRR. S1/S2. no murmur
Lungs: intubated; CTA-bilaterally
Abd: Soft, NT, ND, +NABS. No rebound or guarding. Scars midline
(explorative lap?; scars side of chest)
Extrem: No C/C/E.
Pertinent Results:
[**2158-11-21**] 10:42PM TYPE-ART PO2-260* PCO2-53* PH-7.32* TOTAL
CO2-29 BASE XS-0
[**2158-11-21**] 10:42PM HGB-12.8* calcHCT-38 O2 SAT-93 CARBOXYHB-6*
[**2158-11-21**] 10:35PM WBC-10.4 RBC-4.19* HGB-13.6* HCT-38.5* MCV-92
MCH-32.5* MCHC-35.3* RDW-14.0
[**2158-11-21**] 10:35PM PLT COUNT-524*
[**2158-11-21**] 10:35PM PT-12.0 PTT-22.9 INR(PT)-1.0
[**2158-11-21**] 10:35PM FIBRINOGE-287
[**2158-11-21**] 10:42PM GLUCOSE-114* LACTATE-2.3* NA+-148 K+-3.7
CL--106
[**2158-11-21**] 10:35PM UREA N-10 CREAT-0.8
[**2158-11-21**] 10:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2158-11-21**] 10:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2158-11-21**] 10:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2158-11-21**] 10:35PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-21**] 10:35PM ASA-NEG ETHANOL-341* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2158-11-21**] 10:35PM AMYLASE-47
Brief Hospital Course:
Patient admitted to the trauma ICU. Remained with flaccid
paralysis at bilateral lower extremities throughout
hospitalization.
Transferred to floor on [**11-21**] in stable condition. Returned to
the SICU [**3-8**] respiratory concerns. Transferred to the floor on
[**12-8**] again in stable condition but returned to SICU on [**2158-12-11**]
[**3-8**] respiratory concerns. He was intubated for respiratory
distress. A percutaneous tracheostomy was attempted but
unsuccessful, so an open tracheostomy was placed in the OR. A
PEG tube was subsequently placed. Continued to have elevated
WBC up to 24.5 with temp 101.4, Restarted on linazolid,
flucanazole, and zosyn.
Transferred to step-down unit on [**12-18**]. Continued to have
copious secretions well-controlled with suctioning.
Fever and elevated WBC resolved. Fluconazole and zosyn
discontinued. Had 14 day course of linazolid, discontinued on
discharge to rehabilitation.
He was seen throughout his stay by physical and occupational
therapists.
He failed speech and swallow evaluations on [**12-4**], and
[**12-11**].
Pt is discharged in stable condition and should follow-up with
the trauma surgery clinic as directed.
Medications on Admission:
unknown
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED): Per flowsheet.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Subarachnoid hemorrhage (frontal)
2. Occipital fracture
3. Rib fracture (4th right)
4. Twelfth thoracic vertebrae fracture with spinal cord
compression
5. Eleventh and twelfth thoracic vertebrae facet fractures
6. Scalp laceration
Discharge Condition:
stable
Discharge Instructions:
1. physical and occupational rehabilitation
2. wound care/prevention of pressure ulcers and contractures
3. pulmonary toilet
Take all medications as prescribed. Keep all followup
appointments.
Call your doctor or go to the ER for:
-chest pain, shortness of breath
-fevers, chills
-worsening neurologic status
Followup Instructions:
Call ([**Telephone/Fax (1) 29931**] upon discharge for a follow-up appointment
with the Trauma Clinic in one week.
Call ([**Telephone/Fax (1) 11061**] upon discharge for a follow-up appointment
with Dr. [**Last Name (STitle) 363**] (spine surgeon).
|
[
"806.29",
"518.5",
"807.01",
"806.00",
"801.72",
"507.0",
"305.00",
"E884.9",
"512.1",
"519.02",
"707.03",
"933.1",
"998.81",
"344.1",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.6",
"45.13",
"81.62",
"80.51",
"84.51",
"00.14",
"31.1",
"34.04",
"81.63",
"96.72",
"81.02",
"43.19",
"33.24",
"96.04",
"81.05",
"03.53",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
4606, 4676
|
2849, 4038
|
283, 554
|
4954, 4963
|
1751, 2826
|
5321, 5574
|
1383, 1392
|
4096, 4583
|
4697, 4933
|
4064, 4073
|
4987, 5298
|
1407, 1732
|
228, 245
|
582, 1311
|
1333, 1342
|
1358, 1367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,944
| 150,978
|
47524
|
Discharge summary
|
report
|
Admission Date: [**2187-5-20**] Discharge Date: [**2187-5-24**]
Date of Birth: [**2117-7-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 69M with DM, HTN, past smoking hx, hx of stroke
([**2175**]), family hx of premature CAD (brother with CHF and death
at age 50) who presents with 4 hours of dull upper back pain
that radiated to his bilateral shoulders and down to his right
elbow. this was associated with nausea, lightheadedness and SOB.
Patient reports that he was not having DOE, has been able to
walk a flight of stairs and noticed no decrease in exercise
tolerance recently. The CP was also associated with slight
nausea and "gastritis" for which he [**Last Name (un) **] rolaids and baking
soda without relief. Patient's pain was concerning enough that
his family called EMS.
.
family reports that he's had progressive DOE and decreased
exercise tolerance.
.
Of note, patient has had progressive DOE over the past [**6-3**]
months although denies any new PND or orthopnea. He denies any
recent weight gain or leg swelling. he has had a >50lb weight
loss over the past several months on account of a "gluten"
allergy and avoidance of carbohydrates.
.
As per the family, patient hasn't had any recent coughs or cold,
cough, although may had have a high salt diet over the past 24
hours.
.
On route patient was given 80 IV lasix by EMS and SLNG x 4
without relief of his pain.
.
ED Course: In the ED patient was given Amiodarone 300 IV for SVT
w/ aberrancy vs. VT. Vitals in the ED were:
T: 101.3 133 135/85 32 80%
Patient was given Levaquin for fever and possible pneumonia.
Past Medical History:
Prostate Cancer
CVA
PVD
CRI (baseline Cr 3.3)
? hx of CP in the past at age 34
GERD
Social History:
Social history is significant for the absence of current tobacco
use. Patient does have a 80 pack yr smoking hx although quit ~
20 yrs ago. Patient does have a history of alcohol abuse
requiring hospitalization, although has had no recent struggles
with EtOH and drinks occassionally. Patient's last drink was
several hours prior to admission.
Family History:
There is a family history of premature coronary artery disease
or sudden death - brother with CHF and died at age 50.
Physical Exam:
:98.1 HR:110 BP:130/80 RR:27 O2: 100 CPAP PEEP 12 PS 5
Blood pressure was 130/80 mm Hg while seated. Pulse was 110
beats/min and regular, respiratory rate was 27 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 3 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were labored and there was use of
accessory muscles. The lungs had diminished breath sounnds with
rales presents at the bases bilaterally.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were distant heart
sounds with no obvious thrills, lifts or palpable S3 or S4. The
heart sounds revealed a normal S1 and the S2 was normal. There
were no rubs, murmurs, clicks or gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed damp skin without stasis dermatitis, ulcers,
scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Imaging:
CHEST (PORTABLE AP) [**2187-5-20**] 7:15 PM
Cardiac silhouette and mediastinum are within normal limits.
There is moderate-to-severe congestive heart failure with
increase in the pulmonary interstitial markings. There is
blunting of both costophrenic angles suggestive of small pleural
effusions.
CT PELVIS W/O CONTRAST [**2187-5-21**] 11:03 PM
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Bilateral small pleural effusions and atelectatic changes.
Questionable 6-mm nodule in the right lung base. Follow-up is
recommended.
3. Atherosclerotic changes involving the aorta. Coronary artery
calcifications are noted.
4. Small liver hypodensity, not fully characterized, likely
represents a cyst.
5. Large left renal cyst.
CHEST (PORTABLE AP) [**2187-5-21**] 7:12 AM
IMPRESSION: Improving pulmonary edema.
ECHO Study Date of [**2187-5-21**]
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated with severe global hypokinesis. The apex is heavily
trabeculated. No definite thrombus is seen. Right ventricular
chamber size and free wall motion are normal. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
appear structurally normal with good leaflet excursion. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild to moderate ([**1-30**]+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
cavity dilation and severe global hypokinesis c/w diffuse
process (toxin, metabolic, multivessel CAD, etc.).
Mild-moderate mitral regurgitation. Dilated thoracic aorta. In
the absence of a history of clinical infarction, a cardiac MRI
([**Telephone/Fax (1) 9559**] may be able to distinguish between and ischemic
and non-ischemic cardiomyopathy).
CHEST (PORTABLE AP) [**2187-5-22**] 7:05 AM
Pulmonary edema has cleared. Only a small left pleural effusion
remains of previous small to moderate, bilateral pleural
effusion. Cardiomediastinal silhouette is normal. Large lung
volumes suggest obstructive airways disease.
ECHO Study Date of [**2187-5-23**]
Conclusions:
Overall left ventricular systolic function is severely depressed
with global hypokinesis and akinesis of the inferior and
infero-lateral segments. Tissue synchronization imaging
demonstrates borderline left ventricular dyssynchrony with the
lateral wall contracting 45 ms later than the septum and RV free
wall. Right ventricular systolic function is normal. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-30**]+)
mitral regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2187-5-21**], no
change. This study suggests indeterminate benefit of CRTfor
heart failure.
Micro:
[**2187-5-20**]
Blood Culture: NGTD
Urine Culture: NGTD
[**5-21**], [**2187-5-22**]
Sputum Culture: NGTD
Admission Labs:
[**2187-5-20**] 07:15PM WBC-9.4 RBC-4.12* HGB-14.8 HCT-45.0 MCV-109*
MCH-36.0* MCHC-33.0 RDW-14.9
[**2187-5-20**] 07:15PM FREE T4-1.8*
[**2187-5-20**] 07:15PM TSH-1.2
[**2187-5-20**] 07:15PM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.3
[**2187-5-20**] 07:15PM CK-MB-7 cTropnT-0.16* proBNP-[**Numeric Identifier 70715**]*
[**2187-5-20**] 07:15PM ALT(SGPT)-18 AST(SGOT)-28 LD(LDH)-238
CK(CPK)-121 ALK PHOS-49 TOT BILI-0.3
[**2187-5-20**] 07:15PM GLUCOSE-195* UREA N-33* CREAT-3.3* SODIUM-139
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-25 ANION GAP-18
[**2187-5-20**] 07:26PM LACTATE-3.2*
[**2187-5-20**] 07:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2 TRANS EPI-0-2
Brief Hospital Course:
Patient is a 69M s/p NSTEMI & CHF.
.
#. CAD - Patient with NSTEMI, likely from underlying CAD given
multiple risk factors. In the setting of CRI, it was determined
that the patient would not undergo cardiac catheterization and
medical management be preferred. The patient was continued on
ASA, Aggrenox, Statin, Niacin. Patient was also put on Toprol
XL in lieu of Carvedilol.
.
#. Pump - Patient with depressed EF of 20% as seen on ECHO.
Unclear whether this global hypokineis is from recent event,
although appears to be chronic in nature. Given DNR/DNI status
an ICD was not placed. Resynchronization ECHO was obtained and
there was borderline dysynchronization, although not enough to
warrant a biventricular pacemaker. Patient was maintained on a
BB, and was not started on an ACE given his underlying renal
function. It was thought that this was likely CHF resulting in
a troponin leak, rather than ACS causing CHF, thus the ACE was
not started. He was also started on PO Lasix. Digoxin was held
in this setting on not restarted upon discharge. This can be
readdressed as an outpatient.
.
#. Rhythm - Patient currently with sinus tachycardia with LBBB
pattern. Patient was maintained on telemetry without eveny.
Patient with wide QRS, although not a candidate for
resynchronization therapy.
.
#.CRI: patient with baseline Cr of 3.3, and cardiac
catheterization was deferred in this setting. Patient remained
at baseline while in house. ACE was deferred in this setting.
UPEP and SPEP sent, SPEP negative and UPEP was pending upon
discharge.
.
#.DM:
- Restarted Actos prior to discharge
.
#. Anxiety: continued on celexa, ativan
.
#. Hx of Prostate Ca: Continued on tamsulosin
.
.
After discussion with the patient and the medical team, all were
in agreement that [**Known firstname 429**] [**Known lastname 770**] was a suitable candidate for
discharge.
Medications on Admission:
Tricor 145 mg qd
Crestor 10 mg qd
Niaspan 500 mg tid
Coreg 3.25 [**Hospital1 **]
Digoxin 0.125 q mo wed fri
Aggrenox 200-25 [**Hospital1 **]
Ativan 1 mg tid
Flomax 0.4 mg
Loperamide
Famotidine 20 mg [**Hospital1 **]
Actos 15 mg
Vitamin d 1000 mg qd
Hydrocodone
Celexa 20 mg qd
Imipramine 10 mg qid
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Imipramine HCl 10 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
Disp:*240 Tablet(s)* Refills:*0*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
hr Sig: One (1) Cap PO BID (2 times a day).
Disp:*60 Cap(s)* Refills:*2*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary Diagnoses: Congestive Heart Failure & Myocardial
infarction
.
Secondary Diagnoses:
Prostate Cancer
CVA
PVD
CRI (baseline Cr 3.3)
? hx of CP in the past at age 34
GERD
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating with
assistance.
Discharge Instructions:
You were admitted with Congestive Heart Failure and sustained a
mild heart attack in this setting. You underwent aggressive
fluid removal with good response. It was also decided, given
your underlying renal function, to forego cardiac
catheterization and treat the cardiac issues medically..
.
Discontinued Medications:
Coreg
Digoxin
Tricor
Crestor
.
New Medications:
Furosemide 20 twice a day
Metoprolol 100 once a day
.
1. Please take all medications as prescribed.
2. Please attempt to make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.
Followup Instructions:
Please call your primary care doctor/cardiologist [**Last Name (LF) **],[**First Name3 (LF) **]
at [**Telephone/Fax (1) 50772**] to schedule a follow up appointment in [**1-30**] weeks
after discharge.
Completed by:[**2187-5-30**]
|
[
"585.4",
"250.00",
"799.02",
"403.90",
"V15.82",
"277.7",
"530.81",
"410.71",
"438.89",
"276.2",
"300.00",
"428.0",
"414.01",
"729.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11841, 11908
|
7826, 9699
|
322, 329
|
12127, 12203
|
4038, 7102
|
12848, 13081
|
2303, 2422
|
10048, 11818
|
11929, 11999
|
9725, 10025
|
12227, 12825
|
2438, 4019
|
12020, 12106
|
275, 284
|
357, 1818
|
7118, 7803
|
1840, 1926
|
1942, 2287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,238
| 154,378
|
50581
|
Discharge summary
|
report
|
Admission Date: [**2115-6-16**] Discharge Date: [**2115-6-19**]
Date of Birth: [**2032-6-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Incarcerated giant paraesophageal
hernia.
Major Surgical or Invasive Procedure:
PROCEDURE PERFORMED:
1. Laparoscopic reduction of giant paraesophageal hernia.
2. [**Last Name (un) **] gastroplasty.
3. Toupet fundoplication.
4. Flexible esophagoscopy.
History of Present Illness:
The patient is an 83-year-old
gentleman who was evaluated in the emergency room for
hemotemesis. A CT scan disclosed a large giant paraesophageal
hernia. Given the concern of gastric ischemia, he was brought
to the operating room urgently for reduction of this hernia.
Past Medical History:
DM, Diabetic neuropathy, HTN, GERD, Colon cancer
Family History:
non-contricutory
Physical Exam:
general: well appearing man in NAD
HEENT: unremarkable
Chest: CTA. vats port and chest tube sites healing well.
Cor: RRR S1, S2
Abd: soft, round, Nt, ND, +BS
extrem: no C/C/E
neuro: intact
Pertinent Results:
CTA [**6-17**]
IMPRESSION:
1. No pulmonary embolism.
2. Moderate bilateral pleural effusions with significant
bibasilar
atelectasis.
3. Incompletely visualized hypoattenuation of the left hepatic
lobe, which
may relate to retractor injury. There is a replaced left hepatic
artery, which
does opacify, however the artery cannot be completely evaluated.
If this
would change clinical management, a CTA of the liver is
recommended.
4. Gastric wall edema, likely related to the patient's recent
reduction of a
gastric volvulus, with no free air or leak identified.
barium swallow [**6-17**]
Patient swallowed barium without difficulty, with barium passing
freely through the esophagus into the stomach. There is no
evidence of
obstruction or leak, particularly at the level of the distal
esophagus.
Brief Hospital Course:
PT was admitted and taken to the OR [**2115-6-17**] for:
1. Laparoscopic reduction of giant paraesophageal hernia.
2. [**Last Name (un) **] gastroplasty.
3. Toupet fundoplication.
4. Flexible esophagoscopy.
OR course uneventful. NGT placed intraop and maintained to sxn
w/minimal output.Remained intubated and admitted to the ICU for
ongoing hemodyanic monitoring and ventilatory support. Pt was
weaned and extubated on POD#1and NGT d/c'd. Treated with broad
spectrum IVAB- kefzol, clinda, levaquin. Was transferred from
the ICU later on POD#1. POD#2 diet was advanced to clears then
fulls and [**Last Name (un) 1815**] well. Seen by PT and rehab was recommended.
D/c'd to rehab facility on POD#3. Will remain on full liquid
diet x one week until seen in follow up with Dr. [**First Name (STitle) **]. Med will
be crushed or in liquid form.
Medications on Admission:
Metformin 500', Lipitor 10', Atenolol 25, Protonix 40',
Allopurinol 100'
.
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. regular insulin
per sliding scale based on finger stick.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Hiatal Hernia
Hypertension
Diabetic neuropathy
GERD
Colon cancer
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased cough or shortness of breath
-Increased or painful swallowing, nausea, vomiting, diarrhea
Stay on a full liquid diet until you are seen in clinic w/ Dr.
[**First Name (STitle) **]. take all you meds crushed in apple sauce or in liquid
form.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in [**Hospital Ward Name 23**] clinical center [**Location (un) **] on
[**6-27**]/at 9:30am. Please arrive at 9am and report to the [**Location (un) **]
radiology for a chest XRAY.
Completed by:[**2115-6-19**]
|
[
"552.3",
"357.2",
"401.9",
"250.60",
"530.81",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.7",
"44.69",
"42.23",
"44.67"
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icd9pcs
|
[
[
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3613, 3683
|
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|
363, 536
|
3792, 3808
|
1166, 1970
|
4210, 4468
|
924, 942
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2963, 3590
|
3704, 3771
|
2863, 2940
|
3832, 4187
|
957, 1147
|
281, 325
|
564, 835
|
858, 908
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,527
| 148,492
|
12251
|
Discharge summary
|
report
|
Admission Date: [**2152-2-4**] Discharge Date: [**2152-2-28**]
Date of Birth: [**2079-7-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 13685**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Right IJ hemodialysis catheter placement
PICC line placement
Arterial line placement
Intubation and extubation
History of Present Illness:
72 year old male with h/o CVA with expressive aphasia, OSA,
severe AS (valve area 1.0cm2), [**12-12**]+ AR, CAD, chronic diastolic
CHF, thalassemia presenting for shortness of breath and weight
gain.
.
Of note, the patient has expressive aphasia has difficult giving
a reliable and clear history. The patient currently reports he
has been experiencing stable dyspnea on exertion and stable 2
pillow orthopnea. He does report feeling lightheaded at rest
intermittently over the past 1-3 weeks which lasts 5-20 minutes
and resolves sponatenously. These episodes are associated with
nausea and he has also been experiencing generalized myalgiase
and a non-productive occasional cough. The patient denies chest
pain, dyspnea during these episodes, arm or jaw pain,
diaphoresis. He denies recent fevers, abdominal pain, diarrhea.
.
Per report, the patient was seen by his PCP today on routine
follow-up and was noted to have dyspnea on exertion and a 20
pound weight gain over the past 2 weeks. He was also noted by
the son to be short of breath. He has recently had his Torsemide
increased to 40mg [**Hospital1 **] from 40mg daily, per patient report.
.
In the ED, initial VS: 96.7 95 133/76 22 100% 2L
The patient had a CXR that showed pulm vascular congestion but
no evidence of infection. EKG showed no ischemic changes. Labs
showed Hct at baseline of 27, Cr 2.1 with recently increased
baseline, BNP [**Numeric Identifier 38280**], Trop 0.06 x2. The patient was given ASA
325mg and Torsemide 20mg IV x1. He was admitted for further
management.
.
On the floor, the patient denied complaints including shortness
of breath, chest pain, nausea, lightheadeness. He was breathing
comfortably on 2L NC.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Coronary artery disease s/p stent (LCx, [**2145**] at [**Hospital1 882**])
- Chronic systolic and diastolic CHF (EF 30-35% in the past,
most recently >55%)
- Aortic stenosis (1.0cm2)
- CVA [**2145**], left MCA with expressive aphasia, motor planning
deficits, right-sided neglect. On coumadin in the past, stopped
due to GI bleed
- GI bleed [**2146**], due to hemorrhoids. Also [**6-/2151**] due to
hemorrhoids and coumadin stopped.
- BPH
- Prostate CA, [**Doctor Last Name **] 3+3, s/p XRT [**2142**]
- Thalassemia trait
- G6PD, class I - severe
- OSA on BiPap 16/13 at home. O2 sat 85% at rest, on 2L home O2
- Moderate pulmonary hypertension
- Gout
- Chronic back pain and lumbar spinal stenosis
- Left eye blindess [**1-12**] trauma
- Burn to L shoulder as a child
- Osteoarthritis
- H/o colon polyp
- H/o pancreatitis
.
CARDIAC CATH:
[**2145-4-13**] [**Hospital1 112**] Dr. [**Last Name (STitle) 38281**] [**Name (STitle) **]
DES to Cx
Right heart cath for pulmonary hypertension: RA 9, PCW 15, PA
systolic 36. 80% occlusion in Cx (stented), 45% in RCA.
PA pressure 36/7(23)
Social History:
Lives alone in [**Location (un) 686**]. He is able to cook for himself. Able
to walk [**12-12**] blocks without dypnea. Poor compliance with diet.
Uses bubble packs for his medications. Doesn't know the names of
any of his medications but states he manages them himself. Has
assistance of his son and daughter per review of [**Name (NI) 2287**] records.
Family History:
Mother deceased from MI at age 37. Father deceased with CVA and
lung cancer. Maternal aunts with DM. Brother deceased from
esophageal cancer
Physical Exam:
ON ADMISSION:
============
VS: 97.8 132/78 98 22 99%2L
GENERAL: Alert, interactive, expressive aphasia but appropriate,
NAD
HEENT: L eye shut with evidence of past injury. R pupil round
and sclera anicteric. MMM.
NECK: Supple, JVP to earlobe while sitting at 90 degrees
CARDIAC: RRR, GIII systolic murmer at RUSB, GII holosystolic
murmer at LSB and apex. No thrills, lifts. No S3 or S4.
LUNGS: Decreased BS at RLB, inspiratory crackles to mid lung
fields b/l R>L. No wheezes.
ABDOMEN: Soft, non-distended, mild LQ diffuse tenderness without
guarding or rebound.
EXTREMITIES: No c/c, WWP. 2+ pitting edema to thighs b/l.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ 2+ DP 2+
.
Discharge Exam:
Tm: 98 HR: 79-90 RR: 18 BP: 94-149/57-74O2 Sat: 96-100% RA
GEN: obese, male in NAD, A&O x 1 only (self). Unable to state
year, place. Speech halting but clear.
HEENT: dry moist, JVD about 12 cm.
CV: occasionally irregular, [**1-16**] holosystolic murmur at RUSB.
PULM: [**Month (only) **] BS throughout but no focal findings, no wheezes
ABD: obese, soft, NT, bowel sounds hypoactive
EXT: no edema, palpable peripheral pulses
Pertinent Results:
Labs on admission:
==================
[**2152-2-4**] 02:20PM BLOOD WBC-6.5 RBC-3.70* Hgb-9.4* Hct-31.2*
MCV-84 MCH-25.4* MCHC-30.3* RDW-15.8* Plt Ct-221
[**2152-2-4**] 02:20PM BLOOD Glucose-109* UreaN-46* Creat-2.2* Na-139
K-4.9 Cl-95* HCO3-31 AnGap-18
[**2152-2-4**] 02:20PM BLOOD proBNP-[**Numeric Identifier 38280**]*
[**2152-2-4**] 02:20PM BLOOD cTropnT-0.06*
[**2152-2-4**] 02:55PM BLOOD CK-MB-3
[**2152-2-4**] 02:55PM BLOOD cTropnT-0.06*
[**2152-2-4**] 11:25PM BLOOD CK-MB-3 cTropnT-0.06*
[**2152-2-5**] 08:00AM BLOOD CK-MB-3 cTropnT-0.06*
[**2152-2-4**] 02:55PM BLOOD Calcium-7.8* Phos-4.5 Mg-1.9
.
Microbiology:
[**2152-2-5**] 6:37 pm URINE Source: CVS.
URINE CULTURE (Final [**2152-2-10**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
CIPROFLOXACIN Susceptibility testing requested by DR. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 20564**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S =>8 R
GENTAMICIN------------ 8 I
LINEZOLID------------- 1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S 32 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ =>32 R
.
Imaging:
=========
CXR [**2-4**]: Cardiomegaly with mild pulmonary vascular congestion.
Mild
bibasilar atelectasis with chronic elevation of the right
hemidiaphragm.
.
TTE [**2-7**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is mild to moderate regional left
ventricular systolic dysfunction with focal ak/dyskinesis of the
septum and moderate hypokinesis of the remaining segments (LVEF
= 25-30 %). The right ventricular cavity is moderately dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets are
moderately thickened. There is severe aortic valve stenosis
(valve area 0.8cm2). Moderate (2+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.] At
least moderate [2+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Symmetric left
ventricular hypertrophy with cavity enlargement and regional and
global systolic dysfunction c/w diffuse process. Right
ventricular cavity enlargement with free wall hypokinesis.
Moderate aortic regurgitation. Pulmonary artery systolic
hypertension. Compared with the prior study (images reviewed) of
[**2151-12-1**], biventricular cavity enlargement with more depressed
systolic function is now present. The severity of aortic
regurgitation and mitral regurgitation are slightly increased.
The aortic valve gradient is lower (reflecting reduced cardiac
output). The valve area is likely similar.
.
Renal US [**2152-2-7**]
FINDINGS: Note is made that this is a limited study due to the
patient's body habitus. The right kidney measures 9.9 cm and the
left kidney measures 10.8 cm. There is no hydronephrosis
identified. A moderate amount of ascites is seen in the lower
quadrants.
.
IMPRESSION:
1. No hydronephrosis.
2. Moderate amount of ascites.
.
.
Labs on discharge: [**2152-2-28**]
==================
BUN: 51, creat: 1.4, bicarb: 34
Na: 139, K 3.9
Hct: 29.6, WBC: 7.2, Plt: 318
Ca: 9.7 Mg: 2.1 P: 4.6
Brief Hospital Course:
Mr. [**Known lastname 19122**] is a 72 year-old man with h/o CVA with expressive
aphasia, OSA, AS, CAD, OSA on BiPap, chronic systolic CHF
(EF30-35%) and thalassemia who was admitted for a CHF
exacerbation.
.
# Acute on Chronic Systolic Congestive Heart Failure: Patient
with chronic systolic and diastolic congestive heart failure
admitted for acute exacerbation. He also has severe AS, valve
area 1.0 and mild-moderate AR, with EF>55% in [**11-18**]. He was very
volume overloaded on admission with weight 138kg (dry weight
~122kg). He was initially diuresed with torsemide 40mg IV and
lasix gtt with very low urine output and worsening Cr. He was
placed on a diuresis holiday to allow his kidneys to recover. A
PICC line was placed and he was started on a dopamine drip and
given 100mg IV torsemide with brisk diuresis. Due to renal
failure, patient was not placed on ACE/[**Last Name (un) **]. His respiratory
status worsened, likely in setting of pulmonary edema
complicated by his underlying pulmonary process. He was
transferred to the CCU on [**2152-2-8**] for further management and was
inubated for poor oxygenation on non-rebreathing mask. He was
subseqently continued on a dopamine drip at renal vascular doses
with excellent diuresis to 1-2L negative net fluid balance
daily. He continued to required significant diuresis and his
dopamine drip was subseqently stopped and he was started on a
lasix drip with excellent response achieving lenght of stay
fluid balance approaching negative 20L. He was extubated
successfully on [**2152-2-20**] with appropriate breathing. He was
then transitioned to po torsemide and was discharged on
torsemide 40 mg po daily along with a 1.5 L fluid restriction.
#RESPIRATORY: Patient has several underlying respiratory
comorbidities including OSA, pulmonary hypertension, Obesity
hypoventilation syndrome who has baseline hypercarbia and
relative hypoxemia. [**Name2 (NI) **] is non-compliant with OSA mask at home.
He was intubated on [**2152-2-8**] and he was difficult to extubate,
likely in setting of underlying comorbid pulmonary issues and
decompensated CHF. While intubated, he was diuresed with
dopamine and lasix with goal net output of 2L per day achieving
a length of stay fluid balance approaching negative 20L. He was
successfully extubated on [**2152-2-20**] with appropriate and stable
breathing follwoing extubation. He was continued on nasal
cannula as needed and BiPAP at night. On discharge, he was no
longer requiring nasal cannula. He needs to wear Bipap at night
to avoid CO2 retention and confusion.
#Ventilator-Associated Pneumonia: Patient developed ventilator
associated pneumonia with sputum growing 2 species of
enterobacter cloacea and one species klebsiella pneumoniae. He
completed an 8 day course of cefepime with resolution of his
symptoms.
# Aortic stenosis - severe, area 1.0cm2 in [**11-18**] with repeat TTE
showing valve area 0.8cm2. Prior to admission, pt reports
transient episodes of dizziness and pre-syncopal symptoms which
are likely related to AS. He was seen by CT [**Doctor First Name **] who identified
him as a poor candidate for surgery and was subsequently
evaluated by the Aortic Stenosis Service for possible
percutaenous AVR who also felt that he was a poor candidate for
an intervention. It was explained to the family that pt would
likely continue to have acute CHF episodes despite maximal
medical treatment and suggested that family and pt consider
DNR/DNI and possible comfort care. The pt and family is not
ready for this step but should continue to maintain a dialogue
regarding goals of care. His primary care doctor, Dr. [**Last Name (STitle) **],
has been involved in discussions with the family and should be
contact[**Name (NI) **] at [**Telephone/Fax (1) 3530**].
.
# CORONARIES: Patient with known CAD s/p LCx stent at [**Hospital1 882**].
Patient had no sign of ACS on presentation. Troponins elevated
on admission were most likely related to CKD. He was treated
with aspirin, Metoprolol, statin.
.
# RHYTHM: Patient with QTc 460 remained in NSR with PVCs. His
electrolytes were repleted as neeeded and he was was monitored
on telemetry.
.
# Acute renal failure - His baseline is a Cr 1.0 in from a [**11-18**]
history of acute failure to Cr 7 in setting of diuresis. His Cr
was 2.0 on admission and trended up to 3.0 with torsemide/lasix
diuresis. Fe Urea was 4% indicating poor renal perfusion, likely
in the setting of CHF. He was placed on a diuresis holiday x 36
hours without improvment in Cr. He subseqently responded well a
dopamine drip and subsequently a lasix drip. His Cr on discharge
was 1.4. Please check chem-7 and CBC on Wednesday [**3-1**] and
consider starting ACE inhibitor in a few days if creatinine is
stable.
.
# Hypertension: He was continued on his home dose of metoprolol.
.
# Dyslipidemia: He was continued on his home dose of
simvastatin.
.
# CVA: In [**2145**], he had a left MCA stroke with with 2/2
expressive aphasia, motor planning deficits, right-sided
neglect. He was on coumadin in the past, but stopped due to GI
bleed. He was continued on aspirin. At present, he has guiaic
positive stools but a stable hct. Omeprazole was increased to
[**Hospital1 **]. He is not a candidate for a colonoscopy.
# BPH: He was continued on his home tamsulosin regimen.
.
# Gout: Allopurinol was held initially given ARF and then
restarted when creatinine returned to [**Location 213**].
.
Rehab stay expected to be < 30 days. Health care proxy [**Name (NI) **]
[**Known lastname 19122**] [**Name (NI) **] is making rehab decisions for pt.
Medications on Admission:
1. omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
3. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY 4. 4. Overnight CPAP or oxygen at 4L NC: CPAP is preferred
but patient sometimes refuses in which case overnight O2 by NC
can be used at 4L.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
wehezeing.
9. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
- Torsemide 40mg daily, recently increased to [**Hospital1 **] per pt
- Oxycodone-Acetaminophen 5-325 1-2 tabs q4h prn pain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
10. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
16. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
17. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-12**]
puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Center
Discharge Diagnosis:
Primary:
Acute on chronic systolic Congestive Heart failure: no ACE/[**Last Name (un) **]
[**1-12**] [**Last Name (un) **]
Acute renal failure
Aortic Stenosis
Anemia
Obstuctive sleep apnea on Bipap
Acute on Chronic Kidney Disease
Secondary:
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 19122**],
You were admitted to [**Hospital1 18**] with shortness of breath. You had a
great deal of volume overload with fluid in your lungs which
likely worsened your breathing. We gave you diuretics to remove
the fluid from your lungs. An echocardiogram was done of your
heart which showed worsening heart failure. Your renal function
was worsening and has now improved. Your weight at discharge
which we think is your ideal weight is 185 pounds.
You will need to weigh yourself every day in the morning, call
Dr. [**Last Name (STitle) **] if your weight increases more than 3 pounds in 1 day
or 5 pounds in 3 days.
We have made the following changes to your medications:
- Decrease Torsemide to once daily
- start senna, miralax, bisacodyl and colace to prevent
constipation
- Discontinue albuterol and atrovent nebs
- Increase Metoprolol to 50 mg daily
- Increase omeprazole to twice daily
Followup Instructions:
Name: [**Name (NI) **], [**Name (NI) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
APpt: We are working on an appt for you and the office will
call you at home with the appt. If you dont hear from them by
Monday, please call them directly at the number above.
|
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229, 250
|
9151, 9291
|
428, 2127
|
5162, 9132
|
18189, 18325
|
2316, 3400
|
2149, 2207
|
3416, 3772
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,534
| 112,562
|
33532
|
Discharge summary
|
report
|
Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-22**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
ICU to [**Hospital **] transfer from [**Hospital6 204**] for bilateral
thalamic and cerebellar infarcts.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 77747**] is an 83 year old Armenian speaking male with h/o
hypertension, hyperlipidemia, type 2 DM who presents as an
outside hospital transfer with acute bilateral thalamic and
cerebellar infarcts. The pt was well until last Friday around
noon he was at the grocery store and had the sudden onset of
bitemporal headache. He appeared pale and sluggish to his son.
[**Name (NI) **]
was able to slowly walk to the car, but his speech appeared
unusually slow. His son check his blood sugar upon returning
home
and it was 131. EMS was called and pt did not want to go to the
hospital, he was taken to [**Hospital3 **] for evaluation. There
his speech remained slow, but he seemed to improved, "he was 90%
better" according to his family. Head CT reportedly without any
acute changes. On Saturday the pt was still about 90% of
himself.
Able to write his name, sing a song, able to perform addition.
Sunday afternoon the patient was scheduled for an MRI, as he was
being lifted to the gurney he suddenly became pale, closed his
eyes and became flaccid "passing out" per his son who was at the
bedside. The pt has not improved since this time. The Sunday MRI
was cancelled. Hospital records ? whether the patient may have
transiently developed an AV block during this event. About 1-2
hours following this event on Sunday the patient had assymmetric
shaking motions of his extremities. He was loaded on Dilantin
and
given Ativan. The movements persisted for about 2 hours despite
the administration of AED's, but then later resolved. MRI was
performed today [**4-10**] around 4pm at LGH, revealing bilateral
thalamic infarcts, and bilateral cerebellar infarcts. The pt was
transferred to [**Hospital1 18**] for further care.
Prior to last friday family reports pt feeling well at home,
independent of ADL's, still actively writing Armenian novels.
Past Medical History:
HTN
Hyperlipidemia
DM 2
Social History:
Prior to last friday family reports pt feeling well at home,
independent of ADL's, still actively writing Armenian novels.
ROS- reported chronic right leg pain with ambulation.
Family History:
-
Physical Exam:
Vitals: T 98, HR 106, BP 136/66, R 21, Sat 100% 2L NC
Gen- ill appearing, eyes closed, NAD
HEENT- NCAT,
Neck- no carotid or vertebral bruits, no nuchal rigidity
CV- RRR, no MRG
Pulm- transmitted upper airway sounds, expiratory rhonci at RML.
Abd- soft, NT, ND, BS+
Extrem- no CCE, 2+ DP pulses
Neurologic Exam-
MS- no response to voice, eyes closed, does not follow commands,
localizes noxious stimulation with left hand.
CN- right pupil with corneal opacity 3mm fixed and unreactive to
light, left pupil 3mm fixed and unreactive to light, + scatter
of
light with attempt of funduscopic exam, could not visualize L
fundus, intact corneal reflexes bilaterally. Absent
oculacephalic
reflex, grimaces to nasal tickle, intact (weak) gag.
Motor/Sensory- + grasp reflex bilaterally. winces to nailbed
pressure in both arms, withdraws Left arm. No right arm
withdrawal. Feet with triple flexion bilaterally.
Reflexes- absent patellar and ankle jerks. 1+ biceps, triceps,
brachioradialis bilatarally.
Plantar response was triple flexion bilaterally.
Pertinent Results:
[**4-15**] CT/CT head and neck
CT HEAD WITHOUT IV CONTRAST: There is no evidence of acute
hemorrhage, mass,
or shift of normally midline structures. Prominence of the
ventricles and
sulci is consistent with age-related involutional change.
Regions of
hypodensity in the periventricular white matter are consistent
with small
vessel ischemic disease. In addition, there are regions of
hypodensity in the
left greater than the right thalamus, left periventricular white
matter,
bilateral occipital lobes, and bilateral cerebellar hemispheres.
These are
consistent with age-indeterminate regions of
ischemia/infarction.
The paranasal sinuses and the mastoid air cells are clear except
to note a
small mucus retention cyst in the left side of the frontal
sinus. The patient
is status post replacement of the left ocular lens. A right NG
tube is in
place. Vascular calcifications are noted in the intracranial
vertebral
arteries and the cavernous carotid arteries.
CTA HEAD AND NECK: There are calcified plaques along the aorta
at the origin
of the vertebral arteries and within the carotid system,
particularly along
the proximal ICA which is more notable on the left. There is a
7-mm segment
of the left proximal ICA, which demonstrates 60-70% stenosis.
There is a
55-60% stenosis of the right proximal internal carotid artery.
The vertebral
arteries are irregular, with short segments of narrowing,
without occlusion of
flow. Atherosclerotic calcifications are noted at the origins of
the
vertebral arteries, causing moderate stenosis, without flow
limitation. The
basilar artery is patent.
No masses are seen in the lung apices. There is no evidence of
supraclavicular adenopathy. Degenerative changes are noted at
multiple levels
in the cervical spine, with left foraminal narrowing at C3-4
level. However,
these are not adequately assessed on the present study.
IMPRESSION:
1. Hypodense lesions in bilateral thalami, in the left
periventricular white
matter, bilateral occipital lobes and bilateral cerebellar
hemispheres,
consistent with ischemia/infarction of indeterminate age.
Correlation with MR
performed at outside hospital is recommended for better
assessment.
2. Atherosclerotic plaques, soft and calcified, in the proximal
internal
carotid arteries on both sides, more prominent on the left, with
moderate
stenosis of the proximal internal carotid arteries. No flow
limitation.
3. Atherosclerotic calcifications, involving the vertebral
arteries, with
short segments of narrowing as well as at the origin. No flow
limitation
[**4-19**] HCHCT
There is no evidence of an acute intracranial hemorrhage. There
are well-
defined hypodensities involving the cerebral hemispheres
including the
thalami, occipital lobes, and cerebellar hemispheres consistent
with
multifocal infarcts. The ventricular system is stable in size
and
configuration. There is no evidence to suggest hydrocephalus.
The visualized mastoid air cells and sinuses are unremarkable.
IMPRESSION:
Overall stable appearance to the multifocal infarction without
evidence of
intracranial hemorrhage.
Brief Hospital Course:
Patient was admitted to the neurology service. MRI images were
reviewed with the family - we indicated that he had a bad
prognosis given (1) severe bilateral critical stenosis diffusely
in the posterior circulation on multilple levels, most evidently
in the bilateral vertebrals and (2) by that mechanism he had
stroked bilateral occiput, cerebellum, thalamus - he was at high
risk for recurrence or further strokes, including the brainstem.
(3) Also, if he were to not have further strokes, bilateral
thalamic infarcts can give a severe clinical picture resembling
advanced dementia or an abulic state, with hypersomnolence as
well.
The patient had one brief moment of clinical improvement, with
eyes opening to loud voice, acknowledging presence of his
family, answering Y/N questions appropriately. After that, he
became signficantly infected - and [**1-28**] continued negative
cultures he was eventually treated empirically. The treatment
was aimed on optimizing him physically to formerly assess his
neurological status - but after more than a week of empyric
therapy he continued to spike fever with increasing white count.
Neurologically he had deteriorated more than what would be
attributable to infection, he developed a new left hemiparesis
and lost all horizontal eye-movements other than R eye abduction
with head movements. A CT did not demonstrate a bleed, but
clinically he had stroked out his pons now. Multiple
conversations were held with the family, who were very
understanding, and on the [**6-22**] care was withdrawn. He
died shortly thereafter.
Medications on Admission:
metformin, glyburide, lasix, diltiazem, hydroxyzine, doxazocin,
pentoxyfyline. Not taking any antiplatelet agents.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
None (deceased)
Discharge Condition:
Deceased
Discharge Instructions:
None (deceased)
Followup Instructions:
None (deceased)
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2197-4-25**]
|
[
"250.00",
"401.9",
"780.6",
"276.0",
"272.4",
"518.81",
"433.31",
"434.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8488, 8497
|
6721, 8293
|
368, 374
|
8556, 8566
|
3615, 6698
|
8630, 8768
|
2528, 2531
|
8459, 8465
|
8518, 8535
|
8319, 8436
|
8590, 8607
|
2546, 3596
|
223, 330
|
402, 2268
|
2290, 2316
|
2332, 2512
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,750
| 134,746
|
30796
|
Discharge summary
|
report
|
Admission Date: [**2111-5-1**] Discharge Date: [**2111-5-11**]
Date of Birth: [**2072-10-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
VATS
Bronchoscopy
History of Present Illness:
38 M c no PMH developed rigors followed by pleuritic L sided CP
1 day prior to presentation to OSH. Had several episodes of
cough followed by florid hemoptysis precipitating call to EMS.
([**1-6**] ounces blood on transport out of house). CT scan at OSH
showed multiple nodules c air bronchogram formation. Hx
significant for + TB exposure while in jail in [**2104**]. No travel.
.
At OSH, broad ddx entertained; PPD checked, sputum checked for
afb.. ECHO checked for ? septic emboli. ANCA sent off but
pending. Continued to have intermittent episodes of hemoptysis
with HCT drift from 40.1-37.1-36.4.
.
On transfer to [**Hospital1 18**], pt. had episode of SSCP, resolved with 2
SLNTG. No EKG changes. No complaints in MICU at [**Hospital1 18**]. ROS other
wise negative for any hematuria, sinus infections, rhinorrhea,
recent weight loss, fatigue, malaise.
Past Medical History:
1. Lower back pain c L3/L4 disc bulge and L4/L5 disc tear
Social History:
Smokes cigs, Rare EtOH. No IV drugs. Works as a mechanic.
Family History:
nc
Physical Exam:
VS- 98.0, 61-70, 110-119/64-65, 16-22, 95-98% RA
HEENT- OP clear, MMM, poor dentition
LUNGS- CTA; no crackles, wheeze
HEART- RRR, S1, S2, no rmg
ABD- soft, ND, NT, BS+
EXT- wwp, no edema
NEURO- A*O*3
Pertinent Results:
Lab trends:
Admission CBC: WBC-13.6* RBC-5.27 Hgb-12.0* Hct-35.8* MCV-68*
Plt Ct-268
Discharge CBC: WBC-12.3* RBC-5.11 Hgb-11.4* Hct-34.7* MCV-68*
Plt Ct-299
CBC trends:
WBC: 13.6 - 11 - 17 - 23 - 11 - 12
HCT stable
.
Admission Coags: PT-12.5 PTT-26.6 INR(PT)-1.1 (remained stable)
.
Admission Lytes: Glucose-108* UreaN-6 Creat-0.6 Na-138 K-4.1
Cl-106 HCO3-25 AnGap-11... remained stable
.
LFT Trends;
[**2111-5-2**] 12:25AM BLOOD ALT-80* AST-44* AlkPhos-171* TotBili-0.5
[**2111-5-3**] 03:45AM BLOOD ALT-79* AST-48* LD(LDH)-124 AlkPhos-215*
TotBili-0.5
[**2111-5-4**] 05:22AM BLOOD ALT-127* AST-80* AlkPhos-278* TotBili-0.5
[**2111-5-7**] 06:33AM BLOOD ALT-130* AST-46* AlkPhos-285* TotBili-0.5
[**2111-5-8**] 06:45AM BLOOD ALT-111* AST-43* AlkPhos-325* TotBili-0.4
[**2111-5-9**] 07:30AM BLOOD ALT-121* AST-53* AlkPhos-347* TotBili-0.3
[**2111-5-10**] 07:55AM BLOOD ALT-94* AST-32 LD(LDH)-131 AlkPhos-300*
TotBili-0.3
[**2111-5-11**] 07:05AM BLOOD ALT-64* AST-20 AlkPhos-243* TotBili-0.2
[**2111-5-8**] 06:30PM BLOOD GGT-343*
.
Misc labs:
[**2111-5-6**] 11:13AM BLOOD Iron-20*
[**2111-5-6**] 11:13AM BLOOD calTIBC-317 VitB12-586 Folate-7.1
Ferritn-119 TRF-244
[**2111-5-4**] 05:22AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2111-5-8**] 11:40PM BLOOD AMA-NEGATIVE
[**2111-5-2**] 12:25AM BLOOD ANCA-NEGATIVE B
[**2111-5-6**] 11:23AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40
[**2111-5-8**] 11:40PM BLOOD PEP-NO SPECIFIC BAND IgG-979 IgA-321
IgM-99 IFE-NO MONOCLO
[**2111-5-4**] 05:22AM BLOOD HIV Ab-NEGATIVE
[**2111-5-8**] 11:40PM BLOOD tTG-IgA-4
alpha one antitrypsin not defic
.
Radiography/micro/studies
[**5-2**] RUQ U/S: The liver is normal in echotexture with no focal
lesions. The gallbladder is normal appearing. There is no intra-
or extra-hepatic ductal dilatation. The common bile duct
measures 2 mm. There is appropriate forward portal venous flow.
The spleen is at the upper limits of normal in size measuring 12
cm. The right kidney measures 10.8 cm. The left kidney measures
10.8 cm. There is no ascites. The pancreatic head and neck are
within normal limits. The body and tail are obscured by
overlying bowel gas.
.
[**5-2**]: Admit CXR: Multifocal patchy somewhat spherical
parenchymal opacities, of uncertain chronicity; differential
diagnosis includes multifocal pneumonia (including septic emboli
and aspergillus), aspiration, and pulmonary hemorrhage related
to vasculitis. Dedicated PA and lateral chest radiograph or CT
scan may be helpful for more complete characterization
.
[**5-2**] EKG: NSR, NI NA no acute ST-T changes
.
[**5-4**]: BAL Washings: NEGATIVE FOR MALIGNANT CELLS. Numerous
pulmonary macrophages. No viral cytopathic changes or fungal
organisms seen
.
[**5-4**]: CT Chest: 1. Multifocal poorly defined lung nodules and
wedge shaped consolidation, with slight improvement since recent
outside CT scan. Although nonspecific, in the setting of
hemoptysis, a vasculitis such as limited Wegener's
granulomatosis or other pulmonary hemorrhage syndrome should be
considered. Differential diagnosis includes cryptogenic
organizing pneumonia and/or infection (especially angioinvasive
Aspergillus and Mucor). Malignancy such as BAC is much less
likely given improvement since recent scan. 2. New left lower
lobe consolidation and rapidly evolving right lower lobe
consolidation most likely represents aspiration or hemorrhage.
.
[**5-5**]: BAL/VATS Cytology:
1. Lung, right lower lobe, wedge resection (A-H):
a. Organizing pneumonitis, see note.
b. Focal accumulation of alveolar macrophages consistent with
respiratory bronchiolitis.
2. Lung, right lower lobe, wedge resection #2 (I-L):
a. Organizing pneumonitis, see note.
b. Focal accumulation of alveolar macrophages consistent with
respiratory bronchiolitis.
Note; The organizing pneumonitis has features consistent with
bronchiolitis obliterans/organizing pneumonia (BOOP/COP).
.
[**5-8**]: Repeat CT Chest: FINDINGS: Multiple poorly defined nodular
opacities scattered throughout the lungs have slightly improved
from [**2111-5-4**]. The largest opacity containing an air
bronchogram in the right middle lobe is also slightly smaller
measuring 3.0 x 1.5 cm (previously 3.3 x 2.4 cm), as well as
improvement of additional right upper and lower lobe
consolidations, and left pleural effusion. The right pleural
effusion has increased along with an enlarging right basilar
opacity, but this is at the site of recent VATS and is most
likely post- surgical. Centrilobular emphysema is most prominent
in the apices. The heart and great vessels of the mediastinum
are unchanged, remarkable for multiple lymph nodes measuring up
to 10 mm. The visualized abdomen is unremarkable aside from two
simple subcentimeter hepatic cysts. There is a small
subcutaneous emphysema post-VATS. No suspicious lesions are
identified in the bones. IMPRESSION:
1. Improving multifocal lung abnormalities.
2. Increase in right pleural effusion and focal opacities at
biopsy site, likely post-operative.
.
Discharge CXR on [**5-10**]: Further improvement in pulmonary opacities
with residual poorly defined scattered opacities remaining.
Small residual pleural effusions.
.
MICRO DATA:
C diff negative
Blood and urine cx NGTD
BAL/VATS cx with no microorganisms
sputum AFB neg x3
Brief Hospital Course:
38yo man who presented with fevers, rigos, chills, and
hemoptysis from OSH. Hospital course will start with MICU
course then proceed below:
.
In MICU coags and Hct were stable, pt underwent bronch which
showed diffuse blood in bronchi, indeterminant source. Given
multiple nodules seen on CT from OSH and hemoptysis, cancer, TB,
and autoimmune (Wegner's and Goodpasture's) were prime
consideration. He was covered for pneumonia with levaquin. He
was originally on Vancomycin as OSH blood cultures were known to
be positive for gram positive organisms, however, this was
discontinued once these were speciated as micococcus in one
bottle and bacillus in other bottle, both likely contaminants.
BAL was sent and showed no microorganisms and no malignant
cells. Extensive lab workup as above. He was stabilized and
transferred to the floor. By problem:
.
# Hemoptysis/pulm nodules: The differential was very broad. Lab
data as above did not support the diagnosis of wegener's
granulomatous disease. Additionally, [**Doctor First Name **] was only weakly
positive. HIV was negative. anti GBM was negative. He was AFB
neg x3. The biopsy results suggested COP/BOOP which also did
not point to a clear source. He did not have any episodes of
hemoptysis while on the floor and remained hemodynamically
stable, thus steroids were not administered. He was off oxygen
and afeb for several days prior to discharge. Pulmonary service
followed him on the floor and as above, the repeat CT showed
some improvement in the pulm disease. They would like a repeat
CT in one month and followup in their clinic. The question of
solvent/petroleum exposure was entertained but was difficult to
confirm.
.
# ID: The patient was treated with a 7 day course of levaquin
starting on admission given the consolidation seen on chest
imaging. His fever improved and his wbc remained stable. He
was taken off this while on the floor. He then had a fever to
101 so this medication was restarted to complete a 10 day
course. We entertained the idea of performing a diag [**Female First Name (un) 576**]
during this febrile period to assess for empyema. However,
after d/w interventional pulm, it was decided that there was not
a significant pleural effusion. He then improved quite rapidly.
Given his clinical improvement and unconvincing source of
infection, it was discontinued upon discharge. Micro data
remained NGTD and c diff was neg.
.
# Transaminitis: Present at OSH, worsened slightly during unit
admission here. DDx included viral, autoimmune, medication,
dietary, etoh, toxic, septic emboli, biliary. He persistently
had a normal bilirubin. RUQ US was neg. We were concerned
this was related to his pulmonary issues thus involved the
hepatologists and sent above labs. We considered liver biopsy
but delayed this given his clinical and laboratory improvements.
He will followup with liver in a few weeks to recheck labs and
consider biopsy. The etiology was not clear.
.
# Microcytic anemia: Hct stable 34-38, MCV 68, Fe studies as
above, suggestive of either Fe deficiency [**2-6**] occult bleeding or
malabsorption or thalassemia. Thalessemia workup is still
pending at this time. He was guaiac positive but had no frank
blood or melena. Patient may need a colonoscopy as an
outpatient if this persists.
.
# Post-op care: Patient did require IV morphine postoperatively.
He was transitioned to oxycodone and was discharged with a few
weeks' supply.
.
# Cardiovascular: Pt intially had SSCP relieved by NTG at OSH
and again here in the ED, but has since remained asx, with no
evidence of vasc disease. EKGs have been NSR without ST-T
changes.
.
# CODE: Full. discussed on [**5-6**]
Medications on Admission:
Tylenol
Ativan
Aplisol
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. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough for 1 months.
Disp:*300 ML(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 1 months.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- hemoptysis
- cryptogenic organizing pneumonitis
- transaminitis- etiology unclear. biopsy deferred
- pulmonary nodules s/p VATS and biopsy
Secondary:
- Low back pain
Discharge Condition:
stable
Discharge Instructions:
You were admitted with hemoptysis, left sided chest pain, and
fever. You were monitored in the ICU and underwent a
bronchoscopy and VATS procedure. You had biopsies of some
lesions in your lungs which showed cryptogenic organizing
pneumonitis. You were seen by the pulmonologists and followup
imaging showed improvement.
.
You also had some transient damage to your liver. The etiology
was unclear but it stabilized and improved. The liver team was
consulted to assist with your care. We thought about performing
a biopsy but since it improved, we decided to hold off. You
will have an outpatient appointment with liver to decide the
need for further intervention.
.
Please take your medications as instructed. Please followup
with your PCP as scheduled. Please have a repeat CT chest scan
as scheduled and followup with the pulmonologists. Please
followup with hepatology.
.
Please contact your PCP if you experience chest pain, shortness
of breath, abdominal pain. Please return to the emergency
department if you experience any extreme shortness of breath,
nausea, bloody cough, worsening abdominal pain, weakness, fever.
Followup Instructions:
Please followup with your PCP on Wednesday [**5-13**] at 9:40. Dr.
[**Last Name (STitle) 29117**] can be reached at [**Telephone/Fax (1) **]. His fax number is
[**Telephone/Fax (1) **]
.
Please followup with your thoracic surgeon, Provider: [**Name10 (NameIs) 1532**]
[**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2111-5-19**] 3:00pm.
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-6-9**] 1:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2111-6-16**] 9:00
.
Please followup with Dr. [**Last Name (STitle) **] in pulmonology on [**6-16**] at
10am. ([**Telephone/Fax (1) 513**]
.
Please followup with Dr. [**First Name (STitle) 679**] on Thursday, [**6-4**] at 1:30pm. His
number is [**Telephone/Fax (1) **]
|
[
"280.9",
"790.6",
"518.89",
"V01.1",
"790.4",
"288.60",
"486",
"786.3",
"305.1",
"780.6",
"516.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"33.28",
"34.21",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
11148, 11154
|
6952, 10650
|
283, 303
|
11376, 11385
|
1605, 6929
|
12569, 13395
|
1365, 1369
|
10724, 11125
|
11175, 11355
|
10676, 10701
|
11409, 12546
|
1384, 1586
|
233, 245
|
331, 1193
|
1215, 1274
|
1290, 1349
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,466
| 134,308
|
7800
|
Discharge summary
|
report
|
Admission Date: [**2112-12-28**] Discharge Date: [**2113-1-12**]
Date of Birth: [**2034-7-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Increasing dyspnoea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 78 year old male with a history of congestive heart
failure and EF of 20%, who is now presenting with increasing
dyspnea. He says that over the past 2-3 days, he has had
increasing dyspnea. Denies orthopnea or PND. Also states his
urine output has decreased, with associated poor PO intake. He
went to see his PCP given his symptoms. His PCP noted his blood
pressure to be 80s systolic. He also has a history of chronic
kidney disease with a baseline creatinine of 1.5, which has now
worsened to 2.1. He recently had a cardiac catheterization in
[**2112-10-21**], with BMS to the mid-LAD lesion.
In the ED, he continued to have lower blood pressures, with
systolic around 90. He was not dizzy or lightheaded; no fluids
were given in the setting of likely pulmonary edema. An EKG
showed no new changes; troponin was obtained which was at
baseline.
On the floor, he was saturating at 100% on 2 L. He denied
orthopnea, PND, or shortness of breath (was at baseline). Did
endorse continued leg swelling that he feels is above his
baseline.
Past Medical History:
-CHF, systolic: with last echo showing EF 20%, [**7-30**], global
hypokinesis
-3 v CAD, 40% proximal stenosis of LAD, 80% mid, 40% long mid to
distal and 80% diagonal stenosis s/p PTCA of mid LAD stenosis
([**2112**])
-Cardiomyopathy, unclear cause
-[**Name (NI) 2091**], Cr baseline of 1.4-1.6
-Anemia (baseline HCT 35): Fe 34, TIBC 229, Ferritin 616 in 06
-Hypertension
-RA on chronic steriods
-Gout
-ED
-Sz in setting of etoh withdrawal
-Osteopenia
-GERD
-Osteoarthritis
-Right olecranon bursitis
-Shingles [**2112**]
Social History:
He lives alone. He is retired, but had worked in a candy
factory. Also was a [**Hospital1 **] minister who performed ceremonys.
His Daughter [**Name (NI) **] feels that he is isolated and depressed at
home. Also unclear if he was taking all of his medicines. He
quit smoking over 30 years ago. Hx of excessive alcohol use in
the past, but patient reports no alcohol use in the last year.
Denies drug use
Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28212**] [**Telephone/Fax (1) 28213**] is best contact. Also has a
daughter [**Name (NI) 28214**] that [**Name (NI) **] has requested not get pt information.
Family History:
The patient has eight sisters apparently healthy. One daughter
with arthritis of the knees age 50. Three children, one with
metastatic cancer. His sister died from heart disease
Physical Exam:
At Discharge
VS: 97.5, 105/76, 81, 20, 96% RA
Gen: Black male, lying in bed in no apparent distress
HEENT: Anicteric
Cards: Nl s1/s2 RRR, JVD to ear ([**2-23**] TR)
Pulm: Lungs clear, no rales or wheezes
Abd: soft, nontender, nondistended
Ext: no peripheral edema, pulses palpable
Skin: Has open area on ant shaft of penis with white discharge.
Pertinent Results:
[**2112-12-28**] 07:41PM BLOOD WBC-8.0 RBC-5.03# Hgb-13.8* Hct-44.4#
MCV-88 MCH-28.4 MCHC-32.1 RDW-19.9* Plt Ct-134*
[**2112-12-28**] 07:41PM BLOOD PT-16.5* PTT-29.4 INR(PT)-1.5*
[**2112-12-28**] 07:41PM BLOOD Glucose-108* UreaN-47* Creat-2.1* Na-129*
K-5.0 Cl-95* HCO3-20* AnGap-19
[**2112-12-28**] 07:41PM BLOOD CK(CPK)-92
[**2112-12-28**] 07:41PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
.
Other labs
[**2113-1-3**] 07:15AM BLOOD ALT-38 AST-25 AlkPhos-110 TotBili-2.1*
DirBili-1.4* IndBili-0.7
[**2112-12-28**] 07:41PM BLOOD CK-MB-4 proBNP-[**Numeric Identifier 28215**]*
[**2112-12-28**] 07:41PM BLOOD cTropnT-0.08*
[**2113-1-2**] 08:35AM BLOOD proBNP-[**Numeric Identifier 28216**]*
[**2113-1-3**] 07:15AM BLOOD VitB12-GREATER TH Folate-10.3 Ferritn-163
[**2112-12-28**] 07:41PM BLOOD Osmolal-284
[**2112-12-31**] 07:35AM BLOOD TSH-2.1
[**2112-12-31**] 07:35AM BLOOD Free T4-1.8*
[**2112-12-30**] 06:37PM BLOOD Lactate-3.1*
[**2112-12-31**] 03:11PM BLOOD Lactate-3.5*
[**2113-1-1**] 11:01AM BLOOD Lactate-2.4*
[**2113-1-2**] 08:58AM BLOOD Lactate-2.8*
[**2113-1-3**] 07:48AM BLOOD Lactate-3.0*
[**2113-1-4**] 07:52AM BLOOD Lactate-3.1*
.
.
Urine
.
[**2112-12-29**] 05:30PM URINE Hours-RANDOM UreaN-460 Creat-72 Na-63
K-32 Cl-57
[**2112-12-29**] 05:30PM URINE Osmolal-387
[**2112-12-29**] 05:30PM URINE CastHy-0-2
[**2112-12-29**] 05:30PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2112-12-29**] 05:30PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2112-12-29**] 05:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2112-12-31**] 12:57PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2112-12-31**] 12:57PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2112-12-31**] 12:57PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2112-12-31**] 12:57PM URINE CastHy-[**3-25**]*
.
.
Radiology
CHEST (PORTABLE AP) Study Date of [**2112-12-31**] 11:34 AM \
FINDINGS: As compared to the previous radiograph, there is
unchanged
cardiomegaly with small bilateral pleural effusions. Unchanged
retrocardiac
atelectasis. No newly appeared focal parenchymal opacity
suggesting
pneumonia.
.
.
Cardiology:
.
ECG Study Date of [**2112-12-28**] 5:49:54 PM
Normal sinus rhythm. Intraventricular conduction delay with a
QRS duration of 114 milliseconds. Low voltage in the limb leads.
Poor R wave progression. Left atrial abnormality. Prior inferior
wall myocardial infarction and possible anterior wall myocardial
infarction. Compared to the previous tracing of [**2112-11-9**] no
diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 176 114 420/463 28 -51 126
.
TTE (Complete) Done [**2113-1-2**] at 11:03:01 AM
Conclusions
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thicknesses
and cavity size are normal. There is severe global left
ventricular hypokinesis with mild apical dyskinesis (LVEF = 20
%). No masses or thrombi are seen in the left ventricle. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size is normal
with moderate global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild to moderate ([**1-23**]+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity size with severe global
biventricular systolic dysfunction c/w multivessel CAD or other
diffuse process. Pulmonary artery hypertension. Moderate to
severe tricuspid regurgitation. Increased PCWP.
Compared with the prior study (images reviewed) of [**2112-8-15**],
the left ventricular cavity is smaller and the estimated
pulmonary artery systolic pressure is lower. The other findings
are similar.
LIVER ULTRASOUND:FINDINGS: Gallstones.Unremarkable liver, with
normal Doppler findings.
DISCHARGE LABS [**1-12**]:
[**2113-1-12**]
07:50a
Na: 128
Cl:89
BUN:44
Glucose:100
K:4.6
Bicarb:25
Creat:1.9
estGFR: 34/42
Ca: 9.3 Mg: 2.2 P: 3.4
ALT: 67 AP: 121 Tbili: 2.5
AST: 31
HCT: 42.9, HGB: 13.9, PLT: 127, WBC: 8.8
Brief Hospital Course:
# Cardiomyopathy/Chronic systolic congestive heart failure: EF
of 20%. Unclear [**Name2 (NI) 28217**] of acute exacerbation but likely that pt
was failing at home and poor memory impaired adherance to
medication regimen. Lisinopril was stopped at his last admission
due to hyperkalemia and aldactone has been held. Weight 143
pounds on admission with 3-4+ peripheral edema and SOB. CXR
showed small bilateral effusions. Pt was aggressively diuresed
with milrinone and furosemide intravenously and weight on
discharge is 121 pounds. He was converted to torsemide PO as
this medicine works better with intestinal edema which is common
in right sided failure. His JVD is elevated because of severe
TR. On exam, he appears dry with no peripheral edema, clear
lungs and no O2 requirement. Echo [**1-2**] showed normal
biventricular cavity size with severe global biventricular
systolic dysfunction c/w multivessel CAD or other diffuse
process in addition to pulmonary artery hypertension, moderate
to severe tricuspid regurgitation and increased PCWP. Compared
with the prior study of [**2112-8-15**], the left ventricular cavity
was smaller and the estimated pulmonary artery systolic pressure
was lower. The other findings were similar. He should have daily
weights and close monitoring of his fluid status.
.
# Renal failure: Baseline creatinine has worsened, possibly in
setting of dehydration (clinically appears dry) and recent
diuresis increases in addition to poor po intake. He has been
hyponatremic since admission, thought to be intially wet, then
dry. Would continue to limit po fluid to 1500cc/day. Will need
close monitoring of electolytes. Follow up with Dr. [**Last Name (STitle) **] on
[**1-18**] who can mke a decision about resumeing Lisinopril or
Aldactone.
.
# Hyperbilirubinemia: On [**1-3**] was noted to have a bilirubin
2.1. There were no other localising signs and this is felt
likely [**2-23**] hepatic congestion given his significant CHF. RUQ
ultrasound showed stones and sludge but no signs of inflammation
or obstruction.
.
# Hypotension: Baseline SBP 80's-90's. Pt is not symptomatic
typically. If pt becomes orthostatic, would push PO fluids
before IVF.
.
# Persistent disorientation: Continued to be disoremted in time
and will perseverate. TSH/Ca normal. Difficult to know if this
is close to baseline for him as he likely has an element of
alcoholic dementia due to his years of alcoholism. Previous
normal B12 and folate in [**2112-6-21**]. Had cognitive evaluation
[**1-2**] with MMSE 14 ACE-R 37.5/100 with global dysfunction mostly
affecting verbal fluency, memory and language although pretty
severaly affected across the board
His daughter [**Name (NI) **] states that he is forgetful at home and has
been struggling to care for himself. Also an element of
isolation and depression. Should have geripsych evaluation at
rehab to re-evaluate now that his medical condition has
improved. He will need social service evaluation for appropriate
placement after discharge
.
# Hyponatremia - Likely in setting of diuretic regimen. Is also
intravsscularly dry. Started torsemide [**12-30**] and having
furosemide boluses with Na remained relatively static. Currently
127. Pt should frequent monitoring and fluid restriction of
1500cc/day.
.
# Penile ulcer: Hypopigmented non-tender ulcer on foreskin on
vertal aspect of penis was noted on [**1-1**]. Noted dysuria and a
UA was sent and was negative with negative UCx. RPR was also
negative. It did not look to be HSV and culture negative. He was
seen by wound care who recommended aquaphor ointment.
.
# Chronic anemia: Likely secondary to [**Month/Year (2) 2091**]. Stable.
.
# CAD s/p PTCA: Presentation inconsistent with angina. No new or
concerning EKG changes. Troponins at baseline. Will continue
ASA, clopidogrel, carvedilol, and pravastatin.
.
# Rheumatoid arthritis: Stable. Continue home
Hydroxychloroquine, leflunomide, and Prednisone.
.
# Gout: No sign of flare. Restarted allopurinol at home dose.
.
Medications on Admission:
1. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
3. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
4. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
6. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice
a day.
7. leflunomide 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit
Tablet Sig: One (1) Tablet PO once a day.
12. furosemide 40 mg daily
13. aldactone 25 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
start on Fridays.
3. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
6. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. leflunomide 10 mg Tablet Sig: One (1) Tablet PO daily ().
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
12. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for wund care ulcer: apply to open area
on penis [**Hospital1 **].
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for puritis.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Acute on chronic systolic congestive heart failure
Hyponatremia
Acute on chronic kidney injury
Altered mental Status
Coronary artery disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with acute on chronic systolic congestive
heart failure or fluid overload. You needed to be on 2
intravenous medicines, milrinone and furosemide to take off the
extra fluid. Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] at
[**Telephone/Fax (1) 62**] if weight goes up more than 3 lbs in 1 day or 5
pounds in 3 days. Your weiht at discharge is 121 pounds (55kg)
.
We made the following changes in your medicines:
1. Stop taking furosemide, start torsemide instead to keep the
fluid off
2. Stop aldactone
3. Decrease Carvedilol to 6.25 mg twice dialy
4. Use Aquaphor dressing twice daily to open area on your penis
5. Use sarna lotion as needed for itchy skin
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2113-1-18**] at 11:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2113-1-30**] at 3:00 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
Completed by:[**2113-1-12**]
|
[
"V58.65",
"294.8",
"285.21",
"585.9",
"V45.82",
"715.90",
"573.0",
"425.4",
"607.89",
"584.9",
"733.90",
"714.0",
"276.1",
"428.0",
"428.23",
"403.90",
"458.9",
"414.01",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
13923, 14000
|
7820, 11815
|
333, 339
|
14185, 14185
|
3184, 7797
|
15087, 15718
|
2625, 2804
|
12743, 13900
|
14021, 14164
|
11841, 12720
|
14363, 15064
|
2819, 3165
|
274, 295
|
367, 1414
|
14200, 14339
|
1436, 1958
|
1974, 2609
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,766
| 191,216
|
33863
|
Discharge summary
|
report
|
Admission Date: [**2182-4-12**] Discharge Date: [**2182-4-15**]
Date of Birth: [**2117-5-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
DOE, increasing fatigue
Major Surgical or Invasive Procedure:
[**4-12**] Pericardial drain
History of Present Illness:
64 yo F s/p chest trauma/rib fracture after hot air balloon
accident in [**Month (only) 596**], with flu like symptoms for a few weeks, and
increasing DOE, echo showed increasing pericardial effusion.
Transferred for further management.
Past Medical History:
hypothyroid, hyperlipids, AI/MR mod, diverticulosis, s/p
polypectomy, TIA, R carotid bruit, right kidney atrophied,
tonsillectomy, benign colon polypectomy, rt leg varicose vein
stripping.
Social History:
unemployed
denies tobacco
1 etoh/month
Family History:
NC
Physical Exam:
hr 89 RR 18 BP 130/90
NAD
Lungs CTAB
Heart RRR
Abdomen benign
Extrem warm, no edema
2+ femoral, radial pulses, 1+ dp/pt pulses
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78259**]Portable TTE
(Focused views) Done [**2182-4-13**] at 3:14:18 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2117-5-22**]
Age (years): 64 F Hgt (in): 64
BP (mm Hg): 106/54 Wgt (lb): 138
HR (bpm): BSA (m2): 1.67 m2
Indication: Pericardial effusion. Tamponade
ICD-9 Codes: 423.9
Test Information
Date/Time: [**2182-4-13**] at 15:14 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**Name2 (NI) **] L.
[**Hospital1 **], RDCS
Doppler: Limited Doppler and no color Doppler Test Location:
West SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: Small pericardial effusion. Effusion is loculated.
No echocardiographic signs of tamponade. No significant
respiratory variation in mitral/tricuspid valve flows.
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Right ventricular
chamber size and free wall motion are normal. There is a small
pericardial effusion. The effusion appears loculated, subtending
the right atrial free wall. There are no echocardiographic signs
of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2182-4-12**], the pericardial effusion has been drained;
cardiac tamponade is no longer evident.
CHEST (PA & LAT) [**2182-4-14**] 11:42 AM
CHEST (PA & LAT)
Reason: evaluate for ? effusion
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with s/p pericardial window
REASON FOR THIS EXAMINATION:
evaluate for ? effusion
CLINICAL HISTORY: Patient with pericardial window, evaluate for
effusion.
CHEST
This film was taken in the PA as opposed to the comparison film
which was taken AP. Cardiac outline does appear somewhat more
globular and this is confirmed on the lateral film. Return of
the pericardial effusion is therefore a possibility and cardiac
ultrasound is recommended.
No failure is present, atelectasis is seen at both bases.
IMPRESSION: Change in shape of heart with a somewhat globular
appearance _____ effusion.
[**2182-4-14**] 10:10AM BLOOD WBC-8.2 RBC-4.48 Hgb-13.4 Hct-38.7 MCV-86
MCH-29.9 MCHC-34.6 RDW-13.7 Plt Ct-348
[**2182-4-14**] 10:10AM BLOOD PT-12.4 PTT-30.9 INR(PT)-1.1
[**2182-4-14**] 10:10AM BLOOD Glucose-90 UreaN-19 Creat-0.9 Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
Brief Hospital Course:
She was admitted to cardiac surgery. She was seen by cardiology
and was taken to the cath lab where she underwent pericardial
drain for 610 ml of bloody fluid. Repeat echocardiogram the
following day showed no effusion and her pericardial drain was
discontinued. She was transferred to the floor on post-procedure
day 1. Repeat echocardiogram on [**4-15**] showed small pericardial
effusions and she was ready for discharge home.
Medications on Admission:
levoxyl 50, pravachol 40, norvasc 5, folic acid 2, fosamax,
toprol 50, ASA
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
pericardial effusion
hypothyroid, hyperlipids, AI/MR mod, diverticulosis, s/p
polypectomy, TIA, R carotid bruit
Discharge Condition:
Good.
Discharge Instructions:
Call with shortness of breath, difficulty lying flat, fever,
redness or drainage from incision or weight gain more than 2
pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) 78260**] 1 week
Please have repeat Echo in 2 weeks to evaluate effusion
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2182-4-15**]
|
[
"272.4",
"423.3",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
5214, 5220
|
4134, 4565
|
301, 332
|
5376, 5384
|
1050, 3196
|
5594, 5814
|
883, 887
|
4690, 5191
|
3233, 3279
|
5241, 5355
|
4591, 4667
|
5408, 5571
|
902, 1031
|
238, 263
|
3308, 4111
|
360, 598
|
620, 810
|
826, 867
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,927
| 128,943
|
28257
|
Discharge summary
|
report
|
Admission Date: [**2189-9-28**] Discharge Date: [**2189-10-4**]
Date of Birth: [**2129-10-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic Coronary Artery Disease
Major Surgical or Invasive Procedure:
[**2189-9-28**] - Coronary artery bypass graft x3 (Left internal
mammary artery -> Left anterior descending, saphenous vein graft
-> ramus, saphenous vein graft -> posterior descending artery)
History of Present Illness:
59 year gentleman with known coronary artery disease with PTCA
in [**2176**]. He underwent a routine stress test which was positive
and was referred for a cardiac catheterization. This revealed
severe 2 vessel disease. Given the severity of his disease, he
was referred to Dr. [**Last Name (STitle) 1290**] for surgical revascularization. He
now presents as a same day admission for elective coronary
artery bypass grafting.
Past Medical History:
MI w/ PTCA to Ramus and OM in [**2176**] ([**Hospital1 **])
Hypercholesterolemia
HTN
Encephalitis as child
Mandibular surgery in past
Social History:
Works in a hardware store. Never smoked tobacco. Rarely uses
alcohol. Lives with his wife.
Family History:
Noncontributory
Physical Exam:
74 SR 20 BP(R): 186/98 (L) 180/92 68" 209lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing, cyanosis. 1+ LE edema.
HEENT: Unremarkable
LUNGS: Clear
HEART: RRR, Nl S1-S2. No murmur.
ABD: Benign
EXT: Warm, 2+ Pulses throughout. No varicosities.
Pertinent Results:
[**2189-10-4**] 06:15AM BLOOD WBC-7.9 RBC-4.04* Hgb-13.0* Hct-36.3*
MCV-90 MCH-32.1* MCHC-35.7* RDW-14.2 Plt Ct-315#
[**2189-10-4**] 06:15AM BLOOD Plt Ct-315#
[**2189-10-4**] 06:15AM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-137
K-4.3 Cl-99 HCO3-28 AnGap-14
[**2189-10-3**] CXR
Small left pleural effusion. Subsegmental atelectasis.
Cardiomegaly. No acute change.
[**2189-9-28**] ECHO
1. Overall left ventricular systolic function is low normal
(LVEF 50-55%). There is mild global left ventricular
hypokinesis. Resting regional wall
motion abnormalities include mild anterior hypokinesis. Left
ventricular wall thicknesses and cavity size are normal.
2. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
3. Physiologic mitral regurgitation is seen (within normal
limits).
4. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
5. Right ventricular chamber size and free wall motion are
normal.
6. There are simple atheroma in the descending thoracic aorta.
POST-BYPASS:
No change from pre bypass findings.
[**2189-10-3**] CXR:
Small left pleural effusion. Subsegmental atelectasis.
Cardiomegaly. No acute change.
Brief Hospital Course:
Mr. [**Known lastname 68630**] was admitted to the [**Hospital1 18**] on [**2189-9-28**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. By
postoperative day one, Mr. [**Known lastname 68630**] was awake, extubated and
neurologically intact. Beta blockade, aspirin, a statin and an
ace inhibitor were resumed. His drains and wires were removed
per protocol without complication. On postoperative day two, he
was transferred to the cardiac surgical step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. Mr.
[**Known lastname 68630**] had a burst of atrial fibrillation which was self
limited. His beta blockade was increased and his electrolytes
were repleted. As he continued to be hypertensive, his
medications were adjusted appropriately. Mr. [**Known lastname 68630**] continued
to make steady progress and was discharged home on postoperative
day six.
Medications on Admission:
ASA 81mg QD
Folic Acid
Lipitor 40mg QD
NTG PRN
Norvasc 5mg QD
Coreg 12.5mg [**Hospital1 **]
KCL 20mEq QD
Diovan 320mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
10. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease
Hypertension
Elevated cholesterol
Encephalitis as a child
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr [**Last Name (STitle) 1290**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) 68631**] in 1 week ([**Telephone/Fax (1) 68632**]) please call for
appointment
Dr [**Last Name (STitle) **] in [**1-9**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2189-10-5**]
|
[
"V45.82",
"401.9",
"272.0",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
5519, 5578
|
2837, 4047
|
359, 554
|
5704, 5711
|
1592, 2814
|
6176, 6602
|
1290, 1307
|
4218, 5496
|
5599, 5683
|
4073, 4195
|
5735, 6153
|
1322, 1573
|
283, 321
|
582, 1008
|
1030, 1166
|
1182, 1274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
618
| 155,036
|
26771
|
Discharge summary
|
report
|
Admission Date: [**2117-12-10**] Discharge Date: [**2117-12-15**]
Date of Birth: [**2039-8-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Sepsis.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
78M with Parkinson's disease, CAD s/p CABG and multiple PCI's
with stents, CHF with EF 30%, osteoporosis, and history of
multiple falls who is being admitted to MICU for sepsis from
presumed urinary source. Patient with multiple falls in past,
the last 2 days prior to this admission felt to be mechanical
(tripped on shoe) with head laceration treated with staples. Pt
unsure if he loss consciousness during this but knows that he
hit his head. Denied LH, dizziness, CP, palps, SOB, tongue
biting, incontinence surrounding event. Head CT nml and C-spine
with T3 compression fracture, old. Patient was cleared in ED and
sent home. This a.m. he was getting OJ out of refrigerator and
lost balance, falling backwards. No vertigo, LOC, CP, SOB,
palps, LH, dizziness preceding event ('unsteady on feet'). He
called for help and was brought to the ED this a.m.
In ED had temp to 102.8, HR 118, BP 138/42. BP dropped
transiently to 92/60 but he was repositioned and BP increased to
115/73. Recieved 3L NS in ED, was pancultured, and was given
levofloxacin 500, vancomycin 1g, and flagyl 500 (for abd pain
and h/o diarrhea x 4 months), ASA, ticlid. CE's cycled and
monitored on telemetry. Patient and family do not want central
line placed. Also had inferolat ST depressions on EKG while
tachycardic, and cardiology was curbsided and felt they were
rate related.
Upon arrival to the floor he states that he is comfortable and
without pain. This a.m. patient noted dysuria and frequency, no
urgency. On ROS mouth is dry, he is fatigued, and he has been
having diarrhea x 4 months (W/U as outpt unrevealing - improved
after stopping PPI). Denies fevers, chills, night sweats, weight
loss, HA, vision changes, URI sxs, chest pain, SOB,
palpatations, abdominal pain, melena, hematochezia, nausea,
hematemesis. No focal motor or sensory deficits.
Past Medical History:
1. CAD s/p CABG and NSTEMIs ([**2-/2117**]: LIMA-LAD, SVG->Diag, OM1,
OM2,
SVG->PDA); s/p PCI of proximal SVG-D1-OM 1-OM2 with DES in [**6-29**]
and PCI of SVG-OM/D with DES in [**8-29**].
2. CHF: EF 30%
3. Parkinson's Disease
4. Hypercholesterolemia
5. HTN
6. h/o TIA
7. Bladder CA
8. Osteoporosis
9. s/p right hip fracture, ORIF in [**3-1**]
Social History:
Former prof [**First Name (Titles) **] [**Last Name (Titles) 65926**] at [**Location 2785**]. The patient
lives in [**Location **]. He lives with his wife on the same street as
his daughter. [**Name (NI) **] has another daughter who lives in [**State 3706**]. He
smoked until [**2076**], smoking one pack a day for fifteen years.
Family History:
Positive for father, who died of a stroke, mother who had a
stroke in her 90s and one brother had [**Name (NI) 5895**] disease.
Physical Exam:
Vitals: 97.6, 102, 137/86, 23, 99%2L
Gen: Diaphoretic well nourished male lying flat in NAD,
pleasant, communicative.
HEENT: PERRL, EOMI, anicteric sclera, MM dry, OP clear but
difficult to visualize d/t inability to open mouth fully with
C-collar in place. Dysarthric speech with accent.
Neck: Cervical collar in place
Cardiac: tachycardic, regular rhythm, NL S1 and S2, no MRGs
Lungs: CTAB ant, no wheezes, rhonchi, crackles
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
Ext: warm, 2+ DP pulses, no C/C/E
Neuro: CN: unable to gaze laterally to left with left eye (may
not be cooperating with exam), CN IV,X,VI intact. Easy to open
eyes bilaterally when closed tight. CN IX, X, XII intact. Unable
to assess [**Doctor First Name 81**] d/t C-collar. Motor [**5-28**] throughout, sensory intact.
+ rigidity in UE, L>R. Toes upgoing bilaterally. No clonus. No
tremor noted.
Pertinent Results:
LAB DATA:
CBC:
[**2117-12-9**] 06:40AM BLOOD WBC-13.2* RBC-4.17* Hgb-11.8* Hct-35.3*
MCV-85 MCH-28.3 MCHC-33.4 RDW-16.7* Plt Ct-279
COAGS:
[**2117-12-10**] 09:20AM BLOOD PT-13.6* PTT-26.7 INR(PT)-1.2*
CHEMISTRIES:
[**2117-12-9**] 06:40AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-131*
K-4.3 Cl-99 HCO3-22 AnGap-14
CARDIAC ENZYMES:
[**2117-12-10**] 09:20AM BLOOD cTropnT-0.07*
[**2117-12-10**] 08:04PM BLOOD CK-MB-76* MB Indx-15.3* cTropnT-1.01*
[**2117-12-11**] 03:04AM BLOOD CK-MB-55* MB Indx-13.8* cTropnT-1.60*
[**2117-12-11**] 12:19PM BLOOD CK-MB-34* MB Indx-11.6* cTropnT-1.44*
[**2117-12-12**] 04:54AM BLOOD CK-MB-11* MB Indx-8.1* cTropnT-0.88*
ANEMIA LABS:
[**2117-12-12**] 04:54AM BLOOD calTIBC-222* VitB12-602 Folate-14.5
Hapto-279* Ferritn-30 TRF-171*
[**2117-12-12**] 04:54AM BLOOD Ret Aut-2.0
MISC:
[**2117-12-10**] 09:30AM BLOOD Lactate-4.0*
CT of C-spine ([**2117-12-8**]):
There is a [**Month/Day/Year 1192**] anterior wedge compression fracture of the
T3 vertebral body. The presence of adjacent osteophytes raises
the possibility that the fracture is chronic, but this
observation requires clinical correlation.
CT Head ([**2117-12-8**]):
No intracranial hemorrhage, no fracture. 7mm rounded lymph node
in the right submental region.
CT Head ([**2117-12-10**]):
1. No definite acute intracranial abnormality.
2. Mild atrophy and left more than right basal ganglia chronic
lacunes, with some volume loss.
3. Chronic-appearing ethmoid inflammatory disease with extensive
opacification of bilateral ethmoid air cells, right more than
left.
CXR ([**2118-12-10**]):
Interstitial pulmonary edema.
Renal US ([**2117-12-13**]):
No renal stones or hydronephrosis on either side.
ECHO ([**2117-12-13**]):
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is [**Month/Day/Year 1192**]
regional left ventricular systolic dysfunction with akinesis of
the basal 2/3rds of the inferior and inferolateral walls. The
remaining segments are mildly hypokinetic. No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
is normal with mild free wall hypokinesis. 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. Severe [**Month/Day/Year 1192**] (3+) mitral
regurgitation is seen. [**Month/Day/Year **] [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
1. Sepsis:
Patient with SIRS based on tachycardia and fever with evidence
of end organ damage with lactate of 4.0, qualifying for sepsis.
Was not hypotensive. CXR without evidence of infiltrate. CT
scan did show sinusitis. Overall, the source was presumed to be
urinary as had WBC on UA - urine culture did not grow any
organisms.
In the unit, the patient was treated with IVF. HR and urine
output were followed. Broad spectrum antibiotics were used
initially levofloxacin and vancomycin for urinary and nasal
pathogens. Flagyl was started initially with d/c as there was
no evidence of aspiration or bowel pathogen.
The patient did well in the unit and was called out to the
floor. Treatment was a planned 10 days of levaquin.
On the day of discharge, the patient had an episode of
diapheresis. Oral temperature was 97 with a rectal temperature
of 100. His finger stick was ~170 and an EKG showed no changes.
Given that his WBC had increased slightly from the prior day
(12.3->14.8), blood and urine cultures were drawn. At the time
of discharge, the patient felt well.
2. CAD:
In the setting of sepsis, the patient had an EKG with
inferolateral ST depressions with and a troponin that peaked at
1.6. Cardiology saw the patient and felt this was demand as
opposed to an ACS. As such, they did not feel that an acute
cath was needed. The patient was placed on heparin and
integrillin on the 17th - the heparin was stopped two days later
and the integrillin was stopped the next day. The patient was
followed by cardiology - cardiac cath was considered, but not
pursued. Plan was for outpatient stress test once the patient
was improved s/p sepsis. An echo was repeated showing an EF of
30% (unchaged from [**6-29**]) with mod/severe MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR.
Regarding cardiac meds, the patient was treated with ASA,
ticlopidine (per home regimen), beta-blocker (metoprolol 75mg
[**Hospital1 **]), lisinopril 10mg daily, statin (came in on simvastatin;
atorvastatin used while in-house with plan for resumption of
simvastatin).
In addition to the above, he was transfused 2 units of pRBCs on
[**12-12**] for hct <30. Thereafter, his hct remained >30.
3. CHF:
Initially, CXR with pulmonary edema; did not require oxygen and
was breathing easily with no LE edema. Lasix was held at the
onset, given sepsis. As his BP remained stable, he was gently
diuresed. Thereafter, he was continued on ACEI and lasix.
4. Fall:
Combination of loss of balance and neurologic d/o (Parkinson's).
No LOC, did not sycopize. Head CT negative for bleed. C-spine
film showed no evidence of cervical spine fracture and a stable
wedge deformity of T3 dating back to [**2117-3-16**]. B12 and folate
were normal with a negative RPR. Scalp staples from [**12-9**]
admission were still in place with plan for removal at rehab.
5. Diarrhea:
A chronic issue for the patient. While an inpatient, c.diff was
checked and negative x2.
6. Parkinson's:
Stable while an inpatient; continued home regimen of sinemet and
comtan.
7. HTN:
Antihypertensives held initially given sepsis. Slowly added
back. Metoprolol and lisinopril were continued.
8. Hyponatremia:
Patient has a long history of hyponatremia. Sinemet may be
contributor. Acutely, hypovolemic hyponatremia may have been
playing a role. At the time of discharge, serum sodium was 133.
9. Osteoporosis:
Continue calcium and vitamin D. Outpatient aldendronate was to
be resumed upon discharge.
10. Hyperlipidemia:
As above, simvastatin at home with atorvastatin while in-house.
Cholesterol panel from [**11-3**] showed TC 167, TG 233, HDL 62 and
LDL 58. Plan was for resumption of simvastatin upon discharge.
DNI/DNI.
Medications on Admission:
1. Carbidopa-Levodopa 25-100 mg Tablet 8 TIMES A DAY
2. Comtan 200mg 5 five times a day
3. Aspirin 325 mg Tablet
4. Metoprolol Tartrate 50 mg [**Hospital1 **]
5. Ticlopidine 250 mg Tablet [**Hospital1 **]
6. Lisinipril 10mg daily
7. Furosemide 20 mg PO DAILY
8. Zocor 40 mg Tablet
9. Calcium plus vitamin D
10. Alendronate 70mg qweek on Sunday
11. Multivitamin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed for with
meals.
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
8X/D ().
10. Entacapone 200 mg Tablet Sig: One (1) Tablet PO 5X/day ().
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO
DAILY (Daily).
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
18. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Each Sunday.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Sepsis / UTI
2. Coronary artery disease.
Secondary:
1. Parkinson's disease
2. Hyperlipidemia
3. Hypertension
Discharge Condition:
Good; improved.
Discharge Instructions:
You were admitted after a fall and found to have an infection.
You will be sent home with antibiotics which you should take, as
directed, for the full course.
Given your history of heart failure, you should be sure to weigh
yourself every morning and call your PCP if your weight > 3 lbs.
There were no changes made to any of your current medications.
Followup Instructions:
You have the following appointments scheduled:
[**Doctor First Name 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2118-4-1**] 2:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2118-5-2**]
9:30
In addition to the above, you should call your PCP to be seen
within 1-2 weeks.
|
[
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"038.9",
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"401.9",
"599.0",
"V45.82",
"276.52",
"424.0",
"V45.81",
"995.91",
"410.71",
"332.0",
"276.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12104, 12174
|
6538, 10259
|
325, 332
|
12340, 12358
|
3974, 4290
|
12760, 13196
|
2930, 3059
|
10671, 12081
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12195, 12319
|
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|
12382, 12737
|
3074, 3955
|
4307, 6515
|
278, 287
|
360, 2198
|
2220, 2566
|
2582, 2914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,597
| 167,773
|
45166
|
Discharge summary
|
report
|
Admission Date: [**2187-2-9**] Discharge Date: [**2187-2-15**]
Service: MEDICINE
Allergies:
Heparin Agents / Fish Product Derivatives / Keflex / Iodine;
Iodine Containing / Penicillins
Attending:[**First Name3 (LF) 18988**]
Chief Complaint:
Black stool in ostomy bag.
Major Surgical or Invasive Procedure:
EGD on [**2187-2-10**].
History of Present Illness:
The pt. is an 84 year-old gentleman with a history of metastatic
pancreatic cancer, hypertension, diabetes mellitus and PE/DVT on
anticoagulation who presented to the ED complaining of black
stool in his colostomy bag.
He noted that he had been having loose bowel movements/diarrhea
which were black in color. At the time of admission, he denied
abdominal pain, nausea, vomiting, fever, chills, shortness of
breath, palpitations, dizziness or lightheadedness, or chest
pain. He noted that he has had difficulty swallowing recently
and had one episode of "dry heaves" on the morning of admission.
In the ED, he was found to have guaiac positive black stool in
his ostomy bag. An NG tube was placed and was lavaged resulting
in bright red blood that was unable to clear with saline. He
was admitted to the MICU for presumed upper GI bleed.
Past Medical History:
1. Metastatic pancreatic Ca- diagnosed [**7-12**] with omental biopsy
during ex-lap and decompressible colostomy. Now with extensive
intraperitoneal carcinomatosis-- palliative chemo(gemcitabine)
has been deferred by patient over last few months
2. hx of SBO- medically managed last admission
3. splenic vein thrombosis with varices
4. hx DVT/PE, s/p IVC filter in [**2178**]
5. HIT
6. benign colon polyps
7. HTN- on metoprolol
8. DM- on oral agents
9. PVD- s/p left lower extremity bypass surgery in [**2178**]
10.post-op Afib temporarily on amio- self d/c'd in [**8-12**]
11.hypothyroidism
Social History:
The pt. is a retired chef. He is married, lives with wife.
Denies tobacco or illicit drug use; occasional EtOH in past,
none recently. He is originally from Venice,[**Country 2559**] and moved to
the United States at age 14.
Family History:
Father died of cardiac disease. Mother had breast cancer. One
sibling, a brother with gastric cancer.
Physical Exam:
Vitals: T: 96.5F P: 100(83-101) R: 19 BP: 131/52 (92-144/70-85)
SaO2: 98% RA
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: tachycardic, RR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted, ostomy in RUQ with brown stool.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch, pinprick, vibration or
proprioception throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and ankle
jerks bilaterally. Plantar response was flexor bilaterally.
Pertinent Results:
Studies at admission:
EKG: NSR at 80bpm, q's in III and aVF with poor voltage
inferiorly, no ST/Twave changes from prior EKG
KUB: Nitinol filter. There is an NG tube with tip in the
stomach. There is barium contrast in the rectum. No dilated
loops of small bowel are seen. There is no unknown specific
small bowel gas pattern. There is a small amount of air in the
cecum and descending colon.
Labs on admission:
[**2187-2-9**] 01:00PM BLOOD WBC-5.3 RBC-4.23* Hgb-11.7* Hct-33.7*
MCV-80* MCH-27.7 MCHC-34.8 RDW-16.3* Plt Ct-220#
[**2187-2-9**] 01:00PM BLOOD PT-20.7* PTT-30.1 INR(PT)-2.7
[**2187-2-9**] 01:00PM BLOOD Glucose-141* UreaN-32* Creat-1.2 Na-138
K-4.2 Cl-100 HCO3-28 AnGap-14
[**2187-2-9**] 01:00PM BLOOD Calcium-9.2 Phos-3.5 Mg-1.6
Labs on discharge:
[**2187-2-15**] 05:10AM BLOOD Hct-29.4*
Brief Hospital Course:
1.Upper GI bleed: Shortly after admission, the gastroenterology
service performed an EGD. This showed gastric fundal variceal
bleeding with large blood clot in the fundus and abnormal mucosa
in the stomach. He was given 4U FFP, 2U PRBC, 10mg SC Vitamin K,
started on IV octreotide, and [**Hospital1 **] IV PPI on arrival. He
remained on an octreotide drip for five days. His hematocrits
were cycled roughly q8hours and were noted to be stable. He was
maintained on a PPI [**Hospital1 **]. He had no further episodes of melena.
He was discharged on p.o. protonix b.i.d. and instructed to
discontinue coumadin for fear of a repeat episode of
gastrointestinal bleeding.
2. HTN: The pt's blood pressure was stable for the duration of
the hospital stay. He was restarted on metoprolol on hospital
day four.
3. DM2: He was initially managed with a sliding scale of regular
insulin. Once he began to take p.o., glipizide was
re-introduced.
4. Hypothyroidism: The pt. was maintained on levothyroxine.
Medications on Admission:
1. Levoxyl 25 mcg once a day.
2. Glipizide 5 mg once a day.
3. Coumadin 2.5 mg every other day.
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **].
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
-upper gastrointestinal bleed, likely from gastric varices
-pancreatic cancer
-hypertension
-hypothyroidism
-type 2 diabetes mellitus
Discharge Condition:
Stable.
Discharge Instructions:
Please continue to take all of your medications as prescribed.
You should no longer take coumadin (warfarin). Also, note that
you have been placed on a new medication called protonix. If
you experience any further episodes of abdominal pain, black
stool, bloody vomit, chest pain, shortness of breath or any
other symptoms that are concerning to you, please call your
primary care doctor or come to the emergency department for
urgent evaluation.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-2-22**] 2:30
Please call Dr. [**Last Name (STitle) **] office at [**Telephone/Fax (1) 19968**] to schedule a
follow-up appointment at a time convenient for you within the
next 7-10 days.
|
[
"578.0",
"427.31",
"280.0",
"157.2",
"535.40",
"244.9",
"289.59",
"V58.61",
"199.0",
"537.89",
"V44.3",
"401.9",
"456.8",
"E934.2",
"V12.51",
"287.4",
"578.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.13",
"99.04",
"96.33",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
5886, 5935
|
4261, 5264
|
327, 353
|
6112, 6121
|
3430, 3830
|
6618, 6985
|
2100, 2204
|
5464, 5863
|
5956, 6091
|
5290, 5441
|
6145, 6595
|
2983, 3411
|
2219, 2886
|
261, 289
|
4197, 4238
|
381, 1225
|
3845, 4177
|
2901, 2966
|
1247, 1840
|
1856, 2084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,518
| 168,830
|
54959
|
Discharge summary
|
report
|
Admission Date: [**2185-6-28**] Discharge Date: [**2185-7-4**]
Date of Birth: [**2126-10-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
PICC LINE
Central line
Cardiac catheterization without immediate complications
History of Present Illness:
58 year old man with chronic leukopenia, who presents with
fevers, chills, and malaise 4 days following prostate biopsy.
Initially following his biopsy, he was treated with Levoquin,
then admitted to [**Hospital1 **] for tachycardia and fevers up to 105F.
At [**Hospital1 **], he was started on Ceftriaxone and Flagyl. He also
recieved Vancomycin and was thought to have a rash reaction.
The patient was noted to have posterior EKG changes and was
transferred to [**Hospital1 18**] for cardiology follow-up and possible cath
on Heparin drip, Plavix and ASA.
In [**Hospital1 18**] ED, initial vital signs 98.8 104 85/57 18 98% 2L Nasal
Cannula. Right IJ was placed and 4 Liters of NS were given.
Norepinephrine was started for systolic pressure in the 80's.
Cardiology consult concluded no indication for cath as ST
changes resolved, but ASA, plavix, and heparin continued.
.
On arrival to the MICU, vital signs 99.1 96/70 85. Patient was
interactive and denied pain. He denies syncope, palpitations,
nausea, vomiting, dyspnea.
Past Medical History:
PMH:
lichen planus
chronic leukopenia
.
PSH:
Nasal Polypoectomy years ago
Social History:
[**Name6 (MD) **] is NP[**Hospital1 **]. Lives with wife.
- Tobacco:denies
- Alcohol: denies
- Illicits:denies
Family History:
no known family history of heart disease
Physical Exam:
On admission:
Vitals: 99.1 96/70 85 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis
.
On discharge:
Vitals: 98.6 108/69 83 18 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis
Pertinent Results:
ADMISSION LABS:
[**2185-6-28**] 05:30PM [**Month/Day/Year 3143**] WBC-3.6* RBC-3.99* Hgb-12.2* Hct-36.4*
MCV-91 MCH-30.6 MCHC-33.6 RDW-12.3 Plt Ct-86*
[**2185-6-28**] 05:30PM [**Month/Day/Year 3143**] Neuts-76* Bands-14* Lymphs-9* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2185-6-28**] 05:30PM [**Month/Day/Year 3143**] Glucose-87 UreaN-12 Creat-1.2 Na-139
K-3.5 Cl-109* HCO3-19* AnGap-15
[**2185-6-29**] 04:58AM [**Month/Day/Year 3143**] ALT-48* AST-95* LD(LDH)-189 CK(CPK)-1064*
AlkPhos-121 TotBili-5.1* DirBili-3.0* IndBili-2.1
.
DISCHARGE LABS:
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] WBC-6.4 RBC-4.14* Hgb-12.0* Hct-38.0*
MCV-92 MCH-29.0 MCHC-31.6 RDW-13.1 Plt Ct-228
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] Glucose-107* UreaN-8 Creat-0.9 Na-140
K-4.2 Cl-104 HCO3-28 AnGap-12
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] PT-9.9 PTT-29.1 INR(PT)-0.9
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] Calcium-8.7 Phos-3.2 Mg-2.4
[**2185-7-3**] 06:10AM [**Month/Day/Year 3143**] ALT-52* AST-63* LD(LDH)-312* AlkPhos-292*
TotBili-1.4
.
URINE STUDIES:
[**2185-6-28**] 06:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2185-6-28**] 06:00PM URINE [**Month/Day/Year **]-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2185-6-28**] 06:00PM URINE RBC-1 WBC-28* Bacteri-FEW Yeast-NONE
Epi-<1
[**2185-6-28**] 06:00PM URINE CastHy-4*
.
MICRO DATA:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] cultures:
[**Last Name (NamePattern1) 3143**] CULTURE ESCHERICHIA COLI. ISOLATED FROM AEROBIC AND
ANAEROBIC BOTTLES.
INTERP M.I.C.
------ ------
AMIKACIN S 16
AMPICILLIN R >=32
AMPICILLIN/SULBACTAM R >=32
CEFAZOLIN S <=4
CEFOXITIN S <=4
CEFTAZIDIME S <=1
CEFTRIAXONE S <=1
GENTAMICIN S <=1
IMIPENEM S <=1
LEVOFLOXACIN R >=8
TOBRAMYCIN R >=16
TRIMETHOPRIM/SULFA R >=320
[**2185-6-28**] 5:15 pm [**Month/Day/Year 3143**] CULTURE, Routine (Final [**2185-7-4**]): NO
GROWTH
[**2185-6-28**] 6:00 pm URINE CULTURE (Final [**2185-6-29**]): NO GROWTH.
[**2185-6-28**] 5:30 pm [**Month/Day/Year 3143**] CULTURE (Final [**2185-7-4**]): NO GROWTH.
[**2185-6-28**] 10:06 pm MRSA SCREEN POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS.
[**2185-7-1**] 1:25 am URINE CULTURE (Final [**2185-7-2**]): NO GROWTH.
[**2185-7-1**] 1:25 am [**Month/Day/Year 3143**] CULTURE, Routine (Pending):
[**2185-7-1**] 7:57 pm URINE CULTURE (Final [**2185-7-2**]): NO GROWTH.
.
EKG OSH- ST depressions in II, III, AVF NSR tachycardic to
120's.
EKG [**2185-6-28**] - NSR , No acute ST elevations or depressions, some
T wave flattening in II, III, AVF, V4-V6
EKG [**2185-7-4**] - Sinus rhythm. T wave abnormalities. Since the
previous tracing of [**2185-6-28**] no significant change.
.
CXR [**2185-6-28**]: The right internal jugular central venous catheter
tip is malpositioned, with the catheter coursing across midline
through the left brachiocephalic vein, and terminating in the
region of the left subclavian vein. No pneumothorax is
identified. The remainder of the chest is unchanged. No
pneumothorax is identified.
.
CXR [**2185-6-28**]: Right internal jugular central venous catheter has
been repositioned, the tip now terminating in the proximal right
atrium. No pneumothorax is identified. The cardiac,
mediastinal and hilar contours are normal. Lungs are clear.
There is no pleural effusion.
.
RUQ ultrasound [**2185-6-29**]: The liver is of normal echotexture. No
focal hepatic lesion is noted. There is no evidence of
intrahepatic or extrahepatic biliary ductal dilatation. The
portal vein is patent demonstrating hepatopetal flow. CBD is of
normal caliber measuring 3 mm. The gallbladder is incompletely
distended. There is no gallbladder wall edema or
pericholecystic fluid collection to suggest acute
inflammation. The pancreas is largely obscured by overlying
bowel gas. The spleen measures 11.7 cm and is normal in
appearance. The left kidney measures 11.3 cm, and the right
kidney measures 10.9 cm. There is no evidence of
hydronephrosis. There is no ascites. Imaged intra-abdominal
aorta and IVC are normal in caliber.
.
CXR Picc line placement [**2185-6-30**]: Bedside upright AP radiograph
of the chest demonstrates a new right PICC terminating at or 1
cm below the expected location of the cavoatrial junction. The
lungs are clear. The hilar and cardiomediastinal contours are
normal. There is no pneumothorax or pleural effusion. The
pulmonary vascularity is normal.
.
Cardiac cath [**2185-7-4**]: 1) Selective coronary angiography of this
left-dominant system demonstrated no angiographically-apparent
flow-limiting stenoses in the LMCA, LAD, LCx, or RCA systems.
2) Left ventriculography demonstrated normal wall motion with an
LVEF of
65% and no mitral regurgitation.
3) Limited resting hemodynamics revealed mildly-elevated
left-sided
filling pressures, with an LVEDP of 13mmHg. The central aortic
pressure
was normal at 113/65 mmHg.
4) A TR band was applied to the right radial arteriotomy site.
Brief Hospital Course:
58 year old man with a history of chronic leukopenia admitted
with E. coli urosepsis following prostate biopsy; found to have
EKG changes in the setting of hypotension but clean cardiac
catheterization.
.
# E.coli sepsis/septicemia: The patient was admitted to the ICU
hypotensive and tachycardic. He was fluid resuscitated and a
central line was placed. He was briefly on Levophed to support
his [**Month/Day/Year **] pressure. The patient was started on vancomycin and
meropenem until E. coli cultured from [**Month/Day/Year **] and urine returned
sensitive to ceftriaxone. Pressors were weaned the day following
ICU admission. A PICC line was placed in anticipation of a
2-week course of antibiotics for bacteremia. The patient was
continued on ceftriaxone and his fevers and hypotension
resolved. He was discharged with PICC in place and VNA for 8
remaining days of ceftriaxone. The patient will follow up with
his primary care physician and urology as an outpatient.
.
#Abnormal EKG- The patient presented to [**Hospital1 **] with chest
pressure and diffuse ST depressions with elevation in aVR. EKG
changes resolved on arrival to [**Hospital1 18**] and troponin peaked at
0.06. These changes were likely due to tachycardia. Cardiology
was consulted, and the patient was briefly placed on a heparin
gtt, Plavix, and aspirin until he ruled out for myocardial
infarction. On transfer to the medical floor, the patient
underwent cardiac catheterization that showed normal ejection
fraction and no evidence of significant coronary artery disease.
The patient did not require preventative aspirin or cardiology
followup on discharge.
.
#Thrombocytopenia- Thought most likely to be related to sepsis.
Platelets were trended and returned to [**Location 213**].
.
#Abnormal LFT's - Patient with mildly progressive transaminitis
throughout admission. T.bili peaked on admission at 3.5 and
trended down to 1.4 the day prior to discharge. The patient has
no known history of liver disorder or abnormal LFTs. Abnormal
LFTs on admission likely related to bacteremia/sepsis. RUQ
returned negative for evidence of liver disease. However,
slowly progressive transaminitis may represent drug-induced
cholestasis. The patient should undergo repeat LFTs on [**7-8**].
Antibiotic regimen may need to be changed or further outpatient
workup of transaminitis may need to be performed if continues to
progress.
.
#Code status - full
===================================
TRANSITIONAL ISSUES
# Patient should follow up with PCP for CBC and LFT check 1 week
following discharge. He may require further workup of
transaminitis
# Patient with 8 days of ceftriaxone remaining at discharge
Medications on Admission:
None
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram daily Disp #*8 Syringe Refills:*0
2. Outpatient Lab Work
Please check CBC, LFTs on [**2185-7-8**]. Fax results to [**Last Name (LF) 9468**],[**Known firstname **]
S.F. Fax: [**Telephone/Fax (1) 84944**]. Phone: [**Telephone/Fax (1) 9470**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary diagnosis: Urosepsis
Secondary diagnosis: Chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
.
You were admitted to the intensive care unit with a severe
urinary tract infection, compromising your [**Known lastname **] pressure. You
were started on IV antibiotics, and your infection improved.
You will continue to receive IV ceftriaxone for 8 more days
through a PICC line as an outpatient.
.
While your [**Known lastname **] pressure was low on admission, you experienced
chest pain. You received IV fluids and your [**Known lastname **] pressure
improved. Your chest pain resolved. You underwent cardiac
catheterization that showed no damage to your heart. You do not
require special followup with a cardiologist on discharge.
.
MEDICATIONS CHANGED THIS ADMISSION:
START ceftriaxone 2gm daily for 8 days
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on Wednesday [**2185-7-6**] at 3:00pm.
|
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"995.92",
"284.19",
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icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"38.97",
"88.56"
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icd9pcs
|
[
[
[]
]
] |
11698, 11767
|
8644, 11322
|
317, 398
|
11874, 11874
|
3105, 3105
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1703, 1745
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11378, 11675
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265, 279
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426, 1459
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3121, 3646
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11808, 11818
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1774, 2420
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11889, 12001
|
1481, 1557
|
1573, 1687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,326
| 119,246
|
4927
|
Discharge summary
|
report
|
Admission Date: [**2119-11-27**] Discharge Date: [**2119-12-6**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
IR guided tunneled dialysis line exchange
History of Present Illness:
Patient is a 61 male with history of seizure disorder,
nonischemic cardiomyopathy EF 20-30%, renal disease on HD,
hepatitis B, CAD and CVA with residual right lower extremity
weakness, gout, wheelchair-bound presents with dizziness per
report at rehabilitation facility for the past 4-5 hours.
Patient denies ever feeling dizzy and is complaining of right
knee pain that began 2 days ago. Per EMS, patient was
hypotensive to the 70s systolic. Patient had dialysis [**2119-11-25**],
reports less fluid removed than usual. Denies fever, chest pain,
shortness of breath, abdominal pain, nausea, vomiting but did
endorse diarrhea x 4 on [**11-26**].
In the ED, initial vs were: 10 96.3 89 79/47 18 100%. Exam was
notable for baseline RLE weakness, R knee swollen and
infrapatellar TTP. EKG was sinus 88 IVCD QTc 455. CXR showed no
pneumonia or pleural effusion. Bedside U/S showed no frank
pericardial effusion but difficult anatomy. Labs were
significant for troponin 0.14 (baseline 0.12-0.16). He was given
a 500 cc fluid bolus and SBP improved to the 80s. He was
mentating well. VS on transfer were P: 79, BP: 79/69, O2 sat 99%
on RA
On the floor, patient is complaining of right knee pain. He has
not taken any medication for the pain. He also complained of
intermittent cramping of the leg that is now resolved.
Past Medical History:
- Seizure disorder since mid [**2097**]'s after starting dialysis
- MSSA HD line infection with septic lung emboli [**9-1**] with left
pleural effusion
- H/o Hepatitis B, treated
- Non-ischemic cardiomyopathy, last EF 20-30%
- MI [**2086**] per pt
- CVA [**2086**] per pt (?residual LE weakness)
- ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**].
- Multiple thrombectomies in LUE and R thigh AV fistula
- Graft excision for infected thigh graft [**2117-5-26**]
- Hungry bone syndrome status post parathyroidectomy
- Pituitary mass
- Anemia of chronic disease
- s/p PEG tube placement [**2117-10-29**]
- Admission to MICU in [**10-2**] for seizure and hypotension
- Swab positive for MRSA and VRE at left groin site in [**10-2**] and
MRSA positive from same site [**11-2**]
Social History:
Retired piano and organ teacher. Has 2 PhDs (history and music)
and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at
baseline. Never smoker, no other drug use. Drinks 1 drink/week.
Has 2 sisters that live out of state, son died 3 years ago ("was
shot to death").
Family History:
Father with DM, mother died at age 41 of renal failure
Physical Exam:
On admission:
Vitals: T: 97.1, P: 73, BP: 93/51, RR: 14, 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: right knee with effusion, TTP, minimal warmth, no erythema.
pain with active and passive ROM
Neuro: A&Ox3, CNII-XII intact, baseline RLE weakness
On discharge:
Vitals: 98.7 118/59 76 20 96%RA
General: Alert, oriented, no acute distress
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: right knee with minimal effusion, no erythema, denies pain
Pertinent Results:
On admission:
[**2119-11-27**] 12:40AM BLOOD WBC-10.8# RBC-3.96* Hgb-11.0*# Hct-34.6*
MCV-87 MCH-27.7 MCHC-31.7 RDW-15.3 Plt Ct-448*#
[**2119-11-27**] 12:40AM BLOOD PT-12.5 PTT-34.2 INR(PT)-1.2*
[**2119-11-27**] 12:40AM BLOOD Glucose-107* UreaN-38* Creat-8.6*# Na-139
K-4.5 Cl-92* HCO3-27 AnGap-25*
[**2119-11-27**] 05:06AM BLOOD CK-MB-2 cTropnT-0.11*
[**2119-11-27**] 12:40AM BLOOD cTropnT-0.14*
[**2119-11-27**] 05:06AM BLOOD Calcium-8.0* Phos-4.4 Mg-1.6
[**2119-11-27**] 05:06AM BLOOD TSH-0.68
[**2119-11-28**] 06:33AM BLOOD Cortsol-22.1*
[**2119-11-28**] 06:00AM BLOOD Cortsol-27.6*
[**2119-11-28**] 05:21AM BLOOD Cortsol-12.2
[**2119-11-27**] 05:06AM BLOOD Digoxin-<0.2*
On discharge:
[**2119-12-5**] 06:20AM BLOOD WBC-6.0 RBC-3.36* Hgb-9.0* Hct-29.3*
MCV-87 MCH-26.7* MCHC-30.6* RDW-15.1 Plt Ct-398
[**2119-12-5**] 06:20AM BLOOD Glucose-85 UreaN-47* Creat-9.5*# Na-135
K-5.3* Cl-95* HCO3-31 AnGap-14
[**2119-12-5**] 06:20AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.3
[**2119-11-27**] 05:06AM BLOOD CK-MB-2 cTropnT-0.11*
[**2119-11-28**] 06:33AM BLOOD Cortsol-22.1*
[**2119-12-5**] 06:20AM BLOOD Vanco-14.3
Right knee arthrocentesis:
[**2119-11-27**] 09:05AM JOINT FLUID WBC-140 RBC-0 HCT,Fl-4.0* Polys-39*
Lymphs-37 Monos-24
[**2119-11-27**] 09:05AM JOINT FLUID Crystal-NONE
GRAM STAIN (Final [**2119-11-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2119-11-30**]): NO GROWTH.
Microbiology:
Blood Culture, Routine (Final [**2119-12-3**]): NO GROWTH.
Blood Culture, Routine (Final [**2119-12-1**]):
STAPHYLOCOCCUS EPIDERMIDIS.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final [**2119-11-28**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2119-11-28**]):
GRAM POSITIVE IN PAIRS AND CLUSTERS.
Blood Culture, Routine (Final [**2119-12-1**]):
STAPHYLOCOCCUS EPIDERMIDIS.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Aerobic Bottle Gram Stain (Final [**2119-11-29**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2119-11-29**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Blood Culture, Routine (Final [**2119-12-2**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Aerobic Bottle Gram Stain (Final [**2119-11-30**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2119-11-30**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Blood Culture, Routine (Final [**2119-12-5**]): NO GROWTH.
Blood Culture, Routine (Pending):
[**2119-12-1**] 8:00 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
[**2119-12-1**] 8:15 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
[**2119-12-2**] 11:19 am BLOOD CULTURE Source: Line-dialysis.
Blood Culture, Routine (Pending):
[**2119-12-5**] 6:21 am BLOOD CULTURE Source: Line-Dialysis.
Blood Culture, Routine (Pending):
[**2119-12-4**] 3:56 pm CATHETER TIP-IV
Source: tunneled IJ hemodialysis line.
WOUND CULTURE (Preliminary):
GRAM POSITIVE COCCUS(COCCI). >15 colonies.
ECG [**2119-11-27**]:
Sinus rhythm. Left bundle-branch block. Compared to the previous
tracing
of [**2119-9-9**] there is no significant change.
Portable CXR [**2119-11-27**]:
FINDINGS: Single frontal view of the chest in semi-erect
position
demonstrates stable position of a dual-channel central venous
catheter with tip terminating in the upper right atrium. The
patient is slightly rotated to the left. Cardiomediastinal
silhouette is within normal limits. Multiple clips are seen
overlying the right apex. Rightward upper tracheal
displacement is related to known enlarged left thyroid lobe as
seen on CT
dated [**2117-11-15**]. The lungs are clear with trace, if any,
basilar atelectasis. There is no pneumothorax, vascular
congestion, or pleural effusion. Multiple remote fractures are
seen on the left posteriorly, unchanged.
IMPRESSION: No definite evidence to suggest pneumonia or fluid
overload.
Right knee x-ray [**2119-11-27**]:
FINDINGS: No previous studies available for direct comparison.
There is a small joint effusion. There are no signs for acute
fractures or
dislocations. There is mild lateral compartmental joint space
narrowing.
Vascular calcifications are seen. Prominent spur at the inferior
pole of the patella is seen, which may be sequela of remote
trauma.
IMPRESSION:
Small joint effusion without signs for acute fracture.
TTE [**2119-11-30**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with hypokinesis
of the inferior and inferolateral segments.. Left ventricular
dyssynchrony is present. Right ventricular chamber size and free
wall motion are normal. There is abnormal septal
motion/position. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. 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 [**2119-10-31**],
there is probably less dyssynchrony present. The inferior and
inferolateral walls appear hypokinetic on the current study.
They may have been hypokinetic on prior also but image quality
limited assessment. Cannot exclude endocarditis on the basis of
this study - if clinically indicated, a transesophageal
echocardiogram may better assess for valvular vegetations.
Right lower extremity ultrasound [**2119-12-1**]:
IMPRESSION: No right lower extremity DVT.
Brief Hospital Course:
Patient is a 61 male with history of seizure disorder,
nonischemic cardiomyopathy EF 20-30%, ESRD on HD, hepatitis B,
CAD and CVA who presented with dizziness and hypotension in the
setting of diarrhea.
#Hypotension: Patient has low baseline blood pressure. From [**Company 191**]
records he has had systolic BP as low as 77 but on repeat was
92. He was never symptomatic from hypotension. His relative
hypotension was likely worsened by acute episodes of diarrhea or
secondary to bacteremia. Hypotension resolved with IVFs. His
cortisol level was normal. BPs were taken from his leg per his
usual. BPs ranged 90s to 140s throughout remainder of hospital
stay. His lisinopril continued to be held.
#Bacteremia: Blood cultures from [**2119-11-28**] and [**2119-11-29**] grew coag
neg staph. He was started on vancomycin on [**2119-11-29**], given at
hemodialysis. He was seen by infectious disease who recommended
continued antibiotics for total course of two weeks after first
negative blood culture ([**Date range (3) 20490**]). Subsequent blood
cultures did not show growth to date but final results were
pending at time of discharge. His presumed source of bacteremia
was his tunneled dialysis line. After discussion with
interentional radiology and infectious disease, it was decided
to exchange the line over wire after 48hours of negative blood
cultures. This was decided because the patient had very limited
options in terms of access. Pt underwent IR guided HD line
exchange over wire on [**2119-12-4**]. He subsequently developed small
hematoma at the site. He tolerated dialysis the following day
and was discharged to rehab. He reported feeling well and had
no leukocytosis for his entire hospital stay. He had low grade
temp of 100.5 on [**2119-12-5**] but was afebrile thereafter. This may
have been due to the hematoma at his new dialysis line site.
The tip of the old HD line was sent for culture and was growing
GPCs by time of discharge (final speciation pending). A
vancomycin antibiotic lock was placed before discharge and will
be continued at outpatient dialysis. Of note, TTE was performed
that did not show evidence of vegetations.
# Right knee effusion: Pt has RLE weakness at baseline. He
presented with swelling and pain in the right knee. Joint
aspiration was performed by rheumatology and revealed
hemarthrosis. Patient denied trauma and unclear etiology. Pain
improved after fluid removal and with minimal doses of oxycodone
prn. Fluid culture showed no growth. Right lower extremity
ultrasound was negative for DVT
# Diarrhea: Pt initially reported watery, non-bloody. This
resolved after admission. There was no sign of infection- no
fever or leukocytosis. Etiology may be related to home laxatives
which were held during hospital stay.
# ESRD: Pt undergoes HD on Tu, Th, Sat. He underwent HD
according to his schedule without complications. Tunneled line
was exchanged over wire per above.
# CAD/CHF: no sign of volume overload or ACS. troponin at
baseline. He was continued on his home simvastatin, aspirin,
digoxin.
# Seizure disorder: stable. continued on Levetiracetam and
oxcarbezepine.
Medications on Admission:
(per OMR- confirm with [**Hospital1 1501**] in am)
ALLOPURINOL - 100 mg po every other day
CALCIUM ACETATE - 667 mg- 4 Capsule(s) TID with meals
DIGOXIN - 125 MCG po EVERY OTHER DAY
FOLIC ACID - 1 mg po once a day
GABAPENTIN - 100 mg Capsule - 2 Capsule(s) by mouth Daily
LEVETIRACETAM - 500 mg po TID extra dose post HD.
LISINOPRIL - (On Hold from [**2119-9-21**] to unknown for due to low
BPs) - 2.5 mg Tablet - 1 Tablet(s) by mouth Daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth Daily
OXCARBAZEPINE - 300 mg Tablet - 1 Tablet(s) by mouth tid. On HD
days take one extra tab post HD.
SEVELAMER HCL [RENAGEL] - 800 mg Tablet - 2 Tablet(s) by mouth
with meals tid
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth Daily
ACETAMINOPHEN - 325 mg Tablet - 2 Tablet(s) by mouth every 6
hours as needed for as needed for pain [**Male First Name (un) **] not exceed 4grams in
24 hours
ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth daily
BISACODYL - 5 mg Tablet, Delayed Release (E.C.) - 2 Tablet(s) by
mouth Daily as needed for Constipation
CHLORHEXIDINE GLUCONATE - 4 % Liquid - Use daily for 7 days,
then
1-2 times/week daily
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth daily
SARNA - 0.5-0.5% Lotion - APPLY LIBERALLY TO SKIN ON HANDS, FEET
SENNOSIDES [SENNA] - 8.6 mg Capsule - 1 Capsule(s) by mouth At
bedtime
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA): extra dose to be given on dialysis days after
dialysis.
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three
times a day.
10. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three
times a week (Tues, Thurs, Sat): extra dose to be given on
dialysis days after dialysis.
11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: do not exceed 4 grams in 24
hours.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
16. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
17. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime:
hold for loose stools; pt may refuse.
18. chlorhexidine gluconate 4 % Liquid Sig: One (1) Topical [**12-25**]
times each week.
19. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical once
a day: APPLY LIBERALLY TO SKIN ON HANDS, FEET
.
20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: as directed
Intravenous HD PROTOCOL (HD Protochol): To be dosed based on
trough and given on hemodialysis; continue until [**2119-12-13**].
21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
Bacteremia with staph epidermidis
Right knee effusion
Secondary:
ESRD on HD
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:
It was a pleasure taking care of you in the hospital. You were
admitted with low blood pressures and your blood cultures were
growing a bacteria called staph epidermidis. You were started
on vancomycin which you will continue to receive at hemodialysis
for a total course of two weeks. This infection could have been
caused by your dialysis line; this line was exchanged during
your hospital stay.
You were also seen by our rheumatology team for right knee
swelling. This showed blood in your knee joint.
Please continue dialysis on Tues, Thurs, Sat. You will be seen
by Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] who will be monitoring your tunneled line
site.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
1) Vancomycin, dosed by level at hemodialysis, for a total
course of two weeks (stop on [**2119-12-13**])
2) Oxycodone 5mg every 12 hours as needed for pain
Followup Instructions:
We are working on a follow up appointment in Infectious Disease.
The office will contact you at the facility with the appointment
information. If you have not heard within 2 business days or
have any questions please call [**Telephone/Fax (1) 457**].
Completed by:[**2119-12-6**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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|
2536, 2828
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,696
| 104,193
|
52970
|
Discharge summary
|
report
|
Admission Date: [**2128-9-16**] Discharge Date: [**2128-10-1**]
Date of Birth: [**2051-9-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
increasing weakness and shortness of breath
Major Surgical or Invasive Procedure:
placement and removal of right internal jugular central venous
catheter
History of Present Illness:
76 y/o male with ischemic cardiomyopathy EF 15%, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], restrictive lung disease, and smoldering multiple myeloma
who presented to the ED on [**2128-9-16**] with weakness. He was
initially admitted to the meidicine floor but was transferred to
the MICU for closer monitoring. He does have baseline shortness
of breath but this has worsened over the past couple of days,
especially with exertion. The farthest he can walk is his
bathroom without getting dyspneic and he cannot go up stairs at
home. He denies orthopnea and PND and does not report ankle
swelling. He feels albuterol helps his breathing but he has not
noted wheezing. In the past 4-5 days, he has not been taking
most of his medications because he ran out.
.
In terms of his weight loss, he reports going from 235lbs ->
175lbs in the last four months. He feels bloated when he eats
("like when you drink a lot of water.") There have been no new
changes in his medications, just that he ran out of several of
them recently. He does not admit to dietary indiscretion.
.
[**Date Range **]: Denies recent F/C. Denies CP. Admits to baseline DOE
(cannot walk up his 14 steps at home without having SOB). Denies
melena or hematochezia. Positive for weight loss. Denies cough.
Denies orthopnea or PND. Denies significant increase in LE
edema. No abdominal pain or diarrhea.
Past Medical History:
CAD--not a candidate for revascularization
dilated cardiomyopathy (EF 15% in [**2128-6-25**], with 3+ MR, 3+ TR,
and pulmonary artery HTN)
plasma cell dyscrasia - elevated IgG; also history of follicular
lymphoma s/p XRT, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
pulmonary fibrosis [**2-27**] XRT
gout
hypercholesterolemia
high blood pressure
Social History:
Lives with wife in [**Location (un) 686**] with 2 cats. Retired, but still
works part time on air force base. 30 pack year smoking history,
quit 20 years ago. No alcohol, no illicits.
Family History:
No family history of early CAD or sudden death.
Physical Exam:
VS 97.1 98/77 90 14 98% on 3L NC
Gen: cachectic elderly male. Oriented x3. Mood, affect
appropriate. Breathing comfortably at rest, but only able to
speak a few words before becomes short of breath.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 14 cm. RIJ in place.
CV: PMI diffuse. RR, normal S1, S2. I-II/VI systolic murmur at
apex. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, using accessory muscles. Rales 1/2 up the lung
fields bilaterally. No wheezes or rhonchi.
Abd: Scaphoid. Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: Cool to the touch.
Pertinent Results:
[**2128-9-16**] 10:20AM BLOOD WBC-7.1# RBC-4.66 Hgb-14.8# Hct-48.7#
MCV-104*# MCH-31.8 MCHC-30.5* RDW-18.5* Plt Ct-141*
[**2128-9-16**] 10:20AM BLOOD Neuts-60.9 Lymphs-33.3 Monos-3.7 Eos-0.9
Baso-1.1
[**2128-9-16**] 10:20AM BLOOD PT-19.9* PTT-41.0* INR(PT)-1.9*
[**2128-9-16**] 10:20AM BLOOD Glucose-73 UreaN-51* Creat-1.6* Na-139
K-6.1* Cl-102 HCO3-18* AnGap-25*
[**2128-9-16**] 10:20AM BLOOD CK-MB-NotDone cTropnT-0.05* proBNP-9747*
[**2128-9-16**] 10:10AM BLOOD Type-ART pO2-103 pCO2-21* pH-7.34*
calTCO2-12* Base XS--12 Intubat-NOT INTUBA
[**2128-9-16**] 09:55AM BLOOD Glucose-60* Lactate-9.1* Na-142 K-7.3*
Cl-110
[**2128-9-16**] 10:10AM BLOOD Glucose-76 Lactate-8.9* Na-139 K-5.3
Cl-111
[**2128-9-16**] 11:08AM BLOOD Lactate-6.4*
.
Lower extremity U/S:
IMPRESSION: No evidence of lower extremity deep vein thrombosis,
bilaterally.
.
CXR:
1. Right basal opacity likely representing atelectasis; however,
pneumonia cannot be excluded.
2. Cardiomegaly, unchanged.
3. Chronic pulmonary changes, grossly unchanged.
ECHO:, [**9-17**]:
The left atrium is moderately dilated. The right atrium is
markedly dilated. Left ventricular wall thicknesses are normal.
The left ventricular cavity is moderately dilated. There is
severe global left ventricular hypokinesis (LVEF=15-20%). No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is markedly dilated. There is moderate global
right ventricular free wall hypokinesis. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen with a regurgitant volume of 45 cc/beat. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Biventricular dilatation with severe global
biventricular systolic dysfunction. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary hypertension.
.
[**9-16**] CT abd/pelvis:
IMPRESSION:
1. In this limited study, there are no signs of advanced bowel
ischemia, although ischemia cannot be ruled out on this study.
2. No evidence for pneumonia or large abdominal abscess.
3. Moderate cardiomegaly, anasarca, ascites and right pleural
effusion consistent with known congestive heart failure.
4. Progressive interstitial lung disease; the upper lobe
predominance is not typical for idiopathic pulmonary fibrosis
and suggests etiologies such as sarcoidosis, hypersensitivity
pneumonitis, or silicosis.
.
[**2128-9-27**] 06:25AM BLOOD WBC-6.3 RBC-4.90 Hgb-16.2 Hct-48.9
MCV-100* MCH-33.0* MCHC-33.1 RDW-18.7* Plt Ct-92*
[**2128-9-27**] 06:25AM BLOOD Glucose-88 UreaN-59* Creat-0.6 Na-134
K-3.5 Cl-89* HCO3-35* AnGap-14
[**2128-9-22**] 07:00AM BLOOD ALT-203* AST-178* LD(LDH)-260*
AlkPhos-169* TotBili-4.8*
[**2128-9-27**] 06:25AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0
[**2128-9-21**] 07:05AM BLOOD PEP-BROAD BASE b2micro-4.9* IgG-3146*
IgA-44* IgM-22*
Brief Hospital Course:
76 y/o male with dilated cardiomyopathy EF 15%, HTN, COPD, and
smoldering MM who presented with weakness and mild increase in
shortness of breath, likely representing cardiac cachexia and
decompensating failure. The decision was made with him and his
family to make him comfort measures due to his grim prognosis.
He was very comfortable on discharge. Still arrousable to voice
and able to state his needs.
.
# Cardiac
Ischemia: No evidence of active coronary ischemia. Dilated
cardiomyopathy, cardiac catheterization demonstrated three
vessel disease, but patient is not a candidate for surgical
revascularization based on poor myocardial viability.
.
Pump - end-stage CHF, with dilated ischemic cardiomyopathy and
severe valvular disease. Diuresed initially with lasix infusion
and then with lasix 40mg IV bid, with slight improvement in
valvular regurgitation on echo after diuresis. Discussed
invasive hemodynamic monitoring with tailored therapy as a
potential option with patient and family, but patient did not
wish invasive measures.
.
Rhythm - Sinus rhythm with PVCs
.
COPD, also restrictive lung disease post XRT:
- no real benefit at this time for nebs, but pt may use for
subjective relief
- supplemental O2 as needed
.
ARF: anuric on discharge
.
UTI: UCx negative, completed 7 days of Abx
.
smoldering myeloma: at last visit, disease as stable, no active
issues at this time
.
# Elevated LFT's: most likely [**2-27**] to right sided heart failure
and congestion
- received PO Vitamin K for elevated INR
.
# FEN: diet as tolerated, was not taking much by po on
discharge
.
# Code: comfort measures/DNR/DNI
Medications on Admission:
ASA 81mg
colchicine 0.6mg (last filled [**5-26**] for 1 month)
Toprol XL 25mg daily (last filled [**5-26**] for 1 month)
Lisinopril 5mg (last filled [**8-8**] for 1 month)
Lipitor 40mg (last filled [**7-26**] for 1 month)
Allopurinol 300mg (last filled [**8-9**] for 1 month)
albuterol inh (last filled [**6-2**] for 1 month)
not clear how compliant patient has been with any meds
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
2. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H
(every hour) as needed for Pain or shortness of breath.
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual Q3-4H (Every 3 to 4 Hours) as
needed for for respiratory secretions.
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for agitation/anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
# ischemic cardiomyopathy, ejection fraction 15%
# three vessel coronary artery disease not amenable to
revascularization due to minimal myocardial viability
# IgG plasma cell dyscrasia (smoldering myeloma)
# pulmonary fibrosis
Discharge Condition:
poor
Discharge Instructions:
You have end-stage congestive heart failure. Because of the
extent and prognosis of your heart failure, you have indicated
that you wish your goals of care to be comfort.
Followup Instructions:
With your PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] [**Telephone/Fax (1) 250**], and with your
cardiologist, Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2386**], as needed
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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"V66.7",
"272.0",
"203.00",
"397.0",
"584.9",
"515",
"788.30",
"599.0",
"416.8",
"414.8",
"794.8",
"428.0",
"274.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
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|
6628, 8251
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359, 433
|
9657, 9664
|
3362, 6605
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9883, 10289
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2470, 2519
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8683, 9309
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9406, 9636
|
8277, 8660
|
9688, 9860
|
2534, 3343
|
276, 321
|
461, 1850
|
1872, 2253
|
2269, 2454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
218
| 111,255
|
26757
|
Discharge summary
|
report
|
Admission Date: [**2134-4-16**] Discharge Date: [**2134-4-17**]
Date of Birth: [**2055-1-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
CC:[**CC Contact Info 65907**]
Major Surgical or Invasive Procedure:
Femoral catheterization and successful recanalization, PTA,
cryoplasty and stenting of the left
SFA
History of Present Illness:
HPI: 71 yo F with h/o porcine AVR, CABG (LIMA->LAD), PVD
presenting for elective angioplasty of Left SFA lesion.
Previously, she was found by her cardiologist, to have a R ABI
of 0.59 and a left ABI of 0.5 after complaining of BL
claudication. She presented for elective angiography and PCI of
the left and was to return in 2 weeks for treatment of the R.
This AM, angiography revealed a Left distal SFA lesion with
diffuse disease to the proximal popliteal and proximal occlusion
of the AT and PT with reconstitution distally from collaterals.
She received angioplasty, cryoplasty and stenting of the left
SFA lesion from Right femoral artery access. Her sheath was
subsequently removed at 11 AM with minor oozing at the site of
the wound. An ACT at the time was found to be 220, an EKG
showed NSR with frequent PACs but no acute changes from prior to
procedure. Pressure was held for 30 minutes by the
interventional fellow with attainment of hemostasis. 30 minutes
later, the patient felt wet, and noticed bleeding at the site of
the wound. Pressure was again held at the site of the wound for
30 minutes. While holding pressure, she became persistently
hypotensive HR 40s, SBP 60s. 1 amp of atropine was given and
dopamine was given transiently. She became tachycardic to the
130s and developed [**11-23**] sharp pain below her breasts R>L
without radiation associated with nausea (no SOB, diaphoresis).
She denied having felt this pain before. She was given wide
open fluids x 2 L, a hct was checked and found to be 33 (from
her baseline of 40), and she was given a bolus of 1 unit of
blood. Her BP stabilized at 103/49 and her HR decreased to 104.
Her temp was 94, likely due to the IVF, and she was given warm
blankets. Her RUQ abdominal/chest pain gradually resolved and
she was subsequently transferred to the CCU. In the CCU, she
reported resolution of her CP. No back pain.
Past Medical History:
[**2123-3-4**] AVR porcine, LIMA-LAD
[**2107**] colon Ca remote
high cholesterol
right hernia
Social History:
Widowed 2 years ago, lives alone. Has no help at home. Her
son-in-law and daughter are close. Remote occasional smoking
history (40 years ago). No EtOH.
Family History:
no hx of CAD
Physical Exam:
PE:T 97.3 HR 79 RR 19 100% RA BP 108/52
Gen: WDWN woman lying flat in NAD
HEENT: PERRL, OP clear, MM dry
Neck: no carotid bruits
CV: RRR, nl s1, s2, 2/6 systolic murmur best heard at LUSB
without radiation to apex or carotids
Lungs: CTAB from chest
Abd: BS+, soft, NT, ND, no organomegaly
Ext: R femoral hematoma within marked space (~10x10 cm), 1+ R
femoral pulse, dressing C/D/I, no bruit, L femoral pulse 2+,
dopplerable DP and PT pulses bilaterally, DP>PT, no edema,
warmth or swelling
Pertinent Results:
[**10-18**] TTE
LVEF 60%, LA mild dilation, bioprosthetic aortic valve with
normal function and mean gradient of 15 mm Hg and peak of 27 mm
Hg with 1+ AR, severe mitral annular calcification with 2+ MR,
2+ TR , estimated PAP of 29 mm Hg. Doppler evidence of
diastolic dysfunction.
.
EKG pre-cath [**4-16**] 0731
SR with PACs at 72, left anterior fascicular block, LVH, TWI in
I and aVL, borderline LBBB with QRS 118
.
EKG 14:22
NSR at 76, LAFB, LVH, TWI in I and aVL, borderline LBBB with QRS
116
Femoral Cath Report [**2134-4-16**]
PROCEDURE:
Peripheral Catheter placement was performed.
Peripheral Imaging was performed.
Peripheral PTA was performed.
Peripheral Stenting was performed.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: gms %
FICK
**PRESSURES
AORTA {s/d/m} 144/60/90
**PTCA RESULTS
PTCA COMMENTS: Initial angiography showed a distally
occluded left
SFA. We planned to recanalize the vessel. Heparin was used for
anticoagulation. A 7 French [**Last Name (un) 12297**] sheath was advanced around the
[**Doctor Last Name 534**]
into the left SFA. The lesion was crossed with an angled
GlideWire which
was then exchanged for a FilterWire. The lesion was dilated with
a
4.0x80 mm Amphirion balloon at 2-4 atm. Next, the lesion was
treated
with Cryoplasty using a 5.0x60 mm Polar catheter for multiple
inflations. Angiography showed a residual dissection which was
covered
with a 6.0x56 mm Dynalink stent, post-dilated with a 5.0x40 mm
Submarine
balloon at 8 atm. Final angiography showed a 20% residual
stenosis, no
dissection and normal flow. The patient left the lab in stable
condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 31 minutes.
Arterial time = 1 hour 31 minutes.
Fluoro time = 20 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 175
ml, Indications - Hemodynamic
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 2500 units IV
Other medication:
Benadryl 25 mg iv
Fentanyl 25 mcg IV
Midazolam 0.5 mg IV
Cardiac Cath Supplies Used:
7F COOK, [**Last Name (un) 28712**], 55
200CC MALLINCRODT, OPTIRAY 200CC
150CC MALLINCRODT, OPTIRAY 150CC
4 EV3, AMPHIRION, 80
5 EV3, SUBMARINE PLUS, 40
6 GUIDANT, DYNALINK .018, 100
- [**Company **], FILTER WIRE EZ 300 CM
5 [**Company **], POLARCATH BALLOON .014, 20
- [**Company **], POLARCATH INFLATION UNIT
COMMENTS:
1. Access was obtained via the right CFA in a retrograde
fashion.
2. Resting hemodynamics showed mild central aortic
hypertension.
3. Abdominal aorta: Diffuse moderate disease.
4. Renal arteries: Single bilaterally without lesions.
5. Right lower extremity: The CIA, EIA, IIA and CFA were widely
patent.
6. Left lower extremity: The CIA, EIA, IIA and CFA were widely
patent.
The distal SFA had diffuse disease and was occluded at [**Doctor Last Name 26971**]
canal up
to the proximal popliteal. The PA was the principle vessel to
the foot
with the AT and PT proximally occluded and reconstitution
distally via
collaterals.
7. Successful recanalization, PTA, cryoplasty and stenting of
the left
SFA with a 6.0 mm Dynalink stent, post-dilated to 5.0 mm.
[**2134-4-16**] Femoral Vascular Ultrasound
REPORT: There is normal flow on color flow from the right common
femoral vein and artery. No evidence of hematoma, pseudoaneurysm
or AV fistula is identified.
Brief Hospital Course:
71 yo F with h/o porcine AVR, CABG (LIMA->LAD), PVD s/p PCI of
Left distal SFA lesion complicated by R groin bleed/hematoma
with hct drop of 7.
.
#. Hct drop with groin bleed - Patient with rapid hct drop of 7
from 40 to 33 in the setting of R groin bleed and development of
hematoma. Received 2 L of NS and 2 units of blood, and was
hemodynamically stable on transfer to the MICU. Her metoprolol
and digoxin were held. No evidence of RP bleed. A right
femoral ultrasound showed no evidence of hematoma,
pseudoaneurysm or AV fistula. Her hematocrit remained stable
and there was no evidence of repeat bleeding with serial exams.
She was restarted on her metoprolol XL 25 mg QD and tolerated it
well. Her digoxin was held as her heart rate was well
controlled and she had no evidence of heart failure.
.
#. Chest/RUQ and epigastric Abdominal pain (burning) with
nausea- this was in the setting of the dopamine drip and hct
drop and may have been demand ischemia, though her cardiac
enzymes were flat x 3 and there were no EKG changes. She was
given protonix, maalox, anzemet and tums, and the pain resolved.
- start on omeprazole 40 QD
.
#. PVD - Following her intervention, her distal pulses remained
dopplerable bilaterally. She is scheduled to return in [**3-20**]
weeks for angiography and possible intervention in her RLE.
- continue ASA and plavix indefinitely
.
#. Ischemia - patient s/p CABG (LIMA-> LAD 10 years ago). No
recent cath. No EKG changes with her chest/abdominal pain. Her
cardiac enzymes were cycled and were flat x 3.
- continue ASA and plavix indefinitely
- restart metoprolol XL 25 mg QD
.
#. Pump - last TTE in [**10-18**] showed LVEF 60%, 1+ AR with porcine
valve, 2+ MR and 2+ TR, and evidence of diastolic dysfunction.
- continue metoprolol 25 mg PO QD
- hold digoxin with no evidence of failure and well-controlled
heart rate
.
#. Rhythm - SR, occasional PACs on telemetry
Medications on Admission:
Admission meds:
metoprolol XL 25 mg QD
digoxin 125 mcg QD
ECASA 325 mg QD
MVI
Lipitor 10 mg QD
Plavix 75 mg QD
.
Transfer meds:
Toprol XL 25 QD
Dig 125 mcg QD
ECASA 325 mg QD
Plavix 75 mg QD
MVI
Lipitor 10 mg QD
Tylenol PRN
NTG SL PRN
Simethicone PRN
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
5. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vascular disease s/p revascularization and stenting
of Left SFA/popliteal lesion
Right femoral bleed
Discharge Condition:
Patient is doing well, hemodynamically stable, no chest pain,
ambulating without difficulty
Discharge Instructions:
1. Please take all medications as prescribed. You MUST take
your Aspirin and Plavix EVERY DAY.
2. Please keep all follow-up appointments.
3. Please seek medical attention if you develop chest pain,
shortness of breath, abdominal pain, recurrent or worsened
claudication of the left foot, a larger hematoma, bleeding,
lightheadedness or have any other concerning symptoms.
4. Please refrain from heavy lifting or vigorous activity for 2
weeks.
5. Please refrain from driving until at least 3 days after
discharge from the hospital (after Wednesday, [**4-21**]).
Followup Instructions:
Return in [**3-20**] weeks for angiography and intervention on the
right leg.
Please follow-up with Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 16005**] in [**2-15**]
weeks.
Please follow-up with Dr. [**Last Name (STitle) 911**] at ([**Telephone/Fax (1) 7236**] in [**7-22**] weeks.
Completed by:[**2134-4-18**]
|
[
"V45.81",
"786.50",
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"998.2",
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icd9cm
|
[
[
[]
]
] |
[
"00.45",
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"88.48",
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icd9pcs
|
[
[
[]
]
] |
9750, 9756
|
6799, 8714
|
321, 423
|
9912, 10006
|
3198, 4932
|
10616, 10941
|
2659, 2673
|
9015, 9727
|
9777, 9891
|
8740, 8992
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10030, 10593
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2688, 3179
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4951, 6776
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252, 283
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451, 2352
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2374, 2469
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2485, 2643
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,306
| 145,214
|
22394
|
Discharge summary
|
report
|
Admission Date: [**2141-10-25**] Discharge Date: [**2141-11-23**]
Date of Birth: [**2081-3-12**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
Exploratory laparotomy
Small bowel resection with side-by-side anastamosis
ORIF left open tibial plateau fracture
Tracheostomy
History of Present Illness:
60yo F restrained driver in a MVC, car fell down a 30ft
embankment, +LOC but GCS=15 at outside hospital ED. Pt began
vomiting and was electively intubated prior to transferring to
[**Hospital1 18**], found to have free air in abdomen.
Past Medical History:
Hypertension
Depression
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
VS - 96.8, 101, 132/69, 16, 94%
HEENT - R facial ecchymosis, R forehead laceration
Neck - c/collar in place, midline trachea
Back - no bruising/step-off
Chest - Bilat BS, symmetric rise & fall
Abdomen - distended, ecchymotic, positive FAST exam, rectal=no
tone, guiac neg
Pelvis - stable
Ext - L tib/fib open fx, + deformity, + pulses
Neuro - A&O x 3, CN intact, M&S intact
Pertinent Results:
[**2141-10-25**] 11:56AM BLOOD WBC-11.7* RBC-3.50* Hgb-10.8* Hct-31.9*
MCV-91 MCH-30.8 MCHC-33.8 RDW-12.2 Plt Ct-228
[**2141-10-25**] 11:56AM BLOOD PT-13.8* PTT-23.6 INR(PT)-1.2
[**2141-10-25**] 11:56AM BLOOD Fibrino-292
[**2141-10-25**] 06:47PM BLOOD Glucose-125* UreaN-10 Creat-0.6 Na-141
K-4.7 Cl-109* HCO3-20* AnGap-17
[**2141-10-25**] 06:47PM BLOOD ALT-31 AST-49* AlkPhos-40 Amylase-153*
TotBili-0.7
[**2141-10-25**] 06:47PM BLOOD Lipase-19
[**2141-10-25**] 06:47PM BLOOD Calcium-7.5* Phos-4.8* Mg-1.1*
[**2141-11-10**] 03:04AM BLOOD TSH-3.9
[**2141-11-17**] 09:00PM BLOOD Vanco-8.3*
[**2141-10-25**] 11:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2141-10-25**] 12:06PM BLOOD pO2-155* pCO2-44 pH-7.28* calHCO3-22 Base
XS--5
Brief Hospital Course:
[**10-25**] - Pt admitted s/p MVC, intubated prior to transfer to
[**Hospital1 18**]. Pt underwent exploratory laparotomy with discovery of a
small bowel perforation which was repaired by a small bowel
resection with a sid-by-side anastamosis. She also underwent an
open reduction & internal fixation of a left open tibial plateau
fx. Transferred to T/SICU post-operatively. Pt placed in
cervical collar for C7 fracture. Forehead laceration repaired.
Facial fractures are non-operative.
[**10-28**] - Pt developing ARDS, requiring high PEEP & increasing
sedation
[**10-30**] - Pt paralyzed with cis-atracuronium & placed on ARDS
protocol.
[**10-31**] - Necrotic area on LLE wound debrided.
[**11-1**] - Resolving ARDS, d/c'd paralytic [**Doctor Last Name 360**]. Febrile -> UTI
growing out enterococcus in urine. Pt unable to move limbs
following d/c of paralytic [**Doctor Last Name 360**].
[**11-4**] - C.diff positive stools
[**11-8**] - MRSA & E.coli isolated from sputum.
[**11-10**] - Pt extubated but failed secondary to tachypnea & fatigue
with breathing, re-intubated. Neurology consulted for
generalized weakness - preliminarily thought to be ICU myopathy.
[**11-13**] - Tracheostomy performed.
[**11-14**] - MRSA isolated from sputum.
[**11-15**] - EMG performed: no evidence of a generalized myopathy or
neuropathy.
[**11-16**] - EEG performed: findings consistent with widespread
encephalopathy.
[**11-20**] - Pt passed a bedside speech & swallow evaluation.
Plastics consulted on LLE wound: most likely will heal well, but
will perform flap closure if fails to heal.
[**11-21**] - Pt had successful video swallow study & started on PO
diet. PICC line placed for extended IV antibiotics to treat
MRSA.
[**11-22**] - Pt doing well with PO diet, increasing strength with
PT/OT, dispo planning for rehab facility.
[**11-23**] - Pt discharged to rehab.
Medications on Admission:
Zoloft
Discharge Medications:
1. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 4 weeks.
Disp:*56 syringe* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO QD
().
4. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO QD ().
5. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
6. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL
mL PO BID (2 times a day).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
Q12H (every 12 hours) for 5 days: Completes 14 day course.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days: Completes 14 day course.
11. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day) as needed for constipation.
12. Codeine Sulfate 30 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed for pain.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Motor vehicle crash
Small bowel perforation
Left open tibial plateau fracture
C7 vertebral fracture
Facial fracture (orbital floor/zygomatic/maxillary)
MRSA pneumonia
Myopathy
Discharge Condition:
Good, stable.
Discharge Instructions:
-Cervical collar on at all times for a total of 12 weeks
-PICC line to remain in place for IV antibiotics
-Continue medications as per separate sheet
-Physical therapy for strengthening/conditioning
-Non-weight bearing left leg
-Immobilizer on left leg at all times
-Dry gauze dressing to left leg wound
Followup Instructions:
Follow-up in Trauma Clinic in [**2-14**] weeks, call ([**Telephone/Fax (1) 376**] for
appointment & directions.
Follow-up with Dr. [**Last Name (STitle) 1327**] in Neurosurgery in [**2-14**] weeks with
AP/lateral/oblique cervical spine x-rays, call ([**Telephone/Fax (1) 88**]
for appointment & to schedule x-rays.
Follow-up with Dr. [**Last Name (STitle) **] in ENT for videostroboscopy to
evaluate vocal cord function. Call ([**Telephone/Fax (1) 6213**] to schedule
appointment.
Follow-up with Dr. [**Last Name (STitle) 1005**] in [**Hospital **] Clinic for follow-up
of your knee in [**1-13**] weeks, call ([**Telephone/Fax (1) 8746**] for appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"V09.0",
"801.42",
"008.45",
"518.5",
"802.6",
"863.89",
"873.42",
"823.10",
"E823.0",
"805.07",
"359.81",
"863.29",
"482.41",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"86.59",
"86.28",
"54.75",
"96.72",
"88.72",
"45.62",
"45.91",
"79.36",
"79.66",
"31.1",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
5231, 5301
|
2003, 3874
|
293, 422
|
5521, 5536
|
1212, 1980
|
5888, 6679
|
784, 802
|
3931, 5208
|
5322, 5500
|
3900, 3908
|
5560, 5865
|
817, 1193
|
234, 255
|
450, 687
|
709, 734
|
750, 768
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,034
| 152,797
|
38222
|
Discharge summary
|
report
|
Admission Date: [**2166-4-2**] Discharge Date: [**2166-4-17**]
Date of Birth: [**2090-4-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
2 week history Slurred speech, left sided weakness
Major Surgical or Invasive Procedure:
Right Craniotomy for Tumor Resection [**2166-4-4**]
Peg Placement [**2166-4-10**]
History of Present Illness:
This is a 75 year old male who was noted by his family to be
more lethargic, sluggish speech, and unsteady gait two weeks
prior to presentation. His family reports thta they voiced their
concerns to PCP but no imaging was done at the time. They
noticed on the evening of [**4-1**] that he was fatigued and appeared
to not use his left side well and had a left facial droop. The
morning of admission, the patient fell in the bathroom-the fall
was unwitnessed. He was brought to an OSH where a CT revealed
right sided hemispheric edema of unclear etiology. He was
transferred to [**Hospital1 18**] for furthermanagement. Neurosurgery was
consulted secondary to mass effect noted on the CT. Further
imaging revealed right sided tumor.
Past Medical History:
*CAD s/p MI s/p CABG in [**2145**], Atrial fibrillation
*Hypertension
*Hyperlipidemia
*Obstructive sleep apnea
*GERD
Social History:
Lives alone. Retired. 3 children
Occasional tobacco use. No ETOH.
Family History:
Non-contributory
Physical Exam:
Exam on Admission:
O: T: 97.7 BP: 145/100 HR: 70 R 16 O2Sats 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake but lethargic, needs prompts and cues for
exam
Orientation: Oriented to person, place, and date.
Recall: Able to name current president. Able to name watch and
pen.
Language: Slurred speech. Naming intact. No paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields- unable to assess secondary to
cooperation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Left facial droop
VIII: Hard of hearing but intact to loud voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. L bicep [**2-24**]; L tricep [**3-26**]; L deltoid -[**3-26**], L grasp [**3-26**];
L IP -[**3-26**]; L Quad -[**3-26**]; L Hem -[**3-26**]; L AT/G/[**Last Name (un) 938**] -[**3-26**]
RUE/RLE full motor. There is a slight left sided neglect.
Coordination: Dysmetria noted bilaterally.
EXAM ON DISCHARGE:
XXXXXXXXXXXXXXXXXXXXXXX
Pertinent Results:
LABS ON ADMISSION:
[**2166-4-2**] 02:05PM BLOOD WBC-9.6 RBC-4.92 Hgb-15.0 Hct-42.0 MCV-85
MCH-30.6 MCHC-35.8* RDW-14.5 Plt Ct-255
[**2166-4-2**] 02:05PM BLOOD Neuts-75.5* Lymphs-16.8* Monos-6.1
Eos-1.2 Baso-0.5
[**2166-4-2**] 02:05PM BLOOD PT-18.0* PTT-28.3 INR(PT)-1.6*
[**2166-4-2**] 02:05PM BLOOD Glucose-117* UreaN-12 Creat-0.7 Na-141
K-3.5 Cl-103 HCO3-27 AnGap-15
[**2166-4-3**] 12:48AM BLOOD CK-MB-1 cTropnT-<0.01
[**2166-4-3**] 06:53AM BLOOD Calcium-9.6 Phos-2.6* Mg-2.1 Cholest-PND
LABS ON DISCHARGE:
XXXXXXXXXXXXXXXXXXXXXX
IMAGING:
CT HEAD [**4-2**]:
Large right frontal/parietal mass with internal hemorrhagic
components,
neighboring vasogenic edema, neighboring sulcal effacement, and
13 mm shift of midline structures, with dilated left lateral
ventricles concerning for obstruction. Overall, the findings are
unchanged since the reference study from earlier today. No new
acute changes are seen.
MRI HEAD [**4-3**]:
FINDINGS: Given differences in technique, there has been no
significant
interval change in size of the large 7.5 x 5.2 x 5.2 cm right
hemispheric mass resulting in severe mass effect with
approximately 13 mm leftward shift of midline structures. There
is near-complete effacement of the right lateral ventricle with
dilatation of the left lateral ventricle. The mass demonstrates
a thick nodular rim of enhancement with more solid enhancement
along the superior margin of the mass. There is extensive
surrounding T2 signal abnormality within the adjacent white
matter, which may represent vasogenic edema versus tumor
infiltration. The signal abnormality does extend into the mid
brain where there is moderate mass effect upon the cerebral
peduncle. There is near-complete sulcal effacement throughout
the right hemisphere. There is a small focus of susceptibility
artifact within the posterior left temporal lobe, associated
with hyperintensity as seen on the post-gadolinium
MP-RAGE sequence, which may represent small volume of blood
products, though an additional enhancing focus cannot be
excluded. There is no convincing corresponding FLAIR signal
abnormality. There is marked susceptibility artifact throughout
the enhancing right hemispheric mass compatible with
intralesional hemorrhage. There are scattered areas of decreased
effusion without central decreased diffusion to suggest pyogenic
abscess.
MRA: The intracranial internal carotid arteries are normal, as
are the left middle cerebral artery and anterior cerebral
arteries. There is mass effect upon the right middle cerebral
artery, which is displaced superiorly without identifiable focal
stenosis. There is persistent fetal formation of the left
posterior cerebral artery with a hypoplastic left P1 segment.
The posterior cerebral arteries are otherwise normal.
IMPRESSION: The large hemorrhagic enhancing right hemispheric
mass exterts
moderate mass effect and most likely represents a primary brain
tumor such as GBM. Lymphoma or metastatic disease are much less
likely, and the appearance is atypical for infection. Additional
findings in the posterior left temporal lobe are of unclear
significance, though more likely represent a small volume of
blood products rather than an additional enhancing lesion as
detailed above.
CXR [**4-3**]:
No previous images. The cardiac silhouette is enlarged in this
patient with intact midline sternal wires. No vascular
congestion, pleural
effusion, or acute pneumonia.
There is a suggestion of some displacement of the lower cervical
trachea to the left, raising the possibility of a thyroid mass
on the right.
MRI Brain [**4-4**]:
Pre-operative planning study with surface markers demonstrate
rim-enhancing lesion. The lesion measures 8.1 x 5.4 cm in
anterior-posterior to transverse dimensions. Mass effect is seen
on the right lateral ventricle with compression of the ventricle
and midline shift.
CT head [**4-4**]:
1. Expected post-operative changes after partial resection of
right frontal and temporal lobe mass, including fluid and gas
within the resection bed as well as pneumocephalus. Surrounding
vasogenic edema causes unchanged mass effect, with effacement of
the right lateral ventricle and sulcal effacement. Effacement of
the third ventricle may be slightly decreased, although the left
lateral ventricle remains dilated.
2. Small amount of blood product in the resection bed, likely
mostly residual from prior hemorrhage. No new large intracranial
hemorrhage seen.
NOTE AT ATTENDING REVIEW: Clearly, MRI scanning will provide
more accurate
assessment of the true extent of tumor debulking than the
present non-contrast CT scan.
CXR [**4-5**]:
1. Mild bibasilar atelectasis and questionable small left
pleural effusion.
2. Dobbhoff tube with its tip in the stomach.
MRI brain [**2166-4-5**]:
There is a large area of restricted diffusion, posterior to the
tumor debulking site which involves the cortex and white matter
of the right temporal lobe, suspicious for an acute infarct.
There is extensive
heterogeneous T2 signal and susceptibility within the tumor
resection bed,
which could be Surgicel, blood, or a combination of the two.
Following
intravenous contrast infusion, there is also extensive
enhancement, which
suggests that the tumor was not completely removed. There is
marked mass
effect and continued subfalcine herniation. The left lateral
ventricle
remains moderately dilated, of concern for obstruction at the
foramen of
[**Last Name (un) 2044**].
There does appear to be a mild degree of right sided hippocampal
herniation. There is high T2 signal in the left mastoid sinus,
likely indicating an ongoing inflammatory process.
CONCLUSION: Likely development of infarction posterior to the
tumor resection bed. Incomplete resection of the tumor.
Prominent subfalcine herniation and contralateral left lateral
ventricular dilatation.
CT head [**2166-4-9**]
1. Evolution of a right MCA territorial infarct, posterior to
the resection cavity.
2. Residual hemorrhagic foci within the surgical resection bed.
3. Marked mass effect, with leftward subfalcine herniation and
moderate
dilation of the contralateral ventricle, similar to prior study.
Brief Hospital Course:
Mr. [**Known lastname **] is a 75 year old male who was admitted to the stroke
neurology service via the emergency department for new(2wks in
duration) significant left paresis, confusion, and facial droop.
Though the initial diagnosis entertained was a hemispheric CVA,
CT suggests an underlying mass. MRI confirmed a right
fronto-temporal contrast enhancing lesion measuring 6 x 5 x 5 cm
with significant mass effect.
The patient was taken to the OR on [**4-4**] for surgical debulking
of the tumor. The patient was intubated over-night. After
extubation, detailed neurologic examination revealed worsening
left paresis. MRI of the head revealed a MCA infarct in the
inferior division territory.
On ensuing days, the patient's neurologic status improved. By
POD3, the patient exhibited trace movement of the LUE. The
patient's speech was now coherent. However, he did not pass his
S&S eval. A PEG was placed by general surgery on [**4-11**], and tube
feeds were successfully started 24 hours later. He tolerated it
well. On the morning of [**4-13**] he was transferred out of the ICU
to the floor. He was seen by Cardiology for intermittent,
transient bradycardia, and they recommended that all AV nodal
blocking agents be discontinued. This remedied the problem.
He was evaluated by speech and swallow again on [**4-14**], and they
found that he no longer had any swallowing issues. He was
placed on a regular diet, and his tube feeds were decreased to
cycled feeds.
In a family meeting on [**4-16**] the family had a family meeting with
Dr. [**Last Name (STitle) 3929**] and their decision to go forth with whole brain
radiation is pending. They are to get in touch with Dr.
[**Last Name (STitle) 3929**] directly.
The patient was discharged to rehabilitation subsequently.
Medications on Admission:
- Coumadin 5mg daily
- Amlodipine 10mg daily
- Hydrochlorothiazide 25mg daily
- Pravastatin 20mg daily
- Atenolol 25mg daily
- Benazepril 80mg daily
- Omeprazole 20mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain or fever.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/ wheeze.
10. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection every six (6) hours.
11. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for leg pain.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. 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.
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
19. 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.
20. HydrALAzine 10 mg IV Q6H:PRN SBP > 160
hold heart rate less than 60
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] and rehab
Discharge Diagnosis:
Right Frontal Brain Mass
Thyroid Mass
Right MCA Stroke
Hemiparesis
Malnutrition
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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
?????? 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.
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.
?????? You were on Coumadin (Warfarin)prior to your surgery, you stay
off of this until your Brain [**Hospital 341**] Clinic appointment, and it
should be addressed at that time.
?????? 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, 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.
?????? 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.
?????? 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.
**A thyroid mass was discovered incidentally on on your pre-op
Chest X-ray. You should follow up with your PCP for this within
the next month.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2166-4-28**] at 0930. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] 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 need an MRI of the brain with gadolinium contrast. If
you are required to have a MRI, you may also require a blood
test to measure your BUN and Cr within 30 days of your MRI.
This can be measured by your PCP, [**Name10 (NameIs) **] please make sure to
have these results with you, when you come in for your
appointment.
You should follow up with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 85197**] regarding the
inciedntally found Thyroid mass.
Completed by:[**2166-4-17**]
|
[
"246.8",
"431",
"427.31",
"041.4",
"V17.49",
"V58.61",
"305.1",
"191.1",
"V45.81",
"412",
"434.91",
"E942.6",
"348.5",
"427.89",
"414.01",
"191.2",
"272.0",
"997.5",
"263.9",
"V66.7",
"342.90",
"401.9",
"348.4",
"331.4",
"599.0",
"327.23",
"530.81",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"93.90",
"93.59",
"43.11",
"99.07",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
12852, 12905
|
8949, 10740
|
369, 453
|
13029, 13029
|
2801, 2806
|
18019, 18986
|
1455, 1473
|
10964, 12829
|
12926, 13008
|
10766, 10941
|
13207, 13228
|
1488, 1493
|
16044, 17996
|
279, 331
|
3311, 8926
|
13240, 16017
|
481, 1215
|
1921, 2737
|
2756, 2782
|
2820, 3292
|
13044, 13183
|
1237, 1355
|
1371, 1439
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,733
| 120,970
|
39836
|
Discharge summary
|
report
|
Admission Date: [**2178-1-4**] Discharge Date: [**2178-1-15**]
Date of Birth: [**2100-8-22**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77-y.o. male with PMH of Afib, hld, DMII, peripheral neuropathy,
gastroparesis, ESRD on HD recently admitted to [**Hospital3 **] [**2177-12-25**]--[**2178-1-2**] for cholecystitis requiring
pressors. This hospitalization lasted roughly one week, and his
cholecystitis was treated conservatively with unasyn and he was
discharged Yesterday.
.
Today roughly 15 hours into his stay at the rehab facility he
was hypotensive to the 70's with a HR of 130's in AFIB. In tha
setting he developed chest pain. He was taken to [**Hospital3 **]
where he was given one dose of IV lopressor and cardioverted
with return of blood pressures and resolution of his chest pain.
He was given a dose of unasyn, and full dose ASA.
.
[**Hospital3 **] felt he was too complicated to stay there and sent
him to [**Hospital1 18**].
.
In our ED initial vitals were 98.7 64 98/52 14 100% 4L NC. Labs
were notable for a low glucose of 66, a troponin of .44, and a
lacatate of 1.4. Repeat UA looked contaminated. A heparin drip
was started for NSTEMI, Cardiology saw the EKGs, which looked
like demand ischemia in the setting of rapid AFIB. Here EKG is
sinus. He was seen by transplant surgery who felt his
cholecystitis was not appropriate for operative intervention.
.
Last dialyzed yesterday.
.
On arrival to the floor the patient is hemodynamicly stable,
comfortable with no abdominal or chest pain.
Past Medical History:
PMH
- Plasma cell dyscrasia IgM - not myeloma but ? Wadenstrom's
variant s/p 11 months Melphalan and prednisone (last chemo
[**7-/2177**])
-Renal cell carcinoma s/p left nephrectomy in [**2168**]
-DM2
-peripheral neuropathy
-gastroparesis
-ESRD on HD M/W/F
-HTN
-CAD with mild, nonobstructive lesions seen on cath in [**2166**]
-Hyperlipidemia
-BPH
-gout
-hypothyroidism
-GERD
.
Past Surgical History:
-RCC s/p L nephrectomy in [**2168**]
-s/p splenectomy for ITP
-hernia repair
Social History:
The patient lived at home with his son, [**Name (NI) **], up until this
most recent hospitalization at the OSH when he was started on HD
and discharged to [**Hospital 8612**] Rehab. He has 2 sons and 1 daughter.
[**Name (NI) **] remains independent in his ADLs and this is his first
admission to a rehab facility. He is widowed and his wife passed
away in [**2173**]. He is a retired clerical worker for the IRS. He
currently denies smoking, but does have a history of cigar
smoking for approximately 40 years. He reports no EtOH or
illicit drug history. He mobilises independently and has an ET
of 20yrds.
Family History:
His father died of lung cancer at 81 and his mother died at 90.
His brother died of lung cancer. Uncles with DM2, gout.
Physical Exam:
Admission Physical Exam:
T:97.8 P:63 BP:133/71 RR:18 O2sat:99% 2L
General: awake, alert, NAD
HEENT: NCAT, EOMI, PERRLA, anicteric
Heart: distant RRR, NMRG, dialysis [**Last Name (un) **] in place, clean
Lungs: CTAB, normal excursion, no respiratory distress
Back: no vertebral tenderness, no CVAT
Abdomen: Distended, palpable gas, soft, NT,
Extremities: WWP, no CCE, no tenderness, 2+ B radial/DP/PT
Skin: no rashes/lesions/ulcers
Pyschiatric: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
MICRO PERICARDIAL FLUID [**2178-1-7**]
ENTEROCOCCUS RAFFINOSUS. FINAL SENSITIVITIES.
VANCOMYCIN Sensitivity testing confirmed by Etest.
SPECIATION AND SUSCEPTIBILITY TESTING OF DAPTOMYCIN AND
LINEZOLID
REQUESTED BY DR. [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **].
Daptomycin Sensitivity testing performed by Etest.
SENSITIVE TO Daptomycin @ 1 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS RAFFINOSUS
|
AMPICILLIN------------ 16 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- 16 R
VANCOMYCIN------------ <=0.5 S
.
ECHO [**2178-1-6**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a large
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
IMPRESSION: Large circumferential pericardial effusion without
signs of tamponade. Mild symmetric left ventricular hypertrophy
with normal global and regional biventricular systolic function.
.
Compared with the report of the prior study (images unavailable
for review) of [**2177-11-3**], pericardial effusion is probably
larger. The other findings appear similar. Short-term clinical
and echocardiographic follow-up for stability of pericardial
effusion is recommended. Findings discussed with Dr. [**Last Name (STitle) **] at
1440 hours on the day of the study.
.
Cardiac Cath [**2178-1-7**]
1. Successful pericardiocentesis via left sternal approach using
echo guidance and micropuncture technique. 2. Successful removal
of 260cc of straw colored fluid sent for routine labs and
cytology.
FINAL DIAGNOSIS: 1. Large pericardial effusion without
tamponade. 2. Successful pericardiocentsis with drainage of
260cc of straw colored fluid.
.
Gall Bladder Ultrasound [**2178-1-8**]
1. No intra- or extra-hepatic biliary duct dilatation.
2. Gallbladder filled with sludge.
3. Patent main portal vein.
4. Small amount of perihepatic ascites and a small right pleural
effusion as seen on CT.
5. Fluid collection medial to the gallbladder is similar to
finding seen on recent CT.
.
CT Chest with Contrast [**2178-1-8**]
1. Interval decrease in fluid component of pericardial effusion
with new gas within the pericardial effusion, likely secondary
to drain. The pericardial drain lies along the inferior margin
of the right ventricle and traverses the pleural space.
2. New left upper quadrant and left flank fluid collections, the
upper
quadrant fluid collection is high in attenuation suggesting
hemorrhage and is separate from the larger right upper quadrant
hemorrhagic collection which is unchanged. The left flank
collection is most likely ascites.
3. Slight interval worsening in appearance of acute
cholecystitis.
4. Bilateral moderately large pleural effusions with associated
compressive atelectasis, with slight interval enlargement since
[**2178-1-4**].
.
Trans Esophageal Echo [**2178-1-12**]
No thrombus/mass is seen in the body of the left atrium. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular systolic function is hyperdynamic (EF>75%). There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve. No
mitral regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
.
IMPRESSION: No valvular vegetations or abcess seen.
.
ADMISSION RESULTS
[**2178-1-4**] 11:58PM CK(CPK)-17*
[**2178-1-4**] 11:58PM CK-MB-5 cTropnT-0.46*
[**2178-1-4**] 04:30PM URINE HOURS-RANDOM
[**2178-1-4**] 04:30PM URINE UHOLD-HOLD
[**2178-1-4**] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2178-1-4**] 04:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2178-1-4**] 04:30PM URINE RBC-[**2-7**]* WBC-[**2-7**] BACTERIA-OCC YEAST-NONE
EPI-[**2-7**] RENAL EPI-0-2
[**2178-1-4**] 03:07PM GLUCOSE-66* LACTATE-1.4
[**2178-1-4**] 02:35PM GLUCOSE-66* UREA N-20 CREAT-4.3* SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
[**2178-1-4**] 02:35PM estGFR-Using this
[**2178-1-4**] 02:35PM ALT(SGPT)-8 AST(SGOT)-21 CK(CPK)-22* ALK
PHOS-102 TOT BILI-0.4
[**2178-1-4**] 02:35PM LIPASE-12
[**2178-1-4**] 02:35PM cTropnT-0.44*
[**2178-1-4**] 02:35PM CK-MB-4
[**2178-1-4**] 02:35PM WBC-6.7 RBC-3.63*# HGB-12.3*# HCT-40.0#
MCV-110* MCH-33.8* MCHC-30.7* RDW-23.7*
[**2178-1-4**] 02:35PM NEUTS-63.8 LYMPHS-30.6 MONOS-4.5 EOS-0.8
BASOS-0.3
[**2178-1-4**] 02:35PM PLT SMR-VERY LOW PLT COUNT-75*
[**2178-1-4**] 02:35PM PT-13.5* PTT-34.0 INR(PT)-1.2*
.
PENDING RESULTS
Pericardial Fluid Cytology Pending
Abdominal Fluid Cytology Pending
Final Culture data from Blood, Urine, Pericardial Fluid and
Abdominal Fluid not all finalized
Brief Hospital Course:
HOSPITAL COURSE
This is a 77 year old gentleman with complex medical issues,
including recent hospitalization for medically managed
cholecystitis, presenting with chest pain, found to be in atrial
fibrillation with rapid ventricular response, and admitted to
Medicine. Patient was transferred to the CCU for monitoring
after pericardiocentesis (no tamponade physiology on echo,
procedure performed for diagnostic purposes), who subsequently
developed fever and hypotension requiring pressure support with
phenylephrine. He ultimately opted for re-focus of medical
management to pain management and positioning therapy and was
discharged to a rehabilitation facility.
.
ACTIVE ISSUES
# GOALS OF CARE: After significant discussion with both his
family and his medical providers the patient voiced his desire
for re-focus of his medical management to control of his pain,
and focus on comfort. These discussions arose in the setting of
initiation of permanent dialysis and prolonged and profound
physical and emotional decompensation. The patient stated he
understood that termination of dialysis would not be compatible
with life. The patient was transferred to a rehabilitation
facility for management of pain and positioning therapy.
.
# PERICARDIAL EFFUSION: Echo performed on admission demonstrated
large circumferential pericardial effusion, no evidence of
tamponade. Since the patient had been having transient episodes
of hypotension during HD sessions, and in order to better
clarify the etiology of the pericardial fluid, a
pericardiocentesis was performed. Per report, 260 cc of yellow
serous fluid was removed. Two hours post-procedure the patient
became hypotensive, initially responding to fluid boluses, then
requiring Neo for pressure support. He was pan-cultured and
started on broad antibiotics- vancomycin, cefepime and
metronidazole. It was noted that his pericardial fluid changed
in nature from serous to cloudy pink thick fluid. He then became
febrile, and received more volume resuscitation for likely
septic shock. Studies were consistent with an exudative
effusion and culture grew vancomycin resistant enterococcus.
Broad spectrum antibiotics were discontinued and daptomycin was
started. The source remained unclear, given nothing on imaging
to support contiguous spread, and highly unlikely that the
procedure introduced the organism. Furthermore, blood and urine
cultures were negative throughout his hospital stay. A TEE was
negative for evidence of valvular vegetations. Repeat imaging
showed the effusion was resolved and the pericardial drain was
removed. He was treated with a 5 day course of Daptomycin before
antibiotics were discontinued on discharge following the wishes
of the patient.
.
# HYPOTENSION: The patient was noted to be hypotensive on
admission, thought to be secondary to hypovolemia from poor PO
intake. He also had a recent history of transient hypotension
during hemodialysis for which he was started on midodrine.
Echocardiogram revealed an enlarged pericardial effusion
(details above). Post-pericardiocentesis the patient was treated
with fluid resuscitation and broad antibiotics for presumed
septic shock. His blood pressure was supported with
phenylephrine. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-Stim test was negative for adrenal
insufficiency. Additionally, albumin of 1.7 so likely has poor
intravascular osmotic pressure. Given his history of recent
medically-managed cholecystitis, and known intra-abdominal fluid
collections, a CT torso was obtained to investigate potential
sources of infection. His HD catheter was removed. Surgery was
consulted to investigate possible cholecystitis (details below),
and IR performed a drainage of an intraabdominal fluid
collection, a hematoma. Serial blood and urine cultures were
negative. His hypotension resolved, and he was weaned off
phenylephrine prior to discharge. His midodrine was increased to
5 TID. Medical management was discontinued as the patient
declined further medical management.
.
# SUSPECTED CHOLECYSTITIS: The patient had a recent history of
medically-managed cholecystitis. On admission he was initially
treated with broad spectrum antibiotics, which were then
narrowed to Levaquin. Given our clinical concern for sepsis, a
RUQ ultrasound was obtained and demonstrated a sludge-filled
gallbladder and a small, unchanged fluid collection. CT torso
demonstrated stranding, concerning for acute cholecystitis.
Surgery was consulted and recommended HIDA scan given low
suspicion on physical exam. HIDA scan was positive and a
percutaneous drain was attempted; however, the procedure was
complicated by collapse of the gallbladder (inconsistent with
acute cholecystitis) and development of a small hematoma. A
drain was placed in the abdominal fluid collection, which
appeared to be an old hematoma. Microbiology was sent and was
negative for growth. The drain was removed.
.
# ESRD on HD: The patient normally receives HD on T/Th/Sat.
Renal was consulted. HD initially was on hold given new pressor
requirement and stable electrolytes. Given concern for sepsis,
the tunneled dialysis catheter was removed and replaced with a
temporary catheter. Once stable, the patient received CVVH with
phenylephrine for pressure support. Culture of the catheter tip
revealed no growth. A permanent catheter was not placed as the
patient declined further dialysis.
.
# ATRIAL FIBRILLATION with RAPID VENTRICULAR RESPONSE: Present
on admission. The patient spontaneously cardioverted and
remained in sinus for the rest of his admission. The patient has
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] S2 score of 3; however, given his history of
intraabdominal hematomas, we elected to continue aspirin 325 for
anticoagulation. Medical management was discontinued as the
patient declined further medical management.
.
# CORONARY ARTERY DISEASE: Presented with CP in setting of AF
with RVR, found to have ST changes and elevated troponin
consistent with demand ischemia. Enzymes were cycled and the
patient ruled out for an acute myocardial infarction. We
continued his aspirin and statin. Medical management was
discontinued as the patient declined further medical management.
.
# ANEMIA: No evidence of acute bleeding. Likely secondary to
chronic inflammation. Is on Aranesp as outpatient. Hct trended
down initially on admission and was stable around 20 at the time
of discharge. He required a transfusion of 1 unit of pRBCs with
appropriate response.
.
# THROMBOCYTOPENIA: Relatively stable. Unclear etiology,
reportedly has chronic ITP, and is status post splenectomy.
.
# PERIPHERAL NEUROPATHY: Continued on gabapentin 100 qhs.
Medical management was discontinued as the patient declined
further medical management.
.
# GASTROPARESIS: Continued on metoclopramide 5 mg PO QIDACHS.
Medical management was discontinued as the patient declined
further medical management.
.
TRANSITIONAL ISSUES
- Medical Management: Management of pain and optimization of
positional comfort.
- Pending Studies: Pericardial and Abdominal Fluid Cytology,
finalized culture data
- Code Status: DNR/DNI, do not resuscitate.
Medications on Admission:
acetaminophen 325 mg Tablet PO Q6H PRN
MOM prn constipation
simvastatin 40 mg Tablet PO DAILY
allopurinol 100 mg Tablet Sig:PO DAILY
pantoprazole 40 mg Tablet, Delayed Release PO Q24H
docusate sodium 100 mg [**Hospital1 **]
senna 8.6 mg Tablet Sig: PO BID
tramadol 50 mg PO Q12H
metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS
polyethylene glycol 3350 17 gram/dose DAILY (Daily).
midodrine 2.5 mg Tablet 6A 11A 4p
simethicone 80 mg Tablet, QID as needed for gas.
gabapentin 100 mg HS
B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-7**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
levothyroxine 125 mcg DAILY
Discharge Medications:
1. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for End of life anxiety: Pt is comnfort care.
Disp:*100 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*30 Capsule(s)* Refills:*0*
3. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
4. oxycodone 20 mg/mL Concentrate Sig: 2.5-5 mg PO q2hrs as
needed for pain: Pt is comfort care.
Disp:*30 ml* Refills:*0*
5. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 2.5mg-5mg
Tablet, Rapid Dissolves PO every six (6) hours as needed for
anxiety or agitation.
Disp:*80 Tablet, Rapid Dissolve(s)* Refills:*0*
6. prochlorperazine 25 mg Suppository Sig: One (1) tablet Rectal
three times a day as needed for nausea: nausea if unable to take
POs.
Disp:*30 tabs* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO four times a
day as needed for fever or pain.
8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*1*
9. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for mild pain or neuropathy.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] Immaculate Nursing/Restorative Center
Discharge Diagnosis:
Pericardial Effusion
Cardiac Tamponade
Hypotension
Enterococcus infected Pericardial Fluid Collection
Secondary:
End stage renal disease
Peripheral Neuropathy
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were initially admitted to the hospital after experiencing
several episodes of low blood pressure. During your
hospitalization you were noted to have a large fluid collection
around your heart which was drained and thought to be
infectious. You were treated in the intensive care unit due to
the large fluid collection and your low blood pressure. After a
discussion with you, your providers and your family you decided
you did not want any further medical treatment and wanted to
transition care to management of your pain and positional
discomfort. You are being discharged to a facility to help with
your pain management. We have reconciled your medications to be
more concurrent with your goals of care. You also refused
dialysis and were able to tell us the consequence of stopping
dialysis.
We changed your medications as noted in the discharge summary.
Followup Instructions:
None
|
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52,779
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35359
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Discharge summary
|
report
|
Admission Date: [**2160-12-7**] [**Month/Day/Year **] Date: [**2160-12-22**]
Date of Birth: [**2114-3-20**] Sex: F
Service: MEDICINE
Allergies:
Methotrexate
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
[**2160-12-7**] endotracheal intubation
[**2160-12-7**] femoral central venous catheter placement
History of Present Illness:
46F xfer from OSH ([**Hospital3 **]) after being found down by
VNA earlier today. Recent hosp admission for UTI, Klebsiella PNA
completed antibiotics and discharged home. History is unclear,
however [**Location (un) **] reports that she is on the liver transplant
list. History of rheumatoid arthritis and ankylosing spondylitis
on Florinef. Outside hospital, patient was intubated for her
unresponsiveness. Received vancomycin and Zosyn. Also noted to
have a left hip dislocation that was reduced in the ER.
Hypotensive, requiring norepinephrine after 2 L of IV fluids.
Transferred for further care. PH 7.1, CO2 50 with a bicarbonate
of 18 on initial ABG. At outside hospital, attempted right and
left IJ resulted in subcutaneous fluid extravasation.
.
In the ED, initial vitals she recieved hydrocortisone 100 mg IV
because chronically on florinef and had a right femoral CVL
placed. Also, she underwent a CT head which was negative for
acute bleed and a CT torso which showed bilateral aspiration
versus effusions. Her hip had to be reduced twice, once with
vecuronium.
.
On arrival to the MICU, she was intubated and sedated with
initial vital signs 88/69, 120, 14, 100% on AC (volume).
.
Review of systems not obtained because patient intubated.
Past Medical History:
h/o Tylenol OD [**10/2159**] and [**5-/2160**] c/b hepatic failure
VAP
foot necrosis [**2-6**] pressors
Bilateral DVT [**1-/2160**]
8mm clean ulcer at prepyloric antrum seen on EGD [**2160-4-15**]
(H.Pylori neg) c/b GIB bleed s/p transfusion 4U pRBCs
Psychiatric disorder (anxiety vs bipolar)
chronic pain
h/o domestic abuse
Crohn's disease
anklyosing spondylitis
Long term alcoholism
h/o Hep A
iron-deficiency anemia
Distal ileum resection [**2-/2160**]
CCY [**2156**]
R hip replacement [**2153**] c/b osteomyelitis
L hip replacement [**2156**] also c/b osteomyelitis
back/knee surgeries per past notes
Social History:
Lives in apt in [**Location **] by herself. Not currently in a
relationship per case worker, though has h/o domestic violence
and had been living in a domestic violence shelter last year. Is
divorced but has a positive relationship with her ex-husband.
Daughter is 25 y/o and son is 23 y/o. HCP is [**Name (NI) 553**] [**Name (NI) 1968**] (HCP) -
([**Telephone/Fax (1) 80620**]
Family History:
Father - colitis? (frequent stomach pain)
Mother - RA, ankylosing spondylitis
Grandmother - ankylosing spondylitis
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0, BP: 113/67, P: 119, R: 18 O2: 100% on 100% FiO2
General: intubated, sedated
HEENT: Sclera anicteric, MMM, pupils fixed and non-reactive
Neck: subcutaneous infiltration by saline, unable to assess LAD
or JVP
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, no organomegaly
GU: foley draining yellow urine
Ext: cold, thready pulses, no clubbing, cyanosis or edema. left
lower extremity with chronic ulceration
[**Telephone/Fax (1) 894**] PHYSICAL EXAM:
Vitals: 97.8 150/82 72 18 99%RA
General: WDWN female, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: no lymphadenopathy, no JVD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, no organomegaly, right
hip with small subcentimeter wound with minimal serous drainage
Ext: no clubbing, cyanosis or edema. left lower extremity with
chronic ulceration. left hand with erythema and edema from
previous PIV, pink granulation tissue (much improved since
admission), left hip without swelling or erythema, tender on
palpation but pt able to ambulate
Skin: several macules on right leg and lower back with central
clearing c/w tinea corporis
Neuro: A & O x 3, moving all extremities
Pertinent Results:
ADMISSION LABS:
[**2160-12-6**] 11:20PM BLOOD WBC-17.4* RBC-4.27 Hgb-11.5* Hct-38.5
MCV-90 MCH-27.0 MCHC-29.9* RDW-15.0 Plt Ct-248
[**2160-12-6**] 11:20PM BLOOD Neuts-95.2* Lymphs-3.3* Monos-1.4* Eos-0
Baso-0
[**2160-12-6**] 11:20PM BLOOD PT-11.8 PTT-36.0 INR(PT)-1.1
[**2160-12-6**] 11:20PM BLOOD Glucose-65* UreaN-66* Creat-2.2* Na-141
K-4.2 Cl-107 HCO3-14* AnGap-24*
[**2160-12-6**] 11:20PM BLOOD ALT-156* AST-430* CK(CPK)-[**Numeric Identifier 34197**]*
AlkPhos-132* TotBili-0.3
[**2160-12-6**] 11:20PM BLOOD Lipase-10
[**2160-12-6**] 11:20PM BLOOD cTropnT-<0.01
[**2160-12-6**] 11:20PM BLOOD Calcium-6.7* Phos-7.4* Mg-2.4
[**2160-12-6**] 11:20PM BLOOD Osmolal-314*
[**2160-12-6**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-POS
[**2160-12-7**] 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5
FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17
Intubat-INTUBATED Vent-CONTROLLED
[**2160-12-6**] 11:21PM BLOOD Lactate-0.6
[**2160-12-7**] 04:15PM BLOOD freeCa-1.02*
.
ABG TREND:
[**2160-12-7**] 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5
FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17
Intubat-INTUBATED Vent-CONTROLLED
[**2160-12-7**] 07:12AM BLOOD Type-[**Last Name (un) **] Temp-38.0 Rates-22/0 Tidal V-450
PEEP-5 FiO2-60 pO2-62* pCO2-42 pH-7.21* calTCO2-18* Base XS--10
Intubat-INTUBATED Vent-CONTROLLED
[**2160-12-7**] 09:44AM BLOOD Type-ART Temp-38.2 Rates-22/ Tidal V-450
PEEP-10 FiO2-50 pO2-31* pCO2-51* pH-7.20* calTCO2-21 Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2160-12-7**] 12:21PM BLOOD Type-CENTRAL VE Temp-37.2 pO2-170*
pCO2-35 pH-7.35 calTCO2-20* Base XS--5 -ASSIST/CON
Intubat-INTUBATED Comment-GREEN TOP
[**2160-12-8**] 09:44AM BLOOD Type-ART Temp-36.9 Tidal V-500 PEEP-8
FiO2-40 pO2-146* pCO2-40 pH-7.36 calTCO2-24 Base XS--2
Intubat-INTUBATED
.
[**Month/Day/Year 894**] LABS:
[**2160-12-21**] 12:00PM BLOOD WBC-4.8 RBC-3.30* Hgb-9.0* Hct-28.7*
MCV-87 MCH-27.3 MCHC-31.4 RDW-16.8* Plt Ct-448*
[**2160-12-21**] 12:00PM BLOOD PT-21.7* INR(PT)-2.1*
[**2160-12-21**] 12:00PM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-140
K-4.1 Cl-111* HCO3-23 AnGap-10
[**2160-12-16**] 03:42AM BLOOD ALT-38 AST-23
[**2160-12-21**] 12:00PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.5*
.
URINE:
[**2160-12-6**] 11:25PM URINE Color-LtAmb Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2160-12-6**] 11:25PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2160-12-6**] 11:25PM URINE RBC-5* WBC-30* Bacteri-FEW Yeast-NONE
Epi-2
[**2160-12-6**] 11:25PM URINE UCG-NEGATIVE
[**2160-12-6**] 11:25PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
.
MICRO:
[**12-6**], 4, 6, 7 BLOOD CULTURES NGTD
[**2160-12-7**] 11:00 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2160-12-7**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. HEAVY GROWTH.
BETA STREPTOCOCCI, NOT GROUP A. MODERATE GROWTH.
Blood Culture, Routine (Final [**2160-12-16**]): NO GROWTH.
Blood Culture, Routine (Final [**2160-12-16**]): NO GROWTH.
URINE CULTURE (Final [**2160-12-11**]): YEAST. >100,000
ORGANISMS/ML..
Stool Studies:
FECAL CULTURE (Final [**2160-12-13**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2160-12-13**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2160-12-12**]):
NO OVA AND PARASITES SEEN.
FECAL CULTURE - R/O VIBRIO (Final [**2160-12-13**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2160-12-13**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2160-12-12**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2160-12-12**]):
Feces negative for C.difficile toxin A & B by EIA.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2160-12-17**]):
Feces negative for C.difficile toxin A & B by EIA.
[**2160-12-17**]: C. difficile Toxin PCR Negative
.
IMAGING:
[**12-7**] CT C/A/P: TECHNIQUE: MDCT axial images were obtained from
the chest, abdomen and pelvis with the administration of IV
contrast. Multiplanar reformats were generated and reviewed.
CT OF THE CHEST: Right pleural effusion with adjacent
compressive
atelectasis. Left base opacification likely represents collapsed
left lower lobe which appears airless and filled with higher
density material, possibly blood. The patient has a nasogastric
tube which passes into the stomach. ETT tube appears
approximately 4.7cm above the carina.
The visualized heart and pericardium are unremarkable.
CT OF THE ABDOMEN AND PELVIS: The intra-[**Month/Day (4) 1676**] vasculature
and
intra-[**Month/Day (4) 1676**] solid organs are incompletely evaluated in the
absence of IV contrast. Within this limitation, the liver,
pancreas, and bilateral adrenal glands appear unremarkable. Note
is made of splenomegaly. Both kidneys show no evidence of large
masses. A non-obstructive 9-mm stone is noted within the lower
pole of the left kidney (601B, 32). Small stones are noted
within the right kidney. The patient is status post
cholecystectomy.
Surgical sutures are noted in the RLQ, otherwise,
intra-[**Month/Day (4) 1676**] loops of
large and small bowel appear unremarkable. There is no free air
or free fluid within the abdomen. Retroperitoneal and mesenteric
lymph nodes do not meet size criteria for pathologic
enlargement.
The structures within the pelvis are incompletely evaluated due
to the
presence of streak artifact due to bilateral total hip
replacements. Within this limitation, the patient is status post
a Foley catheter. A right femoral vein catheter is identified. A
possible rectal catheter is noted. Bilateral hip prosthesis are
noted; the right femoral component appears well seated within
the acetabular component; however, the left femoral component is
not well seated within the left acetabular component.
Decrease in vertebral body height of L1 vertebral body is noted
with possible retropulsion of fragment into the spinal canal and
indentation of the thecal sac. This is of indeterminate
chronicity, but likely represents more chronic process with the
presence of what looks like kyphoplasty material within L1
vertebral body. Intra-[**Month/Day (4) 1676**] vasculature is not well
evaluated in the absence of contrast technique.
IMPRESSION:
1. Right pleural effusion with adjacent compressive atelectasis.
Left base
opacification likely represents collapsed left lower lobe which
appears
airless and filled with higher density material, possibly blood.
2. Left lower pole renal calculus.
3. Incomplete evaluation of the pelvis due to streak artifact.
4. Left total hip arthroplasty prosthesis shows femoral
component is not well seated within the acetabular component.
5. Loss of vertebral body height of L1 vertebral body with
possible
retropulsion of fragments into the spinal canal; this is of
indeterminate
chronicity, however, appears to be chronic due to presence of
what appears to be kyphoplastic material.
.
[**12-7**] CT HEAD:TECHNIQUE: Contiguous axial images were obtained
through the head without the administration of IV contrast.
Multiplanar reformats were generated and reviewed.
There is no evidence of acute fracture or traumatic dislocation.
Bilateral
mastoid air cells are clear. Minimal mucosal thickening is noted
within
bilateral maxillary sinuses.
There is no evidence of acute intracranial hemorrhage, discrete
masses, mass effect or shift of normally midline structures. The
ventricles and sulci are normal in size and configuration.
[**Doctor Last Name **]-white matter differentiation is preserved with no evidence
of large acute major vascular territory infarction.
IMPRESSION: No acute intracranial pathological process.
ADDENDUM AT ATTENDING REVIEW: There is marked anterior rotation
of the
odontoid process relative to a thickened appearance of the body
of C2. The
finding likely represents a fracture/subluxation deformity.
There is resultant prominent central canal narrowing at this
level. There is no prevertebral soft tissue swelling at this
locale. It is possible that the finding represents a prior,
healed fracture, but clearly this question must be resolved,
through either obtaining prior records/imaging studies
immediately, and/or subsequent spinal CT imaging. In the
meantime, the patient's neck needs to be stabilized.
.
[**12-8**] CT CSPINE: COMPARISON: CT head from [**2160-12-7**] and
portable C-spine radiograph from [**2160-12-7**].
TECHNIQUE: Helical 2.5-mm axial MDCT sections were obtained from
the skull
base through the level of T2. Sagittal and coronal reformations
were obtained and reviewed.
FINDINGS: There is a large mass of new bone formation causing
fusion of the C1 and C2 vertebral bodies anteriorly, with
anterior subluxation of C1 with respect to C2(400b:27). This
results in severe encroachment on the spinal canal by the
posterior arch of C1. The degree of subluxation is unchanged
from the prior study. There is no fracture identified.
There is extensive fusion of every facet joint from C2 to T3,
comprising all the levels imaged. There is also interbody fusion
involving every cervical level. There has been surgical anterior
fusion at C6-7. There is extensive fusion of the lamina and
interlaminar ligaments throughout the visualized levels. In the
portion of thoracic spine included in the study, there is fusion
of costovertebral and costotransverse articulations. Comparison
with a torso CT of [**2160-12-8**] reveals similar ankylosis in the
lumbar spine and sacroiliac joints. These findings indicate a
spondyloarthropathy with manifestations typical of ankylosing
spondylitis. Correlation with the remainder of her medical
history will be helpful.
IMPRESSION:
1. Anterior subluxation of C1 on C2 without evidence of
fracture. The
anterior arch of C1 is fused to the odontoid process via a thick
layer of bone that contributes to the subluxation. This produces
severe encroachment on the spinal canal by the posterior arch of
C1.
2. There are extensive fusions of multiple spinal joints most
suggestive of ankylosing spondylitis.
3. No evidence of acute fracture.
.
[**12-7**] PELVIS PLAIN FILM: Comparison is made to selected images
from an [**Month/Day (4) 1676**] pelvic CT scan dated [**2160-12-7**].
SINGLE PORTABLE AP PELVIC FILM WAS OBTAINED [**2160-12-7**] AT 0452:
Bilateral total hip replacements are seen. The femoral and
acetabular
components appear to be well approximated on this single AP
view. The distal end of both femoral components is not included
on the image. There is no evidence of loosening of the femoral
components. Hypertrophic bone is seen lateral to the right
femoral component. A right femoral catheter is in place. No
displaced fracture of the pelvis is appreciated. Surgical chain
sutures are seen in the right lower quadrant, suggesting prior
colonic surgery. A Foley catheter is in place. Several
radiopaque densities are seen lateral to the left femoral
component within the soft tissues which may be sutural in
etiology. Clinical correlation is advised.
IMPRESSION:
Bilateral total hip replacements with both appearing to be
normally positioned on this single portable view. No evidence of
displaced fracture of the pelvis.
Left upper extremity ultrasound [**2160-12-11**]:
IMPRESSION: Non-occlusive thrombus within one of two paired
brachial veins, which extends to the axillary vein.
Portable chest x-ray [**2160-12-11**]:
IMPRESSION: Persistent sizable parenchymal infiltrate in left
lower lobe
area. No new abnormalities in this portable chest examination.
Brief Hospital Course:
Ms. [**Known lastname 40984**] is a 46 year old female with a history of suicide
attempts and subsequent liver disease, multiple infections
including ESBL Klebsiella and osteomyelitis who takes chronic
steroids for ankylosis spondylitis presented from an outside
hospital intubated and requiring pressors.
.
ACTIVE PROBLEMS BY ISSUE:
# Acute metabolic acidosis without respiratory compensation:
Her pH upon admission to ICU was 7.1 with a bicarb of 14, later
worsened to 7.09 with bicarb of 12. The possible etiologies of
her primary metabolic acidosis include intoxication versus
sepsis. The active [**Doctor Last Name 360**]/s seem to have suppressed her
respiratory drive (additional respiratory acidosis) as well as
causing a primary metabolic acidosis. She was treated with IV
fluids with bicarbonate as well as hyperventilation on
mechanical ventilation in order to improve the acidosis and
elevated pCO2. Also, the toxicology and psychiatry services
were consulted to assist with identifying the cause of her
ingestion. Finally, she was started empirically on
piperacillin/tazobactam with vancomycin to cover for possible
aspiration pneumonia.
.
# Respiratory failure: She was intubated upon arrival but able
to be ventilated well including a recruitment procedure to open
her atelectatic lung seen on CT. She was extubated easily and
did well on room air afterwards. As discussed above, it was
thought that she aspirated while she was impaired from an
unknown ingestion. Her CT chest was consistent with some small
bilateral pneumonia. Following stabilization and extubation,
induced sputum results returned positive for MRSA. She
completed a 7 day course of vancomycin. She remained afebrile
throughout remainder of course on the medical floor. PICC was
discontinued prior to [**Doctor Last Name **].
.
# Hypotension: Pt was hypotensive on admission to ICU. Her
hypotension is of unclear etiology. It seems possible that she
had sepsis--likely from pneumonia. Also, she may have been down
long enough to miss her home florinef dose, resulting in
hypotension. Lastly, the ingestion itself could have caused
hypotension. She was treated with IV fluids, antibiotics as
above, and stress doses of steroids. Blood pressures were
stable during floor course. She was started on captopril when
she became hypertensive with subsequent good control.
.
# Psychologic issues: We suspect that she had a purposeful
ingestion with suicidal attempt. Blood tox was positive for
benzos and tricyclics. Urine tox was positive for benzos,
cocaine, and opiates. However, the patient did not admit
suicide ideation; she intermittently reported that she may have
accidentally ingested more medications than intended. Psychiatry
was consulted and they recommended a 1:1 sitter. She was placed
on section 12. She was followed by psychiatry and often refused
full interviewing. She did not admit to suicide ideation but
given her prior suicide attempts and depression with inability
to care for herself, she was transferred to psych facility for
further care. All of her psychiatric medications were held
during hospital stay. She was started on low dose seroquel on
the floor prior to transfer to help with sleep.
.
# Rhabdomyolysis: Her admission Creatinine was 2.2 (baseline is
< 1.0) with phosphate >7 and CK of [**Numeric Identifier 24587**]. She was treated with
IV fluids and alkalinization of the urine (with bicarb). Her
creatinine improved to baseline and her CK trended down quickly.
.
# Transaminitis: She has a history of liver disease secondary
to toxic ingestions. Her AST/ALT ratio suggests EtOH damage.
APAP < 2 at OSH. LFTs normalized by time of [**Numeric Identifier **].
.
# Odontoid fracture and Hip dislocation: Patient originally
arrived in the ED with dislocated hip which was reduced.
However, while intubated she awoke and again dislocated her hip
while agitated. It has been put in a brace after a second
reduction. Her CT head showed an old odontoid fracture,
confirmed with CT neck. She was kept immobilized until cleared
by ortho spine team. For her hip, ortho recommended that she
continue with posterior hip precautions. She is weight bearing
as tolerated.
.
# Left upper extremity DVT: Patient failed bilateral internal
jugular central lines in the outside hospital and then failed a
left subclavian and left IR-guided PICC here. Imaging looks
like there is some type of central obstruction, L
brachiocephalic vein no flow past it on venogram. She was
eventually able to get a midline at level of axillary.
Ultrasound showed left upper extremity DVT. She was initially
started on heparin gtt with coumadin. She was then transitioned
to lovenox with coumadin. INR was therapeutic for several days
between 2 and 3 by time of [**Numeric Identifier **] on 3mg of warfarin daily.
Pt currently is at risk of falling (due to her ankylosing
spondylitis and hip dislocations) and syncope from substance
abuse. However, given that she will be transferred to an
extended care facility, it was felt that benefits of
anticoagulation would outweigh the risks at this time. When
ready for [**Numeric Identifier **], there should be another discussion of
anticoagulation. After rehabilitation from both physical and
mental viewpoint, risks/benefits of anticoagulation should be
re-assessed. In the meantime, fall precautions should be
continued at psych facility
.
# Diarrhea: Pt had several loose BMs daily. C.diff was negative
x 2. Given amount of diarrhea, she was empirically started on
oral flagyl 500mg TID. C.diff PCR was sent in the meantime.
PCR returned negative and flagyl was discontinued. She was
started on immodium with symptomatic relief
.
# Tinea corporis: Pt had several macular patches on lower back
and right leg with central clearing. This was consistent with
tinea corporis. She was treated with clotrimazole cream [**Hospital1 **].
.
# Pain control: Pt with longstanding history of narcotic use.
She frequently demanded IV dilaudid for nonspecific complaints,
including [**Hospital1 1676**] pain. Also has ankylosing spondylitis, left
hip dislocation, and left hand IV infiltration of levophed from
OSH that can contribute to pain. Pain consult obtained who
recommended maintaining current narcotic regimen of oral
dilaudid q6h. She was also given lidoderm patch and ibuprofen
for pain relief. Oral dilaudid was transitioned to oral
oxycodone prior to [**Hospital1 **] which patient reported was more
satisfactory.
.
# Communication: [**Name (NI) 553**] [**Name (NI) 1968**] (HCP) - ([**Telephone/Fax (1) 80620**]; [**First Name5 (NamePattern1) **]
[**Name (NI) 80606**] (son) - [**Telephone/Fax (1) 80609**]
Medications on Admission:
clonazepam 1 mg [**Hospital1 **], 0.5 mg daily
tizanidine 2 mg qhs
ranitidine 150 mg [**Hospital1 **]
trazodone 50 mg daily
gabapentin 800 mg tid
fentanyl patch 50 mcg/hr every 72 hours
ketoconazole
tramadol 50 mg qid
macrobid 100 mg [**Hospital1 **]
[**Hospital1 **] Medications:
1. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): On for
12 hours daily.
3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
4. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day): Use twice daily until [**2160-12-31**].
5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
8. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
[**Hospital1 **] Diagnosis:
Overdose
Depression/ Hx of suicide attempt
Pneumonia
Left upper extremity DVT
Hypertension
Tinea corporis
[**Hospital1 **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Hospital1 **] Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted after being found in your home unconscious. You were
intubated and in the ICU. You likely had an ingestion that
caused you to lose consciousness. You will be transferred to a
psychiatric facility where you will continue to receive mental
health care.
During your hospital stay, you were treated for pneumonia with
an IV antibiotic; you finished this course.
You were also started on a blood thinner called coumadin for a
blood clot found in your left arm. You will need to have levels
of this medication in your blood monitored 2-3 times weekly.
After psychiatric and physical rehabilitation, the risks and
benefits of blood thinners should be revisited so that we can
determine how long you should stay on this medication.
Please see attached sheet for your new medications.
Followup Instructions:
You will be seen by psychiatrists and physicians at your
facility.
Completed by:[**2160-12-22**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.97",
"79.75",
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] |
icd9pcs
|
[
[
[]
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4312, 4312
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25502, 25601
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24622, 25479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,526
| 151,636
|
29576
|
Discharge summary
|
report
|
Admission Date: [**2104-5-19**] Discharge Date: [**2104-5-23**]
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Fever at dialysis.
Major Surgical or Invasive Procedure:
Hemodialysis.
History of Present Illness:
This is a [**Age over 90 **]-year-old man with a history of Alzheimer's
dementia, Hypertension, ESRD on HD (M/W/F), history of
aspiration pneumonia found to have temperature of 101 at
hemodialysis this morning. He underwent a revision of left
forearm AV fistula on [**2104-4-26**] for two aneurysmal areas with skin
ulceration but recently evaluated by transplant surgery and
thought to be fine to use. The patient last underwent HD on
Friday (3 days prior to admission), which was unremarkable, but
felt chills after. Over the weekend he was afebrile, no cough,
SOB, no increased sputum production (question whether had an
aspiration event). He is AOx0 at baseline and per the daughter
mental status is at baseline.
.
In the ED, initial vs were: T 101 HR 86 126/65 20 97% on 3L (no
O2 at home). Exam with decreased breath sounds bilaterally. WBC
of 14.2. CXR initially concerning for possible right apical
pneumothorax. Thoracic surgery was consulted recommending repeat
CXR to evaluate for PTX stability. Final CXR read as no
pneumothorax (skin fold presents mimic) but with small bilateral
pleural effusions and moderate pulmonary edema without definite
consolidation. He received one dose of clindamycin, vancomycin,
and ceftazadine. Patient developed rash to clindamycin so given
solumedrol, tylenol. Benadryl held given h/o benadryl allergy.
.
He was given 30PR of kayexcelate for potassium of 6.2. Signout
was being given to medicine floor team but in worsening
respiratory distress requiring BiPAP and hypertensive (180/50)
requiring nitro gtt so transferred to MICU.
.
In the MICU [**5-4**] blood cultures from ED grew GPCs in clusters. He
was continued on Vancomycin and Cefepime. Thoracic surgery
signed off given no evidence of pneumothroax. Patient received
HD on [**5-19**] with 2L removed. Vitals on transfer to the floor
were HR 72 BP 101/42 94% on 3L.
.
Currently, he appears in no acute distress, lying in bed.
Denies chest pain, shortness of breath, cough, fevers, chills,
or any other concerning signs or symptoms. Patient is alert to
person, but not to place or event.
Past Medical History:
# HTN
# ESRD HD [**2099**] (hypertensive nephropathy), receives HD qMWF
# Alzheimer's Dementia on donepezil(recently discontinued [**3-4**]
nocturnal wakenings)
# [**Month/Day (2) 8974**] bacteremia treated with 8 weeks IV cefazolin [**10-8**]
# Pseudomonas bacteremia [**11-7**] rx w/ Cipro at VA
# C. difficile colitis [**11-7**]
# Bladder CA s/p resection at 60, 83 y/o. Most recent resection
[**2102-11-20**] - followed w/ yearly cystoscopies as now
anuric
# Aortic ulcerations [**3-9**], unchanged on [**2101-9-25**] abd CT
# Temporary HD catheter line infection with [**Date Range 8974**] in [**3-9**], rx
with nafcillin, cathether has since been removed
# Additional episode of [**Date Range 8974**] bacteremia [**9-6**], unclear source.
Rx'ed with nafcillin and 4 wks of outpt cefazolin
# Chronic low back pain
# Chronic diastolic CHF
[**2104-4-26**] Aneurysmorrhaphy x2 of left arteriovenous
fistula.
Social History:
-Prior supervisor of flight kitchen.
-Lives at [**Hospital 1501**] [**Hospital 3145**] Nursing and Rehab center ([**Telephone/Fax (1) 70915**])
-Daughter [**Name (NI) **], very supportive (wife w/ dementia lives w/
her)
-No known alcohol or tobacco history.
Family History:
CAD Brothers (2), Mom ESRD (unknown etiology).
Physical Exam:
ADMISSION EXAM
Vitals: 99.2 170/58 87 Bipap 8/5 60%FiO2 99% 20
General: Lying in bed at 10 degrees, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: unlabored respirations, decreased breath sounds bases,
crackles bibasilarly, no wheezes/rhonchi
CV: S1, S2 regular rhythm, normal rate
Abdomen: soft, NTND, no gaurding
GU: no foley
Ext: no edema, LUE fistula sight erythema, crusting, no drainage
Vitals on discharge:
T: 97.1, HR: 78, BP: 152/62, SPO2: 95% on RA.
Pertinent Results:
[**2104-5-19**] 09:29PM TYPE-[**Last Name (un) **] PO2-147* PCO2-41 PH-7.51* TOTAL
CO2-34*
[**2104-5-19**] 09:29PM LACTATE-0.9
[**2104-5-19**] 12:37PM COMMENTS-GREEN TOP
[**2104-5-19**] 12:37PM LACTATE-2.4* K+-6.2*
[**2104-5-19**] 12:20PM GLUCOSE-97 UREA N-53* CREAT-8.3*# SODIUM-140
POTASSIUM-6.2* CHLORIDE-93* TOTAL CO2-29 ANION GAP-24*
[**2104-5-19**] 12:20PM estGFR-Using this
[**2104-5-19**] 12:20PM ALT(SGPT)-6 AST(SGOT)-27 LD(LDH)-333*
CK(CPK)-24* ALK PHOS-103 TOT BILI-0.7
[**2104-5-19**] 12:20PM CK-MB-NotDone proBNP-[**Numeric Identifier 70916**]*
[**2104-5-19**] 12:20PM ALBUMIN-3.8 CALCIUM-9.6 PHOSPHATE-3.4
MAGNESIUM-2.2
[**2104-5-19**] 12:20PM WBC-14.8*# RBC-4.89 HGB-12.7* HCT-41.4 MCV-85
MCH-26.0* MCHC-30.7* RDW-18.1*
[**2104-5-19**] 12:20PM NEUTS-84* BANDS-5 LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2104-5-19**] 12:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2104-5-19**] 12:20PM PLT SMR-NORMAL PLT COUNT-303
[**2104-5-19**] 12:20PM PT-13.8* PTT-34.2 INR(PT)-1.2*
CXR [**2104-5-19**]:
INDICATION: A [**Age over 90 **]-year-old male with fever. Evaluate for
pneumonia.
COMPARISON: CT chest of [**2104-1-12**] and chest radiographs of
[**2104-1-11**].
CHEST, AP AND LATERAL VIEWS: Compared to the prior studies,
there is
decreased right-sided pleural effusion and persistent small left
pleural
effusion. Allowing for low lung volumes, the heart size is
enlarged. There
is diffuse interstitial opacity consistent with pulmonary edema.
Tortuosity of the thoracic aorta and atherosclerotic
calcification of the aortic arch is noted, but the mediastinal
silhouette is otherwise unremarkable. No pneumothorax is seen
although a skin fold presents a mimic in the upper right
hemothorax. Bones are diffusely demineralized. There is
dextroconvex scoliosis of the thoracic spine with degenerative
change, as before.
IMPRESSION: Small bilateral pleural effusions, left greater than
right, but decreased on the right compared to the prior study.
Findings compatible with moderate to severe pulmonary edema. No
definite focal consolidation. Repeat radiograpy after diuresis
is recommended to assess for underlying infection.
TTE [**2104-5-20**]:
The left atrium is markedly dilated. There is moderate symmetric
left ventricular hypertrophy. Regional left ventricular wall
motion is normal and overall systolic function is normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is a small to moderate sized pericardial
effusion without echocardiographic signs of tamponade. The
effusion appears circumferential.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
preserved regional and global systolic function.
Small-to-moderate circumferential pericardial effusion without
echocardiographic signs of tamponade. No valvular vegetations
identified.
Compared with the findings of the prior study (images reviewed)
of [**2102-10-3**], the pericardial and pleural effusions are new. The
severity of pulmonary hypertension has increased.
[**2104-5-20**] SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Shortness of breath.
There has been worsening of mild-to-moderate pulmonary edema,
small bilateral pleural effusions and bilateral atelectasis.
Cardiomediastinal silhouette otherwise unchanged.
Brief Hospital Course:
This is a [**Age over 90 **]-year-old man with a history of Alzheimer's
dementia, Hypertension, ESRD on HD (M/W/F), history of
aspiration pneumonia with hypoxemia and fever at hemodialysis.
.
# HYPOXEMIA: Likely due to volume overload (with supporting
physical exam, CXR, and ECHO findings) in setting of
hypertensive emergency in ED. A missed dialysis session and
congestive heart failure simply pushed patient into pulmonary
edema. (Symptoms resolved with nitro gtt and BiPap in the ED
and dialysis the day after admission). There was inital question
of aspiration pneumonia, yet again, there was no evidence of
pneumonia on CXR. After inital 24 hours in the MICU, patient
was weaned completely from oxygen. He continued to sat well on
room air throughout the rest of his hospitalization. He was
discharged without an oxygen requirement. Mr. [**Known lastname **] was
maintained on his preadmission anti-hyperensives and continued
dialysis 3 days a week.
.
# BACTEREMIA: Patient with fevers at dialysis and blood
cultures growing out MRSA. Upon admission, etiology of
bacteremia was unclear, and patient was treated broadly with
vancomycin, cefepime, and flagyl. These antibiotics were
streamlined to just vancomycin when is was apparent that patient
did not have PNA. Mr. [**Known lastname **] has a long history of bacteremia in
the past ([**Known lastname 8974**] and psuedomonas). Most likely, source of
infection is AV fistula. On day of discharge, blood cultures
had been negative for 48 hours. Mr. [**Known lastname **] will need ~4 weeks of
treatment with vanc, to be dosed at dialysis. Our ID team will
be in touch with [**Hospital1 3145**] with specific instructions. Patient
will also have ID follow-up. A TTE was negative for
vegetations, and a TEE was negative in the past. White count
and fever curve normalized. ID and [**Hospital1 1106**] will need to decide
how to procede in the long term with AV fistula. However, at
this time, AV fistula is ok to use for dialysis. Day #1 for
vanc: [**5-19**].
.
#HYPERKALEMIA: Likely due to end stage renal disease in setting
of missing hemodialysis on day of admission. Resolved with
dialysis.
.
#HYPERTENSION: Most likely secondary to volume overload in the
setting of not taking home antihypertensives on day of admission
and missed HD session. Patient was continued on his home
antihypertensives with good effect.
.
# ACUTE ON CHRONIC DIASTOLIC CHF: TTE from [**5-20**] shows new
pericardial and pleural effusions with worsening pulmonary
hypertension. Patient initially with volume overload (as
described above) that resolved with dialysis. Patient was ruled
out for MI with 2 sets of troponins. He was continued on
metoprolol, ASA, simvastatin, and lisinopril.
.
# ALLERGIC REACTION: Patient reportedly had rash after
administration of clindamycin in the ED. Upon arrival to the
floor (after administration of steroids in ED), patient did not
have rash, and there was no evidence of bronchospasm or upper
airway edema. Clindamycin was added to his allergy list.
.
# MENTAL STATUS: Patient is AOx1 at baseline with poor
short-term memory and known Alzheimer's dementia. As per
daughter, he is at baseline.
.
# ESRD: The patient was dialyzed uneventfully on the day of
admission. He was followed by the Nephrology service with
dialysis on MWF. Patient was maintatined on calcium acetate
with meals.
.
# CAD: Patient was continued on metoprolol, ASA, simvastatin,
and lisinopril.
.
# SPEECH AND SWALLOW: Patient was seen by speech and swallow
service and had a video swallo study. It was suggested that he
only take nectar-thickened liquids, pureed foods, crushed pills,
and 1:1 supervision with eating. Also recommended: no straws,
can follow each bite with a sip of liquid and end the meal with
sips of liquid. Also with TID oral care.
Medications on Admission:
1. Amlodipine 10 mg daily
2. Nephrocaps one capsule daily
3. Calcium acetate 1350 mg three times daily
4. Aricept 10 mg daily
5. Lansoprazole 30 mg daily
6. Lisinopril 20 mg daily
7. Metoprolol 50 mg twice daily
8. Minoxidil 2.5 mg daily
9. Simvastatin 80 mg daily
10. Aspirin 81 mg daily
11. Colace
12. Senna
13. Aspirin 81 mg po daily
Discharge Medications:
1. Amlodipine 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap
PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Donepezil 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO HS (at bedtime).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
7. Minoxidil 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
8. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
11. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Vancomycin in D5W 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous HD PROTOCOL (HD Protochol) for 4 weeks.
13. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Nursing Home - [**Location (un) 3146**]
Discharge Diagnosis:
Primary:
1. MRSA bacteremia
.
Secondary:
1. HTN
2. ESRD on HD MWF
3. [**Location (un) 8974**] bacteremia
4. Psudomonas bacteremia
5. H/o C.diff colitis
6. Bladder CA s/p resection
7. Aortic ulcerations
8. Chronic low back pain
9. Chronic dCHF
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you on this admission. You
came to the hospital because you had a fever at dialysis. We
did blood cultures, which showed bacteria growing in your blood.
You will need antibiotic treatment for the next 3 weeks. You
will receive your antibiotics at dialysis. You will also need
close follow-up with the infectious disease doctors and the
[**Name5 (PTitle) 1106**] surgeons.
.
The following changes were made to your medications:
1. START taking vancomycin at dialysis as directed by kidney
and infectious disease doctors for the next 4 weeks. You will
need to have close monitoring of your vancomycin levels. Day #1
is [**5-19**].
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
.
Return to the hospital if you develop chest pain, shortness of
breath, nausea, vomiting, diarrhea, fevers, chills, bright red
blood per rectum, or any other concerning signs or symptoms.
Followup Instructions:
Department: ADVANCED VASC. CARE CNT
When: TUESDAY [**2104-6-10**] at 8:45 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2104-6-11**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2104-7-7**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 16976**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"294.10",
"041.12",
"428.33",
"403.91",
"331.0",
"V10.51",
"V45.11",
"790.7",
"428.0",
"585.6",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13657, 13743
|
8047, 11105
|
238, 253
|
14039, 14039
|
4204, 8024
|
15205, 16151
|
3609, 3657
|
12280, 13634
|
13764, 14018
|
11910, 12257
|
14188, 15182
|
3672, 4124
|
4138, 4185
|
180, 200
|
281, 2383
|
14054, 14164
|
2405, 3317
|
3333, 3593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,236
| 121,214
|
27366
|
Discharge summary
|
report
|
Admission Date: [**2144-3-26**] Discharge Date: [**2144-4-7**]
Date of Birth: [**2090-10-2**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Transfer from [**Hospital3 **] ED for septic shock, possible
NSTEMI, and possible stroke.
Major Surgical or Invasive Procedure:
radial arterial line
History of Present Illness:
53-year-old female with a history of alcohol abuse and cirrhosis
who was brought to the [**Hospital1 2436**] ED by her husband for
[**Name2 (NI) 67045**]-sided weakness and lethargy. She reportedly went out
drinking last night and then felt "hung over" this morning. Her
husband left for work and she stayed in bed since she was not
feeling well. When he came home from work she was still in bed
and was felt to have right-sided weakness. She was brought to
[**Hospital1 2436**] ED where there was concern for a stroke.
.
In the [**Hospital1 2436**] ED she was found to have a fever of 104.7
rectally, and her exam was notable for right-sided neglect and
right-sided weakness. Her head CT showed no hemorrhage or edema,
but her lab results vrealed a leukocytosis with 28% bands. Her
chest x-ray "looked like aspiration pneumonia." An LP was
performed after receiving two units of FFP that showed normal
counts, protein and glucose. She was treated empirically for
bacterial meningitis with Vancomycin and Ceftriaxone.
.
Her initial ABG was 7.30/38/117, but a repeat ABG was 7.32/31/67
and she was intubated for hypoxia and airway management. Upon
intubation she had purulent drainage from the ETT with suction.
.
A left femoral central access attempt was made, but the artery
was cannulated and a hematoma resulted. A [**Hospital1 67045**] femoral TLC was
placed. She was given Clindamycin, Vancomycin and Ceftriaxone.
Past Medical History:
Lupus
Alcohol abuse
Hepatitis C
Cirrhosis
Osteoporosis
Social History:
She is an alcoholic - drinks one pint of vodka a day. She smokes
a pack of cigarettes a day x40 years. She smokes marijuana
occasionally, but does not use other drugs.
Husband [**Doctor Last Name **] cell = [**Telephone/Fax (1) 67046**]
Husband [**Name (NI) **] = [**Telephone/Fax (1) 67047**]
Family History:
No hereditary conditions per the husband.
Physical Exam:
EXAM: HR 112, BP 88/58, RR 30 (on vent), O2 sat 85-92%
VENT: AC 30/10/500/100%
GEN: Intubated, sedated. Moves all four extremities and responds
to pain.
HEENT: Intubated. Pupils were equal, round, and sluggish in
response to light. The pupils were initially 4-5 mm bilaterally.
CV: Regular tachycardia without obvious murmurs.
LUNGS: Diffuse rhonchi throughout.
ABD: Soft, mildly distended, nontener. Rectal with
brownish-yellow stool that was guaiac negative.
BACK: No ulcers or skin breakdown.
EXT: No LE edema.
NEURO: Moves all 4 limbs, responds to pain. PERRL.
SKIN: no rash
Pertinent Results:
LABS:
WBC 13.1 (73P, 21B, 3L), HCT 38, PLT 117
Na 136, K 3.6, Cl 98, HCO3 22, BUN 25, Creat 1.9, Gluc 143
ALT 108, AST 202, AlkPhos 127, TB 2.9, DB 0.7, [**Doctor First Name 674**] 219, LIP 327
Ammonia = 13
PT 17.6, INR 1.6, PTT 58.3
Myoglobin = 5494.0
Troponin I = 17.25
CPK = 514, CK-MB = 20.1, MBI = 3.9
.
Serum Tox Screen = EtOH 0, Tylenol < 2.0, Salicylate <2.8
.
LP (CSF): Opening pressure =
WBC = Pending
RBC = Pending
Protein = 70
Glucose = 120
.
UA: no UTI.
.
EKG: Sinus tachycardia with ST depressions in the inferior leads
and in V3-V6.
.
CXR: Bilateral patchy alveolar opacities. Right-sided rib
fractures, ? old.
.
HEAD CT: Small low density area in white matter of right
frontoparietal region. ? microangiopathic change vs. small
subacute infarct vs. edema from a small underlying lesion. No
bleed or mass effect.
Echo: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is severe regional left ventricular systolic
dysfunction. Overall left ventricular systolic function is
severely depressed. Resting regional wall motion abnormalities
include septal akinesis and lateral akinesis/hypokinesis. Apical
function appears relatively preserved in suboptimal views. The
inferior and anterior walls are not fully visualized. No
definite left ventricular thrombus visualized (cannot exclude).
Right ventricular chamber size is normal. Right ventricular
systolic function may be depressed. The aortic valve leaflets
are mildly thickened. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
.
Brief Hospital Course:
53-year-old female with a history of alcohol abuse and cirrhosis
here with septic shock.
.
#. Septic Shock/Cardiogenic shock - Suspected source for sepsis
was community acquired pneumonia vs. aspiration pneumonia. She
was started on vancomycin, zosyn and levofloxacin. However, on
arrival her extremities were cold and not well-perfused.
Troponins were elevated with ST depressions in V3-V5. She failed
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim and was started on steroids. She was volume
ressucitated with ~ 10 L of NS. A Central venous O2 sat was
17%. Given her likely NSTEMI she was felt to have a combined
distributive and cardiogenic shock picture. She was continued on
Levophed and Dobutamine was added to try to increase her cardiac
output. Echo showed global hypokenesis with markedly depressed
EF. Levophed was weaned of and dobutamine continued. A right IJ
central venous line was placed and swan floated. Initial swan
numbers on 4.3 mcg dobutamine showed PAP s/d 38/28, PCWP 23, CVP
21, and CO 1.95 by thermodilution. A lasix drip was started with
improved CO and decreased PCWP. Pt was continued on dobutamine
and levophed weaned off. She was also intubated at the OSH for
acidosis and respiratory failure. Her vent settings were weaned
to minimal support but intubation continued due to pressor
requirement and copious secretions. She was eventually weaned
off dobutamine and a repeat ECHO showed normal EF. Her SWAN
numbers were normal prior to d/c of SWAN. On transfer out of
[**Hospital Unit Name 153**], she was extubated and had stable vital signs. Pt
completed a 2 week course of Vanco/Zosyn prior to discharge, and
pt remained afebrile with normal WBC count during her stay. Pt
was discharged off Abx to f/u with her PCP.
.
#. NSTEMI - Likely due to demand related ischemia from septic
shock and hypotension since she has been febilre to 104. The
fever to 104 makes NSTEMI leading to pure cardiogenic shock less
likely. Given the thrombocytopenia and dropping HCT we held ASA.
We started beta blockers once she was off dobutamine. She does
not have a clear diagnosis of CAD; she should have a workup for
this as an outpt.
.
#. Mental Status - There was no evidence of hemorrhage on her
Head CT. She has multiple possible etiologies for encephalopathy
including cerebral hypoperfusion, hepatic encephalopathy,
sepsis, and alcohol withdrawal. No evidence of obvious weakness
on limited exam. CT showed no clear evidence of
ischemic/hemorrhagic etiology of MS change. After extubation,
she experienced some alcohol withdrawal manifest by
hyperautonomaticity and auditory hallucinations. She was
tapered off a Versed drip and transitioned to diazepam. She
persisted in psychosis and thought was given to the possibility
that she may have some psychiatric disorder at baseline. Psych
was consulted and was following along on transfer from [**Hospital Unit Name 153**].
She was treated with Haldol with good effect as per Psych recs.
The delirium resolved and the patient remained with mental
status changes that were unclear in etiology but suspected due
to ICU psychosis. An MRI was performed that was negative, and
patient was discharged with MS intact.
.
#)LFT abnormalities- Consistent with hepatitis which may be
chronic or acute, and could be due to chronic alcohol use, viral
hepatitis, iron overload, or poor perfusion. Repeat hepatitis
serologies here did not show evidence of Hep A, B, or C
infection. LFTs remained elevated. U/S showed echogenic findings
consistent with fatty liver vs cirrhosis. Outpatient f/u was
encouraged.
#. Alcohol abuse - See above.
- Thiamine, Folate, MVI, Vitamin K
.
#. Acute renal failure - Likely due to septic and cardiogenic
shock. There are no schistocytes on the smear which makes TTP
less likely. Continued hydration with IVFs and continued
treating her septic/cardiogenic shock. Resolved with hydration.
.
#)Coagulopathy - Initially looked like DIC with low PLTs, low
fibrinogen, and increased INR and PTT. Smear did not show any
schistocytes. Treated the underlying infection and also given
vitamin K. Some component of her coagulopathy is likely due to
thrombocytopenia from chronic alcohol abuse and from liver
synthetic function.
.
# Anemia: likely due to chronic ETOH abuse. VitB12 and Folate
were given. F/U was encouraged as an outpatient.
.
DISPO
- Full Code. Pt was discharged home in stable condition to f/u
with her PCP, [**Name10 (NameIs) **] psychiatry/addictions counseling.
Medications on Admission:
"high blood pressure pill"
"Fluid pill"
Forteo
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
NSTEMI
Septic/cardiogenic shock
Delirium
ETOH abuse
Thrombocytopenia now resolved
Anemia
Acute renal failure now resolved
Transaminitis
.....................
Discharge Condition:
stable, mental status improved, ambulating
Discharge Instructions:
PLease come back to the hospital or inform your primary care
providers if you have any chest pain, shortness of breath,
fevers, mental status changes or any other concerns.
.
Please take all medications as instructed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2144-4-16**] 1:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2144-4-10**]
|
[
"518.81",
"785.52",
"995.92",
"507.0",
"038.9",
"584.9",
"287.5",
"291.81",
"410.71",
"070.70",
"571.2",
"303.91",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9759, 9817
|
4753, 9256
|
371, 393
|
10018, 10062
|
2909, 3538
|
10328, 10613
|
2250, 2293
|
9354, 9736
|
9838, 9997
|
9282, 9331
|
10086, 10305
|
2308, 2890
|
242, 333
|
421, 1843
|
3547, 4730
|
1865, 1922
|
1938, 2234
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,172
| 129,086
|
8911
|
Discharge summary
|
report
|
Admission Date: [**2117-8-18**] Discharge Date: [**2117-8-25**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Chief Complaint: SOB and LE swelling
Reason for MICU transfer: hypotension
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
[**Age over 90 **]M presents with several days of increased DOE and fatigue
(started [**8-15**]). He lives alone is normally fully independent.
Daughter notes gradual and severe worsening in his symptoms. Pt
with severe aortic stenosis, s/p recent valvuloplasty. Pt denies
chest pain. Family and patient noted increased LE edema over
this time frame. Pt hasn't slept well. SOB worse with
exertion. Has had episodes like this before but never this bad.
No cough, confusion, dysuria, abdominal pain, change in bowel or
bladder habits. No recent weight gain. As per patient, he
weighs himself every day, and he actually lost pound and a half
in past day. He hasn't slept well recently due to SOB. Not on
O2 at home. No positional change in SOB. Pt denies fever,
change in speech, focal weakness, sick contacts. His legs have
never been this swollen before. He takes torsemide and has been
taking it regularly.
In the ED, 99.6 HR: 50 BP: 93/55 Resp: 28 O(2)Sat: 99.
Consulted cards, who did not think this was c/w cardiogenic
shock, based on patient being warm. ED thought cardiogenic
shock, but treated with fluids 300cc when patient had falling
SBPs, to as low as 73. They started RIJ and norepinephrine
pressor.
On arrival to the MICU, patient was mentating well, but did
report feeling SOB.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, 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:
Severe aortic stenosis - s/p BAV ([**2117-7-14**])
Diabetes mellitus
CAD s/p stenting RCA and LAD, last cath 4 yrs ago
Hypercholesterolemia
Hypertension
Senile purpura
right axillary vein thrombus
Colon cancer s/p colon resection and s/p splenectomy [**2083**]
Macular degeneration, left eye
Osteoarthritis
Mild Aortic stenosis (valve area 1.2-1.9)
Squamous Cell Carcinoma
Osteoarthritis
BPH
Abdominal Aortic Aneurysm
Right total knee replacement
Social History:
WWII vet. Retired newspaper printer. Remote history of smoking
20 pack years. No alcohol/drugs. His wife recently passed away.
He has two daughters, a son who is an ophthalmologist in CT.
Family History:
No family history of early MI, arrhythmia, cardiomyopathy, or
sudden cardiac death.
Physical Exam:
Admission Exam:
Vitals: T: 97.7 BP: 98/61 P: 93 R: 28 O2: 96% 5L NC
General: Alert, oriented, increased work of breathing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD, no LAD
CV: irregularly irregular, normal S1, single S2, no definitive
murmur appreciated
Lungs: B/L crackles from bases to mid lung fields, no wheezes or
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, 2+ pulses, no clubbing, 2+ edema present B/L to below
knees
Neuro: A+Ox3, CNII-XII intact
PHYSICAL EXAMINATION:
VS- T 97.2 , HR 113 in chart, ~90 on exam, RR 18, 97 RA. I/O
over past 8 h: 0/1375, over [**8-24**]: [**0-0-**]
GENERAL- WDWN elderly man sleeping in bed, easily rousable.
Oriented x3.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CARDIAC- 3/6 SEM in R and L USB. RR, no thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Pt
talking w/o effort, no pausing. CTAB. No wheezes/rhonchi.
ABDOMEN- Soft, NTND.
EXTREMITIES- trace edema in LE bilaterally. W/w/p, no c/c/e.
Pertinent Results:
[**2117-8-18**] 12:53PM PT-13.6* PTT-28.4 INR(PT)-1.3*
[**2117-8-18**] 12:53PM PLT SMR-NORMAL PLT COUNT-316
[**2117-8-18**] 12:53PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2117-8-18**] 12:53PM NEUTS-68 BANDS-0 LYMPHS-22 MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2117-8-18**] 12:53PM WBC-6.9 RBC-3.76* HGB-10.5* HCT-34.2* MCV-91
MCH-27.9 MCHC-30.6* RDW-18.6*
[**2117-8-18**] 12:53PM proBNP-[**Numeric Identifier 30976**]*
[**2117-8-18**] 12:53PM cTropnT-0.03*
[**2117-8-18**] 12:53PM estGFR-Using this
[**2117-8-18**] 12:53PM GLUCOSE-108* UREA N-29* CREAT-1.2 SODIUM-142
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16
[**2117-8-18**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2117-8-18**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2117-8-18**] 04:45PM URINE UHOLD-HOLD
[**2117-8-18**] 04:45PM URINE HOURS-RANDOM
[**2117-8-18**] 11:39PM PT-13.1* PTT-27.9 INR(PT)-1.2*
[**2117-8-18**] 11:39PM PLT SMR-NORMAL PLT COUNT-317
[**2117-8-18**] 11:39PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
TARGET-OCCASIONAL PENCIL-OCCASIONAL
[**2117-8-18**] 11:39PM NEUTS-68 BANDS-0 LYMPHS-20 MONOS-9 EOS-2
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2117-8-18**] 11:39PM WBC-7.5 RBC-3.71* HGB-10.5* HCT-34.2* MCV-92
MCH-28.3 MCHC-30.7* RDW-18.3*
[**2117-8-18**] 11:39PM URINE UHOLD-HOLD
[**2117-8-18**] 11:39PM URINE HOURS-RANDOM
[**2117-8-18**] 11:39PM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.1
[**2117-8-18**] 11:39PM cTropnT-0.04*
[**2117-8-18**] 11:39PM GLUCOSE-184* UREA N-25* CREAT-1.1 SODIUM-143
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-24 ANION GAP-17
[**2117-8-18**] 11:53PM LACTATE-1.4
.
CXR [**2117-8-18**]:
SINGLE AP VIEW OF THE CHEST:
Cardiomediastinal silhouette remains enlarged. New right lower
lobe opacity is concerning for pnuemonia. Additional hazy
bibasilar opacities obscuring the costophrenic angles are likely
again due to a combination of atelectasis as well as effusions.
Mild vascular congestion is present in both lungs. Osseous and
soft tissues are unremarkable.
IMPRESSION:
1) New right lower lobe opacity concerning for pneumonia.
2) Small effusions and mild congestion.
.
EKG [**2117-8-18**]: sinus arrhythmia, LAD/LVH, ST depression V5/V6,
new T-wave inversion V4/V5
ECHO: [**2117-8-20**]:
"The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated with severe global hypokinesis (LVEF = 20-25 %). No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal. with
moderate global free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Critical aortic valve stenosis. Left ventricular
cavity enlargement with severe global hypokinesis c/w diffuse
process. Right ventricular free wall hypokinesis. Mild aortic
regurgitation. Increased PCWP. Dilated aortic sinus.
Compared with the prior study (images reviewed) of [**2117-7-15**],
the gradient across the aortic valve is lower, but critical
aortic stenosis persists.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on [**2111**]
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
symptomatic (angina, syncope, CHF) and a surgical candidate,
surgical intervention has been shown to improve survival."
DISCHARGE LABS:
[**2117-8-25**] 05:35AM BLOOD WBC-7.3 RBC-3.60* Hgb-9.9* Hct-33.0*
MCV-92 MCH-27.6 MCHC-30.1* RDW-18.6* Plt Ct-289
[**2117-8-25**] 05:35AM BLOOD Glucose-113* UreaN-25* Creat-1.2 Na-140
K-4.1 Cl-102 HCO3-29 AnGap-13
[**2117-8-25**] 05:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
Brief Hospital Course:
[**Age over 90 **]M w/ extensive cardiac hx including CHF with EF~15% presented
with SOB and LE edema, found to be hypotensive and in mild acute
renal failure.
.
Acute Diagnoses
#Decompensated CHF / Hypotension: Required pressors in the ED,
though per Cardiology report, patient has very soft pressures at
baseline. His presentation is more c/w cardiogenic than septic
shock. Hypovolemic shock is unlikely given HCT is at baseline.
In the MICU, we initially continued the norepinephrine drip, and
we treated him with Lasix 20mg IV. He put out a L of fluid, and
his SOB improved. O2 by nasal cannula was used to maintain O2
sats over 90% and to decrease SOB. Troponins were essentially
normal. Patient was initially treated with vancomycin and
cefepime, but given his normal white count, his lack of fever,
the fact that the CXR finding could be increased vasculature
instead of PNA, and the fact that the hypotension was much more
likely to be due to CHF, we stopped treating for PNA and
discontinued the antibiotics. We were able to stop the
norepinephrine drip on [**2117-8-19**], and patient was transferred to
the cardiac floor.
.
On the cardiac floor, patient continued to show soft systolic
blood pressures to the mid-80s, but patient was judged to be
stable, as he continued to mentate well and put out adequate
urine. He was observed overnight without diuresis or fluids. By
morning his pressures had climbed the 100s, and he was feeling
much more energetic, with improved breathing. He was found to be
tachycardic to the 110s, asymptomatic. He was started on
metoprolol tartrate 12.5 [**Hospital1 **], and digoxin 0.125 mcg (no dig
loading per pharm, as med is being used for inotropic effect).
His heart rate fell to the 80s, with no drop in pressure; he
continued to feel well. Over the next days, metoprolol was
titrated upward to slow his rate and allow better filling; he
continued to feel well with blood pressures in the 100s. At 50
mg [**Hospital1 **] lopressor, however, pt experienced increased SOB with
signs of overload and a blood pressure drop back into the 80s,
although as before he tolerated this SBP with no signs of shock.
This prompted a trigger [**3-4**] marked nursing concern; pt received
IV lasix and his breathing and BP improved. Metoprolol succinate
12.5 daily was added when pt was well diuresed, and torsemide
was added back to his med regimen at a higher dose of 20 mg QD
(10 mg daily home dose prior to admission). He was sent home
with VNA services in good condition; the importance of limiting
salt intake and taking strict daily weights was emphasized.
.
#[**Doctor First Name 48**]: Likely due to cardiogenic shock/decompensated CHF. We
monitored the patient's creatinine. When the patient was
diuresed with Lasix, the creatinine improved. His creatinine
continued to remain within normal limits.
.
Chronic Diagnoses
#HTN: We held the patient's lisinopril and torsemide; torsemide
restored before discharge.
.
#DM: The patient's home glipizide and metformin were held, and
the patient was placed on insulin sliding scale.
.
# CHF/CAD/AS/HLD: Fluid status and acute cardiovascular issues
were managed as discussed above. Aspirin 81mg and simvastatin
20mg daily were continued.
Transitional issues:
Patient should follow up with his PCP to monitor his status on
his new medications.
Medications on Admission:
CEPHALEXIN - 500 mg Capsule - Take 4 capsules by mouth 30
minutes
prior to dental procedures or cleanings.
GLIPIZIDE - 5 mg Tablet - [**2-1**] Tablet(s) by mouth once a day dm
LISINOPRIL - (On Hold from [**2117-6-17**] to unknown for low bp) -
5
mg Tablet - [**2-1**] Tablet(s) by mouth once a day bp
METFORMIN - 850 mg Tablet - 1 Tablet(s) by mouth twice a day dm
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually as directed as needed for chest pain
POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - Mix 1 dose (17
grams) in drink and take DAILY as needed for constipation.
SIMVASTATIN - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
TORSEMIDE - 10 mg Tablet - 1 Tablet(s) by mouth once a day chf
Medications - OTC
ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other
Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s)
by
mouth once a day
SENNOSIDES-DOCUSATE SODIUM - 8.6 mg-50 mg Tablet - 2 Tablet(s)
by
mouth qam constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Torsemide 20 mg PO DAILY
RX *Demadex 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. GlipiZIDE 2.5 mg PO DAILY
5. MetFORMIN (Glucophage) 850 mg PO BID
6. Nitroglycerin SL 0.4 mg SL PRN Chest pain
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. sennosides-docusate sodium *NF* 8.6-50 mg Oral QAM
Constipation
9. Digoxin 0.125 mg PO DAILY
hold for hr < 60 sbp < 80
RX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Metoprolol Succinate XL 12.5 mg PO DAILY
Hold for BP < 80, HR < 50
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12448**] Home Care Agency, Inc.
Discharge Diagnosis:
Acute systolic Heart failure, Critical Aortic Stenosis
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:
It was a pleasure taking care of you during your stay here at
[**Hospital1 69**]. You were admitted for
shortness of [**Hospital1 1440**] and fatigue. You were found to have heart
failure, with a low blood pressure. You were treated with
diuretics (water pills), and your blood pressure improved. We
also started two new medications, metoprolol and digoxin, to
help control your heart rate and to encourage your heart to beat
more strongly. We also increased your torsemide (water pill).
You should follow up with your doctors to make sure you are
doing well on these medications. Also, you should weigh yourself
every morning, and call your PCP if your weight increases by
more than 3 lbs.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: THURSDAY [**2117-8-26**] at 9:10 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: MONDAY [**2117-8-30**] at 9:00 AM
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
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62**]
When: Dr. [**Last Name (STitle) 30977**] office is working on a follow up appointment
for you in [**5-9**] days after your hospital discharge. You will be
called at home with the appointment date and time. If you have
not heard from the office in 2 business days please call the
office number listed below.
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2117-8-26**]
|
[
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"428.0",
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"414.01",
"V15.82",
"V70.7",
"V12.51",
"V45.72",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
13436, 13593
|
8360, 11591
|
325, 350
|
13692, 13692
|
4076, 7776
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1706, 2124
|
227, 287
|
378, 1687
|
13707, 13851
|
2146, 2594
|
2610, 2800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,259
| 113,482
|
12610
|
Discharge summary
|
report
|
Admission Date: [**2188-8-21**] Discharge Date: [**2188-9-8**]
Date of Birth: [**2111-12-1**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Decadron
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Meningioma
Major Surgical or Invasive Procedure:
[**2188-8-20**]: Left Craniotomy for Meningioma with reconstruction
[**2188-8-31**]: G-tube placement
History of Present Illness:
76-year-old male with history of recurrent meningioma s/p
bifrontal craniotomy with cranioplasty and bone flap [**2188-8-21**],
transferred from TICU for further management of post-operative
atrial fibrillation. Patient has baseline sinus bradycardia and
underwent ablation after presentation with tachyarrythmia on
[**2188-7-16**]. Patient unable to give history.
Past Medical History:
1. Atypical Reccurent Right Frontal Meningioma: Symptoms began
in [**2180-6-22**] per [**First Name8 (NamePattern2) 38984**] [**Last Name (NamePattern1) **] "when he became forgetful and
sluggish. Initially he was treated for depression. A head MRI
showed a large dura-based mass in the right frontal brain. A
resection was done by [**Name6 (MD) 1528**] Cares, MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital1 38994**]. Pathology was atypical meningioma. He did well until
[**10-22**] when the mass recurred. He had a second resection on
[**2182-1-9**] by Dr. [**Last Name (STitle) 38985**]. This was followed with involved-field
cranial irradiation by [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 38986**], MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital1 **]
from [**Month (only) **] to [**2182-3-22**] to 5760 cGy. A follow up MRI on [**2183-6-26**]
showed a 0.5-mm dural based nodular enhancement and he was
referred here for SRS. Surveillance MRI on [**2184-12-8**] revealed
growth of the meningioma in the superior margin of the surgical
cavity invading the skull. He underwent craniectomy on [**2185-1-26**]
by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 38987**]. There had been invasion
into the inner and outer tables of the skull. A piece of Duagen
dural substitute was placed over the dural defect and then
Methyl Methacrylate cranioplasty was placed over the skull
defect. Pathology revealed atypical meningioma." Underwent
cyberknife therapy in [**2-27**]. He has been maintained on temodar
(chemo) 25mg/m2.
2. Atrial fibrillation: Known to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and followed
by Dr. [**Last Name (STitle) 16958**].
3. GERD
4. OA of knee
5. Hypothyroid
Social History:
Married with two children. Used to smoke a pack a day but quit
in [**2151**]. Used to drink beer but stopped when he was put on
Coumadin. Mother died at 80 from stroke. Father died at 60's,
unclear cause. Bother died 60 from lung cancer.
Family History:
Non-contributory
Physical Exam:
Gen: elderly male in NAD. Oriented x 1. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CV: Regular rate, normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. Poor air
flow bases bilateral. No wheezes or crackles.
Abd: Soft, NTND. PEG tube inplace. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars.
Pertinent Results:
[**2188-8-22**] Echocardiogram: The left atrium is mildly dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Overall left ventricular
systolic function is normal (LVEF 60%). The right ventricular
cavity is dilated with depressed free wall contractility. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is a small pericardial effusion. There is an
anterior space which most likely represents a fat pad. There are
no echocardiographic signs of tamponade.
.
Compared with the findings of the prior study (images reviewed)
of [**2188-7-15**], the findings are similar.
.
Head CT [**2188-8-31**]: Multifocal intraparenchymal hemorrhage
centered within the right frontal lobe with surrounding edema is
relatively unchanged when compared to prior exam. A small amount
of extra-axial hemorrhage along the right frontal craniotomy is
stable in appearance as well. Areas of pneumocephalus near the
right frontal craniotomy mesh is persistent. There is no shift
of normally midline structures. The ventricle configuration is
unchanged. Hypodensity in the periventricular and subcortical
white matter reflects chronic microvascular and vascular
ischemic changes. Secretions in the right frontal sinus is
unchanged.
.
MRI [**2188-8-22**]: Status post interval resection of right frontal
scalp mass and the contiguous extra-axial enhancing lesions.
There is stable enhancing heterogeneous tissue in the inferior
right frontal lobe. There are findings suggestive of ischemia in
the right frontal lobe which is new compared to the prior study
of [**2188-8-21**]. There is a new mesh cranioplasty in the right
frontal region.
.
Labs on Admission:
[**2188-8-21**] 11:30AM BLOOD WBC-2.5* RBC-3.39* Hgb-11.0* Hct-29.7*
MCV-87 MCH-32.5* MCHC-37.1* RDW-14.1 Plt Ct-202
[**2188-8-21**] 08:20AM BLOOD PT-23.0* PTT-33.7 INR(PT)-2.2*
[**2188-8-21**] 05:45PM BLOOD Glucose-196* UreaN-15 Creat-1.2 Na-142
K-3.9 Cl-105 HCO3-26 AnGap-15
[**2188-8-21**] 05:45PM BLOOD Calcium-10.0 Phos-3.3 Mg-2.5
.
Labs on Discharge:
Brief Hospital Course:
Patient was electively admitted on [**8-21**] for a planned surgical
resection and esthetic reconstruction of his left cranium for
recurrent meningioma. On admission, his coagulation studies
were elevated, requiring the use of FFP infusion and vitamin K
infusion to correct prior to surgery. This was done
uneventfully, and surgery proceded. Intraoperatively, he had
several episodes of atrial fibrillation with rapid ventricular
response, which was refractory to cardioversion. He also
underwent an intraoperative TEE for further interrogation of
this process. Post-operatively, he was admitted to the ICU for
this reason, and cardiology consulted for control of his atrial
fibrillation he was started on an Amiodarone drip and Diltiazem
drips which eventually converted him. He remained abulic,
followed commands inconsistently and answered in one word
answers.
.
# Atrial Fibrillation: On [**8-27**] he was transferred to the step
down unit. On [**8-27**]: Back into afib on Esmolol. On [**8-29**]: amio 200
[**Hospital1 **], LFTs wnl; back in afib. Lopressor 37.5mg PO BID. On [**2188-8-29**],
patient was transferred from trauma SICU to medicine cardiology
service. On arrival, he was in atrial fibrillation with RVR. Per
cardiology recs, he was given acebutolol 200mg via the NG tube.
Overnight, patient pulled out his NG tube. Given that he had
failed swallow studies twice in the previous week, he was not
able to take any medications by mouth. Plan was to give patient
IV beta-blockers as needed until a PEG tube was placed. On the
morning of [**2188-8-30**], patient was given metoprolol IV 5mg x1 for
atrial flutter with heart rate in 130s. Patient converted back
to sinus rhythm. On [**2188-9-1**] patient re-entered A Fib with RVR.
Patient was started on Acebutolol, Amiodarone 100mg qd and
digoxin 0.125mg. Metoprolol was not started as patient become
bradycardiac last time he converted. However, patient did not
convert with Acebutolol titrated up to 400mg [**Hospital1 **] consequently we
started Metoprolol. Patient converted on [**2188-9-6**] when titrated
to Metoprolol 100mg [**Hospital1 **]. No significant pauses or brady on
conversion. Patient recently had ablation in [**6-29**]. Pacemaker
placement not an ideal option as patient will require multiple
MRI for meningioma resection follow-up.
- Discharge on the following medications for rate control:
Metroprolol 75mg po BID, Amiodarone 100mg po qd, Digoxin
0.125mcg po every other day.
- Started Aspirin 81 mg, Neurosurgery stated this was ok.
**** Per neurosurgery, need to wait 1 month before
anticoagulation can be started due to recent craniotomy. Patient
is a candidate for anti-coagulation, was in A Fib with AVR
during hospitliazation. In 1 month need to discuss with
Neurosurgery and Cardiology re-starting anti-coagulation ****
.
# s/p frontal craniotomy: Of note, on [**2188-8-30**] plastic surgery
noted fluid build up at the incision site on frontal region.
Fluid was cultured and final report was no growth. Patient
received vancomycin for a 5 day course given that infection to
that area could be devastating. Kept head of bed elevated.
Continued Keppra for seizure prophylaxis. Patient has follow-up
appointments with Neurosurgery and Plastic surgery (will be
removing sutures).
.
# FEN: Patient has failed swallow study twice. Patient pulled
out NG tube night of [**2188-8-29**]. G tube placed [**2188-8-31**]. On tube
feeds with banana flakes secondary to bowel incontinence.
- Diet order per nutrition in page 1
- discontinue banana flakes if patient becomes constipated
- peg site needs to changed daily with dry dressing
.
# Hypothyroidism: Repeat TSH 1.3, however free T4 remained
elevated at 1.9. Decreased Levothyroxine from 50mcg to 37.5 mcg.
- Recheck TSH and free T4 in 1 month
.
# Hematuria: Urine culture negative. Repeat Ua no RBC. Hematuria
most likely secondary to trauma from patient pulling at foley.
Condom cath did not work, patient currently incontinent.
Discharge on foley. When patient becomes more oriented can d/c
foley
- recheck Ua for hematuria in [**1-23**] months
.
# DM: Morning NPH units increased to 14 from 12 as blood sugars
slightly elevated.Can adjust sliding scale at rehab as
appropriate.
.
#. Hypertension: Well-controlled throughout admission. Continued
lisinopril 10mg PO daily, for rate control patient on Metoprolol
75 mg [**Hospital1 **] with hold parameters.
.
# Code Status: Full, confirmed with wife
Medications on Admission:
1. Amiodorone (200 mg daily)
2. Coumadin [Warfarin] (stopped [**2188-8-17**])
3. Levoxyl (50mcg daily)
4. Lisinopril [Prinivil, Zestril] (10 mg daily)
5. Metoprolol succinate [Toprol XL] (25 mg daily)
6. Neurontin (Gabapentin)(400 mg [**Hospital1 **])
7. Sanctura 20 mg [**Hospital1 **])
8. Pepcid (Famotidine)(20 mg daily)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
Meningioma
Atrial fibrillation with RVR
.
Secondary Diagnosis:
Hypothyroidism
Diabetes
GERD
Discharge Condition:
Vitals stable, sinus rythm.
Discharge Instructions:
You were admitted on [**2188-8-21**] for removal of a meningioma. During
the hospital course you were transferred to the cardiology
service for further management of a fast heart rhythm. You
eventually converted to sinus rythym.
.
We have made changes to your medications please take them as
directed.
.
Please attend your follow-up appointments as listed:
1) You have an appointment with Plastic Surgery Clinic on
[**2188-9-12**] 01:30p [**Hospital6 29**], [**Location (un) **]. They will be
removing your sutures.
2) You have an appointment with Radiology on [**2188-10-7**] 08:30a XCT
[**Apartment Address(1) 9394**] [**Hospital Ward Name **] CC CLINICAL CENTER, [**Location (un) **] RADIOLOGY to
have a CT head. Immediately following you have an appointment
with Neurosurgery on [**2188-10-7**] 9:30 am with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]
M. LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST. You will not
need an MRI of the brain, as this was done during your hospital
stay. If you have any questions there number is [**Telephone/Fax (1) 1669**].
3) Follow-up with your Cardiologist, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on
[**10-16**] at 10:20am. His office is at [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY
4) Follow with primary care doctor Mr. [**Name13 (STitle) **] in [**2-25**] weeks.
Have [**Hospital **] rehab call [**Telephone/Fax (1) 38995**] to make an appointment.
.
Call your primary care doctor or go to the ER if you experience
rapid heart rate, feeling dizzy, pass out, chest pain, shortness
of breath or any other symptoms.
.
The following discharge Instructions have been provided by
Neurosurgery regarding your surgery:
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc.
- If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
- Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
- New onset of tremors or seizures.
- Any confusion or change in mental status.
- Any numbness, tingling, weakness in your extremities.
- Pain or headache that is continually increasing, or not
relieved by pain medication.
- Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
- Fever greater than or equal to 101?????? F.
Followup Instructions:
1) You have an appointment with Plastic Surgery Clinic on [**8-23**] 1:30pm at [**Hospital Ward Name 23**] Building [**Location (un) 470**]. They will be removing
your sutures.
.
2) You have an appointment with Radiology on [**2188-10-7**] 08:30a XCT
[**Apartment Address(1) 9394**] [**Hospital Ward Name **] CC CLINICAL CENTER, [**Location (un) **] RADIOLOGY to
have a CT head. Immediately following you have an appointment
with Neurosurgery on [**2188-10-7**] 9:30 am with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]
M. LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST. You will not
need an MRI of the brain, as this was done during your hospital
stay. If you have any questions there number is [**Telephone/Fax (1) 1669**].
.
3) Follow-up with your Cardiologist, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on
[**10-16**] at 10:20am. His office is at [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY
.
4) Follow with primary care doctor Mr. [**Name13 (STitle) **] in [**2-25**] weeks.
Have rehab call [**Telephone/Fax (1) 38995**] to make an appointment.
Completed by:[**2188-9-8**]
|
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icd9cm
|
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[
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icd9pcs
|
[
[
[]
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|
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|
291, 394
|
10856, 10886
|
3458, 5407
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|
2932, 2950
|
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10274, 10599
|
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241, 253
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5780, 5780
|
422, 788
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10804, 10835
|
10741, 10783
|
5421, 5759
|
810, 2661
|
2677, 2916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,568
| 198,677
|
54212
|
Discharge summary
|
report
|
Admission Date: [**2114-10-15**] Discharge Date: [**2114-11-10**]
Date of Birth: [**2047-6-23**] Sex: F
Service: MEDICINE
Allergies:
Influenza Virus Vaccine / Shellfish Derived / Egg / adhesive
bandage / Heparinoids
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
"JP drains falling out"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 67 yo F with MMP including CAD s/p CABG in [**3-/2113**] with
subsequent chronic sternal wound infection with multiple highly
resistant organisms and a recent admission for fever who now
re-presents from rehab because one of her two JP drains was
accidentally pulled out and the other partially displaced at
rehab. Rehab facility noted displaced JP drains on morning
rounds and patient sent to ED.
In the ED, initial VS were T 99.3 H 140 BP 110/60 RR 20 O2 Sat
100% on RA. Pt then developed a rectal temp of 102.2. Labs
showed elev WBC, low K and low Mg. Lactate was 2.3, but no anion
gap. UA was indicative of infection, urine cx was sent and is
pending. Pt received IVF with K in ED as well as some Mg. Pt was
on Daptomycin and Colistin for FUO from recent hospital stay. Pt
received COlistin in ED, but not the Daptomycin. Pt was
evaluated by Plastic Surgery in the ED who thought there were no
signs of wound infection and pt does not need JP drain
replacement at this time. CXR preliminarily did not show any
consolidation. CT head showed no bleed, just a known mass with
no surrounding edema. Pt also got Tylenol in ED for fever. Pt's
HR improved to 100s after fluids. BP hsa been stable throughout.
RR in 20-24 range, satting high 90s on 2L NC. Urine and [**Year (4 digits) **] cx
have been sent. On trasnfer, VS were T 99.6 HR 110 BP 128/70
RR 26 O2 100% on 2L NC.
On the floor, pt appears chronically ill, unable to answer more
than "yes and no" questions. Pt denies any pain. Denies
shortness of breath, cough.
Past Medical History:
- Diabetes
- Hypertension
- CAD s/p prior RCA stenting c/b ISR x 2, Cypher stenting in
[**2106**] for NSTEMI, s/p CABG x 2 with LIMA-LAD, SVG-PDA [**3-/2113**]
- MVR [**3-/2113**]: 25 mm [**Company 1543**] mosaic porcine valve
- Non sustained polymorphic VT s/p [**Company 1543**] ICD placement [**2-24**]
- Chronic sternal wound infection since [**4-1**] with multiple
highly resistant organisms
- VTE on warfarin
- HIT (Heparin-induced thrombocytopenia)
- Mengingioma, formerly on chronic steroids
- Osteopenia/porosis
- s/p TAH-BSO
- h/o C diff
- depression
- anxiety
- hypercholesterolemia
- H/o large post cath RP hematoma, [**2105**]
- Gastroesophageal reflux disease
- History of pulmonary nodules, followed by serial imaging
- History of H. pylori
- History of GI bleed in the setting of anticoagulation
Social History:
Currently at [**Hospital 1459**] Nursing and Rehab. She has a brother and
sister who are her supports and she plans to live with her
brother when discharged from rehab. Past smoker (30 pk yr), no
EtOH or drugs. Currently in a wheelchair at baseline.
Family History:
Father died at age 50 of an MI and "enlarged heart." Brother
with drug abuse. Mother had depression and panic attacks, DM.
Physical Exam:
Admission Physical Exam:
Vitals: T: 95.3 BP: 114/64 P: 104 R: 16 O2: 100% on 2L NC
General: appears comforable, alert but oriented to only person,
answers only "yes or no" questions
HEENT: sclera anicteric, PERRL, dry mucous membranes
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation anteriorly
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, PICC in RUE w/o surrounding erythema or ttp, JP sites in
R axilla and anterior chest wall c/d/i
Discharge:
VS: T: 96.6, P: 76, BP: 140/70, RR: 22, 96% on RA
GEN: thin, chronically-ill appearing woman in NAD. AAOx person,
[**Location (un) **], hospital, month not year
HEENT: MMM, no JVD
CV: reg rhyrhm & rate, no m/r/g
Chest: wound over right lateral chest- bandaged; anterior chest
wound- clean dry intact
PULM: CTAB on anterior lungs
EXT: LE in waffle boots, no edema
Pertinent Results:
Hematology:
[**2114-10-31**] 03:06AM [**Month/Day/Year 3143**] WBC-6.0 RBC-3.31* Hgb-10.0* Hct-30.2*
MCV-91 MCH-30.2 MCHC-33.0 RDW-17.4* Plt Ct-204
[**2114-10-15**] 01:48PM [**Month/Day/Year 3143**] WBC-11.3* RBC-3.87* Hgb-11.7* Hct-34.1*
MCV-88 MCH-30.1 MCHC-34.2 RDW-16.8* Plt Ct-302
[**2114-10-31**] 03:06AM [**Month/Day/Year 3143**] PT-23.6* PTT-59.9* INR(PT)-2.2*
[**2114-10-15**] 01:48PM [**Month/Day/Year 3143**] PT-29.0* PTT-37.0* INR(PT)-2.9*
Chemistries:
[**2114-10-31**] 03:06AM [**Month/Day/Year 3143**] Glucose-97 UreaN-21* Creat-0.6 Na-141
K-4.5 Cl-110* HCO3-26 AnGap-10
[**2114-10-15**] 01:48PM [**Month/Day/Year 3143**] Glucose-100 UreaN-9 Creat-0.7 Na-145
K-2.6* Cl-103 HCO3-29 AnGap-16
[**2114-10-31**] 03:06AM [**Month/Day/Year 3143**] ALT-13 AST-27 LD(LDH)-204 CK(CPK)-60
AlkPhos-70 TotBili-0.2
[**2114-10-16**] 05:36AM [**Month/Day/Year 3143**] ALT-13 AST-27 CK(CPK)-110 AlkPhos-67
TotBili-0.3
[**2114-10-31**] 03:06AM [**Month/Day/Year 3143**] Albumin-2.0* Calcium-8.7 Phos-3.7 Mg-2.0
Micro:
[**2114-10-30**] URINE URINE CULTURE-FINAL {KLEBSIELLA
PNEUMONIAE, PROTEUS MIRABILIS}
[**2114-10-24**] [**2114-10-24**] ABSCESS GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY {PROTEUS MIRABILIS}; ANAEROBIC CULTURE-FINAL
[**2114-10-15**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-FINAL
{ENTEROCOCCUS FAECALIS, STAPHYLOCOCCUS, COAGULASE NEGATIVE};
Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram
Stain-FINAL
[**2114-10-30**]:
Chest X-ray:
FINDINGS: As compared to the previous radiograph, the technique
of the image is improved. Borderline size of the cardiac
silhouette. No pulmonary edema. No focal parenchymal opacity
except for a small retrocardiac atelectasis. No pleural
effusions. Left pectoral pacemaker and right PICC line in
unchanged position.
Brief Hospital Course:
Patient is a chronically ill 67 yo female with CAD s/p CABG
complicated by sternal wound infection, diastolic CHF admitted
after JP drains fell out, found to have fever to 102 in ED and
BCx + for enteroccocus and Coag neg staph, hospital course
complicated by hypotension and pulmonary edema requiring MICU
transfers with goals of care now focusing on comfort.
# History of PE: The pt was intially on coumadin but noted to
refuse, pocket or spit out many po meds daily. Once admitted to
MICU the pt was started on argatroban (due to history of HIT)
for bridging to a therapeutic INR. She had a CTA that was
negative for PE. Her coumadin was stopped per goals of care.
# Bacteremia: [**Month/Day/Year **] cultures grew enterococcus faecalis and coag
neg staphyloccus both sensitiv to daptomycin. She was afebrile
without leukocytosis. TTE did not show valve vegatations. She
was continued on colistin/dapto until [**2114-10-31**] when all
antibiotics were stopped per goals of care without plan to .
# Normocytic Anemia: Iron studies consistent with anemia of
chronic disease. HCT dropped with daily survillience [**Month/Day/Year **]
cultures and improved when [**Month/Day/Year **] draws were limited.
# Chronic sternal wound infection: Sternal wound is clean, dry,
intact. She was seen and evaluated by plastics and there was no
need to replace drains at this time. She was continued on
dapto/colistin until [**2114-10-31**]. Her wounds were dressed per wound
care recommendations.
# Diabetes II: FS at goal, she did not require insulin and
insulin sliding scale was stopped.
# Afib/NSVT: HR regular. has ICD. Metoprolol XL 200 mg po was
decreased to 25 mg po BID.
# Chronic diastolic heart failure: Stable on discharge. On [**10-23**]
the pt was noted to be tachypneic, tachycardic, and requiring
increasing amts of supplemental oxygen. The pt required NRB O2,
and was transferred to the MICU. Her respiratory status improved
with lasix, and in the ICU the pt was diuresed gently. She was
not restarted on an ACE inhibitor as she was hypotensive for
much of her admission. She was discharged on furosemide 20 mg po
QOD.
# [**Month/Year (2) **] pressure: Patient was hypotensive for much of her
admission, thought secondary to poor po intake and hypovolemia.
Her metoprolol and furosemide were decreased on discharge.
# Depression/Anxiety: Continued on citalopram.
#Nutrition: dysphagia diet with assistance for meals.
# Mental Status: Patient is AAOx person and place. She has
baseline low cognitive function likely secondary to chronic
illness, frontal menigioma, depression, possible dementia.
#GOALS of CARE: Family meeting was held with [**Name (NI) 17766**] (son) and
[**Name (NI) **] (sister) on [**2114-10-31**] with family in the presence of the
patient. Given patient's decline in functional status without
evidence of improvement on aggressive medical care over the last
several months, decision was made by the family to transition
goals of care to comfort based care.
# Code Status: DNR/DNI (confirmed with son [**Name (NI) 17766**], HCP)
Medications on Admission:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP < 100.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aripiprazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO BID (2 times a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day). Capsule(s)
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. colistimethate sodium 150 mg Recon Soln Sig: 75 mg Recon
Solns Injection Q12H (every 12 hours): Last Day [**2114-11-10**].
14. daptomycin 500 mg Recon Soln Sig: 300 mg Recon Solns
Intravenous Q24H (every 24 hours): Last Day [**2114-11-10**].
15. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day: hold for K > 5.0.
17. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
please hold your coumadin dose until [**10-14**] and have your INR
rechecked.
18. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. acetic acid 0.25 % Solution Sig: One (1) Appl Irrigation [**Hospital1 **]
(2 times a day) as needed for w-d dressing for right posterior
wound.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
9. bacitracin 500 unit/g Ointment Sig: One (1) Topical once a
day: as needed for wound care.
10. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary: Bacteremia
Secondary: Coronary Artery Disease, Chronic Sternal Wound
Infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with fevers and bacteria in
your [**Location (un) **]. You were given intravenous antibiotics. You had
several complications during your hospitalization, including low
[**Location (un) **] pressure and pulmonary edema (water on the lungs).
We had a meeting with you and your family to discuss your goals
of care. It was decided that the goals of care should be focused
on your comfort.
The following changes were made to your medications:
-Decreased lasix from 20 mg once a day to 20 mg every other day
-Decreased metoprolol from 200 mg once a day to 25 mg twice a
day
-STOPPED: daptomycin, colistin, coumadin, simvastatin, aspirin,
aripiprazole, divalproex, calcium carbonate, lorazepam
Followup Instructions:
Hospice care
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,487
| 169,196
|
51046
|
Discharge summary
|
report
|
Admission Date: [**2145-4-10**] Discharge Date: [**2145-4-15**]
Service: MEDICINE
Allergies:
Aspirin / Tamiflu
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory Distress, Fever
Major Surgical or Invasive Procedure:
ICU care
Mechanical Ventilation
History of Present Illness:
[**Age over 90 **] yo M with PMH of severe depression, dementia, CAD s/p CABG
3VD, who presents with hypoxia, hypotension, and fever from
rehabilitation facility. Per OMR notes: [**2145-4-5**] the NH noted
confusion and congestion/rhinitis. On [**2145-4-8**] shaking chills adn
temp 101.8 Tamiflu is mentioned in NH nursing note as given on
[**4-8**] (not clear if this was the first day).
On [**4-9**] in 7am nursing note "whole body rash" and itching are
noted, and are postulated to be "reaction to Tamiflu." Tamiflu
was apparently d/c'd. Per notes, he had a LLL infiltrate
identified on CXR on [**4-9**], and was started on levofloxacin on
[**2145-4-9**] around 11pm or midnight on [**4-10**]. He received IVF as
well. It seems as though he developed respiratory distress in
the early morning with oxygen saturation down to 86-90% on 8L
NC. The rash was apparently ongoing at this time. The time
course is difficult to interpret from the notes. He was given
benadryl for the rash. He then developed labored breathing,
reportedly new confusion and BP 90/60, P 100s, T 102.8. He was
then brought to the ED by EMS.
.
In the ED, his vitals were: 101.6 (104 rectal), 80/36, 120, 38,
83% on RA. He was intubated and given fentanyl/versed for
sedation. Given IVF for sepsis given BP in the 70s. Received
zosyn/vanc/azithro. Solumedrol given for hives and 1g tylenol.
Central line placed and levophed started for hypotension. Sepsis
protocol initiated. He was admitted to the ICU for further care.
Past Medical History:
Dementia - sees Dr. [**Last Name (STitle) **] for Alzheimer's Dz vs vasc dementia
Depression with several hospitalizations
S/p MVA [**2142**] with L fibula fx
CAD s/p CABG x 3v in [**2139**]
high chol
orthostatic hypotension
ARF in [**8-31**] that had p/w slurred speech and change in mental
status
thrombocytopenia (periodically on RhoGam)
hearing loss
BPH
Social History:
The patient was born and raised in [**Location (un) 686**].
He has 4 siblings.
His father owned a bakery in the [**Hospital3 **].
The patient graduated high school and served in the military in
WW2 in [**Country **], [**Country **], and [**Country **].
He returned to the U.S. and worked in jobs at the housing
authority and managing properties. After retirement, he
volunteered at a half way house for the mentally ill.
He is married for 50 years.
He lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in [**Location (un) 745**] with his wife.
He has a son who has 2 children. He also has a daughter with MS.
Family History:
Denies
Physical Exam:
T: 98.6 BP: 127/64 P: 105 RR: 29 O2 sats: 96% on vent
VENT: AC 400x12, PEEP 5, FiO2 80%
Gen: Intubated, sedated.
HEENT: PERRL, anicteric, MM sl dry.
Neck: RIJ in place.
CV: RRR, no m/r/g
Resp: Diffuse rhonchi b/l
Abd: +BS, soft, NT/ND
Ext: Warm, no edema.
Neuro: Opens eyes to name. Follows simple commands. Moving all
extremities.
Pertinent Results:
[**2145-4-10**] 04:45AM BLOOD WBC-1.6*# RBC-4.55*# Hgb-14.5# Hct-43.6#
MCV-96 MCH-31.9 MCHC-33.3 RDW-13.4 Plt Ct-56*
[**2145-4-10**] 01:06PM BLOOD WBC-1.9* RBC-4.10* Hgb-13.2* Hct-40.0
MCV-98 MCH-32.3* MCHC-33.0 RDW-13.6 Plt Ct-63*
[**2145-4-11**] 02:17AM BLOOD WBC-3.5*# RBC-4.20* Hgb-13.6* Hct-41.2
MCV-98 MCH-32.4* MCHC-33.1 RDW-13.8 Plt Ct-51*
[**2145-4-15**] 02:31AM BLOOD WBC-22.3* RBC-3.14* Hgb-10.0* Hct-30.1*
MCV-96 MCH-31.8 MCHC-33.2 RDW-14.6 Plt Ct-102*#
[**2145-4-10**] 04:45AM BLOOD Neuts-14* Bands-22* Lymphs-36 Monos-15*
Eos-0 Baso-0 Atyps-10* Metas-3* Myelos-0
[**2145-4-10**] 01:06PM BLOOD Neuts-36* Bands-27* Lymphs-10* Monos-8
Eos-0 Baso-1 Atyps-0 Metas-17* Myelos-1*
[**2145-4-10**] 04:45AM BLOOD PT-13.8* PTT-32.0 INR(PT)-1.2*
[**2145-4-10**] 04:45AM BLOOD Plt Smr-VERY LOW Plt Ct-56*
[**2145-4-15**] 02:31AM BLOOD PT-12.8 PTT-21.8* INR(PT)-1.1
[**2145-4-13**] 03:19AM BLOOD Gran Ct-[**Numeric Identifier **]
[**2145-4-10**] 04:45AM BLOOD Glucose-95 UreaN-37* Creat-1.6* Na-139
K-4.0 Cl-103 HCO3-25 AnGap-15
[**2145-4-10**] 01:06PM BLOOD Glucose-107* UreaN-30* Creat-1.2 Na-140
K-3.7 Cl-112* HCO3-19* AnGap-13
[**2145-4-11**] 02:17AM BLOOD Glucose-118* UreaN-31* Creat-1.4* Na-140
K-4.5 Cl-112* HCO3-17* AnGap-16
[**2145-4-14**] 03:16AM BLOOD Glucose-151* UreaN-36* Creat-0.9 Na-142
K-4.4 Cl-113* HCO3-21* AnGap-12
[**2145-4-15**] 02:31AM BLOOD Glucose-188* UreaN-43* Creat-1.0 Na-140
K-4.9 Cl-111* HCO3-21* AnGap-13
[**2145-4-10**] 04:45AM BLOOD ALT-24 AST-83* CK(CPK)-1241* AlkPhos-27*
TotBili-0.6
[**2145-4-10**] 08:45AM BLOOD ALT-18 AST-65* AlkPhos-17* TotBili-0.5
[**2145-4-10**] 04:45AM BLOOD CK-MB-7 cTropnT-<0.01
[**2145-4-10**] 01:06PM BLOOD CK-MB-7 cTropnT-0.01
[**2145-4-10**] 04:45AM BLOOD Cortsol-119.0*
[**2145-4-10**] 08:45AM BLOOD Cortsol-172.6*
[**2145-4-10**] 02:34PM BLOOD freeCa-1.02*
[**2145-4-10**] 05:37PM BLOOD freeCa-1.06*
[**2145-4-10**] 08:50PM BLOOD freeCa-1.09*
[**2145-4-10**] 05:15AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2145-4-14**] 10:40AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2145-4-10**] 05:15AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2145-4-14**] 10:40AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2145-4-10**] 5:45 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
VANCOMYCIN Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 2 S
GRAM STAIN (Final [**2145-4-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2145-4-12**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Brief Hospital Course:
SEPSIS CAUSED BY
METHICILLIN-RESISTANT STAPH. AUREUS PNEUMONIA AND BACTEREMIA
The patient was transferred from nursing home with fever, and
was found to be in septic shock. He was treated as a "Code
Sepsis" and a CVL was inserted and CVP transduced. He was fluid
bolused to maintain adequate CVP 8-12. Levophed was started in
the ED, maintaining MAP >65. CXR was consistent with multifocal
pneumonia, and he was started on vancomycin/zosyn/azithromycin.
This was later narrowed to vancomycin when blood and sputum
cultures grew out MRSA. Transthoracic echocardiogram showed no
evidence of endocarditis.
RESPIRATORY FAILURE
The patient was intubated and ventilated for multifocal
pneumonia.
URTICARIA
The patient had hives in the ED, and this was possibly related
to tamiflu or levofloxacin. Both were quickly discontinued, and
benadryl was given. The hives abated, but later returned without
context of new medicine, eventually fading again with benadryl.
ACUTE RENAL FAILURE
The patient had an elevated creatinine on admission in setting
of sepsis, and this improved with fluid resussitation.
LEUKOPENIA
The patient was initially leukopenic with sepsis on admission,
but elevated as the hospital course continued.
GOALS OF CARE
The patient was DNR, but on [**2145-4-15**], due to the lack of
progress, and the clearly previously expressed wishes of the
patient, the family agreed to focus care on comfort. The
patient was extubated, and died quietly in the presence of his
family.
Medications on Admission:
levofloxacin 250mg started [**4-9**]
donepezil 10mg daily
trazodone 25mg qhs
cholecalciferol 1000units daily
calcium carbonate 650mg [**Hospital1 **]
senna 2 tabs daily
tylenol 650mg q4 prn
fluticasone NS
venlafaxine 75mg daily
benadryl 25mg q6hr prn started [**4-9**]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY
MRSA Pneumonia
Septic Shock, Severe
Acute Renal Failure
SECONDARY
Chronic Kidney Disease
Dementia
Immune Medicated Thrombocytopenia
Coronary Artery Disease
Discharge Condition:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"600.00",
"311",
"482.41",
"995.92",
"518.81",
"496",
"294.8",
"287.31",
"585.9",
"785.52",
"038.11",
"584.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8986, 8995
|
7148, 8637
|
253, 286
|
9203, 9339
|
3240, 5600
|
2864, 2872
|
8957, 8963
|
9016, 9182
|
8663, 8934
|
2887, 3221
|
5644, 7125
|
186, 215
|
314, 1811
|
1833, 2193
|
2209, 2848
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,531
| 157,022
|
24135
|
Discharge summary
|
report
|
Admission Date: [**2192-5-23**] Discharge Date: [**2192-6-25**]
Date of Birth: [**2128-7-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
proximal tracheal stenosis- shortness of breath w/
rehabilitation s/p cardiac surgery
Major Surgical or Invasive Procedure:
1. Bronchoscopy.
2. Transcervical tracheal resection and primary
reconstruction.
History of Present Illness:
Ms. [**Known lastname **] is a 63 year old
Portuguese woman diabetic, who had a long, complicated
postoperative course after coronary bypass grafting. She was
intubated for greater than 5 weeks and after eventual
extubation and a long rehab course, was found to have
proximal tracheal stenosis, which is limiting her recovery.
She has an approximately 4 to 5 mm airway that also
completely collapses with associated malacia. This was over a
2 to 3 cm length and therefore a primary resection and
reconstruction was recommended, to which the patient consented.
Past Medical History:
tracheal stenosis
prolonged intubation (5-6 weeks) after
CABG X 3 performed at OSH in 12/[**2190**].
Balloon dilitation of the proximal trachea with excision of
granulation tissue on anterior tracheal wall,
IDDM, CAD, MI, PNA [**2189**]
Social History:
son and daughter live in [**Name (NI) 5503**] area. Very supportive
family
Physical Exam:
General- Awake alert female lying in bed, NAD
HEENT- PERRLA, no adenopathy;T-tube in place to trach mask
humidification; doboff feeding tube in nares
REsp- course BS, decreased at bases
Cor-RRR
Abd- soft, + BS, NT, ND
Ext- no edema, fair tone
Neuro- awake, alert, cooperative at times, passive
intermittently
Pertinent Results:
[**2192-5-23**] 01:00PM BLOOD WBC-10.0 RBC-3.76* Hgb-11.2* Hct-33.5*
MCV-89 MCH-29.9 MCHC-33.5 RDW-13.5 Plt Ct-252
[**2192-5-23**] 01:00PM BLOOD PT-13.4* PTT-25.4 INR(PT)-1.2
[**2192-5-23**] 01:00PM BLOOD Glucose-213* UreaN-39* Creat-1.2* Na-139
K-5.3* Cl-107 HCO3-26 AnGap-11
[**2192-5-23**] 01:00PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
[**2192-5-24**] 09:23AM BLOOD Type-ART O2 Flow-2 pO2-159* pCO2-59*
pH-7.29* calHCO3-30 Base XS-0 Intubat-NOT INTUBA
[**2192-5-23**] [**2192-5-23**] [**2192-5-25**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies: [**Numeric Identifier 61330**] ANTERIOR TRACHEAL TISSUE
DIAGNOSIS
Trachea:
Squamous metaplasia, marked fibrosis, and chronic inflammation.
Clinical: Tracheal stenosis.
Brief OR Reports
OR [**6-5**]- trachea widely patent. At the
resection site, there were several sutures reaching into the
airways, and a significant amount of necrotic tissue and what
appeared to be partial cartilage debris. This was all
debrided carefully with the help of flexible forceps until
full patency was established. The sutures were not cut at the
time.
OR [**6-8**]- Still residual supraglottic edema with erythema of the
cords and
more extensive infraglottic edema with a 3-4 mm airway.
Distal to this, the proximal area of the anastomosis was seen
followed by a segment of circumferential granulation tissue
with free floating Prolene sutures consistent with complete
dehiscence. After a gap of near circumferential granulation
tissue, the distal airway was visualized and appeared
healthy. There was no significant purulence in the distal
airways. It was clearly apparent that this dehisced area was
completely malacic as the bronchoscope was placed on suction
the entire airway collapsed. Based on this, I felt that this
was not amenable to extubation and that treatment options for
either a tracheostomy which would threaten her ability to
phonate or insertion of a T-tube, done [**6-13**].
Brief Hospital Course:
63 y/o Portuguese speaking female admitted SDA for tracheal
resection for tracheal stenosis. Post-op course complicated by
subquetaneous emphysema at neck area and electively intubated
via bronchoscopy and transferred to ICU, atrial fibrillatin
started on amiodarone gtt, and ENT consult for paralysed vocal
cord and supraglottic edema of 5mm [**5-28**]. Edema treated w/
decadron x3 doses w/ resolution; dehiscence of wound
necessitating placement of t-tube, and later passey-muir valve
placement.
[**5-29**]- Neck incision red, tender and edema, I&D for purulent
drainage, started on Vanco and levofloxacin for 21 days, W>D to
wound. OR [**6-8**] revealed complete dehiscence; NPO, doboff placed
and tube feeding started- Impact w/ fiber at 60/hr.
T-tube placement [**6-13**] (see pertinent results for brief OR
report), vent x3 days,then weaned to trach collar [**6-17**] w/o
complication. Secretions abundant initially, now suctioning
q4hrs prn w/ excellent cough of white sputum to back of throat.
Speech and swallow [**5-24**]- revealed vocal cord edema> ENT consult,
able to take sips, no straws; [**5-28**]- NPO- for aspiration of thin
liquids, [**5-29**]- FEES- unable to visualize due to copious
secretions; [**6-18**]- Passey Muir valve placed w/ success.
[**6-22**]-Video swallow passed for liquids, refused to take solids
due to behavioral issues of depression and feeling of lack of
control despite daughter assisting w/ evaluation.
Pt cont on tube feeding as mentioned above w/ gradual
advancement of po intake. Plan for re-eval of video swallow when
patient more cooperative.
T-tube capped [**6-25**] with nasal cannula prn. T-tube and P-M
attachments and instructions enclosed.
Physical Therapy following- OOB to chair w/ [**12-4**] assist when
cooperativing, otherwise Hoya lift to chair.
Family very involved and supportive. They live in [**Location (un) 5503**]
area.
See discharge instructions and enclosed t-tube and passey muir
instructions for specific instructions. Adaptor enclosed for
t-tube for sublemental O2 via t-tube.
Medications on Admission:
Zoloft 100', Lasix 40', Miralex 17gm, ECASA 325', Protonix 40',
KCL 10', Amiodarone 100', Advair 500/50, Lopressor 50", Humalog
75/25, 26 units AM, 12 units PM, Lisinopril 5', Neurontin 300',
Synthroid 150', Duroneb, COlace 200', Senna 2"
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever or pain.
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) cc PO
BID (2 times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) cc PO DAILY
(Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
bottle Injection every six (6) hours as needed for per blood
sugar.
16. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 54351**] - [**Location (un) 5503**]
Discharge Diagnosis:
Cervical tracheal stenosis.
Discharge Condition:
good
Discharge Instructions:
1. Call office if you experience: fever, chills, shortness of
breath, chest pain, productive cough, incisional redness or
discharge
YOu may shower, no tub baths or swimming for 3-4 weeks.
Call Cr. [**Doctor Last Name **] office for any post-op surgical
issues.[**Telephone/Fax (1) 170**].
See enclosed T-tube instructions and adaptors for specifics.
See enclosed passey-muir instructions for specifics.
Followup Instructions:
1.please call for appointment in [**9-14**] days or when discharged
from Rehab facility [**Telephone/Fax (1) 170**]
please arrive 45 minutes prior to appointment for chest xray in
[**Hospital Ward Name **] 4 radiology department.
2. please schedule follow up with ENT for stroboscopy for vocal
cord assessment at [**Telephone/Fax (1) 2349**]
Completed by:[**2192-6-25**]
|
[
"272.0",
"412",
"998.59",
"998.31",
"V58.67",
"E879.8",
"427.31",
"519.1",
"707.07",
"998.81",
"478.6",
"998.89",
"V45.81",
"707.03",
"414.00",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"31.42",
"86.09",
"96.6",
"86.04",
"31.79",
"31.5",
"96.05",
"33.23",
"33.22",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7716, 7791
|
3774, 5829
|
407, 490
|
7863, 7869
|
1777, 3751
|
8320, 8695
|
6118, 7693
|
7812, 7842
|
5855, 6095
|
7893, 8297
|
1447, 1758
|
281, 368
|
518, 1080
|
1102, 1340
|
1356, 1432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,434
| 172,194
|
15073+56605+56606
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2190-3-12**] Discharge Date: [**2190-3-16**]
Date of Birth: [**2129-9-17**] Sex: F
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female who was recently admitted to this hospital for hepatic
artery stenosis and stenting along with cholangitis who is
presenting again from a rehabilitation facility with
decreased alkaline phosphatase on routine laboratory testing.
The patient herself does not have any specific complaints.
She denies any abdominal pain, nausea, vomiting, diarrhea,
fevers or chills. She denies any headache. She denies any
bright red blood per rectum or melena. She denies any chest
pain or shortness of breath. The patient's other liver
function tests have been stable.
PAST MEDICAL HISTORY: Please see recently dictated discharge
summary from prior admission for detailed past medical
history.
MEDICATIONS ON ADMISSION:
1. Plavix 75 mg q. day.
2. Lasix 40 mg b.i.d.
3. Captopril 25 mg t.i.d.
4. Metoprolol 50 mg b.i.d.
5. Sulfa 500 mg q.i.d.
6. Prograf 0.5 mg b.i.d.
7. Aspirin 325 mg q. day.
8. Compazine 5 mg t.i.d.
9. Fentanyl patch 35 mcg patch q. 72h.
10. Remeron 15 mg q. hs.
11. Ativan 0.5 mg q. 4-6h. as needed.
12. Morphine sulfate immediate release (MSIR) 15 mg q. 4-6h.
as needed for pain.
13. Epogen 40,000 units q. week.
14. Bactrim single strength one tablet q. day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.9, blood
pressure 134/90, pulse 86, respiratory rate 16, oxygen
saturation 98% on trach mask with 40% oxygen. In general,
the patient is somnolent but easily arousable and answers
questions appropriately. She is alert and oriented times
three. HEENT examination shows bilateral medial rectus
muscle palsy. The pupils are constricted. Sclerae are
anicteric. Moist mucus membranes. Neck examination shows a
trach with no jugular venous distention, no lymphadenopathy.
Chest is clear with the exception of basilar rales.
Cardiovascular examination shows a regular rate and rhythm
with normal S1, S2. 3/6 systolic ejection murmur at the left
sternal border. Abdominal examination is soft, non-tender,
non-distended with normoactive bowel sounds. There is an
area of ongoing wound healing at the superior portion of a
surgical wound. This area is clean, dry and intact without
any exudate or surrounding erythema. Extremities: The
patient has extensive lymphedema of the bilateral lower
extremities with chronic stasis changes. Dorsalis pedis
pulses are 2+ bilaterally.
LABORATORY ON ADMISSION: CBC notable for a white count of
6.1 and hematocrit of 48.2 which is far above the patient's
baseline in the 30's. Chem-7 significant for a creatinine of
1.2, potassium 5.3, glucose 40. Liver function tests show
alkaline phosphatase of 851 which is up from 512 on [**3-2**]. Albumin is 2.5. AST is 73 and ALT 33 with a total
bilirubin of 0.6.
HOSPITAL COURSE BY ISSUE:
1. Increased alkaline phosphatase: Several possibilities
for the initial increase in alkaline phosphatase at admission
include re-stenosis of the patient's hepatic artery which was
recently stented, cholangitis, worsening of her hepatitis C
chronic infection, rejection of her liver transplant. The
patient had a right upper quadrant ultrasound done to assess
for patency of her hepatic arteries as well as any other
liver abnormalities. However, this study was normal showing
patent hepatic arteries. There was also no evidence for
cholangitis or other acute liver infection. It is possible
that this was due to worsening hepatitis C and hepatitis C
viral load was done and pending at the time of this
dictation. Soon after admission the patient's alkaline
phosphatase began to decrease gradually each day. Her other
liver function tests remained stable. The patient was
continued on aspirin and Plavix for the recent hepatic artery
stent.
2. Liver transplant: There were no signs of acute rejection
of her liver to account for the liver function test
abnormalities. She was maintained on CellCept. Prograf
which she was recently started on was at a subtherapeutic
level of 1.6; however, this is a desirable level as patient
had previously had renal complications from this class of
immunosuppressive drugs. Dose was actually decreased during
the hospital admission from 0.5 mg b.i.d. to 0.5 q. day. She
is also continued on Bactrim for prophylaxis.
3. Urinary tract infection: The urinalysis on admission was
suggestive of a UTI. Further urine culture and sensitivity
showed by Pseudomonas and Klebsiella infections of the
urinary tract. The Klebsiella was only sensitive to
meropenem and possibly cefepime. The patient was therefore
started on meropenem which was renally dosed and would be
continued for seven days.
4. Delirium: At times the patient appeared delirious during
the hospitalization. It was thought that this was secondary
to narcotics which the patient had for pain control. Her
fentanyl patch dose was reduced from 75 mcg to 50 mcg and her
breakthrough morphine sulfate immediate release was also
reduced in dosage and frequency. She did appear to have less
mental status change after this change.
5. Depression: The patient was continued on Remeron for
depression.
6. Hematocrit: On admission the patient's hematocrit was
elevated much over her baseline. Therefore, her Epogen was
discontinued. Her hematocrit remained stable for the
hospitalization despite discontinuation of the Epogen.
7. Fluids, Electrolytes and Nutrition: The patient was on a
low sodium, low fat diet; however, she was having poor p.o.
intake even though she stated she had a good appetite. Her
blood glucose remained low much of the time in the 60's. She
was encouraged to take increasing amounts of p.o. At the
time of this dictation calorie counts were being done and
there was a possibility the patient might require
supplemental feeding through a nasogastric tube.
The rest of this dictation will be completed at a later date.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Name8 (MD) 5709**]
MEDQUIST36
D: [**2190-3-16**] 17:07
T: [**2190-3-16**] 17:21
JOB#: [**Job Number 44032**]
Name: [**Known lastname 2288**], [**Known firstname 4497**] C Unit No: [**Numeric Identifier 8011**]
Admission Date: [**2190-3-12**] Discharge Date: [**2190-4-5**]
Date of Birth: [**2129-9-17**] Sex: F
Service:
ADDENDUM TO HOSPITAL COURSE
1. End-Stage Liver disease, status post liver transplant
times two, increasing alkaline phosphatase. The patient's
Hepatitis C viral load was found to be greater than 700,000.
There was no evidence of cholangitis. Alkaline phosphatase
was fluctuating. Right upper quadrant ultrasound was
repeated and showed patent hepatic artery. The patient was
continued on aspirin and Plavix. Prograf was added for
immunosuppression. However, kept the level as
sub-therapeutic since the patient has a history of worsening
renal failure.
The patient had another right upper quadrant ultrasound that
showed patent hepatic artery and hepatic and portal veins and
no change from prior study. The patient's alkaline
phosphatase peaked at a level of 1000. This was thought to
be a combination of probable sub-acute rejection and status
post sepsis from urinary tract infection and pneumonia. The
patient's Prograf was increased and renal function tests
followed carefully. The patient may benefit from liver
biopsy after discharge.
2. ID. The patient had an episode of hypotension/sepsis
from urinary tract infection and pneumonia. The patient was
initially being treated with Meropenem for urinary tract
infection and finished a seven day course. Meropenem was
stopped for one day. The following morning the patient was
found to be uncommunicative however, would nod to yes and no
and had an apparent dystonic reaction to Phenergan. The
patient subsequently suffered an episode of hypotension which
was transient which was thought to be secondary to
administered intravenous Benadryl. However, the patient
remained hemodynamically unstable, developed a left bundle
branch block which was new and was transferred to the
Intensive Care Unit where the patient was stabilized
hemodynamically. The patient had pseudomonas in her sputum
and pseudomonas in the urine was resistant to Meropenem. The
patient decided to be treated with short course of Zosyn,
total of ten days for urinary tract infection and for likely
pseudomonas colonization in the sputum. The patient was also
initially started on Flagyl for a finding of bowel wall
thickening of the colon with questionable inflammatory
etiology however, the patient's C. diff toxins were serially
negative and this finding on the CAT scan was reviewed and
was found to be chronic. There was no evidence of bowel
ischemia. The patient was hemodynamically stable and Flagyl
was stopped.
3. Chronic renal insufficiency. Creatinine has been stable
with maintenance fluid hydration.
4. Coronary artery disease. The patient had an episode of
demand ischemia with a Troponin leak and development of the
left bundle branch block in the setting of hypotension. The
patient's echocardiogram revealed normal ejection fraction.
The patient was restarted on Metoprolol 12.5 mg twice a day.
The patient was kept on Telemetry and has had periodic
electrocardiograms which were unchanged. The patient has not
had any symptoms of chest pain.
5. Mental status change. As described above in the setting
of a dystonic reaction to Phenergan and Hypotension. The
patient had an urgent CAT scan of the head which showed no
evidence of stroke. The patient was followed by Neurology
service who felt that the patient's mental status change was
multi-factorial. Oxidating medicines were held and the
patient returned to the baseline mental function.
6. Depression. The patient was continued on Remeron as per
Psychiatry consult.
7. Anemia. Was stable, assumed to be anemia of chronic
disease. Hematocrit has been stable and patient has not
required any transfusions.
8. Diarrhea. As mentioned above the patient's C. diff toxin
was negative serially. The patient was initially started on
low residue diet and Imodium. The patient's diarrhea finally
resolved with tube feeding manipulation.
9. FEN. The patient has shown very poor p.o. intake and had
to undergo post pyloric tube placement. Tube feeds were
initiated to maintain better nutritional status in the
setting of status post sepsis and with history of chronic
liver disease and status post hemodialysis.
10. Hypoglycemia. The patient had an initial episode of
hypoglycemia during an episode of bacteremia/sepsis. The
patient then continued to be hyperglycemic, requiring D10
glucose drip which was presumed to be due to a combination of
liver disease and poor p.o. intake. Hypoglycemia completely
resolved with the initiation of tube feeds.
11. Decubitus ulcers. The patient was changed to air
mattress, frequent turning from side-to-side wound care.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation place.
DISCHARGE DIAGNOSIS:
1. Chronic liver disease, status post transplant times two.
2. Hepatitis C.
3. Diabetes mellitus.
4. Elevated alkaline phosphatase.
5. Hepatic artery stenosis, status post stent.
6. Coronary artery disease.
7. Chronic renal insufficiency.
8. Hypertension.
9. Tracheostomy for failure to wean off the vent, chronic.
10. Chronic obstructive pulmonary disease.
11. Depression.
12. Failure to thrive.
13. Right groin arteriovenous fistula.
14. Chronic anasarca.
15. Gastroparesis.
16. Urinary tract infection with pseudomonas and Klebsiella.
17. Pseudomonas sputum colonization.
18. Decubitus ulcers.
DISCHARGE MEDICATIONS:
1. Oxycodone 5 mg p.o. q 4 to 6 hours p.r.n. for pain.
2. Tacrolimus 0.5 mg p.o. twice a day
3. Miconazole powder 2% one application Transderm three
times a day p.r.n.
4. Imodium 2 mg p.o. four times a day for diarrhea to the
maximal of 16 mg a day.
5. Ambien 5 mg p.o. q h.s. p.r.n.
6. Ursodiol 300 mg p.o. three times a day.
7. Lasix 20 mg p.o. q day.
8. Zosyn 4.5 mg intravenous q 8 hours, today is day 9 of 10.
Please administer Zosyn for one additional day.
9. Magnesium Oxide 800 mg p.o. twice a day.
10. Lopressor 12.5 mg p.o. twice a day.
11. Bactrim single strength one tab p.o. q day.
12. Morphine sulfate 2 mg intravenous q 6 hours p.r.n. for
pain.
13. Colace 100 mg p.o twice a day.
14. Reglan 10 mg p.o./IV three times a day.
15. Linsoprazol oral suspension 30 mg per Nasogastric tube q
day.
16. Heparin subcutaneously 500 units q 12 hours.
17. Albuterol neb q 6 hours.
18. Atrovent neb q 6 hours.
19. Aspirin 325 mg p.o. q day.
20. Plavix 75 mg p.o. q day.
21. Mycophenolate Mofetil 500 mg p.o. four times a day.
FOLLOW-UP:
1. The patient is to be followed up with Hepatology service.
The patient needs to schedule an appointment with Dr [**Last Name (STitle) 833**]. The
patient also needs serial alkaline phosphatase levels
followed at the rehabilitation place. The patient also needs
to schedule an appointment with her outpatient physician.
[**Name6 (MD) 904**] [**Name8 (MD) **], M.D. [**MD Number(1) 6350**]
Dictated By:[**Name8 (MD) 4104**]
MEDQUIST36
D: [**2190-4-5**] 13:58
T: [**2190-4-5**] 19:47
JOB#: [**Job Number 8017**]
Name: [**Known lastname 2288**], [**Known firstname 4497**] C Unit No: [**Numeric Identifier 8011**]
Admission Date: [**2190-3-12**] Discharge Date: [**2190-4-8**]
Date of Birth: [**2129-9-17**] Sex: F
Service:
ADDENDUM TO HOSPITAL COURSE:
1. End stage liver disease, status post liver transplant
times two, increasing alkaline phosphatase - It was felt
that the elevated alkaline phosphatase was likely due to
transplant rejection. The patient's immunosuppressive agents
were titrated up and at the time of this dictation the
patient's alkaline phosphatase was trending downward. It was
felt there was no need for a liver biopsy at this time.
2. Infectious disease - The patient completed her course of
pseudomonas for urinary tract infection and/or likely
pseudomonized colonization.
3. Diarrhea - The patient's diarrhea continued despite
feeding tube manipulation. She was continued on the low
residue diet and the Imodium was changed throughout the
clock. In addition the magnesium oxide was stopped as this
may have been contributing to the diarrhea..
4. Nausea and vomiting - The patient had two episodes of
bilious vomiting. A plain film of the abdomen was negative
for obstruction and her right upper quadrant ultrasound was
negative for biliary obstruction. The patient was continued
on her anti-emetics including Reglan and she had no further
episodes of vomiting.
FINAL DISCHARGE DIAGNOSIS: As listed in prior discharge
summary.
UPDATED FINAL DISCHARGE MEDICATIONS:
1. Plavix 75 mg once a day.
2. Mycophenolate 500 mg p.o. q.i.d.
3. Aspirin 325 a day.
4. Albuterol nebulizer q. 6 hours prn.
5. Atrovent nebulizer q. 6 hours.
6. Prevacid 30 mg once a day.
7. Reglan 10 mg t.i.d.
8. Trimethoprim Sulfa 400/80 one tablet p.o. q. day.
9. Lopressor 12.5 b.i.d.
10. Lasix 20 mg a day.
11. Ursodiol 300 mg t.i.d.
12. Miconazole powder t.i.d. prn.
13. Tacrolimus .5 mg p.o. b.i.d.
`14. Oxycodone 5 mg p.o. q. 4-6 hours prn pain.
15. Imodium 2 mg p.o. q.i.d.
[**Name6 (MD) 904**] [**Name8 (MD) **], M.D. [**MD Number(1) 6350**]
Dictated By:[**Name8 (MD) 5408**]
MEDQUIST36
D: [**2190-4-8**] 08:09
T: [**2190-4-8**] 08:56
JOB#: [**Job Number 8018**]
|
[
"038.9",
"599.0",
"292.81",
"995.92",
"070.51",
"785.52",
"707.0",
"496",
"996.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15084, 15805
|
15008, 15061
|
931, 1461
|
13831, 14986
|
184, 778
|
2597, 11171
|
801, 905
|
11196, 11280
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,986
| 143,395
|
11681+56270
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-11-11**] Discharge Date: [**2137-11-14**]
Date of Birth: [**2061-6-25**] Sex: F
Service: CCU
The patient was transferred to the Medicine Service on
[**2137-11-14**], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as attending.
CHIEF COMPLAINT: The patient was admitted with a chief
complaint of transfer from [**Hospital3 27946**] with a chronic
positive cardiac enzymes.
HISTORY OF PRESENT ILLNESS: The history was obtained from
medical records and family. Per the family, the patient had
shortness of breath for two days prior to admission at
[**Hospital3 27946**]. She had increased cough over her
baseline. She then presented to [**Hospital3 27946**] on
blood gases at that time was 7.20, pCO2 64, pO2 278, with a
respiratory rate of 32 and the patient then was intubated as
she began tiring. She failed a trial of BiPAP prior to
intubation.
An electrocardiogram at that time then showed ST elevations
in V2 and a tachycardia to approximately 130 to 140 with a
changing P wave morphology. Cardiac enzymes were positive
with a CK of 342, MB of 16.9 with an index of 4.9, and a
troponin I was 3.1. Twenty-four hours later, CK was 500, MB
27.2, index 4.4 with troponin of 4.89. The patient denied
any chest pain when she first presented to the Emergency
Department per the records.
Heparin was started at that time when she began ruling in and
then stopped secondary to guaiac positive stool. The
tachycardia in the Emergency Department was initially
controlled with Diltiazem drip and the patient was
transferred to the Intensive Care Unit at the outside
hospital.
At that time, a right heart catheterization was performed
with pulmonary artery pressures of 34/16, pulmonary capillary
wedge pressure of 11, cardiac output of 4.68. White blood
count was elevated at 20.8 and 8% bandemia. A sputum gram
stain showed greater than 25 PMNs with 0-1 epithelial cells
and gram positive cocci in pairs. Given the lack of
resolution of the cardiac enzymes and concern for acute
myocardial infarction, the patient was transferred to [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease. The patient is on
home oxygen two liters nasal cannula for her chronic
obstructive pulmonary disease.
2. History of pneumonia.
3. History of epistaxis.
4. History of Bell's palsy.
5. Hypertension.
6. Hyperlipidemia.
7. Osteoporosis.
8. Depression.
MEDICATIONS ON ADMISSION:
1. Plendil 5 mg p.o. q.d.
2. Pravachol 10 mg p.o. q.d.
3. Paxil 20 mg p.o. q.d.
4. Uniphyl 400 mg p.o. q.d.
5. [**Doctor First Name **] 60 mg p.o. b.i.d.
6. Multivitamin q.d.
7. Fosamax 70 mg p.o. q.d.
ALLERGIES: The patient has allergy to Simvastatin for which
she has a myositis.
SOCIAL HISTORY: The patient lives alone. She denies any
alcohol or intravenous drug use. She quit tobacco
approximately ten years ago with a sixty pack year history.
The family contacts are a son, [**Telephone/Fax (1) 36993**] for cell phone,
home [**Telephone/Fax (1) 36994**] and a daughter, [**Name (NI) **], [**Telephone/Fax (1) 36995**].
PHYSICAL EXAMINATION: On examination, vital signs revealed
temperature 97.0, pulse 92, blood pressure 120/87,
respiratory rate 17. She was ventilated, tidal volume 550,
respiratory rate status 16, SIMV with a PEEP of 5, FIO2 35%.
Gas on this 7.40, pCO2 41, pO2 79. In general, she is an
elderly woman who is sedated and comfortable. Head, eyes,
ears, nose and throat examination - The pupils are equal,
round, and reactive to light and accommodation. No scleral
icterus. Mucous membranes are moist. Neck - She has a right
IJ line without any hematoma or bruit. The lungs are clear
to auscultation bilaterally. Cardiovascular - regular rate
and rhythm, normal S1 and S2, no murmurs, rubs or gallops,
distant heart sounds. Abdominal examination is soft,
nondistended, minimal right upper quadrant tenderness,
positive bowel sounds. Extremities - no cyanosis, clubbing
or edema. Dorsalis pedis 2+ bilaterally. Neurologic
examination - she is sedated. The pupils are equal, round,
and reactive to light and accommodation. She withdraws to
pain. She moves all four extremities. Lines - She has a
right IJ and a right radial line.
DRIPS ON TRANSFER: She is on a Nitroglycerin drip at 20
mcg/minute, Heparin drip and she is on a Propofol drip as
well.
LABORATORY DATA: On presentation to the outside hospital,
white blood count 20.8, hematocrit 50.2, platelets 451,000
with 74 neutrophils, 8 bands. INR 0.9, partial
thromboplastin time 29.3. On [**2137-11-11**], white count 18.4,
hematocrit 42.8, platelets 283,000. Also on [**2137-11-11**], she
had a SMA7 with sodium 142, potassium 4.1, chloride 109,
bicarbonate 26, blood urea nitrogen 22, creatinine 1.7,
glucose 173. Urinalysis was negative at the outside
hospital. Theophylline level was 7.3.
She had serial enzymes drawn. On [**2137-11-10**], on presentation,
CK 342, MB 16.9, index 4.9, troponin 3.11. Later on
[**2137-11-10**], CK 382, MB 18.3, index 4.8, troponin I 4.3. On
[**2137-11-11**], CK 402, MB 18.7, index 4.7, troponin I 4.9. Later
on [**2137-11-11**], CK 500, MB 22.2, index 4.7, troponin I 4.9.
At [**Hospital1 69**], her pulmonary artery
pressure was 51/37, wedge 25, cardiac output 4.1, cardiac
index 2.11.
Chest x-ray showed a right pleural effusion, right lower lobe
infiltrate. She had an endotracheal tube in place. She had
a pulmonary artery line in place. Electrocardiograms from
[**2137-11-10**], showed sinus tachycardia versus MAT, increased ST
in V2. From [**2137-11-12**], at [**Hospital1 188**], no ST changes and she has diffuse T wave inversions.
ASSESSMENT: This is a 76 year old female most likely
bacterial pulmonary process leading to a chronic obstructive
pulmonary disease flare leading to MAT versus an
supraventricular tachycardia leading to cardiac ischemia.
The patient was admitted to the Intensive Care Unit on the
CCU team. Heparin, Aspirin, Lopressor will be continued.
Enzymes will be cycled. She will be placed on telemetry and
echocardiogram will be obtained and plan for cardiac
catheterization in the morning.
1. Pulmonary - Levofloxacin will be continued, ventilatory
support will be continued and weaned as tolerated,
Solu-Medrol intravenous 40 mg q6hours will be given for
chronic obstructive pulmonary disease flare.
2. Renal - Creatinine 1.4, acute or chronic is the debate.
This will be followed.
3. Infectious disease - The patient will be fully cultured
with every temperature spike. Cultures from the outside
hospital will be followed and the patient will be continued
on Levofloxacin.
4. Gastrointestinal - Heme positive stools - The patient
will be started on Protonix and stools will be guaiac tested
and serial hematocrit will be followed and the patient will
need an outpatient colonoscopy once she recovers from this
acute exacerbation.
CODE: The patient is full code, and family contacts are as
above.
HOSPITAL COURSE: By hospital day number two, cardiac enzymes
had trended down to normal. Neurologic examination remained
normal and the right IJ line was changed over a wire. Drips
were continued.
An echocardiogram was also obtained on the previous day that
showed mildly dilated left atrium and left ventricle with
mild to severe global hypokinesis, right ventricular wall
hypertrophied with normal function and 1+ mitral
regurgitation. The creatinine trended down leaving only
cardiovascular and pulmonary as the active systems involved
at this time.
Also on hospital day number two, a cardiac catheterization
was performed that showed mild pulmonary artery hypertension
with elevated right atrial pressures, low normal ejection
fraction of the left ventricle, and coronary angiography
showed severely calcified right dominant system with mild
luminal irregularities. No interventions were indicated or
taken.
On hospital day number three, Captopril was increased. The
patient had a weaning trial and indicated her readiness for
extubation. The patient was extubated without complications.
Later on hospital day three, [**2137-11-14**], the patient was
transferred to the floor for further and continuing care.
At the time of transfer, her central line, her arterial line
and her nasogastric tube were discontinued. The patient was
placed on a regular diet as tolerated. The patient was given
care for a chronic obstructive pulmonary disease flare
including MDIs, Levaquin and oxygen. The patient was
requiring four liters of oxygen at this point time to
maintain saturation greater than 94%. She is on two liters
home oxygen. Prednisone was continued at 60 mg p.o. q.d.
Cardiac - The cause of the patient's global left ventricular
hypokinesis and elevated enzymes is unclear. Whether it is a
mild viral myocarditis or Prinzmetal's angina or a resolved
blockage prior to catheterization or tachycardia induced
cardiomyopathy, the suspicious of the team is possible viral
myocarditis triggering both a chronic obstructive pulmonary
disease exacerbation and an enzyme leak with the chronic
obstructive pulmonary disease exacerbation leading to the
tachycardia.
The patient is being maintained on an ace inhibitor for its
remodeling benefits. A beta blocker is not indicated given
the patient's current chronic obstructive pulmonary disease
flare. The patient is also being given a daily Aspirin. She
is also being maintained on MDIs of Fluticasone, Atrovent and
Salmeterol.
The plan is to obtain a physical therapy consultation, wean
the oxygen as tolerated and continue primary prevention of
heart disease. The patient will be discharged either to
short term rehabilitation facility or to home when her oxygen
is weaned down to her baseline of two liters oxygen.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 177**] 11-988
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2137-11-15**] 15:40
T: [**2137-11-15**] 16:17
JOB#: [**Job Number 36996**]
Name: [**Known lastname **], [**Known firstname 779**] Unit No: [**Numeric Identifier 6616**]
Admission Date: [**2137-11-14**] Discharge Date: [**2137-11-25**]
Date of Birth: [**2061-6-25**] Sex: F
Service: MEDICINE
As noted in the previous discharge summary, the patient was
transferred from the Medical Intensive Care Unit to the
general medicine service on [**2137-11-14**].
HOSPITAL COURSE: Starting [**2137-11-15**].
1. Pulmonary - This remained the only area of active care
for the patient during her stay. She required treatment for
her severe chronic obstructive pulmonary disease for which
she is on two liters of home oxygen. She required four to
five liters oxygen to maintain saturation greater than 93%.
She also was maintained on Levaquin throughout her hospital
course until her date of discharge, [**2137-11-25**].
Over her hospital course, she was slowly weaned down to her
baseline of two liters nasal cannula oxygen on [**2137-11-21**],
however, that evening she became anxious and agitated and
desaturated on the two liters down to 60% and required
increasing oxygen to four to five liters. Throughout the
rest of her hospital course, she required anywhere from four
to five liters, occasionally six, and rarely three liters, to
maintain adequate saturation.
During the hospital course, the patient also required
nebulized treatments with Albuterol and Atrovent. Attempts
were made to space these out to every six hours, however, the
patient would become bronchospastic and desaturate to the mid
to low 80s on her four to five liters nasal cannula oxygen.
After receiving treatments, the patient would begin to
breathe more easily. Her wheezing on examination would
decrease and she would begin to move more air and her
saturation would come up to the mid to low 90s. Attempts to
wean her nebulized treatments were unsuccessful and the
patient continued to require them approximately every 3.5 to
4.5 hours through her entire stay until her date of
discharge.
The patient was also maintained on Levaquin until her date of
discharge. The patient was also on Prednisone which was
slowly weaned early on and then maintained at 30 mg because
the patient showed no improvement in her decreased use of
oxygen or decreased use of nebulized treatments and
Prednisone was left at 30 mg p.o. q.d.
At the time of discharge, it is unclear if this represents a
new baseline pulmonary status for this 76 year old woman with
severe chronic obstructive pulmonary disease and extensive
smoking history or whether with time she will slowly return
to baseline of two liters nasal cannula oxygen at home with
nebulized treatments and MDIs every six hours. Also during
this time, she was maintained on MDIs of Serevent and
Flovent.
2. Cardiovascular - The patient showed no signs of clinical
heart failure. A repeat echocardiogram was not obtained as
the patient had no episodes of chest pain, no episodes of
tachycardia or other rhythm abnormalities and on clinical
examination was not in failure, either left or right sided.
The last echocardiogram obtained prior to discharge from
transfer from the Medical Intensive Care Unit to the general
medicine floor showed an ejection fraction of 40% with clean
coronaries. The presumed diagnosis is a myocarditis which
should improve with time, however, repeat echocardiogram was
not performed. No other cardiac care was given. The patient
was maintained on an ace inhibitor for blood pressure control
and remodeling benefits. The patient was not maintained on a
beta blocker because of her severe chronic obstructive
pulmonary disease.
DISPOSITION: The physical therapy team saw the patient and
recommended a short term rehabilitation stay. The patient
was screened for short term rehabilitation without response
until [**2137-11-25**], when [**First Name5 (NamePattern1) 1612**] [**Last Name (NamePattern1) 5553**] stated they could take the
patient and handle her pulmonary issues including monitoring
oxygenation and nebulized treatments.
The patient has remained approximately stable for the
previous ten days requiring four to five liters oxygen nasal
cannula per minute and nebulized treatments every 3.5 to 4.5
hours consisting of Albuterol and Atrovent. Also, the
patient was maintained on Serevent and Flovent MDIs during
this time. Attempts to wean the oxygen and space out the
nebulized treatments were unsuccessful.
[**First Name5 (NamePattern1) 1612**] [**Last Name (NamePattern1) 5553**] is aware of this and is ready to accept the
patient upon transfer. The patient is aware of this and the
patient's son is also notified and the primary care physician
arranged the transfer for closer monitoring by Dr. [**First Name (STitle) **] and
the patient's primary care team.
The patient was discharged on [**2137-11-25**], to [**First Name5 (NamePattern1) 1612**] [**Last Name (NamePattern1) 5553**] in
stable condition with her chronic medical problems.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Pneumonia.
3. Non Q wave myocardial infarction by troponin leak with
clean coronaries on cardiac catheterization.
4. Hypertension.
5. Dyslipidemia.
6. Osteoporosis.
7. Depression.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. q.d.
2. Atrovent MDI two puffs q4-6hours as needed when not
taking nebulized treatments.
3. Cepacol lozenges as needed.
4. Heparin 5000 units subcutaneous b.i.d.
5. Albuterol nebulizer treatment one nebulizer p.o.
q3-5hours as needed for wheezing and hypoxia.
6. Atrovent one nebulizer p.o. q3-5hours p.r.n. wheezing and
hypoxia.
7. Prednisone 30 mg p.o. q.d.
8. Tylenol 650 mg p.o. q4hours as needed.
9. Colace 100 mg p.o. b.i.d.
10. Flovent 110 mcg MDI two puffs p.o. b.i.d.
11. Serevent MDI two puffs p.o. b.i.d.
12. Aspirin 81 mg p.o. q.d.
13. Paxil 20 mg p.o. q.d.
14. Lisinopril 30 mg p.o. q.d.
15. Levaquin 500 mg p.o. q.d. The patient has been treated
on Levaquin for two weeks as of [**2137-11-25**], the date of
discharge.
The patient was discharged on [**2137-11-25**], to [**First Name5 (NamePattern1) 1612**] [**Last Name (NamePattern1) 5553**] in
stable condition with her chronic obstructive pulmonary
disease requirements necessitating a short term
rehabilitation stay.
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 6617**], M.D. [**MD Number(1) 6618**]
Dictated By:[**Last Name (NamePattern1) 3253**]
MEDQUIST36
D: [**2137-11-25**] 13:19
T: [**2137-11-25**] 13:59
JOB#: [**Job Number 6619**]
cc:[**Last Name (NamePattern1) 6620**]
|
[
"272.0",
"486",
"491.21",
"416.0",
"733.00",
"410.71",
"401.9",
"429.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"96.71",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
15055, 15288
|
15314, 16655
|
2509, 2801
|
10491, 15034
|
3171, 7020
|
314, 443
|
471, 2162
|
2184, 2483
|
2818, 3148
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,362
| 126,999
|
47228
|
Discharge summary
|
report
|
Admission Date: [**2145-2-28**] Discharge Date: [**2145-3-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Sepsis/Pulmonary Edema
Major Surgical or Invasive Procedure:
Intubation/Mechanical Ventilation
Central Venous Catheter Placement
Thoracentesis
Bronchoscopy
History of Present Illness:
The pt is an 84y/o F with a PMH of severe Alzheimer's dementia,
CAD s/p CABG and aortic stenosis admitted with fever,
hypotension and dyspnea. The patient was brought from her
nursing home with complaints of worsening shortness of breath,
found to have temp 103.
.
In the ED, initial vs were: T102.4 P140 BP142/72 R36 O2 sat92%
NRB. Initial exam concerning for pulmonary edema and the patient
was given lasix 40mg IVx1 with no subsequent urine output. She
then dropped her BP to 70s systolic. CXR with no clear evidence
of PNA but was covered with Vanc/Zosyn given fever. Placed on
Bipap with continued hypotension BP to 70s. Pt given 2L NS.
After discussion with her son, the patient's code status was
made DNR but okay to intubate. Given phenylephrine around
intubation and etomidate and succinycholine for intubation.
Placed on versed and fentanyl. Pink sputum in ET tube. ECG with
no focal ischemia. Placed on levophed and RIJ placed for access.
BP dropped again on levophed and was given 2additional L IVF and
neosynephrine was added.
.
Past Medical History:
- CAD s/p CABG
- Aortic stenosis
- Hypothyroidism
- Alzheimer's Dementia Severe
Social History:
Lives at [**Location 100007**] [**Hospital3 **] [**Telephone/Fax (1) 100008**].
Family History:
NC
Physical Exam:
Vitals: T:95.3 BP:81/38 P:89 R:16 18 O2:100% FI02 100%
General: intubated and sedated
HEENT: Sclera anicteric, ET in place
Neck: supple, JVP not elevated, no LAD, R IJ
Lungs: rhonchorous throughout, + occ wheezes
CV: Regular rate and rhythm, normal S1 + S2, II/VI SM
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: cool, clammy, 1+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
[**2145-2-28**] 08:30PM WBC-9.9 RBC-5.04 HGB-13.6 HCT-40.9 MCV-81*
MCH-26.9* MCHC-33.2 RDW-16.0*
[**2145-2-28**] 08:30PM NEUTS-82.1* LYMPHS-16.3* MONOS-1.0* EOS-0.5
BASOS-0.2
[**2145-2-28**] 08:30PM PLT COUNT-293
[**2145-2-28**] 08:30PM PT-13.3 PTT-20.6* INR(PT)-1.1
[**2145-2-28**] 08:30PM GLUCOSE-204* UREA N-27* CREAT-1.5* SODIUM-145
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-22 ANION GAP-22*
[**2145-2-28**] 08:30PM ALT(SGPT)-19 AST(SGOT)-23 CK(CPK)-77 TOT
BILI-0.8
[**2145-2-28**] 08:30PM LIPASE-18
[**2145-2-28**] 08:30PM CALCIUM-8.7 PHOSPHATE-4.5 MAGNESIUM-1.5*
[**2145-2-28**] 08:30PM CK-MB-NotDone proBNP-5932*
[**2145-2-28**] 08:30PM cTropnT-0.05*
[**2145-2-28**] 08:35PM LACTATE-4.5*
Brief Hospital Course:
84 yof with a PMH of severe Alzheimer's dementia, CAD s/p CABG
and aortic stenosis admitted with severe septic shock now with
respiratory failure
.
#. Severe Septic Shock - The patient presented with fever to 102
and hypotension despite 5L IVF in the ED. She initially required
triple pressor therapy with levophed, neosynephrine and
vasopressin. Stress dose steroids were added. Lactate elevated
to 4.5. After aggressive volume repletion the patient was slowly
weaned off of pressors. Unclear source of infection, with the
only positive culture data being a Urine culture with
10,000-100,000 cfu/ml. she was treated with a 10 day course of
vancomycin and zosyn.
.
#. Respiratory Failure (non ARDS) ?????? The patient required
intubation on arrival to ED for respiratory distress. CXR
consistent with pulmonary edema. Likely [**3-1**] to severe AS and
sepsis requiring fluid resusciation. The patient developed
persistent pulmonary edema despite aggressive diuresis following
the wean of her pressors. She had several episodes of acute
respiratory distress related to flash pulmonary edema or mucus
plugging. She underwent bronchoscopy with suctioning of
secretions. She also underwent left thoracentesis with
improvement in left effusion on CXR. R sided effusions felt not
large enough to tap. Following extubation the patient has
required intermittent bipap with aggressive pulmonary toileting
and suctioning.
.
#. Severe Aortic Stenosis - The patient has is severe aortic
valve stenosis (area <0.8cm2) with a gradient of 75. She
underwent TEE to rule out vegetation and endocarditis as a
source of sepsis which was negative.
.
# CAD s/p CABG - Ruled out ischemia with negative cardiac
enzymes. Patient was unable to take ASA due to aspiration risk.
.
# Severe Alzheimer's Dementia - baseline speaks in monosyllables
and says yes or no to any questions. Unable to initiate PO meds
at this time.
.
# Hypothyroidism ?????? cont synthroid
.
# FEN: Given baseline dementia, speech and swallow team was
consulted following extubation. Based upon this result, patient
was recommended to be strictly NPO given ongoing aspiration
risk. Pt evaluated by IR for possible percutaneous gastrostomy
placement however given respiratory status was not a candidate
at this time. TPN was initiated following failed swallow
evaluation.
.
# Code: Following extubation a family meeting was held and code
status changed to DNR/DNI. On [**3-17**], a family meeting was held
to discuss patient's inability to remain off NIPPV for long
periods of time. Goals of care were transitioned to comfort
measures and a morphine drip was started. Patient expired less
than 24 hours later.
Medications on Admission:
Unknown
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Respiratory failure
Aspiration
Aortic stenosis
Sepsis
Urinary tract infection
Acute renal failure
Alzheimer's disease
Discharge Condition:
Expired
Followup Instructions:
n/a
|
[
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"424.1",
"041.4",
"244.9",
"507.0",
"785.51",
"038.9",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
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icd9pcs
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[
[
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5615, 5624
|
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|
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223, 247
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|
1572, 1654
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,247
| 121,375
|
51579
|
Discharge summary
|
report
|
Admission Date: [**2141-12-15**] Discharge Date: [**2141-12-28**]
Service: MEDICINE
Allergies:
Phenytoin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain and SOB
Major Surgical or Invasive Procedure:
cardiac cath; no intervention
History of Present Illness:
[**Age over 90 **] yo f w/ a h/o who noted the onset of SSCP last night. Reports
that she had the sudden onset of severe SSCP associated with SOB
last night. The pain began last night.
Associated w/ nausea, vomiting x2 (non-bloody).
.
Per EMS notes, patient was initially c/o SOB, not responsive to
nebs. Subequently had onset of CP -> given sl nitro x3 w/o
response. Noted to have rales, given 40mg iv lasix. Initial bp
110/60, hr 122.
.
In [**Hospital1 **] [**Location (un) 620**] ED, given lopresser 5mg iv x1, asa, and started
on heparin gtt. Transiently on BiPAP. ck 49, TnT 0.513,
Nt-proBNP 5088. D-dimer 2.77.
.
In [**Hospital1 **] ED, t100.6, hr 93, bp 88/64, 96% NRB. Given Levoxyl,
flagyl, heparin. Attempted to place RIJ. Converted to fem line.
Started on levophed. Had bedside TTE.
Past Medical History:
osteoporosis
benign CNS tumor, removed age 70, by report now recurrent
diverticulosis
hypertension
R pubic ramus fracture and R humerus fx [**1-26**] fall sustained [**10-30**]
Social History:
Lives with daughter. Denies history of etoh, tobacco. Prior to
fall from chair one month ago was independent for ADLs.
Family History:
Mother died 78 of MI. Daughter 50s, has mitral valve replacement
of unknown etiology.
Physical Exam:
bp 97.2, hr 89, bp 105/60, rr 22, 6L NC
Well appearing elderly female. No respiratory distress. Speaking
in full sentences.
PERRL.
OP clr.
10cm jvp. Thyroid benign.
Regular s1,s2. IV/VI SEM, radiating throughout the precordium
b/l rales to [**1-27**] lung height.
+bs. soft. nt. nd.
no le edema.
Pertinent Results:
ecg (OSH): 2mm ST elevation in III, 1mm in F. STd in I/L, and
V3-V6.
subsequent ecg in house shows resolution of STe, but remaining
depressions. Follow up on MICU admission shows resolution of
lateral changes, new Qws inferiorly and hyperacute Tws.
.
[**12-15**] TTE: Severely depressed LVEF with regionality c/w CAD.
Severe mitral regurgitation. Moderate pulmonary hypertension.
.
[**12-15**] CT chest/abd:
1. No evidence of aortic dissection, aneurysmal dilatation, or
pulmonary embolism. Bilateral pleural effusions with perihilar
edema and interstitial edema are suggestive of underlying
congestive heart failure.
2. Multiple thoracic wedge compression fractures of uncertain
chronicity and probable nonacute right humeral surgical neck
fracture. Recommend correlation to clinical exam and if acute
fracture is suspected, dedicated imaging to this region.
3. Diffuse coronary and vascular calcifications.
4. Noncalcified sub 5 mm right lower lobe pulmonary nodule.
Given patient's age followup is probably not needed, however, if
clinically indicated, a repeat scan in one year may be ordered
to assess stability if patient has no known primary malignancy.
5. Cholelithiasis without evidence of cholecystitis.
.
[**12-15**] CXR: Probable CHF with pulmonary edema and/or associated
multilobar pneumonia. Incidental note of fracture of neck of
right humerus.
.
Cardiac cath: 1. Selective coronary angiography of this heavily
calcified right dominant system revealed diffuse severe three
vessel and mild-moderate left main disease. The LMCA was heavily
calcified with ostial 30-40% and distal 40% stenoses. The LAD
had diffuse disease with a proximal-mid 80% lesion after a
small-caliber D1 branch (which itself was subtotally occluded
proximally prior to a bifrucation). A long D2 had a proximal
subtotal occlusion. The mid LAD had an 80% lesion involving D3
followed by an aneurysm with diffuse disease in a long distal
LAD. Septal
collaterals supplied the RPDA. The LCX had an ostial 40% lesion,
a
proximal 80% lesion, a modest AV groove vessel with mid 50% and
distal
80% lesions before LPLs. Distal collaterals supplied the RPL
system. The
major OM had an aneurysmal bifurcation lesion with 80% stenosis
into the
lower pole. The RCA had a proximal 60-70% lesion and then was
totally
occluded after the conus and atrial branches with only faint
filling of
acute marginal branches via vasa collaterals; the mid-distal RCA
filled
only retrogradely via left-to-right collaterals.
2. Resting hemodynamics revealed mild pulmonary hyptertension
with PA
pressures 38/14 mmHg. The mean PCW was slightly elevated at 12
mmHg.
Cardiac index was low normal at 2.75 L/min/m2 (based on an
assumed
oxygen consumption). Although the systemic arterial saturation
was low
on 4 L/min NC, it rose appropriately with higher concentration
oxygen
therapy, arguing against significant right-to-left shunting.
3. Left femoral vascular access was utilized due to a right
pelvic
fracture. The left common femoral artery was calcified. The
patient had
a heavily calcified and tortuous left common iliac artery
looping into
the abdominal aorta (traversed using a Magic Torque wire and a
[**First Name8 (NamePattern2) **]
[**Last Name (un) 2493**]-Tip introducing sheath).
4. Left ventriculography was not performed.
.
pelvic Xray:
Evidence of remote trauma involving the right inferior pubic
ramus. No acute fracture seen.
.
discharge labs:
Na 136, K 4.5, bicarb 28, BUN 19. Cr 1.0,
WBC 4.2, hct 28.4, plt 164
.
wbc 4.2, hct 28.4, plt 164
Brief Hospital Course:
A/P: [**Age over 90 **] yo f w/ inf STEMI and subsequent pulmonary edema, 4+MR,
and hypotension.
.
1) CV:
A. Coronaries: pt presented with inf STEMI. Cardiac
cathterization showed severe diffuse three vessel and
mild-moderate left main coronary artery disease; these lesions
were not ammenable to stenting or CABG. She was medically with
heparin gtt x48h, asa 325, plavix 75 QD, lipitor at 40. She
tolerated metoprolol XL at 75mg daily. She developed
hypotension with both imdur and lisinopril (which were stopped).
Her outpatient cardiologist/PCP should restart lisinopril if
her BP can tolerate.
.
B. pump: Ms [**Known lastname **] has left ventricular dysfunction and CHF with
EF 25-30%. She also has papillary muscle dysfunction with 4+ MR,
2+TR. She has had persistant pulmonary edema on exam (L>R) but
this has improved over her course. She was on aldactone for
class III-VI heart failure but this was discontinued due to poor
po intake and hypotension.
.
C. Rhythm: Ms [**Known lastname **] had no ectopy on telemetry
.
2) hypotension- Ms [**Known lastname **] has been periodically hypotense inhouse
likely [**1-26**] combination of volume depletion in the setting of
severe mitral regurg. She was briefly on levophed which was
d/c'd and she was able to be started on BB.
.
4) pelvis fracture- Ms [**Known lastname **] has a pelivic XR showing remote
trauma of R inf pelvic ramus. She also has an old RUE humerus
fx s/p sling. ortho was consulted and did not rec any further
imaging or treatment as fx was old. She was started on lovenox
for anticoag given her pelvic fracture. She should WBAT with a
walker and limit WB to 10lbs of RUE.
.
5) renal insufficiency- Ms [**Known lastname **]' Cr has ranged between 0.7 and
1.1 largely secondary to very poor po intake and dehydration.-
encourage PO intake
.
6) fen- cardiac diet; very poor po intake [**1-26**] decreased
appetite.
.
8) ppx: senna, pantoprazole, lovenox
.
9) full code- confirmed with patient on [**12-17**]
Medications on Admission:
mvi
tylenol prn
asa 81mg qday
folic acid
clonazepam
iron sulfate
triamterene/hctz
phenobarbital 30mg QID
sertraline 50mg qhs
vitamin d 400iu
metoclopromide
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenobarbital 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours).
12. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): hold for sedation or RR<10.
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary diagnosis:
interior STEMI
CAD
Class III-IV NYHA CHF
hypotension
hypertension
left ventricular dysfunction and systolic CHF with EF 25-30% and
MR 4+, TR 2+
pelvic fracture and right humoral from [**10-30**]
Discharge Condition:
fair
AFVSS
Discharge Instructions:
You had a heart attack. You have been given new medications to
help regulate your heart rate and function and try to prevent
any chest pain. Please take these medications as prescribed.
.
You should be careful with your diet and limit your fluid intake
to 1L per day and your salt intake to 2g per day. You should
also weight yourself daily and call your physician if you gain
>3lbs.
.
Your lisinopril was stopped because your blood pressure was low.
Your primary care physician may decided to restart this
medication if your blood pressure can tolerate it.
.
Please notify your physician or go to the emergency room if you
have fevers >100.4, chills, chest pain, shortness of breath,
swelling in your legs, vomiting or abdominal pain or any other
symptoms which are concerning to you.
Followup Instructions:
Follow up appointment made with Dr. [**First Name (STitle) 251**] [**Last Name (NamePattern4) 677**], M.D. and
Dr. [**Last Name (STitle) **]. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2142-3-14**] 3:00PM
.
please follow up with your outpatient orthopaedic doctor for
your right arm fracture
Completed by:[**2141-12-28**]
|
[
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"416.8",
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"276.51",
"428.0",
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"424.0",
"584.9",
"410.41",
"414.01",
"428.40",
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
9016, 9093
|
5417, 7406
|
237, 268
|
9351, 9364
|
1865, 5277
|
10201, 10530
|
1446, 1533
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7613, 8993
|
9114, 9114
|
7432, 7590
|
9388, 10178
|
5293, 5394
|
1548, 1846
|
179, 199
|
296, 1092
|
9133, 9330
|
1114, 1294
|
1310, 1430
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,830
| 144,145
|
14753
|
Discharge summary
|
report
|
Admission Date: [**2178-4-5**] Discharge Date: [**2178-4-18**]
Date of Birth: [**2122-8-11**] Sex: M
Service: SURGERY
Allergies:
Valganciclovir Hcl / Ganciclovir Sodium / Acyclovir Sodium
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
HCV cirrhosis
Major Surgical or Invasive Procedure:
[**2178-4-5**] liver transplant
[**2178-4-10**] hepaticojejunostomy
History of Present Illness:
55 y.o. female with HCV cirrhosis genotype IV diagnosed [**9-1**]
with tow HC lesions s/p ablation with RFA. Presents for possible
transplant. Seen by Dr. [**Last Name (STitle) 497**] most recently [**1-31**]. At that time
MELD was 10 and Chi9ld's score was 7. Was treated with
interferon and ribavirin uintil [**10-2**] when treatment was
disontinued for panytopenia.
Past Medical History:
HCV cirrhosis, 4 varieal cords (esophageal), IDDM, s/ right
colectomy [**12-29**], for toxic colitis Herpes simplex 1, EBV , s/p
appendectomy, cholelithiasis
Social History:
Married. Lives with wife and 11 y.o. son from a prior
relationship
Physical Exam:
NAD, A&O, EOMI
RRR, no murmurs
CTA,
abd obese, soft, NT/ND. midline scar healed. 4cm periumbilical
hernia without tenderness
legs-healing left knee lateral arthroscopy site. residual
erythema with black eshar. 1+ non-pitting edema bilaterally
Pertinent Results:
[**2178-4-5**] 12:39PM PT-13.9* PTT-35.3* INR(PT)-1.2*
[**2178-4-5**] 12:39PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-2.7
MAGNESIUM-1.7
[**2178-4-5**] 12:39PM ALT(SGPT)-41* AST(SGOT)-73* ALK PHOS-82 TOT
BILI-1.8*
[**2178-4-5**] 12:55PM WBC-3.0* RBC-4.07* HGB-12.5* HCT-38.1* MCV-94
MCH-30.7 MCHC-32.8 RDW-14.9
[**2178-4-17**] 05:00AM BLOOD WBC-7.3 RBC-3.14* Hgb-9.4* Hct-27.6*
MCV-88 MCH-29.9 MCHC-34.1 RDW-16.2* Plt Ct-117*
[**2178-4-17**] 05:00AM BLOOD Glucose-177* UreaN-18 Creat-1.5* Na-138
K-3.9 Cl-99 HCO3-32 AnGap-11
[**2178-4-17**] 05:00AM BLOOD ALT-67* AST-21 AlkPhos-51 TotBili-1.4
[**2178-4-16**] 05:00AM BLOOD Albumin-2.7* Calcium-7.8* Phos-5.2*
Mg-1.1*
Brief Hospital Course:
On [**2178-4-5**] he underwent orthotopic liver transplant. Surgeon was
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see operative note for complete details.
Standard induction immunosuppression was given (solumedrol and
cellcept). Two JP drains were placed. Postop, he was transferred
to the SICU intubated where he was extubated the next day. He
received PRBC and plts to keep hct and plt count within
established criteria per pathway. He required an insulin drip
for hyperglycemia. [**Last Name (un) **] was consulted. Diet was slowly
advanced and tolerated.
LFTs trended down each day. Prograf was started on pod1. Dosing
was adjusted based on daily trough levels. The medial JP was
removed on [**4-9**] pod 4. On pod 5 the lateral JP drainage appeared
bilious and bile started to leak from his incision. The t.bili
also was increased to 2.0. He was evaluated by Dr. [**Last Name (STitle) 816**] who
brought him back to the OR ([**4-10**])and performed a Roux en Y
hepaticojejunostomy for a bile leak. He had Diet was slowly
advanced and tolerated. LFTs trended back down to near normal
levels.
On [**2178-4-15**], drip infusion cholangiogram was performed opacifying
the jejunal limb of right hepaticojejunostomy. There was no
reflux into bile ducts and no extraluminal contrast was seen.
The Roux tube was subsequently capped. The JP drainage averaged
700-1000cc per day. Gradually, this output decreased and the
drain was removed on [**4-17**].
He required diuresis with lasix [**Hospital1 **] for several days as he had
anasarca and weight was up ~15 kilograms. Edema improved and
weight dropped to 129.6 kg from 140kg.
He consented to participating in the Maribavir Study and was
enrolled in this study.Pt will take study drug until 14 weeks
post-txp. He is not to receive valcyte during 14 wks while on
study.
PT worked with him and declared him safe for discharge home.
Self medication was implemented. Vital signs remained stable.
Medications on Admission:
amiloride 10mg [**Hospital1 **], lasix 40mg qd, lantus insulin 54 units qhs,
Humalog ss, nadolol 40mg [**Hospital1 **], protonix 40mg qd, protonix 40mg
qd, ursodiol 900 mg qhs, percocet prn, colace 100mg [**Hospital1 **], iron
325mg qd.
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*14 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-26**] Sprays Nasal
QID (4 times a day) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Maribavir Study
continue same dosing instrutions for study protocol
13. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Thirty Eight
(38) units Subcutaneous at bedtime.
Disp:*1 pen* Refills:*2*
14. Insulin Lispro 100 unit/mL Insulin Pen Sig: follow sliding
scale Subcutaneous four times a day.
Disp:*1 pen* Refills:*2*
15. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO qd.
Disp:*30 Tablet(s)* Refills:*2*
17. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Thirty Six
(36) Subcutaneous at bedtime.
Disp:*1 * Refills:*3*
18. lancets
Please provide lancets for his insulin pens - quantity
sufficient for one month
19. test strips
Please provide with one month of test strips for his one touch
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass
Discharge Diagnosis:
HCV cirrhosis
bile leak
DM
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
incision redness/drainage or bleeding
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2178-4-23**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2178-4-30**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2178-5-7**] 3:40
Completed by:[**2178-4-21**]
|
[
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"572.3",
"070.54",
"V12.79",
"V18.0",
"782.3",
"576.8",
"997.4",
"571.5",
"401.9",
"155.0",
"553.1",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"99.07",
"99.04",
"50.69",
"99.06",
"38.93",
"87.54",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
6198, 6253
|
2036, 4023
|
330, 400
|
6324, 6331
|
1342, 2013
|
6558, 7041
|
4310, 6175
|
6274, 6303
|
4049, 4287
|
6355, 6535
|
1079, 1323
|
277, 292
|
428, 799
|
821, 980
|
996, 1064
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,628
| 199,338
|
39355
|
Discharge summary
|
report
|
Admission Date: [**2107-4-26**] Discharge Date: [**2107-5-1**]
Date of Birth: [**2039-8-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending:[**First Name3 (LF) 7744**]
Chief Complaint:
Worsening shortness of breath
Major Surgical or Invasive Procedure:
rigid bronchoscopy and tracheostomy [**2107-4-29**]
History of Present Illness:
67yo female with a history of schizoaffective disorder, DM, HTN
with a history of respiratory failure requiring intubation, then
failure to wean off ventilator (required trach and PEG), now
with post-intubation tracheal stenosis requiring multiple
bronchoscopic procedures with trials of T tubes, tracheostomy
tubes.
This morning she woke up feeling like her normal self. She
usually has a feeling of phlegm in her throat, and for the last
4 days or so her chronic cough has become productive of yellow
sputum. She has had temps up to 99F, but no frank fevers. No
chest pain, palpitations, orthopnea, or worsening LE edema.
After breakfast, around 9am, she acutely felt 'tight', like she
was 'breathing through a straw'. She became very anxious, and
reportedly desaturated to the mid 80's on room air. EMS was
called to her nursing home, but she said she was more relaxed
and her symptoms had improved by the time she was being taken
away by ambulance an hour later. She had one briefer episode of
difficulty breathing in the ambulance, but only lasted about 10
minutes.
Of note, Dr. [**Last Name (STitle) **] has been recommending tracheal resection and
reconstruction. However, the patient has been reluctant.
In the ED, initial VS were: 96.6,146/66,76,19,100 @2L
CXR was clear, and a 20G was placed in the R hand. She was given
albuterol nebs.
Vitals prior to transfer were 96.6,146/66,76,19,100 @2L.
On arrival to the MICU, the patient reported feeling her
baseline. On ROS she notes 3 loose bowel movements per day. She
denies nausea/vomiting, abdominal pain, dysuria. At baseline she
walks with a walker and has not had worsening dyspnea on
exertion or chest pain. She has some chronic joint pains in her
hands. No rash. All other ROS negative.
Past Medical History:
1. Respiratory failure requiring intubation, followed by failure
to wean, requiring tracheostomy.
2. Post-intubation tracheal stenosis, requiring chronic
tracheostomy.
3. Subglottic stenosis causing nearly 90% occlusion of the
airway status post rigid bronchoscopy, tracheal dilatation and
redo percutaneous tracheostomy on [**2106-10-12**].
4. Type 2 diabetes mellitus, insulin dependent.
5. Chronic pain disorder.
6. Schizoaffective disorder.
7. Depression.
8. Hypertension.
9. Glaucoma.
10. Cataracts bilaterally.
.
PAST SURGICAL HISTORY:
1. Trach and PEG placement initially in [**2105-5-5**].
2. Rigid bronchoscopy, tracheal dilatation and redo percutaneous
tracheostomy on [**2106-10-12**].
Social History:
Prior to hospitalization for PNA in Summer [**2104**], the patient
lived alone in [**Location (un) 1294**]; she now lives at [**Hospital 44563**]
nursing home ([**Hospital1 **] system). She retired as a school teacher
(French and [**Doctor First Name 533**]). She smoked 2 ppd for 40 years.
HCP: (brother) [**Name (NI) 2174**] [**Name (NI) **] [**Telephone/Fax (1) 86961**]
Family History:
Father: died brain tumor
Mother: died from CHF
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.4 BP: 141/63 P: 81 R: 28 O2: 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, prominent adenoids, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi. Has inspiratory stridor
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
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
DISCHARGE
Vitals: 99.5 122/75 89 20 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Lungs: mild ronchi, otherwise clear to auscultation bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley w/ yellow, clear urine
Pertinent Results:
Lab Results on Admission:
[**2107-4-26**] 03:40PM BLOOD WBC-9.2# RBC-3.62* Hgb-10.7* Hct-34.0*
MCV-94 MCH-29.6 MCHC-31.5 RDW-14.7 Plt Ct-305
[**2107-4-26**] 03:40PM BLOOD Neuts-65.1 Lymphs-25.4 Monos-5.5 Eos-3.5
Baso-0.4
[**2107-4-26**] 03:40PM BLOOD Glucose-142* UreaN-16 Creat-0.8 Na-138
K-4.4 Cl-99 HCO3-25 AnGap-18
[**2107-4-26**] 03:40PM BLOOD proBNP-83
[**2107-4-27**] 06:54AM BLOOD Calcium-8.7 Phos-4.6*# Mg-2.3
Imaging:
Radiology Report CHEST (PA & LAT) Study Date of [**2107-4-26**] 3:52 PM
IMPRESSION: No acute cardiopulmonary process.
Discharge labs:
[**2107-5-1**] 07:24AM BLOOD WBC-10.7 RBC-3.42* Hgb-9.8* Hct-31.3*
MCV-92 MCH-28.8 MCHC-31.4 RDW-14.3 Plt Ct-249
[**2107-4-30**] 10:58AM BLOOD Glucose-83 UreaN-14 Creat-0.8 Na-139
K-4.2 Cl-99 HCO3-31 AnGap-13
[**2107-5-1**] 07:24AM BLOOD Glucose-234* UreaN-21* Creat-0.9 Na-135
K-4.3 Cl-96 HCO3-28 AnGap-15
[**2107-4-30**] 10:58AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.2
[**2107-5-1**] 07:24AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.2
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 67yo female s/p
post intubation for hypoxic respiratory failure with subsequent
tracheal stenosis, s/p multiple IP procedures, who presents with
an episode of stridor and difficulty breathing. The episode
self-resolved but given patient's tenuous airway with stenosis
and increased sputum, she was admitted for observation and
potential IP management.
ACUTE CARE:
# Tracheal stenosis:
Unclear whether this was a discrete episode, or a worsening that
requires urgent intervention, but patient did experience desats
to 80's at rehab. While she's had an increase in yellowish
sputum, but no fevers and no leukocytosis to suggest infection.
Given that she was not having difficulty breathing following
admission she was not given a repeat dose of steroids and there
was no evidence to start antibiotics. The patient was seen by IP
who recommended tracheal resection and reconstruction with
thoracic surgery, however, the patient deferred in favor of
repeat trach. She underwent successful trach on [**2107-4-29**] w/
placement of #6 cuffed Portex, and resumed a normal diet on
[**2107-4-30**] with no issues. Pt had minimal pain and bleeding after
the procedure. Pt was discharged to [**Hospital1 1501**] w/ instruction for the
facility to provide a portex thermovent tracheostomy valve to be
used during the day and then removed at night and leave to the
trach collar humidifier. The portex thermovent tracheostomy
valve will need to be changed daily. The [**Hospital1 1501**] will also provide
Passy Muir valve to be used during the day as needed to aid with
speech. Pt will use only the Trach collar at night.
The rehab facility should remove the 2 sutures holding the trach
in 2 weeks and keep the trach collar belt on thereafter. IP has
also recommended red cap trials as tolerated for one hour at a
time starting on Tuesday [**2107-5-3**].
# Anemia
Patient with chronic anemia likely due to anemia of chronic
disease. Did note a HCT drop from baseline 33-35 to 31
following tracheostomy. No signs of active bleeding and patient
remained hemodynamically stable. Would recommend repeat HCT upon
discharge to ensure remains stable.
# Urinary Retention
Patient developed urinary retention following IP procedure.
Possibly related to anesthesia. Patient does report h/o urinary
retention with previous hospitalizations. Bladder scan revealed
up to 800cc urine. Patient straight cathed several times, then
foley placed on [**2107-5-1**]. She will need a voiding trial in about
two days. If she continues to have difficulty voiding, could
consider holding Benztropine as this can cause urinary retention
with further investigation of underlying cause.
CHRONIC CARE
# Diabetes:
Continued home insulin regimen.
# CAD/Hypertension:
Continued home lisinopril, labetalol, amlodipine, aspirin and
atorvastatin.
# Depression/Anxiety:
Continued home citalopram, clonazepam and lorazepam.
# Schizoaffective:
Continued resperidone and benztropine.
# GERD:
Continued home omeprazole and ranitidine.
TRANSITION OF CARE:
-followup with interventional pulmonary clinic
-voiding trial and evaluation of urinary retention
-repeat CBC
Medications on Admission:
Duonebs IH QID
Lasix 20mg PO daily
Flonase 1 spray NU daily
Clonazepam 0.5mg PO BID
Clonazepam 0.5mg PO Q4H:PRN insomnia
Bisacodyl 10mg daily:PRN consiptation
Milk of Mag 30mL daily:PRN constipation
Lisinopril 30mg PO daily
Tylenol 650mg PO/PR Q4H:PRN pain/fever
Lipitor 10mg PO QHS
Acidophillus 1 tab PO BID
Amlodipine 10mg PO daily
Senna 1 tab PO QHS
Citalopram 20mg PO daily
Risperidone 4mg PO BID
Benztropine 0.5mg [**Hospital1 **]
Labetalol 200mg PO BID
Colace 100mg PO BID
guaifenesin 600 mg ER PO BID
latanoprost 0.05% 1 drop OU QHS
Ranitidine 300mg PO QHS
Lantus 58 units SC QHS
Novolog 12 units before breakfast/lunch, 8 units before dinner
MVI 1 tab PO daily
ASA 81mg PO daily
Omeprazole 40mg PO daily
Discharge Medications:
1. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) nebulizer Inhalation four times a day.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO once a day as needed for constipation.
8. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Acidophilus Capsule Sig: One (1) Capsule PO twice a day.
12. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. risperidone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
20. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic OU
QHS.
21. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
22. insulin glargine 100 unit/mL Solution Sig: Fifty Eight (58)
UNITS Subcutaneous at bedtime.
23. Novolog 100 unit/mL Solution Sig: AS DIRECTED Subcutaneous
AS DIRECTED: 12 units before breakfast/lunch, 8 units before
dinner .
24. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
25. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
26. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
27. Medical Equipment
Please provide a portex thermovent tracheostomy valve. Change
daily. Only use during the day. (Trach collar at night).
28. Medical equipment
Please provide Passy Muir valve to aid with speech when needed.
Remove this at night. (Use trach mask at night)
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 44563**] Nursing and Rehabilitation Center - [**Hospital1 10478**]
Discharge Diagnosis:
Subglottic Tracheal stenosis
Secondary:
type 2 diabetes
chronic pain
schizoaffective disorder
depression
hypertension
glaucoma
cataracts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 174**],
You were admitted to [**Hospital1 18**] because you were having trouble
breathing. We were concerned that this was related to your
tracheal stenosis. You underwent successful tracheostomy. It is
very important that you protect against self-deccanulation.
Please follow up with the interventional pulmonologist after
discharge.
No changes were made to your medications. Please continue taking
all of your medications as previously prescribed. It was a
pleasure taking care of you.
You will be provided with a passy muir valve and a portex
thermovent at your rehabilitation facility.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2107-5-10**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2107-5-10**] at 10:00 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"E938.4",
"295.70",
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"278.03",
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"V85.36",
"300.4",
"788.20",
"496",
"793.11",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.29",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
11872, 11982
|
5451, 8624
|
311, 365
|
12164, 12164
|
4437, 4449
|
12993, 13686
|
3281, 3329
|
9387, 11849
|
12003, 12143
|
8650, 9364
|
12347, 12970
|
5005, 5428
|
2715, 2872
|
3344, 3358
|
241, 273
|
393, 2151
|
4464, 4989
|
12179, 12323
|
2173, 2692
|
2888, 3265
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,093
| 145,101
|
48896
|
Discharge summary
|
report
|
Admission Date: [**2114-12-16**] Discharge Date: [**2115-1-1**]
Date of Birth: [**2062-3-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Pericardial drain placement and removal
History of Present Illness:
This is a 52 y/o woman with h/o HIV (last CD 4 801, VL 84,700 on
[**2114-11-21**]) who p/w chief complaint of chest pain. Patient states
that beginning last friday she began to feel short of breath.
First noted the sensation with exertion when she was nearly
unable to climb the three flights of stairs to her residence.
Thereafter she noted that she felt short of breath with
speaking, and began to have chest pain. She says the pain was
sharp, located in the center of her chest but at times radiated
to the back, and shoulder. This pain was constant, but worse
with exertion and ? worse with breathing. Patient endured pain
over the weekend, but on Sunday AM was brought to ER by EMS
after counselor in her shelter insisted.
.
In ED, T98.2, HR 120's, BP 123/83, RR 20, 96-100% on
non-rebreather. Patient was uncomfortable appearing and c/o
pleuritic chest pain. pulsus 7mmHg. EKG demonstrated diffuse PR
depressions and 1mmHg ST elevations. CT chest demonstrated large
pericardial effusion and possible RV diastolic collapse. Cards
consult found pulsus to be 11mmHg. Patient was given ASA 325,
Morphine 2mg x3, zofran, levofloxacin 500mg PO and taken to Cath
lab for treatment/evaluation of tamponade.
.
In Cath lab, RA pressure was mean 22mmhg (pre-drain), RV 37/19
mean 17, wedge 18mmHg, PA sat 39%, PA Pressure 46/25 mean 33,
pericardial opening pressure of 20mmHg. After 685cc sanguinous
fluid was removed RA pressure was 4, pericardial pressure was 4.
Patient complained of [**7-8**] left shoulder pain following drain,
better with movement, given 75ucg of fentanyl with some relief.
Patient then admitted to CCU for management.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- HIV: Last CD4 801, VL 84,700. Not on HAART. Denies h/o
opportunistic infections.
- Depression
- Lung Cancer - diagnosed on recent admission -> found to have
post-obstructive pneumonia, Bronchoscopy demonstrated non-small
cell lung cancer in washings although endobronchial lesion
reportedly negative for malignancy. Recent MRI brain negative
for metastatic disease to brain, PET scan + for mets to left
lung, hilar lymphadenopathy, possibly r-ischium and spleen.
Splenic lesions possibly c/w lymphoma or inflammatory response
to tumor.
.
Cardiac Risk Factors: No known history of diabetes,
dyslipidemia, hypertension
Social History:
Patient has a history of tobacco use, recently quit and is on
the nicotine patch 7mg/day, denies illicit drug use but has
history of cocaine use, lives at a shelter for women with HIV x
8 months. Applying for Mass Health for housing assistance. Has
two children. History of domestic abuse from ex-husband (?).
Family History:
Family history non-contributory.
Physical Exam:
VS: T 99.3, BP 127/82, HR 114 Sinus , RR 28, O2 100 % on 4L NC,
pulsus 7mmHg
Gen: Middle-aged woman, uncomfortable appearing, diaphoretic
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple.
CV: Pericardial drain in place, +pericardial friction rub,
Normal S1, S2, no S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were labored. No wheezing, rales, ronchi.
Abd: Overweight, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. R-femoral groin line in place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
CTA chest [**2114-12-16**]: 1. Massively increased pericardial effusion
which is now large and measures slightly dense, worrisome for
complex effusion including malignant or hemorrhagic etiologies.
There appears to be compression on the right ventricle and right
atrium and echocardiogram is recommended to assess for
tamponade. No evidence of pulmonary embolism or aortic
dissection. 2. No significant interval change to known non-small
cell lung carcinoma involving the right suprahilar region
causing obstruction of the posterior upper lobe bronchus. New
peripheral opacity within the upper lobe likely represents a
post-obstructive pneumonitis/pneumonia. 3. Slight enlargement of
bilateral metastatic lesions since chest CT [**2114-12-3**]. New small
bilateral pleural effusions (right greater than left). 4.
Increased interstitial septal thickening, best appreciated
within the left upper lobe, is likely related to mild amount of
interstitial pulmonary edema. Lymphangitic carcinomatosis cannot
be excluded. 5. Persistent but unchanged axillary, mediastinal,
and hilar lymphadenopathy.
.
Chest PA/Lat: 1. Short interval development of marked cardiac
enlargement, without overt pulmonary edema, concerning for
pericardial effusion. 2. Right upper lobe opacity, consistent
with known mass/consolidation. Numerous pulmonary nodules
consistent with metastatic disease.
.
ECHO [**12-16**]: Overall normal left ventricular cavity size and
systolic function (LVEF>50%). Regional function could not be
assess. The right ventricular cavity is mildly dilated with
hypokinesis of the mid-free wall. The aortic valve is grossly
normal. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a trivial pericardial effusion. A catheter is seen in
the pericardial space.There are no echocardiographic signs of
tamponade. Compared to the prior study of earlier in the day
(images reviewed; [**2114-12-16**]), the pericardial effusion has
nearly resolved and tamponade physiology is no longer observed.
Right ventricular cavity enlargement with free wall hypokinesis
is now identified.
.
ECHO [**12-16**]: Overall left ventricular cavity size and systolic
function are normal (LVEF>55%). The right ventricular cavity is
somewhat small. There is a large circumferential pericardial
effusion with right ventricular and right atrial diastolic
collapse as well as accentuated respiratory variation in
mitral/tricuspid valve inflows all consistent with impaired
fillling/tamponade physiology.
.
Pericardial fluid: Pericardial fluid: POSITIVE FOR MALIGNANT
CELLS consistent with non-small cell carcinoma. Markedly
atypical cells present.
.
CXR [**12-18**]: 1. Interval decrease in overall cardiac size as well
as pulmonary vascular congestion. Pericardiocentesis catheter
noted.
2. Right upper lobe volume loss and right suprahilar mass as
well as multiple pulmonary nodules again noted. 3. Persistent
left basilar atelectasis.
.
[**12-18**] ECHO: Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%) Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are mildly thickened. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2114-12-17**], the findings are similar. There is no
accumulation of pericardial fluid.
.
[**12-19**] ECHO: Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size is normal. Right ventricular
systolic function is normal. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade. Compared with the prior study (images reviewed) of
[**2114-12-18**], the findings are similar. The previously seen focal
hypokinesis of the right ventricular free wall (mentioned on
report of [**2114-12-17**]) is not seen on the current study. The
right ventricular free wall may be slightly thickened.
.
[**12-21**] ECHO
.
This study was compared to the prior study of [**2114-12-19**].
LEFT VENTRICLE: Overall normal LVEF (>55%).
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2114-12-19**],
no change.
[**2114-12-16**] 09:40PM TYPE-[**Last Name (un) **]
[**2114-12-16**] 09:40PM LACTATE-1.0
[**2114-12-16**] 09:30PM GLUCOSE-111* UREA N-11 CREAT-0.7 SODIUM-133
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-9
[**2114-12-16**] 09:30PM LD(LDH)-249 CK(CPK)-46 AMYLASE-118*
[**2114-12-16**] 09:30PM CK-MB-NotDone cTropnT-<0.01
[**2114-12-16**] 09:30PM TOT PROT-6.5 ALBUMIN-3.2* GLOBULIN-3.3
CALCIUM-8.5 PHOSPHATE-2.5* MAGNESIUM-2.1 IRON-20*
[**2114-12-16**] 09:30PM calTIBC-241* FERRITIN-181* TRF-185*
[**2114-12-16**] 09:30PM URINE HOURS-RANDOM
[**2114-12-16**] 09:30PM URINE bnzodzpn-POS barbitrt-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
[**2114-12-16**] 09:30PM WBC-7.6 RBC-3.20* HGB-9.4* HCT-28.6* MCV-89
MCH-29.3 MCHC-32.8 RDW-13.5
[**2114-12-16**] 09:30PM PLT COUNT-298
[**2114-12-16**] 09:30PM PT-13.9* PTT-25.1 INR(PT)-1.2*
[**2114-12-16**] 05:30PM OTHER BODY FLUID WBC-8950* HCT-24.5* POLYS-36*
LYMPHS-8* MONOS-0 EOS-1* MESOTHELI-17* MACROPHAG-22* OTHER-16*
[**2114-12-16**] 09:36AM LACTATE-2.9*
[**2114-12-16**] 09:30AM GLUCOSE-131* UREA N-12 CREAT-0.8 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-23 ANION GAP-15
[**2114-12-16**] 09:30AM estGFR-Using this
[**2114-12-16**] 09:30AM CK(CPK)-46
[**2114-12-16**] 09:30AM CK-MB-NotDone cTropnT-<0.01
[**2114-12-16**] 09:30AM WBC-8.5 RBC-3.58* HGB-10.6* HCT-31.2* MCV-87
MCH-29.5 MCHC-33.9 RDW-13.7
[**2114-12-16**] 09:30AM NEUTS-62.0 LYMPHS-32.8 MONOS-4.1 EOS-0.9
BASOS-0.2
[**2114-12-16**] 09:30AM PLT COUNT-297
[**2114-12-16**] 09:30AM PT-13.2 PTT-24.8 INR(PT)-1.1
.
AT DISCHARGE
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2114-12-31**] 06:40AM 4.6 3.23* 9.4* 28.4* 88 29.0 33.0 14.6
249
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2114-12-28**] 08:05AM 19* 0 76* 2 0 2 1* 0 0
Brief Hospital Course:
ASSESSMENT/PLAN: 52 y/o F with h/o HIV (last CD4 801, VL [**Numeric Identifier 102681**]
on [**2114-11-21**]), not on HAART, p/w chest pain and SOB found to be
in pericardial tamponade and admitted to the CCU s/p
pericardiocentesis and drain placement, transferred to OMED for
chemotherapy.
.
# Pericardial Effusion: With clinical and echocardiographic
signs of cardiac tamponade on presentation. The patient was sent
emergently to the cath lab where tamponade physiology was
confirmed with a R heart cath and a pericardiocentesis was
performed with aspiration of 685 ccs of sanguinous fluid. After
pericardiocentesis, the RA pressure and pericardial pressures
were 4. She was then transferred to the CCU where a repeat TTE
was significant for an absence of remaining pericardial fluid.
Pericardial fluid studies were significant for malignant cells
consistent with non-small cell lung carcinoma. All other
studies, including a gram stain, bacterial culture, fungal
culture, and AFB stain were negative. A PPD was negative. The pt
was given toradol, percocet, and IV morphine prn for pain.
Serial EKGs, pulsus pardoxus, and TTEs were all negative for a
rapidly reaccumulating pericardial effusion. The pericardial
drain was pulled on [**12-18**]. Subsequently, she was assessed
clinically daily and visited often by Dr [**First Name (STitle) 437**] (cardiologist),
with no recurring signs of jugular distention or tamponade.
Oncology was reconsulted who recommended palliative
chemotheraphy. Cardiac and thoracic surgery teams were also
called for possible placement of a pericardial window prior to
initiation of chemotherapy and the patient was determined to not
be a good surgical candidate.
In OMED, the patient received chemotherapy
(carboplatin/gemcitabine regimen)
but a second dose was not feasible due to neutropenia.
Neutropenia subsequently corrected. The functional status of the
patient was good throughout her stay in OMED and toward the end
of her stay her main issue keeping her in the hospital was her
unwillingness to be placed at the various institutions
recommended by the team, social work, and case management. This
was resolved satisfactorily in the end. It was felt that she
would be a good candidate for further outpatient chemo. She did
receive chemo again prior to discharge.
.
# ID/HIV: The patient had never previously been on HAART and CD4
count 801 in [**11-4**]; HAART therapy initiated due to need for
palliative chemotherapy. She was started on efavirenz and
emtricitabine-tenofovir. PPD was negative for w/u of her
hemorrhagic pericardial fluid. HAART had to be stopped due to
renal failure, tghen restarted at discharge. She was also
arranged for follow up with infectious disease.
.
# Anemia: c/w anemia of chronic disease. Hct decrease from 37 to
31 over 1 week, likely [**3-2**] hemorrhagic pericardial effusion.
Stools were guaiac negative. Iron studies c/w ACD.
.
# Asthma: Continued albuterol and ipratropium PRN.
.
# Tobacco/Substance Abuse: +UTox for cocaine in [**2112**], utox on
admission negative. Recently quit smoking, provided Nicotine
patch.
.
#Depression: Continued Quetiapine 200mg qhs, 100mg [**Hospital1 **].
.
Follow up was arranged with all of the different specialists and
the patient was not SOB and had no pain at discharge.
Medications on Admission:
Quetiapine 200mg qhs, 100mg [**Hospital1 **]
Albuterol INH q6h
Ipratropium INH q6h
Discharge Medications:
1. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*1 bottle* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Non-small cell lung cancer
HIV
Secondary:
Depression
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with
appropriate follow up.
Discharge Instructions:
You were admitted to the hospital with chest pain and trouble
breathing and you were found to have fluid around your heart.
The fluid was drained and your symptoms of chest pain and
shortness of breath improved. The cause for the fluid around
your heart is related to your cancer. You were found to have
non-small cell lung cancer and you were treated with two cycles
of chemotherapy with gemcitabine and carboplatin.
Please keep all follow up appointments. They are listed below.
You will need to follow up with your new oncologist Dr. [**Last Name (STitle) 3274**]
and your new cardiologist Dr. [**First Name (STitle) 437**].
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] or seek medical attention in
the emergency room if you experience any chest pain, shortness
of breath, nausea, vomiting, abdominal pain, or any other
concerning symptom.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2115-1-8**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2115-1-8**] 9:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2115-1-2**] 10:30
Call Dr [**First Name (STitle) 437**] (cardiology) to make an appointment at [**Telephone/Fax (1) 102682**] as unable to make an appointment.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"423.8",
"785.6",
"785.0",
"042",
"423.3",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"99.25",
"88.72",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
14117, 14175
|
10345, 13633
|
326, 367
|
14282, 14372
|
3997, 10322
|
15300, 15971
|
3167, 3201
|
13766, 14094
|
14196, 14261
|
13659, 13743
|
14396, 15277
|
3216, 3978
|
276, 288
|
395, 2179
|
2201, 2822
|
2838, 3151
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,990
| 166,067
|
51856
|
Discharge summary
|
report
|
Admission Date: [**2133-5-5**] Discharge Date: [**2133-5-9**]
Service: MEDICINE
Allergies:
Tetanus Toxoid
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Shortness of Breath, Black Stool
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
87 M with CAD, CHF, afib w/ pacer on warfarin, as well as
diverticulosis and atrophic gastritis who presented to clinic
c/o 3 week band-like shoulder and chest pain assoc w/SOB in
setting of black stools. Reports shortness of breath primarily
with exertion. No associated light headedness, dizziness,
nausea, palpitations. Reports slight chest tightness with
exertion but not as great as CP he has experienced in the past.
.
Over the past week PCP had [**Name9 (PRE) 107391**] diuresis with metazolone
and furosemide given increased LE edema and sob and concern for
pulmonary edema. Pt presented to [**Hospital 6435**] clinic today with above
complaints where vitals Pt w/ BP of 82/50, HR 70 (paced) RR 16.
Regarding black stool, pt has known h/o atrophic gastritis and
diverticulosis by last endoscopy in 5/[**2132**]. On arrival to ED
labs concerning for anemia to hct 23 and elevated INR at 6.
.
In ED, recevied 1 L NS, 2 u FFP, 5 mg IV vitamin K, 40 mg IV
protonix. Noted to have HCT drop to 23.9 from 31. NG lavage
done in ED, clear. On arrival to MICU, pt. hemodynamically
stable.
Past Medical History:
-CAD: status post IMI [**2115**], status post 3 vessel CABG.
-CHF, diastolic: EF 55% in [**2131**]
-Hypercholesterolemia
-Atrial fibrillation with history of slow ventricular response,
requiring [**Company 1543**] pacer
-Asbestosis: previous pipefitter. Stable calcified pleural
plaques. PFT's [**2131-7-13**] showed mild restrictive ventilatory
defect.
-Thrombocytopenia
-Occult blood positive stools
-GERD
-Arthritis
-Stable pleural effusion, since approximately [**2132-9-26**]
Social History:
No prior tobacco use. Has not drank in past 10-15 years.
Previously worked as a plumber/pipefitter.
Lives alone. Five children live in area.
Family History:
Father died of CAD. Mother suffered from diabetes. Family
history of CAD.
Physical Exam:
VS: 96.7 / 125/53 / 60 / 16 / 100% RA
GEN: Pleasant, articulate, A&Ox3, not in acute distress, not SOB
lying at 30 degrees in bed on 2 pillows
HEENT: JVD to 12 cm, no LAD, OP clear, EOM intact, anicteric
sclerae. No obvious collection of blood/clot in oropharynx.
Tissue stained with blood in R nostril at site of NGL.
LUNGS: CTA
HEART: RRR, 2/6 SEM at apex, no r/g
ABD: distended but soft, tympanitic, no fluid wave. nontender,
normal bowel sounds., mildly obese Rectal - no melena, blood
oozing from anus.
EXTR: Warm, 1+ pitting edema bilaterally
NEURO: [**5-30**] motor, sensation grossly intact
SKIN: No rash
Pertinent Results:
LABS - HCT 23.9, Cr 2.1, INR 6.1
IMAGING -
<b>CXR</b> - diffuse patchy b/l infiltrates c blurring of L
hemi-diaphragm, cardiomegaly though AP film
EKG - paced rhythm at 60
EGD [**2133-5-6**]:Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Brief Hospital Course:
A/P: 87 M c CAD p/w GIB.
.
1. GIB - Ddx included UGIB [**2-27**] gastritis vs. ulcer vs. LGIB [**2-27**]
diverticulosis. Hx is more consistent with a UGIB. In MICU, pt.
received 2 u pRBCs, 4 u FFP to reverse supratherapeutic INR.
Anti-HTN meds held. Pt. remained HD stable and HCT bumped
appropriately. Tx c IV PPI drip prior to upper scope. Upper
endoscopy performed showing normal stomach, duodenum. Pt was
transferred to regular hospital floor where he tolerated regular
diet and was stooling w/o BRBPR/melena. Pt had stable HCT.
.
2. SOB - Felt likely related to anemia rather than worsening
CHF. Pt. on discahrge from MICU was able to get out of bed to
chair without difficulty; plans made for PT to eval pt.
.
3. CAD - Elevated troponin noted and felt to be [**2-27**] renal
failure. CK normal and pt. ruled out for MI. No episodes of CP
in MICU. Beta blockers, ace-I held and gradually restarted.
Isosorbide mononitrate given intermittently as BP allowed.
.
4. Afib - Anticoagulation held; Beta blockers as above.
.
5. Renal Failure - Cr 2.1; baseline 1.2-1.3. With volume
resuscitation, pt. quickly returned Cr to 1.4; suspect prerenal
etiology. No evidence of obstruction.
Medications on Admission:
1. Isosorbide Mononitrate 20 mg PO BID
2. Aspirin 81 mg DAILY
3. Atenolol 25 mg DAILY
4. Furosemide 40 mg twice a day
5. Lisinopril 10 mg DAILY
Discharge Medications:
1. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 QS* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GI bleed
Discharge Condition:
stable
Discharge Instructions:
You had a condition called a GI bleed. Please present to the
hospital or call your primary care physician if you have blood
in your stool, if you have chest pain/shortness of breath,
fever/chills, headache/dizzyness.
We have restarted you on your blood pressure medications except
for the lasix(furosemide) please be sure to be seen in your
primary care clinic within the next week with regard to
restarting your lasix.
Please take all of your medications as directed and follow up
with all of your appointments.
Followup Instructions:
You have the following appointments:
Please be seen in your primary care clinic to have your
hematocrit checked as well as for restarting lasix dosing within
the next week.
Provider: [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2133-6-9**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2133-5-26**] 11:00
Gastroenterology: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD.
Please call ([**Telephone/Fax (1) 2233**] for an appointment.
|
[
"V58.61",
"790.92",
"V45.81",
"530.81",
"428.32",
"272.0",
"427.31",
"244.9",
"535.51",
"501",
"428.0",
"285.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5063, 5120
|
3090, 4282
|
252, 258
|
5173, 5182
|
2793, 3067
|
5744, 6393
|
2066, 2142
|
4476, 5040
|
5141, 5152
|
4308, 4453
|
5206, 5721
|
2157, 2774
|
180, 214
|
286, 1382
|
1404, 1889
|
1905, 2050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,632
| 187,176
|
8740
|
Discharge summary
|
report
|
Admission Date: [**2145-8-1**] Discharge Date: [**2145-8-11**]
Date of Birth: [**2073-12-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Nsaids
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Intubation, tunnelled hemodialysis catheter placement
History of Present Illness:
71 y.o. male NH resident with h/o DM, ESRD, [**Hospital 3593**] transferred from
[**Hospital **] Hospital [**2145-8-1**] where he presented with L sided
weakness after dialysis. [**Name6 (MD) **] [**Name8 (MD) **] RN upon return from HD, the pt
refused his dinner, was incontinent of urine, conused. T101.1,
128, 74/56 and 92% on RA. He was then transferred to [**Hospital **]
Hospital, where T 103.1, bp 147/55. He then became hypotensive
to 92/42, AT OSH, Urine culture, blood cultures drawn, X ray,
and head CT performed and he received NS and tylenol. He was
noted to be unable to lift left arm or squeeze with left hand
and c/o LLQ pain. He was then transferred to [**Hospital1 18**] per family
request. In the ED here, he received 8 L IVF, vancomycin,
levofloxacin, and metronidazole prior to admission to the ICU
for presumed sepsis. In ED head CT (-) for acute change, Abd CT
(-).
*
Following MICU admission, pt was continued on levo/flagyl/vanco.
On [**8-1**] a.m., he became acutely SOB, ABG c/w hypercarbic
respiratory failure, at which time pt was intubated and started
on levophed for blood pressure support. Blood cultures from [**8-1**]
grew [**3-8**] S. aureus (sensitivities pending), at which time his
abx were changed to vanco/gent. He was extubated the evening of
[**2145-8-1**] and his tunnelled dialysis cathter was removed [**8-2**] a.m.
He was transferred to the medical floor following verification
of hemodynamic stability.
Past Medical History:
1) Diabetes mellitus, c/b Diabetic neuropathy, nephropathy
2) End-stage renal disease on hemodialysis- new catheter on
[**2145-7-13**]
3) Coronary artery disease s/p CABG [**2133**]
- [**7-7**] PMIBI: severe fixed inferior perfusion defect, partially
reversible lateral defect EF 18%
- [**7-7**] TTE: LA mod dil, RA mildly dil, inferior akinesis and
severe anteroseptal and mid to distal inferolateral hypokinesis.
EF 30%
4) Hypertension.
5) History of supraventricular tachycardia.
6) History of L pontine CVA in [**2143-7-5**]- head MR [**First Name (Titles) **] [**Last Name (Titles) 4579**]d moderate stenosis in the mid-basilar artery region
-p/w L sided weakness.
7) History of chronic anemia.
8) Depression
9) h/o Klebsiella UTI
Social History:
Resident of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Has two sons. > 100 pk yr history; quit
2 years ago. H/o heavy EtOH use but has quit (unable to state
when he quit and how much he used to drink). Pt is unable to
state when he quit and how much he used to drink.
Family History:
Father and mother had DM. Cannot recall what they died of.
Physical Exam:
Tc 98.9, Tm 99.8, pc 90, pr 90s-110s, bpc 121/88, bpr
100s-130s/40s-50s, resp 11, 98% 2L NC
Gen: chronically-ill appearing, elderly male, A&OX3, NAD
HEENT: anicteric, pale conjunctiva, OMMM, OP clear, neck supple,
no LAD, JVP ~ 11 cm.
Cardiac: distant heart sounds, S1, S2, II/VI SM at apex, no R/G
Pulm: Carckles at bases bilaterally
Abd: NABS, soft, NT/ND, no HSM
Extremities R AKA, L BKA, Stage I sacral decubitus, warm with
good cap refill
Neuro: (+) left face droop, otherwise CN II-XII grossly intact
and symmetric bilaterally, 4+/5 strength throughout, symmetric
bilaterally.
Pertinent Results:
[**2145-8-2**]
wbc 8.5, Hgb 85, HCT 27.9 (from 24.7), plt 113 MCV 106, RDW 17.2
Na 141, K 3.8, Cl 107, HCO3 23, BUN 24, Cr 3.2, glc 216 AG 11,
MG 1.3 (repleted)
lactate 1.9 (from 4.1)
.
[**2145-8-1**]
PT 14.9, INR 1.5, PTT 37.7 FBG 224
Brief Hospital Course:
1) S. aureus bacteremia: The patient was admitted directly to
the MICU from the ED with the diagnosis of sepsis. He required
a brief period of intubation and blood pressure support, but was
quickly weaned off of the ventilator. Vancomycin and Gentamycin
were started, with renal dosing. The left subclavian
hemodialysis catheter was removed, and prurulent drainage was
visualized during removal. A temporary right IJ was inserted
for central venous access. The patient was then transferred to
the medical floor for further care. A temporary hemodialysis
catheter was placed in a left groin location. Surveillance
cultures were drawn, revealing [**12-8**] positive for s. aureus, then
0/4 and 0/4 on subsequent days. Infectious disease consult was
obtained. A TTE and TEE were both performed and were negative
for vegetations. Bilateral subclavian ultrasounds were
performed, revealing no abscesses, but the right side was
notable for a non-occlusive thrombus in the R subclavian. For
this reason, the decision was made to continue vancomycin
treatment for 4 weeks, with trough goal between 15-20.
Gentamycin was stopped.
.
2) CAD: An initial EKG performed on admission revealed ST
depressions in leads V4-V6. Cardiac enzymes were obtained and
revealed no elevations in troponins x3. The patient was
continued on his statin and Plavix, but due to his sepsis his
beta-blocker was held until he was transferred back to the
medical floor. He was then started on low dose metoprolol,
which can be titrated up as his BP increases.
.
4) L sided weakness: The patient experienced a worsening of his
left sided previous CVA symptoms in the context of his
infected/septic state. These symptoms improved with treatment
of the infection and the patient had returned to his baseline by
the termination of the hospitalization.
.
5) Hypertension: the patient's lisinopril and B-blockers were
both held on admission secondary to hypotension. Once he had
been transferred back to the general medical floor, low dose
lopressor was started to provide some B-blockade in the context
of his CAD. The B-blocker can be titrated up after discharge,
and his lisinopril can be added back as blood pressure
tolerates.
.
6) Anemia: The patient reportedly has a baseline anemia that was
initially worsened during the hospitalization by large volume
fluid resuscitation. Iron studies were sent and were consistent
with anemia of chronic disease. Folate supplementation was also
begun. The patient was noted to have trace guiac positive
stools, which should be followed up with an outpatient
colonoscopy. The patient received 2u PRBC in his first dialysis
following transfer to the general medical floor, with an
appropriate hematocrit increase. Transfusion threshold was set
at 28 due to the patient's coronary artery disease.
.
7) ESRD: Because the patient's permacath HD catheter in the L
subclavian had to be discontinued due to the patient's septic
state, a temporary L groin catheter was inserted for
hemodialysis. Unfortunately, this temporary catheter did not
work for long and had to be removed. Hence, a new tunnelled
right subclavian hemodialysis catheter was placed, with the long
term goal of developing a fistula for continued HD. The patient
was dialyzed every other day, and experienced very few
electrolyte disturbances during his stay. Renal doses of his
medications were given, particularly his antibiotics.
Vancomycin trough levels were drawn just before his dosing at
HD, with goal troughs of 15-20.
.
8) Type II DM: The patient was continued on his home dose of
6units of Lantus insulin qHS, as well as a regular insulin
sliding scale. The patient should be continued on this regimen
as an outpatient in rehab.
.
9) Thrombocytopenia: The patient developed a thrombocytopenia
into the mid 90s following his transfer to the floor. A HIT
antibody was drawn and heparin containing products were
discontinued. The HIT antibody came back negative, but because
of the improvement off heparin products, it was decided to avoid
heparin for the remainder of his stay.
Medications on Admission:
Zestril 2.5 mg po MWF
Protonix 40 mg po qd
Folic Acid T mg po daily
Plavix 75 mg po daily
Iron sulfate 325 qd
Reglan 10 mg po before meals and at bedtime
Vitamin C 500 mg po daily
Lomotil T tab po T, thurs, Sat
Lopressor 25 mg po 3x/day
Lomotil T po T,[**Doctor First Name **], Sat
Lopressor 25 mg po 3x/dy
Nephrocap 100 mg po qd
Atarax 25 mg po 3x daily prn
Novasource, renal 120 cc po tid
Lipitor 20 mg po daily
Percocet 10 mg q 6hrs prn
Tylenol prn
Bisacodyl 10 m supp
Insulin SSI, Lantus 6U SQ qhs
MOM
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. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) milliliters
PO BID (2 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY
(Daily).
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
15. Vancomycin HCl 1000 mg IV Q48H
16. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary Dx:
Sepsis
End-stage renal disease
Diabetes Mellitus
Peripheral Vascular Disease
.
Secondary Dx:
Hypertension
Coronary Artery Disease
Anemia
Depression
Prior stroke
Discharge Condition:
stable
Discharge Instructions:
If you experience fevers, chills, nausea, vomiting, chest pain,
shortness of breath, or any other concerning symptoms, contact
your physician or return to the emergency room.
Followup Instructions:
Please follow up with your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5057**], in the
next two weeks. [**Telephone/Fax (1) 5763**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2145-8-11**]
|
[
"518.81",
"250.60",
"785.52",
"250.40",
"996.62",
"V45.81",
"453.8",
"995.92",
"357.2",
"403.91",
"285.21",
"287.4",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.72",
"99.04",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9877, 9982
|
3868, 7949
|
306, 362
|
10199, 10208
|
3608, 3845
|
10431, 10719
|
2929, 2989
|
8505, 9854
|
10003, 10178
|
7975, 8482
|
10232, 10408
|
3004, 3589
|
261, 268
|
390, 1843
|
1865, 2604
|
2620, 2913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,268
| 127,767
|
37568
|
Discharge summary
|
report
|
Admission Date: [**2141-1-18**] Discharge Date: [**2141-1-20**]
Service: NEUROSURGERY
Allergies:
Penicillins / Cipro
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Fall, Unresponsive
Major Surgical or Invasive Procedure:
.
History of Present Illness:
88 yo woman with history of A Fib, pace-maker, on ASA?Plavix but
not coumadin, HTN, CABG, Vertigo, Falls, hypercholesterolemia,
UTIs who was last seen well at 1300 and was found down
unresponsive in her bathroom at 8pm. At the scene,EMS reported
her as nonverbal with GCS of 10. She was intubated at [**Hospital **]
Hospital where she was noted to intermittently respond, moving
her lower extremities to noxious stim. Head CT there showed
left parietal elitpical shaped extraaxial blood.
Past Medical History:
A Fib, pace-maker, on ASA/Plavix but not coumadin, HTN, CABG,
Vertigo, Falls, hypercholesterolemia, UTIs
Social History:
Lives at home with family.
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM: ON ADMISSION
O: T: 99.0 BP: 149/89 HR: 125-141 R 25 O2Sats
100vented
Gen: Intubated.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated. No sedation since intubation. Does
not open eyes or move to command midline or appendicularly.
Extemnds LUE and withdraws BLE weakly to noxious stim. No
movement of RUE to noxious stim.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally. NO blink to threat.
III, IV, VI: Eyes midline. Cannot track. Cannot perform Dolls.
V, VII: INtubated
IX, X: No gag.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Extemnds LUE and withdraws BLE weakly to noxious stim.
No movement of RUE to noxious stim.
Sensation: as above
Reflexes: B T Br Pa Ac
Right 1 1 1 1 0
Left 1 1 1 1 0
EXAM ON DISCHARGE: EXPIRED
Pertinent Results:
[**2141-1-18**] 02:10AM WBC-17.3* RBC-4.70 HGB-13.6 HCT-41.0 MCV-87
MCH-29.0 MCHC-33.1 RDW-14.6
[**2141-1-18**] 08:20AM WBC-18.5* RBC-4.21 HGB-12.1 HCT-37.0 MCV-88
MCH-28.8 MCHC-32.7 RDW-14.6
[**2141-1-18**] 02:30AM URINE RBC-0-2 WBC-[**12-9**]* BACTERIA-MOD
YEAST-NONE EPI-0-2 RENAL EPI-0-2
CT head [**2141-1-18**]
Extensive area of hypodensity involving the right cerebral
hemisphere,
involving the cortex, white matter and right basal ganglia, and
genu of the corpus callosum, crossing across the midline to the
left side involving the left frontal lobe.
The possibilities include edema with extensive acute
infarction/hypoxic/anoxic injury. To correlate clinically and
consider CT angiogram, when the renal parameters are
appropriate. MR studies are precluded given the presence of a
pacemaker. Radionuclide studies can also be considered to assess
for cerebral perfusion.
Brief Hospital Course:
The patient was admitted to the Neurosurgical ICU where she
remained intubated. Because she had an elevated creatinine of
1.6 and a pacemaker implantation, a CTA or MRI could not be
performed. A repeat Head CT demonstrated an increasingly large
hypodensity in the entire R hemisphere of the brain. Her SDH
remained unchanged. Stroke neurology was consulted, and
following and exam of the patient and a discussion with the
patient's daughter/ health care proxy, it was determined that
the patient had a very poor prognosis, and the decision was made
to do no aggressive surgical or medical interventions.
The patient remained intubated overnight on [**1-18**], and once the
family arrived on [**1-19**] and she was made CMO on [**2141-1-20**]. She was
pronounced at 1125.
Medications on Admission:
ASA, Ultram 1 tab Q4-6 prn, Bumex
2mg daily, Plavix 75 daily, Carvedilol 3.125 daily , Reglan 5mg
daily, Lanoxin 0.125 daily, Klor Con, Kdur, Micro K, Synthroid
50
mcg daily, Prinivil 2.5 daily, Zocor 40mg daily.
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Large R MCA infarct, L SDH
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2141-1-20**]
|
[
"432.1",
"414.00",
"434.91",
"V45.01",
"799.1",
"780.4",
"272.0",
"585.9",
"288.60",
"V45.81",
"427.31",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3961, 3970
|
2891, 3665
|
250, 253
|
4041, 4051
|
1980, 2868
|
4107, 4241
|
962, 971
|
3929, 3938
|
3991, 4020
|
3691, 3906
|
4075, 4084
|
1001, 1242
|
192, 212
|
281, 774
|
1474, 1933
|
1952, 1961
|
1257, 1458
|
796, 902
|
918, 946
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,044
| 176,782
|
46295
|
Discharge summary
|
report
|
Admission Date: [**2172-11-29**] Discharge Date: [**2172-12-4**]
Date of Birth: [**2094-4-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Change in mental status, hematemesis
Major Surgical or Invasive Procedure:
EGD
Central line
History of Present Illness:
Ms. [**Known lastname 71441**] is a 78 year-old woman with a history of a recent
left-sided stroke with subsequent left carotid stenting and
initiation of warfarin therapy for atrial fibrillation who was
brought in from [**Hospital 100**] Rehab today for deteriorating mental
status. She is intubated and sedated, and thus unable to
provide her own history. Per EMS records, she was noted by
staff this morning to be unresponsive around 8am this morning.
She had a FSBG that was >600 at that time, and other labs were
significant for a hematocrit of 19.6 from a baseline of 27, a
creatinine of 3.8 and PT of 23.6. She was noted at that time to
be responsive only to painful stimuli with a pinpoint right
pupil (midline, reactive left pupil) and left facial droop.
When her labs returned to, EMS was called. When EMS attempted
intubation, she had a gag reflex and vomitted a small amount of
coffe ground material.
.
Upon arrival to the ED, her heart rate was in teh 80s with a BP
of 100/60 and an O2 Sat of 100%. She was intubated for airway
protection and, per the ED resident, the patient had a difficult
intubation in that she had episodes of bradycardia requiring
atropine. GI was called and a gastric lavage via her PEG
revealed coffe ground material without any fresh blood. She
received 2 units of fresh frozen plasma, 4 units of PRBCs, and
10 mg of SC phytonadione. A femoral line was placed for
emergent IV access. She was also given ampicillin/sulbactam for
a dirty urinalysis.
.
Of note, during her recent hospitalization, she was noted to
drop her hematocrit from 32.8 on admission down to a nadir of
24.1; this responded to 29.3 with 2 units of PRBCs on [**2172-11-9**].
Two days later, her hematocrit had drifted down to 26.9 and she
was given an additional 2 units of PRBCs with a response up to
35.0. By the time of discharge, her hematocrit was back down to
27.2, though stable.
.
.
Review of Systems: unable to obtain from patient due to
sedation/intubation; per son, no [**Name2 (NI) **], hematochezia, fevers
Past Medical History:
- hypertension
- recent left MCA stroke [**10/2172**]
- left ICA stent placed [**2172-11-9**]
- operative PEG placement [**2172-11-18**] following failure of swallow
eval
- paroxysmal atrial fibrillation, recently started on warfarin
- reported COPD; no PFTs in [**Hospital1 18**] records
- chronic renal failure, baseline creatinine approx 2.6 with
secondary hyperparathyroidism
- chronic diastolic CHF
- hyperlipidemia
- type 2 diabetes mellitus
- depression
- morbid obesity
Social History:
Up until her recent hospitalization, Ms. [**Known lastname 71441**] lived with her
son for several decades; upon discharge from [**Hospital1 18**] last week,
she was sent to [**Hospital 100**] Rehab. She is a former smoker with a ~50
pack-year history; she quit approximately 10 years ago. She has
a history of rare alcohol use without any active use at this
time.
Family History:
One sister died of heart disease at age [**Age over 90 **]; another sister has
heart disease. Her brother died of colon cancer at age 68.
Three of her four children have died, one from AIDS, one from
drowning and one from ?choking.
Physical Exam:
T 97.7 BP 156/68 HR 83 RR 22 Sat 100%
Vent: AC Vt 450cc RR 16 PEEP 5 FiO2 0.50
General: sedated, grimacing to pain, resisting opening of her
eyelids
HEENT: PERRL, no icterus, (+) ETT
Neck: obese, supple, no lymphadenopathy detected
Chest: clear to auscultation throughout, no w/r/r
CV: rrr, nl s1s2, no murmurs
Abdomen: obese, (+) PEG, nondistended, no HSM
Extremities: 1+ edema to mid-shins, 1+ DP pulses, right femoral
line
Neuro: sedated, PERRL (5mm -> 3mm), grimacing and gagging to
suctioning, moving all four extremities and wthdrawing to pain,
opening eyes slightly to verbal command, 1+ patellar reflexes,
plantar response equivocal bilaterally
Pertinent Results:
ECG ([**2172-11-29**]):
Normal sinus rhythm at 91 bpm, normal axis, normal intervals, no
obvious ST segment changes, though unsteady baseline may be
obscuring subtle ST segment changes.
.
Head CT w/o contrast ([**2172-11-29**]):
No evidence of intracranial hemorrhage. Marked mucosal
thickening within the nasal cavity and ethmoid air cells without
fluid levels to suggest the presence of acute sinusitis.
Small-vessel angiopathy as described.
.
CXR ([**2172-11-29**]):
The lung volumes are diminished. No focal consolidation,
pneumothorax or pleural effusion is detected. The
cardiomediastinal contour is within normal limits. ET tube
terminates 1.5 cm above the carina. NG tube enters the stomach.
The tip has been excluded.
.
[**11-30**] EGD:
Impression:
Normal mucosa in the esophagus
Blood in the fundus
There was some superficial ulceration with a small amount of
oozing from around the G tube. No other bleeding site seen.
Patent rotated for maximum visability given presence of large
clot.
Normal mucosa in the duodenum
Otherwise normal EGD to second part of the duodenum
.
Recommendations: serial hematocrits
[**Hospital1 **] proton pump inhibitor
Repeat EGD if acutely rebleeds
AP CHEST 10:05 P.M, [**12-2**]
HISTORY: Increased wheezing, crackles and dyspnea, assess for
aspiration or pneumonia.
IMPRESSION: AP chest compared to [**11-29**]:
Lung volumes are very low, and the anatomic detail in the lungs
is obscured by respiratory motion, but there appears to be new
consolidation in the right mid and upper lung consistent with
pneumonia due to aspiration. Moderate cardiomegaly has increased
also and there is no mediastinal vascular engorgement suggesting
cardiac decompensation, though I doubt that edema is present.
Pleural effusion if any is small, decreased since [**11-29**]. No
pneumothorax.
Discharge labs
[**2172-12-4**] 06:48AM BLOOD WBC-9.6 RBC-3.13* Hgb-9.4* Hct-29.0*
MCV-93 MCH-29.9 MCHC-32.3 RDW-15.6* Plt Ct-285
[**2172-12-4**] 06:48AM BLOOD Neuts-77.8* Lymphs-15.6* Monos-4.4
Eos-2.1 Baso-0.2
[**2172-12-4**] 06:48AM BLOOD Plt Ct-285
[**2172-12-4**] 06:48AM BLOOD PT-13.0 INR(PT)-1.1
[**2172-12-4**] 06:48AM BLOOD Glucose-144* UreaN-109* Creat-2.7*
Na-150* K-4.2 Cl-115* HCO3-26 AnGap-13
[**2172-12-4**] 06:48AM BLOOD Mg-2.1
Brief Hospital Course:
Ms. [**Known lastname 71441**] is a 78 year-old woman with a recent left-sided
ischemic stroke and subsequent left internal carotid stenting
who presents with altered mental status following a large GI
bleed in the setting of recent initiation of aspirin,
clopidogrel, and warfarin.
.
## Acute blood loss anemia secondary to GI blood loss: Hct on
admission was as low as 15. She was admitted to the MICU and
monitored with serial Hcts. She received 4 units of PRBCs
intially with Hct rise to 29. She received an EGD which showed
blood in the fundus and superficial ulceration surrounding the G
tube but no active bleeding. She was continued on [**Hospital1 **] PPI. Her
aspirin, plavix, and coumadin were initially held. The following
day her plavix and aspirin were restarted. Aspirin was
decreased to 81 mg. Her coumadin was held and should likely not
be restarted in the future given multiple episodes of
significant GI bleeds. Following her EGD, her Hct continued to
slowly trend down to 25 and she received another unit of PRBCs
with appropriate response to 30. Upon transfer to the floor her
vital signs were stable and her hematocrit remained between
28-30. She was scheduled follow up with Dr. [**First Name (STitle) 572**] of GI on [**12-7**]
and neurology to decide on restarting coumadin weighing the
risks of GIB and recurrent stroke.
.
## Altered mental status: Unclear cause. Had evidence of UTI on
admission. Also potentially secondary to hypoperfusion in the
setting of profound anemia. Also possible contribution of
uremia given concurrent renal failure. Head CT without any
acute change. Toxicology screen negative. Her baseline prior to
last discharge was reportedly interactive. However, after
discussions with physicians at her rehab, it seems that her
baseline there upon arrival was minimally verbal and minimally
interactive. Her mental status improved with blood transfusions
and improvement in her renal failure. Her mental status at
discharge was occasional one word answers and nodding yes or no.
Acoording to her son and HCP this has been her baseline since
she suffered the CVA in [**Month (only) **] of this year.
.
# Respiratory failure: She was intubated for airway protection
in the setting of hematemesis and altered mental status. She
was quickly weaned from the vent and was extubated without
complication. Her mental status remained poor following
extubation and there was concern for her respiratory status in
this setting but her ABGs continued to be excellent not
requiring further intervention. On the medical floors her oxygen
ranged from 84-93 on room air, she was discharged on 1 liter NC
saturating at 92-94 percent. Her oxygen requirements decreased
with the addition of furosemide to her regimen which had been
held during her ICU course. She had a chest x-ray on [**12-3**] which
was consistent with volume overload and possible aspiration. She
was not treated for aspiration pneumonia given she remained
afebrile and WBC count was normal, her oxygen requirements also
decreased with addition of furosemide.
.
## Urinary tract infection: Evidence of UTI on U/A and received
Unasyn in ED. On her recent hospitalization, she had a urine
culture that grew our Enterococcus which was senstive to both
vancomycin and ampicillin. She was started empirically on
ampicillin and cipro. Unfortunately, urine culture was not sent
prior to antibiotic administration and repeat urine culture grew
only yeast. She was changed from ampicillin/cipro to augmentin.
Her renal function and leukocytosis improved over the course of
admission. She completed a course of Augmentin which was stopped
upon transfer to the floor.
.
## Acute on chronic renal insufficiency: acute exacerbation is
most likely due to prerenal azotemia in the setting of massive
GI blood loss. Her baseline Cr was ~2.3-2.7. On admission, Cr
3.8 and BUN significantly elevated to 168 from her last value
prior to discharge of 68. Urine lytes were consistent with
prerenal etiology. She was volume resuscitated with NS and renal
function improved. Unclear if followed by renal as an
outpatient. Will need to be seen by renal if not already seen
by a nephrologist. At discharge her creatinint was back at
baseline of 2.7.
.
## Hypernatremia: Treated with free water through PEG tube,
discharged on 400cc Q4H until hypernatremia resolves. Will need
daily electrolytes until this resolves.
.
## Recent left-sided ischemic stroke; s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting. Her
aspirin was decreased to 81 mg but she was otherwise continued
on both aspirin and plavix.
.
## Chronic diastolic CHF: Her metoprolol and lasix were
initially held. With stability following her EGD, her
metoprolol was restarted and uptitrated. Her lasix was held in
the setting of her ARF and restarted upon transfer to medical
floor. She was discharged on furosemide 60mg [**Hospital1 **], this will need
to be titrated up to dose of 100mg [**Hospital1 **] which she was on as
outpatient. She needs close I/O and daily weights to determine
her volume status.
.
## Atrial fibrillation: Remained in in sinus rhythm. Recently
started on warfarin for her atrial fibrillation which was
discontinued in the setting of her GI bleed. Her beta blocker
was initially held but was quickly restarted. Decision to
restart coumadin will be made by GI, neurology, and her PCP.
[**Name10 (NameIs) **] up within the next few weeks was arranged with all three.
.
## Type 2 diabetes mellitus, uncontrolled with complication.
She had significantly elevated FSBGs while in house despite
holding her tube feeds. Her glargine was titrated and she was
continued on insulin sliding scale. Will need to increase
glargine and adjust sliding scale as indicated.
.
## Hypertension: antihypertensives intially held given
significant bleeding but then restarted as above. Titrate up
metoprolol as needed for hypertension. [**Month (only) 116**] need addition of
another [**Doctor Last Name 360**], consider ACE inhibitor if creatinine allows given
her diabetes.
.
## Hyperlipidemia: continued on statin
.
## Depression: continued on citalopram
.
## FEN: TFs were restarted following EGD and extubation. TFs
residuals were >100 on day prior to discharge, this resolved
with as needed reglan. Continue with as needed prokinetic [**Doctor Last Name 360**]
to keep gut motility adequate.
.
## DVT Prophylaxis: pneumoboots
.
## Communication: son [**Name (NI) **] [**Name (NI) 18915**] ([**Telephone/Fax (1) 98454**] who is HCP
.
## Code: Full, per son who is HCP.
Medications on Admission:
(per discharge summary from [**2172-11-24**]; patient and son unable to
verify)
citalopram 20 mg daily
atorvastatin 80 mg daily
nitroglyerin patch q6h
ipratropium nebulizer q4h prn
albuterol nebulizer q4h prn
clopidogrel 75 mg daily
aspirin 81 mg daily
ferrous sulfate 325 mg daily
calcitriol 0.25 mcg daily
lansoprazole 30 mg daily
furosemide 100 mg [**Hospital1 **]
docusate 100 mg daily
metoprolol 50 mg tid
insulin glargine 14 units qhs
insulin lispro sliding scale
warfarin 2 mg qhs
bisacodyl prn
acetaminophen prn
ondansetron prn
Discharge Medications:
1. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
3. Calcitriol 0.25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
4. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q4H (every 4 hours) as needed.
6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
10. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
11. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Twenty Two (22)
units Subcutaneous at bedtime: titrate as blood sugars indicate.
12. Humalog 100 unit/mL Cartridge [**Last Name (STitle) **]: One (1) Subcutaneous
four times a day: sliding scale as directed.
13. Furosemide 80 mg Tablet [**Last Name (STitle) **]: 1 and [**12-24**] Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Gastrointestinal bleed
Secondary:
Heart failure
h/o CVA
Diabetes type II
Atrial fibrillation
Hypernatremia
Acute renal failure
COPD
UTI
Discharge Condition:
Stable, hematocrits stable>96 hours, mental status at baseline
Discharge Instructions:
You were admitted for a bleed likely originating from your
stomach. This was likely caused by a combination of gastritis
along with being on several blood thinner medications. Your
blood counts stabilized.
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2172-12-7**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 7976**]
Date/Time:[**2172-12-8**] 11:30
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2172-12-9**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2172-12-16**] 11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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"578.9",
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"428.0",
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"276.0",
"518.81",
"V44.1",
"V58.61",
"427.31",
"403.90",
"278.01",
"588.81",
"496",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.13",
"38.93",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15089, 15155
|
6561, 7926
|
354, 373
|
15345, 15410
|
4272, 6538
|
15667, 16362
|
3342, 3575
|
13713, 15066
|
15176, 15324
|
13153, 13690
|
15434, 15644
|
3590, 4253
|
2329, 2441
|
277, 316
|
401, 2310
|
7941, 13127
|
2463, 2942
|
2958, 3326
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,603
| 120,291
|
34394
|
Discharge summary
|
report
|
Admission Date: [**2181-7-13**] Discharge Date: [**2181-7-24**]
Date of Birth: [**2102-3-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
LE edema and SOA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 2727**] is a 79 yo man who has had right LE swelling over the
last two days in addition to SOB. He initially presented to
[**Hospital **] hospital where CTA showed multiple PE's and a thoracic
aorta mural thrombus. He was give lovenox 90 mg and then sent
to [**Hospital1 18**] for further tx and evaluation. Vascular surgery saw
the patient in the ED and did not want to do any surgery at this
point. Pt was admitted to the [**Hospital Unit Name 153**] to monitor mental status and
to initiate anticoagulation therapy.
Past Medical History:
Prostate CA s/p radiation
Hypercholesterolemia
COPD
Daughter denied history of CHF, CAD, stroke, DM, CKD and GIB
Social History:
Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son.
Physical Exam:
Per Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **]
VS on transfer from [**Location (un) **]: T 95.3, P 74, BP 112/60, RR 16,
93-99% 4L
General: NAD, appears comfortable in bed
Lungs: crackles at bases b/l, wheezing diffusely
Heart: muffled heart sounds
Abd: + BS, soft/obese, NTND
Extremities: R >> L LE swelling, right 3+ pitting edema;
diminished pulses on palpation but dopplerable.
Neuro: AA, Ox3, CN II - XII in tact
Pertinent Results:
Labs ([**2181-7-13**]) 04:27
134 100 17 AGap=13
-------------< 97
4.7 26 0.9
Ca: 8.4 Mg: 2.2 P: 3.8
ALT: 16 AP: 68 Tbili: 1.4 Alb: 3.5
AST: 28 LDH: 358
PSA: 0.01
14.2
7.7 >-----< 192
44.0
N:69.2 L:17.2 M:6.6 E:6.6 Bas:0.4
OSH Imaging:
Duplex US: right LE DVT from the common femoral vein to the
popliteal vein.
.
CT Head: no ICH or mass effect, perventricular small vessel
ischemia 9left parietal lobe)
.
CTA Chest:
1. extensive mural thrombus through the thoracic aorta involving
the arch and descending aorta as well as abdominal aorta.
2. pulmonary emboli at the junction of the R upper and middle
lobe arteries. Other emboli in RML, RLL, and LLL arteries.
3. 2x1 cm left adrenal mass
Brief Hospital Course:
79 yo man remote hx prostate cancer, presenting to OSH with RLE
swelling and found to have multiple regions of thromboses
including DVT, PE, aortic mural thrombosis
1) Multiple thromboses, both arterial and venous:
a) RLE DVT
b) Extensive mural thrombus of aortic arch and descending
abdominal aorta
c) PE: junction right upper and right middle lob artery; also PE
of RML, RLL, LLL distal vessel
Vascular surgery was consulted on arrival to ED and felt pt did
not have clinical need for surgical intervention/thrombectomy at
this time. He remained hemodynamically stable but was admitted
to ICU for close observation due to his significant clot burden.
On admission pt was placed on heparin drip and started on
coumadin. Etiology of clots are unknown; denies hx of prior
clots or FH of hypercoagulable state. Patient has a distant
history of prostate cancer (previously seen by a radiation
oncologist) but PSA ([**2181-7-13**]) was found to be 0.1. Given an
adrenal nodule of undetermined significance on OSH CT, an
adrenal protocol CT scan was done that showed adrenal
hyperplasia but no evidence of malignancy. Retroperitoneal and
periportal lymph nodes were found to be enlarged but not meeting
pathologic criteria. LDH, Cr, CBC, and Ca were normal. He will
need outpt age-appropriate cancer screening as well as f/u in
with hematology (Dr. [**Last Name (STitle) **] for evaluation of
hypercoagulablity. He has also been instructed to initiate care
with a new PCP. [**Name10 (NameIs) **] was initiated on coumadin, and will have his
INR followed at rehab. After that he will need to have his INR
monitored by his new PCP, [**Name10 (NameIs) **] perhaps the [**Hospital3 **]
in [**Location (un) 620**].
2) COPD: Pt was placed on 4L NC on admission, given nebs for
mild sx of dyspnea. Sx likely related to PE; no evidence of
COPD flare. He also had small bilateral effusions with
associated compressive atelectasis, likely related to his
systolic heart failure. His O2 requirement decreased slightly
with gentle diuresis.
3) Alcohol abuse: Pt has a history of alcohol abuse and seemed
to be confabulating at times. Pt was started on folate,
thiamine, and electrolytes were monitored. Due to alcohol use
pt was thought to be at high risk for gastritis and was started
on PPI prophylaxis. Pt was given valium for withdrawal
prophylaxis in ICU. After discussion with patient's family, it
was felt that patient was at his baseline mental status.
4) Eosinophilia of unclear significance: developed in-house. As
the absolute eosinophil count was less than 1000 and he had no
signs or symptoms of allergic drug reaction or end-organ damage.
He will need to have this monitored in the outpatient setting.
5) Systolic heart failure: the patient was found to have an EF
of 35% by TTE. Calls to his current and prior PCP produced no
evidence of having had prior echos. His heart failure is of
unknown chronicity or etiology. He denies a history of CAD,
although he has dyslipidemia. He was started on low-dose beta
blocker and ACEI which he tolerated, and he was diuresed gently
as above. He was made an appointment to follow up with an
outpatient cardiologist.
6) Aortic stenosis: He was found to have moderate to severe
aortic stenosis of TTE. This is of unknown chronicity but the
patient has been asymptomatic with no history of chest pain or
syncope. Lasix was dosed cautiously given this finding, and he
will follow up with an outpatient cardiologist.
Medications on Admission:
albuterol
lipitor
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for SOB, wheezing.
3. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-10**] Sprays Nasal
QID (4 times a day) as needed.
8. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day:
***This has been on hold for the last 2 days of
hospitalization****.
11. Outpatient Lab Work
Please check INR/PT on Thurs [**7-26**] and adjust coumadin as needed
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
1) Multiple thromboses, both arterial and venous:
a) RLE DVT
b) Extensive mural thrombus of aortic arch and descending
abdominal aorta
c) PE: junction right upper and right middle lob artery; also PE
of RML, RLL, LLL distal vessels
d) aortic stenosis
e) congestive heart failure
f) mild eosinophia
Discharge Condition:
Good
Discharge Instructions:
You were admitted with multiple pulmonary emboli, a deep vein
clot, and clots in your aorta. You also have aortic stenosis
(tight valve) and congestive heart failure. You were started on
a medication that thins your blood.
Please return to the emergency room should you develop shortness
of breath, chest pain, lightheadness, or leg swelling. You
should also return to the emergency room should you develop dark
stools, blood in your stool, or abdominal pain.
Followup Instructions:
1) Cardiology: Friday [**8-10**] at 10:45am with Dr. [**First Name (STitle) **]
[**Name (STitle) 50213**]. [**Hospital1 18**] [**Location (un) 620**]: [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 79101**]
2) Hematology/Oncology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Friday [**7-27**] at
11am. Patient has to check in in admitting office at 10:45am.
[**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 38619**]
3) You will need to establish care with a new primary care
doctor
|
[
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"496",
"272.0",
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"444.1",
"424.1",
"415.19",
"303.91",
"288.3",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
6944, 7021
|
2387, 5854
|
331, 337
|
7363, 7370
|
1646, 1987
|
7880, 8524
|
5922, 6921
|
7042, 7342
|
5880, 5899
|
7394, 7857
|
1177, 1627
|
275, 293
|
365, 911
|
1996, 2364
|
933, 1047
|
1063, 1162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,544
| 174,463
|
35872
|
Discharge summary
|
report
|
Admission Date: [**2112-4-27**] Discharge Date: [**2112-5-5**]
Date of Birth: [**2069-2-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
1) Intubation
2) Central venous catheterization times two (one for temporary
dialysis)
History of Present Illness:
43 yo male with history of IDDM, prior SI, was admitted to [**First Name3 (LF) **]
on [**2112-4-23**]. Per the patient's wife, the patient was admitted to
[**Name (NI) **] after an anxiety attack during family counciling. He
initially presented to [**Hospital3 **] for medical clearance, and was
found to have normal labs including BUN 30, Crn 1.2. He has a
history of SI, but denies any ingestions at this time. The wife
reports he had no symptoms on the day of admission to [**Hospital3 **] other
than anxiety. Over the course of days, he began to complain of
nausea, vomiting, abdominal pain and fatigue starting on [**Hospital3 766**]
with progressive worsening. He also reported worsening vision.
Per [**Hospital3 **], the patient has not urinated in 3 days and has had
worsening mental status changes. It appears his BG have been
fluctuating over the course of the day as low as 40.
.
In the ED, initial vs were: T: 95.2 HR: 110 BP: 175/102 RR: 32
SatO2: 100% 10L NRB. Initially found to have EKG with wide
sinusoidal pattern concerning for hyperkalemia v. TCA or other
med overdose. He was treated with 5 amps of calcium gluconate
for empiric hyperkalemia prior to lab return. He was then found
to have a profound acidosis of 6.8, K of 9.3, lactate of 12.4,
phos 16.4, Crn of 13.7. He was subsequently treated with
boluses of bicarb as well as a drip at 250cc/hr. A right fem
line was placed, however concern for arterial placement after
ABG sent from the line with PO2 of 189. He was also given
vanc/zosyn as unclear etiology of acidosis. He was also started
on insulin drip. Toxicology was consulted and recommended high
dose thiamine as well as fomepizol which were given in the ED
for possible methanol/ethylene glycol toxicity. Renal was
consulted and recommended emergent dialysis for severe anion gap
metabolic acidosis. Has remained 100% on NRB, but RR increasing
and becoming more somnolent. The patient went to CT prior to
arrival in the MICU.
.
On the floor, the patient is somnolent but arousable. He denies
any ingestions. He complains of neck pain, but otherwise does
not have any complaints.
.
Upon discussing the patient's condition with the family, the
wife asked to speak with me separately. She endoresed that they
are separated, and he has been living with his mother. She
expressed concern that his mother may want to "find blame" in
someone for her son's condition. His wife expressed she does
not want excessive "investigation" into the cause of his illness
as he has been "poked" enough. She has also asked for the
medical team to clarify who has right to autopsy, and has asked
as HCP that she would decline at this time, despite the fact
that patient's condition is critical but stable.
Past Medical History:
-depression
-suicidal ideation
-diabetes
-hypertension
-arthritis
-chronic fatigue
-fibromyalgia
-sleep apnea: he does not wear his CPAP regularly.
-s/p back surgery
Social History:
Works at the [**Company 3596**] cleaning towels, has two daughters and is
separated from his wife.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
-mother: heart disease
-father: depression
Physical Exam:
On admission:
=============
Vitals: T: BP: 128/59 P: R: 18 O2:
General: Somnolent, but arousable, orientedx2, delirious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV: irregularly irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On discharge:
=============
Vitals:97.9(98)-134/77-71-18-95%RA.
General:Alert and Oriented x 3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV: Regular, 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 cce.
Pertinent Results:
Admission labs:
===============
[**2112-4-27**] 10:15PM BLOOD WBC-15.9* RBC-4.61 Hgb-13.6* Hct-43.7
MCV-95 MCH-29.6 MCHC-31.2 RDW-13.2 Plt Ct-357
[**2112-4-27**] 10:15PM BLOOD Neuts-79.9* Lymphs-15.4* Monos-4.1
Eos-0.2 Baso-0.3
[**2112-4-28**] 01:20AM BLOOD PT-13.9* PTT-29.4 INR(PT)-1.2*
[**2112-4-27**] 10:15PM BLOOD Glucose-214* UreaN-122* Creat-13.7*
Na-132* K->10 Cl-91* HCO3-<5
[**2112-4-27**] 10:15PM BLOOD ALT-60* AST-138* CK(CPK)-567* AlkPhos-89
TotBili-0.3
[**2112-4-27**] 10:15PM BLOOD Lipase-222*
[**2112-4-27**] 10:15PM BLOOD cTropnT-0.15*
[**2112-4-28**] 01:20AM BLOOD CK-MB-6 cTropnT-0.23*
[**2112-4-28**] 07:32AM BLOOD cTropnT-0.26*
[**2112-4-27**] 11:15PM BLOOD Calcium-9.9 Phos-16.3* Mg-2.4
[**2112-4-28**] 11:06AM BLOOD Hapto-195
[**2112-4-27**] 11:15PM BLOOD Osmolal-358*
[**2112-4-28**] 11:06AM BLOOD Cortsol-23.0*
[**2112-4-28**] 11:06AM BLOOD Vanco-6.8*
[**2112-4-27**] 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2112-4-27**] 11:22PM BLOOD Type-ART pO2-138* pCO2-18* pH-6.80*
calTCO2-3* Base XS--33
[**2112-4-28**] 12:03AM BLOOD Type-ART pO2-77* pCO2-22* pH-6.80*
calTCO2-4* Base XS--33
[**2112-4-28**] 12:19AM BLOOD Type-ART pO2-391* pCO2-12* pH-6.86*
calTCO2-2* Base XS--32
[**2112-4-28**] 03:09AM BLOOD Type-ART Temp-35.0 pO2-84* pCO2-32*
pH-7.04* calTCO2-9* Base XS--21 Intubat-INTUBATED
[**2112-4-28**] 05:13AM BLOOD Type-ART Temp-36.8 Tidal V-550 PEEP-5
FiO2-50 pO2-71* pCO2-34* pH-7.34* calTCO2-19* Base XS--6
Intubat-INTUBATED
[**2112-4-28**] 06:59AM BLOOD Type-ART Rates-26/ Tidal V-550 PEEP-10
FiO2-60 pO2-88 pCO2-37 pH-7.37 calTCO2-22 Base XS--3 -ASSIST/CON
Intubat-INTUBATED
[**2112-4-28**] 07:36PM BLOOD Type-ART pO2-106* pCO2-45 pH-7.39
calTCO2-28 Base XS-1
[**2112-4-29**] 12:39PM BLOOD Type-ART Temp-38.4 pO2-118* pCO2-39
pH-7.26* calTCO2-18* Base XS--8 Intubat-INTUBATED
[**2112-4-30**] 08:11AM BLOOD Type-ART Temp-37.2 PEEP-10 pO2-159*
pCO2-37 pH-7.48* calTCO2-28 Base XS-4 -ASSIST/CON
Intubat-INTUBATED
[**2112-5-1**] 02:28AM BLOOD Type-ART Temp-36.9 Rates-/12 Tidal V-600
PEEP-5 FiO2-40 pO2-112* pCO2-52* pH-7.36 calTCO2-31* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2112-5-2**] 03:06AM BLOOD Type-ART Temp-37.1 pO2-84* pCO2-43
pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2112-4-27**] 10:20PM BLOOD Glucose-184* Lactate-11.2* Na-137 K-8.6*
Cl-102 calHCO3-3*
[**2112-4-28**] 12:03AM BLOOD Glucose-293* Lactate-11.8* K-8.4*
[**2112-4-28**] 12:59AM BLOOD ALCOHOL PROFILE-negative
[**2112-4-28**] 01:22AM BLOOD ETHYLENE GLYCOL-negative
[**2112-4-28**] 03:14AM BLOOD CYANIDE-negative
Imaging:
========
[**4-27**] ECG: Irregular tachy-arrhythmia of uncertain mechanism but
may be atrial fibrillation or possible multifocal atrial
tachycardia. Intraventricular conduction delay. ST-T wave
changes with prominent and peaked T waves. Findings raise the
consideration of hyperkalemia. Clinical correlation is
suggested. No previous tracing available for comparison.
.
[**4-28**] TTE: Normal left ventricular cavity size and wall thickness
with low-normal global left ventricular systolic function.
Extensive network in right atrium consistent with likely Chiari
network, as well as probable visualization of catheter tip
within the right atrium, but no discrete mass or vegetation
appreciated. No clinically significant valvular disease. Normal
pulmonary artery systolic hypertension.
.
[**4-28**] CT head: Study limited due to artifacts. No large focus of
acute intracranial hemrorhage. Vague dense foci in the upper
cervical cord and in the brain parenchyma are likely
artifactual. Consider followup study for better assessment or MR
if nto CI, if there is continued concern for abnormality.
.
[**4-28**] Renal U/S:
1. No hydroureteronephrosis or stones.
2. Major renal vasculature patent with normal waveforms. No
evidence of
renal venous thrombosis.
3. Echogenic liver, incompletely evaluated, most compatible with
diffuse
fatty change, but other forms of liver disease or advanced liver
disease
including fibrosis or cirrhosis cannot be excluded.
.
[**4-30**] CXR:
Tip of endotracheal tube now terminates 4.2 cm above the carina.
Right internal jugular catheter continues to terminate within
the right atrium. Improving atelectasis in both lower lobes with
residual patchy and linear atelectasis remaining.
.
[**2112-5-5**] 07:15AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.9* Hct-28.5*
MCV-87 MCH-30.2 MCHC-34.7 RDW-13.0 Plt Ct-356
[**2112-5-5**] 07:15AM BLOOD Glucose-109* UreaN-35* Creat-2.8* Na-144
K-3.9 Cl-106 HCO3-25 AnGap-17
[**2112-4-30**] 03:15AM BLOOD ALT-37 AST-16 AlkPhos-77 TotBili-0.3
Brief Hospital Course:
43 yM h/o IDDM, depression with history of SI, admitted for
severe anion gap metabolic acidosis.
# Severe anion gap metabolic acidosis: On admission pH was
6.73 and patient had altered mental status and vision changes.
He was intubated for airway protection. Lactic acidosis
differential included metformin-associated (given ARF as below)
and ingestion though ethylene glycol, cyanide, methanol, and tox
panel was negative. He was initially started on fomipezole as an
antidote but this was stopped after negative results. Toxicology
and renal were consulted and patient was emergently dialyzed
with improvement in pH. He required 2 HD sessions on admission
with no further HD given improving acidosis and normal lactate.
Patient's HCO3 and pH continued to be acidotic for 3 days but
lactate was normal and HD was not continued. He was
hyperventilated on assist control ventilation and acidosis
resolved. Pt was successfully extubated on [**5-1**] and was patient
was transferred to the medical floor for further management of
his ARF (see below). He had large volume diuresis, and was
encouraged to take PO fluids. His kidney function continued to
improve.
# ARF: Patient's Cr had been worsening slowly prior to
admission (documented to be 0.7 at baseline and 1.2 on [**4-23**]), Cr
13.7 on admission and slowly improved to 6.1 on transfer from
MICU after 2 sessions of HD. Most likely etiology was poor PO
intake with diarrhea/vomiting prior while patient was still
taking lisinopril. Pt presented with oliguric ATN and likely
metformin-associated lactic acidosis given ongoing metformin
use. Renal ultrasound with Doppler did not show any flow
abnormalities. Patient had high urine output at time of
transfer. His metformin and lisinopril were being held. While on
the medical floor, his creatinine continued to trend down
towards the normal range. He continued to have increased urine
output and we were repleting his electrolytes as needed, with
BUN/Creatinine trending towards normal range. Pt is scheduled
to follow up with renal team to ensure that his function returns
to baseline.
# Respiratory failure: secondary to severe acidosis and altered
mental status, patient was intubated on admission for airway
protection. CXR shows some evidence of volume overload vs. ARDS
with no consolidations suggestive of pneumonia. He was initially
started on azithromycin, vanco, and zosyn. He completed a 5-day
course of azithromycin and vanco/zosyn were discontinued given
patient had negative sputum cx, afebrile and no leukocytosis and
no clinical evidence of pneumonia. Patient was successfully
extubated with no complications.
# DM: In MICU his glucose was controlled with insulin drip and
sliding scale. Metformin was held given above. Patient and his
family would like to follow up at [**Hospital **] clinic on discharge. On
the floor he was on a sliding scale. He will follow up with
[**Hospital **] clinic on discharge. He will be sent home on Lantus with
an insulin sliding scale and instructions not to take metformin.
# Psych: On admission, home regimen of abilify, effexor,
wellbutrin, topomax, klonopin, and lamictal were all held given
AMS. On the medicine floor, pt was restarted on Clonazepam,
Wellbutrin and prn abilify with the psychiatry consult service
following. The Psychiatry team felt that he was safe to return
home with outpt follow up and recommended holding the rest of
his home psychiatric medications until he is seen by his primary
outpt Psychiatrist.
.
# HLD: Restarted simvastatin 80 prior to discharge.
.
# HTN: Held lisinopril given dense renal failure. This may
need to be restarted once his renal function normalizes.
----
TRANSITIONAL ISSUES:
1. Psych - will be followed closely in an outpatient treatment
program near his home. His medications will need to be
re-evaluated and/or restarted at some point.
2. HTN - given hypotension in the unit, and renal failure these
were adjusted inpatient. These will need to be restarted once
renal function normalizes.
3. DM - patient left on insulin sliding scale.
Medications on Admission:
-abilify 2.5 mg PO BID
-effexor 37.5 mg po daily
-metformin 1000 mg po BID
-simvastatin 80 mg po qhs
-lisinopril 40 mg po daily
-topamax 50 mg [**Hospital1 **]
-lamictal 25 mg po qhs
-klonopin 0.5 mg po daily
-klonopin 1 mg po qhs anxiety
-tigan 300 mg po q4 prn emesis
-tigan 200 mg im q4 prn emesis
-imodium 2 mg po prn diarrhea
-insulin lantus 80 units sc qhs
-insulin regular sliding scale
-wellbutrin sr 150 mg po daily
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
please draw blood for CBC, Chem 10 on or around [**2112-5-9**].
Please fax results to Dr.[**Last Name (STitle) 4920**] at ([**Telephone/Fax (1) 81523**]
5. insulin lispro 100 unit/mL Insulin Pen Sig: sliding scale
units Subcutaneous three times a day.
Disp:*1 pen* Refills:*0*
6. prescription
glucometer test strips - one months supply for three times a day
testing - total of 90.
7. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
8. aripiprazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for agitation/racing thoughts .
9. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous at bedtime.
Disp:*1 pen* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1)Metabolic Acidosis
2)Acute Renal Failure
Secondary Diagnoses:
1)Bipolar Disorder
2)Depression
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 admitted to our hospital with complaints of
nausea/vomiting, diarrhea, altered mental status.
You were briefly in our intensive care unit, intubated to reduce
severe metabolic derangements that we have found in your blood.
You were eventually extubated and transferred to the medical
floor. Your kidney function has improved greatly since your
admission.
The following changes were made to your medications:
MENTAL HEALTH MEDICATIONS
STOP Effexor, Topomax, Lamictal
CONTINUE klonipin, wellbutrin
CHANGE Abilify 2.5 mg to once daily AS NEEDED for racing
thoughts or agitation
These will have to be carefully adjusted with your psychiatrist
at some point.
OTHER MEDICATIONS
STOP Metformin - you may need to restart this medication once
your kidney function normalizes. Please discuss this with your
primary care doctor.
START Carvedilol - take 1 tablet twice a day to control your
blood pressure.
STOP lisinopril,imodium
You will need your blood drawn to evaluate your kidney function
on [**Last Name (LF) 766**], [**2112-5-9**].
Followup Instructions:
Please follow up with your psychiatrist and primary care doctor
within 4-8 days after leaving the hospital.
[**Doctor Last Name **] DAY PROGRAM: Go to [**Location (un) **] ([**Hospital 1263**] Hospital),
[**Last Name (LF) 766**], [**5-9**] at 9 am at - [**Location (un) 861**] Psychiatric Unit. Lunch
will be served.
Name: [**Last Name (LF) 81524**],[**First Name3 (LF) 6811**] A.
Location: CARITAS PHYSICIAN NETWORK
Address: [**Street Address(2) 8727**] STE 105W, [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 33743**]
*Dr. [**Last Name (STitle) **] is working on an appointment for you within one
week. If you dont hear from him by [**Last Name (STitle) 766**], please call his
office directly.
Name: [**Last Name (LF) 1557**], [**First Name3 (LF) **] PA
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: [**Telephone/Fax (1) 766**] [**5-9**] at 1:30PM
Dr. [**Last Name (STitle) 4920**] - [**6-17**] at 10AM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
YOU WILL BE CONTACT[**Name (NI) **] BY DR.[**Doctor Last Name 81525**] Office regarding earlier
appointment.
Completed by:[**2112-5-6**]
|
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32,389
| 179,426
|
32245
|
Discharge summary
|
report
|
Admission Date: [**2136-11-23**] Discharge Date: [**2136-12-1**]
Date of Birth: [**2069-6-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 67 year old man with h/o hypertension, permanent
pacemaker, IDDM, CHF with EF 10%, and ESRD on HD who was
transferred to the CCU for management of hypotension. He
presented to OSH from his NH on [**2136-11-20**] with complaints of
bilateral leg swelling, calf pain, and heel cellulitis, and was
transferred to [**Hospital1 18**] earlier today for revascularization of his
LLE.
.
At the OSH, ulcers were noted to the left fourth and fifth
toe-web area with purulent drainage, with diminished pulses.
Ultrasound was without evidence of DVT. Dopplers showed a high
grade plaque with abnormal wave forms in the left [**Hospital1 1793**], little
flow in the [**Hospital1 1793**]. No flow seen in any of the three run off
vessels. The patient was noted to have MRSA in nares, proteus in
wound, and c diff + stool. He was started on vancomycin, flagyl
and ertapenem. He was then transfered to [**Hospital1 18**] for
catheterization for revascularization. In the catheterization
lab, he was found to have total occlusion of L [**Hospital1 1793**] and is s/p
PTAx2 of [**Name (NI) 1793**], PTA to anterior tibialis/tibialis posterior. He
received [**2129**] units of heparin and 300 mg of plavix.
.
On the floor his SBP was <75 for approx 30 minutes. He had an
ACT>230, despite protamine bolus. After additional protamine,
his ACT went to 215 and his sheath was removed.
.
Of note, per the [**Hospital Unit Name 196**] team's discussion with his daughter,
[**Name (NI) **], he has been in [**Name (NI) 6930**] [**Hospital1 1501**] for 14 months. He has been
increasingly debilitated. In [**Month (only) 216**] he had a loculated pleural
effusion (?empyema) requiring drain. Since then he has had
dysphagia and inability to ambulate. Review of systems was
otherwise unable to be obtained due to patient's poor baseline
mental status.
.
Cardiac review of systems is notable for absence of chest pain.
Otherwise unable to obtain further ROS.
.
Past Medical History:
Hypertension
Hyperlipidemia
ESRD on hemodialysis x 4 years (M/W/F), has R SCL HD catheter
IDDM, not on insulin at rehab
depression
anemia
esophageal reflux
MRSA
Cdiff
CAD s/p "6+" MIs, no CABG, per report EF of 10% has ?PPM in
place
s/p CVA [**2128**] - residual L sided weakness
.
Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
.
Pacemaker/ICD placed- unsure of date placed
Social History:
Social history is significant for the absence of current tobacco
use. Per daughter he used to smoke cigars. There is no history
of alcohol abuse.
Physical Exam:
VS: T 97.8, BP 72/37, HR 73, RR 14, O2 97% on 1LNC
Gen: elderly, chronically ill appearing male in NAD, resp or
otherwise. Lying flat. Oriented x1. alert, responds to
questions, albeit inappropriately
HEENT: Conjunctiva were pink
Neck: Supple; difficult to determine JVP as patient was in
supine position.
CV: RR, normal S1, S2. No S4, no S3.
Chest: Resp were unlabored, no accessory muscle use. bilateral
coarse BS with decreased BS anteriorly on the right. Bilateral
crackles ausculated. no wheezes.
Abd: soft, NTND normal BS.
Ext: No edema. No femoral bruits. left foot with dark 5-6 cm
long eschar over plantar surface. dusky appearance to 4th/5th
toes on right. Anterior ankle ulcer with good granulation
tissue- no evidence of pus. Dry, black 2 cm round right heel
ulcer.
Right foot, cool to touch. dry ulcers noted- well scabbed and no
sign of active infection.
Pulses:
Right: Carotid 2+; Femoral with sheath in place; DP/PT not
dopplerable
Left: Carotid 2+ ; Femoral 1+; DP/PT dopplerable
Pertinent Results:
EKG demonstrated regular rate, 66, demand pacing with right axis
deviation. No prior for comparison.
.
PERIPHERAL CATH: Cath showed patent bilateal renal artery stents
with poor flow, RLE patent to CFA, LLE patent to CFA, high grade
subtotal [**Year (4 digits) 1793**], high grade popliteal/TPT, 100%ant
tib/peroneal/post tib with poor flow seen at mid/calf/foot.
Intervention: Successful PTA of [**Year (4 digits) 1793**] x2, successful PTA of the
ant tib/tpt with straight continuous flow restored to foot via
dorsalis pedis.
.
2D-ECHOCARDIOGRAM: no ECHO report here; reportedly EF 10%; will
attempt to obtain previous ECHO reports
.
[**2136-11-23**] CXR: my right sided pleural effusion extending to apex;
.
From OSH:
[**11-23**] wbc 7.0, hct 37.9 plt 94*** *(139 on admit); K 3.7, bun
17, creat 3.8 (no INR drawn). Blood sugar this morning was 84.
yesterday was 69. Alb 1.6, Prealb 8.0.
Brief Hospital Course:
67 M CHF with EF 10%, biV pacer, and PVD; also ESRD on MWF HD
transferred for ischemic foot. Initially transferred to [**Hospital1 **] where he received a few days of abx. On [**11-23**] came to
[**Hospital1 18**], on cath showed total occlusion of L [**Hospital1 1793**] and s/p PTAx2 of
[**Name (NI) 1793**], PTA to anterior tibialis/tibialis posterior. Transferred
to CCU with persistent hypotension, thought to be likely
secondry to sepsis. He was continued on vancomycin, flagyl and
meropenem and started on dopamine drip. Vascular surgery was
consulted for ischemic foot but because of his sepsis, surgical
intervention was not recommended. On [**11-29**], CVVHD started. On
[**11-30**], he was made CMO by his family and on [**12-1**], he expired.
Medications on Admission:
Bactroban to both nares
Celexa 20mg
Coreg 3.125mg qd
Ecotrin 81mg daily
Flagyl 250mg po bid
Heparin with dialysis
Invasz 500mg every 24 hours
Lipitor 40mg
Lovenox 30mg daily (last given yesterday morning)
Nexium 40mg
Trazodone 25mg HS PRN
Vicodin Q4 prn
MOM
Vancomycin with HD
Tylenol
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Not applicable
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2136-12-24**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,814
| 101,543
|
52781
|
Discharge summary
|
report
|
Admission Date: [**2163-9-20**] Discharge Date: [**2163-9-30**]
Date of Birth: [**2079-1-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Bacteremia
Major Surgical or Invasive Procedure:
Transesophagealechocardiogram
History of Present Illness:
84 year old male with h/o CAD s/p stenting, systolic CHF
(EF40-45%), atrial fibrillation, h/o cardiac arrest with heart
block s/p AICD/pacemaker, trach/PEG, recent MRSA bacteremia, and
recent MICU admission for hematuria and GI bleed who presents
with fevers and baceteria.
He was recently admitted [**Date range (1) 105469**] for pneumonia and MRSA
bacteremia and sepsis. Discharged on IV vancomycin which he has
been on since. He was then readmitted [**9-10**] to [**9-12**] for
hematuria and blood from his colostomy bag felt to be secondary
to recent aspirin initiation. He was discharged to [**Hospital 15159**] [**Hospital 100**]
Rehab.
He has had persistent fevers with Tm 101.5 and positive MRSA
blood cultures at rehab. [**Hospital 4273**] cough, cold symptoms, nausea,
or vomiting. Has had diarrhea over the last several days.
[**Hospital 4273**] CP or SOB. His family reports that he was doing poorly
a few days ago but has turned around in the past few days.
[**Hospital 4273**] increasing secretions and he is vent-dependent.
In the ED, initial vitals were 98.8 70 120/52 96%. He is being
admitted to the MICU for an endocarditis workup given history of
positive blood cultures. Currently, he reports feeling tired
but otherwise okay. Complains of pain in his back and his legs.
Review of systems:
(+) Per HPI
(-) [**Hospital 4273**] chills, night sweats, recent weight loss or gain.
[**Hospital 4273**] headache, sinus tenderness, rhinorrhea or congestion.
[**Hospital 4273**] cough, shortness of breath, or wheezing. [**Hospital 4273**] chest
pain, chest pressure, palpitations, or weakness. [**Hospital 4273**] nausea,
vomiting, constipation, abdominal pain, or changes in bowel
habits. [**Hospital 4273**] dysuria, frequency, or urgency. [**Hospital 4273**]
arthralgias or myalgias. [**Hospital 4273**] rashes or skin changes.
Past Medical History:
Rectal cancer s/p excision and XRT ([**2157**])
CAD s/p stents (?[**2159**])
CVA in [**2150**] with residual right hand dysthesia
Complete heart block s/p pacemaker
H/o cardiac arrest (now with AICD)
GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p
cauterization via EGD
Atrial fibrillation, not on [**Year (4 digits) **]
Systolic CHF (EF 40-45%)
S/p Fall with multiple rib fractures ([**2163-6-23**])
MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]
Social History:
Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with
his wife, now w some depression about moving out of their 42
year home. Has two children. Retired computer science professor.
- Tobacco: 5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol: Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**]
Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.
Physical Exam:
On Admission:
Vitals: 97.7 70 108/49 18 100% AC 500x12, PEEP 5, FiO2 35%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
with clear/white secretions
Neck: supple, no LAD
Lungs: Coarse rales at bases, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at apex
Abdomen: soft, non-tender, distended, ostomy in place, bowel
sounds present, no rebound tenderness or guarding
GU: Foley in place
Skin: 3cm sacral decub without surrounding erythema. PICC in
place on right arm, only mild redness at insertion.
Ext: Warm, well perfused with 2+ pitting edema, ulcerations on
bilateral shins
On discharge:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
Neck: Supple, no LAD
Lungs: Coarse rales at bases, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at apex
Abdomen: Soft, non-tender, distended, ostomy in place, bowel
sounds present, no rebound tenderness or guarding
GU: Foley in place
Skin: 3cm sacral decub without surrounding erythema. PICC in
place on left.
Ext: Significant ulcerations on bilateral shins, some pain and
swelling of both knees that is stable
Pertinent Results:
Admission Labs:
[**2163-9-20**] 04:15PM WBC-8.9 RBC-2.79* HGB-8.0* HCT-24.2* MCV-87
MCH-28.8 MCHC-33.3 RDW-15.8*
[**2163-9-20**] 04:15PM NEUTS-80.3* LYMPHS-9.0* MONOS-9.9 EOS-0.5
BASOS-0.2
[**2163-9-20**] 04:15PM PLT COUNT-168
[**2163-9-20**] 04:15PM PT-15.8* PTT-30.4 INR(PT)-1.4*
[**2163-9-20**] 04:15PM LIPASE-69*
[**2163-9-20**] 04:15PM ALT(SGPT)-26 AST(SGOT)-96* ALK PHOS-266* TOT
BILI-1.1
[**2163-9-20**] 04:15PM GLUCOSE-127* UREA N-70* CREAT-1.7* SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12
[**2163-9-20**] 05:00PM COMMENTS-GREEN TOP
[**2163-9-20**] [**2163-9-20**] 4:15 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2163-9-23**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
STAPH AUREUS COAG +
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
[**2163-9-20**] 4:15 pm URINE Site: CATHETER
URINE CULTURE (Final [**2163-9-23**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
[**2163-9-21**] 4:00 pm SWAB Source: decubitus ulcer.
GRAM STAIN (Final [**2163-9-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2163-9-24**]):
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML PSEUDOMONAS AERUGINOSA
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
LINEZOLID------------- 1 S
MEROPENEM------------- 8 I
PENICILLIN G---------- 8 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ =>32 R
[**2163-9-22**] 2:51 pm URINE Source: Catheter.
URINE CULTURE (Final [**2163-9-25**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
PSEUDOMONAS AERUGINOSA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 16 I 2 S
CEFTAZIDIME----------- 16 I =>64 R
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I <=1 S
MEROPENEM------------- 8 I <=0.25 S
NITROFURANTOIN-------- =>512 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
[**2163-9-21**] 3:54 am BLOOD CULTURE Source: Line-midline.
Blood Culture, Routine (Final [**2163-9-27**]): NO GROWTH.
[**2163-9-22**] 3:00 am BLOOD CULTURE FROM MIDLINE.
Blood Culture, Routine (Final [**2163-9-28**]): NO GROWTH.
[**2163-9-23**] 3:51 am BLOOD CULTURE: Pending
[**2163-9-24**] 3:51 am BLOOD CULTURE: Pending
Studies:
CXR [**2163-9-20**]: No significant change from [**2163-9-9**] radiograph, with
cardiomegaly, pulmonary vascular congestion and bilateral
pleural effusions again noted. Left lower lobe opacity is
compatible with atelectasis and/or pneumonia.
TTE [**2163-9-21**]: The left atrium is moderately dilated. The left
atrium is elongated. The right atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. The right ventricular cavity is moderately dilated
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta 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. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior study dated [**2163-9-8**] (images reviewed), the degree of
pulmonary pressures is much lower (likely underestimated as the
IVC was not well visualized). No vegetations or abscesses
visualized.
TEE [**2163-9-22**]: No vegetations seen on the cardiac leaflets. No mass
or vegetation seen on the cardiac wires. Simple atheroma aortic
arch. At least moderate in severity eccentric mitral
regurgitation. Moderate tricuspid regurgitation. Mild to
moderate pulmonary artery systolic hypertension.
BLE Ultrasound [**2163-9-24**]: Limited study demonstrates no evidence
of right or left lower extremity DVT.
CXR [**2163-9-25**]: As compared to the previous radiograph, the
position of the
tracheostomy tube and of the pacemaker wires is unchanged.
Unchanged moderate cardiomegaly with bilateral areas of
atelectasis and substantial enlargement of the vascular
structures at the lung hilus. Unchanged moderate pulmonary
edema. No newly appeared focal parenchymal opacities.
WBC scan [**2163-9-26**]: 1. Splenomegaly. 2. No focal source of
infection localized.
Bilateral UE ultrasound [**2163-9-28**]: No evidence of upper extremity
deep venous thrombosis.
Labs prior to discharge:
[**2163-9-29**] 02:57AM BLOOD WBC-7.1 RBC-2.89* Hgb-8.1* Hct-24.9*
MCV-86 MCH-28.0 MCHC-32.5 RDW-15.8* Plt Ct-154
[**2163-9-29**] 02:57AM BLOOD Neuts-75.9* Lymphs-11.7* Monos-10.6
Eos-1.2 Baso-0.5
[**2163-9-29**] 02:57AM BLOOD Glucose-154* UreaN-49* Creat-1.4* Na-135
K-3.5 Cl-96 HCO3-29 AnGap-14
[**2163-9-29**] 02:57AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1
[**2163-9-29**] 11:06AM BLOOD Tobra-1.9*
[**2163-9-28**] 09:00PM BLOOD Tobra-2.5*
[**2163-9-28**] 04:03AM BLOOD Vanco-21.5*
[**2163-9-27**] 07:50PM BLOOD Vanco-21.7*
[**2163-9-28**] 02:07PM BLOOD Type-[**Last Name (un) **] Temp-37.4 Rates-/35 Tidal V-309
PEEP-5 FiO2-50 pO2-48* pCO2-42 pH-7.48* calTCO2-32* Base XS-6
Intubat-INTUBATED Vent-SPONTANEOU
Brief Hospital Course:
Primary Reason for Hospitalization: Mr. [**Known lastname 108855**] is a 84 year
old male with h/o CAD s/p stenting, systolic CHF (EF40-45%),
atrial fibrillation, h/o cardiac arrest with heart block s/p
AICD/pacemaker, trach/PEG, and recent ICU admission with GI
bleed, hematuria, and MRSA bacteremia, who presented from rehab
with fevers and persistent MRSA bacteremia while on vancomycin.
#. MRSA Bacteremia: The source of the patient's persistent
bacteremia was not found. He grew MRSA from multiple blood
cultures at rehab and also on initial presentation despite
appropriate vancomycin troughs. Multiple sources of persistent
seeding were considered. He had a TTE and TEE which were both
negative for vegetations and did not show any involvement of his
pacer leads. A tagged WBC scan was performed to look for occult
focus of infection which was negative. An upper extremity
ultrasound was also performed to look for possible infected clot
but was negative. His PICC line which had been recently replaced
at [**Hospital **] rehab was removed. A new one was not placed until he
had negative blood cultures. He was continued on vancomycin and
dosing was changed to 1g q48h. Further blood cultures were
negative. Ultimately it was felt he likely has an endovascular
source but it was not found during this hospitalization. He
should be continued on IV vancomycin for 6 weeks from the date
of his last positive blood culture, with last day [**2163-11-2**].
#. Pseudomonas and Klebsiella UTI: Given that he has an
indwelling foley it was suspected that this might be
colonization however his cultures were positive even after
changing his foley. He was found to have pseudomonas in his
urine as well as wound culture. It was multidrug resistant
pseudomonas and he was treated with tobramycin for a seven day
course. He needs one more dose of tobramycin 320mg IV x 1 when
trough < 1. He also grew multidrug resistant klebsiella in his
urine and was started on a 7 day course of cefepime with last
day [**10-2**].
#. Fevers: He had fevers on admission felt to be related to his
MRSA bacteremia. Other cultures returned positive as above. He
also had a knee arthrocentesis which was not consistent with
septic arthritis. His PICC was changed after a 24 hour line
holiday. He was ruled out for C diff.
#. Acute renal failure: BUN/creatinine elevated to 70/1.7 on
admission felt to be related to ongoing infection and poor
forward floor from chronic systolic CHF. His creatinine slowly
improved with diuresis.
#. Chronic respiratory failure: He was continued on mechanical
ventilation during this admission and was unable to be weaned to
trach mask for any length of time. This was felt to be related
to chronic respiratory fatigue in addition to substantial
pulmonary edema. Diuresis was difficult due to his large
obligate fluid intake, but was eventually acheived with lasix
80mg IV q6h plus metolazone 2.5mg po bid. His metolazone may
need to be decreased over the next several days if he is
overdiuresed as he was on average 1L negative on this regimen
for the few days prior to discharge. On the day of discharge,
he was on pressure support [**12-19**], PEEP 5, FiO2 50% with TV in the
300's.
#. Anemia: His hematocrit remained stable in the low 20's during
this admission.
#. Chronic Diastolic CHF: Has EF 55%. He was continued on his
home carvedilol. His lisinopril has been on hold indefinitely
and was not restarted due to renal failure. He was diuresed
with IV lasix and metolazone as above and will need his
creatinine and electrolytes monitored closely with ongoing
diuresis.
#. Sacral decubitus ulcer: Stage IV. He was started on a
fentanyl patch and continued on prn oxycodone for pain control.
#. Atrial fibrillation: His heart rate and blood pressure
remained stable during this admission. He is off
anticoagulation due to h/o GI bleeding and hemothorax. He was
continued on carvedilol.
#. Wound care: He was evaluated by the wound care team who
recommended the following:
1. Follow pressure ulcer guidelines. First Step for fluid
management. Turn q 2 hours.
2. Cleanse wounds with commercial wound cleanser. Pat dry.
3. Apply Aquacel ag to sacrum wound, cover with 4x4's and soft
sorb dressing, secure with Medipore tape. Change daily.
4. BLE ulcerations - cover with Adaptic dressing, place 4x4 and
wrap with Kerlix. Secure with paper tape.
5. No tape on skin.
6. Mid upper back ulcer - Apply Mepilex 4x4 and change q3 days.
7. Mid lower back ulcer - apply DuoDerm wound gel to bed to
assist with autolytic debridement of yellow slough. Cover with
Mepilex 4x4 dressing, and change q 3 days.
8. Apply Critic Aid clear skin barrier ointment to scrotal
tissue to protect from fluid exposure daily. Elevate scrotum to
assess with edema.
9. Waffles bilateral feet.
10. Apply aloe vesta ointment to dry intact skin daily.
11. Support nutrition and hydration.
TRANSITIONAL ISSUES:
- Monitor I/O's closely and check electrolytes closely given
large doses of lasix and metolazone. [**Month (only) 116**] need to back off on
metalazone if signs of overdiuresis. However, would continue to
aim for -500cc daily I/O balance.
- Needs tobramycin trough drawn [**2163-10-1**] AM. Give tobramycin
320mg IV x 1 when trough is <1.0.
- Continue vancomycin until [**2163-11-2**] for MRSA bacteremia.
Should have trough measured intermittently to assess for
appropriate dosing.
- Needs 2 more days of cefepime treatment
- Continue ventilator weaning and trach collar trials if
possible. Diuresis should help with this.
- Please draw weekly labs: CBC/diff, chem-7, LFTs and fax to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions
regarding outpatient antibiotics should be directed to the
when clinic is closed
Medications on Admission:
Acetaminophen 650mg po q4h prn pain
Lidocaine patch 5% TD daily
Trazodone 25mg po qhs prn insomnia
Citalopram 20mg po daily
Docusate 50mg po bid
Ferrous sulfate 300mg po daily
Folic acid 1mg po daily
Multivitamin 1 tab po daily
Omeprazole 20mg po daily
Albuterol sulfate 90mcg q4h prn SOB/wheeze
Simethicone 80mg po tid
Miconazole nitrate 2% application qhs
Oxycodone 5-10mg po q4h prn pain
Lasix 40mg po daily
Vancomycin 500mg IV q12h
Psyllium one packet po tid
Sucralfate 1gram po qid
Carvedilol 6.25mg po bid
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution [**Telephone/Fax (1) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Age over 90 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. trazodone 50 mg Tablet [**Age over 90 **]: 0.5-1 Tablet PO at bedtime as
needed for insomnia.
4. citalopram 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg
PO twice a day: Hold for loose stools.
6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Age over 90 **]: Three
Hundred (300) mg PO once a day.
7. folic acid 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
8. multivitamin Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for sob,
wheeze.
11. simethicone 80 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet,
Chewable PO TID (3 times a day).
12. miconazole nitrate 2 % Powder [**Age over 90 **]: One (1) Appl Topical HS
(at bedtime) as needed for rash.
13. oxycodone 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. fentanyl 12 mcg/hr Patch 72 hr [**Age over 90 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. psyllium Packet [**Age over 90 **]: One (1) Packet PO TID (3 times a
day).
16. sucralfate 1 gram Tablet [**Age over 90 **]: One (1) Tablet PO QID (4 times
a day).
17. carvedilol 6.25 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2
times a day): Hold for SBP<100, HR<55.
18. cefepime 1 gram Recon Soln [**Age over 90 **]: One (1) gram Injection Q24H
(every 24 hours) for 2 days: Last day [**2163-10-2**].
19. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) gram
Intravenous q48h: Until [**2163-11-2**].
20. furosemide 10 mg/mL Solution [**Year (4 digits) **]: Eighty (80) mg Injection
Q6H (every 6 hours).
21. metolazone 2.5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times
a day): 30 minutes prior to Lasix dose.
22. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
23. tobramycin sulfate 40 mg/mL Solution [**Year (4 digits) **]: Three Hundred
Twenty (320) mg Injection ONCE (Once) for 1 doses: Give one dose
of 320mg when trough level < 1.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
MRSA bacteremia
Klebsiella and pseudomonas UTI
Chronic diastolic congestive heart failure
Respiratory failure
Secondary Diagnosis:
Coronary Artery Disease
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital due to persistent fevers and a
bacterial infection in your blood. You underwent multiple
studies to evaluate the source of your infection. It does not
appear that your heart valves or your pacemaker are infected.
You were treated with antibiotics for your bloodstream
infection, as well as urinary and wound infections. We also
tried to give you diuretics to help your breathing.
Changes to your medications:
Increased docusate to 100mg po bid
Increased albuterol to 4-6 puffs q4h prn SOB/wheeze
Start fentanyl patch 12mcg/hr TD q72h
Start cefepime 1g IV q24h for 2 more days, last day [**2163-10-2**]
Change vancomycin to 1g q48h, last day [**2163-11-2**]
Change furosemide to 80mg IV q6h
Add metolazone to 2.5mg po bid, 30 mins prior to lasix dose
Add tobramycin, needs one more dose of 320mg when trough <1.0
You should be weighed every day and the providers at rehab
should be notified if your weight goes up by more than 3 pounds.
Followup Instructions:
You have the following appointments scheduled:
Department: INFECTIOUS DISEASE
When: [**Month/Day/Year **] [**2163-10-14**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2163-10-31**] at 9:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GASTROENTEROLOGY
When: MONDAY [**2163-10-31**] at 1:15 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,420
| 133,534
|
2988+55435
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-7-15**] Discharge Date: [**2174-7-27**]
Date of Birth: [**2110-9-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
Coiling of Aneurysms
placement of right frontal external ventricular drain
History of Present Illness:
HPI: 63F who was in her USOH until about 6pm when she developed
sudden, severe headache. She has experienced occasional mild
headaches over the past several months, all successfully treated
with Aleve. The headache that she is currently experiencing was
of sudden onset, involved the nuchal and occipital regions and
quickly radiated to the vertex. It severe and intensity was
maximal at onset. She endorsed nausea, denied vomiting. She
denied photo- or phonophobia. She denied diplopia, weakness,
numbness.
Past Medical History:
hypertension
hyperlipidemia
Social History:
Lives at home alone.
Family History:
No known h/o ICH but mother died spontaneously from
unknown causes.
Physical Exam:
on admission
PHYSICAL EXAM:
O: 97.3 73 187/109 100
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: Slight nuchal rigidity.
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. Attentive
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3.5 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-14**] throughout. No pronator drift
Sensation: Intact to light touch throughout.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes downgoing bilaterally
Coordination: normal rapid alternating movements
ON DISCHARGE
The patient is awake, alert, and oriented. She follows commands
with all extremities. PERRL. EOMS intact. Moves all extremities
spontaneously and to command. Incisions are clean, dry, and
intact.
Pertinent Results:
Cardiology Report ECG Study Date of [**2174-7-15**] 7:05:22 PM
Sinus rhythm
Left axis deviation
Left anterior fascicular block
Lateral ST-T changes are nonspecific
Nonspecific intraventricular conduction delay
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 178 114 410/434 50 -57 71
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2174-7-15**] 7:18 PM
HEAD CT:
There is extensive subarachnoid hemorrhage seen in the basal
cisterns
extending to sulci and fissures with blood within the fourth
ventricle. There is mild dilatation of the lateral ventricles
including prominence of the temporal horns.
CT ANGIOGRAPHY OF THE HEAD:
The CT angiography of the head demonstrates an aneurysm with
wide neck arising from the upper portion of the basilar artery
measuring 14 x 9 mm. The aneurysm points anteriorly towards the
left side and is adjacent to the supraclinoid left Internal
carotid artery and occupies the left side of the suprasellar
cistern. There is some irregularity of the aneurysm identified
with small lobes at the anterior superior portions.
A second aneurysm is identified in the left internal carotid
artery at its
junction with the ophthalmic artery. The aneurysm points
superiorly and
measures approximately 5 mm in size. A distinct neck is
visualized in
relation to this aneurysm. No other aneurysms are seen. No
vascular
occlusion identified. No vasospasm is noted.
IMPRESSION:
1. Extensive subarachnoid hemorrhage seen on CT with prominent
ventricles
including prominence of the temporal horns. Findings indicate
obstructive
hydrocephalus.
2. Large aneurysm arising from distal basilar artery from its
anterior left aspect and extending to the left side of the
suprasellar cistern measuring 14 x 9 mm with some irregularity
of the superior portion anteriorly.
3. A 5 mm left carotid ophthalmic aneurysm is identified
pointing superiorly.
4. No evidence of vasospasm or vascular occlusion.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2174-7-16**] 8:01
AM
Final Report
AP CHEST
FINDINGS: The tip of the nasogastric tube is projected over the
stomach.
No definite acute consolidation is seen. There is no evidence of
Pneumothorax. No pleural effusion is seen. No other significant
findings.
IMPRESSION: The tip of the nasogastric tube is with the tip
projected over
the stomach.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2174-7-16**]
9:44 AM
Final Report
FINDINGS: Extensive subarachnoid hemorrhage identified as seen
on the
previous study with blood within the ventricular system. There
is moderate
ventriculomegaly seen with prominence of temporal horns which is
slightly
increased since the previous study. A right frontal ventricular
drain ends in the right lateral ventricle and the anterior [**Doctor Last Name 534**].
No areas of brain
parenchymal hypodensities identified.
IMPRESSION: Extensive subarachnoid hemorrhage as before. The
ventricular
size appears to have slightly increased with placement of the
right frontal ventricular drain. Continued followup recommended.
Head CT [**2174-7-20**]:
FINDINGS: Allowing for differences in slice selection and
angulation, the
size of the ventricles appears stable. The tip of the right
transfrontal
ventriculostomy catheter appears unchanged in position. There is
stable
evolving hematoma along the tract of the right frontal
ventriculostomy
catheter. There is slight decreased conspicuity of diffuse
subarachnoid
hemorrhage. Blood continues to layer dependently in bilateral
occipital
horns, also less conspicuous than on prior examination. Blood is
no longer
present in the fourth ventricle; however, a 9-mm clot layers
dependently in the cisterna magna. No new foci of hemorrhage are
present.
Extensive streak artifact from basilar aneurysm coils slightly
limits
evaluation. There is no shift of normally midline structures and
[**Doctor Last Name 352**]-white matter differentiation remains well preserved. There
is a burr hole in the right frontal calvaria; otherwise, the
osseous structures appear intact. Paranasal sinuses, ethmoid and
mastoid air cells are clear.
IMPRESSION:
1. Stable appearance to the lateral ventricles with stable
position of
ventriculostomy catheter.
2. Slight decreased conspicuity of diffuse subarachnoid
hemorrhage.
3. Decreased intraventricular hemorrhage with clearance of blood
from the
fourth ventricle; however, a 9-mm clot layers dependently in the
cisterna
magna.
4. Evolution of hematoma along the right frontal approach
ventriculostomy
catheter, unchanged in size.
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2174-7-22**] 3:55 PM
Final Report
EXAM: CT angiography of the head.
CT HEAD:
Again subarachnoid hemorrhage and intraventricular hemorrhage
identified with mild-to-moderate ventriculomegaly with
dilatation of the temporal [**Doctor Last Name 534**]. Blood is seen in the right
frontal region along a track, which could represent a previous
placement of the ventricular drain. Artifacts from coiling are
seen in the left supraclinoid region.
CT PERFUSION:
CT perfusion of the head is limited due to artifacts from the
coil. No
diagnostic information was obtained.
CT ANGIOGRAPHY OF THE HEAD:
The CT angiography of the head demonstrates mild-to-moderate
vasospasm with decreased caliber of both middle cerebral
arteries compared to the previous CT angiography. However, there
remains vascular flow within both middle cerebral territories in
the sylvian region. The posterior circulation arteries are
normal. No vascular occlusion is seen. Artifacts obscure the
evaluation of the left supraclinoid internal carotid artery.
IMPRESSION:
1. CT of the head shows no significant change with
intraventricular and
subarachnoid blood and moderate ventriculomegaly.
2. CT perfusion of the head is not of diagnostic quality
secondary to
artifacts and motion.
3. CT angiography of the head demonstrates mild-to-moderate
vasospasm with
decreased caliber of both middle cerebral arteries.
4. No evidence of vascular occlusion.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2174-7-23**]
3:50 PM
FINDINGS:
Extensive subarachnoid and intraventricular blood is
redemonstrated, overall unchanged in magnitude from the study
done one day earlier. The size and configuration of the
ventricles is unchanged. A focus of intraparenchymal gas and
hyperdensity is noted in the right frontal lobe (2:24) unchanged
and presumably the sequela of a surgical tract. Extensive
artifact from coils in the left suprasellar region limit
sensitivity of the adjacent structures. There is no new focus of
hemorrhage. Extracranial soft tissue structures are notable for
post-surgical change, which is stable and are otherwise
unremarkable. The included paranasal sinuses and mastoid air
cells are clear. Extracranial soft tissue structures are
unremarkable.
IMPRESSION: Overall, minimal change from the study done one day
prior with
extensive subarachnoid, intraventricular blood, as well as
unchanged
postoperative sequela as above.
Brief Hospital Course:
This pt was admitted through the emergency department after
inital work up revealed SAH and aneurysm. She was admitted to
the ICU placed on Nimodipine and Dilantin.
She was taken to the Angio suite where she had an external
ventricular drain placed.
Her aneursyms were coiled without event. She was kept on
heparin at 500 units per hour till the following am. Then it
was discontinued.
On the am on [**2174-7-18**] she underwent a CTA of the brain which did
not show vasopsasm. Her EVD was clamped the am of this same
day.
On [**7-20**] CT was performed to evaluate interval enlargement of
ventricles, the CT was not suspicious for the development of
hydrocephalus. The EVD was discontinued and the patient was
transferred to the neuro step down unit.
On [**7-22**] patient's neuro exam remained stable and she was taken
off of telemetry monitoring and transferred to the floor. She
became lethargic and underwent CTA which showed mild vasospasm
MCA bilaterally. Then she spiked a fever and underwent blood and
urine cultures as well as LP and was empirically started on
antibiotics to cover meningitis and UTI. The urine culture came
back + for enterococcus and the antibiotics were continued. ID
was consulted and they recommended completing a 14day course of
antibiotics. They also recommended weekly labwork to be done at
rehab.
Her exam remained stable however her Na level dropped and she
was placed on fluid restriction and salt tabs. On [**7-26**] her Na
tabs were decreased. Her Na improved and she was taken off the
fluid restriction the day of discharge. She remained on Na
tablets and was discharged on them.
The patient has pending blood cultures at the time of discharge
but she is afebrile. Her neuro exam remains stable.
Physical and Occupational therapy determined that the patient
was a candidate for rehab. She was screened and sent to an
appropriate facility on [**2174-7-27**].
Medications on Admission:
pravastatin, lisinopril
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for prophylaxis.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headache.
10. Nimodipine 30 mg Capsule Sig: One (1) Capsule PO Q2H (every
2 hours).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever.
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
13. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3
times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 10 days.
17. Ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Basilar Aneurysm Coiling
Carotid Ophthalmic Artery Aneurysm Coiling
Hydrocephalus / Obstructive
urinary tract infection
Discharge Condition:
neurologically Stable
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? 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
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
Followup Instructions:
You have an appointment to be seen by Dr. [**First Name4 (NamePattern1) **] [**8-18**] at 3pm
on the [**Location (un) **] of the [**Hospital Unit Name **]. You will have a non
contrast CT of the brain before at 2pm on the [**Location (un) **] of the
Clinical Center [**Hospital Ward Name 517**]. Call [**Telephone/Fax (1) 1669**] with any
questions.
You need to have weekly lab work at rehab - LFTs, CBC with
differential, vanco trough. You also need to have a phenytoin
level drawn. Please fax the results to the nurse practitioner in
Dr.[**Name (NI) 935**] office at [**Telephone/Fax (1) 87**].
Completed by:[**2174-7-27**] Name: [**Known lastname 2266**],[**Known firstname **] F. Unit No: [**Numeric Identifier 2267**]
Admission Date: [**2174-7-15**] Discharge Date: [**2174-7-27**]
Date of Birth: [**2110-9-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 599**]
Addendum:
The patient needs an MRI/A in one month to rule out
recanulization of Basilar artery aneurysm. This appointment will
be made by the office and will be communicated to the rehab.
facility tomorrow.
[**First Name4 (NamePattern1) 1239**] [**Last Name (NamePattern1) 2268**] PA-C [**Numeric Identifier 2269**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1174**] [**Hospital **] [**Hospital 2270**] Rehab Unit at
[**Hospital6 2271**] - [**Location (un) 437**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2174-7-27**]
|
[
"599.0",
"305.1",
"276.8",
"430",
"E942.6",
"322.0",
"348.5",
"997.09",
"272.4",
"E879.8",
"458.29",
"401.9",
"276.1",
"293.0",
"275.3",
"041.04",
"331.4",
"275.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"39.72",
"02.2",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
16790, 17071
|
9725, 11637
|
342, 419
|
13613, 13636
|
2659, 3071
|
15437, 16767
|
1068, 1138
|
11712, 13281
|
13470, 13592
|
11663, 11689
|
13660, 14492
|
14518, 15414
|
1182, 1382
|
279, 304
|
447, 959
|
1644, 2640
|
7366, 9702
|
3080, 7357
|
1397, 1628
|
981, 1013
|
1029, 1052
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,601
| 190,567
|
1496
|
Discharge summary
|
report
|
Admission Date: [**2129-2-7**] Discharge Date: [**2129-2-24**]
Date of Birth: [**2087-1-19**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Pt transfered to MICU after drug overdose.
Major Surgical or Invasive Procedure:
Left forearm and bilateral hand fasciotomies with closure.
History of Present Illness:
42 y/o male w/ hx of depression, recently diagnosed c HIV.Pt was
found down today at noon by family who called EMS. +AMS. Per
report took ~25 100mg Elavil tablets. After talking to pt he
admits takling " a whole bottle of " Elavil and Percocet and has
been using crystal methadone over the last 2 days.
In [**Name (NI) **] pt was somnolent but responsive. HR 100-110, BP 160/100's,
Serum tox positive for amp, tylenol (tylenol levels of 175) and
tcas. Given 2grams of charcoal PO and bicarb drip with 3 amps
NaHco3 in D5w. ecg QRS ~100sec.He was started on Mucomyst drip.
Xrays of LUE neg for fracture.
Past Medical History:
Depression
HIV + recently diagnosed
MRSA Pneumonia d/ced 2 weeks ago
S/P lumbar spine fusion
Chronic back pain
Social History:
Denies EtOH or tobacco.
Unemployed.
Family History:
unknown
Physical Exam:
T 98.5 BP 160/80 HR 75 SpO2 95 % on RA
Gen:nad, somnolent
HEENT:noorla lesions. L maxillary area c edematous and
erythematous , c isolated blisters and excoriations
Neck: cerviacal collar
CHEST: cta bl, L side of chest indurated and erythematous
over L pectoral area
CVR:RRR no m/g/r
ABDOMEN:nt, nd, no signs of abdominal trauma.
EXT: L forearm edematous and tender to palpation.Pt has pain
upon passive and active ROM of fingers . Wrist c severely
decreased ROM.
Neuro:AO x 3
.
Pertinent Results:
..... 88
15.1>---<245
.....40.9
N:82.1 L:14.3 M:3.3 E:0.3 Bas:0.1
.
143 | 107 | 18 .............AGap=11
----------------<203
4.2 | 25 | 1.3
CK: [**Numeric Identifier 8794**] MB: 148 MBI: 1.0
Ca: 8.0 Mg: 2.1 P: 4.9 D
PT: 12.9 PTT: 21.5 INR: 1.1
.
ALT: 59 AP: 104 Tbili: 0.4 Alb: 4.2
AST: 136 LDH: Dbili: TProt:
[**Doctor First Name **]: 143 Lip:
.
Serum TOX:
Serum Acetmnphn 151.6 - Serum Tricyc Pos
Serum ASA, EtOH, [**Last Name (LF) 2238**], [**First Name3 (LF) **] Negative
.
Urine Tox:
.
Urine Benzos Pos
Urine Amphet Pos
Urine Barbs, Opiates, Cocaine, Mthdne Negative
.
U/A - o bact, 0-2 wbc, nl LE, nl Nitr.
Brief Hospital Course:
A&P: 42 yo man c history of depression admitted after being
found down after drug overdose (Tylenol, TCA and amphetamines)
noted to have compartment syndrome left arm and taken to OR for
decompression.
.
# Toxicology (tylenol and anticholinergic overdose): On
admission, the patient had elevated Tylenol levels with elevated
ALT/AST but INR and Tbili normal. He also had elevated CKs. He
was tachycardic and had EKG changes concerning for possible
prolonged qtc. He was given charcoal and started on NaHCO3 and
Mucomyst in ED. He was maintained on IVF and N-Acetylcysteine
in the ICU. Daily ECGs were done and showed resolution of ECG
changes on day 2. His LFTs also trended down and had largely
resolved by his transfer from the ICU. Once on the floor he was
medically stable from the standpoint of his overdose.
.
# Compartment syndrome - On initial exam in the MICU, pt noted
to have swelling and decreased pulses in L Arm. An emergent
orthopedics consult was obtained. Orthopedics took patient to OR
for fasciotomy for compartment syndrome of l arm and b/l
hands.The patient also underwent bediside hand fasciotomies by
plastics on [**2-8**] and [**2-9**]. He underwent a repeat surgery for
washout and closure of dorsal fasciotomies on [**2-10**]. Volar
fasciotomies were closed on [**2-22**]. Throughout his course in the
hospital the patient underwent a two week course of IV
vancomycin for his wounds. At the time of discharge the
patient's wounds were stable and were being following daily by
orhthopedics. He is to have continued dry sterile dressings
changed by ortho while he is on the psychiatric service.
.
# Rhabdomyolisis - On admission the patient had a urine dipstick
+ for large amount of blood but with only 2 rbc also increased
CK upto ~30K. He was given aggressive volume initially. His
creatinine remained stable and CKs trended down.
.
#Respiratory failue/assistance - Patient was intuabed prior to
OR procedure on day of admission and was unable to be extubated
immediately post operative. He was maintained on minimal
ventilatory support and was ultimately successfully extubated on
[**2-10**].
.
#Psych: Due to the patient's active suicidality he was watched
by a 1:1 sitter while in-house. Following extubation he was
placed benzodiazpenes for anxiety and was started on lamictal
for his bipolar disaorder. The patient is to be transferred to
psychiatry for further evaluation following his admission on
medicine.
.
#HIV: currently not on HAART or OI prophylaxis; will f/u with
his outpt ID physician
.
#Prophylaxis: The pt was maintained on a PPI and Heparin sc
throughout admission.
.
#FEN: Once extubated the pt was placed on aregular diet
throughout admission.
.
#Comm-This was through his parents who were involved w/ his
care.
Medications on Admission:
Elavil 200 qd
Klonopin 0.5 tid
Seroquel 200 qd
Dufloxetine
Percocet
Fentanyl patch 75 mcg/h x 3 d
Discharge Medications:
1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for fever.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
17. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
18. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
major depression with suicide attempt
b/l compartment syndrome
HIV
Discharge Condition:
Fair
Discharge Instructions:
Please take all medications as directed. If you experience
fever (temp>100.5), increased pain, drainage from you wounds, or
any other symptoms of concern to you, please call your doctor.
Followup Instructions:
Please call your PCP: [**Name10 (NameIs) 8795**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 8796**] for
followup within 1-2 weeks.
Orthopedics: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1228**] for a
followup appointment in 2 weeks.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"V08",
"965.4",
"276.2",
"296.7",
"729.9",
"969.0",
"682.0",
"518.81",
"E950.0",
"311",
"728.88",
"E950.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71",
"82.12",
"83.14",
"83.45",
"04.43",
"83.39",
"93.59",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
6937, 6982
|
2399, 5170
|
319, 380
|
7093, 7100
|
1752, 2376
|
7336, 7749
|
1220, 1229
|
5318, 6914
|
7003, 7072
|
5196, 5295
|
7124, 7313
|
1244, 1733
|
237, 281
|
408, 1017
|
1039, 1151
|
1167, 1204
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,196
| 114,944
|
26227
|
Discharge summary
|
report
|
Admission Date: [**2151-1-27**] Discharge Date: [**2151-3-23**]
Date of Birth: [**2071-8-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
placement of gallbladder drain
Central venous line
Hemodialysis
Percutaneous jejunostomy tube placement
PICC line
History of Present Illness:
79M with CAD s/p recent CABG & AVR, CHF (EF 20%), DM2,
hyperlipidemia, and HTN who has been at [**Hospital **] Rehab for the
past 2 weeks following a prolonged hospitalization at [**Hospital1 112**] for
CHF, CABG, AVR c/b difficulty weaning and trach placement (since
removed), G-tube placement, line infection, ileus, oral
candidiasis, and sacral decub ulcer. On day of admission, pt was
in an ambulance on his way to a scheduled cardiology appt when
his SBP was noted to be in the 60s and he was instead brought to
the ED for further evaluation.
<br>
Of note, pt had increased sputum at [**Hospital1 **] and was started on
[**First Name9 (NamePattern2) 64983**] [**1-26**] for presumed bronchitis vs PNA. This AM,
covering rehab MD [**First Name (Titles) 8706**] [**Last Name (Titles) 7968**] UOP, elevated HR, and "low but
unchanged SBP in 100-120 range." In addition, pt's lisinopril 5
mg daily was held due to creatinine 2.2 (up from 1.3 per
report).
<br>
Upon arrival to [**Name (NI) **], pt's BP 67/44, HR 110s, temp 101.2, Sat 97%
2L NC. SBP improved to 90s within ~ 2 hours after IVF given. In
addition, patient was found to have RUQ tenderness so CT
abd/pelvis was obtained & showed "sludge within a distended
appearing gallbladder. There may also be pericholecystic fluid
or wall edema that is concerning for acute cholecystits." CT
also revealed pericardial and bilat pleural effusions, moderate
ascites, and R-inguinal hernia with nonobstucted small bowel.
Surgery was consulted & recommended IV antibiotics and urgent
percutaneous GB drainage catheter placement by IR. Labs were
signif for WBC 15 w/88% neut, 0% bands, Hct 24, K+ 5.7, proBNP
30,000. Lactate 1.5, INR 2.2 on coumadin. Pt rec'd [**Name (NI) 64983**],
flagyl, vancomycin, 2U PRBC, 1L NS, and Tylenol PR. Two sets
blood Cx sent.
<br>
Upon my eval in the ED, he denies any abdom pain, F/C, N/V, or
diarrhea (in fact is slightly constipated). He has noted
increased sputum production (yellow, thick) over the past few
days. Pt also c/o pain in his buttocks at the site of skin
breakdown. Denies CP, SOB, palpitations. Pt also denies any
lightheadedness, visual changes, or known confusion when his BP
was low. Also denies BRBPR, melena, hematuria, or new bruises.
No known aspiration or choking episodes.
Past Medical History:
-CAD s/p stents in [**2146**]; s/p CABG, AVR(bioprothetic),
pericardial stripping on [**2150-12-16**] at [**Hospital1 112**]. On coumadin.
-DM2 x ~40 yrs on oral hypoglycemics at home
-hyperlipidemia
-HTN (although SBP 100-120 & only on lisinopril 5 @ rehab)
-Atrial fibrillation
-GERD
Social History:
-transferred from [**Hospital **] Rehab
-remote TOB: ~10 pack-yrs; quit >40 yrs ago.
-HCPs is son & daughter
Physical Exam:
-VS: temp 101.2->96.3 (after Tylenol in ED), HR 75-85, BP 106/30
(in ED), repeat BP 83/55 with MAP 67 (in ICU), RR 20, Sat 100%
NC. Pulsus <10 mmHg.
-Gen: cachectic elderly M sitting in stretcher in NAD
-Skin: former trach site w/thick, yellowish mucus; sacral
dressing over known decub; G-tube site without erythema;
sternotomy site intact, nonerythematous.
-HEENT: OP clear, dry MM, poor dentition. [**Name (NI) 3899**], [**Name (NI) 64984**] ptosis
(per family, has been like this x years). ~1 mm pupils
bilaterally.
-Neck: JVD to mandible, supple, full ROM
-Heart: S1S2, irreg irreg, II/VI SM
-Lungs: coarse upper airway sounds anteriorly. Posteriorly:
[**Name (NI) 7968**] B.S. R-lower [**12-29**] and L-base. Crackles 1/2 up on right
and 1/3 up on left. Fair air movement. No wheezes appreciated.
-Abdom: mild tenderness to palp in RUQ; somewhat tense muscles
but no rebound or guarding. +B.S.
-Extrem: thin; 1+ pitting edema bilat LEs up to knees; 1+
pitting sacral edema; trace DP pulses bilat; 1+ radial pulses
bilat.
-Neuro/Psych: A&Ox3, answers ?s in [**12-28**] word phrases, speech
fluent but difficult as former trach site still open. [**4-30**]
strength in upper extrem. 2/5 strength in lower extrem. CN2-12
intact.
Pertinent Results:
Admission labs
<BR>
[**2151-1-27**] 01:45PM GLUCOSE-174* UREA N-77* CREAT-2.1* SODIUM-137
POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2151-1-27**] 01:45PM ALT(SGPT)-27 AST(SGOT)-26 CK(CPK)-17* ALK
PHOS-141* AMYLASE-22 TOT BILI-1.0
[**2151-1-27**] 01:45PM CK-MB-4 cTropnT-0.31* proBNP-[**Numeric Identifier 64985**]*
[**2151-1-27**] 01:45PM ALBUMIN-2.5*
[**2151-1-27**] 01:45PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.8*
[**2151-1-27**] 01:45PM HAPTOGLOB-268*
[**2151-1-27**] 01:45PM DIGOXIN-2.2*
[**2151-1-27**] 01:45PM WBC-15.0* RBC-2.69* HGB-8.1* HCT-23.9* MCV-89
MCH-29.9 MCHC-33.7 RDW-20.1*
[**2151-1-27**] 01:45PM NEUTS-88.8* BANDS-0 LYMPHS-6.7* MONOS-4.2
EOS-0.1 BASOS-0.2
.
Discharge Labs:
WBC 8.9, Hct 34, plt 156
inr 1.3, ptt 34
na 143, k 5.2, cl 109, bicarb 26, bun 51, creat 2.8
ca 9.2, phos 3.2, mag 1.8
alt 14, ast 19, ap 171, Tbili 0.4, amylase 18, lipase 7
PTH 52
Vanco (random, [**2151-3-16**]) = 33.2
Digoxin ([**2151-3-17**]) 0.8
ABG 7.46/40/95 ([**2151-3-11**])
<BR>
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a small
pericardial effusion. There are coronary artery calcifications.
A metallic clip is seen in the region of the pericardium. There
are moderate large bilateral pleural effusions, right greater
than left. There is bibasilar atelectasis/consolidation, as well
as consolidation/collapse within the right middle lobe. There is
a 4-mm calcified nodule in the left lower lobe. There is also
fluid in the left major fissure. On the unenhanced scan, the
liver, adrenal glands, kidneys, and pancreas are unremarkable.
Multiple calcifications are seen within the spleen. There are
multiple vascular calcifications within the abdomen. There is
atherosclerotic calcification of the descending aorta, including
at the major branch points of the celiac axis, and inferior
mesenteric arteries, as well as bilateral renal arteries. There
is high attenuation layering within the gallbladder consistent
with sludge. There is a small-to-moderate amount of ascites seen
adjacent to the liver, spleen, and pancreas. There also appears
to be fluid in the gallbladder fossa, some of which may
represent wall edema or pericholecystic fluid. The gallbladder
itself is distended. Lymph nodes are seen within the mesentery
measuring approximately 7-8 mm. There are similar appearing left
paraaortic lymph nodes. There is a G-tube in place. There is
also stranding of the mesentery. There are no dilated loops of
large or small bowel.
<BR>
CT OF THE PELVIS WITHOUT IV CONTRAST:
1 Pericardial effusion, and moderate bilateral pleural
effusions. Bibasilar atelectasis/consolidation. 2 Moderate
ascites. 3 Sludge within a distended appearing gallbladder.
There may also be pericholecystic fluid or wall edema. This is
concerning for acute cholecystits in the appropriate clinical
setting. 4. Right inguinal hernia containing nonobstructed small
bowel and fluid.
<BR>
PORTABLE CHEST RADIOGRAPH: The patient is status post median
sternotomy with sternal wires seen. The patient is status post
mitral valve replacement. There are bibasilar opacities which
could be secondary to pulmonary edema and/or overlying
consolidation. There are bilateral pleural effusions, left
greater than right. IMPRESSION: Developing pulmonary edema with
possible underlying consolidations.
<BR>
[**2-12**] NON-CONTRAST CT SCAN OF THE NECK: An endotracheal tube is
in place. Contrast is visualized around the upper aspect of the
endotracheal tube and in the cervical esophagus. No definite
sizeable masses are identified in the neck. No definite free
fluid collections within the neck are identified. There is a
right subclavian catheter.
<BR>
IMPRESSION: Contrast material visualized within the upper airway
perhaps secondary to reflux from placement of contrast material
for CT of the torso obtained at the same time. No definite
evidence of pathologic fluid collection in the neck.
<BR>
EKG (admit): Atrial fibrillation with rapid ventricular
response, Multifocal PVCs, Poor R wave progression, Nonspecific
ST-T wave changes, No previous tracing available for comparison
Rate PR QRS QT/QTc P QRS T
117 0 98 [**Telephone/Fax (2) 64986**] 157
<BR>
ECHO: The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (ejection fraction 40 percent), mainly due to abnormal
left ventricular electrical/mechanical activation sequence. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. A bileaflet aortic valve prosthesis
is present. The aortic prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion. Impression: ventricular dyssynchrony with
reduced left ventricular ejection fraction
<BR>
FINDINGS T-tube cholangiogram: Appropriate position of
cholecystostomy tube. Normal opacification of gallbladder,
common bile duct, and intrahepatic bile ducts with drainage into
the duodenum. Small amount of retrograde flow of contrast along
the cholecystostomy tube likely of little clinical significance
in the absence of the patient's symptoms.
<BR>
RENAL ULTRASOUND: The right kidney measures 10.7 cm, the left
kidney measures 10.7 cm. There are no renal stones, masses or
hydronephrosis. A Foley catheter is within the bladder. A small
amount of ascites is seen within the right upper quadrant.
IMPRESSION: No hydronephrosis.
<BR>
CHEST (PORTABLE AP) [**2151-3-13**] 10:17 AM:
The right pleural effusion has [**Month/Day/Year 7968**] since the previous
exam, however, there is suggestion of larger effusion on the
left extending along the lateral chest wall. Overall the
parenchymal opacities remain stable with compressive atelectasis
in the left lung base. The degree of the pulmonary edema shows
no change since the previous exam.
<BR>
There is a right PICC line with the tip in SVC and left
subclavian dialysis catheter. A tracheostomy tube is in place.
The patient is status post CABG and AVR.
<BR>
[**2151-2-5**] 11:01 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2151-2-5**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
<BR>
RESPIRATORY CULTURE (Final [**2151-2-7**]):
OROPHARYNGEAL FLORA ABSENT.
ENTEROBACTER CLOACAE. HEAVY GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
<BR>
[**2151-2-2**] 2:56 pm SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS
(Final [**2151-2-6**]): ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
<BR>
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
<BR>
[**2151-2-8**] 10:52 am BRONCHIAL WASHINGS
GRAM STAIN (Final [**2151-2-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
<BR>
RESPIRATORY CULTURE (Final [**2151-2-11**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2451**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
<BR>
[**2151-3-14**] 2:36 am SPUTUM Source: Endotracheal.
<BR>
GRAM STAIN (Final [**2151-3-14**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM AND
PROPIONIBACTERIUM SPECIES.
<BR>
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
Please contact the Microbiology Laboratory ([**6-/2451**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
STAPH AUREUS COAG +. SPARSE GROWTH. 2ND STRAIN.
Please contact the Microbiology Laboratory ([**6-/2451**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
<BR>
SENSITIVITIES: MIC expressed in
MCG/ML
_<BR>________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ <=1 S <=1 S
Brief Hospital Course:
79M with CAD s/p CAGB, AS s/p AVR, DM2, Afib admitted to MICU
for hypotension, suspected cholecystitis, likely PNA, and ARF.
Hospital course outlined by problem.
.
HYPOTENSION: Initially BP stabilized after NS and PRBCs, but
intermittently became hypotensive during the begining of his
hospital stay thought to be related to sepsis. Blood cultures
remained persistently sterile. [**Last Name (un) **] stim showed preservation of
adrenal function with baseline at 21.9 and a rise to 38 after 1
hour after cosyntropin. Regardless was transiently placed on
hydrocort. Continued to be hypotensive during CVVH only, but
later was able to maintain his BP during HD sessions as time
went on. Blood pressure meds should be held on his HD days for
more effective ultrafiltration. Over the latter part of his
hospital course, he has maintained systolic blood pressures
greater than 90. He was able to tolerate small doses of
hydralzyine 10 q 6 hours (holding for sbp than 90) and was
recently started on toprol 12.5 mg qd. He has been aggressively
dialyzed and bp meds should be held during hd days.
.
POSSIBLE ACUTE CHOLECYSTITIS: noted on CT abd/pelvis. RUQ
tenderness but no peritoneal signs. Percutaneous gallbladder
drain placed by IR on Febuary 3 & drained well, and initially
covered on levo/flagyl/amp. IR study showed good drainage
contrast into duodenum, so drain was clamped and LFT's/AlkP were
followed with the surgery team. After the labs remained stable,
this drain was pulled. Remained afebrile without abdominal pain
after his course of antibiotics was completed.
.
RECURRENT PNA: he initially noted increased sputum, fever, and
some infiltrates on CXR (CHF vs infiltrate) c/w PNA. Initially
on levo/flagyl/amp and vanco for empiric coverage for
cholecystitis, pneumonia, and skin flora. Sputum Cx grew back
MRSA and enterobacter, changed to CTX after sensitivity panel.
He later was treated for 2 full courses Vanc and Meropenem for
PNA which was completed on [**3-6**]. There was evidence of aspirated
contrast by CT initially, so pt's PEG was changed to PEJ to help
prevent aspiration. Approximately 6 days prior to his hospital
discharge he began having copious secretions. His CXR showed no
evidence of a new pulmonary infiltrate. His WBC count rose
slightly. Sputum grew MRSA and he was started on a 10 day
course of vancomycin for MRSA tracheobronchitis. His vanc
levels were dosed at 1g to keep levels >25 for good pulmonary
penetration. His last vanco course will be completed on
[**2151-3-20**].
.
RESPIRATORY FAILURE: With his worsening respiratory difficult a
trach was re-placed at the site of his prior trach site and he
was vented as tolerated in the setting of CHF and PNA. Attempts
were made to wean his from the trach, but were difficult in the
setting of CHF, PNA, and severe deconditioning. He was
gradually weaned off the vent with removal of fluid through
hemodialysis / ultrafiltration and treatment of his pneumonias.
He was on trach mask for >1 week prior to his discharge. He was
speaking with a passy muir valve, however care must be taken to
suction his secretions intermittently while the valve is on. He
is able to cough some of his secretions into his mouth and has a
good gag.
.
CHF: EF reportedly ~20% pre-CABG. ProBNP markedly elevated in ED
but O2 sat stable on NC even after 2U PRBC in ED. JVD and
crackles. Digoxin was held for serum level 2.2 and evidence of
dig toxicity on EKG (accelerated junctional rhythm). He
required two doses of digibind before his rhythm improved.
Repeat EF showed EF of 30%. His bioprosthetic aortic valve was
noted to be well seated. His CHF is complicated by severe
malnutrition and low albumin, creating for marked third spacing.
He has improved with aggressive ultrafiltration as alluded to
above but still requires ultrafiltration at least 3 days per
week. Hydralzyine was started in hopes of providing afterload
reduction for improved forward flow - given his marginal
pressures, he does not have much room to titrate up. In
consultation with cardiology and given his atrial fibrillation,
he was restarted on digoxin. However, near the end of his
course, there were again concerns about av block and as such dig
has been d/c'd. Finally, he was started on low dose
beta-blocker, metoprolol 12.5 [**Hospital1 **] to help w/ ventricular
remodeling. As mentioned below, pending renal function, an ACEI
may be considered.
.
ARF: creat was 2.1 in ED, but apparently creat was 1.2 in recent
past per rehab note. Initially thought to be ATN given prolonged
hypoTN in ambulance and initially in ED. He later became anuric,
and underwent CVVH for fluid removal. A tunned HD line was
placed by renal, and he later tolerated full HD sessions without
difficulty. He continues to require hemodialysis and hasn't
made any signs of renal recovery. The etiology of his renal
function remains unclear. [**Name2 (NI) **] did have renal u/s demonstrating
normal blood flow and no evidence of obstructive physiology. As
such, he continues w/ UF on Tuesday, Thursday, and Saturday.
Recently, he has been able to tolerate as much as 4L removal
during these sessions. Nephrology feels that he may regain his
renal function and have recommended that he not be placed on an
ACEI. This will need to be readdressed over time as he will
benefit from an ACEI from a CHF and blood pressure standpoint.
.
AFIB/CAD: it was initially unclear if pt is chronically in Afib
or paroxysmal, however he remained in AFIB throughout his entire
hospital stay. Upon talking w/ daughter later in hospitlization,
it appears that pt may chronically be in afib. It was presumed
he was on coumadin for AVR & Afib. While here he had a GIB with
an episode of hypotension in the setting of a supratherapeutic
INR. Coumadin was stopped and was not be restarted during his
stay. GI was consulted who recommended an outpatient coloscopy.
In the setting of his acute renal failure, he developed dig
toxicity with EKG changes (accelerated junctional rhythm). He
required two rounds of digibind before this resolved and dig was
discontinued. He was started on IV amiodarone (load) and was
tolerating PO amio but maintained in atrial fibrillation. Later
in his hospitalization, cardiology (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**]) was
reconsulted regarding the utility of continuing amiodarone in
the setting of likely chronic afib w/ enlarged atria, chf, and
respiratory failure (making conversion to SR unlikely). It was
recommended to d/c amiodarone and to restart his digoxin at a
low dose 0.625 qod while checking dig levels frequently to keep
his dig level <1.5. Dig was contineud but recently there were
concerns about ?AV block on dig. Given his history of dig
toxicity and renal failure, it was decided to d/c dig on [**3-19**].
Subsequent rate control will be through beta-blockade,
metoprolol 12.5 [**Hospital1 **]. His rates have generally been well
controlled although occasionally noted to be in low 100's during
HD and during pain. As mentioned above, given his recent
bleeding, it was elected not to anti-coagulate pt. He will be
maintained on ASA. Future discussions regarding
re-anticoagulation could be revisited by cardiologist or PCP. [**Name10 (NameIs) **]
was initiated on metoprolol for CHF and rate control. He was
s/p CABG 1 month ago prior to admission w/ bioprosthetic aortic
valve placed during [**11-30**]. He was continued on an ASA and
statin.
.
GIB/ANTICOAGULATION: he was restarted on Coumadin and then began
to have bright red blood per rectum, and hypotension in the
setting of supratherapeutic INR. Coumadin was stopped, vitamin K
IV, FFP, and PRBCs administered. GI consulted and reluctant to
scope patient in tenous clinical situation. Despite this
reversal, his INR continued to be elevated for unclear reasons.
It was questioned what his true need for Coumadin is since he
has a bioprosthetic valve with Afib. After his GIB is was felt
that Coumadin should be held during this hospitalization, and
that he should continue an ASA and re-address risks of Coumadin
after discharge. He has no further bleeding during the last [**1-29**]
weeks of hospitlization and no further transfusion requirements.
.
DECUB: he has significant sacral decub ulcers that were
evaluated by the wound care team, as well as a L-heel pressure
ulcer that was followed as well. He continues to have SEVERE
pain in the buttock region. We have been increasing his
fentanyl patch and using morphine IV for breakthrough pain.
Zinc and vitamin C were given orally daily. His wound has been
slowly improving. He requires frequent turning and an air
mattress. His fentanyl patch was increased to 200mcg/hr on [**3-17**].
It will be important to titrate this medication upwards but
mindful not to avoid oversedation. In fact, pt was found heavily
sedated on [**3-18**] - this was attributable to this increased
narcotic dosage and subsequently has been reduced to 125 mg
every 3 days (last changed [**3-18**]). His mental status has
subsequently returned to baseline. Nutrition will be important
in hopes of improving decub.
Diabetes: He was maintained on sliding scale insulin and Lantus
10. Given chronic tube feeds, this dose may be titrated
according to sliding scale measurements.
Malnutrition: Pt did have PEG placed for nutrition. Earlier in
hospital course, it was demonstrated that pt was in fact
aspirating and as such, PEG was converted to PEJ to reduce risk
for aspiration. He did have repeat swallow study which continued
to demonstrate high risk for aspiration. As such, he should
continue on current tube feeding recommendations. There is mild
erythema at site of PEJ that is felt to represent inflammation
rather than infection. This should be followed closely.
Access: He has double lumen PICC placed earlier in [**Month (only) 958**]. Only
one port is flushing at this point but not clear that pt
requires a great deal of IV medications so this will suffice. In
the future, it could be decided to remove PICC. Finally, he does
have left subclavian dialysis port.
.
GOALS OF CARE: it was addressed several times about the goals of
care, and the family repeatedly insisted that all aggressive
measures should be taken. They have been advised about the
severity of his many illnesses and the chance for recurrent
complications or repeat hopsitilzations. There was question if
the patient had expressed wished to withhold aggressive care,
but was unclear if he truly understood scenario and this goes
against his family's wishes. Communication with his son [**Name (NI) **]
[**Telephone/Fax (1) 64987**] and daughter [**Name (NI) **] who is the HCP. This will need
to be reevaluated now that he is speaking with his Passy Muir
valve.
Medications on Admission:
-lasix 40 daily
-coumadin 5 mg daily
-digoxin 0.125 mg daily
-lisinopril 5 daily (held starting today at [**Hospital1 **] due to K+)
-aspirin daily
-simvastatin 40 daily
-sucralfate 1 gm [**Hospital1 **]
-Epo qWed
-insulin SS
-nystatin TID
-iproatrop neb prn
-albut neb prn
-artificial tears prn
-zinc sulfate 220 mg daily
-Mg hydroxide 30 mL daily
-lansoprazole 30 daily
-lactulose 20 daily
-Na bicarb 10 cc daily
-MVI
-ferrous sulfate 300 daily
-oxycodone 5 mg q4h prn
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
Disp:*90 injection* Refills:*2*
13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold for sbp less than 90 and during HD days.
14. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) unit Transdermal
Q72H (every 72 hours): last change was on [**3-18**].
15. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) patch Transdermal
every seventy-two (72) hours: last patch of 125 on [**3-18**].
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous DAILY (Daily) as needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): please hold on HD days and for sbp less than 85
and hr less than 60.
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
21. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Insulin Glargine 100 unit/mL Cartridge Sig: 10 units units
Subcutaneous once a day.
23. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale units Subcutaneous every six (6) hours: Sliding Scale
Sugar Insulin
0-60 1 amp d50
61-150 0 units
151-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
>401 12 units.
24. Outpatient [**Name (NI) **] Work
Pt should have chemistry 7 w/ ca/mag/phos checked every other
day - please fax to covering nephrologist
25. ultrafiltration
Please continue w/ ultra-filtration every monday, wednesday, and
friday
Please call Dr. [**Last Name (STitle) 174**] at [**Telephone/Fax (1) 60**] for questions with regards
to dialysis
26. Outpatient Speech/Swallowing Therapy
Pt is deemed to be aspiration risk and should be maintained NPO
from mouth.
A repeat swallow eval could be performed in [**12-28**] weeks to
determine if improved.
27. PICC line
One port of LUE PICC not flushing. Pt has minimal IVF needs and
could consider removal of PICC line as condition continues to
improve.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Acute Renal Failure now on hemodialysis
GIB in setting of coumadin
pneumonia with MRSA
aspiration pneumonia
sepsis
MRSA tracheobronchitis
sacral and heel decubitus ulcers
secondary:
CAD s/p cabg
aortic stenosis s/p AVR
Discharge Condition:
fair
Discharge Instructions:
When the patient's clinical status improves, he needs a
colonoscopy for his GIB. If he has no lesions, anti-coagulation
with coumadin could be considered. Patient is to be out of bed
to chair at least once per day. He should have labs (chem 7 w/
calcium, mag, phos and digoxin) checked atleast every other day
(with HD).
Followup Instructions:
Follow up with his PCP [**Name9 (PRE) 6983**] [**Name9 (PRE) **] (see phone above) within 7
days of his discharge.
Hemodialysis/Ultrafiltration three times weekly Monday,
Wednesday, and Friday
|
[
"286.9",
"482.83",
"263.9",
"273.8",
"507.0",
"427.31",
"V42.2",
"578.9",
"E942.1",
"V45.81",
"038.9",
"575.0",
"785.52",
"427.0",
"518.84",
"482.41",
"428.0",
"707.07",
"707.03",
"584.5",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"89.64",
"87.54",
"96.04",
"33.22",
"31.74",
"44.32",
"39.95",
"99.07",
"38.93",
"00.17",
"51.01",
"96.72",
"38.95",
"33.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
29953, 30025
|
15539, 26281
|
327, 481
|
30288, 30295
|
4492, 5202
|
30664, 30860
|
26802, 29930
|
30046, 30267
|
26307, 26779
|
30319, 30641
|
5218, 14349
|
3240, 4473
|
14390, 15516
|
276, 289
|
509, 2790
|
2812, 3099
|
3115, 3225
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,728
| 166,686
|
5808
|
Discharge summary
|
report
|
Admission Date: [**2120-2-15**] Discharge Date: [**2120-2-27**]
Date of Birth: [**2040-3-17**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
Exploratory laparotomy, pyloromyotomy, oversewing gastric ulcer
and ligation of the gastroduodenal artery.
History of Present Illness:
Mr. [**Known lastname 20042**] is a 79M with a recent history of pancreatitis
transferred from OSH for management of UGI bleed. Patient
presented to OSH on [**2-8**] from nursing home with melena and Hct of
24. Patient was started on protonix gtt and transfused 3U PRBCs.
Upper endoscopy was attempted at that time, however the patient
did not tolerate the procedure and it was aborted. Repeat
endoscopy showed a large duodenal ulcer with exposed vessel.
Clipping was attempted however unsuccessful and associated with
increased bleeding. IR embolization was attempted at that time
but aborted due to poor access via calcified femoral vessels.
Patient continued to have melenic stool with downtrending Hct
and transfusion requirement. CT was performed and by verbal
reportshowed active bleeding from the GDA, necrosis of the head
of the pancreas, and a previously identified psoas fluid
collection that was decreased in size. Patient underwent
successful IR coiling of the GDA via left axillary access on
[**2120-2-13**]. Since coiling, he has
had persistent melena and required an additional 2U PRBC today.
Since [**2-8**], he has received a total of 8U PRBCs. He has been
hemodynamically stable and not required pressors. Of note,
patient was admitted to OSH in Janurary for pneumonia,
pancreatitis, and possible Cdiff. Stool cultures during this
admission again showed positive Cdiff for which he is receiving
po vanco. Patient currently denies abdominal pain, nausea, and
malaise.
Past Medical History:
Left inguinal melanoma s/p IFN-a, Type II diabetes, COPD
Infection History: Cdiff colitis, Recurrent LLE Cellulitis +
bacteremia from MSSA, Urinary tract infection, +MRSA and +VRE by
swab
PSH: Left groin dissection [**2105-7-14**], open cholecystectomy,
Amputation of left 2nd toe for melanoma
Social History:
The patient is married and lives with his wife in [**Name (NI) 38**], MA.
He has 2 children, one daughter is a case manager at [**Hospital1 18**].
He was a heavy tobacco smoker for 45+ years at 3 packs per day
and quit in [**2101**]. He denies any alcohol use. He is a former
construction superintendent. Daughter is the health care proxy.
Family History:
Father and uncle with lung cancer. Brother and father died of
pancreatic cancer.
Physical Exam:
VS: 98.1, 74, 122/53, 20, 95% 2L
Gen: Appears comfortable, A&Ox3
CV: RRR
Resp: CTAB, decreased breath sounds at bases
Abd: Soft, nontender, nondistended, well healed right subcostal
incision with reducible hernia, umbilical hernia reducible, 2
former drain sites with tegederm dressings c/d/i
Ext: Warm, no edema, well healed left groin incision, well
healed
left 2nd toe amputation site, doppler DP b/l
Pertinent Results:
On Admission: [**2120-2-15**]
WBC-12.5* RBC-2.96* Hgb-9.1* Hct-25.6* MCV-87 MCH-30.7
MCHC-35.5* RDW-15.6* Plt Ct-118*
PT-14.3* PTT-27.3 INR(PT)-1.3*
Glucose-159* UreaN-46* Creat-1.0 Na-145 K-4.3 Cl-118* HCO3-23
AnGap-8
ALT-12 AST-14 AlkPhos-48 TotBili-0.7 Lipase-68*
Calcium-7.3* Phos-3.7 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 20042**] is a 79 y/o male who was admitted with upper GI
bleed. He requires multiple transfusions of PRBC. EGD was
performed noting large hiatal hernia,blood in the whole stomach,
3cm Ulcer in the duodenal bulb (endoclip). He was started on a
PPI drip and was take to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who
performed exploratory laparotomy, pyloromyotomy,oversewing
gastric ulcer and ligation of the gastroduodenal
artery.Two JPs were placed. Postop, he was sent to the SICU for
management. He remained there for 5 days. He was extubated on
[**2-16**]. Hct remained stable. He passed some melanotic stools
(expected). He continued on Vanco pr for h/o recent C.diff. On
[**2-21**], a feeding tube was placed and tube feeds were started.
On [**2-22**], he transferred out to the Med-[**Doctor First Name **] ([**Hospital Ward Name 121**] 10). He
require aggressive respiratory management with aggressive
incentive spirometry, nebs, chest PT. On [**2-23**], he was somnolent
and O2 sats were in the 88%range. He was pan-cultured and CXR
done. CXR demonstrated bilateral pleural effusions and
atelectasis. UA was positive. He was started on Ciprofloxacin.
Urine culture isolated Enterobacter aerogenes sensitive to
Cipro. A 5 day course was ordered for Cipro.
Respiratory status improved. Foley was removed and a condom cath
was applied. PT worked with him and recommended rehab. He
required [**Doctor Last Name 2598**] lift to get OOB to chair. On [**2-26**], feeding tube
was inadvertently pulled out. A video swallow was then done by
Speech therapy which he failed. The following was noted:
moderate-severe oropharyngeal dysphagia as described above
including aspiration of thin and
nectar thick liquids and pharyngeal residue of solids as well as
evidence of his known esophageal dysmotility. Safest
recommendation remains NPO with continued non-oral
nutrition,hydration, and medication during his acute admission.
Of note, he was coughing up (with chest PT/vibration)green
phlegm. Repeat CXR was negative for pneumonia. O2 NC @2L was
continued with sats in 92-94% range.
On [**2-26**], feeding tube was replace, however, this clogged during
the night. Several attempts were replaced, but were unsuccessful
due to patient being unable to tolerate. The decision was made
to start TPN and re-assess next week. He remained NPO. PR Vanco
for h/o C.diff finished on [**2-22**]. Last BM was on [**2-26**].
Abdominal JP drains were removed on [**2-19**] and [**2-26**]. Right sided
ABD drain site appeared red due to drain irritation. Abdominal
incision appeared pink at staple insertion sites on right side
where he also had some swelling and pain to touch. Swelling was
felt to be due to a seroma that was required no intervention at
this time. He will f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**3-7**].
The plan is to transfer to [**Hospital **] Rehab in [**Location (un) 701**]. PO meds
were held. Atenolol was switched to IV Lopressor and IV Cipro
was continue for a total of 10 days (stop date [**3-3**]) for UTI and
respiratory status. Last non-bloody BM was [**2-26**].
Medications on Admission:
omeprazole 20', glipizide 10'', pioglitazone 30', MVI',
simvastatin 80 QHS, colace 100' QAM, 200 [**Last Name (LF) 7918**], [**First Name3 (LF) **] 81',
oxybutynin chloride 5'', Vit C 500'', Vit B12 1000', Folic acid
1', tylenol [**Telephone/Fax (1) 1999**] QID prn, FeSO4 325'', Atenolol 50 QHS,
Tamsulosin 0.4', Lisinopril 2.5', Reglan 10''', ibuprofen 200'
prn
Current hospital meds: Vanco 250mg po QID, RISS, Ipratropium
nebs, albuterol nebs, B12, morphine prn
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze/sob.
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold until passes swallow eval.
6. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q12H (every 12 hours) for 11 doses.
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. 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.
9. Picc line care per protocol
10. TPN
via central line daily. start day 1 bag on [**2-27**]
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold until passes swallow eval.
12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime): hold until passes
swallow eval.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
hold until able to swallow.
15. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold until passes swallow eval.
16. Lopressor 5 mg/5 mL Solution Sig: Five (5) mg Intravenous
every six (6) hours: hold for sbp <110 or HR 60.
17. Hold po meds until repeat speech and swallow evaluation
18. NPH insulin human recomb 100 unit/mL Suspension Sig: Four
(4) units Subcutaneous twice a day: please monitor for need to
adjust as patient off TF and starting TPN [**2-27**].
19. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
20. tylenol Sig: Six [**Age over 90 1230**]y (650) mg Rectal every eight
(8) hours as needed for pain.
21. pantoprazole 40 mg Recon Soln Sig: One (1) dose Intravenous
twice a day.
22. UA, Urine culture after Cipro course completed
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Upper GI bleed
Duodenal Ulcer
c. Diff colitis
Urinary Tract Infection
s/p Exploratory laparotomy, pyloromyotomy, oversewing gastric
ulcer and ligation of the gastroduodenal artery.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 20042**],
You were admitted to the [**Hospital1 18**] surgery service for a procedure
to fix your gastrointestinal bleeding. You have improved since
surgery and at this time we think you should go to rehab to
continue your recovery.
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the following: temperature of 101, shaking chills, nausea,
vomiting, increased abdominal pain, wound edges appear red,
blood in your stool, dark/black stools or any other concerns.
Please refer to the attached medication reconciliation to see
your most recent list of medications.
Thank you for letting us participate in your care. We wish you
a speedy recovery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2120-3-7**] 3:00.
Completed by:[**2120-2-27**]
|
[
"041.85",
"008.45",
"577.8",
"V49.72",
"998.13",
"E878.8",
"532.40",
"250.00",
"276.0",
"599.0",
"496",
"V10.82",
"511.9",
"553.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.86",
"44.43",
"53.51",
"44.42",
"43.3",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9385, 9457
|
3449, 6636
|
285, 394
|
9682, 9682
|
3128, 3128
|
10600, 10782
|
2605, 2688
|
7153, 9362
|
9478, 9661
|
6663, 7130
|
9858, 10577
|
2703, 3109
|
231, 247
|
422, 1910
|
3142, 3426
|
9697, 9834
|
1932, 2230
|
2246, 2589
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,676
| 104,976
|
23489
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 60165**]
Admission Date: [**2131-12-19**]
Discharge Date: [**2131-12-19**]
Date of Birth: [**2060-9-8**]
Sex: M
Service: TRA
HISTORY: Trauma.
PRESENT ILLNESS: Mr. [**Known lastname **] is a 71-year-old man who was
transferred from an outside hospital after he fell down 4 to
10 stairs at home. He arrived in an intubated condition
without a pulse.
PHYSICAL EXAMINATION: On arrival, the patient was intubated
and pale in appearance. There was no heart beat on palpation
or auscultation. The lungs were clear on a ventilator. The
abdomen was soft. Extremities were cool and pale.
PERTINENT X-RAYS: None.
PROCEDURES PERFORMED:
1. Right groin cordis placement.
2. Emergency room thoracotomy.
3. Exploratory laparotomy.
4. Transesophageal echocardiography.
CONCISE SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] was brought
by Med-flight to the [**Hospital1 69**] in
an intubated condition after being unstable at an outside
hospital for several hours. On arrival, he did not have a
palpable pulse and an ACLS protocol was initiated. He did
have a narrow complex rhythm; and given that an emergency
room thoracotomy was undertaken. After the thoracotomy, and
cardiac massage and ACLS protocol a heart beat was obtained.
The patient was emergently transferred to the operating room
where the patient's heart stopped again. With further
resuscitation, the heart beat was regained again. At this
time, a small laparotomy was conducted elucidating
serosanguineous ascites type of fluid. An exploratory
laparotomy was then conducted which was negative for any
abdominal source of bleeding. The abdomen was closed with a
[**Location (un) 5701**] bag, and the patient was transferred to the intensive
care unit in an unstable condition. Within 1 hour of transfer
to the intensive care unit the patient had a PEA arrest. ACLS
protocol was initiated and was unsuccessful. The patient was
declared dead at that time.
CONDITION ON DISCHARGE: Death.
DISCHARGE STATUS: Expired.
DISCHARGE DIAGNOSES:
1. Multiple trauma.
2. Emergency room thoracotomy.
3. Exploratory laparotomy.
4. Cardiac arrest.
5. Cirrhosis and ascites.
FOLLOW-UP PLANS: None.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 22102**]
MEDQUIST36
D: [**2132-1-18**] 13:22:39
T: [**2132-1-19**] 10:55:45
Job#: [**Job Number 60166**]
|
[
"805.07",
"570",
"286.7",
"730.28",
"807.06",
"860.2",
"E880.9",
"789.5",
"305.00",
"427.5",
"401.9",
"805.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"34.04",
"37.91",
"37.12",
"99.04",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
2044, 2173
|
839, 1961
|
412, 810
|
2191, 2486
|
1986, 2023
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,984
| 149,299
|
22790
|
Discharge summary
|
report
|
Admission Date: [**2153-12-26**] Discharge Date: [**2154-2-1**]
Date of Birth: [**2129-6-16**] Sex: M
Service: MEDICINE
Allergies:
Propofol / Imipenem/Cilastatin Sodium / Aztreonam/Dextrose-Water
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Tracheostomy placement
Central venous line placement
PICC placement
Radial arterial line placement
History of Present Illness:
24 yo M with morbid obesity, R popliteal DVT, OSA, originally
admitted to [**Hospital3 51058**] [**2153-12-20**] after falling asleep at
the wheel --> MVA. WBC - 18. Initially started on levoflox [**12-21**]
for ? pneumonia - nothing definitive on CXR. [**2153-12-22**], found to
have respiratory failure, ABG - 7.27/56/50, failed bipap and
intubated. CTA performed after difficulty with oxygenation. Pt.
dx with R apical and L lower lobe PE on [**2153-12-25**], LENIs showed R
sided popliteal DVT. Pt. spiked fever to 101.5 on [**2153-12-26**], found
to have peri-coxxyx ulcer with drainage of pus, culutured,
started on imipenem empirically. Transferred to [**Hospital1 18**] for
persistent hypoxia (fio2 up to 0.80 and peep up to 10) and
respiratory acidosis. Most recently, WBC persistently elevated
at 16.6 with 6% bands. [**2153-12-26**] UA with 7-14 WBC, but LE/UN neg.
Past Medical History:
-OSA
-morbid obesity - weight gained after taking psych meds
(clozaril, risperdal, effexor, wellbutrin, zonegran)
-schizoaffective disorder
-pulmonary hypertension
-DVT with PE
-h/o rectal abscess
-h/o hernia repair
Social History:
Smokes cigars, occasional EtOH
Family History:
Positive for coronary artery disease
Physical Exam:
VS T98.5 P82 BP120/48 RR17 O2Sat100% 12L 0.4 trach mask
GENERAL: NAD
HEENT: OP clear, NCAT, EOMI, PERRL
NECK: Supple, JVP impossible to evaluate, passy muir in place
and functioning
CARDIOVASCULAR: S1, S2, RRR, no murmurs
LUNGS: CTAB
ABDOMEN: Obese, active bowel sounds, NT, ND, no rebound or
guarding.
EXTREMITIES: 1+ LE edema, no clubbing or cyanosis. Warm,
distal pulses intact
NEURO: Awake and alert, speaking, able to answer questions.
Moving all four extremities on command, however, decreased
strength RUE
Pertinent Results:
ECG Study Date of [**2153-12-26**] 10:25:14 PM
Sinus tachycardia
Right atrial abnormality
S1 Q3 T3 pattern
Inferior and right precordial lead ST-T wave abnormalities
Clinical correlation is suggested for possible RV overload
No previous tracing for comparison
BILAT LOWER EXT VEINS PORT [**2153-12-28**] 1:24 PM
Equivocal minimal thrombus in the right popliteal vein,
age-indeterminant, with no evidence of proximal extension. The
appearance may represent possible minimal acute, subacute, or
chronic thrombus. No evidence of deep vein thrombosis in the
left lower extremity. The findings were discussed with Dr.
[**Last Name (STitle) **] at 4:40 p.m. on [**2153-12-28**].
ECHO Study Date of [**2153-12-28**]
1. The left atrium is mildly dilated. A small patent foramen
ovale is present.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
3. The right ventricular cavity is markedly dilated. There is
severe global
right ventricular free wall hypokinesis. There is abnormal
diastolic septal
motion/position consistent with right ventricular volume
overload.
4. There is mild pulmonary artery systolic hypertension.
5. There is a small pericardial effusion.
ECHO Study Date of [**2154-1-9**]
IMPRESSION: Markedly dilated RV cavity with free wall
hypokinesis. Normal LV
cavity size and systolic function. Abnormal septal motion c/w RV
pressure/volume overload. Moderate pulmonary hypertension. Small
pericardial
effusion.
Compared to the study (tape reviewed) dated [**2153-12-28**], the RV
function has
improved but still remains dilated.
CTA CHEST W&W/O C &RECONS [**2154-1-24**] 12:00 PM
CT CHEST WITH IV CONTRAST: There is multifocal air-space
disease, with areas of air-space disease within the left upper
lobe, left lower lobe, lingula, right upper lobe and right lower
lobe. No cavitary lesion is identified within the left lung to
correspond to findings on recent chest x-ray.
There is a small amount of fluid within the major fissure on the
right. There is bibasilar atelectasis, right greater than left.
Though non-diagnostic for evaluation of acute pulmonary embolus
due to poor contrast delivery, there is heterogeneity within the
right pulmonary artery, which may correspond to the known
pulmonary embolus. However, correlation with prior (i.e. outside
studies), is advised. Alternatively, V/Q scan or repeat CT could
be performed if clinically indicated.
EEG Study Date of [**2154-1-29**]
IMPRESSION: This is a normal routine EEG obtained predominantly
in
drowsiness. No lateralizing abnormalities were seen. During the
recording notation was made of twitching without electrographic
evidence
of seizure activity.
[**2154-1-30**] 9:21 AM CT HEAD W&W/O IV CONTRAST: No intraparenchymal
or subarachnoid hemorrhage is seen. No major vascular
territorial infarct is identified. Ventricles are not dilated,
and there is no shift of normally midline structures. There are
no abnormal areas of contrast enhancement within the brain
parenchyma. The density of the brain parenchyma is within normal
limits. The osseous structures are normal. Mucosal thickening is
noted in the left frontal air cell, the sphenoid air cells, and
the maxillary sinuses bilaterally.
CT C-SPINE W/CONTRAST [**2154-2-1**] 9:50 AM
Contrast-enhanced CT images were obtained from the skull base
through the thoracic inlet. The field of view is large to
evaluate the soft tissues of the neck. There are no previous
studies for comparison.
Due to the patient's body habitus, there is marked streak
artifact across the lower cervical and upper thoracic spine
images. The spinal canal is fairly well-visualized from the
skull base through C4, and there does not appear to be stenosis
or neural impingement at these levels. Inferior to this,
although bony anatomy is defined, the intraspinal structures are
obscured.
Sagittal and coronal reformatted images demonstrate normal
vertebral alignment. No fractures are identified. There are no
asymmetries or abnormally-enhancing structures in the cervical
paraspinal region examined. There is no destructive change of
the bones to suggest the presence of an osteomyelitis.
A tracheostomy is in place and the pharyngeal soft tissues
appear collapsed. The adenoids are enlarged. There is some fluid
and mucosal thickening within the paranasal sinuses.
Brief Hospital Course:
24 yo M with OSA p/w with hypercarbic and hypoxic respiratory
failure, found to have bilateral PEs, transferred for difficulty
in vent management.
1) Respiratory failure - Multifactorial. Mostly hypoxic in
origin. Pt was requiring high FiO2 and PEEP to maintain
oxygenation. On admission, mild CHF w/o consolidations on CXR.
Likely hypoxia secondary to bilateral pulmonary emboli,
developed ventilator associated pneumonia (klebsiella); further
complicated by obesity/hypoventilation. TTE documented small
R-->L shunt; hypoxic w/ positional changes. As ventilation
course appeared to be prolonged, patient had tracheostomy placed
on [**2154-1-15**]. However, patient's respiratory status and
ventilation requirements continued to improve, and patient was
placed on trach mask trial [**2154-1-25**]. Patient was completely
weaned from mechanical ventilation by the next day, and
maintained O2 saturations above 94% for the remainder of
hospitalization on 12L FiO2 40% trach mask and spontaneous
breathing.
2) Metabolic acidosis: Patient was initially tx w/ bicarb
infusion, but required 3 days of CVVHD, which was initiated
[**1-4**]. CVVHD was discontinued as urine output improved and
acidosis resolved.
3) Fever -
a) Ventilator Associated Pneumonia: Initially felt to be
secondary to pulmonary emboli and UTI at outside hospital.
However, patient continued to be febrile despite broad spectrum
coverage including aztreonam/linezolid/metronidazole/Zosyn.
Patient's cultures did speciate to klebsiella, and therapy was
tailored to meropenem following desensitization therapy.
Patient completed a two week course, and accordingly sputum gram
stains cleared and secretions decreased dramatically.
b) Line infection: However, following completion of the
meropenem treatment, as he continued to spike, patient was
started empirically on vancomycin, and a central line that had
been in place for several days was removed. Consequently, blood
cultures drawn prior to vancomycin revealed vancomycin-resistant
enterococcus in the blood. Therefore, although patient
defervesced and cultures cleared following initiation of
vancomycin, vancomycin was discontinued and linezolid was
initiated on [**2154-1-26**] for a seven day course per infectious
disease consultants. At the time of discharge, patient was
afebrile for greater than 72 hours and had one remaining day of
linezolid therapy to complete. Of note, early in
hospitalization, patient did have a peri-rectal abscess,
concerning as a source, however, no cultures never speciated an
organism suggestive of skin flora.
4) Bilateral Pulmonary Emboli: Patient was noted to have
bilateral pulmonary emboli with RV strain noted both on EKG and
Echocardiography, however given the lack of hemodynamic
instability, patient was not given tPA. However, patient was
started on heparin infusion with good effect, and repeat CTA
revealed no significant pulmonary emboli later during hospital
course. Given PEs, patient was started on coumadin for long
term anticoagulation, and heparin infusion was discontinued when
INR reached therapeutic level.
5) Acute Renal Failure: This was thought to be secondary to
acute illness and sepsis. As noted above, patient required
three days of CVVHD, however, throughout hospital course,
patient's creatinine improved and by the time of discharge,
patient's urinary output was excellent, and renal function had
completely normalized.
6) Hypotension: During middle of [**Hospital 228**] hospital course, mean
arterial pressures fell to 50s, and this was felt to be most
likely due to sepsis. Therefore, patient was managed with fluid
boluses in conjunction with stress dose hydrocortisone. As
antibiotic regimen was stabilized and patient's infection
cleared, patient's hypotension stabilized, and patient had been
completely hemodynamically stable for a two weeks at the time of
discharge.
7) Congestive heart failure: As noted above, patient had signs
of RV strain on Echo/EKG secondary to pulmonary emboli.
Therefore, patient was briefly initiated on nesiritide for two
days during the middle of hospital course. However, at the time
of discharge, patient had not signs or symptoms of fluid
overload. A followup echocardiogram was recommended following
discharge.
8) Schizoaffective disorder: Patient was initiated on standing
haloperidol for empiric treatment, and patient had minimal signs
or symptoms of paranoia or psychosis. However, as patient was
weaned from sedation, standing haldol was increased, as patient
began to endorse hallucinations. Unfortunately, patient was
noted by neurology consultants to have significant bradycardia
and cogwheeling rigidity most likely secondary to haldol induced
parkinsonism. In addition, patient was noted to have
seizure-like activity, and although EEG revealed no signs of
seizures, haldol was discontinued as this was thought to be
contributing possible seizures.
At the time of discharge patient denied any signs or symptoms of
schizoaffective disorder despite the fact that he was not being
treated with any neuroleptics.
9) Seizures: During the final week of hospitalization, while
being treated with standing haloperidol, patient was noted to
have seizure like activity, although an EEG was negative for
elliptiform activity. Nonetheless, neurology consultants
recommended a fosphenytoin load and standing phenytoin 100mg
TID, with a target level of [**10-10**]. Following discontinuing
haldol, patient had no further seizure like activity, however,
phenytoin was continued for prophylaxis.
10) Weakness: As noted above, patient was significantly
bradykinesic, thought to be secondary to haldol parkinsonism.
However, as parkinsonism improved following removal of haldol,
patient continued to have deltoid weakness, thought to be in a
cervical spinal distribution. Therefore, on the day of
discharge, patient underwent a CT of the cervical spine (patient
could not fit in MRI scanner) with contrast, and review by
neuroradiology demonstrated no evidence of fracture,
malalignment, or soft tissue abnormalities or bony destruction
suggestive of abscess or infection. It was felt that patient
would best benefit from rehabilitation and neurology followup.
Medications on Admission:
Effexor 75
Clozapine 350
Zonegram 100
Risperdal 3 [**Hospital1 **]
Abilify 10
Wellbutrin 100
Topamax 200 [**Hospital1 **]
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours).
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed.
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 45AM
25PM Units Subcutaneous qAM and HS.
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 days.
10. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
12. Lorazepam 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q4H (every
4 hours) as needed.
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 1110**]
Discharge Diagnosis:
Ventilator associated pneumonia
Bilateral pulmonary emboli
Respiratory failure
Renal failure
Metabolic acidosis
Schizoaffective disorder
Seizures
Drug-induced parkinsonism
Discharge Condition:
Good - patient breathing on trach mask without ventilatory
support, hemodynamically stable and afebrile. No further signs
of seizure like activity.
Discharge Instructions:
Continue medications as directed.
Followup with psychiatrist and restart psychiatric medications
as directed by outpatient psychiatrist.
Please call your primary care physician and make [**Name Initial (PRE) **] followup
appointmen within two weeks of discharge. Call neurology for a
followup appointment within a month of discharge for further
management of phenytoin.
Routine tracheostomy care and teaching.
Followup Instructions:
Check INR twice weekly while taking warfarin with target level
INR [**1-24**]. Check dilantin level twice weekly with target level
[**10-10**].
Issues for followup:
- Followup with neurology for question of continued seizure
prophylaxis and titration of phenytoin dose
- Followup with outpatient psychiatrist on need for restarting
antipsychotics
- Followup on right deltoid weakness following aggressive
physical therapy - consider cervical spine source of weakness
(CT with contrast revealed no source of weakness).
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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2,093
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46008
|
Discharge summary
|
report
|
Admission Date: [**2150-11-27**] Discharge Date: [**2150-12-4**]
Date of Birth: [**2065-3-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy on [**2150-12-2**]
History of Present Illness:
85 year old female with a-fib, HTN, HL, hypothyroidism p/w
abdominal pain and vomiting of 2 day duration. Patient reports
diffuse [**9-6**] abdominal pain for the past 2 days. Describes
associated nausea and non-bloody vomiting. Patient describes
associated fevers and one episode of diarrhea. Patient currently
lives in a nursing home and is unsure if others have been sick.
She has a long-standing history of abdominal pain (see below)
but typically is not associated with nausea or vomiting.
Patient has had multiple admissions for abdominal pain over the
past four years with a negative work-up to date. Work-up has
included multiple CT scans including CTA, surgical/[**Month/Year (2) 1106**]/GI
consults and admissions. Most recent note from GI stated felt to
be related to constipation and chronic abdominal pain syndrome.
Felt unlikely to be mesenteric ischemia as does not occur after
meals and no weight loss. Her most recent admission with similar
complaints was on [**2150-7-14**], at which time CT scans of her
abdomen and pelvis were negative for ulcers, obstructions, or
lesions. Her pain decreased during her hospital stay with
Tylenol. Her diet was advanced as tolerated and she was able to
tolerate po meals her 1st night in-house onwards. She was also
diagnosed with a UTI for which she was started on Bactrim.
In the ED, initial vitals were 99.5 118 152/90 22 100% 6L NC.
Lactate was found to be 2.2. Temperature spiked to 103.2
rectally. She was given Zofran, morphine 4 mg x 2, Acetaminophen
rectal 650 mg early in the night; later on she was started on
Zosyn, Vancomycin, 1 mg Dilaudid, and 650 mg Tylenol. CT
abd/pelvis showed no significant change from prior. CXR was wnl.
EKG demonstrated A Fib. Patient was persistently tachycardic and
consequently admitted to the ICU for close monitoring.
On arrival to the ICU patient reports overall improvement. Her
son who [**Name2 (NI) 97944**] her reports she has mostly been complaining
of abdominal pain, chest pain, nausea and vomiting. The nausea
and vomiting are not typical for her. Patient reports mild
[**Name2 (NI) **]/sneezing today. She denies dysuria, increased urinary
frequency. She reports pain from her "head to her belly" - but
most notable in her abdomen. It is unclear whether she has been
having chest pain and overall is a difficult historian. She
reports overall mild headache, no nucchal rigidity or
significant pain when moving her neck. She reports chronic
muscle aches and shortness of breath. Otherwise ROS negative.
Past Medical History:
Chronic Abdominal pain with multiple admissions, most recently
[**6-/2150**] - she has been evaluated by Gen [**Doctor First Name **], GI and [**Doctor First Name 1106**]
with negative work-up so far.
-TYPE B AORTIC DISSECTION : open abdominal aortic aneursym s/p
repair with Aorto-bifemoral graft [**2144-10-14**]
-BARRETT'S ESOPHAGUS - last EGD in [**2143**]
-PEPTIC ULCER DISEASE - nonbleeding ulcers on EGD [**2143**], negative
for H. pylori Ab [**8-5**]
-HYPERTENSION
-HYPERLIPIDEMIA
-Diastolic CHF, chronic (on Lasix daily), last Echo [**10/2149**] with
EF > 55%, mild RV dilatation, mild pulmonary hypertension, no
regional wall motion abnormalities
-Paroxysmal Afib -not Anti-coagulated due to fall risk
-SPINAL STENOSIS - chronic lower back pain & bilateral
radiculopathy: T2 compression fx, s/p vertebroplasty on [**2148-1-18**]
-ASTHMA - long-standing
-Depression/Anxiety-often manifests as exacerbation of
pain-never seen a psychiatrist/psychologist
-h/o urinary retention
-DIVERTICULOSIS - seen on prior colonoscopy (last colonoscopy in
[**2143**])
-H/O abdominal hernias-no h/o incarceration, no indication for
[**Doctor First Name **]
-CATARACTS AND GLAUCOMA S/P BILATERAL EYE SURGERY -> legally
blind
-S/P HYSTERECTOMY
-S/P RIGHT KNEE SURGERY
-s/p Cholecystectomy
Social History:
Currently lives in nursing home as sister who takes care of her
is away. The patient worked at [**Hospital1 **] for almost 50 years in the
food service department and moved to the US from [**Location (un) 4708**] 55
years ago. Able to ambulate with walker and assistance but is
dependent for most ADLs except eating. Remote smoking history
approx 10 pack year total. Per sister no ETOH or illicit drug
use.
Family History:
Positive for glaucoma in her daughther and her mother. [**Name (NI) **] family
history of MI, ovarian/gyn cancers, colon cancers.
Physical Exam:
Admission Physical Exam:
VS: Temp: 99 BP: 147/81 HR: 96 O2sat: 99% 2 L
GEN: pleasant, comfortable, NAD
HEENT: EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy
Neck: Full range of motion, no nuchal rigidity, negative
brudzinski's sign
RESP: CTA b/l with good air movement throughout, mild bibasilar
crackles
CV: Irregular rate, S1 and S2 wnl, no m/r/g
ABD: nd, hyperactive bowel sounds, soft, diffuse tenderness to
deep palpation only, no rebound or gaurding
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3.
Rectal: guaiac negative in ED
Pertinent Results:
ADMISSION LABORATORY STUDIES;
- [**2150-11-27**] 06:30PM GLUCOSE-133* UREA N-14 CREAT-0.9
SODIUM-139 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
LACTATE-2.2* ALT(SGPT)-22 AST(SGOT)-51* CK(CPK)-79 ALK PHOS-132*
TOT BILI-1.2 LIPASE-17 CK-MB-2 cTropnT-<0.01 ALBUMIN-4.4
CALCIUM-10.4* PHOSPHATE-3.3 MAGNESIUM-2.0 PTH-98*
- [**2150-11-27**] 06:30PM WBC-5.3 (NEUTS-90.0* LYMPHS-6.2* MONOS-2.4
EOS-0.5 BASOS-1.0) RBC-4.66 HGB-14.3 HCT-42.5 MCV-91 MCH-30.7
MCHC-33.6 RDW-14.9 PLT COUNT-219
- [**2150-11-27**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-1.011 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
DISCHARGE LABORATORY STUDIES;
- [**2150-12-4**] 07:55AM BLOOD UreaN-6 Creat-0.7 Calcium-9.5 Phos-3.7
Mg-1.8
- [**2150-12-2**] 07:55AM BLOOD WBC-3.7* RBC-3.69* Hgb-11.4* Hct-34.5*
MCV-93 MCH-30.7 MCHC-32.9 RDW-14.6 Plt Ct-206
Imaging:
CT PELVIS W/CONTRAST Study Date of [**2150-11-27**] 7:28 PM
IMPRESSION:
1. Unchanged large paraumbilical hernia containing small bowel
and omental
fat. There is no evidence of obstruction or strangulation.
2. Extensive colonic diverticulosis, with no evidence of
diverticulitis.
3. Severe atherosclerotic disease of the abdominal aorta, main
branches,
unchanged since the prior examination. A patent aortobifemoral
graft is
redemonstrated. Aneurysmal changes in the internal iliac artery
are stable.
There is unchanged near-complete occlusion of the bilateral
superficial
femoral arteries and moderate stenosis of the mid portion of the
internal
iliac arteries.
CHEST (PA & LAT) Study Date of [**2150-11-27**] 9:09 PM
IMPRESSION: No acute cardiopulmonary abnormality. Unchanged
aneurysmal
dilatation and tortuosity of the thoracic aorta, previously
evaluated on CTA of the chest from [**2150-3-28**].
MRCP [**2150-11-30**]:
1. Somewhat limited study due to non-breathhold technique.
2. Mild intrahepatic biliary dilatation with CBD dilated up to 1
cm,
without definite evidence of choledocholithiasis.
3. Dilated atherosclerotic suprarenal abdominal aorta.
ERCP ON [**2150-12-2**]: Biliary Tree: A moderate diffuse dilation was
seen at the biliary tree with the CBD measuring 12 mm. Given
high clinical suspicion and the severe major papilla stenosis, a
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire. Some sludge was
removed using a balloon catheter. Occlusion cholangiogram did
not reveal any filling defects. Excellent drainage of bile and
contrast was noted. Impression: A severe stenosis of the major
papilla was noted Cannulation of the biliary duct was performed
with a sphincterotome using a free-hand technique A moderate
diffuse dilation was seen at the biliary tree with the CBD
measuring 12 mm. Given high clinical suspicion and the severe
major papilla stenosis, a sphincterotomy was performed in the 12
o'clock position using a sphincterotome over an existing
guidewire.
Some sludge was removed using a balloon catheter. Occlusion
cholangiogram did not reveal any filling defects. Excellent
drainage of bile and contrast was noted.
MICROBIOLOGY:
- [**2150-11-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE} in Aerobic Bottle only
- [**2150-11-28**] BLOOD CULTURE: No growth
- [**2150-11-29**] BLOOD CULTURE: No growth
- [**2150-11-30**] BLOOD CULTURE: No growth
Brief Hospital Course:
Ms. [**Known lastname 1663**] presented with fever and an elevated lactate. The
source of her fevers were never clearly identified but may have
been related to early cholangitis. She improved markedly with
ciprofloxacin and will complete her course of antibiotics on
[**2150-12-6**]. She also has significant chronic abdominal pain
despite a thorough evaluation. During this admission and
evaluation for cholangitis she was noted to have a dilated
common bile duct. On ERCP she had a dilated common bile duct and
severe papillary stenosis. A sphincterotomy was performed.
Unfortunately, at this time it did not seem to improve her pain.
Management of these and other active medical problems outlined
below:
1. Suspected early cholangitis
- complete ciprofloxacin course on [**2150-12-6**]
- she does not need to follow-up with the ERCP team but should
avoid heparin, aspirin, Plavix, Coumadin, and NSAIDs until
[**2150-12-7**] given her sphincterotomy
2. Chronic Abdominal Pain:
- as above, etiology is unclear
- she had an abnormally elevated PTH on admission; in the
setting of critical illness this is difficult to interpret but a
calcium, phosphate, and PTH should be repeated in [**11-29**] weeks to
evaluate for hyperparathyroidism as a cause of her chronic
abdominal pain
3. Congestive heart failure with preserved ejection fraction
- last TTE [**10/2149**] with LVEF >55%; no indication for
beta-blocker or Ace-In but on labetalol for hypertension control
- she does not smoke
- continue Lasix and supplemental potassium
- discharge weight: 206 lbs
4. Bacteremia:
- coag negative staph on admission blood cultures, repeat
cultures drawn prior to antibiotics were negative. This was
likely a contaminant.
5. Atrial fibrillation:
- continued on home medications (diltiazem and labetalol) with
good rate control
- unclear why she is not on stroke prophylaxis with warfarin,
aspirin, or Plavix. However, as above these need to be avoided
until [**2149-12-7**]. Her primary care doctor can discuss stroke
prophylaxis at their next visit in [**11-29**] weeks.
No other changes were made to her medication regimen other than
outlined above. No tests were pending at discharge. Ms. [**Known lastname 1663**]
was Full Code during this admission though previous notes
suggest she may be DNR with intubation OK. This will need to be
explored in detail in the future. She should follow-up with her
primary care doctor, Dr. [**Last Name (STitle) **], phone [**Telephone/Fax (1) 608**] in [**11-29**]
weeks.
Medications on Admission:
- Diltiazem HCl 240 mg SR Daily
- Labetalol 100 mg [**Hospital1 **]
- Mirtazapine 15 mg QHS
- Omeprazole 20 mg Capsule Twice daily
- Senna 8.6x2 mg [**Hospital1 **]
- Quetiapine 50 mg Tablet QHS
- Cholecalciferol (Vitamin D3) 800 unit Tablet Daily
- Betaxolol 0.25 % Drops, R eye [**Hospital1 **]
- Fentanyl 50 mcg/hr Patch Q72H
- Fluticasone-Salmeterol 250-50 mcg/Dose Disk 1 INH [**Hospital1 **]
- Acidophilus Capsule [**Hospital1 **]
- Xalatan 0.005 % Drops 1 gtt in R eye QHS
- Spiriva with HandiHaler 18 mcg Capsule DAILY
- ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler 2 puff QID PRN
SOB
- Furosemide 40 mg Daily
- Klor-Con 20 mEq Packet Sig: Two (2) PO once a day.
- Heparin TID
- Milk of Magnesia 30 mg po qd as needed for constipation
- Senna prn
- Simethicone 80 mg every 6 hours prn
- Colace 100 mg 2 caps qd
- Tylenol 500 mg 2 tabs every 8 hours
- Buspirone 10 mg TID
- Ativan 0.5 mg 1 tab every 6 hours prn anxiety
Discharge Medications:
1. diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
2. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
6. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. betaxolol 0.25 % Drops, Suspension Sig: One (1) drop
Ophthalmic twice a day: right eye.
9. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
11. Acidophilus Capsule Sig: One (1) Capsule PO twice a day.
12. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): right eye.
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Klor-Con 20 mEq Packet Sig: Two (2) packets PO once a day.
17. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) serving
PO once a day as needed for constipation.
18. simethicone 80 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
20. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
21. buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
22. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
23. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis: fever and suspected cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 1663**],
You were admitted with fevers. We think you had an infection of
your gall bladder though it is not entirely clear if this was
the source of your fevers. Fortunately, your fevers resolved on
antibiotics and you should continue taking these with you last
dose on [**2150-12-6**].
We also noticed that your bile duct was very narrow and tried to
open this up in an attempt to help your chronic abdominal pain.
However, your pain has not changed as of yet. You should have
repeat bloodwork to test your parathyroid gland to be sure this
is not causing your pain.
We made the following changes to your medications:
- continue ciprofloxacin as above with your last dose on
[**2150-12-6**]
- because you had a sphincterotomy (cut in your bile duct)
please do not take your heparin, aspirin, Plavix, coumadin, or
NSAIDs unitl [**2150-12-7**].
- continue your other medications as before
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You were admitted to the hospital with abdominal pain. You were
treated with antibiotics.
Please make your follow up appointments and take your
medications as prescribed.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of your discharge from the hospital: [**Last Name (LF) **],[**First Name3 (LF) 8207**] M.
[**Telephone/Fax (1) 608**]
Department: [**Hospital3 1935**] CENTER
When: THURSDAY [**2150-12-31**] at 2:45 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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[
[
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[
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icd9pcs
|
[
[
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|
8859, 11380
|
320, 366
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14644, 14644
|
5421, 8836
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|
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266, 282
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394, 2909
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14589, 14623
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14659, 14803
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2931, 4215
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4231, 4639
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
943
| 161,470
|
47360
|
Discharge summary
|
report
|
Admission Date: [**2154-4-6**] Discharge Date: [**2154-4-17**]
Date of Birth: Sex:
Service:
HISTORY OF THE PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
with multiple medical problems including atrial fibrillation,
chronic obstructive pulmonary disease, coronary artery
disease, congestive heart failure, who lives in a nursing
home at [**Hospital3 2558**], who was found to be pale and weak
with difficulty breathing. The patient's oxygen saturation
on two liters was 61% and increased from 86% to 88% on eight
liters nasal cannula. Vital signs at that time revealed the
following: The patient was afebrile at 98.6, blood pressure
80/60, heart rate 96 to 120 and irregular. She was
subsequently transferred to [**Hospital1 188**] for further evaluation. She was noted to have
significant respiratory distress breathing at 30. She was
started on BiPAP. She was found to be hypercapnic with
respiratory failure with pCO2 of 50, oxygen 99 and pH of
7.36.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
in [**2144**] and [**2148**], CHF with EF of 20% to 25%; COPD on home
oxygen two liters, osteoarthritis, degenerative joint
disease, atrial fibrillation, aortic stenosis, gouty
arthritis, GERD, anxiety, history of adrenal insufficiency,
and 3+ PR and 2+ MR.
MEDICATIONS ON ADMISSION:
1. Coumadin 2.5 mg q.d.
2. Multivitamin.
3. Colace.
4. Lasix 80 mg b.i.d.
5. Ativan 0.25 mg q.8h.
6. Albuterol inhaler.
7. Atrovent inhaler.
PHYSICAL EXAMINATION: On admission, the patient was afebrile
at 98. Blood pressure 92/64, heart rate 120, breathing at
34, saturating 96% on BiPAP. GENERAL: The patient is an
elderly-appearing female in respiratory distress, currently
on BiPAP. HEART: Heart revealed prominent external jugular
distention with no LAD, mild regurgitation. CHEST: Diffuse
crackles bilaterally. CARDIAC: Irregularly irregular
tachyatrial fibrillation, 3/6 systolic murmur at base.
ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: 2+
lower extremity edema bilaterally up to the knees.
LABORATORY DATA: Laboratory data revealed the following:
Hematocrit 35.5, white blood cell count 13.9, platelet count
197,000, PT 20.6, PTT ...................., INR 3. Urine
negative for nitrites. BUN was 42, and creatinine 1.7.
Serial chest x-ray showed moderate cardiomegaly with some
bilateral opacifications in the left upper and right upper
lobes with multifocal pneumonia. EKG showed atrial
fibrillation at 120, with poor R-wave progression with left
axis deviation, pseudochanges in T waves in V1 through V3,
compared to 6/[**2144**].
HOSPITAL COURSE:
#1. PULMONARY: The patient was subsequently placed on BiPAP
overnight, while in the MICU. The oxygenation status
improved significantly overnight. She was subsequently able
to tolerate saturation well. On 5 liters nasal cannula
saturating 95%. She was subsequently called out of the unit
and she was continued on Albuterol and Atrovent inhalers.
Chest CT and supplemental oxygen as well as Mucomyst. She
was started on Levofloxacin for presumed pneumonia and sputum
cultures were sent. Sputum culture subsequently came back
with MRSA pneumonia as well as H. influenza pneumonia. The
patient was subsequently started on Vancomycin for treatment.
The patient's oxygenation status defervesced on hospital day
#4 at which point she was found to be in respiratory distress
once again, breathing at 44 and saturating 90% on 1%
nonrebreather. The patient was subsequently transferred to
the unit once again. However, overnight, she was
subsequently found to be grossly fluid overloaded, diuresed
aggressively. The patient was initiated on Lasix, starting
at 40 mg p.o. and titrated up to 80 mg b.i.d. IV. The
patient was subsequently transferred out of the unit after an
overnight stay and continued on supplemental oxygenation as
well as Albuterol and Atrovent. She was started on Flovent
and Combivent metered dose inhalers. She was also continued
on Lasix to 80 mg IV to maintain her fluid status. The
patient was known to be in chronic obstructive pulmonary
disease and we maintained oxygen saturations to 91% to 95% on
two to three liters nasal cannula goal.
Cardiac patient with a history of CHF, as well as ejection
fraction found to be 15% to 20% with dilated left atrium and
right atrium, LV, and severe left ventricular global
hypokinesis with moderately dilated right ventricle. The
patient was continued on the Lasix, as well as started on
Captopril and Aldactone for treatment of her CHF. The
patient has history of atrial fibrillation. She was started
on Coumadin at a regular dose of 2.5 mg q.d. to maintain the
INR between two to three.
The patient has transient pneumonitis while in the hospital
which resolved most likely secondary to hepatic congestion
secondary to CHF. The patient was found to have negative
hepatic serology studies as well as right upper quadrant
ultrasound fatty liver with no ductal dilatation or
gallbladder distention or evidence of cholecystitis or
cholelithiasis.
CODE STATUS: The patient was made DNR/DNI after multiple
discussions with her family, as well as proxyholder.
GASTROINTESTINAL: The patient underwent a sleep and swallow
study and modified barium study on hospital day #8, which
revealed that the patient had difficulty swallowing pills,
but, otherwise, did not aspirate significantly. She was
subsequently continued on a pureed solid with nectar-thick
liquids diet.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 31245**]
MEDQUIST36
D: [**2154-4-16**] 15:43
T: [**2154-4-16**] 16:07
JOB#: [**Job Number 100244**]
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
[
[
[]
]
] |
1377, 1526
|
2674, 5791
|
1549, 2656
|
1030, 1351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,006
| 161,449
|
39980+58339
|
Discharge summary
|
report+addendum
|
Admission Date: [**2163-12-5**] Discharge Date: [**2164-1-2**]
Date of Birth: [**2129-12-2**] Sex: M
Service: MEDICINE
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
multifocal PNA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
34 yo male s/p unrestrained MVA 1 wek ago and he reports a
question of a thoracic fracture at that time. He reports pain
now in his groin, abdomen, LE, L chest, and back of the neck on
both sides. 4 days ago he developed worsening pain and found it
extremely painful to get up due to LE muscle soreness. He
reports 5 days ago he began to have watery diarrhea 3-4x a day
with only 2 episodes on the day of admission. He drank large
amounts of water but had extreme thirst. He also notes feeling
dizzy. He started having fever up to 102.7 2 days ago and to 103
the morning of admission. He stopped making urine on Saturday.
For his pain he's been taking aspirin 2 tabs BIS, Percocet
5/day, he finished 4 pills of tylenol with codeine, and he's
been taking Ibuprofen 800mg 2 pills QID. He denies any use of
cocaine.
.
He presented to the [**Hospital6 **] with vitals of T 98.1
BP 104/53 P123 RR20 96% on NRM. He was found to have PNA,
transaminitis ARF, hyponatremia, gap of 19 with bicarb 19, WBC
of 4.6, HCT 37.9, and plts of 67. In the ED CT scan
chest/abd/pelvis notable for multifocal PNA and LAD. At the OSH
he got ancef 1gram, 2L IVF, morphine 4mg, and dilaudid 1mg. In
the ambulance he received 2L IVF, zofran 4mg IVx1, 50mg of
fentanyl, and a duoneb. He got 2 additional liters of IVF on
route to BBI
.
On arrival to the ED at [**Hospital1 **] vitals were T98.9 BP108/64 HR 133
RR24 86% on NRB (touble getting o2 sat likely never this low).
HR ranged 117-129 SBP 99-128/54-82 RRR 19-33. Labs additionally
notable for lactate of 2.2. Lung exam was notable for Rhonchi.
Pt tachypnic but speaking in full sentences. He made 1600cc of
urine in ED which was after 5L of IVF counting all the fluid
since arrival to [**Hospital1 34**]. He received Vancomycin 1gram IV x1,
levoquin 750mg IV once, and flagyl was ordered but not given
prior to transfer. He also received NS x1 L, calcium gluconate
1gm x1, mg sulfate 2grams x1, and dilaudid 1mg IV x1. Urine tox,
urine lytes, and serum tox were pending at the time of transfer.
Vitals prior to transfer were T98.4 HR117 BP 99/46 (SBP as low
as 95 per ED resident) RR33 94% on 5L NC.
Past Medical History:
Etoh Abuse
? psych hx
Broken jaw
Surgery on right 3rd digit
Social History:
Smoker. Previous h/o etoh abuse. New [**Location (un) 1468**] with wife and kids.
Unemployed as carpenter. h/o cocaine but denies any for 1 yr,
h/o etoh abuse that was significant last beer was 1 5 days ago.
Distant h/o marijuana. Denies any recent illicit drug use.
Family History:
No FH kidney dz
Physical Exam:
VS: T97.1 BP 97/54 HR 125 RR26 97% 5L easily weaned to 3L
GEN: ill appearing
HEENT: PERRL, EOMI, anicteric, dry mm, no supraclavicular or
cervical lymphadenopathy (althought tender to palpation), no
palpable axillary LAD, no jvd
RESP: + crackles diffusesly with rhonchi in the lower [**3-2**] of
left lung
CV: tachycardic, no m/r/g
ABD: +bs, tender to palpation in lower abd, no rebound/guarding,
no HSM, inguinal LN small bilaterally
EXT: no c/c/e, tender to palpation in LE especially in lower
posterior calves
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
1. OSH labs:
Na 128, Cl 90, co2 19, gap 19, BUN 51, creatinine 4.6, AST 265,
ALT 319, ABG 7.43/29/49, trop I 0.11 (nl range up to 0.3), WBC
4.7, HCT 37.9, plts 67
.
2. Labs at [**Hospital1 18**] on admission:
[**2163-12-5**] 02:20AM BLOOD WBC-2.7* RBC-4.54* Hgb-13.2* Hct-39.0*
MCV-86 MCH-29.1 MCHC-33.9 RDW-12.8 Plt Ct-81*
[**2163-12-5**] 02:20AM BLOOD Neuts-49* Bands-34* Lymphs-14* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2163-12-5**] 02:20AM BLOOD PT-12.3 PTT-28.7 INR(PT)-1.0
[**2163-12-5**] 06:14AM BLOOD Gran Ct-1260*
[**2163-12-5**] 02:20AM BLOOD Glucose-70 UreaN-48* Creat-4.0* Na-131*
K-4.3 Cl-98 HCO3-20* AnGap-17
[**2163-12-5**] 02:20AM BLOOD ALT-350* AST-336* CK(CPK)-117 AlkPhos-56
TotBili-0.8
[**2163-12-5**] 02:20AM BLOOD Lipase-12
[**2163-12-5**] 02:20AM BLOOD cTropnT-<0.01
[**2163-12-5**] 06:14AM BLOOD Albumin-2.7* Calcium-7.1* Phos-4.8*
Mg-1.8 Iron-11*
[**2163-12-5**] 06:14AM BLOOD calTIBC-203* Ferritn-600* TRF-156*
[**2163-12-5**] 06:14AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE, HBV Ab-POSITIVE
[**2163-12-5**] 02:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-12-5**] 02:27AM BLOOD Lactate-2.2*
.
3. Labs at [**Hospital1 18**] on discharge:
.
WBC 8.6, Hb 11.1, Hct 31.5, Plt 242
.
PT: 13.4 INR: 1.1
.
134 / 99 / 19
---------------
3.9 / 27 / 0.7
.
Mg: 1.8
.
LFTs within normal limits (ALT 23, AST 37, AP 92, T. bili 0.4
.
- ASPERGILLUS GALACTOMANNAN ANTIGEN: neg
- B-GLUCAN: neg
- COCCIDIOIDES ANTIBODY, IMMUNODIFFUSION: neg
- HIV (HUMAN IMMUNODEFICIENCY VIRUS) ANTIBODY: positive
- HIV GENOTYPE = pending upon discharge
- HCV GENOTYPE = 1a
- CSF CRYPTOCOCCAL ANTIGEN: neg
- CSF RAPID PLASMA REAGIN: neg
- CSF TB, [**Male First Name (un) 2326**], HSV, and VDRL neg
.
4. OSH imaging:
CT chest with contrast:
Dense parenchymal lung consolidtaion in LUL, RML, and RUL.
Multiple air bronchograms. Findings compatable with multifocal
PNA. No discrete pulm nodules. No pleural effusions or PTX.
Multiple scattered axillary LN, pathologically enlarged 11mm
pretracheal/mediastinal LN and scattered mediastinal LN. 15mm
subcarinal LN.
.
CT abd non contrast:
Slightly increased attenuation of GB likely contrast. Liver,
spleen, pancreas, adrenal glands, kidneys, sm and lg bowel
unremarkable. No LAD.
.
CT pelvis non contrast:
Multiple scattered pelvic and inguinal LN which do not meet size
for pathologic enlargement.
.
x-ray right knee: no acute fracture or dislocation
.
5. Imaging/diagnostics at [**Hospital1 18**]:
- Echocardiogram ([**2163-12-5**]): The left atrium is mildly dilated.
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal. Quantitative
(biplane) LVEF = 52 %. The estimated cardiac index is high
(>4.0L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
.
- Echocardiogram ([**2163-12-17**]): 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 aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
.
- CT spine and head with contrast ([**2163-12-5**]): 1. Multifocal areas
of parenchymal consolidation most compatible with multifocal
pneumonia.
2. Small amount of sludge within the gallbladder. 3. Intact
osseous structures, with no evidence of acute thoracic vertebral
body injury.
4. Multiple in number mildly enlarged axillary, mediastinal, and
retroperitoneal lymph nodes, for which correlation to exclude
lymphoproliferative disorders is recommended.
.
- CT torso ([**2163-12-8**]): 1. Interval worsening of multifocal
airspace disease as described above, including areas of
pulmonary consolidation along with extensive ground-glass
opacities. 2. New bilateral pleural effusions. 3. Axillary,
mediastinal, mesenteric and retroperitoneal lymphadenopathy,
with size and distribution essentially unchanged from the prior
study.
.
- CT torso ([**2163-12-15**]): 1. Extensive bilateral pulmonary
consolidatory changes which demonstrate interval improvement,
well appreciated in the inferior lobes with improved aerated
lung volume. 2.Hypodense area seen in the papillary region of
the right kidney suspicious for papillary necrosis vs calyceal
diverticulum. 3. Moderate hepatomegaly is identified. No
identifiable abscesses, inflammatory proccess in abdominal or
the pelvic cavities.
- EKG: Sinus tachycardia, nl axis, nl intervals, j point
elevation in v2 and v3.
.
- MRI brain ([**2163-12-21**]): 1. A few small scattered FLAIR
hyperintense foci, likely nonspecific in appearance. 2. Study
significantly limited due to motion-related artifacts, in
particular the post-contrast sequences. Within these
limitations, there is no large area of abnormal enhancement
noted. No acute infarction. 3. Diffuse mucosal thickening in the
mastoid air cells with or without small amount of fluid; fluid
in the sphenoid sinus, enlarged adenoids likely obstructing the
eustachian tubes. Correlate with ENT examination.
.
- EEG ([**2163-12-23**]): Abnormal EEG due to the prominently slow
background rhythm throughout most of the recording and due to
the bursts of generalized slowing. These findings indicate a
widespread encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. There were no areas of prominent focal slowing,
but
encephalopathies may obscure focal findings. There were no
clearly
epileptiform features. Some of the 5 Hz background was
relatively
rhythmic, but it did not include clearly epileptiform features.
.
Brief Hospital Course:
This is a 34 year old male s/p recent MVA who presented with
fevers to 103, difficulty breathing, decreased UOP, and pain in
legs/arm/chest/abdomen who was found to have a severe multifocal
PNA with significant bandemia requiring intubation/ventilator
support, [**Last Name (un) **], lactic acidosis, elevated LFTs, borderline
hypotension, tachycardia, and bone marrow suppression who was
also newly diagnosed with hepatitis C and HIV this admission.
Developed swallowing difficulties and tongue dysmotility s/p
intubation, deemed an aspiration risk. Kept strict NPO and
placed G-J tube for outpatient nutritional needs until
swallowing function returns.
.
#. Sepsis: The patient was found to be septic on admission to
the ICU with hypotension and sinus tachycardia likely secondary
to severe multifocal pneumonia visualized on CXR. He was also
noted to have a high lactate, a low WBC count with 34% bands,
and a 4L NC oxygen requirement on admission. He was intubated
within a few days after arrival to the ICU in part due to
increased agitation (urine tox positive for cocaine and opiates
on admission) and also had borderline oxygenation. There were
gram positive cocci in pairs and chains isolated in a blood
culture at an OSH which turned out to be strep pneumo sensitive
to levofloxacin. He was initially given broad coverage with
levofloxacin, vancomycin, and metronidazole upon admission. His
serial CXRs continued to worsen and he would spike fevers as
high as 103 on a daily basis, so his covereage was later
broadened to vancomycin, Levaquin, cefepime, and metronidazole.
He was borderline hypotensive and responsive to fluids
initially, but later required norepinephrine drip. Chest CT
showed multifocal pneumonia as well as extensive mediastinal and
retroperitoneal lymphadenopathy. He ended up completing a 14
day course of levofloxacin.
.
# HIV: There was clinical suspicion for an underlying immune
suppressive disease given his pancytopenia the severe
presentation of his multifocal pneumonia. HIV Ab, CD4 count, and
HIV VL were sent after discussion with the ethics support
service as the patient was intubated and could not consent. HIV
antibody positive, confirmed by Western blot with a CD4 count of
692 and a viral load of 16,800. Infectious Disease recommended
genotyping HIV prior to starting treatment. This was sent and
was pending at discharge. He will be followed by Infectious
Diseases as an outpatient as well.
.
#. Altered Mental Status: It is likely that his altered mental
status was secondary to withdrawal from substance abuse as his
tox screen was positive for opiates and cocaine on arrival.
Despite escalating doses of valium and haloperidol, he became
increasingly agitated and eventually was intubated for his own
protection in addition to increasing O2 requirements. He
required propofol, midazolam, and fentanyl drips for proper
sedation and became acutely agitated when sedation was
lightened. Prior to weaning his sedation before extubation, he
was started on methadone and Seroquel. His mental status was
clear upon discharge.
.
# Seizure: Patient had one episode of witness seizure after
extubation and prior to transfer to the floor but no others. MRI
of the brain was unremarkable and EEG did not show seizure
focus. He was kept on prophylaxis acyclovir until the CSF HSV VL
came back negative. Patient was placed on Levetiracetam 500 mg
q12hr for seizure precautions and stopped several days prior to
discharge per neurology recommendation. There was no recurrence
of clinical seizure activity. Etiology is most consistent with
withdrawal, either from alcohol, prior substance abuse, sedative
medications including seroquel, or aseptic meningitis. CSF
showed a lymphocytic predominance, with negative serologies.
.
# Loss of tongue motility / nutrition: Patient lost the ability
to move his tongue after extubation with difficulty clearing
secretions, dysphonia, and inability taking PO
nutrition/medication. Etiologies considered included viral
meningitis or compression injury following intubation ([**Doctor Last Name 72916**]
syndrome). He was evaluated by speech and swallow and failed. He
was kept NPO and NG tube was placed with tubefeeds initiated.
ENT evaluate and noted unilateral vocal cord paralysis. Together
with neurology they recommended doing MRI brain w/ w/out
contrast and MRI neck soft tissue to evaluate the brain stem and
cranial nerves. Patient was informed and agreed to the studies,
however was unable to tolerate the actual exam and could not
stay still. Given that patient has previous history of
difficulty with sedation from the MICU course, decision was made
not to pursue further imaging after consultation with neurology.
His tongue motility slowly improved during the hospitalization
although on repeat evaluation by speech and swallow he continued
to be at high risk for aspiration and could not tolerate PO
intake. Given this risk, a G-J tube was placed by interventional
radiology on [**2163-12-29**]. He will follow-up with
Neurology, ENT, and Speech & Swallow as an outpatient.
.
# Renal failure: Likely prerenal from sepsis on admission and
resolved with aggressive IVF rehydration. He was pretreated
with bicarb and mucomyst prior to CT.
.
# Elevated LFTs: He was noted to have a transaminitis with
ALT=350, AST=336 on admission. These trended down throughout
his stay, but a hepatitis panel sent as part of a transaminitis
work-up revealed that he was newly diagnosed with hepatitis C.
.
Medications on Admission:
- Motrin
- Percocet
- Tylenol
Discharge Medications:
1. Peptamen 1.5 Full strength, 6 cans per day to be given at
rate of either 80ml for 18 hours OR 120ml for 12 hours, flush
with 150ml H20 before and after feeds
2. enteral pump for home use
3. IV pole
4. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for pain.
Disp:*2 bottles* Refills:*0*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary diagnoses:
Pneumonia
Sepsis
Acute renal failure
Transaminitis
Lactic acidosis
Seizure
Tongue dysmotility
HIV positive
Hepatitis C
.
Secondary diagnoses:
Alcohol abuse
Opiate abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 7046**], you were admitted to the [**Hospital1 827**] because you had a car accident and was having
whole body pain, fever, and diarrhea. We found that you had
pneumonia, your kidneys were not working, your liver was
inflammed, your blood counts were low, and you were positive for
Hepatitis C and HIV. You were treated with antiotics for the
pneumonia. Your kidneys and liver improved. You developed
extreme agitation and had to be put on a breathing machine for
your safety. After we took out the breathing tube, you developed
a seizure. We gave you medication to prevent the seizure and got
an MRI to look for anything abdnormal in your brain. The MRI was
normal and you will not need to take any more medications at
home for your seizure. You were not able to move your tongue and
you had trouble with eating and speaking. You were found to
have vocal fold paralysis, which is contributing to your
hoarseness. We put a feeding tube down and gave you nutrition
that way. You regained partial ability to speak and you are
continuing to improve, but we felt that putting a feeding tube
in your stomach would be slightly more comfortable and was the
best way to make sure you get adequate nutrition since it is not
safe for you to eat by mouth for the time being.
.
You should follow-up with the Infectious Disease doctors,
Neurologist, Ear/Nose/Throat doctor, and Nutrition/Speech &
Swallow after discharge. They will help determine when you can
start eating again and when the feeding tube can be removed.
The appointments are listed below.
.
We made the following changes to your medications:
START Tramadol 50mg every 4 hours as needed for abdominal pain
(take through the feeding tube)
START Throat spray every 4 hours as needed for sore throat/dry
mouth
START Lansoprazole ODT 30mg daily to promote healing of your
throat
Followup Instructions:
You have many follow-up appointments. It is very important that
you see all of these doctors, as you were quite sick when you
were here. They will then decide with you how often to
follow-up:
.
Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 303**] will be your new physician in at [**Hospital1 18**]. Dr.
[**Last Name (STitle) 303**] works closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3535**] so both will be
involved in your care. Please call your insurance company and
change your primary care provider to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3535**] in
[**Hospital3 **]. Your insurance company needs to be aware
of who your primary care provider [**Last Name (NamePattern4) **]. [**Name10 (NameIs) **] you have changed your
provider to Dr. [**First Name (STitle) 3535**], please call [**Hospital3 **] at
[**Telephone/Fax (1) 250**] to make an appointment with Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 303**]. Dr.
[**Last Name (STitle) 303**] speaks Portuguese. You need to be seen sometime during
the week of [**1-9**].
.
Department: RADIOLOGY (Speech and Swallow / Nutrition)
When: THURSDAY [**2164-1-5**] at 1 PM
With: [**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) 2621**], CCC-SLP [**Telephone/Fax (1) 3731**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: OTOLARYNGOLOGY (ENT)
When: THURSDAY [**2164-1-5**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
.
Department: NEUROLOGY
When: FRIDAY [**2164-1-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASES
When: [**2164-1-19**] 08:50a
With: [**Last Name (LF) **], [**First Name3 (LF) **]
Building:LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **])
.
Department: INFECTIOUS DISEASES
When: [**2164-2-16**] 11:00a
With: [**Last Name (LF) 10000**], [**First Name3 (LF) **]
Building: LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **])
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Name: [**Known lastname 13942**],[**Known firstname 126**] Unit No: [**Numeric Identifier 13943**]
Admission Date: [**2163-12-5**] Discharge Date: [**2164-1-2**]
Date of Birth: [**2129-12-2**] Sex: M
Service: MEDICINE
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 758**]
Addendum:
For the category "Major Surgical or Invasive Procedures", the
following 2 items should be listed:
1) Intubation and extubation
2) Gastrojejunostomy tube placement
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
[**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**] MD, [**MD Number(3) 765**]
Completed by:[**2164-1-3**]
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50,575
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32229
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Discharge summary
|
report
|
Admission Date: [**2153-2-8**] Discharge Date: [**2153-2-14**]
Date of Birth: [**2082-10-2**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lipitor /
Verapamil / Lescol / Etodolac / Rofecoxib / Valdecoxib
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
"occipital intraparenchymal hemorrhage and
right [**Last Name (NamePattern1) **] field cut"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname 12067**] is a 70 year old right-handed female with a
history of coronary artery disease, osteoporosis, asthma and
right occipital hemorrhage ([**2149**]) from amyloid angiopathy who
now
presents with headache and vision loss. Yesterday ([**2-8**])
afternoon while doing some strenuous yardwork (cutting/hauling
branches) she developed a bilateral dull headache with the left
side being more intense sharp pain than the right side. She
then
noticed that her left eye seemed to be "frozen." Thereafter,
she
says that she lost vision in her left eye and began bumping into
furniture. She did not want to go to the hospital yesterday.
Headache persisted this morning and she took aspirin 81mg
without
relief. She also developed some nausea but no weakness, no
sensory changes or confusion.
She eventually agreed to be taken to [**Hospital3 7571**]Hospital
today where head CT showed a left occipital intraparenchymal
hemorrhage without any midline shift or herniation. She was
given IV dilaudid and reglan and transferred to [**Hospital1 18**] ED for
further care. In the ED, initial blood pressure was 121/72 and
she was given IV zofran, morphine and tylenol. Neurology was
consulted for further management.
On neuro ROS, the pt endorses dull bilateral headache, loss of
vision in her left eye, no blurred vision, no diplopia, no
dysarthria, no dysphagia. No vertigo, no tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness or parasthesiae. No
bowel or bladder incontinence or retention. No unsteadiness
with
ambulation but is bumping into walls/furniture.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. No cough
or shortness of breath. Denies chest pain or tightness,
palpitations. No nausea or vomiting. No diarrhea,
constipation.
No abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-right occipital intraparenchymal hemorrhage (biopsy confirmed
amyloid angiopathy)-brought on by vigorous snow shoveling.
-osteoporosis
-asthma
-coronary artery disease
-hypertension and hyperlipidemia (mentioned in cardiology
records)
Social History:
Lives with daughter, granddaughter, grandson. Used to
work in a factory. Smoked 1ppd her entire life until yesterday
when she quit. No alcohol or drug use.
Family History:
Mother died of stroke in her 80's. Father had asthma
and emphysema. Brother died of heart attack in his 60's.
Physical Exam:
At admission:
Vitals: T: 98.5 P: 74 R: 20 BP: 121/72 SaO2: 94% on 2L.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rash or lesions.
Neurologic:
-Mental Status: Alert, oriented x 2. Tells me her name, [**Hospital1 18**]
and [**2153**] but cannot remember month or day. Able to relate
history without difficulty but at time confuses order of events
from yesterday. Able to name DOW forwards but not backwards. .
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name both high and low frequency objects. Not able to test
[**Location (un) 1131**] secondary to [**Location (un) **] field deficits. Could identify
single letters of words without difficulty. Speech was not
dysathric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall 0/3 at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. Dense right homonymous hemianopia
and spotty left peripheral field deficit. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was downgoing bilaterally.
-Coordination: No tremors. No dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally but does pass point slightly
secondary to her vision loss.
-Gait: Deferred gait and Romberg for bedrest. Was walking
normally earlier in the day per family.
At discharge:
Neuro: Dense right homonymous hemianopia and left peripheral
[**Last Name (un) **] field deficit, no motor deficits. Mood is anxious and
frequently tearful
Pertinent Results:
[**2153-2-8**] 07:38PM WBC-10.6 RBC-4.53 HGB-14.2 HCT-42.2 MCV-93
MCH-31.4 MCHC-33.7 RDW-12.9
[**2153-2-8**] 07:38PM NEUTS-75.1* LYMPHS-18.5 MONOS-4.3 EOS-1.4
BASOS-0.7
[**2153-2-8**] 07:38PM PLT COUNT-186
[**2153-2-8**] 07:38PM PT-12.0 PTT-31.5 INR(PT)-1.1
[**2153-2-8**] 07:38PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2153-2-8**] 07:38PM GLUCOSE-106* UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2153-2-14**] 05:30AM BLOOD WBC-7.6 RBC-3.84* Hgb-12.2 Hct-35.7*
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.7 Plt Ct-144*
[**2153-2-14**] 05:30AM BLOOD Glucose-104* UreaN-9 Creat-0.5 Na-139
K-3.2* Cl-103 HCO3-32 AnGap-7*
[**2153-2-14**] 05:30AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
[**2153-2-8**] 07:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ECG:
Sinus rhythm. Diffuse ST-T wave abnormalities most noticably in
the
anterolateral leads. Cannot rule out underlying myocardial
ischemia. Compared to the previous tracing of [**2149-2-18**]
anterolateral ST-T wave changes persist. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 140 104 404/419 29 2 40
[**2153-2-8**] NCHCT:
IMPRESSION:
1. Left occipital intraparenchymal hemorrhage with extension
into the
extra-axial space. Mild-to-moderate surrounding vasogenic edema
and sulcal and left lateral ventricle effacement. Slight
effacement of the left ambient cistern is noted but with overall
relatively little mass effect.
2. New but chronic-appeearing focus of encephalomalacia in the
left anterior frontal lobe.
EEG:
FINDINGS:
ABNORMALITY #1: Occasional bursts of right posterior quadrant
[**2-23**] Hz
delta frequency activity were seen.
ABNORMALITY #2: In the most electrographically awake-appearing
portions
of this tracing, a symmetric 7-7.5 Hz theta frequency background
was
seen.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as the patient was
unable to
cooperate.
INTERMITTENT PHOTIC STIMULATION: The technologist inadvertently
did not
perform this activation procedure; if clinically warranted, a
repeat
tracing to obtain photic stimulation will be provided.
SLEEP: Periods of a more symmetric 7-7.5 Hz theta frequency
background
were seen along with periods of a slower (but still symmetric) 6
Hz
theta frequency background were seen. This variability may be
due to
periods of relative drowsiness and wakefulness, though clinical
correlate through video review did not appreciably demonstrate a
change
in clinical state.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 72 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of
occasional
bursts of slowing seen involving the right posterior quadrant
superimposed upon a slow background. The former abnormality may
represent a focal area of subcortical disturbance, while the
slow
background is more consistent with a larger, subcortical, deep
midline
abnormality. No frank epileptiform activity was seen during this
recording, but if the patient has frequent symptoms, continuous
EEG
recording with event monitoring and spike and seizure detection
algorithms may provide additional diagnostic information
Portable NCHCT:
IMPRESSION: Intraparenchymal hemorrhage with small extraaxial
component in
the left occipital lobe is unchanged compared with prior exam,
without
significant mass effect.
[**2153-2-9**] NCHCT:
IMPRESSION:
Essentially unchanged left occipital lobe hemorrhage and small
left subdural hemorrhage given differences in scan technique.
[**2153-2-11**] NCHCT:
IMPRESSION:
1. No significant interval change in size of the left occipital
lobe
intraparenchymal hemorrhage with continued mass effect on the
occipital [**Doctor Last Name 534**] of the left lateral ventricle, unchanged.
2. Small subdural hematoma overlying the left parietal lobe is
less
conspicuous on the present study.
3. No new intracranial hemorrhage or infarction.
[**2153-2-12**] NCHCT:
IMPRESSION:
1. Little change in comparison to prior study from yesterday
with no
significant change in the interval size of the left occipital
intraparenchymal
hemorrhage with continued mass effect on the occipital [**Doctor Last Name 534**] of
the left
lateral ventricle.
2. Stable appearance of small subdural hematoma overlying the
left parietal lobe.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 12067**] is a 70 year old right-handed female with a
history of coronary artery disease, osteoporosis, asthma and
right occipital hemorrhage ([**2149**]) from amyloid angiopathy who
now presents with headache and vision loss. Her neurological
exam is significant for right homonymous hemianopia and spotty
left peripheral field deficit. She is also having some mild
memory deficits and inability to perform DOW backwards both of
which are reportedly new according to her family. These are most
likely due to her anxiousness and has improved prior to
discharge. Head CT shows a left occipital intraparenchymal
hemorrhage. Her right [**Year (4 digits) **] field deficits are consistent with
the hemorrhage in the left occipital cortex. The left peripheral
field deficits are chronic deficits due to the prior right
occipital hemorrhage in [**2149**]. The most likely etiology of her
hemorrhage is from cerebral amyloid angiopathy.
.
NEURO: Amyloid angiopathy with new occipital hemorrhage
- mannitol used initially for symptomatic improvement. Weaned
off.
- HA pain control with acetaminophen and oxycodone prn.
Anxiousness is a large contributing factor
- cont celexa 20mg po daily to help with mood and rehabilitation
- completed 1 week of anti-sezire prophylaxis with Keppra. No
need to continue at this time
- goal SBP 140-160, hydralazine 10mg prn SBP>170
.
GI: Patient is on regular diet but has been intermittently
nauseated. Concern about how many calories she is taking in.
- I and O's and calorie count. Starting Enlive and magic cup
supplements
- nutrition consult following
- started remeron 15mg po qhs for appetite stimulus and further
mood improvement
.
HOSPITAL ISSUES:
-activity as tol
-regular diet
-SQH tid
-senna/colace, ranitidine and pneumoboots for prophylaxis
-full code
-Dispo: floor
-contact: [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Name (NI) 13916**] [**Telephone/Fax (1) 75348**] or [**Telephone/Fax (1) 75349**]
Medications on Admission:
albuterol prn wheezing
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-22**] puff Inhalation q4hrs as needed for shortness of breath or
wheezing.
8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**4-27**]
hours as needed for pain: for headache. Limit to < 4 grams per
day.
9. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as
needed for Pain: Please use as breakthrough if acetaminophen is
not effective.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
left occipital lobe hemorrhage
amyloid angiopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: Dense right homonymous hemianopia and left peripheral
[**Hospital3 **] field deficit, no motor deficits. Mood is anxious and
frequently tearful
Discharge Instructions:
Dear Mrs. [**Known lastname 12067**],
It was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of vision changes and
confusion. It was found that you had a bleed on the left side of
your brain, in the area known as the occipital lobe, which
process [**Known lastname **] information. Unfortunately, since a few years ago
you had a bleed in the same area on the right side of your
brain, your vision is now very limited. Understandably this is
certainly causing a degree of anxiousness that would be
expected. To help you with this anxiousness and with your
recovery we have started you on a medication, celexa 20mg by
mouth daily.
The cause of the current bleed is the same as your previous, a
disorder called amyloid angiopathy, which makes your brain
arteries more likely to have these bleeds.
You have not felt like eating much due to things not tasting
well. A formal swallow evaluation showed that when you eat you
have no trouble from their perspective. We have started you on a
appetite stimuling medicine, remeron 15mg by mouth nightly,
which will also likely help with your mood. Please continue to
eat/drink nutrition supplements as well to ensure you are
getting all your nutrients.
We would like you to follow up with an outpatient neurologist.
We have made an appointment for you with Dr. [**Last Name (STitle) **] as listed
below. We would like you to have a repeat MRI of your brain
vessels given that on your imaging there was an incidental
finding of a small 3.5mm aneurysm. An aneurysm of this size
typically do not bleed, but this should be followed over time
with repeat imaging to ensure it does not enlarge over time.
Additionally, we have asked our Neuro-ophthalomolgist, Dr.
[**Last Name (STitle) **], to see you in her clinic to evaluate your vision. We have
made you an appointment on [**3-6**] at 9:30am with [**Month (only) **] field
testing at 10:30am.
Followup Instructions:
Please follow up in the [**Hospital 75350**] clinic with Dr.
[**Last Name (STitle) **]. The clinic is located in the [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Bldg, [**Location (un) 442**]
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2153-3-6**]
9:30am
Provider: [**Name10 (NameIs) **] FIELD SCREENING Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2153-3-6**] 10:30am
MRI of brain vessels
[**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name **], [**Hospital Ward Name 23**] Bldg, [**Location (un) **].
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2153-3-19**]
3:15
Please follow up in [**Hospital 878**] clinic with Dr. [**Last Name (STitle) **]. The clinic
is located on the [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **].
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2153-4-2**] 1:30
|
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13597, 13649
|
12537, 12561
|
14006, 15936
|
4516, 5957
|
3139, 3665
|
5971, 6128
|
342, 436
|
508, 2557
|
13685, 13982
|
2579, 2817
|
2833, 2994
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,122
| 188,587
|
45559
|
Discharge summary
|
report
|
Admission Date: [**2106-5-20**] Discharge Date: [**2106-6-9**]
Date of Birth: [**2032-1-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Bleeding fistula
Major Surgical or Invasive Procedure:
Hemodialysis by AV fistula
PICC line placement
History of Present Illness:
Mr. [**Known lastname **] is a 74M with cryptogenic cirrhosis, h/o PE,
chronically low BP, and ESRD on HD recently discharged on
[**2106-5-19**] who was brought to ED by EMS after HD when he had
persistent bleeding from fistula site. Dialysis clamp placed and
he had no further bleeding in ED. He was also noted to have
positive blood cx from [**5-19**] which were drawn due to hypotension
and leukocytosis. He denied any other complaints of
lightheadedness, dizziness, CP, SOB, palpitations, orthopnea,
cough, abdominal pain, N/V, decreased PO intake, melena,
hematochezia. Diarrhea is stable at his baseline and he is
incontinent of stool.
.
In the ED, initial VS were: T 98.6, P 73, BP 95/50, RR 17. He
was comfortable in NAD and had no further active bleeding from
fistula site. Due to positive blood cx from [**5-19**] so he was given
Vancomycin 1g IV. Pt was admitted to the floor with vitals on
transfer T 97.6, P 100, BP 78/50 (baseline in UEs 60s-70s), RR
16, O2sat 95%RA
.
On the floor, he reported feeling "lousy" but denied any other
complaints as above. BP was 60/dopp in UE. Previous notes stated
that LE BP's more reliable (baseline 100-120), so this was
checked and also found to be 60/dopp although pt mentating at
baseline. His midodrine (discontinued during [**Date range (1) 33701**] admission)
was restarted, and he was given 500cc NS x 2 without improvement
so was transferred to the MICU for further monitoring.
.
On evaluation, pt continues to report no significant change from
baseline other than fatigue from his lengthy work-up today.
.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting,
constipation or abdominal pain. No dysuria. Denies arthralgias
or myalgias.
Past Medical History:
1. Cryptogenic cirrhosis: A portal hypertension, splenomegaly,
and ascites per MRI of abdomen. Portal vein thrombosis noted on
MRI from [**1-/2105**] as well as more recent ultrasound.
2. Chronic kidney disease stage IV-V currently undergoing
hemodialysis, possibly due to chronic nephrolithiasis, in turn
caused by a bowel surgery, possibly combined with chronic
hypokalemia and nonsteroidal use. More recently suggested that
the possibility of amyloidosis be explored. The patient has
secondary hyperparathyroidism due to renal failure.
3. Chronic secretory diarrhea: Carcinoid syndrome,
neuroendocrine tumors, pellagra, microscopic colitis,
hyperthyroidism, and infectious etiologies have been ruled out
with an extensive workup in 06/[**2104**]. Currently, attributed to a
history of ileal resection.
4. History of PE during hospitalization [**7-/2104**] at [**Hospital1 18**].
Formerly on Coumadin is stopped in 01/[**2105**].
5. A history of likely gallstone pancreatitis with lipase
greater than 900 during hospitalization in 06/[**2104**].
6. H. pylori gastritis treated in [**2104**].
7. MGUS by SPEP.
8. A 1.2-cm hypoechoic nodule on the left thyroid lobe without
enlargement on ultrasound, follow up in [**2105**]. TSH remains
normal.
in 01/[**2105**].
9. Left inguinal hernia.
10. Status post ileal resection in [**2056**] for possible Crohn's
disease.
11. Status post surgical repair perforated ulcer in the [**2066**].
12. Status post surgical removal of renal stone in [**2066**].
13. Cataracts
14. Paracentesis induced bowel perforation in [**2-14**]
Social History:
No tobacco, rare ETOH. Lives alone in [**Location (un) 2312**]. Supportive
family. His friend [**Name (NI) **] [**Name (NI) 28181**] is a particularly important
person in his life - called partner in some prior notes.
Family History:
Denies family history of liver or kidney disease.
Physical Exam:
Vitals: T 96.3, P 108, BP 102/50, RR 14, O2sat 96RA
General: Cachectic male, tired but alert, oriented x 3, no acute
distress
HEENT: Sclera slightly icteric, MM dry, + oral thrush,
oropharynx clear
Neck: Supple, JVP not elevated
Lungs: Clear to auscultation bilaterally with faint crackles at
bases, no wheezes or rhonchi
CV: Irregular rhythm with mild tachycardia, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: Soft, distended with +ascites. Nontender. Bowel sounds
present, no rebound tenderness or guarding, +splenomegaly
Ext: Cool to touch. Dopplerable pulses, 3+ edema to upper thigh,
no clubbing, cyanosis. RUE AV fistula with palpable thrill; no
bleeding and bandaid C/D/I.
Neuro: Oriented x 3. CN 2-12 intact. No asterixis. MAE
Skin: Dry, cracked skin throughout. 2 x 3 cm area of superficial
ulceration over sacrum with pink granulation tissue. No erythema
or purulent drainage. No stigmata of endocarditis appreciated
Pertinent Results:
Labs on admission:
[**2106-5-19**] 01:40AM PLT COUNT-100*#
[**2106-5-19**] 01:40AM NEUTS-77.7* LYMPHS-17.8* MONOS-3.6 EOS-0.3
BASOS-0.6
[**2106-5-19**] 01:40AM WBC-13.9* RBC-5.26 HGB-12.9* HCT-42.1 MCV-80*
MCH-24.5* MCHC-30.7* RDW-21.2*
[**2106-5-19**] 01:40AM ALT(SGPT)-19 AST(SGOT)-32 ALK PHOS-232* TOT
BILI-2.3*
[**2106-5-19**] 01:40AM GLUCOSE-90 UREA N-17 CREAT-4.3* SODIUM-140
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-16
[**2106-5-19**] 02:23AM PT-22.2* PTT-40.3* INR(PT)-2.1*
[**2106-5-19**] 10:00AM PT-23.8* PTT-42.6* INR(PT)-2.3*
[**2106-5-19**] 10:00AM PLT COUNT-99*
[**2106-5-19**] 10:00AM NEUTS-72.0* LYMPHS-23.8 MONOS-2.9 EOS-0.6
BASOS-0.8
[**2106-5-19**] 10:00AM WBC-10.0 RBC-5.31 HGB-13.0* HCT-42.8 MCV-81*
MCH-24.4* MCHC-30.3* RDW-21.1*
[**2106-5-19**] 10:00AM antiDGP-7
[**2106-5-19**] 10:00AM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2106-5-19**] 10:00AM ALT(SGPT)-21 AST(SGOT)-35 LD(LDH)-383* ALK
PHOS-233* TOT BILI-2.0*
[**2106-5-19**] 10:00AM GLUCOSE-125* UREA N-19 CREAT-4.7* SODIUM-139
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
[**2106-5-20**] 10:25PM PT-19.6* PTT-36.7* INR(PT)-1.8*
[**2106-5-20**] 10:25PM PLT COUNT-110*
[**2106-5-20**] 10:25PM NEUTS-82.9* LYMPHS-13.2* MONOS-2.9 EOS-0.5
BASOS-0.4
[**2106-5-20**] 10:25PM WBC-11.8* RBC-5.16 HGB-12.9* HCT-41.5 MCV-81*
MCH-25.0* MCHC-31.1 RDW-21.1*
[**2106-5-20**] 10:25PM estGFR-Using this
[**2106-5-20**] 10:25PM GLUCOSE-193* UREA N-14 CREAT-3.3*# SODIUM-136
POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-29 ANION GAP-11
MICRO:
- [**2106-5-19**] Blood culture positive for E. faecalis (vancomycin
sensitive)
- [**2106-5-19**] Blood culture positive for E. faecium (vancomycin
resistant)
- [**2106-5-19**] PICC line tip culture no growth
- [**2106-5-19**] Blood culture pending, no growth
- [**2106-5-20**] Blood culture pending, no growth
- [**2106-5-20**] Blood culture pending, no growth
- [**2106-5-21**] Stool study negative for C. difficile toxin
- [**2106-5-22**] Blood culture pending, no growth
- [**2106-5-22**] Blood culture pending, no growth
IMAGES/STUDIES:
CXR [**2106-5-19**]: FRONTAL VIEW OF THE CHEST: Left-sided PICC line
with the tip at distal superior vena cava is seen. The right
hemidiaphragm remains elevated. Low lung volumes limit
evaluation of the pulmonary parenchyma. Right lower lobe
atelectasis and right pleural effusion are present. A dense
opacity overlying the liver may be a pulmonary mass or
consolidation. There is no pneumothorax. Opacity in the
retrocardiac region is grossly stable and may represent
atelectasis. There has been interval increase in stomach and
small bowel loop dilatation. IMPRESSION: 1. Dense opacity
overlying the liver may be a pulmonary mass or consolidation.
Right lower lobe atelectasis and pleural effusion. A CT of the
chest is suggested for further evaluation. 2. Interval increase
in stomach and small bowel loop dilatation since [**2106-5-9**].
ECG [**2106-5-19**]: Baseline artifact and extremely low voltage
conspire to preclude adequate interpretation. The rhythm may be
sinus with frequent atrial ectopy as previously recorded on
[**2106-5-13**]. Probable prior inferior and anterior myocardial
infarctions without diagnostic interim change.
ECG [**2106-5-19**]: Sinus rhythm and frequent atrial ectopy. Diffuse
low voltage. Probable prior inferior and anterior, as well as
lateral, myocardial infarction. Compared to the previous tracing
of [**2105-5-21**] no diagnostic interim change.
AV fistulogram [**2106-5-21**]: Final read pending at the time of
discharge. Preliminary read: No evidence of outflow stenosis.
KUB [**2106-5-31**]: FINDINGS: There is diffuse severe gaseous
distention of the stomach, which has progressed since the
earlier study of [**2106-5-30**]. The bowel gas pattern in the small
and large bowel loops is unremarkable. Multiple rounded calcific
densities in the right kidney and pelvis represent renal and
bladder calculi. No free air is seen in the left lateral
decubitus radiographs. Bibasilar atelectasis is noted.
Brief Hospital Course:
74M with cryptogenic cirrhosis and ESRD on HD admitted with
bleeding fistula and bacteremia with hypotension on floor; he
was then transferred to the MICU. The following issues were
addressed at this admission.
# Hypotension: Pt has chronically low BP with SBP 60s-70s UEs
and 100s-120s LEs but BP on arrival to floor was found to be
60/D in LUE and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/L. In retrospect, this may have been a
false measurement as pt was mentating at baseline throughout and
LE BPs on arrival to the MICU measured back at baseline. His
hypotension was felt to be multifactorial, related to his
underlying renal disease, blood loss from his fistula, chronic
diarrhea, and bacteremia (cultures from admission ultimately
grew two species of enterococcus). He had a normal cortisol
level of 22 from his prior admission in early [**Last Name (LF) 547**], [**First Name3 (LF) **] this was
not repeated. Elevated lactate to > 5 supported a role for
sepsis/bacteremia. He was treated with 1 L of IVF initially,
placed on midodrine, and treated with antibiotics for presumed
sepsis. He received daptomycin as initial cultures grew gram
positive cocci (ultimately enterococcus) and the patient was
known to be swab-positive for VRE in the past. Surveillence
cultures from [**2106-5-20**] forward were negative at the time of
death. Blood pressures initially returned to baseline at
90s-100s in lower extremities. However, he was no longer able
to tolerate dialysis, as any attempt at dialysis was complicated
by severe hypotension and altered mental status, even with
midodrine and albumin. When he again became hypotensive at
dialysis [**2106-6-2**], cefepime was added to his antibiotics and he
was transferred back to the ICU where he was again given small
boluses of fluid. When he was transferred back to the floor
with stable pressures, but now with SBPs in the 80s, it was
decided that he would be DNR/DNI and we would not re-attempt
dialysis unless it was absolutely indicated. Over the next
week, the team met repeatedly with the patient's partner, Mr.
[**Name13 (STitle) 28181**], his family and palliative care. The decision was made
to make the patient comfort measures only on [**2106-6-8**]. He passed
away peacefully the next morning.
# Sepsis/bacteremia: Blood cultures from the day of admission
were positive for E. faecalis and E. faecium as above. Both
organisms grew from only one bottle, raising the possibility
that this may have been a contaminant; however, patient was
treated based on overall clinical picture. Patient received
daptomycin given history of +VRE colonization, and E. faecium
indeed speciated as vanco-resistant. PICC line was pulled in
setting of presumed infection and tip was cultured though showed
no growth. Patient was afebrile during this admission, with
maximum leukocytosis to 13.9 on admission trending down to ~11
at discharge. Lactate was elevated to > 5 but trended down to
2.9 by [**5-23**]. Patient will continue on daptomycin dosed QHD, with
an initial plan to complete a two-week course. When he became
repeatedly hypotensive at dialysis, the daptomycin was
continued. [**2106-6-2**] he had a rapidly rising INR with concern for
DIC. His antibiotics were broadened and he was given FFP. He
initially improved, but later had refractory hypotension as
mentioned above.
# R AV fistula bleeding: Pt presented with his second episode of
bleeding from AV fistula in his last 2 HD sessions. He was seen
by transplant surgery in ED and they felt bleeding had resolved;
he underwent fistulogram which did not show abnormality (final
read still pending at time of discharge). His Hct trended down
slightly from his baseline in the 40s to ~37, but he showed no
further evidence of active bleeding. His inpatient HD sessions
did not result in complications from fistula bleeding.
.
# Chronic diarrhea: Etiology unclear; this has been an ongoing
issue and is in the process of outpatient work-up. Patient was
empirically treated for cdiff when chronic diarrhea worsened and
he had a new white count. He was started on Flagyl with a
planned 14-day course with improvement in his diarrhea. He
later had some fecal incontinence with repeated bouts with small
amounts of liquid stool. His diarrhea improved as his oral
intake dropped off.
.
# Gastric distension: The patient had increasing abdominal
distension [**2023-5-30**] and KUB showed a very large gastric bubble.
He did not have any pain and his abdominal exam remained benign,
as he only experienced a sensation of fullness. An NG tube was
placed [**6-2**] and he was made NPO with improvement in his
symptoms. TPN was not given because he was not able to get
dialysis. The NG tube was clamped and removed [**6-4**] and he was
able to tolerate small amounts of food.
.
# Sacral decubitus ulcers: The patient was seen by the wound
consult team with the following assessment: "The pt's sacral
area has a large area of stage 2 breakdown with a small adjacent
area of stage 3 at 1 o'clock. The stage 2 is approximately 5.5 x
2cm and is 100% red. There is moderate sersoang drainage without
odor. The stage 3 is 0.7 x 0.4 cm and has a thin yellow
covering. The surrounding tissue is warm and not indurated."
His albumin was only 1.5, leaving little possibility of healing.
The wounds were kept as clean as possible, and the patient did
not have any pain in the area.
.
# Oral candidiasis: This is concerning for immunocompromised
state; patient has been known to refuse HIV testing in the past.
He was maintained on nystatin swish and swallow during this
admission.
Medications on Admission:
1. Rifaximin 200 mg Tablet Sig: One Tablet PO TID
2. Omeprazole 20 mg Capsule PO BID
3. Loperamide 2 mg Capsule Sig: One Capsule PO TID prn
4. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
5. Cholestyramine-Sucrose 4 gram Packet Sig: One Packet PO BID
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
- Bleeding AV fistula
- Hypotension
- Bacteremia
Secondary:
- End-stage renal disease
- Chronic diarrhea
- Stage 2 and 3 sacral decubitus ulcers
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2106-6-11**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,924
| 193,729
|
21237
|
Discharge summary
|
report
|
Admission Date: [**2172-6-11**] Discharge Date: [**2172-7-24**]
Date of Birth: [**2115-11-15**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
right blown pupil, slumped in the grocery store
Major Surgical or Invasive Procedure:
intubation, central line and arterial line placement,
tracheostomy, percutaneous gastric tube placement, bronchoscopy.
History of Present Illness:
56 yo unknown handedness female with h/o DM, mechanical valve on
coumadin, afib who presents s/p slumping down in the grocery
store. Her daughter was with her at the time. At approximately
1:30pm she was walking in the grocery store when she slumped
down, lost consciousness and became unresponsive. EMS intubated
her in the field, noted she had a blown right pupil, transferred
her to the [**Hospital1 18**] for furtherworkup. Per the family, she has been
feeling fatigued for several days, has had several episodes of
"feeling as though she may pass out" but never lost
consciousness. + Family stressors. No other symptomatology per
family - no fever/chills, CP, SOB, abdominal pain, headache,
nausea/vomiting, or other symptoms that the family is aware of.
Past Medical History:
1. DM on PO meds and insulin prn
2. Mitral valve replacement 6 yrs ago with [**Hospital3 9642**] valve at
[**Hospital1 2025**], secondary to damage from Rheumatic heart disease.
Cardiologist is Dr. [**Last Name (STitle) 17204**] at [**Hospital1 2025**]. Tricuspid valve repair
[**2169**].
? Cardiologist records were faxed here. [**Hospital3 **] makers faxed
a
statement saying their valves are MRI safe.
3. Painful peripheral neuropathy for which she takes neurontin
4. Hypothyroidism
5. HTN vs. liver disease given nadolol on med list
Social History:
does not work at this time, no tob/etoh/drugs per family.
Has 2 daughters and a son, married but seperated at this time.
Lives with her granddaughter whom she raised.
Family History:
unkown
Physical Exam:
In the ED upon presentation:
Vitals: FS 158 134/71 heart rate 63 100% on mech vent, no
temp available
GEN: intubated, sedated
Chest: CTA bilaterally
CV: irreg irreg rhythm with a crisp S1 (click) heard best at
apex, I/VI systolic murmur.
ABD: obese, soft
Extrem: vericose veins and some overlying skin changes,
spontaneously moving lower extremities
Neuro:
Mental status: sedated (for intubation). not opening eyes to
voice or pain.
CN: right pupil 4mm, no constriction to light. left pupil 3mm-
>2mm. corneal reflex intact bilaterally
Sensory: decerebrate response to painful stimuli bilateral arms
Motor: moving lower extremities spontaneously
Reflexes: upgoing toes bilaterally
Notable changes in physical exam 2 weeks after admission:
GEN: tracheostomy of the neck, lying in bed
SKIN: no breakdown on the back per nursing
CHEST: decreased breath sounds at the left lung base anteriorly
CV: irreg irreg rhythm with a crisp S1 heard best at apex
ABD: obese, soft, + BS, percutaneous gastric tube in place
without exudate
Extrem: vericose veins and some overlying skin changes
bilaterally
MS: Follows commands via right hand squeezing, attempts to open
eyes when asked, nonverbal
CN: right pupil is 8mm and nonreactive, left pupil is 3->2mm
and sluggish, left eye is able to look downwards only, right eye
- no EOM. Visual acuity: counting fingers. Weak cough with
suction. ? unable to tell if she has face droop.
Motor: moves right arm and right leg when instructed to do so.
Flacid paralysis of left arm and leg
DTRs: triple reflex of the left leg, otherwise 1
Sensation: extensor response of the LUE to pain, otherwise
withdrawls in all other extremities
Pertinent Results:
[**2172-6-11**] 05:09PM %HbA1c-7.4*
[**2172-6-11**] 10:03PM CK-MB-NotDone cTropnT-<0.01
[**2172-6-11**] 02:35PM GLUCOSE-195* UREA N-30* CREAT-1.2* SODIUM-141
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-30* ANION GAP-14
[**2172-6-11**] 02:35PM ALT(SGPT)-33 AST(SGOT)-31 LD(LDH)-335*
CK(CPK)-107 ALK PHOS-101 AMYLASE-71 TOT BILI-1.1
[**2172-6-11**] 02:35PM CK-MB-2 cTropnT-<0.01
[**2172-6-11**] 02:35PM PLT COUNT-198
[**2172-6-11**] 02:35PM PT-15.4* PTT-28.1 INR(PT)-1.6
INR upon admission: 1.6 (subtheraputic)
WBC peak: 20K
Studies:
[**2172-6-11**] MRI/A: IMPRESSION: Acute brainstem and right thalamic
infarct, due to vertebrobasilar occlusive disease.
CT angio [**2172-6-12**]: 1) Patient with known history of basilar
occlusion status post TPA, now with improved blood flow in the
basilar artery with persistent thrombus at the basilar tip. 2)
The right posterior cerebral artery is not well visualized and
overall caliber is small and irregular. 3) Hypoplastic left
distal vertebral artery with the dominant right vertebral artery
supplying the basilar artery. The remainder of the intracranial
circulation demonstrates no evidence of critical stenosis or
aneurysms.
TEE on [**2172-6-12**]: Conclusions:
1. The left atrium is dilated. The right atrium is dilated.
2. There is symmetric left ventricular hypertrophy. The left
ventricular
cavity is dilated. Overall left ventricular systolic function is
moderately
depressed.
3. A bileaflet mitral valve prosthesis is present. The mitral
prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular
gradients.
4. The tricuspid valve leaflets are mildly thickened. A
tricuspid valve
annuloplasty ring is present.
5. No definitive cardiac source of embolism identified.
CXR (multiple): LLL infiltrate, small pleural effusion
Sinus CT ([**6-30**]): IMPRESSION: Diffuse sinus opacification. With
the history of nasal packing
the significance of this finding is uncertain.
CT ABD ([**7-2**])IMPRESSION: 1. No evidence of intra-abdominal
abscess or retroperitoneal
hematoma.
2. Patchy opacities at the left lung base with an area of
consolidation could
represent a pneumonic process.
MRI/MRA ([**7-9**]): IMPRESSION:
1. The MR study of the brain reveals evolution of the previously
seen
infarction involving the right thalamus, medial temporal, and
occipital lobes,
and cerebral peduncle with evidence of prior hemorrhagic
transformation.
2. Evidence of chronic small vessel ischemic infarcts, which are
unchanged.
3. Opacification of the paranasal sinuses, as seen previously on
the sinus CT
of [**2172-6-29**]. Since [**2172-6-12**], there is evidence of
bilateral fluid
accumulation in the mastoid air cells.
4. The MR angiogram shows restored basilar flow, but still no
left vertebral
artery flow.
CXR ([**7-21**]): IMPRESSION:
1) Tip of PICC is in the upper to mid SVC.
2) Stable cardiomegaly and mild CHF, with improvement in the
appearance of
pneumonia.
3) Small persistant opacity at the left hilum may represent
residual pneumonia
or prominent pulmonary vessels--followup to resolution is
suggested.
Brief Hospital Course:
HOSPITAL COURSE UNTIL [**2172-6-26**]:
56 yo woman with h/o mechanical valve and afib on coumadin,
subtheraputic, who presents with brainstem lesion findings on
exam, given t-PA in ED for suspected basilar artery occlusion.
MRI/A confirms this diagnosis. Occlusion likely secondary to
subtheraputic INR and clot from afib or mechanical valve.
1. For her stroke, she was admitted to the neuro ICU. Her blood
pressure was mainated between SBP 130-150. A head CT after the
tPA was obtained and showed no bleed. A CT angio was obtained
which showed a partially reperfused basilar, still with some
clot at tip of the basilar. She was placed on heparin drip. She
was started on a statin and recieved blood transfusions to
maintain a goal HCT>30. A carotid duplex scan showed a right
60-69% stenosis, normal left ICA, left vertebral artery with no
flow, right vertebral artery is ok. She should have a f/u duplex
in 6 months.
2. During her admission to the Neuro-ICU she developed daily
temperature spikes to a max temp of 102. Culture data obtained
and revealed MSSA in the sputum and LLL infiltrate on CXR.
Ceftriaxone was initially begun on [**6-14**] but her fever persisted,
so CTX was discontinued and zosyn was started on [**6-17**]. ID was
consulted as she remained persistently febrile. They
recommended increasing the dose of zosyn and continue to follow
cx data. Her a-line was discontinued and her central line was
changed over a wire. All blood cx NGTD, MRSA screens negative,
nasal packing discontinued (see below).
3. Excessive nose/op bleeding, noted first on the night of
admission after intubation in the field, worsening after
starting heparin. ENT was consulted. They packed her nares and
then removed the packing on [**6-25**]. She still continued to ooze
from her nares and bloody secretions were suctioned from her
trach and oropharynx.
4. HTN: Her BP regimen was ajusted multiple times throughout
her course to optimize cerebral blood flow. She is currently on
labetolol, captopril, lasix
5. Afib: continued digoxin, beta blocker for rate control,
heparin.
6. Anemia: likely 2o2 nose bleed, on heparin. She was
transfused on [**8-28**].
7. EKG changes (rapid afib, RBBB, lateral ST depressions): She
ruled OUT for MI, tele was revealing for only rapid afib, AM EKG
unchanged. She was betablocked for rate control.
8. Mechanical Mitral valve ([**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**]>: a TEE was performed
while she was intubated on [**6-12**], no clot was discovered, no
endocarditis, + PFO. Blood cx were NGDT. Heparin was started
24 hours after t-PA was given for a goal PTT on 40-60.
Coumadin was initially restarted but was held secondary to OP
bleeding and the need for possibly surgeries.
9. Hypothyroidism: she was continued on her levoxyl (home dose
unknown). Will need her TSH checked after her acute illness
issues have resolved.
10. Resp: She was intubated as she could not control her
secretions, extubated on [**6-12**] but had to be re-intubated later in
the day as not able to control secretions again. A trach/[**Month/Day (4) **] was
placed on [**6-24**] by Dr. [**Last Name (STitle) **]. She is now satting well on
cool mist trach mask.
11. Renal: her creatinine was followed and peaked at 1.3 likely
secondary to a pre-renal state as her fractional excretion of
urea was < 35%, she began to hemoconcentrate and her CL was
rising. Her meds were renally dosed. Dig level checked to
ensure no toxicity. During her hospitalization course an ACEI
was added to her BP regimen to help improve blood flow to the
kidneys and help in secondary stroke prophylaxis.
12. DM: while in the ICU she was maintained on an insulin drip,
then converted to NPH and oral regimen with RISS.
13. Peripheral neuropathy, very painful - neurontin increased to
1200 TID
14. At one point she complained of abdominal pain, this
resolved. Her LFTs were mildly elevated so a RUQ US was
obtained and showed absent GallBladder, no CBD dilation.
15. Hypernatremia - resolved with free water boluses x 3 days.
16. Constipation: PO fleets
17. PPx: pneumoboots, PPI, replete lytes prn , PT/OT, OOB, bowel
regimen
18. FEN: TF gastric tube
Pt transfered to medicine floor on [**6-26**]. On [**6-29**] pt became
hypoxic and was trasnfered back to the ICU.
HOSPITAL COURSE BY PROBLEM AS OF [**2172-6-29**]:
On [**2172-6-29**], the patient desaturated on being turned and was
transferred to the MICU for further treatment. Hypoxia was felt
to be secondary to a combination of pneumonia and/or a blood
clot plugging of airways. CTA was negative for PE. A head CT
showed pan-opacification of the sinuses, considered to be
sinusitis. MICU team called to evaluate, pt transfered to MICU
for desaturation. Pt intubated in MICU.
1. Respiratory Failure: Bibasilar aspiration MRSA PNA on vent.
- MRSA in sputum on [**7-3**]. Multiple attempts to wean with rapid
sequence breathing indices. Pt is taking breaths on her own.
Bronchoscopy performed to evaluate trach placement to see if
mechanical problems causing failure to wean. Trach in place
suggesting more central causes of failure to wean. In addition,
pt producing copiuos secreations which would be very difficult
to clear.
[**7-19**] pt has PERSISTENT LLL pna even after completing vanc and
ceftaz course, still copoius secretion.
[**7-20**]: Abx coarse complete. Repeat Sputum cx + for MRSA
suggesting colonization. Changed abx to oxacillin and
ceftriaxone for treatment of presumed osteo. Will follow CXR to
evaluate pna status. d/c'd vanc/ceftaz. ID following and agreed
with plan to stop Vanco and Ceftaz.
*
2. FEVERS- PNA sputum posititive to MRSA.
Neg RUQ USG, c.diff, urine cx, blood cxs, TEE, ANCA. One blood
cx on [**7-17**] + for Staph non-aureus in [**12-8**] bottle. Suspected
contamination, second set of cx's negative.
-s/p sinus drainage by ENT, aspirated + for MRSA.
Lines D/C'd to rule out as cause of fevers. Pt only with
peripheral IV's until afberile.
Bronch: BAL showed + MRSA.
- completed zoysn [**6-28**] (CTX [**6-14**], then switched to zosyn [**6-17**]
for broader coverage).
-[**7-11**]- Ceftaz d/c'd per ID recs since no sputum cx w/ GNR. Other
possible infectious source is sacral decub ulcer. ?osteo.
Plastics following- plastics felt they were able to probe to
bone on debridement suggesting stage 4 decub and osteomyelitis.
-[**7-12**] - growing GPC [**12-6**] in blood cultures; on vanco and
ceftazidime restarted. cont for 14 d course.
-[**7-13**]- GPC still [**12-6**] two bottles, fevers better, wbc 28
yesterday now 21. holding tylenol around the clock to see what
fever is (was started given high hr). Felt that LP and bone bx
was too invasive at this point given pt's respiratory status.
Decided to presume osteo based on ability to probe to bone and
treat accordingly.
-[**7-14**]: ID signed off. Called it MRSA sinusitis and GNR pna.
One more week of abx recommended. Pt completed full course of
abx therapy for pna.
-[**7-21**]: Vanco and Ceftaz D/c'd as pt received full course and
started on Oxacillin and CTX for presumed Osteo. Pt to conintue
this course for an additional 4 weeks for full treatment of
osteomyelitis. Of note, wound cultures of Decub were negative
with pt on abx.
3. NSTEMI/A fib - Found to have elevated CEs on [**7-3**] with no EKG
changes. Controlled HR and Afib with RVR with Amiodarone started
on [**7-12**]. BP and HR also controlled with Lopressor. Pt was
already on ASA, started on Heparin gtt. Pt's Afib with
occasional RVR required additional doses of IV Lopressor and
fluid boluses. Pt restarted on Coumadin and became therapeutic
with goal INR between [**1-7**]. Checked INR on daily basis and
adjusted dose based on INR.
- Kept HCT >30 with transfusions as needed due to recent hx of
MI.
- [**7-20**]: talked to primary cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17204**],
[**Telephone/Fax (1) 56219**]; apprised him of situation. Appreciated update.
- Treated with ASA, Heparin gtt, betablocker.
- Transfused to keep HCT >30.
- On coumadin for St. Jude valve. Goal INR [**1-7**].
4. Stroke - Dense neurodeficit. As per previous Neuro note, the
patient was [**Last Name (un) 56220**] to follow commands initially. Become more
unresponsive and F/U MRI showed evolution of stroke with
hemorrhage. Pt now, unresponsive to commands. Blown R pupil and
sluggish L pupil. Opens L eye to name but does not track. Does
not follow commands. Will with draw R arm and both legs to pain.
Spontaneous movements of R arm and b/l legs. L arm flaccid. B/l
upgoing toes. Positive cough and gag with suction.
-carotid duplex - R 60-69% stenosis, L OK, left vert no flow, rt
vert ok. f/u duplex in 6 months.
- statin d/c'd because of elevated liver enzymes and CK's.
- therapeutic on coumadin
5. Elevated LFTs: RUQ USG neg. viral serologies EBV IgG pos,
CMV pending.
6. Mechanical Mitral valve [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**]
- therapeutic INR w/ coumadin. d/c'd heparin gtt [**7-15**].
7. Hypothyroidism: levoxyl; TSH/T4 normal [**7-19**]
8. DM: restart insulin gtt for BS in 200-300s
- goal 90-120s
- on lantus starting [**7-6**] - able to stop insulin gtt
- Pt requiring Lantus 90U Qam and furhter coverage with Insulin
sliding scale. Pt did well with this regimen.
9. AFIB- [**7-15**] INR 2.2 (d/c heparin gtt) cont coumadin goal INR
[**1-7**]
- changed amiodarone to 200 qd after 7 days of Amiodarone 200mg
[**Hospital1 **].
10. Peripheral neuropathy prior to admission.
- holding neurotin for ? cause of fevers?
11. Anemia: likely [**1-6**] nose bleeds and chronic illness, on
heparin, s/p multiple tranfusions with goal HCT > 30.
-hct bumps appropriately after PRBC
12. Stage 4 decub ulcer- Consulted Plastic surgery who feels
that the ulcer probes to bone. Presumptive osteo. On CTX and
oxacillin. Plastics has debrided decub again [**2172-7-18**] and again
on [**7-22**]. Pt has been on air mattress while in ICU with Q2
turning.
13. PSYCH: started celexa recommended by Neuro based on location
of CVA.
14. [**Name (NI) 1623**] Pt had [**Name (NI) **] tube placed for nutrition. Tolerating tube
feeds well, at goal. Pt on bowel regimen, no problems with
constipation or diarrhea. Also received free water boluses via
[**Name (NI) 282**]. Seen by nutrition for recommendations on tube feeds.
15. Access- foley, [**Name (NI) 282**]
[**7-12**]- R IJ placed (placed as on heparin gtt but increase risk
of infection as close to trach)
[**7-20**] change foley cath today for yeast in urine. Urine Cx
negative.
[**7-22**]- R IJ d/c'd ; R PICC line placed.
16. [**Name (NI) **] sisters- [**Name (NI) **] and [**Name2 (NI) **], with family [**Name (NI) **] husband
(separated)[**Telephone/Fax (1) 56221**], [**Last Name (un) **] daughter [**Telephone/Fax (1) 56222**],
granddaughter [**Name (NI) **]. Health care proxy now sister [**Name (NI) **]
[**Name (NI) 1557**].
17. Prophylaxis- Protonix, IV Coumadin, Pt seen by PT who gave
recommendations for therapy, bowel regimen, chlorhexidine
mouthwash; head of bed >30 degrees.
18. DNR - as per discussion on [**7-13**].
Patient was made CMO on [**2172-7-24**] by the health care proxy [**Name (NI) **]
[**Name (NI) 1557**]. The patient was made comfortable with morphine, ativan
and scopolamine for secretions and expired soon after
extubation.
Medications on Admission:
coumadin 4mg qHS except 2mg on tues
dyazide 25/37.5 qd
nadolol 40mg qd
neurontin 800 TID
actose 45 qd
KCl 20 mEq qd
tramadol 50 QID
glyburide/metformin 2.5/500 [**Hospital1 **]
digoxin 0.25 qd
lasix 80 mg qD
thyroid replacement (dose?)
Discharge Medications:
1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-6**]
Tablet, Delayed Release (E.C.)s PO QD (once a day).
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-6**] Sprays Nasal
TID (3 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
7. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous
membrane [**Hospital1 **] (2 times a day).
8. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
9. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO QD
(once a day).
10. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
QD (once a day).
11. Warfarin Sodium 5 mg Tablet Sig: [**12-6**] Tablet PO HS (at
bedtime): Keep INR between [**1-7**]. .
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO QD (once
a day).
14. Insulin Glargine 100 unit/mL Solution Sig: Ninety (90) Units
Subcutaneous qam.
15. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for FUNGAL GROIN.
17. Sodium Chloride 0.9% Flush 3 ml IV QD:PRN
Peripheral IV - Inspect site every shift
18. Lorazepam 0.5-1 mg IV Q6H:PRN
19. Fentanyl Citrate 25-100 mcg IV Q4H:PRN
20. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) Grams
Injection Q6H (every 6 hours) for 4 weeks.
21. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
gram Intravenous Q24H (every 24 hours) for 4 weeks.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Cerebrovascular accident
Discharge Condition:
Fair
Discharge Instructions:
Please administer all medications as prescibed.
Followup Instructions:
None
|
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79,842
| 135,130
|
34692
|
Discharge summary
|
report
|
Admission Date: [**2189-9-11**] Discharge Date: [**2189-9-15**]
Date of Birth: [**2134-6-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
dizziness / hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 55-yo man w/ recent large ICH and DVT s/p IVC filter
not on anticoagulation, who presents from rehab with
hypotension, and found to have PEs on Chest CTA at OSH as well
as increased bleeding at the site of his ICH, in the setting of
INR 1.3. The pt was doing well at [**Hospital **] Rehab but was found to be
hypotensive today, so was transferred to [**Hospital6 5016**].
There, Chest CTA revealed small PEs in the RLL, and Head CT
revealed re-bleeding at the site of the previous ICH, so he was
transferred here for Neurosurgical evaluation.
In the ED: VS - Temp 98.1F, HR 108, BP 138/94, R 25, O2-sat 98%
2L NC. He was found to have a WBC 20 with 84% PMNs, INR 1.4,
lactate 1.5, and subtherapeutic Dilantin level of 2.6. UA was
negative, CXR was clear, and Blood Cx were sent x2. ECG revealed
ST-segment changes in V4-V5, and he ruled-out for an MI with 2
sets of negative CEs. Head CT revealed a large left
frontoparietal intraparenchymal hemorrhage with moderate edema
and mild mass effect on the left lateral ventricle, with no
midline shift or evidence of herniation. Head MRI confirmed the
large left frontoparietal intraparenchymal hemorrhage with
surrounding vasogenic edema, with left-sided sulcal effacement
but no evidence for uncal herniation or transtentorial
herniation; it also revealed bifrontal subdural hematomas as
well as subdural hematomas along the interhemispheric cistern
and the falx; there was no evidence for infarction. He was seen
by Neurosurgery, who recommended repeat CT neck / brain and CTA
brain to assess the vasculature. He was continued on Dilantin,
started on steroids, and coumadin was continued to be held. He
is being admitted to the ICU for close neurological monitoring
Past Medical History:
- Pt had MVA [**2189-8-26**] after cough-related syncopal event.
Unconscious at the scene, admitted to [**Hospital 12017**] Hospital. Head
CT and pan-CT were unremarkable, INR was 2.8 at the time. Within
36 hours, developed large intracerebral hematoma, MRA negative.
Coumadin was stopped. Transferred to [**Hospital **] Rehab, where he has been
since.
- Hypertension
- Chronic atrial fibrillation
- Hyperlipidemia
- COPD
- Cough-related syncope
Social History:
Occupation: Formerly employed as tech at [**Company 1543**] designing
catheters.
Drugs: Remote h/o IVDU, none in last 8 years.
Tobacco: Smoked 1PPD x32years.
Alcohol: Significant EtOH use hx: 0-3 drinks/day during week,
[**7-2**] drinks/day on weekends.
Other:
Family History:
Non-contributory
Physical Exam:
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36.7 ??????C (98 ??????F)
HR: 104 (96 - 132) bpm
BP: 116/83(91) {94/59(67) - 138/95(101)} mmHg
RR: 20 (13 - 26) insp/min
SpO2: 98%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 108.3 kg (admission): 108.3 kg
Height: 77 Inch
General Appearance: Well nourished, No acute distress, No(t)
Anxious, well-appearing man in NAD, comfortable, appropriate
Eyes / Conjunctiva: PERRL, PERRL, EOMI, sclerae anicteric
Head, Ears, Nose, Throat: Normocephalic, resolving e/o trauma to
face and head, MMM
Lymphatic: Cervical WNL, Supraclavicular WNL, supple, no LAD /
JVD
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic), irreg irreg,
tachycardic, nl S1-S2, no MRG
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present), 2+ peripheral pulses (radials, DPs)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : ), CTA bilat, no r/rh/wh
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, +BS, soft/NT/ND, no masses or HSM, no
rebound/guarding
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing, WWP, no c/c/e
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): 3, Movement: Purposeful, Tone:
Normal, awake, A&Ox3, CNs II-XII grossly intact, decreased
proximal RUE muscle strength and RLE muscle strength, decreased
sensation to light touch and proprioception in RLE, muscle
strength 5/5 on left and sensation grossly intact on left; gait
not assessed
Pertinent Results:
[**2189-9-15**] 05:25AM BLOOD WBC-15.1* RBC-3.06* Hgb-9.9* Hct-28.3*
MCV-92 MCH-32.3* MCHC-35.0 RDW-12.9 Plt Ct-346
[**2189-9-11**] 07:09PM BLOOD Neuts-88.4* Lymphs-6.8* Monos-3.1 Eos-1.1
Baso-0.6
[**2189-9-13**] 05:55AM BLOOD PT-15.9* PTT-27.5 INR(PT)-1.4*
[**2189-9-15**] 05:25AM BLOOD Glucose-106* UreaN-15 Creat-0.7 Na-135
K-3.6 Cl-101 HCO3-24 AnGap-14
[**2189-9-15**] 05:25AM BLOOD ALT-198* AST-146* AlkPhos-609*
TotBili-2.6*
[**2189-9-13**] 05:55AM BLOOD Lipase-84*
[**2189-9-11**] 09:42AM BLOOD cTropnT-<0.01
[**2189-9-11**] 09:42AM BLOOD CK-MB-3
[**2189-9-10**] 10:40PM BLOOD cTropnT-<0.01
[**2189-9-10**] 10:40PM BLOOD CK-MB-3
[**2189-9-15**] 05:25AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2
[**2189-9-14**] 06:35AM BLOOD TSH-2.5
[**2189-9-10**] 10:40PM BLOOD Digoxin-1.3
[**2189-9-12**] 04:35AM BLOOD Phenyto-3.5*
NCHCT ([**9-10**]) - There is an acute intraparenchymal hemorrhage
within the left frontoparietal lobes centered deep in the medial
subcortical white matter, measuring 5 cm AP x 3.5 cm CC x 2.3 cm
TRV. There is a moderate amount of surrounding vasogenic edema.
No discrete underlying mass is identified. There is one area
where the hemorrhage appears more heterogeneous (2:24), and this
may be due to swirling of blood (perhaps acute on chronic
hemorrhage) or an underlying mass. There is no evidence of
intraventricular extension of hemorrhage. There is mild mass
effect on the left lateral ventricles. No shift of the normally
midline structures. The suprasellar and basal cisterns are
preserved. There is a small amount of mucosal thickening in the
left maxillary sinus and a mucus retention cyst in the right
axillary sinus. The mastoid air cells are normally pneumatized
and aerated. A spongy lucent lesion in the left parietal bone
likely represents arachnoid granulations. There is no soft
tissue abnormality.
IMPRESSION: Large left frontoparietal intraparenchymal
hemorrhage with moderate edema and mild mass effect on the left
lateral ventricle. No midline shift or evidence of herniation.
The location of the hemorrhage is atypical for hypertension, and
the acuity of the bleed in unusual two weeks post-contusion
unless this represents hemorrhagic transformation of an infarct,
or rebleeding. An underlying mass, AV malformation, and amyloid
angiopathy are also considerations and could be evaluated for by
CTA or MRI.
NOTE ADDED AT ATTENDING REVIEW: It would be helpful to compare
to prior studies. The hemorrhage on this study does not appear
acute, given the extensive surrounding edema, but there might be
rebleeding into an established hematoma. I agree that the
etiology is not apparent, and that further work up is needed to
distinguish among the diagonstic possibilities listed.
CXR ([**9-11**]) - The lungs are clear, with no evidence of pneumonia.
No effusion or pneumothorax. The cardiomediastinal silhouette is
normal.
Head MRI ([**9-11**]) - (PFI) Large left frontoparietal
intraparenchymal hemorrhage with surrounding vasogenic edema
previously seen on CT examination. There is left-sided sulcal
effacement but no evidence for uncal herniation or
transtentorial herniation. There are also bifrontal subdural
hematomas as well as subdural hematomas along the
interhemispheric cistern and the falx. There is no evidence for
infarction. CTA or MRA could be used to further evaluate
intracerebral vasculature.
MRA intra and extra cranial vessels
1. Unremarkable cranial and cervical MRA, with no flow-limiting
stenosis or
aneurysm larger than 3 mm in diameter.
2. No evidence of vascular abnormality in the region of the
large left
parieto-occipital evolving hematoma.
3. Note that the thin, though extensive, subdural hematoma,
containing
predominantly extracellular methemoglobin ("late subacute")
largely layering
about the left cerebral convexity, was not "new" on the [**2189-9-11**]
MR
examination; rather, it was present on the admission CT of the
day before.
These findings are all consistent with post-traumatic,
multicompartmental
Bilateral LENI
Extensive bilateral DVT as described above. If there is clinical
concern, and alteration in management will occur a dedicated MRV
can be used to evaluate for more proximal thrombosis.
Brief Hospital Course:
Mr. [**Known lastname **] is a 55 year old gentleman with recent large ICH and
DVT s/p IVC filter not on anticoagulation, who presented to an
OSH with hypotension where he was found to have multiple
subsegmental PEs as well as what was thought to be increased
bleeding at the site of his ICH, in the setting of INR 1.4.
1. Intracerebral hematoma/subdural hematoma: The patient was
admitted with a question of re-bleeding into his previous ICH,
noted on Head CT and MRI. Unclear underlying etiology given that
INR 1.3 on arrival. MRI also noted bilateral SDH. Neurosurgery
and neurology were both consulted during admission. Final read
per radiology was consistent with subacute injury from original
inciting event with no acute process. The patient was initially
continued on phenytoin, but was changed to keppra due to
transaminitis. He will need to have his keppra titrated to
therapeutic level as indicated in discharge instructions.
2. Pulmonary emboli: The patient was noted to have multiple RLL
subsegmental pulmonary emboli on CTA at OSH. He is status post
IVC filter placement and not anticoagulated with an INR of 1.4
on admission. He remained hemodynamically stable throughout his
hospital course, and repeat lower extremity noninvasive studies
demonstrated bilateral LE DVTs. The patient is not a candidate
for anticoagulation secondary to ICH and SDFH. After discussing
with neurology, he was started on 325 mg ASA.
3. ECG changes: Pt presented with concerning ST-changes on ECG,
unknown baseline. Ruled-out for MI w/ 2 sets negative CEs while
in ED. As stated above, he was started on ASA therapy during
hospitalization.
4. Atrial fibrillation: Patient with afib on ECG on admission,
and was intermitently tachycardic during hospitalization. Rate
controlled at home on atenolol and verapamil, not
anticoagulated. We continued verapimil on short acting dose and
converted to metoprolol while admitted, which was slowly
titrated up for adequate rate control. He was continued on
digoxin and verapamil during his hospital course. The patient
was also noted on telemetry to have a 20 beat run of what
initially appeared to be asymptomatic VT, which was concerning
in the setting of his recent MVA attributed to cough syncope.
Cardiology was asked to interpret the telemetry strip, which was
determined to be Afib with aberration. No further diagnostic
work-up was performed, but the patient will likely need a TTE as
an outpatient if not already performed.
5. Transaminitis: Patient was found to have increasing
transaminitis during his hospital course that peaked at 221/166
ALT/AST. On day of discharge, his ALT/AST were 198/146 with alk
phos 609 and tbili of 2.6. He was switched from phenytoin to
keppra over some concern of drug induced transaminitis. On
further questioning, the patient also has a significant EtOH
history, stating that he drinks at least a 6 pack of beer a day.
A RUQ ultrasound was negative for liver lesions with borderline
splenomegaly and biliary sludging. A follow-up appointment was
scheduled for the patient in outpatient gastroenterology clinic
at [**Hospital1 18**]. On discharge, hepatitis serologies were pending.
6. Hypertension: Patient initially admitted on atenolol and
verapamil, which was converted to metoprolol and verapamil
during hospitalization.
7. Hyperlipidemia: Continued on home statin therapy during
hospitalization.
8. COPD: Continued on home therapy during hospitalization.
Medications on Admission:
- lansoprazole 30mg PO daily
- verapamil 240mg PO daily
- digoxin 250mcg PO daily
- allopurinol 300mg PO daily
- atenolol 25mg PO daily
- simvastatin 20mg PO daily
- fluticasone 220mcg PO BID
- dilaudid 2mg PO PRN
- dilantin 230mg PO BID
- albuterol 3ml PRN
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Verapamil 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H (every 8
hours).
3. Digoxin 250 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
4. Allopurinol 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
7. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: [**1-21**] puff Inhalation Q4H (every 4 hours) as
needed.
11. Senna 8.6 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary
1. Intracerebral hematoma
2. Subdural hematoma
3. Pulmonary embolism
Secondary
- Hypertension
- Chronic atrial fibrillation
- Hyperlipidemia
- COPD
- Cough-related syncope
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. You were admitted for an increase in the bleeding in your
head. A cat scan and multiple MRIs were performed, and you were
also evaluated by neurosurgery and neurology, who felt that this
was a subacute process that was caused by your original car
accident. You will need to follow-up with neurosurgery as an
outpatient as indicated below. You were also started on an
anticonvulsant for seizure prophylaxis while admitted. The
instructions for this medication are:
Keppra 500 mg by mouth twice daily x6 days, then
Keppra 500 mg in the morning and 1000 mg at night x7days, then
Keppra 1000 mg twice daily
2. You were also found to have multiple pulmonary emboli as well
as clots in your legs, which are of uncertain age. You are not
a candidate for anticoagulation because of the bleed in your
head, but you were started on aspirin during this hospital
course.
3. You were also found to have elevated liver enzymes while
hospitalized. You had an ultrasound of your abdomen while
admitted. You will need to follow-up at the [**Hospital1 18**] liver center
as indicated below.
4. You should resume all of your medications as indicated. It
is very important that you take all of your medications as
prescribed.
5. It is very important that you make all of your doctors
[**Name5 (PTitle) 4314**].
6. If you develop a fever, chest pain, shortness of breath, or
other concerning symptoms, call your PCP or go to your local
Emergency Department immediately.
Followup Instructions:
Provider: [**Name10 (NameIs) 8758**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2189-10-13**] 1:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2189-10-15**] 1:30
Completed by:[**2189-9-15**]
|
[
"415.19",
"272.4",
"907.0",
"348.5",
"432.1",
"401.9",
"453.41",
"496",
"427.31",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13779, 13826
|
8796, 12254
|
338, 344
|
14050, 14096
|
4588, 8773
|
15606, 15908
|
2874, 2893
|
12562, 13756
|
13847, 14029
|
12280, 12539
|
14120, 15583
|
2908, 4569
|
275, 300
|
372, 2100
|
2122, 2575
|
2591, 2858
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
770
| 140,093
|
9989+10021
|
Discharge summary
|
report+report
|
Admission Date: [**2127-1-28**] Discharge Date: [**2127-2-21**]
Date of Birth: [**2058-3-13**] Sex: F
Service: MICU
CHIEF COMPLAINT: Fever, cough
HISTORY OF PRESENT ILLNESS: This 68-year-old with a history
of insulin dependent diabetes mellitus and coronary artery
disease presented to the [**Hospital3 **] Emergency Department on
three to four days. The patient also reported some nausea
with no vomiting. The patient had fallen at home twice in
the preceding day and it was the falls that prompted the
patient to seek medical care. The patient notes sick contact
with several members of the family, including the patient's
husband who was sick with similar symptoms for several days.
In addition to the patient's fever, cough and falls, the
difficult to control with blood sugars reaching upwards of
400 from a baseline of 1 to 200. History is negative for
chest pain.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus since age 5
2. Normal pressure hydrocephalus status post
ventriculoperitoneal shunt in [**2123**]
3. Coronary artery disease, status post coronary artery
bypass graft in [**2118**]
4. Degenerative joint disease
5. Depression
MEDICATIONS:
1. NPH insulin
2. Prevacid
3. Lasix
4. Neurontin
5. Zoloft
6. Premarin
7. Lipitor
ALLERGIES: THE PATIENT HAS ALLERGIES TO PENICILLIN WHICH
CAUSES A RASH, KEFLEX WHICH CAUSES A RASH, ERYTHROMYCIN WHICH
CAUSES TONGUE SWELLING AND QUININE WHICH CAUSES
THROMBOCYTOPENIA BY REPORT.
SOCIAL HISTORY: The patient lives at home with her husband,
is functional with a walker at home. Denies drug or alcohol
abuse.
PHYSICAL EXAM ON ADMISSION:
VITAL SIGNS: The patient had a temperature of 100.2??????, heart
rate 91, blood pressure 197/81, respiratory rate of 20,
oxygen saturations were in the high 70s.
GENERAL: The patient was ill appearing and rigoring.
HEAD, EARS, EYES, NOSE AND THROAT: The patient's pupils were
equal and reactive with anicteric sclerae and dry mucous
membranes.
NECK: Supple without meningeal signs. There was no palpable
lymphadenopathy, no jugular venous distention.
RESPIRATORY: Bilateral coarse rhonchi, right greater than
left.
CARDIAC: S1, S2, regular rhythm without murmur.
ABDOMEN: Soft, nontender with positive bowel sounds. The
patient had no costovertebral angle tenderness.
EXTREMITIES: There was no clubbing or cyanosis. There was
bilateral trace edema. The skin was noted to have no rash.
NEUROLOGIC: The patient was alert and oriented x2, moving
all extremities, nonfocal exam.
ADMISSION LABS: The patient's white blood cell count was 11.
Hematocrit was 33.3, platelets 184. Sodium 136, potassium
4.2, chloride 90, bicarbonate 30, BUN 50, creatinine 2.6.
Glucose was 227.
IMAGING IN THE EMERGENCY DEPARTMENT: A head CT scan was
ordered and was negative for acute bleed, but did reveal
hydrocephalus with a ventriculoperitoneal shunt. Chest x-ray
revealed right upper and right middle lobe infiltrates.
HOSPITAL COURSE: The patient was given a dose of Levaquin in
the Emergency Department and admitted to the medical floor
for multilobar pneumonia. Upon admission to the floor team,
the patient was continued on Levaquin as well as Flagyl which
was added for the concern of aspiration pneumonia. However,
over her eight days on the floor the patient continued to
require large amounts of oxygen and was becoming short of
breath as well. Additionally, the patient's white blood cell
count which was 11 on admission had suddenly increased to
11.6 on the day of transfer. All micro data, including a CSF
blood, sputum and urine cultures were negative. Legionella
antigen was negative. The pulmonary service was consulted on
the 13th and the patient underwent bronchoscopy which
revealed watery bilateral secretions more consistent with
pulmonary edema than an infectious process. Bronchoalveolar
lavage samples taken at the time were negative for
microorganisms, however it did reveal highly atypical
epithelial cells consistent either an infectious or possibly
malignant process. The patient also underwent
echocardiography on [**2-5**] which revealed a congestive heart
failure picture with left ventricular dysfunction, ejection
fraction of approximately 30%. A chest CT performed on [**2-3**]
revealed consolidation in both lungs bilaterally, all lobes,
with a moderate right effusion and a small left effusion.
Owing to the patient's increasing oxygen requirement and
declining clinical course, the patient was transferred to the
Medical Intensive Care Unit on [**2-5**] for further care.
MEDICAL INTENSIVE CARE UNIT COURSE: On [**2-5**], the patient was
admitted to the Medical Intensive Care Unit. The clinical
impression of the Medical Intensive Care Unit team was that
the patient likely had a mixed picture of both possibly
infectious process as well as congestive heart failure.
Owing to her worsening respiratory distress. In addition to
the patient's declining cardiopulmonary function, the patient
also now had an acute on chronic renal failure as well as
difficult to control blood sugars. The [**Hospital 228**] Medical
Intensive Care Unit course by systems is outlined below.
1. RESPIRATORY: Owing to the fact that the patient likely
had a congestive heart failure component owing to her hypoxic
respiratory failure, the patient was diuresed upon admission
to the Medical Intensive Care Unit day 1 through day 3. On
Medical Intensive Care Unit day 1, the patient diuresed
approximately 1 liter and her respiratory status was noted to
be improving. The patient also underwent aggressive chest PT
and suctioning. She was noted to have excessive secretions.
On [**2-8**] at approximately 4 a.m., the patient was noted to be
in increasing respiratory distress with increasing rancorous
breath sounds. The patient was intubated emergently and then
large amounts of secretion were suctioned from the patient's
airway.
Following intubation, the patient continued to be
aggressively diuresed and was placed on a Lasix drip. The
patient's respiratory status improved with diuresis and the
patient was weaned to pressure support ventilation on the
18th where she remained for several days until the following
day. However, the patient's respiratory status again
declined and she was placed back on assist control
ventilation. Bronchoscopy was repeated on [**2-11**] which again
revealed diffuse edematous and hyperemic airways with a
watery secretion noted. The patient was also noted to have
mild dynamic collapse at the posterior wall of the trachea.
It was still unclear from this whether the process was
infectious or cardiac, but was felt likely to have components
of both. BAL samples were taken and again were negative for
organism, but did reveal some atypical cells on cytological
examination.
Chest x-ray at this time revealed diffuse bilateral fluffy
infiltrates which could have been consistent with congestive
heart failure or developing ARDS. The patient remained
intubated until [**2-14**] when after several days on pressure
support the patient was extubated in the morning. However,
the patient lasted approximately only 30 minutes before
desaturating and apparently having difficulty clearing
copious secretions. Therefore, the patient was reintubated
shortly thereafter on [**2-14**]. The patient was extubated again
on the 24th and this time the patient faired better and did
not require reintubation. Over the time from the 24th
through the [****], the patient had gradually
improving respiratory status, including decreasing oxygen
requirement as the patient was weaned to 2 liters by nasal
cannula. However, the patient's respiratory state was
notable for frequent copious secretions that required
suctioning by staff every one to two hours. For this reason,
the patient was not transferred to the floor and it was felt
that pulmonary rehabilitation would be a better disposition
for the patient.
2. CARDIOVASCULAR: The patient underwent echocardiography
on [**2-5**] which revealed poor left ventricular function with an
ejection fraction of 30%. The patient was therefore diuresed
throughout her Medical Intensive Care Unit course. In order
to better determine the patient's hemodynamic and fluid
status, a Swan-Ganz catheter was inserted on [**2127-2-10**]. The
patient was noted to have increased pulmonary capillary wedge
pressures in the high teens to low 20s as well as mildly
elevated pulmonary arterial pressures ranging systolic high
50s to diastolic high 20s. This data further supported the
use of diuresis for the patient. By the [**1-14**], the
patient was placed on a Lasix drip which continued through
the [**1-20**]. Over the patient's course, the patient
diuresed a total of over 8 liters of fluid and concurrent
with this, the patient's respiratory status improved.
Additionally, the patient's peripheral edema also began to
resolve. Upon discontinuation of the patient's Lasix drip,
the patient was switched to 60 mg intravenous [**Hospital1 **] of Lasix
with which continuous improvement was noted. Additionally,
the patient was treated with captopril which was titrated up
to 50 mg tid as the patient's blood pressure was tolerating
this well.
3. INFECTIOUS DISEASE: The patient was initially treated
with Levaquin and Flagyl upon admission. The patient
continued to be treated with these agents through her floor
hospital course. Upon transfer to the Medical Intensive Care
Unit, the patient was started on vancomycin offering triple
antibiotic coverage. Through the [**1-14**], the patient
had no positive blood, sputum or urine cultures. However, on
[**2-11**], a sputum sample was positive for Methicillin resistant
Staphylococcus aureus. The patient's antibiotic regimen was
changed to include only vancomycin 750 mg intravenous qd.
The patient will continue on this vancomycin course through
[**2127-2-26**].
4. ENDOCRINE: The patient's blood sugars were difficulty to
control throughout the beginning of her Medical Intensive
Care Unit stay. As a result, the patient was placed on an
insulin drip which was titrated to blood glucoses between 80
and 120. The Medical Intensive Care Unit drip was continued
through the [**3-21**] when the patient was switched back
over to NPH insulin. Upon discharge, the patient is
requiring between 30 and 35 units of NPH insulin [**Hospital1 **].
5. RENAL: The patient was noted to have elevated BUN and
creatinine upon admission. These levels gradually coursed
down throughout the [**Hospital 228**] Medical Intensive Care Unit
stay in spite of aggressive Lasix diuresis. At the time, the
patient's BUN and creatinine have been stable for several
days with BUN in the 30s and creatinine ranging form 1.2 to
1.4 which are apparently improved from the patient's
baseline.
6. GASTROINTESTINAL: Following intubation, tube feeds were
initiated through a nasogastric tube, however, the patient
tolerated these poorly, likely secondary to her diabetic
gastroparesis. The tube feeds were difficult to get in over
the first Medical Intensive Care Unit week, however the
patient gradually began tolerating more and more and was soon
at her goal of Ultracal via a nasogastric tube in order to
ensure more reliable feeding and disposition to an acute
rehabilitation facility. The patient underwent GJ tube
placement on [**2127-2-20**] without complications. The patient's
current tube feeding regimen is Ultracal with a goal of 70 cc
an hour.
For access, the patient had a right sided PICC line placed
for interventional radiology. At the time of discharge, both
lumens are working appropriately.
7. NEUROLOGY: The patient's mental status was slow to
return to baseline following extubation likely secondary to
multiple medications. However, at the time of discharge, the
patient is alert and oriented x2 answering questions
appropriately and appears to be at her baseline per family.
At no times during the admission were there any neurosurgical
issues or issues related to the patient's
ventriculoperitoneal shunt.
DISCHARGE DIAGNOSES:
1. Hypoxic respiratory failure
2. Congestive heart failure
3. Methicillin resistant Staphylococcus aureus
tracheobronchitis
4. Insulin dependent diabetes mellitus
5. Acute on chronic renal failure
6. Diabetic gastroparesis
DISCHARGE MEDICATIONS:
1. NPH insulin 30 units subcutaneous [**Hospital1 **]
2. Regular insulin sliding scale
3. Captopril 50 mg po tid
4. Reglan 10 mg po qd
5. Colace 100 mg po bid
6. Albuterol and Atrovent metered dose inhalers inhaled q4h
prn
7. KCL 20 milliequivalents po qd
8. Lasix 60 mg intravenous [**Hospital1 **]
9. Zoloft 100 mg po qd
10. Aspirin 325 mg po qd
11. Digoxin 0.25 mg po qd
12. Nystatin Swish and Swallow
13. Vancomycin 750 mg intravenous qd through [**2127-2-26**]
Additionally, the patient were requiring the following
treatments at rehabilitation: Pulmonary rehabilitation: The
patient requires frequent suctioning and repositioning in
addition to chest PT. The patient will also require speech
and swallow evaluation and therapy directed at returning the
patient to taking fluids and solids po. The patient will
require physical therapy.
DIET ORDERED: The patient is presently NPO following a
speech and swallow evaluation that determined she was a high
aspiration risk. Nutritional supplementation is with
Ultracal tube feeds via GJ tube with a goal feeding rate at
70 cc per hour.
DISCHARGE CONDITION: The patient is ready for discharge on
[**2127-2-21**] in good condition.
[**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**]
Dictated By:[**Name8 (MD) 24599**]
MEDQUIST36
D: [**2127-2-21**] 07:31
T: [**2127-2-21**] 07:52
JOB#: [**Job Number 33433**]
Admission Date: [**2127-1-28**] Discharge Date: [**2127-2-26**]
Date of Birth: [**2058-3-13**] Sex: F
Service:
THIS IS AN ADDENDUM TO DISCHARGE SUMMARY DICTATED BY DR.
[**Last Name (STitle) **] FOR THE ADMISSION STARTING [**2127-1-28**]. PATIENT'S
ACTUAL DISCHARGE DATE IS [**2127-2-26**].
Patient's discharge was postponed due to the need for further
diuresis as well as no bed availability at the
rehabilitation. Meanwhile, patient was diuresed well with
intravenous Lasix and converted to Lasix per nasogastric
tube. Additionally, carvedilol was started for her
congestive heart failure medication. Additionally, she was
transfused one unit of packed red blood cells for anemia with
hematocrit of 26 with an appropriate bump of her hematocrit
to approximately 31. Her hematocrit has remained stable and
has still remained OB negative. The anemia laboratories were
sent out and are currently pending.
Her most updated discharge medication list includes:
1. Sliding scale of insulin.
2. Digoxin 0.125 mg per tube q.d.
3. Colace 100 pg tube b.i.d.
4. Miconazole powder 2% applied to affected areas b.i.d.
5. Metoclopramide 10 per tube q.i.d.
6. Sertraline 100 mg per tube q.d.
7. Heparin 500 units subcutaneous q. 12 hours.
8. KCL 20 mEq q.d.
9. Lansoprazole 30 mg pg tube q.d.
10. Tylenol prn q. 4-6 hours.
11. ............15 mg q.h.s. prn.
12. Albuterol 1-2 puffs q. 6 hours prn.
13. Atrovent 2 puffs q. 4-6 hours prn.
14. Aspirin 325 mg q. G tube q.d.
15. Insulin NPH 26 units q.p.m. and 30 units q.a.m. with
fingersticks q.i.d.
16. Furosemide 80 mg po b.i.d.
17. Lisinopril 30 mg po q.d.
18. Carvedilol [**12-27**] to 5 mg pg tube b.i.d.
19. Tube feeds, Ultracal full strength at 17 ml/hour at goal.
Patient will follow-up with her primary care physician.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33512**], M.D. [**MD Number(1) 33513**]
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2127-2-26**] 22:40
T: [**2127-2-26**] 22:40
JOB#: [**Job Number 33514**]
|
[
"518.81",
"250.61",
"536.3",
"285.9",
"584.9",
"331.4",
"428.0",
"485",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.56",
"96.6",
"44.32",
"96.72",
"89.64",
"96.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
13440, 15844
|
12060, 12290
|
12313, 13418
|
2986, 12039
|
154, 168
|
197, 899
|
2555, 2968
|
1649, 2538
|
921, 1491
|
1508, 1635
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,505
| 173,537
|
45230
|
Discharge summary
|
report
|
Admission Date: [**2126-9-29**] Discharge Date: [**2126-11-9**]
Date of Birth: [**2054-11-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Dalmane
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
[**2126-10-4**] Redo sternotomy, Redo aortic valve replacement with a
21-mm [**Doctor Last Name **] Magna ease aortic valve bioprosthesis, Redo mitral
valve replacement with a 29-mm St. [**Male First Name (un) 923**] Epic valve, Extensive
reconstruction of the aortic annulus and aortic root area with
core matrix xenograft product, annular enlargement, with repair
of innominate vein tear with a bovine pericardial patch.
.
[**2126-11-6**] Right video-assisted thoracoscopy evacuation of
hemothorax, decortication of lung.
.
[**2126-11-7**] Exploratory laparotomy and cholecystectomy.
History of Present Illness:
The patient is a 71-year-old gentleman who had a previous
coronary artery bypass grafting and aortic and mitral valve
replacements done approximately 2 years ago. The patient came
into the hospital approximately 4 weeks ago
with infected pacemaker which was removed but a piece was
retained in the subclavian vein to internal jugular
vein/superior vena cava complex which required median sternotomy
to obtain proximal and distal control to remove.
Initially he was known to have mitral valve endocarditis but the
valve was well-seated and there was no involvement of the aortic
valve and the plan was to treat him medically for his prosthetic
valve endocarditis. The patient was recently readmitted to the
hospital approximately a week ago with recurrent fevers and new
transesophageal echo showed aortic root abscess, partial
dehiscence of the aortic valve and the preexisting mitral valve
vegetations. We felt the patient needed to proceed with surgery
at this point in time.
Past Medical History:
- Diabetes Mellitus
- Dyslipidemia
- Hypertension
- History of Symptomatic sinus bradycardia, s/p dual chamber PPM
[**2119-12-13**], with pocket revisions in [**2119**] and [**2120**] x pocket
infection; Guidant Insignia PPM
- Hepatitis C, chronic, no cirrhosis
- History of cocaine use; history of IVDU
- History of Lung cancer, s/p resection of left upper lobe
- Asthma
- History of Stroke
- s/p redo sternotomy with infected lead extraction and
generator removal on [**2126-9-11**]
- s/p CABG x4 with saphenous vein graft to OM ramus PLV and
LIMA to LAD/ aortic valve replacement with a 21 mm [**Doctor Last Name **]
pericardial tissue heart valve, and mitral valve replacement
with
a [**Street Address(2) 44058**]. [**Male First Name (un) 923**] bioprosthesis Date:[**2124-10-19**] at [**Hospital3 **]
- s/p Spine surgery, metal rods in place
Social History:
The patient lives by himself in an apartment as part of a group
home. He is an ex-smoker- 2ppd x60y, quit seven years ago.
History of IVDU (30 years ago) and cocaine abuse (25years ago).
He no longer drinks alcohol but used to abuse alcohol. Works at
Salvation Army as drug counselor now
Family History:
Mother-deceased of MI at age 65. Grandma deceased of MI.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
Height:70" Weight:86 kgs
Temp 98.6 HR 80 BP 127/93 RR 20 92%
awake alert oriented
not toxic
lungs with good air movement
sternum stable; incision has several openings w/o drainage;
however, able to express some purulent thick material. These
areas feel superficial with probing except for the one at the
lowest end which extends about 1.5 cm down. 2 exposed v-lock
sutures which were removed.
R infracavicular area healing well. staples in place, will
remove
them today.
abd soft, not distended and not tender.
Pertinent Results:
ADMISSION LABS:
[**2126-9-28**] WBC-8.3 RBC-2.83* Hgb-8.3* Hct-23.6* MCV-84 Plt Ct-263
[**2126-9-29**] WBC-6.9 RBC-3.02* Hgb-9.0* Hct-25.8* MCV-85 Plt Ct-247
[**2126-9-28**] Neuts-76.8* Lymphs-14.4* Monos-7.5 Eos-1.2 Baso-0.2
[**2126-9-29**] Neuts-73.1* Lymphs-17.1* Monos-7.1 Eos-2.5 Baso-0.3
[**2126-9-28**] Glucose-144* UreaN-23* Creat-2.3* Na-134 K-3.5 Cl-97
HCO3-24
[**2126-9-29**] Glucose-134* UreaN-22* Creat-1.9* Na-136 K-3.3 Cl-100
HCO3-26
[**2126-9-30**] Albumin-2.9* Mg-1.5*
.
[**2126-10-2**] Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
revealed native 3 vessel coronary artery disease. The LM had 50%
stenosis. The LAD has 90% mid stenosis. The LCx has 40-50% mid
stenosis. The RCA had 80% mid stenosis.
2. Selective arterial conduit angiography revealed patent LIMA
to LAD. Selective venous conduit angiography revealed patent SVG
to OMB and SVG to PDA. The SVG to diagonal was patent with 60%
mid diagonal lesion.
3. Limited resting hemodynamics revealed normal systemic
arterial pressure of 113/52mmHg.
.
[**2126-10-4**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT - TEE
Prebypass:
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta. A bioprosthetic aortic valve
prosthesis is present. The transaortic gradient is higher than
expected for this type of prosthesis. There is a moderate-sized
vegetation on the aortic valve. An aortic annular abscess is
seen. Mild (1+) aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The prosthetic mitral valve
leaflets are thickened. The gradients are higher than expected
for this type of prosthesis. There is a moderate-sized
vegetation on the mitral valve. Mild (1+) mitral regurgitation
is seen. Moderate [2+] tricuspid regurgitation is seen. There is
a trivial/physiologic pericardial effusion.
.
Post bypass:
Patient is AV paced and receiving an infusion of epinephrine,
norepinephrine and vasopresssin. Biventricular systolic function
is unchanged.
Bioprosthetic valve seen in the mitral position. The valve
appears well seated.The mean gradient is 9 mm Hg with a cardiac
output of 5.6 litres/minute. There is no mitral regurgitation.
Bioprosthetic valve seen in the aortic position. The valve
appears well seated. The mean gradient is 28 mm Hg in the
setting of a cardiac output of 5.6 litres/minute. There is no
aortic insufficiency.
.
[**2126-11-7**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT - TEE
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size is
normal. with borderline normal free wall function. There are
simple atheroma in the descending thoracic aorta to 30 cm from
the incisors. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis leaflets appear to move
normally. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. Cannot rule out aortic abscess
however, the peri-valvular tissue appears inflamed. A
bioprosthetic mitral valve prosthesis is present. Motion of the
mitral annulus is abnormal and suggestive of partial dehiscence.
A paravalvular mitral prosthesis leak is probably present along
the posterior aspect of the mitral valve. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**2126-11-8**] Abdominal Ultrasound:
Current examination is highly limited by a midline dressing over
the abdomen and two right-sided chest tubes. The liver to the
limited extent visualized, demonstrates no focal or textural
abnormality. There is no biliary dilatation. The common duct is
3 mm. The portal vein demonstrates no occlusive thrombus, but
stable pulsatile waveforms, consistent with right heart failure.
The spleen measures 12 cm, containing multiple calcified
granuloma. There is no abdominal ascites, with interval
resolution since CT dated [**2126-10-31**].
.
BLOODWORK:
[**2126-11-8**] WBC-18.1* RBC-3.01* Hgb-8.7* Hct-28.7* RDW-20.9* Plt
Ct-83*
[**2126-11-7**] WBC-20.0* RBC-3.05* Hgb-8.7* Hct-29.6* RDW-19.4* Plt
Ct-123*
[**2126-11-6**] WBC-12.1* RBC-3.61* Hgb-10.1* Hct-34.7* RDW-18.4* Plt
Ct-122*
[**2126-11-5**] WBC-11.1* RBC-3.55* Hgb-10.0* Hct-33.2* RDW-18.9* Plt
Ct-109*
[**2126-11-3**] WBC-10.2 RBC-3.44* Hgb-9.9* Hct-32.6* RDW-19.2* Plt
Ct-154
[**2126-10-31**] WBC-9.2 RBC-3.20* Hgb-9.5* Hct-30.4* RDW-19.8* Plt
Ct-163
[**2126-11-8**] PT-38.3* PTT-46.4* INR(PT)-3.9*
[**2126-11-8**] PT-31.7* PTT-42.5* INR(PT)-3.1*
[**2126-11-7**] PT-29.5* PTT-47.3* INR(PT)-2.9*
[**2126-11-7**] PT-28.7* PTT-45.1* INR(PT)-2.8*
[**2126-11-7**] PT-19.7* PTT-38.0* INR(PT)-1.8*
[**2126-11-8**] Glucose-127* UreaN-73* Creat-4.2* Na-148* K-4.8 Cl-97
HCO3-19*
[**2126-11-7**] Glucose-107* UreaN-67* Creat-3.7* Na-143 K-4.7 Cl-99
HCO3-14*
[**2126-11-6**] Glucose-90 UreaN-69* Creat-3.4* Na-129* K-4.9 Cl-98
HCO3-15*
[**2126-11-6**] Glucose-104* UreaN-67* Creat-3.5* Na-131* K-4.6 Cl-98
HCO3-20*
[**2126-11-5**] Glucose-98 UreaN-66* Creat-3.0* Na-133 K-3.6 Cl-98
HCO3-22
[**2126-11-4**] Glucose-93 UreaN-68* Creat-3.6* Na-129* K-4.1 Cl-94*
HCO3-18*
[**2126-11-3**] Glucose-92 UreaN-70* Creat-4.4* Na-131* K-4.4 Cl-96
HCO3-21*
[**2126-11-1**] Glucose-119* UreaN-55* Creat-4.5* Na-132* K-4.7 Cl-97
HCO3-18*
[**2126-11-8**] ALT-295* AST-746* LD(LDH)-640* AlkPhos-42 TotBili-4.1*
[**2126-11-8**] ALT-291* AST-787* LD(LDH)-699* AlkPhos-39* TotBili-4.1*
[**2126-11-7**] ALT-149* AST-468* LD -805* AlkPhos-40 Amylase-148*
TotBili-3.4*
[**2126-11-4**] ALT-27 AST-24 LD(LDH)-252* AlkPhos-80 Amylase-113*
TotBili-2.1*
[**2126-10-30**] ALT-26 AST-45* LD(LDH)-287* AlkPhos-61 Amylase-39
TotBili-1.3
[**2126-10-26**] ALT-10 AST-16 LD(LDH)-348* AlkPhos-69 TotBili-0.9
[**2126-11-7**] Lipase-214*
[**2126-11-6**] Lipase-262*
[**2126-11-3**] Lipase-202*
[**2126-11-2**] Lipase-470*
[**2126-11-1**] Lipase-536*
[**2126-10-30**] Lipase-36
[**2126-11-8**] 03:33PM BLOOD WBC-18.1* RBC-3.01* Hgb-8.7* Hct-28.7*
MCV-96 MCH-28.9 MCHC-30.2* RDW-20.9* Plt Ct-83*
[**2126-11-8**] 03:33PM BLOOD Plt Ct-83*
[**2126-11-8**] 03:33PM BLOOD PT-38.3* PTT-46.4* INR(PT)-3.9*
[**2126-11-7**] 09:30PM BLOOD Fibrino-136*
[**2126-11-8**] 03:33PM BLOOD Glucose-127* UreaN-73* Creat-4.2* Na-148*
K-4.8 Cl-97 HCO3-19* AnGap-37*
[**2126-11-8**] 03:33PM BLOOD ALT-295* AST-746* LD(LDH)-640* AlkPhos-42
TotBili-4.1*
[**2126-11-7**] 09:30PM BLOOD Lipase-214*
[**2126-11-8**] Albumin-3.6 Calcium-9.5 Phos-7.4* Mg-2.2
[**2126-11-8**] Vanco-23.9*
Brief Hospital Course:
Detailed and important Pre-Hospital course:
71yo man with Hx of CAD, PPM [**1-30**] to symptomatic bradycardia,
pocket infections with revisions x 2, but no wire replacement;
Hx of bioprosthetic mitral and aortic valve replacements; who
presented to [**Hospital6 1597**] with fever,rigors and mental
status changes on [**2126-9-5**], was found to have 6/6 bottles with
staph aureus and an 8mmx8mm vegetation on the RV lead seen on
TEE. Patient was started on rifampin, ceftriaxone, vancomycin,
gentamicin at the OSH and then he was transferred to [**Hospital1 18**] on
[**2126-9-7**] for further care and lead extraction.
Blood cultures showed [**Last Name (LF) 8974**], [**First Name3 (LF) **] vancomycin was switched to
Cefazolin 2gm IV q8h, and he was continued on Gentamicin 1mg/Kg
q8h plus Rifampin 300mg PO q8h. On [**9-9**], patient underwent PPM
and wire removal and a piece of the atrial wire broke and kept
retain in the substernal space. Patient went to the OR on [**9-11**],
an intra-OP TEE
showed MV vegetation and severe TR, but it was decided that
valve replacement was not needed, so he underwent sternotomy
plus removal of pacing lead and closure of the pacemaker pocket
site. After that, he started spiking fevers almost every night.
A comprehensive ID work-up was done, but U/A was clean, CXR
showed no infiltrates, all the cultures came back negative, and
patient had no obvious source of infection. Pt underwent a new
TTE on [**9-18**] and Chest/Abd/Pelvis CT scan on [**9-19**], and the only
abnormality was a 2x2 cm collection under surgical wound and
over the right sternoclavicular joint. Cardiac surgery was
consulted and a conservative approach was recommended and
antibiotics were continued. The patient became afebrile on [**9-23**],
two days prior to being discharged on IV cefazolin and PO
rifampin. Of note, pt has
watery diarrhea since [**9-9**], but C. diff toxin has been (-) x 4
and C. diff PCR has also been (-), so the patient was discharged
off Flagyl. He also has increasing creatinine (2.0) at the
moment of discharge on [**9-25**], secondary to use of lasix,
gentamicin and dehydration.
At rehab, he continue having low grade temperatures, 99.5, and
his creatinine continued increasing up to 2.3. Patient was
tolerating antibiotics without any problems, and he denies
subjective fevers/chills, nausea/vomiting, SOB/CP/cough, abd
pain or dysuria. Diarrhea resolved almost completely, and he
continued having unchanged mild urinary urgency. Only complaint
was pain around the surgical wound. On [**9-28**], he spiked a fever
of 101.6 after 3 days at rehab and in his 3rd week of abx for
endocarditis. At ED, he was afebrile, hemodynamically stable, so
antibiotics were continued and he was admitted to the cardiac
surgery service on [**2126-9-29**]. The incision has several openings
w/o drainage; however, with manual pressure some purulent thick
material was expressed. These areas were superficial except for
the one at the lowest end which extends about 1.5 cm down. At
admission, CXR showed no infiltrates, U/A was clean and a repeat
Chest CT scan showed stable fluid collection 2x2cm under upper
end of the incision.
On [**2126-10-4**] he was taken to the operating room where he
underwent:
1. Redo sternotomy.
2. Redo aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna ease
aortic valve bioprosthesis. Model #3300TFX, serial #[**Serial Number 96670**].
3. Redo mitral valve replacement with a 29-mm St. [**Male First Name (un) 923**] Epic
valve, reference #[**Serial Number 10859**], serial #[**Serial Number 96671**].
4. Extensive reconstruction of the aortic annulus and aortic
root area with core matrix xenograft product, annular
enlargement.
5. Repair of innominate vein tear with a bovine pericardial
patch.
Post-operatively he was admitted to the CVICU intubated and
sedated and on mutliple pressors and inotropes. He was kept
intubated and sedated due to hemodynamic instability and volume
overload. On POD1 he was hemodynamically stable on Epi and
Levophed infusions, his sedation was lightened to assess neuro
status and he was resedated as he was not ready to wean from
ventilator. He remained stable from cardiovascular viewpoint on
POD2 but was febrile and pancultured which revealed gram
negative rods in blood- he awas started on appropriate
antibiotics.He was noted to have rising creatinine, an attempt
was made to lighten sedation again but he failed attempts to
wean from ventilator. On POD3 Propofol was stopped and he was
awake but not following commmands, he was weaned to pressure
support ventilation but not able to extubate. An abdominal US
was done revealing a distended gallbladder and general surgery
was consulted, ultimately a cholecysectomy tube was placed.
Total bili continued to trend downward post chole tube
placement. Creatinine continued to rise, etiology of ARF was
thought to be due to nephrotoxic agents. Inotrope support was
weaned but continued to have pressor requirement due to sepsis.
In addition to his leukocytosis he developedand
thrombocytopenia, was HIT negative. Thrombocytopenia thought to
be likely due to sepsis. Platelets recovered over time. On POD#5
([**2126-10-9**]) he was successfully extubated. After extubation, he
became agitated with increased work of breathing and was hypoxic
requiring CPAP. On POD# 6 ([**10-10**]) he was reintubated and
bronch'd. On POD#7 ([**10-12**]) he was found to have a significant
right pleural effusion and a right chest tube was replaced. He
was aggresively diuresed. On POD#7 sedation was weaned but he
did not follow commands. On [**2126-10-13**] a neuro consult was
obtained and a head CT was negative for acute process. Sedation
and mechcanical ventilation were weaned over the next several
days and he was again extubated on POD# 11 ([**2126-10-15**]). He
remained extubated with slowly recovering pulmonary and mental
status. It should be noted that during this time the lower pole
of his sternal wound dehisced, the wound was debrided, plastic
surgery service was consulted and a wound VAC was placed. On POD
13 he was transferred from the ICU to the stepdown floor. He
also underwent Nafcillin desensitization. Once on the floor Mr
[**Known lastname **] continue to make slow progress. His renal function was
noted to again be on the rise- he had been having episodes of
diarrhea and it was felt he was dehydrated. Urine lytes were
checked, these indicated he was prerenal but there was concern
he was reacting to the Nafcillin(previous PCN allergy). There
were no Eos in urine so volume was given to rehydrate.
Creatinine continued to rise, with a peak of 3.1. Renal was
consulted. It was determined that the patient had Acute
Interstitial Nephritis. Nafcillin was discontinued, and he was
placed on a Cipro, Vancomycin regimen. It may take several
weeks for the kidneys to recover, Creatinine will be monitored.
On [**2126-10-29**] Mr. [**Known lastname **] was noted to have increase work of
breathing and worsening renal failure with creat increasing to
4.2, oliguria and he unintentionally dislodged his chole tube.
He was transferred back to the CVICU for ongoing monitoring and
management. Abd CT scan was negative for bilious leak. His creat
improved slowly with increased urine output and he was
transferred out of the ICU on [**2126-11-4**].
On [**2126-11-6**] he was taken tot he operating room for right
VATS/decortication and washout of recurrent right pleural
effusion.
Following the VATs proceedure the patient again developed a
metabolic lactic acidosis and transfplant surgery was consulted
to evaluate for ischemic bowel. He was brought to the operating
room for exploratory laparotomy which did not reveal any
malperfused bowel. Following this procedure the patient returned
to the cardiac surgery ICU, his sedation was stopped and he
extubated. After discussions with the patient surgeon and
family(health care proxy) a decision was made to make him
comfort measures only and he expired at 0400 on [**11-9**]
Medications on Admission:
Rifampin, Kefzol, Trazodone, Insulin, Neurontin, Aspirin,
Metoprolol
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2126-11-15**]
|
[
"580.89",
"V12.54",
"V10.11",
"041.11",
"584.9",
"276.2",
"272.4",
"493.90",
"998.11",
"999.32",
"E930.0",
"575.12",
"482.83",
"790.7",
"V42.2",
"421.0",
"998.2",
"996.61",
"511.89",
"038.44",
"V58.67",
"401.9",
"998.32",
"070.54",
"V49.86",
"V45.81",
"998.59",
"433.10",
"414.01",
"287.49",
"518.52",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"34.06",
"88.56",
"51.01",
"51.22",
"39.61",
"96.6",
"54.91",
"96.72",
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"35.23",
"86.04",
"88.72",
"34.52",
"35.21",
"96.71",
"33.24",
"39.56"
] |
icd9pcs
|
[
[
[]
]
] |
19135, 19144
|
10972, 10999
|
304, 891
|
19195, 19204
|
3838, 3838
|
19260, 19299
|
3096, 3268
|
19103, 19112
|
19165, 19174
|
19010, 19080
|
11016, 18984
|
19228, 19237
|
3283, 3819
|
258, 266
|
919, 1900
|
3854, 10949
|
1922, 2773
|
2789, 3080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,305
| 161,071
|
8321
|
Discharge summary
|
report
|
Admission Date: [**2188-7-19**] Discharge Date: [**2188-8-2**]
Date of Birth: [**2130-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Variceal bleeding
Major Surgical or Invasive Procedure:
EGD
TIPS
Central Line (internal jugular)
History of Present Illness:
57yo man HepC cirrhosis, with recent bleeding esophageal
varices, banded X 4 at [**Hospital3 **] by primary hepatologist,
Dr. [**Last Name (STitle) **] who presented to [**Location (un) **] [**7-18**] with
melena/hematemasis. Pt was noted to have hc to 25 and was
transfused 5 units of PRBC, 2 U FFP and 1U platelets and was
transferred to [**Hospital1 18**] for further management and TIPS evaluation.
He was started on protonix and octreitide drips at [**Location (un) **].
.
Upon arrival to [**Hospital1 18**] MICU on [**7-19**], pt's hct was 28.2.
Past Medical History:
Hepatitis C with liver cirrhosis
Esophageal varices, banded [**3-26**], [**4-22**], [**6-20**], [**7-9**]
Diabetes Mellitus
Hypertension
OSA, being evaluated for CPAP
Chronic back pain, on methadone, being tapered 1mg/week
Social History:
lives with wife and 2 kids 19 and 15 in lunenberg. smokes 1 PPD,
total of ~40pack year history smoking. Denies ETOH, IVDU. Per
pt., likely hepC exposure was through sexual contact
Family History:
h/o DM, no CAD
Physical Exam:
VS Tm 98, Tc 98, 131/76 (117-131/61-76), HR 53 (50s-60s), 11
([**9-4**]), 98% on RA (93-100%)
GEN: sitting in a wheelchair, comfortable
HEENT: anicteric, PERRL, EOMI, MMM, No cervical LAD
CHEST: bibasilar crackles, otherwise CTA bilat
CARDS: sinus brady, I/VI SEM at LUSB
ABD: soft, NT, ND, +NABS
EXT: No edema
NEURO: AOx 3. No focal deficits. + mild L asterixis.
Pertinent Results:
[**2188-7-19**] 05:17PM BLOOD WBC-3.3* RBC-3.23* Hgb-9.7* Hct-28.2*
MCV-87 MCH-29.9 MCHC-34.3 RDW-16.0* Plt Ct-68*
[**2188-8-2**] 06:25AM BLOOD WBC-6.2 RBC-3.45* Hgb-10.1* Hct-30.7*
MCV-89 MCH-29.1 MCHC-32.7 RDW-17.5* Plt Ct-109*
[**2188-7-19**] 05:17PM BLOOD PT-12.1 PTT-26.4 INR(PT)-1.0
[**2188-8-2**] 06:25AM BLOOD PT-23.5* PTT-66.7* INR(PT)-2.3*
[**2188-7-19**] 05:17PM BLOOD Glucose-112* UreaN-21* Creat-1.0 Na-137
K-4.0 Cl-104 HCO3-25 AnGap-12
[**2188-7-26**] 05:35AM BLOOD Glucose-109* UreaN-14 Creat-1.0 Na-129*
K-3.7 Cl-96 HCO3-26 AnGap-11
[**2188-8-1**] 06:00AM BLOOD Glucose-165* UreaN-21* Creat-1.2 Na-133
K-5.4* Cl-99 HCO3-25 AnGap-14
[**2188-8-2**] 06:25AM BLOOD Glucose-158* UreaN-21* Creat-1.1 Na-134
K-4.5 Cl-97 HCO3-27 AnGap-15
[**2188-7-19**] 05:17PM BLOOD ALT-17 AST-26 LD(LDH)-176 AlkPhos-69
Amylase-38 TotBili-0.6
[**2188-7-24**] 05:28AM BLOOD ALT-553* AST-901* LD(LDH)-653* AlkPhos-93
TotBili-1.2
[**2188-8-2**] 06:25AM BLOOD ALT-87* AST-47* AlkPhos-179* TotBili-0.7
[**2188-7-19**] 05:17PM BLOOD Albumin-3.4 Calcium-8.1* Phos-2.9 Mg-2.0
[**2188-8-1**] 06:00AM BLOOD Albumin-3.4 Calcium-9.2 Phos-3.9 Mg-1.9
[**2188-7-20**] 06:01AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
[**2188-7-19**] 06:01PM BLOOD AMA-NEGATIVE ANCA-NEGATIVE B
[**2188-7-29**] 05:41AM BLOOD AFP-1.7
[**2188-7-20**] 06:01AM BLOOD IgG-1437 IgA-327 IgM-317*
[**2188-7-20**] 06:01AM BLOOD HCV Ab-POSITIVE
Studies:
[**2188-7-20**] EGD:
Findings: Esophagus:
Protruding Lesions 3 cords of grade II varices were seen in the
lower third of the esophagus. There was severe linear ulceration
on the varices at the site of previous banding. There was
stigmata of recent bleeding on the ulcers. These ulcers
prevented further attempts at banding.
Stomach:
Mucosa: Diffuse erythema of the mucosa was noted in the antrum
and stomach body. These findings are compatible with Portal
Hypertensive Gastropathy.
Duodenum: Normal duodenum.
Impression: Three cords of grade 2 esophageal varices wiith
severe banding ulceration.
Portal Hypertensive Gastropathy
Otherwise normal EGD to second part of the duodenum
Recommendations: Requires:
1) Prilosec - 20mg [**Hospital1 **]
2) Caralfate - 1g tid for 7 days
3) Nadolol - 40mg [**Hospital1 **]
4) Referral for TIPS [**Hospital1 766**]
.
[**2188-7-22**] TIPS:
1. Successful TIPS stent placement gradient normalized from 19
mmHg to 1 mmHg after Wallstent placement.
2. Placement of triple-lumen trauma line.
.
TTE [**2188-7-22**]:
The left atrium is dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is normal (LVEF 60-70%). There is
no ventricular septal defect. The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The ascending aorta is moderately dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
[**2188-7-25**] RUQ U/S:
1. Limited evaluation of the TIPS stent due to technical
factors, the stent does remain patent, however, wall-to-wall
flow cannot be documented.
2. Interval development of non-occlusive portal vein thrombus.
[**2188-7-28**] RUQ U/S:
1. Persistent nonocclusive portal vein thrombosis.
2. Patent TIPS shunt, with wall-to-wall flow and velocities
approximately 140 cm/sec throughout. Hepatofugal flow within the
left intrahepatic and anterior right portal veins.
[**2188-7-28**] CTA Abdomen:
1. Nonocclusive thrombus seen within the main portal vein, SMV,
and splenic veins.
2. Poorly defined areas of low attenuation seen within the right
lobe of the liver, concerning for infarct.
3. TIPS identified, which appears patent.
4. Splenomegaly.
Brief Hospital Course:
# GI bleeding:
Most likely source is varices. EGD showed multiple ulcerated
varices but no active bleeding. Given multiple failures of
banding, pt underwent TIPS on [**2188-7-22**] uneventfully. Hct was
stable and 1 unit RBCs were given on [**7-24**]. Medically he was
treated with octreotide x72hrs, nadolol, PPI, and sucralfate.
There was no further evidence of GI bleeding throughout
admission despite anticoagulation. Hematocrit fluctuated
somewhat but was overall stable at 28%. Stool was guaiac
negative on discharge.
.
# non-occlusive portal vein thrombus: pre- and post-TIPS RUQ U/S
demonstrated interval development of non-occlusive portal vein
thrombosis. These tests were followed up with CTA of the
abdomen which demonstrated thrombus in the SMV and splenic veins
as well as questionable partial infarct of the right lobe of the
liver. Review of the films with the radiologist suggested that
this was new thrombus and therefore the patient was
anticoagulated with heparin despite history of recent GI bleed.
As detailed above, he showed no evidence of recurrent bleeding
and was successfully bridged to coumadin, with a therapeutic INR
of 2.3 at discharge. He received coumadin doses of 5mg, 5mg,
7.5mg, 7.5mg and was discharged on 2.5mg PO daily.
.
# HepC cirrhosis:
HCV Viral load was 19,300 IU/mL on [**2188-7-28**] and HBV viral load was
undectectable. After TIPS he had some confusion, and this was
made worse by a few doses of ativan which he received for
insomnia. Sedating agents were discontinued, and lactulose
titrated to 3 bowel movements per day resulting in resolution of
hepatic encephalopathy. He was scheduled for further follow-up
and transplantation evaluation at [**Hospital1 18**].
Mr. [**Known lastname **] developed elevated liver chemistries on HD5. This
was thought to be due to portal venous thrombosis and/or hepatic
infarct.
He also retained a significant amount of fluid as ascites and
lower extremity edema, but this resolved with Lasix and
Spironolactone.
.
# sleep apnea: during period of increasing encephalopathy,
patient was found sleeping standing up, sitting on edge of bed,
and in kitchen. [**Name (NI) **] wife reported that he has a history
of sleep apnea, and often falls asleep during the day. This may
have contributed to abnormal sleep pattern induced by hepatic
encephalopathy.
.
# Chronic back pain: continued methadone 92.5 mg qday
.
# DM: blood sugars were high throughout day. Insulin regimen
was slowly titrated up, but blood sugars were still in the 150s
at discharge. Mr. [**Known lastname **] should follow up with his PCP
regarding blood sugar control.
.
# Access: a right internal jugular central line was placed
during TIPS procedure without incident and discontinued two days
before discharge.
Medications on Admission:
propanolol 40 [**Hospital1 **]
glipizide 20 qdaily
lasix 20 qdaily
metformin 850mg tid
lantus 20 qdaily
enulose 10mg [**Hospital1 **]
prilosec qdaily
methadone 94 qdaily
Discharge Medications:
1. Glipizide 10 mg Tablet Sig: Two (2) Tablet PO once a day.
2. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
[**Hospital1 **]:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Methadone 10 mg Tablet Sig: 9.25 Tablets PO once a day:
please take as previously indicated.
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 5 days.
[**Hospital1 **]:*20 Tablet(s)* Refills:*0*
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation for 2 weeks: please
titrate to [**1-22**] BMs per day.
[**Month/Day (2) **]:*1000 ML(s)* Refills:*0*
8. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
[**Month/Day (2) **]:*120 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have PT/PTT/INR and electrolytes checked on [**Month/Day (2) 766**] [**8-4**] at your PCP's office
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
[**Month (only) **]:*60 Tablet(s)* Refills:*2*
11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
pls adjust per discussion with your PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2*
12. methadone
Pt received a dose of 92.5mg of methadone on [**2188-8-2**]. this is
NOT a prescription
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Endstage liver disease
Hepatitis C
Esophageal varices
Portal vein non-occlusive thrombus
Secondary:
Diabetes Mellitus
Chronic lower back pain
Discharge Condition:
stable. no signs of bleeding. no abdominal pain.
Discharge Instructions:
You were admitted with a GI bleed. You were treated in the ICU
and underwent a TIPS procedure. You tolerated this well. You
had a transient transaminitis and were found to have a
non-occlusive clot in the portal vein and were started on a
heparin drip to prevent further occlusion. We transitioned you
to coumadin and you tolerated this well.
.
Please followup with your PCP and GI doctor. Please contact
your PCP or go to the [**Name (NI) **] if you experience any bleeding,
weakness, worsening confusion.
.
Please take all of your medications as instructed.
Tell your doctor that you received the following coumadin doses:
coumadin 5mg, 5mg, 7.5mg, 7.5mg. We discharged you on 2.5mg
daily. You will need your coumadin level checked on [**Name (NI) 766**].
Also have your PCP check your potassium and liver function on
[**Name (NI) 766**] to assess any need to change your diuretics.
Followup Instructions:
Please followup with Dr. [**Last Name (STitle) **] on Thursday [**8-7**] at
3:45pm. His number is ([**Telephone/Fax (1) 29473**]. Fax: [**Telephone/Fax (1) 29474**]
.
Please followup with your PCP on [**Name9 (PRE) 766**] [**8-4**] at 11:00am.
You need to have your INR/coumadin level checked at that time.
Also have your electrolytes checked at that time.
.
Please followup with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20585**] on 9:30am on [**8-7**]. His number is [**Telephone/Fax (1) **] and fax is [**Telephone/Fax (1) **].
.
Please followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] on [**Last Name (LF) 766**], [**9-15**] at
11am. His number is [**Telephone/Fax (1) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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"452",
"327.23",
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"572.3",
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"250.00",
"571.5",
"724.5",
"305.1",
"537.89",
"300.00",
"401.9",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.1",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10256, 10262
|
5800, 8580
|
332, 375
|
10457, 10510
|
1830, 5777
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|
1415, 1431
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8800, 10233
|
10283, 10436
|
8606, 8777
|
10534, 11427
|
1446, 1811
|
275, 294
|
403, 956
|
978, 1202
|
1218, 1399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,489
| 153,461
|
53907
|
Discharge summary
|
report
|
Admission Date: [**2126-7-8**] Discharge Date: [**2126-7-15**]
Date of Birth: [**2043-11-2**] Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / prednisone / simvastatin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
CoreValve placement
Major Surgical or Invasive Procedure:
[**2126-7-9**] Percutaneous aortic valve replacement (CoreValve)
History of Present Illness:
Ms. [**Known lastname 110573**] is a delightful and energetic 82 year old
woman who has known aortic stenosis, atrial fibrillation,
osteoporosis, hypertension and diabetes mellitus. She has been
in reasonable cardiovascular health over the past several years
until 4 months ago when she began to notice increasing shortness
of breath with exertion to the point that she is dyspneic when
walking across the room. Her initial echocardiogram showed a
mean aortic valve gradient 94 mmHg and peak gradient 135 mmHg.
The aortic valve area was 0.4 cm2. The LVEF was 65%. Cardiac
catheterization showed insignificant coronary artery disease.
She was referred to cardiac surgery for surgical AVR and was
deemed of extreme risk prohibitive for cardiac surgery due to
calcified aorta. She was referred for screening for
Corevalve/TAVR. She met all inclusion criteria and did not meet
any exclusion criteria. Warfarin was discontinued 4 days prior
to admission. She returned on [**2126-7-8**] for Corevalve/TAVR.
Per signout, the patient tolerated the procedure well. A
percutaneous transfemoral approach was performed. A [**Company **]
cardiac CORE VALVE was placed, with rebalooning performed in the
presence with a perivavular leak, with attenuation of the leak
after rebalooning. The patient had 200 cc's of blood loss with
a drop in HCT from 38 to 30. 2.1L of crystalloid fluid was
provided during the procedure, and PAP's were noted to be around
60mmHg systolic.
Forty mg of IV furosemide was administered with about 600 cc's
of UOP. Patient noted at baseline to have a less than 1 cm
pericardial effussion that did not increase periprocedurally.
In the CCU, patient is intubated and sedated.
REVIEW OF SYSTEMS
Unable to be obtained as patient is intubated and sedated
Past Medical History:
hepatitis B diagnosed [**2076**]
diabetes type II
critical aortic stenosis
atrial fibrillation
arthritis
hypertension
Spinal stenosis
Macular degeneration
Past Surgical History:
right knee replacement [**2118**]
back surgery (spinal stenosis)
appendectomy
Social History:
Widowed female, 4 sons, 2 live locally. Lives alone in
independent senior housing, apartment, elevator. Southshore VNA
3 days/week
[**First Name5 (NamePattern1) 892**] [**Known lastname 110573**] ([**Telephone/Fax (1) 110574**]) - Healthcare Proxy
[**First Name4 (NamePattern1) 40095**] [**Known lastname 110573**] ([**Telephone/Fax (1) 110575**])
-Tobacco history: Quit in the [**2074**]'s.
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Mother passed
away from pancreatic cancer. Family hx HTN.
Physical Exam:
On Admission
VS: T=97.9 BP=133/47 HR=65 Intubated RR 15 on PS 100% 02
GENERAL: Intubated and sedated.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma. RIJ in place
CDI.
NECK: Supple, trachea midline.
CARDIAC: systolic murmer [**3-4**] RSB radiating throughout, loudest
parasternally.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Coarse
breath sounds without crackles or rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Left femoral line in
place. Right radial arterial line and 2 b/l PIVs.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On Discharge
VS: Tm 97.7 HR 76 BP 145/58 RR18 O299%RA I/O 1008/1700+ Weight
52.2kg
GEN: Sitting in chair, NAD
HEENT: PERLLA, OP without erythema, MMM, no LAD, JVP not
elevated
CHEST: CTABL
CV: RRR, 2/6 systolic murmur best heard over LSB, crisp s1, s2
ABD: Soft, NT, ND, NABS, No rebound guarding or HSM
EXT: WWP, no edema, bilateral groin sites c/d/i although mildly
ecchymotic
NEURO: CNII-XII intact 5/5 strength throughout, steady gait with
walker
PSYCH: Calm, pleasant, appropriate
Pertinent Results:
ADMISSION LABS:
[**2126-7-8**] 11:20AM BLOOD WBC-8.0 RBC-4.12* Hgb-13.2 Hct-40.6
MCV-99* MCH-32.1* MCHC-32.6 RDW-12.8 Plt Ct-161
[**2126-7-8**] 11:20AM BLOOD PT-14.0* PTT-27.2 INR(PT)-1.3*
[**2126-7-8**] 11:20AM BLOOD Glucose-105* UreaN-23* Creat-0.7 Na-145
K-3.5 Cl-98 HCO3-39* AnGap-12
[**2126-7-8**] 11:20AM BLOOD ALT-148* AST-53* CK(CPK)-59 AlkPhos-111*
TotBili-0.8
[**2126-7-8**] 11:20AM BLOOD Albumin-4.2
[**2126-7-8**] 11:20AM BLOOD Digoxin-0.5*
[**2126-7-9**] 08:30AM BLOOD Type-ART pO2-543* pCO2-29* pH-7.62*
calTCO2-31* Base XS-9
[**2126-7-9**] 08:30AM BLOOD Glucose-103 Lactate-0.6 Na-138 K-3.3
Cl-99
[**2126-7-9**] 08:30AM BLOOD Hgb-12.4 calcHCT-37
[**2126-7-9**] 08:30AM BLOOD freeCa-1.14
URINE:
[**2126-7-8**] 02:37PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2126-7-8**] 02:37PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
PERTINENT REPORTS:
[**2126-7-8**] Radiology CHEST (PRE-OP PA & LAT)
Moderate-to-severe cardiac enlargement, unchanged from [**Month (only) 547**],
without acute chest abnormality or pulmonary edema. No
pericardial effusion was present in [**Month (only) 547**] at which time the
cardiac silhouette was similarly enlarged, and therefore cardiac
enlargement may be the result of cardiomyopathy
[**2126-7-9**] Cardiovascular ECHO
Prevalve Implant
No atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate to severe (3+) mitral regurgitation is seen.
There is a very small pericardial effusion. Drs [**Last Name (STitle) **], [**Name5 (PTitle) **] and
[**Name5 (PTitle) **] were notified in person of the results on [**2126-7-9**] at
845 am.
Post valve Implant
Corevalve seen in the aortic position. It appears well seated .
There are two perivalvular leaks present. 1- 2 + aortic
insufficiency present. LV function unchanged. Mild to moderate
mitral regurgitation present. Rest of examination is unchanged.
[**2126-7-10**] Cardiovascular ECHO
The left atrium is moderately dilated. There is mild-moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. An aortic CoreValve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
Two jets of ? paravalvular aortic valve leak are seen at 7 and 5
o'clock (the first is mild, the second is mild-moderate) in the
short axis view (clip [**Clip Number (Radiology) **]). There is no central aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study dated [**2126-6-6**] (images reviewed),
a CoreValve prosthesis is now appreciated with normal
transaortic gradients and mild-moderate aortic regurgitation,
likely paravalvular in location. Left ventricular systolic
function appears slightly more hyperdynamic. Pulmonary pressures
are lower.
[**2126-7-15**] TEE POST-COREVALVE:
This study was compared to the prior study of [**2126-7-10**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Aortic CoreValve. Normal AVR gradient.
Paravalvular leak. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Very small pericardial effusion. No
echocardiographic signs of tamponade.
Conclusions
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. An aortic CoreValve
prosthesis is present. The transaortic gradient is normal for
this prosthesis. A paravalvular aortic valve leak is probably
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2126-7-10**],
the findings are similar.
PERTINENT MICROBIOLOGY:
[**2126-7-8**] 2:37 pm URINE Source: CVS.
**FINAL REPORT [**2126-7-9**]**
URINE CULTURE (Final [**2126-7-9**]):
PRESUMPTIVE GARDNERELLA VAGINALIS. >100,000
ORGANISMS/ML..
DISCHARGE LABS:
WBC 7.4, Hct 28.2, Plts 358, MCV 100
PT: 21.0 PTT: 63.4 INR: 2.0
Cr 0.6
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
Ms. [**Known lastname 110573**] is a 82 year old woman with atrial fibrillation
and critical aortic stenosis admitted for percutaneous aortic
valve replacement (CoreValve). She had successful placement of
the corevalve and did well post-operatively.
ACTIVE PROBLEMS:
#Critical aortic stenosis: Patient with aortic valve area of
0.6 prior to procedure. She underwent CoreValve TAVR procedure
on [**2126-7-9**] after aspirin and plavix loading. Please see HPI and
op note for procedure details. She tolerated the procedure
well. Following the procedure, her blood pressures were managed
closely with nitroglycerin to maintain MAP<90. Blood pressure
normalized within days following procedure and her home
antihypertensives were restarted with good control on her home
po regimen. She is to continue aspirin alone for her
anticoagulation and follow up with Dr. [**Last Name (STitle) **] following
discharge.
# Atrial fibrillation: Patient with history of chronic Afib on
coumadin, diltiazem, and digoxin at home. Coumadin was held for
several days prior to procedure and INR was 1.3 on admission.
Diltiazem was initially held before titrating slowly to home
dose post procedurally. She was also continued on her home
dosing of digoxin. She was restarted on coumadin following the
procedure, and bridged with IV heparin drip during her
hospitalization. INR of 2.0 on discharge, continued bridging
following discharge was deemed unecessary. Notably, patient was
asked to stop taking her Vitamin E due to interaction with
coumadin.
# Hypertension: Patient on home regimen of Captopril, diltiazem
and hydrochlorothiazide. All were held preoperatively. She was
hypertensive following procedure and she required nitroglycerin
drip on the evening of [**7-9**], but was quickly weaned off. Home
diltiazem was titrated back to home dose over the subsequent few
days and captopril was changed to lisinopril 5mg daily for ease
of dosing. Hydrochlorothiazide was not restarted as patient was
normotensive after reintroduction of ACEI and diltiazem.
CHRONIC PROBLEMS
# Diabetes: Januvia was held while in house. Sugars were well
controlled with HISS.
# Spinal stenosis: No current symtpoms with pain well controlled
during hospitalization. Physical therapy worked with the patient
who recommended discharge home with physical therapy.
TRANSITIONAL ISSUES
- Recheck PT/INR on Wednesday [**2126-7-17**] and adjust coumadin
as needed
Medications on Admission:
CAPTOPRIL 25 mg [**Hospital1 **]
DIGOXIN 125 mcg Daily. 4 times/week (TTSS)
DILTIAZEM HCL 240 mg Daily
VITAMIN D2 Dosage Daily
ZETIA 10 mg Daily
HYDROCHLOROTHIAZIDE 25 mg Daily
JANUVIA 50 mg Daily
WARFARIN 2.5 mg Daily - last dose [**2126-7-3**]
ASCORBIC ACID 1000mg Daily
CALCIUM CARBONATE Daily
MULTIVIT-IRON-MIN-FOLIC ACID Daily
FISH OIL 4x/week (M/W/F/Sa)
VITAMIN E 4x/week (M/W/F/Sa)
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
Please hold for SBP < 100
RX *lisinopril 5 mg daily Disp #*90 Capsule Refills:*3
2. Diltiazem Extended-Release 240 mg PO DAILY
hold for hr<50 or sbp
3. Ezetimibe 10 mg PO DAILY
4. Ascorbic Acid 1000 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg daily Disp #*3 Capsule Refills:*0
8. Outpatient Lab Work
Please check PT/PTT/INR and hematocrit on [**7-16**]. Send results to
[**Last Name (LF) **],[**First Name3 (LF) **] B., [**Hospital3 **] INTERNAL MEDICINE, [**Street Address(2) 110576**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] Fax:
[**Telephone/Fax (1) 29683**]
Atrial Fibrillation ICD-9 427.31
9. Digoxin 0.125 mg PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA)
10. Vitamin D 1000 UNIT PO DAILY
11. Docusate Sodium 100 mg PO BID
12. sitaGLIPtin *NF* 25 mg Oral daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
13. Senna 1 TAB PO BID:PRN constipation
14. Warfarin 2.5 mg PO DAILY16
15. Furosemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
1. Critical aortic stenosis
2. Atrial Fibrillation
3. Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 110573**],
You were admitted to the hospital because you had severe
symptomatic aortic stenosis (a narrowing or your aortic valve).
You underwent a transcatheter aortic valve replacement using the
CoreValve. You tolerated very well. Please note the following
changes to your medications:
START Lisinopril 5mg daily (this medication takes the place of
the captopril)
START Aspirin 81mg daily
INCREASE Coumadin (Warfarin) to 4 mg daily. You can take four
1mg tablets. You will need to have your INR checked on Tuesday
[**7-16**] to have your dosage adjusted.
STOP Captopril (we started you on a similar medication you only
need to take once a day)
STOP Hydrochlorthiazide (your blood pressures have been well
controlled off of it, your primary care doctor may elect to
restart it)
STOP Vitamin E. This medication may interact with your coumadin
TAKE only half of your Januvia daily (only 25mg). Continue to
check your blood sugars as you will likely need to resume your
full dose at some point.
Please review the additional discharge instructions you
were provided. These include:
1. weigh yourself daily - notify MD/NP if weight increases 3 lbs
in 2 days, or 5 lbs in 5 days.
2. inspect your groin sites daily for any symptoms of infection
(redness, drainage, pain)
3. check your blood sugars as you are not yet back on your full
dose of Januvia,and this will likely need to be increased at
some point.
4. you will need to have your bloodwork done to monitor your
Coumadin which you are on for atrial fibrillation - your goal
INR is 2-2.5.
No other changes were made to your medications. You should make
an appointment with your primary care doctor for later this
week. Dr.[**Name (NI) 32659**] office will also call you to schedule a follow
up appointment.. You should also have your blood checked on
Tuesday [**7-16**]. It has been a pleasure taking care of you.
Followup Instructions:
You should make an appointment with your primary care doctor for
next week. Dr.[**Name (NI) 32659**] office will also call you to schedule a
follow up appointment.
|
[
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icd9cm
|
[
[
[]
]
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[
"35.05"
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icd9pcs
|
[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,017
| 168,404
|
42637
|
Discharge summary
|
report
|
Admission Date: [**2129-11-19**] Discharge Date: [**2129-11-23**]
Date of Birth: [**2050-12-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13685**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Pacemaker Implantation
History of Present Illness:
78 year old woman with history of atrial fibrillation on
coumadin and h/o CVA (residual mild right hemiparesis),
presented initially to OSH with syncope and bradycardia. She was
found sitting on the floor without recollection of the events
preceeding. Denied preceeding chest pain, lightheadedness or
diaphoresis. Upon waking, had new right shoulder and right hip
pain as well as a new ecchymosis on right forehead.
.
At the OSH ([**Hospital **] Hosp), she was found to have a small right
frontal parietal subcutaneous hematoma, CT head was without
acute intracranial pathology. ECG showed afib with inferolateral
scooping ST depressions. INR was therapeutic at 2.4. She was
hemodynamically stable despite brief epsisodes of bradycardia
into the high 30s. Her neurological exam was at baseline. Xrays
of right hip and right shoulder were negative. ASA 325mg and
nitropaste were administered and she was transferred to BIMDC
for further workup. She received nitropast and aspirin prior to
admission.
.
Her daughter left the hospital prior to patient arriving on the
floor thus the history is somewhat abreviated. Per report from
the caridology fellow who saw her in the ED, she was recently
confused and was aggressive towards her daughter which is
unusual.
.
In the ED, initial VS: 99.8 67 148/57 18 97% 2l. Labs notable
for trop 0.07, Creatinine 1.4, BUN 33, Digoxin 2.2, WBC 10.9,
HCT 29.9 with MCV 93, INR 2.5, K 3.6. ECG showed depressed
scooped ST segments in I, II, avF and V3-V6. Most recent set of
vitals: 97.6 63 (in & out of afib with episodes of bradycardia
to the 30's not causing hemodynamic or subjective compromise)
141/57 22 98% RA.
.
Upon arrival to the floor, HR ranged from 33-70s without
symptoms or evidence of AV block. She denies chest pain, SOB,
palpitations, lightheadedness or dizziness. No vision changes or
color changes in field of vision. She does not recall todays
morning events (cannot remember waking up or eating breakfast).
No paresthesias or weakness above her baseline. She has
intermittent diarrhea, last occured 1 week prior to admission.
Poor appetite recently.
Past Medical History:
atrial fibrillation on coumadin
CVA with mild residual right sided hemiparesis
DM2
HLD
HTN
Social History:
Lives with her daughter, she is widowed. No tob, ETOH or IVDA.
Walks independently without walker or cane. ADL independent.
Does not drive.
Family History:
brother with throat cancer, no CAD/DM2 or malignancy
Physical Exam:
ADMISSION EXAM
VS - 98 175/77 63 sinus 20 97% RA
GENERAL - NAD, comfortable, appropriate, subtle poor short term
memory
HEENT - NC/AT, PERRLA, EOMI intact during interviwe, but upon
testing EOM she does not follow well on right indicating
possible visual field deficit, sclerae anicteric, MM dry, OP
clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
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 (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-7**] throughout, sensation grossly intact throughout
.
DISCHARGE EXAM
VS: 98.1, BP 120-140/50-70, HR 80, RR 18, O2 sat 97% on RA
GEN: NAD, A & O X2 (person and place)
NECK: supple, JVD flat,
HEART: Irregularly irregular, good S1, S2, no m/r/g
LUNG: CTA BL, no w/r/rh
ABD: soft, NT/ND, no HSM
EXT: no pitting edema, 2+ DP/PT bilaterally
Pertinent Results:
ADMISSION LABS
[**2129-11-19**] 07:55PM BLOOD WBC-10.9 RBC-3.21* Hgb-9.8* Hct-29.9*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.1* Plt Ct-242
[**2129-11-19**] 07:55PM BLOOD Neuts-81.1* Lymphs-15.0* Monos-3.4
Eos-0.1 Baso-0.3
[**2129-11-19**] 07:55PM BLOOD PT-26.4* PTT-35.0 INR(PT)-2.5*
[**2129-11-19**] 07:55PM BLOOD Glucose-206* UreaN-33* Creat-1.4* Na-137
K-3.6 Cl-97 HCO3-27 AnGap-17
[**2129-11-19**] 07:55PM BLOOD TotProt-6.9 Calcium-9.6 Phos-2.4* Mg-1.2*
.
DISCHARGE LABS
[**2129-11-23**] 06:00AM BLOOD WBC-9.6 RBC-2.90* Hgb-9.1* Hct-27.4*
MCV-94 MCH-31.3 MCHC-33.2 RDW-16.3* Plt Ct-206
[**2129-11-23**] 06:00AM BLOOD PT-25.8* PTT-31.3 INR(PT)-2.5*
[**2129-11-23**] 06:00AM BLOOD Glucose-183* UreaN-37* Creat-1.4* Na-135
K-4.2 Cl-97 HCO3-27 AnGap-15
[**2129-11-23**] 06:00AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.3
.
CARDIAC ENZYMES
[**2129-11-19**] 07:55PM BLOOD CK-MB-6
[**2129-11-19**] 07:55PM BLOOD cTropnT-0.07*
[**2129-11-20**] 08:09AM BLOOD CK-MB-4 cTropnT-0.08*
[**2129-11-21**] 04:17AM BLOOD CK-MB-3 cTropnT-0.05*
.
PERTINENT STUDIES
[**2129-11-22**] 06:45AM BLOOD ALT-17 AST-46* AlkPhos-57 TotBili-0.5
[**2129-11-22**] 06:45AM BLOOD TSH-1.8
[**2129-11-19**] 07:55PM BLOOD Free T4-1.7
[**2129-11-20**] 09:13AM BLOOD Lactate-1.8
[**2129-11-19**] 07:55PM BLOOD Digoxin-2.2*
[**2129-11-23**] 06:00AM BLOOD Digoxin-1.5
.
PERTINENT STUDIES
# CXR [**11-20**]
There is moderate cardiomegaly. There is mild vascular
congestion. Bibasilar atelectasis are larger on the right side.
There is no evident pneumothorax or pleural effusion.
.
# CT noncontrast [**11-20**]
FINDINGS: There is no evidence of hemorrhage or recent
infarction. Regions
of hypodensity in the left frontal, parietal, and occipital
lobes as well as in the right parietal love (2; 23) represent
sequelae of prior infarction; these appear similar to prior
exam. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There
is no edema or mass effect. Prominence of the ventricles
reflects age-related atrophic change. Subtle periventricular
hypodensities represent chronic small vessel ischemic changes.
The mastoid air cells are clear. The visualized paranasal
sinuses demonstrate mild mucosal thickening of the sphenoid
sinuses.
IMPRESSION: Sequelae of old infarction but no evidence of
hemorrhage or
recent infarction.
.
# ECHO (TTE) [**11-21**]
Conclusions
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with apical
aneurysm/dyskinesis and near akinesis of the anterior wall and
distal septum. The remaining segments contract normally (LVEF =
40%). The estimated cardiac index is normal (>=2.5L/min/m2). No
masses or thrombi are seen in the left ventricle. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction (mid-LAD distribution) and apical
aneurysm. Mild pulmonary artery systolic hypertension.
.
# Carotid series [**11-21**]
IMPRESSION: On the right, minimal plaque with less than 40%
carotid stenosis. On the left, possible ICA occlusion; however,
no confirmatory study. Please review information above.
.
# CXR PA/LAT [**11-22**]
The left-sided pacemaker has been placed with its tip
terminating in the
expected location of the right ventricle. There is no
substantial change in the cardiomegaly. There is substantial
interval improvement up to complete resolution of pulmonary
edema. Still present small bilateral pleural effusions are
noted. There is no definite pneumothorax seen, but minimal
amount of apical pleural air cannot be excluded.
Brief Hospital Course:
78 y/o woman with atrial fibrillation on coumadin and h/o CVA,
who was transferred from OSH s/p syncope and was found
bradycardic.
.
ACTIVE ISSUES:
# Digixin toxicity: Pt presented with bradycardia in 40-50s,
with occasional drop to 30s. Although the cause of bradycardia
is likely multifactorial, digoxin toxicity was high on the
differential given her subacute worsening of diarrhea and
personality changes in the past several weeks. Her digoxin
level on admission was 2.2, however, the digoxin level does not
correlate with toxicity, especially in elderly. Pt had a ~6 sec
pause on the night of admission, and subsequently responded
after one round of CPR. Two vials of digoxin binder was given
in this setting. Her repeat digoxin level was 1.5.
.
# Bradycardia: Pt presented with hemodynamically stable
bradycardia on admission. The causes of her bradycardia include
digoxin toxicity, tachy-brady syndrome, and iatrogenic effect
from nodal agents. Her medication were held on admission, and
digoxin binder was provided in the setting of asystole. A
single lead ventricular pacemaker was placed. Pt tolerated the
procedure well with native atrial fibrillation rhythm in 70-80
bpm at the time of discharge.
.
# Syncope: Pt underwent unwitnessed fall at home, which she did
not have recollection of, likely representing a syncopal
episode. At OSH, workup was notable for right frontal/parietal
hematoma, but no evidence of subdural hematoma or fractures.
Her INR was therapeutic at 2.4. A repeat CT-head noncontrast
was performed after the transfer, which again did not reveal
intracranial bleed. The cause of her syncope was unclear, but
could be explained by the bradycardia.
.
# Altered mental status: Pt presented with borderline mental
status, was significantly worse than her baseline per family.
There was a subacute process, notable for more aggressive
behavior in the past 2-3 weeks prior to admission. There was
also a more acute change to wax-[**Doctor Last Name 688**] confusion and somnolence.
The etiology is felt multifactorial. Digoxin toxicity could be
responsible for the subacute changes. However, the more acute
changes likely represents a delirious process. Pt was found to
have developed UTI during this admission, which was treated with
iv antibiotics. Workup was notable for normal TSH, liver
function. Pt received monthly B12 infusion, thus unlikely the
culprit. Delirium in elderly going through acute stress of
hospitalization is most likely explanation. However, acute on
chronic vascular dementia secondary to a recent CVA cannot be
completely ruled out.
.
# UTI: Pt was found to have developed positive UA during this
admission. She had no urinary symptoms. We decided to treat
given her altered mental status. We avoided Cipro and Bactrim
given she was on coumadin and treated her with iv ceftriaxone.
.
# systolic CHF: Pt was found to have worsened systolic function
to 40% from 55-60% last year. ECHO also revealed LVH with
regional systolic dysfunction (mid-LAD distribution), apical
aneurysm as well as mild pulmonary artery systolic hypertension.
Pt represented with mildly elevated troponin with no CKMB
elevation. Pt was otherwise asymptomatic, with no EKG changes.
The elevated troponin most likely came from bradycardia in the
setting of worsening kidney function. However, a subacute
ischemic event could not be completely ruled out, especially
given the new ECHO findings. Pt may need repeat ECHO.
.
# Hypoxia: Pt developed pulmonary edema in the setting of iv
fluid on the presumption of hypovolemia on admission. She was
treated with iv lasix which she responded well.
.
CHRONIC ISSUES
# Atrial fibrillation: Pt has paroxysmal atrial fibrillation
with CHADS score [**3-8**]. We continued her warfarin at home dose,
and adjusted her rate control with metoprolol 50 mg daily.
.
# Renal insufficiency: Pt's Cr during this admission is 1.2-1.4,
which were close to her recent value of 1.4-1.5.
.
TRANSITIONAL ISSUES
# CODE STATUS: FULL CODE
# CONTACT: [**Name (NI) **] (daughter, HCP [**Telephone/Fax (1) 92199**])
# PENDING STUDIES AT DISCHARGE:
- urine culture on [**11-22**] - no growth to date
# MEDICATION CHANGES:
- STOP digoxin
- STOP diltiazem
- START ceftriaxone 1 g iv once dose on [**11-24**]
- START metoprolol succinate 50 mg qd
- START valsartan 40 mg [**Hospital1 **]
- START aspirin 81 mg qd
- DECREASE allopurinol to 100 mg qd given current GFR
# FOLLOW UP PLAN
- Please give one more dose of iv ceftriaxone 1 g iv on [**11-24**]
- Please closely monitoring electrolytes given pt is on
diuretics and recently started on valsartan
- Consider uptitrate valsartan as BP tolerates given pt has
CHF
- Please follow up with Dr. [**First Name (STitle) **] for pacemaker placement
- Please arrange PCP followup at the time of leaving rehab
- Will recommend repeat ECHO for new worsening in sCHF
- Pt has calculated GFR of 33, may not be a good candidate for
metformin if her creatinine continue to deteriorate
Medications on Admission:
metformin 850mg daily
simvastatin 20mg daily
digoxin 0.125mg daily
folic acid 1mg daily
allopurinol 200mg daily
diltiazem 240mg daily
metoprolol succinate 25mg daily
glipizid 2.5mg daily
bumetanide 1mg daily
warfarin 2.5mg on M/Th, 2.0 mg on rest
omeprazole 20mg daily
.
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
3. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
4. warfarin 2 mg Tablet Sig: One (1) Tablet PO 16 PM ON TUE,
WED, FRI, SAT, SUN ().
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Q16PM ON MON,
[**Doctor First Name **] ().
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. valsartan 40 mg Tablet Sig: One (1) Tablet PO twice a day.
12. ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once
a day for 1 days: Please give on [**11-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
Primary diagnosis
- digoxin toxicity
- Tachy-brady syndrome
Secondary diagnosis
- atrial fibrillation
- bradycardia
- diabetes mellitus type 2
- hypertension
Discharge Condition:
Mental Status: Alert and confused (oriented x place and person)
at times
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 92200**],
.
You came to our hospital after having a fall and striking your
head. You were found to have low heart rate as well. You were
found to have elevated levels of digoxin which were likely
contributing to your symptoms. Your digoxin was stopped and you
were also given a medication to decrease the level of
medicaiton. You had a pacemaker placed for your low heart rate.
You also repeated an Cat scan of your head and this was
reasurring that there was no bleeding or other acute changes.
You were then discharge to a rehabilitation facility.
We have made the following changes to your medications:
- Please STOP digoxin
- Please STOP diltiazem
- Please INCREASE metoprolol succinate to 50 mg tablet by mouth
daily
- Please START ceftriaxone 1 g iv for one additional dose on
[**11-24**] for urinary tract infection
- Please START valsartan 40 mg by mouth twice a day
- Please START aspirin 81 mg by mouth daily
- Pleaes DECREASE allopurinol to 100 mg tablet by mouth daily
- Please continue to take the rest of your medication
We also recommend that you discuss with your PCP the change of
your anti-diabetic medications given your age, creatine
clearance and CHF.
.
Please continue your routine followup at [**Hospital 2786**] clinic
at [**Location (un) 2274**] after leaving the rehab. It has been a pleasure taking
care of you here at [**Hospital1 18**]. We wish you a speedy recovery.
Followup Instructions:
When: FRIDAY [**2129-12-2**] at 11:10 AM
With: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
ADDRESS: [**Location (un) 4363**], [**Location (un) 86**], [**Numeric Identifier 4364**]
TELEPHONE: [**Telephone/Fax (1) **]
|
[
"428.0",
"427.81",
"250.00",
"584.9",
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"416.8",
"920",
"599.0",
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"V58.61",
"428.23",
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"438.20",
"293.0",
"401.9",
"780.2",
"427.31",
"272.4",
"E942.1",
"995.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.82",
"37.71",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
14234, 14324
|
7870, 8003
|
315, 340
|
14538, 14538
|
3829, 7847
|
16212, 16447
|
2759, 2813
|
13210, 14211
|
14345, 14517
|
12915, 13187
|
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|
2828, 3810
|
11987, 12040
|
15394, 16189
|
12062, 12889
|
268, 277
|
8018, 9572
|
368, 2472
|
14553, 14735
|
2494, 2586
|
2602, 2743
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,763
| 136,416
|
31380+57745+57746
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2197-7-20**] Discharge Date: [**2197-8-1**]
Date of Birth: [**2136-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Naprosyn
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 60-year-old female with oxygen-dependent COPD who was
admitted from an [**Hospital3 **] facility for "failure to
thrive" over the past several days as well as shortness of
breath. These are according to paperwork. However, the patient
actually denies any changes in her breathing. She has not had
any cough, increased sputum production, or shortness of breath.
She has had fevers and sweats. She has not had any chest pain,
abdominal pain, or nausea.
She does state that she has not been getting out of bed as much
as usual. She was hospitalized in [**Month (only) 205**] and treated with
antibiotics and steroids for COPD flare. She states that she
has been tired, and has not been getting out of bed because the
facility staff have made her sleep in a different position and
she is not as comfortable. She denies depression.
She has not had dysuria or increased urinary frequency, but she
does wear a depends. She has noted more foul smelling urine
over the past few weeks. She has not had any headache, limb
weakness, or numbness. She has not had a good appetite.
In the ED she was given Levaquin for a possible pneumonia, and
she was ordered for 60 mg of Prednisone which she refused.
Past Medical History:
1. COPD (FVC 23% predicted, FEV1 15% predicted), on oxygen 3L NC
2. Hyperlipidemia
3. Anxiety disorder
4. Sinus tachycardia
Social History:
She lives in [**Hospital3 **]. She does not smoke and does not
drink alcohol.
Family History:
Non-contributory.
Physical Exam:
T 97.1, HR 100, BP 98/54, RR 20, O2 sat 95% on 2L
GEN: Cachectic, thin caucasian female in no acute distress.
HEENT: Supple neck. No elevated JVP. No cervical LAD. Dry MM.
Anicteric sclera.
CV: Distant sounds. No murmurs.
LUNGS: No dullness to percussion. Very little air movement
throughout. No crackles or wheezes. She is mildly tachypneic
and does breath through pursed lips.
ABD: Scaphoid. Soft. Nontender. Nondistended.
EXT: No leg edema or calf tenderness.
NEURO: Oriented. CN II-XII intact bilaterally. Grip strength 5/5
bilaterally. Sensation grossly intact in all four limbs. She
initially was slow to respond to questions, but did give
appropriate answers with very understandable speech. However,
she improved during the H&P and she stated that she was tired
because I woke her up from sleeping.
SKIN: Dry skin, no rashes.
Pertinent Results:
Admit Labs/Studies:
LACTATE-1.4
GLUCOSE-123 BUN-15 CREAT-0.4 SODIUM-141 POTASSIUM-3.7
CHLORIDE-87 TOTAL CO2-49* ANION GAP-9
WBC-15.7 HCT-40.1 MCV-91 PLT 290
NEUTS-89.5 BANDS-0 LYMPHS-6.2 MONOS-3.6 EOS-0.4 BASOS-0.3
CXR:
The lungs are significantly hyperinflated consistent with
underlying obstructive lung disease. There are large bullae in
the apices. There is a rounded opacity projecting within the
left costophrenic angle. Otherwise, the lungs are clear with no
superimposed edema. There is atherosclerotic disease of the
aorta. The cardiac silhouette is within normal limits for size.
No definite effusion or pneumothorax is seen. There is height
loss of L2 which may represent compression fracture of
indeterminant chronicity.
IMPRESSION: COPD. There is a focal opacity projecting within
the left
costophrenic angle of indeterminant origin. This may represent
a focus of
early consolidation, possibly pneumonia. Correlate with
clinical exam.
EKG: Sinus tachycardia. Atrial abnormality. Poor R wave
progression. No ischemic changes.
.
Other Labs:
[**2197-7-23**] 06:45AM BLOOD calTIBC-259* Ferritn-192* TRF-199*
[**2197-7-20**] 03:55PM BLOOD VitB12-1058* Folate-GREATER TH
[**2197-7-20**] 03:55PM BLOOD TSH-0.82
[**2197-7-21**] 02:01AM BLOOD Type-ART O2 Flow-3 pO2-54* pCO2-65*
pH-7.48* calTCO2-50* Base XS-20 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2197-7-24**] 09:58AM BLOOD Temp-36.7 FiO2-35 O2 Flow-4 pO2-68*
pCO2-73* pH-7.42 calTCO2-49* Base XS-18 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2197-7-24**] 07:33PM BLOOD Type-ART pO2-73* pCO2-83* pH-7.34*
calTCO2-47* Base XS-14
[**2197-7-25**] 06:28AM BLOOD Type-ART pO2-53* pCO2-61* pH-7.45
calTCO2-44* Base XS-14
Blood Culture ([**7-20**]) - Negative x 2.
.
Other Studies:
CT HEAD W/O CONTRAST [**2197-7-21**] 2:28 AM
FINDINGS: There is no evidence of hemorrhage, mass, mass effect,
or large vascular territorial infarction. The ventricles and
sulci are normal in caliber and configuration. No fractures are
identified.
There is hypodensity in bilateral periventricular white matter
likely due to chronic small vessel ischemic disease. There is
also a region of hypodensity in the posterior limb of the left
internal capsule consistent with an old lacunar infarct. If
clinically indicated, MRI of head with diffusion study is more
sensitive for acute CVA.
IMPRESSION:
1. There is no evidence of acute intracranial process.
2. Hypodensity in the posterior limb of the left internal
capsule consistent with an old lacunar infarct.
EEG ([**7-21**]):
FINDINGS:
ABNORMALITY #1: Frequent episodes of left frontotemporal
moderate
amplitude theta frequency slowing were noted.
BACKGROUND: An 8 Hz somewhat disorganized and poorly modulated
rhythm
was noted in the waking state. This attenuated appropriately
with
frequent eye blinking.
HYPERVENTILATION: Could not be performed as this was a portable
study.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: The patient remained in the waking or drowsy state.
CARDIAC MONITOR: The cardiac monitor was obscurred by movement
and/or
electrode artifact for the majority of the tracing.
IMPRESSION: This is an abormal portable EEG due to the presence
of
intermittent left frontotemporal slowing, suggestive of an
underlying
region of subcortical dysfunction. No epileptiform features were
noted.
No electrographic seizure activity was seen.
EEG ([**7-22**]):
FINDINGS:
ROUTINE SAMPLING: Showed an alpha frequency background rhythm
posteriorly during wakefulness. At other times, there were brief
periods of theta frequency slowing seen in the left temporal
regions.
There were no clearly epileptiform features and no
electrographic
seizures were noted.
SLEEP: The patient progressed from wakefulness to slow wave
sleep at
appropriate times and with no additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm with
occasional
PVCs.
SPIKE DETECTION PROGRAMS: There were no clearly epileptiform
features
in any of these entries. The majority were due to EKG or
electrode
artifact.
SEIZURE DETECTION PROGRAMS: There were 9 entries in these files.
Several of these files demonstrated brief one to two second
bursts of
high amplitude polymorphic slow wave activity at a frequency of
about 4
Hz lasting two to three seconds at a time prior to return to the
previous background rhythm. Several of these events occurred
without an
accompanying video making it difficult to comment on whether
they are
related to movement or other artifact. They were not clearly
epileptiform however.
PUSHBUTTON ACTIVATIONS: There were one. There was no clear
change in
the electrographic tracing with this pushbutton. On video, the
patient
was seen sitting up in bed being attended to by nursing staff.
She was
answering questions appropriately.
IMPRESSION: This telemetry captured one pushbutton activation
during
which there was no clear change in the electrographic tracing.
Routine
sampling and spike and seizure detection programs, for the most
part,
showed a normal background rhythm with occasional periods of
left
temporal theta frequency slowing suggestive of an underlying
area of
subcortical dysfunction in that region. In addition, seizure
detection
programs demonstrated brief bursts of high amplitude polymorphic
slow
waves in a more generalized distribution. Unfortunately, there
was no
accompanying video for these detections making it difficult to
comment
on their exact nature. They did not appear clearly epileptiform,
however. No electrographic seizures were noted.
CHEST (PORTABLE AP) [**2197-7-25**] 5:35 AM
Compared to the prior study, there has been no interval change.
The lungs remain hyperinflated. There are no focal infiltrates
or CHF.
IMPRESSION: No interval change from prior study. No infiltrate.
Brief Hospital Course:
1) Respiratory Status/COPD
Patient has severe COPD with FEV1 15%, on home O2. The patient
did not have any evidence of pneumonia. She received an initial
dose of Levaquin the ED, but this was not continued. HCO3
elevated to 49 consistent with chronic CO2 retention. Was
becomming hypoxic on floor and ABG showed increase in pCO2 from
65 -> 73, however pH was normal so she appears to be
well-compensated. She was somewhat more unresponsive/catatonic,
so was transferred to the [**Hospital Unit Name **] on [**7-24**] morning. Repeat ABG on
[**7-25**] showed CO2 of 61. (Baseline believed to be in 60s-70s
range.) She remained stable on 1L-2L O2 NC with adequate
saturations (high 80s-100%) during ICU course on standing
nebulizer treatments and MDIs. She was continued on azithromycin
for 5 days for empiric treatment of bronchitis. She was
continued on fluticasone, and advair, as well as
albuterol/ipratropium nebs prn. She was started on Spiriva.
Alpha-1-anti-trypsin levels were sent and were normal. After
the patient returned to the floor, her O2 sats were in the low
to mid 90s at rest on 2-3L O2 via NC. However, the patient
continued to breathe with pursed lips and used a fan blowing in
her face at night.
2)Catatonia/MS changes
The patient had been intermittantly catatonic on the floor
exhibiting immobility, mutism, staring, posturing and withdrawl.
Psychiatry and neurology were involved. CT head negative and
EEG without evidence of seizure activity. Thought to be most
likely [**1-6**] bipolar disorder/depression. Psychiatric history
could not be obtained from PCP or brother and patient did not
volunteer this information. She did have brief period of
resolution following bromocriptine, however experienced
hypotension. Toxic metabolic workup unrevealing with normal
B12/folate, normal iron studies, nml TSH. No clear infection.
Unlikely secondary to hypercarbia since symptoms did not change
with variations in CO2 (and patient was well compensated). Per
psychiatry's recommendations, patient was started on ritalin
2.5mg [**Hospital1 **] on [**2197-7-24**]. This dose was subsequently uptitrated to
10mg [**Hospital1 **]. Pt had improved mental status on exam, AAOx3 and
asking appropriate questions. Appetite improved as well.
However, she continued to have episodes where she would become
more withdrawn.
3) Fatigue/lethargy/malnutrition
The etiology of this was somewhat unclear. [**Name2 (NI) **] discussions with
her brother [**Name (NI) **], she seems to be having a hard time handling
her disease and is in denial about the overall prospects. As a
result she is in a state of depression. She was seen by
nutrition who instituted calorie counts. Vitamin supplements
were added. The patient's appetite seemed to improve after she
started taking the Ritalin.
4) Disposition
Based on the patient's overall poor functional status in
[**Hospital3 **] and the severity of her COPD, the patient would
ideally be a candidate for pulmonary rehab. It was unclear if
patient would accept a longer-term placement, so psychiatry was
asked the question about whether the patient had the capacity to
make this decision. However, this evaluation was deferred when
the patient agreed to go to pulmonary rehab. The patient also
appointed her brother, [**Name (NI) **], as her HCP. She was seen by PT
who cleared her in terms of mobility. However, her oxygen
saturation did decrease on ambulation. Her insurance company
would not approve payment for pulmonary rehabilitation as we
suggested, but did approve placement at a skilled nursing
facility. She was discharged to skilled nursing facility on her
current medical regimen.
Medications on Admission:
From [**Hospital3 400**] Med List:
1. Spiriva one puff daily
2. Advair [**Hospital1 **]
3. Beconase nasal 2 sprays each nostril [**Hospital1 **]
4. Albuterol neb QID and PRN
5. MVI
6. Calcium carbonate 500 TID
7. Flovent 2 puffs [**Hospital1 **]
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Neb Inhalation Q6H (every 6 hours) as needed.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Nursing and Rehab
Discharge Diagnosis:
Primary:
1. Psychosis of unclear etiology
2. COPD (FVC 23% predicted, FEV1 15% predicted), on oxygen 3L NC
Secondary:
1. Hyperlipidemia
2. Anxiety disorder
3. Sinus tachycardia
Discharge Condition:
Afebrile. O2 sat: on L
Discharge Instructions:
You were admitted to the hospital due to difficulty managing at
home. During this admission, you were started on a new
medication, Ritalin, which is intended to help make you more
alert. You should continue to take this medication as well as
all of your other medications.
.
Please call your doctor for a follow up appointment.
Followup Instructions:
Please call your primary care doctor, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 34720**])
for a follow up appointment within the next 1-2 weeks.
Name: [**Known lastname **],[**Known firstname 1940**] Unit No: [**Numeric Identifier 12253**]
Admission Date: [**2197-7-20**] Discharge Date: [**2197-8-1**]
Date of Birth: [**2136-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Naprosyn
Attending:[**First Name3 (LF) 429**]
Addendum:
On the day of discharge, psychiatry recommended that her ritalin
dose be increased to 15 mg [**Hospital1 **] (at 8 am and at 2 pm) given her
clinical response. The discharge instructions for the skilled
nursing facility were amended to reflect this recommendation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12254**] Nursing and Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 430**] MD [**MD Number(2) 431**]
Completed by:[**2197-7-31**] Name: [**Known lastname **],[**Known firstname 1940**] Unit No: [**Numeric Identifier 12253**]
Admission Date: [**2197-7-20**] Discharge Date: [**2197-8-1**]
Date of Birth: [**2136-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Naprosyn
Attending:[**First Name3 (LF) 429**]
Addendum:
Insurer called re: pt.s appeal to get payment for inpatient
pulmonary rehabilitation on [**2197-7-31**]. They stated that appeal
was still in process, therefore, discharge was delayed for
another day. On the following day ([**2197-8-1**]), the insurer called
stating the appeal was denied. She is being discharged to
Skilled Nursing Hospital ([**Location (un) 12254**]) in [**Hospital1 1263**] as original
plan. She will need psychiatric follow up there, and in the
future. The above was discussed with her PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2886**]
[**Last Name (NamePattern1) 12255**], of [**Hospital1 6925**], at [**Telephone/Fax (1) 12256**] and the pt.s
brother and health care proxy, [**First Name8 (NamePattern2) **] [**Name (NI) **], on the day of
discharge.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12254**] Nursing and Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 430**] MD [**MD Number(2) 431**]
Completed by:[**2197-8-1**]
|
[
"272.4",
"296.54",
"263.1",
"518.84",
"276.50",
"427.89",
"300.00",
"491.22",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16452, 16671
|
8549, 12220
|
325, 332
|
13799, 13825
|
2724, 3779
|
14203, 15004
|
1833, 1852
|
12518, 13490
|
13598, 13778
|
12246, 12493
|
13849, 14180
|
1867, 2705
|
266, 287
|
360, 1573
|
1595, 1721
|
1737, 1817
|
3791, 8526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,133
| 191,996
|
39174+58266
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-2-14**] Discharge Date: [**2153-3-6**]
Date of Birth: [**2093-11-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Pantoprazole
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
esophageal adenocarcinoma
Major Surgical or Invasive Procedure:
[**2153-2-14**]: Ivor-[**Doctor Last Name **] esophagectomy. Buttressing of
esophagogastric anastomosis with intercostal muscle.
Laparoscopic jejunostomy.
Esophagogastroduodenoscopy.
[**2153-2-20**]: . Right thoracotomy. Decortication of lung. Revision
of esophagogastric anastomosis. Coverage of anastomotic repair
with pleural tent.
[**2153-3-1**]: Single Lumen PICC: Left Cephalic: 45 cm terminate in
mid SVC
History of Present Illness:
59 year old male who presented an esophageal stricture. During
EGD, he was found to have a small nodule in the distal esophagus
which the biopsy was positive for adenocarcinoma. His endoscopic
culture stage was T1b N0. His PET scan disclosed no evidence of
metastatic disease. He was admitted for esophagectomy.
Past Medical History:
Hypertension
Hyperlipidemia
Insulin dependent DM with poor control
Ulcerative colitis controlled x several years
GERD
PSH:
Umbilical hernia repair [**2150**]
Social History:
Lives with daughter. [**Name (NI) **] 5 adult children
Tobacco: 40 pack year. Quit [**2136**]
ETOH none
Family History:
Father died from lung cancer
Physical Exam:
VS: T: 97.2 HR: 85 SR BP: 146/70 Sats: 94% RA Wt: 239.6
([**2153-3-2**])
BS: 98-386
General: 59 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: decreased breath sounds with faint bibasilar crackles
GI: obese, BS+ abdomen soft non-tender/non-distended
Extr: warm tr edema
Incision: Right thoracotomy site with staples, clean, dry
intact, no erythema
Neuro: awake alter, slightly unsteady on feet.
Pertinent Results:
[**2153-3-1**] WBC-19.3* RBC-3.30* Hgb-9.4* Hct-29.6 Plt Ct-1363*
[**2153-2-28**] WBC-21.0* RBC-3.15* Hgb-9.0* Hct-28.0* Plt Ct-1158*
[**2153-2-23**] WBC-15.5* RBC-3.25* Hgb-9.0* Hct-29.5* Plt Ct-485*
[**2153-2-20**] WBC-20.9* RBC-3.76* Hgb-10.8* Hct-34.0 Plt Ct-352
[**2153-2-18**] WBC-15.7* RBC-3.33* Hgb-9.4* Hct-29.3* Plt Ct-236
[**2153-2-13**] WBC-12.0* RBC-4.66 Hgb-13.7* Hct-39.5* Plt Ct-388
[**2153-2-23**] Neuts-84.2* Lymphs-7.6* Monos-5.4 Eos-2.2 Baso-0.5
[**2153-3-1**] Glucose-79 UreaN-24* Creat-1.0 Na-139 K-5.3* Cl-102
HCO3-24
[**2153-2-28**] Glucose-186* UreaN-29* Creat-1.0 Na-140 K-4.7 Cl-104
HCO3-26
[**2153-2-26**] Glucose-177* UreaN-35* Creat-1.2 Na-141 K-4.4 Cl-105
HCO3-26
[**2153-2-20**] Glucose-79 UreaN-27* Creat-1.1 Na-142 K-3.9 Cl-110*
HCO3-25
[**2153-2-19**] Glucose-162* UreaN-31* Creat-1.2 Na-142 K-4.0 Cl-109*
HCO3-24
[**2153-2-18**] Glucose-65* UreaN-32* Creat-1.3* Na-145 K-3.5 Cl-112*
HCO3-25
[**2153-2-15**] Glucose-173* UreaN-25* Creat-1.2 Na-138 K-4.4 Cl-105
HCO3-26
[**2153-2-15**] Glucose-157* UreaN-30* Creat-1.3* Na-137 K-5.6* Cl-105
HCO3-24
[**2153-3-1**] Calcium-8.0* Mg-2.3
CT Scan:
TORSO [**2153-2-28**] IMPRESSION:
1. Status post esophagectomy, with no evidence of contrast
extravasation.
2. Interval placement of two additional right-sided chest tubes,
with
decreased lateral right pleural fluid. Minimally increased
pleural fluid at the right base, with two foci of gas, likely
related to the chest tube. Decreased left pleural fluid.
3. Decreased right lung consolidation. Interval resolution of
right
pneumothorax.
TORSO [**2153-2-18**] IMPRESSION:
1. Status post esophagectomy and gastric pull-through, with no
evidence of
leak, allowing for lack of contrast opacification at the level
of the
anastomosis.
2. Small bilateral pleural effusions, and gas and fluid tracking
in the right lateral chest wall.
3. Mostly dependent consolidation in the right lung, although
infection
cannot be fully excluded. Dependent consolidation at the left
lung base
likely represents atelectasis. Small right pneumothorax.
4. Submucosal fat perforation in the rectum and sigmoid colon,
consistent
with chronic inflammation. Correlate with history of
inflammatory bowel
disease.
Esophagus: [**2153-2-27**]:
1. Patent esophagogastric anastomosis with no evidence of leak.
2. 20-minute delayed imaging reveals no passage of contrast into
the
duodenum. Gastric emptying can be evaluated with a delayed
image.
MICROS:
[**2153-2-18**] PLEURAL FLUID..
GRAM STAIN (Final [**2153-2-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
FLUID CULTURE (Final [**2153-2-22**]):
[**Female First Name (un) **] (TORULOPSIS) GLABRATA. MODERATE GROWTH.
[**Female First Name (un) **] ALBICANS. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2153-2-22**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
[**Female First Name (un) **] (TORULOPSIS) GLABRATA.
ID PERFORMED ON CORRESPONDING ROUTINE CULTURE.
[**Female First Name (un) **] ALBICANS. ID PERFORMED ON CORRESPONDING ROUTINE
CULTURE.
ACID FAST SMEAR (Final [**2153-2-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2153-2-17**] SPUTUM Site: EXPECTORATED
GRAM STAIN (Final [**2153-2-18**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2153-2-23**]):
SPARSE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. HEAVY GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
YEAST. SPARSE GROWTH.
YEAST. MODERATE GROWTH. SECOND MORPHOLOGY.
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN G---------- S
FUNGAL CULTURE (Preliminary):
YEAST.
Brief Hospital Course:
Mr. [**Known lastname 86762**] was admitted on [**2153-2-14**] for an Ivor-[**Doctor Last Name **]
esophagectomy, buttressing of esophagogastric anastomosis with
intercostal muscle, laparoscopic jejunostomy, and
esophagogastroduodenoscopy. He tolerated the procedure well. He
was transferred to the SICU intubated. He was successfully
extubated on [**2153-2-15**]. However during this period, the patient
became more agitated and tachycardic. Chest tube output changed
in color from serosanginous to black fluid. He then underwent an
EGD which showed some ischemic changes proximal to the
anastamosis. When the conduit was insufflated with air, there
was a leak seen on his chest tubes thereby confirmed the leak.
He was taken back to the OR on [**2-20**] for decortication, revising
the anstamosis, and pleural tent buttressing.
Neuro: After extubation, the patient was transitioned to Roxicet
liquid via his J-tube. His pain was well controlled and he
reported minimal pain.
Respiratory: Aggressive pulmonary toilet, nebs and chest PT were
performed. He weaned off supplemental oxygen to room air with
oxygen saturations of 96%.
Bronchscopy was done on [**2153-2-21**] BAL.
Tubes & Drains: R anterior apical CT and R basilar CT were d/c'd
on POD9 with sufficiently low output. The JP drain at the
anastamosis site was removed on [**2153-3-2**]
PICC: Single Lumen Left Cephalic 45 cm terminates in the mid SVC
place [**2153-3-1**]
Cardiac: Remained in sinus rhythm on beta-blockers and was
hemodyanmically stable during the inpatient admission.
GI: NG tube was removed by the patient on POD2 following the
second procedure. A barium swallow was performed on POD5
without leak.
Nutrition: He was seen by nutrition who recommended Nutren
Pulmonary Full strength; Beneprotein, 35 gm/day Goal rate:75
ml/hr Cycle start:1500 Cycle end:0700
Tube feeds were started on POD1 and titrated to goal without
difficulty. He was started on a clear liquid diet advanced to
soft solid on [**2153-3-2**] that was tolerated well.
Renal: episode of ATN with a peak creatinine - 1.5 and potassium
- 6.0 which returned to baseline with IV fluids. He had good
urine output. The foley was removed and he subsequently voided
without difficulty
Endocrine: Blood sugars were elevated 150-300's. He was
restarted on insulin with better control. Consultation from
[**Last Name (un) **] Center resulted in adjusting basal and insulin sliding
scale with NPH and Humalog insulin.
Heme: On [**2-18**] his HCT was 28 (baseline HCT 38). He was
transfused with 1 Unit PRBC.
Pain: he was followed by the acute pain service. His pain was
well controlled with a
an epidural until POD2. He converted to PO pain medication with
good control.
ID: Infectious disease was consuled on [**2153-1-24**] for anastomotic
leak and empyema. They recommended levofloxacin, flagyl and
fluconazole for fungal coverages. Cultures were sent. Found to
have RUL pneomomia expectorated sputum and BAL cultures
growing Strep pneumo (sensitive to levofloxasin) and pleural
fluid growing [**Female First Name (un) 564**]
glabrata, C. albicans, as well as Strep viridans and
Corynebacterial species. Given his anaphylactic PCN allergy, he
was started on Levoflox 750 on [**2-21**] for better
pneumococcal and other gram positive oral and respiratory flora.
MRSA screen was negative. Given his culturing of C. glabrata he
is on micafungin 100mg IV daily which was changed to fluconazole
400mg daily once based on sensitivities results. They will
follow-up with him as an outpatient.
PICC: Single Lumen Left Cephalic 45 cm terminates in the mid SVC
place [**2153-3-1**]
Neurological: While in the SICU he developed intermittent
confusion which resolved once transferred to the floor and
restarted on his home dose of Wellbutrin.
Disposition: He was seen by physical therapy and occupational
therapy. STR was recommended. He continued to make steady
progress and was discharged to a rehabilitation facility. He
will follow-up with Dr. [**First Name (STitle) **], infectious disease service, and
[**Last Name (un) **] as an outpatient.
Medications on Admission:
lisinopril 40mg po in am
balsalazide 750mg tab- pt takes three tabs po TID
glyburide 10mg po BID
metformin 1000mg po BID
bupropion 150mg po BID
ranitidine 300mg po qhs
simvastatin 40mg po qhs
lorazepam (taking since CA dx) 0.5mg po prn QID (takes daily)
novolin 70/30 28 units [**Hospital1 **]
Aspirin 81mg po daily
MVI po daily
Discharge Medications:
1. Acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
3. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q6H (every 6 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Balsalazide 750 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
13. Insulin Regular Human Injection
14. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q24H (every 24 hours).
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours).
16. Fluconazole in NaCl (Iso-osm) 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours).
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
18. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Androscoggin VNA
Discharge Diagnosis:
Hypertension
Hyperlipidemia
Insulin dependent DM with poor control
Ulcerative colitis controlled x several years
GERD
PSH:
Umbilical hernia repair [**2150**]
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - with assistance
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Difficulty or painful swallowing, nausea, vomiting
-J-tube falls out or sutures come loose please call immediately
-NOTHING through J-tube unless it is in liquid form
-You may shower. No tub bathing or swimming for 4 weeks
-Incision develops drainage: staples remain until seen by Dr.
[**First Name (STitle) **]
[**Name (STitle) 86763**] tube site remove dressing and cover with a bandaid until
healed
-Daily weights. Keep a log a bring with you to your appointment
Continue IV antibiotics: Fluconazole 400mg, Flagyl 500mg &
levofloxacin 750mg until seen in follow-up by infectious
disease.
Weekly labs CBC, Electrolytes, BUN/Cre and LFTs and fax results
to [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1352**] [**Telephone/Fax (1) 432**]
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**2153-3-20**]:00 on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology Depart 30 minutes before your
appointment.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-3-21**] 10:30 in the [**Last Name (un) 2577**] Building [**First Name8 (NamePattern2) **]
[**Location (un) 86**]
Weekly labs CBC, Electrolytes, BUN/Cre and LFTs and fax results
to [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1352**] [**Telephone/Fax (1) 432**]
[**Hospital **] Clinic please call [**0-0-**] for appointment, please
call
Completed by:[**2153-3-3**] Name: [**Known lastname 13726**],[**Known firstname 63**] G. Unit No: [**Numeric Identifier 13727**]
Admission Date: [**2153-2-14**] Discharge Date: [**2153-3-6**]
Date of Birth: [**2093-11-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Pantoprazole
Attending:[**First Name3 (LF) 1999**]
Addendum:
The patient was kept as inpatient on intended day of discharge
due to elevated potassium (5.7) on morning electrolyte labs;
asymptomatic and ECG with no findings related to hyperkalemia
and nephrology was consulted. They recommmended checking plasma
potassium as the potassium level could be elevated due to his
high platelet count. Plasma K was 4.9. The patient was also
reevaluated by physical therapy and it was decided that he would
no longer need a rehab facility and he would be appropriate for
discharge home with service. The patient was set-up with home
services and had insulin teaching. He will follow up with
[**Last Name (un) 616**] and Dr. [**First Name (STitle) **] as indicated in his discharge planning
paperwork. The patient was deemed stable for home discharge
today.
DC VS:
T: 98.7, HR 78 SR BP 114/66, RR 20, O2 sats 99%RA
PE:
Gen: pleasant A and O x 4 without focal deficits. MAE to
command.
Lungs: decreased RRR, slight crackles LLL, clear otherwise.
Right thoractomy reddened but healing with intact sutures.
CV: RRR S1, S2, no MRG or JVD
Abd:soft, NT, ND
Ext: warm, 2+ BLE edema
DC labs [**2153-3-5**]
Na 130, BUN 22, Creat 1.2, K 4.9 Glucose 278
WBC 12.2, Hct 26.1 Plt 1253
DC Medications (revised):
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
3. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q6H (every 6 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Balsalazide 750 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
x 7 days
11. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
14. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 2238**]y (750) mg Intravenous Q24H (every 24 hours).
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours).
16. Fluconazole in NaCl (Iso-osm) 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours).
-lisinopril 5mg po BID
Insulin insulin scale
Fingerstick before meals and at bedtime Insulin Subcutaneous
Fixed Dose Orders Breakfast take: NPH 15 Units Bedtime take: NPH
35 Units Meal sliding scale. Regular insulin in units: glucose:
Bfast Lunch Dinner Bedtime 71-119 0 0 2 0 120-159 2 2 7 0
160-199 7 7 9 2 200-[**Telephone/Fax (2) 13728**]0-279 10 10 12 6 280-319 12
12 14 10 [**Telephone/Fax (2) 13729**] 16 12 [**Telephone/Fax (2) 13730**] 18 14 > 400 mg/dL
Notify M.D. Notify M.D. Notify M.D. Notify M.D.
Aspirin 325mg po daily
Discharge Disposition:
Home With Service
Facility:
Androscoggin VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**]
Completed by:[**2153-3-6**]
|
[
"510.9",
"997.4",
"276.7",
"486",
"338.18",
"403.90",
"585.9",
"V15.82",
"272.4",
"E849.7",
"150.9",
"556.9",
"V58.67",
"250.02",
"276.2",
"458.9",
"518.81",
"518.0",
"451.82",
"584.5",
"041.09",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"38.91",
"45.13",
"46.39",
"34.99",
"44.5",
"96.04",
"34.51",
"38.93",
"96.6",
"42.40"
] |
icd9pcs
|
[
[
[]
]
] |
17919, 18122
|
6196, 10297
|
319, 733
|
12730, 12730
|
1960, 5069
|
13848, 17896
|
1396, 1426
|
10676, 12458
|
12549, 12709
|
10323, 10653
|
12882, 13825
|
1441, 1941
|
5446, 6125
|
6161, 6173
|
254, 281
|
761, 1075
|
12745, 12858
|
1097, 1258
|
1274, 1380
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,652
| 132,248
|
20272
|
Discharge summary
|
report
|
Admission Date: [**2121-11-6**] Discharge Date: [**2121-11-24**]
Date of Birth: [**2047-2-27**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman,
who has a history of known coronary artery disease had been
managed medically over the last several years with a PTCA in
[**2106**]. Recently has been experiencing increased exertional
angina. Had a positive stress test in [**2121-9-20**],
which showed a large reversible inferolateral wall defect
with a fixed component of inferior apex, an ejection fraction
of 38%. An echocardiogram [**10/2121**] showed mild left
ventricular hypertrophy, moderate inferior wall hypokinesis,
and ejection fraction of 50%. Patient was referred to [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hyperlipidemia.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Zocor 40 mg p.o. q.d.
2. Procardia 30 mg p.o. q.d.
3. Isosorbide dinitrate 30 mg p.o. t.i.d.
4. Inderal 30 mg p.o. t.i.d.
5. Aspirin 325 mg p.o. q.d.
Patient was admitted to the Cardiac Catheterization
Laboratory on [**2121-11-7**]. Cardiac catheterization showed
left ventricular end diastolic pressure of 26, ejection
fraction of 25%, 95% distal left main involving the ostia,
the LAD, and circumflex, 30% mid LAD, 95% very proximal left
circumflex, and 95% mid left circumflex after OM-1, dominant
diffusely diseased RCA with 90% mid lesion and 90% distal
lesion. Patient was referred for cardiac surgery.
Patient was originally scheduled for surgery on [**11-11**]
or [**11-12**], however, on the evening of [**11-9**],
patient had episode of ventricular fibrillation, which
required d-c cardioversion with 200 joules. Patient was
cardioverted into a sinus rhythm. Patient recovered a good
blood pressure. Patient was then transported to the Cardiac
Catheterization Laboratory, where an intra-aortic balloon
pump was placed, and Cardiac Surgery was consulted. It was
decided at that time to take the patient urgently for a CABG
with Dr. [**Last Name (STitle) 1537**].
Patient underwent a CABG x4: LIMA to LAD, SVG to OM-1, SVG
to OM-2, and SVG to PDA. Patient tolerated the procedure
well. Was transported to the Intensive Care Unit in stable
condition on Levophed and milrinone as well as intra-aortic
balloon pump. Patient awoke postoperatively, followed
commands, moved all extremities, and was nonfocal
neurologically.
Patient was weaned and extubated from mechanical ventilation
on postoperative day #1. The milrinone and Levophed were
weaned down to off. The intra-aortic balloon pump was
discontinued on postoperative day #1. Liver function tests
were drawn as it was felt that the patient had some jaundice.
The liver function tests were all significantly elevated with
an ALT of 1433, AST [**2075**], LDH 2408, alkaline phosphatase of
69, and a total bilirubin of 0.6.
It was recommended by the Hepatology service that a right
upper quadrant ultrasound be obtained to check flow to the
patient's liver. However, it was felt that the etiology was
most likely ischemic hepatitis due to the poor forward flow
during the arrest and subsequent CABG.
The right upper quadrant ultrasound showed no obstruction, no
evidence of cholecystitis, and good blood flow to the liver.
The patient's liver function tests continued to rise. It was
also recommended by the Hepatology service that a hepatitis
panel be sent which is pending at this date.
It was noted by the nurses on postoperative day #2, that this
patient's right upper extremity was felt to be weak. It was
recommended carotid ultrasounds be obtained and patient have
a CT scan of his head. Carotid ultrasound showed that the
patient had less than 40% narrowing of his carotids
bilaterally.
Around this time, the patient also had episodes of rapid
atrial fibrillation which causes decrease in his blood
pressure requiring cardioversion. Patient had been started
on amiodarone due to the patient's elevated liver function
tests. Electrophysiology service was consulted for
alternative to amiodarone. It was recommended by
Electrophysiology service to discontinue the amiodarone due
to the patient's elevated liver enzymes. Start the patient
on digoxin for rate control should the patient go into atrial
fibrillation, and it was also recommended to switch the
patient from Lopressor to atenolol.
On postoperative day #3, patient began working with Physical
Therapy. Was able to ambulate only about 100 feet, still in
the Intensive Care Unit. Still requiring Neo-Synephrine to
maintain adequate blood pressure.
On the early morning of postoperative day three, patient
developed periods of agitation and confusion. It was felt
that this was due to Percocet. Percocet was discontinued.
Patient was given low dose Haldol, and subsequently cleared.
Patient was switched to Dilaudid for pain control. Patient's
mediastinal chest tubes were removed.
Left sided watershed stroke: Neurology thought this was
likely due to hypoperfusion. Patient's right upper extremity
weakness continued to improve. Electrophysiology service was
again reconsulted for patient's atrial fibrillation as well
as patient's preoperative ventricular fibrillation, and the
need for electrophysiology study. Echocardiogram per the EP
service, showed ejection fraction of 25-30% and it was
planned to take the patient for an EP study and question of
AICD implantation.
The day the patient was scheduled to go for his study, it was
noted the patient had elevated white blood cell count of
21,000. The case was cancelled and the patient was brought
back to [**Hospital Ward Name 121**] 2. Patient was pancultured and it was found
that patient had a mild pancreatitis. The EP service felt
that the ventricular fibrillation was likely due to his
ischemic state preoperatively. They felt that the study
could be deferred for 1-2 weeks while patient recovered from
his surgery.
A General Surgery consult was obtained for the patient's
pancreatitis. Patient's lipase was 502 with an amylase of
183 and mild left upper quadrant pain. Patient was made NPO.
CT scan of the abdomen was obtained, which showed no evidence
of significant pancreatitis. The patient continued to be
NPO.
On [**11-20**], patient's amylase and lipase were trending
downward. Patient had no abdominal pain. Was started on
clear liquids and advanced to a regular diet without any
abdominal pain. Patient's amylase and lipase continued to
trend downward. It was decided by the Electrophysiology
service that patient was safe to be discharged to home and
will return for his study.
By postoperative day #15, patient had completed a level five
with Physical Therapy, and the patient was cleared for
discharge to home.
CONDITION ON DISCHARGE: T max 99.1, pulse 80 sinus rhythm,
blood pressure 104/52, respiratory rate 16, on room air
oxygen saturation 97%. Neurologically, the patient is awake,
alert, and oriented times three. Right upper extremity has
significantly improved strength with barely perceptible
weakness. Right lower extremity and left lower extremity
have equal strength bilaterally. Heart: Regular rate and
rhythm without rub or murmur. Breath sounds are clear
bilaterally. Abdomen is soft, nontender, nondistended,
positive bowel sounds, tolerating regular diet. Sternal
incision: The staples are intact, clean, and dry. There is
no erythema or drainage. Right lower extremity vein harvest
site is clean and dry. Steri-Strips were intact. There is
minimal erythema over the medial portion of the incision.
Extremities have 1+ edema.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Preoperative ventricular fibrillation.
3. Postoperative atrial fibrillation.
4. Postoperative pancreatitis.
5. Postoperative ischemic hepatitis.
DISCHARGE MEDICATIONS:
1. Zocor 40 mg p.o. q.d.
2. Enteric coated aspirin 325 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Dilaudid 2 mg p.o. q.4-6h. prn.
5. Atenolol 100 mg p.o. q.d.
6. Digoxin 0.125 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: The patient is discharged to home in
stable condition with home Occupational and Physical Therapy.
Patient is to followup with Dr. [**Last Name (STitle) 54429**] in his office in
[**11-21**] weeks. Patient has an appointment for an
electrophysiology study on [**12-5**] at 7 a.m. Patient
will be contact[**Name (NI) **] by the Electrophysiology Department for
further instructions, and patient should see Dr. [**Last Name (STitle) 1537**] in one
month.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2121-11-24**] 12:50
T: [**2121-11-24**] 12:49
JOB#: [**Job Number 54430**]
|
[
"570",
"428.0",
"414.01",
"577.0",
"427.5",
"997.02",
"427.31",
"411.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"39.61",
"37.22",
"88.53",
"37.61",
"36.13",
"99.62",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7648, 7825
|
7848, 8040
|
8065, 8804
|
915, 6780
|
161, 781
|
803, 889
|
6805, 7627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,527
| 130,259
|
2346+55374
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-2-22**] Discharge Date: [**2150-2-25**]
Date of Birth: [**2093-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
sepsis code
Major Surgical or Invasive Procedure:
tracheostomy
foley
R sclavian triple lumen line
History of Present Illness:
56 w/hz head/neck Ca (s/p trach, recurrent aspiration PNA)
presents from [**Hospital3 672**] rehab with septic shock. Patient
admitted there from [**Hospital1 2177**] with diagnosis of aspiration pneumonia
on [**2150-1-30**]. Patient recently completed course of Levaquin/
Imipenem / Flagyl (5 days prior to admission). Patient on
[**2150-2-21**] found with tachycardia decrease o2 sats on vent (80-90 on
A/C of 100%), and decreased mental status. Labs wbc 25.1,
lactate 2.1, trop 0.31, lacatate 1.5, ua wbc 14. ekg? st
depression, xray RLL pneumonia with small pleural effusions.
At ED, was found to have fever 104.8 BP 130/83. Physical exam
wtih intact neurologically and unremarkable physical exam
Past Medical History:
Head and Neck Ca s/p XRT 96 (PEG/Trach)
history of recurrent aspiration pneumonias.
Recent discharge from [**Hospital1 2177**]
IDDM, Hep C, hz IVDU, Anxiety, PTSD
history of pericarditis ([**12-24**] hospitalizaiton)
history of MRSA pneumonia
history o pseudomonas
Social History:
has 2 daughters
Physical Exam:
on admission:
HEENT: PERRL, EMOI
CV: RRR
Neck: SOme scar tissue around trach tube
Lung: CTAB
Abd: S, NT/ND +BS
Ext: no edema or cyanosis
Neuro: follows comands, able to move all extremity
Exam on discharge
Afebrile T 99 P 48 BP 120/65 R 18 O2 100%
CVP 5-11
Vent setting of AC/ Fi O2 50 %/TV 500/ RR 18/PEEP 5
Skin: warm
HEENT: PERRL
CV: brady, regular
Lung: coartse breath sound bilaterally
Abd: +BS, tender around old PEG site, tender to percussion
Ext: no edema
Neuro: alert, appropriate, following commands
Pertinent Results:
[**2150-2-22**] 06:00AM BLOOD WBC-11.4*# RBC-2.51*# Hgb-7.3*# Hct-24.5*
MCV-97 MCH-29.2 MCHC-30.0* RDW-17.1* Plt Ct-173
[**2150-2-23**] 04:54AM BLOOD Plt Ct-214
[**2150-2-22**] 06:00AM BLOOD PT-15.1* PTT-35.2* INR(PT)-1.4
[**2150-2-22**] 06:30AM BLOOD Cortsol-110.8*
[**2150-2-23**] 10:51AM BLOOD Type-MIX pO2-46* pCO2-48* pH-7.31*
calHCO3-25 Base XS--2
[**2150-2-22**] 09:08AM BLOOD freeCa-0.89*
Stool c diff neg
Cath tip cx- negative
Sputum [**2-22**]- negative
Blood culture [**2-22**], [**2-21**]
Yeast [**2-21**]- >100,000
CXR ([**2150-2-23**])
1) Decreased right pneumothorax with residual small right apical
pneumothorax
remaining.
2) Slight improvement in pulmonary opacities in the right lung,
but worsening
opacity in the left retrocardiac area.
3) Slight overdistention of endotracheal tube cuff
Brief Hospital Course:
Septic shock: nl lactate, cortisol 36
He was started on sepsis protocol on empiric
vanc/zosyn/hydrocort and his PICC on arrival was d/c on
arrival. He later grew GNR in his sputum> He was intially
started on Vancomycin and zosyn for broad coverage. Vancomycin
was d/c and was changed to zosyn only by [**2-25**] upon finding of
psuedomonas in his sputum. He should continue on 7 more days of
zosyn upon discharge. His other cultures was unrevealing. His
urine culture also grew yeast, but this was unlikely to
represent yeast infection. He is also to continue on his
hydrocortisone and fludrocortisone for 5 more days from
discharge for empiric adrenal insuffiency ( no cortisol stimu
test was done). HIs blood pressure was stabilized. He refused CT
of his chest/abd on [**2-24**], which was intending to find the cause
of his abdominal distention
.Hypernatremia - His hypernatremia was improving w/ free water
boluses. His sodium was 145 on the day of discharge
.
History of elevated trop: He was ruled out for MI, normal
variant false chord in LV, otherwise normal echo.His CK and
troponin remained low even during the day of his discharge. He
had persistent .
Hypoxia: His 02 sats was stable at the day of discharge on the
last vent setting of AC FIo2 50%/ tidal volume 500/respiratory
rate 18/PEEP 5.
.
Feeding - (PEG pulled on last admission to [**Hospital1 2177**]. was getting TPN,
awaiting J tube)
-patient refusing J-tube. He was restarted on his TPN as of
[**2150-2-25**].
.
Endo - He is continued on sliding scale insulin
.
prophylax - He was getting lovenox as per his outpatient regimen
.
Access - left subclavian
.
Anemia - This is stable upon discharge
.
Communication -Extensive discussion w/aunt although daughters
are official healthcare proxy..
Code: DNR/DNI- He has made his intention clearly on [**2-24**] that he
does not want further invasive intervention , i.e ABG< arterial
line or NGT. He wants his code status to be DNR/DNI on the day
of discharge
Medications on Admission:
Protonix 40 mg iv, ativan 4 mg tid, morphine 2 mg iv q4, haldol
[**1-24**] mgIM q4, tylneol, tpon, lovenox 40 u sq, fentanyl 50 mcg,
bisacodyl, nicotine patch, lorazepam
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily).
4. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
5. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO
DAILY (Daily).
6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
7. Pantoprazole 40 mg IV Q24H
8. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig: One
(1) Recon Soln Injection Q6H (every 6 hours).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): please check finger stick four
times a day and given sliding scale insulin coverage
150-200-2 unit; 200-250-4 units; 250-300- 6 units; 300-350- 8
unit; 350-400- 10 units; >400-give 10 units and notify MD.
10. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
septic shock
Discharge Condition:
stable
Discharge Instructions:
please take your medications and call your doctor or 911 if you
experience chest pain, shortness of breath.
Followup Instructions:
please make appointment with your primary doctor in 2 weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Name: [**Known lastname 1805**],[**Known firstname 394**] Unit No: [**Numeric Identifier 1806**]
Admission Date: [**2150-2-22**] Discharge Date: [**2150-2-25**]
Date of Birth: [**2093-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1807**]
Addendum:
in the [**Hospital 1808**] hosp course section:
He had persistent low cardiac enzyme and no further intervention
was done.
Extensive discussion was made with the patient regarding his
code status. He did not want further invasive intervention. He
understands the risk and benefits of no further interventions (
such as arterial -line, ABd CT scan which was intended to find
out the cause of his abdominal distention). He is to be DNR/DNI
on day of discharge.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1809**]
Completed by:[**2150-2-25**]
|
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icd9cm
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[
[
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[
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[
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6223, 6231
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,737
| 130,527
|
47380
|
Discharge summary
|
report
|
Admission Date: [**2111-11-28**] Discharge Date: [**2111-12-23**]
Date of Birth: [**2044-4-5**] Sex: F
Service: NEUROLOGY
Allergies:
Ativan / Shellfish Derived / Levofloxacin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left arm shaking associated with left arm weakness and
dysarthria
Major Surgical or Invasive Procedure:
R hemicraniectomy
Trach and PEG placement
History of Present Illness:
Pt is 67 yo female with insulin-dependent diabetes, HTN s/p
renal transplant 9 years ago, cad s/p angioplasty x2 who
presents with complaints of left arm weakness and slurred speech
this morning. Ms. [**Known lastname 813**] has had shaking of the L arm and both
legs in intermittently over the past 4 months. She states that
the shaking is more a jerking movement, that is not sustained
and not rhythmic. It will occur in L arm randomly and then
either leg without a clear trigger, most often in the morning
when she wakes up and resolves on its own. She has never taken
her blood sugar at the time of these events. Her FSs range
betwen to 80s to 170s at home. She denies incontinence, tongue
biting, and post-ictal confusion. She also denies f/c, neck
stiffness, photophobia, and back pain. In addition she also
denies amaurosis fugaux. She has had no CP, N/V, LOC, cough,
pnd, dysuria.
.
She was seen in the ED yesterday for complaints of left arm
jerking/weakness and bilateral LE jerking for this yesterday and
told that it may have been due to low magnesium, which was 1.2.
She woke up at 8 am yesterday and had difficulty holding her
phone in her left arm. She felt lightheaded when she woke up,
but denied vertigo. Lightheadedness was relieved by lying down.
She was repleted with magnesium and discharged. She did not have
recurrence of these symptoms until today however this morning
she had L arm weakness as well as dysarthria and L arm weakness
which seems to have lasted only a few minutes. One of her
daughters noticed the dysarthria on the phone this morning, and
decided she should come to the ED. By the time her daughter
arrived at her apt, the dysarthria had resolved (within 30
minutes) and left arm weaknes had improved. The jerking however
has intermittently continued.
.
In the ED, patient's initial vs were: T 98.4 HR 84 BP 200/60 R
20 O2 sat 100% RA. CXR and CT head were negative. Patient had
low magnesium and phosphorous. Neuro was consulted and thought
it could be TIA vs seizure vs toxic metabolic and recommended
MRI, EEG and continued work-up. Patient was admitted to medicine
for further work up.
Past Medical History:
-s/p living-unrelated renal transplant 10 years ago for ESRD
presumably due to hypertension and diabetes, baseline Cr 1.2-1.6
-peripheral vascular disease s/p bilateral below-knee
amputations
-CAD s/p MI in [**2100**] with a stent to the LAD and a repeat MI in
[**2101**] with a repeat stent to her LAD.
-Hypertension
-DM
-GERD
-Anemia, baseline Hct 29-31
-cataracts
-Osteoporosis
-L rotator cuff tear
-legally blind
Social History:
She lives alone at [**Hospital3 400**] facility in [**Location (un) 2268**], has a
daughter who is actively involved in her care. She does not
drink or smoke, denies illicit drug use.
Family History:
Diabetes (sister), HTN (mother), heart murmur (sister),
Physical Exam:
GEN: NAD
HEENT: NCAT, anicteric, no injections, PERRLA, EOMI, MMM
Neck: supple, no rigidity, no LAD, no carotid bruit
Cor: RRR, S1s2, 2/6 SEM LUSB, no rubs or gallops
Pulm: CTA b/l
Abd:+bs, soft,nt,nd, no masses or hsm
Extrem: no cce, bka bilaterally
Neuro: A and O x3. Naming intact. + WORLD backwards. Intact
short term recall. slight facial droop on the LEFT, otherwise CN
II-XII intact. No dysarthria. 2+ reflexes UE and LEs. Strength
[**4-5**] throughout except [**3-6**] LEFT biceps. Finger nose pass pointing
with both hands. Sensation intact to gross touch throughout. No
asterexis. LEFT sided pronator drift.
Skin: no rashes or jaundice
Pertinent Results:
[**2111-12-2**] HEAD CT: Large area of hypoattenuation in the right
frontal,
parietal and temporal lobe is consistent with evolving right MCA
territory
infarct. Degree of mass effect on to the right lateral ventricle
secondary to surrounding edema is not significantly changed.
There is no hemorrhage,
hydrocephalus, shift of normally midline structure. The
[**Doctor Last Name 352**]-white matter
differentiation in the left cerebral hemisphere is preserved.
The paranasal sinuses and mastoid air cells are normally
aerated.
[**2111-12-5**] HEAD CT: Evolving right MCA territory infarction with
increase in extent and new infarction in the right putamen,
internal capsule and caudate head.
[**2111-12-8**] HEAD CT:
1. Status post right frontal craniectomy with dramatic decrease
in the shift of midline structure.
2. Unchanged infarction of the entire right anterior cerebral
and nearly the entire right middle cerebral artery distribution.
No hemorrhage is noted.
[**2111-12-12**] HEAD CT: Little interval change.
Echo: Mild symmetric left ventricular hypertrophy with preserved
global biventricular systolic function. Bubble study could not
be performed due to technical limitations involving intravenous
access.
CXR [**2111-12-22**]: Continued left basilar opacification that could
reflect atelectasis and effusion, though a supervening pneumonia
can certainly not be excluded. Mild haziness of pulmonary
vessels suggest vascular engorgement from fluid overload or CHF.
Tracheostomy tube and right central catheter remain in place.
[**2111-12-23**] 12:11PM BLOOD WBC-8.0 RBC-3.13* Hgb-7.9* Hct-24.0*
MCV-77* MCH-25.3* MCHC-33.0 RDW-17.0* Plt Ct-477*
[**2111-12-22**] 04:57AM BLOOD Glucose-155* UreaN-38* Creat-1.0 Na-139
K-4.8 Cl-109* HCO3-22 AnGap-13
[**2111-12-21**] 05:09AM BLOOD Calcium-10.0 Phos-4.1 Mg-1.7
[**2111-12-23**] 05:51AM BLOOD tacroFK-3.2*
Brief Hospital Course:
1. Limb shaking TIAs/Right MCA and ACA infarcts: The patient is
a 67 year old right handed woman with a history of CAD s/p MI
x2, hypertension, DM, PVD s/p bilateral BKA, and s/p living
un-related renal transplant 10 years prior who initially
presented to [**Hospital1 18**] on [**2111-11-28**] with a [**12-6**] month history of left
arm shaking, which on the 2 days prior to admission was
associated with left arm weakness, and 1 day prior to admission
associated with left arm weakness and dysarthria. She was
initially seen in the [**Hospital1 18**] ED on [**2111-11-27**], and her symptoms
were thought to be due to hypomagnesemia (her Mg was 1.2). She
was given supplemental magnesium and sent home. However, she
continued to have symptoms of left arm jerking on [**11-27**], but
this time it was associated with left arm weakness and
dysarthria. She was brought back to the [**Hospital1 18**] ED where bp on
admission was 188/70 but peaked at 204/68 in the ED.
Neurological exam on admission showed possible L drift and
weakness of the delts and triceps, however this is in the
context of shoulder pain. The remainder of her exam was
non-focal. She was initially admitted to medicine, as her
symptoms were thought to be myoclonus vs. TIA vs. re-expression
of an old lesion. However, the shaking of her left arm and leg
were most likely a limb-shaking TIA.
Her ASA was increased to 325 mg daily. MRI/MRA brain on [**11-27**]
showed no evidence of acute ischemia. On the morning of [**11-29**],
the patient was re-evaluted by neurology after she awakened at
4:00 am and was found to have left arm weakness. Physical exam
showed left sided neglect, left pronator drift, and slight left
hemiparesis (left delt, tri were [**3-6**]; biceps were 5-/5; WE's
[**4-5**]; bilateral IP [**4-5**]). She had a STAT MRI/MRA brain/neck on the
morning of [**11-29**] showed a new small focus of DWI abnormality of
the superior portion of the right frontal lobe is suggestive of
subacute infarction, diffuse narrowing of the A1 and M1 segment
of both internal carotid arteries. Carotid ultrasound showed
moderate to severe left ICA stenosis causing luminal narrowing
in the 60 to 69% range with poor flow through the left ICA.
Given her intracranial stenosis, her antiplatelet was changed to
Plavix 75 mg daily. Upon repeat evaluation by neurology during
the day, she was found to "not elevate arm or participate in
formal strength testing". Her mental status declined through the
day, and an LP was recommended but was unable to be obtained by
the medicine resident and attending and the neurology resident.
She triggered for mental status changes, and was transferred to
the MICU. A head CT on the evening of [**11-29**] showed a large acute
infarction in the right middle cerebral artery territory. Her
care was transferred to the NeuroICU team.
Given her large R MCA stroke, on [**11-30**] she was Plavix loaded
with 300 mg PO x1, then continue Plavix 75 mg daily. A repeat
Head CT on [**12-5**] showed evolving right MCA territory infarction
with increase in extent and new infarction in the right putamen,
internal capsule and caudate head. On [**12-7**], the patient had
increased somnolence, and a repeat Head CT showed dramatic
increase in mass effect and right-to-left midline shift with
infarction of the entire right anterior cerebral artery and
nearly the entire right middle cerebral artery distributions.
This was discussed with the patient's family, who decided they
wanted everything done for the patient. Neurosurgery was
consulted, and the patient had a right hemicraniectomy on [**12-7**].
She received 20 cc of 23.4% Normal Saline prior to surgery.
Prior to the surgery, she was found to have brief episodes of
rhythmic movements of her right arm and leg, which were thought
to be either seizure vs. limb shaking TIA due to edema around
her left ACA from the midline shift. She was Dilantin loaded,
which was subsquently changed to Keppra given the interactions
between Dilantin and Tacrolimus. Her Plavix was discontinued
prior to the surgery, and she has subsequently been restarted on
ASA 81 mg daily on [**12-10**].
Patient's labetalol was titrated upto 500 [**Hospital1 **] (home dose was 400
[**Hospital1 **]). Her FLP showed Chol 159, TG 115, HDL 60, LDL 76, so her
Atorvastatin was increased to 80 mg qhs. Hypercoaguable work up
showed homocysteine slightly up at 13.5, lupus anticoagulant
negative; Prot C 92% (nl), Prot S 54% (nl), AT III 70% (nl), ACA
Ab normal, prothrombin negative.
2. Renal: Nephrology transplant was consulted on admission given
her history of living unrelated donor renal transplant. She was
continued on Prednisone 2.5 mg daily. Her Prograf was increased
to 8 mg [**Hospital1 **] given low levels in the setting of previously
receiving Dilantin. Her Cellcept was held after the
hemicraniectomy per renal recommendations given fevers and
post-op status. Her Cr initially ranged 1.3-1.5, but increased
from 1.4->2.8 on [**12-5**] (likely prerenal), and trended back down
with IVF. Renal transplant ultrasound showed no transplant
hydronephrosis or peritransplant collection, patent transplant
vasculature.
Patient will be following up with Dr. [**Last Name (STitle) **] and Cellcept is
held until told otherwise per renal recommendation. Tacrolimus
was continued and renal recommends once weekly check of
tacrolimus level and the result should be forwarded to Dr.
[**Last Name (STitle) **].
3. Insulin dependent diabetes: HgA1c 7.1% on admission. The
patient was transferred back to the NeuroICU on [**12-5**] given FSBGs
in the 400s despite being placed back on her home doses of 70/30
once tolerating PO foods. She was placed on regular insulin gtt,
and [**Last Name (un) **] was consulted. She was transitioned to Lantus 70 qhs
and RISS.
4. Hematology: The patient's Hct initially ranged 27-31, but
decreased to 23-25 after the hemicraniectomy. Her Hct decreased
to 20.4 on [**12-11**], and she received 1 U PRBCs. Stools were guaiac
negative. Medicine was consulted who recommended checking
hemolysis labs which showed LDH 271-278, hapto 334-375, T bili
normal. Retic count 1.8-3.0. Fe studies: Fe 55, ferritin 1099,
TIBC 195. Patient's hct ranging between 22~25 at the time of
discharge.
5. ID: The patient continued to spike fevers during the
admission. Urine culture [**12-5**] showed 3000 GNR, 1000 GNR#2, 1000
GNR#3 and [**2102**] GPB. She was initially on Bactrim, which was
changed to CTX x3 days. Given that she is immunosuppressed, this
was changed to Vanc/Zosyn. All other blood, urine, and C. diff
cultures showed no growth. ID was consulted given that she was
spiking fevers and was immunosuppressed and recommended
vancomycin and ceftazidime for 14 days and the last day of ABX
is [**2112-1-3**].
6. Respiratory: The patient was electively intubated prior to
the R hemicraniectomy, and required trachestomy. She tolerated
weaning off the ventilation and is currently stable and satting
well with trach mask only even overnight. She requires
suctioning every ~4 to 6 hrs.
7. GI/FEN: PEG was placed as well and patient is at goal for
TFs.
Medications on Admission:
-ASA 81 mg daily
-Lipitor 40 mg qhs
-Labetolol 400 mg [**Hospital1 **]
-Humulin 70/30 34 u qam and 10 units qhs
-Cellcept [**Pager number **] mg [**Hospital1 **]
-Prednisone 2.5 mg daily
-Prograf 5 mg [**Hospital1 **]
-Lactulose 30 ml daily
-Protonix 40 mg daily
-MVI daily
-Calcium 600 + Vitamin D 1 tablet [**Hospital1 **]
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): 14 day course,
[**Date range (2) 100272**].
2. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours): 14 day course, [**2111-12-21**] -
[**2112-1-3**].
3. Tacrolimus 1 mg Capsule Sig: Eight (8) Capsule PO Q12H (every
12 hours).
4. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) U
Subcutaneous at bedtime.
6. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) U
Subcutaneous QACHS: per sliding scale attached.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
16. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
18. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
19. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q8H
(every 8 hours).
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
21. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
22. Labetalol 200 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Right MCA and ACA infarct s/p R hemicraniectomy
Secondary:
HTN
CKD s/p renal transplant
DM
hx of bilateral BKA
Discharge Condition:
Opens eyes to voice, follows some motor commands especially with
R arm and leg, some spontaneous movement of right arm and leg
with resistance, and reflexive withdrawal of left arm with pain
Discharge Instructions:
You were admitted with numbness and weakness in your left arm
and slurred speech. This was thought to be due to a stroke in
the right side of your brain. Unfortunately there was swelling
from the stroke, requiring a surgical procedure (right
hemicraniectomy) to relieve the pressure.
Please take all medications as directed. Please also get
regular labs including CBC at least 3x/week (MWF) initially
given known but significant anemia. If stable, frequency may be
decreased. Once all numbers Also, you need at least weekly labs
including tacrolimus level - please check [tacrolimus] every
Friday and forward the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 100273**]
(nephrology) for further instructions.
Please follow-up with all outpatient appts.
Please call your doctor or return to the ED if you experience
any fever, chest pain, difficulty breathing, weakness/numbess in
your body or any other concerning symptoms.
Followup Instructions:
Renal: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 673**], Monday [**2111-12-28**] at
2:40 PM.
Neurology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2112-1-22**] at 2:30 PM. [**Hospital Ward Name 23**] 8, [**Hospital Ward Name 5074**], [**Hospital1 18**] ([**Location (un) **])
Neurosurgery: Dr. [**First Name (STitle) **], [**Telephone/Fax (1) 1669**], [**Hospital **] Medical Building,
[**Last Name (NamePattern1) **], [**Hospital Unit Name 12193**]. CAT SCAN Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2112-1-28**] 11:45 and with Dr. [**First Name (STitle) **] at 1pm.
Completed by:[**2111-12-23**]
|
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icd9cm
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[
[
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15343, 15422
|
5869, 12977
|
378, 422
|
15587, 15780
|
3978, 3994
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16789, 17480
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3240, 3297
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13352, 15320
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15443, 15566
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3312, 3959
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450, 2583
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2605, 3023
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,966
| 125,540
|
12690
|
Discharge summary
|
report
|
Admission Date: [**2107-12-19**] Discharge Date: [**2107-12-23**]
Date of Birth: [**2044-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Transfer from other hospital for catheterization for NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
Repair of femoral artery injury
History of Present Illness:
Transfer for cath
.
History of Present Illness: 63 male with DM2, HTN, CAD (s/p CABG
[**2091**]), lipids, chronic AF who was admitted to [**Hospital3 **] [**2107-12-14**]
with a complaint of chest pain, exertional, assoc with
diaphoresis; ntg did not help. His HR was poorly controlled at
the time (170s) and he was started on dilt IV with good effect.
He had elevated biomarkers at the outside hospital; the decision
was made to transfer him to [**Hospital1 18**] for catheterization. ECG
without ischemic change. he was started on lovenox treatment
dose, warfarin stopped, given [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin, beta blocker.
.
He was also complaining of back pain, and an MRI showed
compression fractures that will need neurosurg evaluation.
.
Review of Systems: As above, otherwise feels well.
Past Medical History:
Myasthenia [**Last Name (un) 2902**]
CAD s/p CABG [**2091**]
Hypertension
Dyslipidemia
Atrial flutter
Diabetes Mellitus
Social History:
Quit tobacco [**2094**]; rare drink; lives with his wife; currently on
disability.
Family History:
nc
Physical Exam:
T 99.2 / HR 79 / RR 10 / BP 110/67 / 96% O2 Sats on 3L
Gen: sitting comfortably in bed, no acute distress, obese
HEENT: Clear OP, MMM; right eye hematoma
NECK: Supple, thick neck, difficult to assess JVD
CV: irregularly, irregular, NL rate. NL S1, S2. No murmurs, rubs
or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: obese; [**5-15**] inch ventral hernia - easily reducible,
nontender; Soft, NT, ND. NL BS.
EXT: 1+ edema to mid-shins. 1+ DP/PT pulses BL; right groin
hematoma with ecchymoses; tender to palpation; drain in place
draining bright red blood
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2107-12-20**] 04:08AM BLOOD WBC-17.0* RBC-3.32* Hgb-10.1* Hct-29.1*
MCV-88 MCH-30.3 MCHC-34.6 RDW-15.9* Plt Ct-234
[**2107-12-23**] 06:30AM BLOOD WBC-10.0 RBC-3.34* Hgb-9.6* Hct-29.8*
MCV-89 MCH-28.6 MCHC-32.1 RDW-16.5* Plt Ct-217
[**2107-12-23**] 06:30AM BLOOD PT-11.5 PTT-23.4 INR(PT)-1.0
[**2107-12-20**] 01:29AM BLOOD Glucose-141* UreaN-17 Creat-0.8 Na-138
K-4.0 Cl-108 HCO3-25 AnGap-9
[**2107-12-20**] 04:08AM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-139
K-4.3 Cl-109* HCO3-25 AnGap-9
[**2107-12-23**] 06:30AM BLOOD Glucose-94 UreaN-23* Creat-1.1 Na-142
K-4.1 Cl-105 HCO3-31 AnGap-10
[**2107-12-20**] 01:29AM BLOOD CK(CPK)-31*
[**2107-12-20**] 09:40AM BLOOD CK(CPK)-53
[**2107-12-20**] 09:25PM BLOOD CK(CPK)-49
[**2107-12-21**] 08:00AM BLOOD CK(CPK)-38
[**2107-12-20**] 01:29AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2107-12-20**] 09:40AM BLOOD CK-MB-NotDone cTropnT-0.34*
[**2107-12-20**] 09:25PM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2107-12-21**] 08:00AM BLOOD CK-MB-NotDone cTropnT-0.37*
[**2107-12-20**] 01:29AM BLOOD Calcium-7.6* Phos-3.8 Mg-1.7
[**2107-12-23**] 06:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
[**2107-12-22**] 06:15AM BLOOD Digoxin-0.4*
[**2107-12-19**] 11:27PM BLOOD Glucose-151* Lactate-1.6 Na-136 K-4.3
.
[**2107-12-19**] ECG: Atrial flutter with variable A-V block.
Non-specific diffuse ST-T wave changes.
No previous tracing available for comparison.
.
[**2107-12-19**] cath: 1. Selective coronary angiography of this right
dominant system
demonstrated native 3 vessel coronary artery disease. The LMCA
was
non-obstructed. The LAD was occluded in its mid vessel. The LCX
had a
90% proximal stenosis in the OM. The RCA was occluded distally
and was
filled by right to right collaterals. The SVG-D had an 80%
ostial and a
90% mid vessel stenoses. The SVG-ramus was non-obstructed. The
SVG-RCA
was occluded. The LIMA-LAD was widely patent but the LAD was
occluded
beyond the touchdown.
2. Limited resting hemodynamics were performed. The left sided
filling
pressures were mildly elevated (LVEDP was 17mmHg). The systemic
arterial
pressures were within normal range measuring 110/72mmHg. There
was no
significant gradient across the aortic valve upon pull back of
the
catheter from the left ventricle to the ascending aorta.
FINAL DIAGNOSIS:
1. Native 3 vessel coronary artery disease.
2. Patent SVG-D, SVG-RCA and LIMA-LAD. Occluded SVG-RCA.
3. Mildly elevated left sided filling pressures.
.
[**2107-12-20**] tte: The left atrium is elongated. The right atrium is
moderately dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity
size is normal. Due to suboptimal technical quality, a focal
wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall
motion are normal. The aortic root is mildly dilated. The
ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral
valve prolapse. There is no pericardial effusion.
IMPRESSION:
Moderate left ventricular hypertrophy with preserved overall
preserved
biventricular function. Due to technically suboptimal images, a
regional wall
motion abnormality cannot be fully excluded.
Brief Hospital Course:
.
Briefly, Mr. [**Known lastname 7493**] is a 63 male patient with a history of CAD,
now s/p CABG, myasthenia [**Last Name (un) 2902**], atrial fibrillation / flutter,
diabetes, who presented as a transfer from [**Hospital3 **] Hospital
after he was found to have an NSTEMI. He had been noting
exertinal dyspnea and chest discomfort. He had elevated
biomarkers there, and on arrival he was taken to the cardiac
cath lab, where a cypher DES was placed to SVG to D1. He also
had disease in his LCx/OM, and this was planned to be intervened
on in a staged fashion later in the week. He was continued on
his beta blocker and ace inhibitor, as well as aspirin. He was
started on clopidogrel, and the importance of taking this
medication every day was stressed. His statin was also
continued.
.
The evening after the cath, the sheath was pulled from his right
groin. He developed a lot of bleeding at this site. IT was
felt that the bleeding could not be controlled due to damage to
the femoral vessel sustained during catheter insertion. The
bleeding was significant, and eventually required three units of
PRBC. He was taken to the operating room that night and had an
emergent right common femoral artery injury repair with
evacuation of hematoma. He was transferred to the cardiac
intensive care unit for the night following that surgery. He
remained stable following this procedure. His groin had a JP
drain for 24 hours after the surgery, which had minimal drainage
and was removed by the vascular surgery team. He maintained
good pulses distally after the procedure.
.
Due to the complication with the groin bleed, as well as the
guaiac positive stools taht will be discussed later, the
decision was made to not pursue the second catheterization
during this admission. He was given follow up plans with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] to disucss this.
.
Prior to being transferred, and once during the admission, he
had a dark brown, guaiac positive stool. Subsequent to this,
his bowel movements became lighter in color, (normal per his
report), and his hematocrit was completely stable without any
trasnfusions for 72 hours. He was changed from an H2 blocker to
[**Hospital1 **] PPI therapy with protonix for 4 days. ON discharge, he was
continued on protonix. He will likely need endoscopic
evaluation, but unless it becomes emergent, will try to avoid
while on [**Hospital1 4532**]. He likely has some element of gastritis / PUD
on chronic prednisone therapy.
.
He was consistently in atrial flutter during the
hospitalization. When transferred to the CCU, he was noted to
go fast to the 150s,and with tenuous blood pressure, he was
given IV digoxin and started on a PO regimen. He was continued
on his beta blocker, and the dose was increased.
.
He was not in clinical heart failure during the admission. He
did develop some LE edema, which he says is not abnormal for
him. He was re-started on PO lasix, and was instructed to
resume his home regimen until his swelling resolves. He was
contiuned on his ACE i and hydralazine.
.
His myasthenia [**Last Name (un) 2902**] was stable. His primary neurologist, Dr.
[**First Name (STitle) **], was [**Name (NI) 653**], and [**Name2 (NI) 39183**] no deviation from his
current treatment plan, consisting of imuran and prednisone. He
has been on 60mg prednisone since [**2107-2-9**]. The plan, per
Dr. [**First Name (STitle) **], is to uptitrate the imuran and decrease the
prednisone. Ultimately, the goal is to get to cell cept when it
is covered by his insurance. His pyridostigmine was continued
at his home regimen of 6/day and sustained release at night.
.
He was also transferred to [**Hospital1 18**] on levaquin for question of a
lingular pnuemonia. GIven a relative leukocytosis (not expected
to still be this elevated after such chronic steroid use), it
was continued to complete a 7 day course. It was stopped on the
day of discharge, and his WBC was within normal limits.
.
His diabetes was controlled with his oral hypoglycemic and an
insulin sliding scale. It is possible that he will need insulin
therapy at home.
.
His code status was full during this admission.
Medications on Admission:
.
Medications at home:
Mestinon
Prednisone 60 qd
Lisinopril 10 qd
Hydralazine 10 tid
Metoprolol 75 qd
Ranitidine 150 [**Hospital1 **]
Warfarin 5 qd
Glipizide 2.5 qd
Crestor 10 qd
Imuran 50 [**Hospital1 **]
.
Medications on transfer:
Pyridostigmine 20mg 6x/day and 80mg qhs
Prednisone 60 qd
Lisinopril 10 qd
Hydralazine 10 tid
Pepcid 20 [**Hospital1 **]
Glyburide 2.5 qd
RISS
Aspirin 325 qd
Colace
Atorvastatin 20 qd
Clopidogrel 75 qd
Metoprolol 75 [**Hospital1 **]
Lovenox q12
Imuran
50 [**Hospital1 **]
Levaquin 250 qAM (started [**2107-12-15**]) for pos. infiltrate
Discharge Medications:
1. Outpatient Lab Work
Please check CBC on Sunday [**2107-12-25**] at your local lab. Please
have result paged to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] at [**Telephone/Fax (1) 33138**].
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) serving
PO 6X/D (6 times a day).
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Pyridostigmine Bromide 180 mg Tablet Sustained Release Sig:
One (1) Tablet Sustained Release PO QHS (once a day (at
bedtime)).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for swelling.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease, s/p drug eluting stent
Atrial flutter
Right femoral artery injury, s/p surgical repair
Myasthenia [**Last Name (un) 2902**]
Pneumonia
Discharge Condition:
Good, afebrile, tolerating PO diet,
Discharge Instructions:
If you experience any chest pain, difficulty breating, bleeding,
lightheadedness, or any other concerning symptom, please seek
immediate medical attention.
.
Please continue to take all medications as prescribed. Please
resume your lasix (one tablet daily) until your swelling is
improved.
.
Please keep all follow up appointments.
.
You are not on coumadin now becuase of the bleeeding your bowel
movements. YOu will need to address this with your primary
doctor, and should not resume for two weeks.
.
You should follow up with Dr. [**Last Name (STitle) 7047**] regarding your cardiac
cath and groin bleed on Tuesday.
.
Please refrain from strenuous physical activity until you see
Dr. [**Last Name (STitle) 7047**].
Followup Instructions:
Dr. [**Last Name (STitle) **] in two weeks.
.
Dr. [**Last Name (STitle) 7047**] Tuesday [**2107-12-27**] at BGPMA, call [**Doctor First Name **] at
[**Telephone/Fax (1) 24523**] for appt.
.
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80,027
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41381
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Discharge summary
|
report
|
Admission Date: [**2110-10-8**] Discharge Date: [**2110-10-9**]
Date of Birth: [**2024-1-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86yoM with h/o 3v CABG [**24**] yrs ago, now s/p NSTEMI and cath in
[**4-/2110**] showing all grafts down who presented with chest
tightness since 9pm radiating to his right arm. CP began while
he was getting ready for bed. He denied associated SOB,
diaphoresis, nausea/vomiting. He took 3 SL NTG at home without
relief and was given an ASA by EMS.
.
In the ED: 97.9 p113 144/92 18 97% 4L Nasal Cannula. He denied
SOB, n/v, fevers, chills, cough/cold sxs. EKG showed sinus 122,
normal axis/intervals, STD in I, II, aVL, and V3-6. He was pain
free after on sublingual NTG. He was started on Heparin bolus +
gtt.
.
Vitals before admission: p125 127/78 16 98%2L --> p114 21 99%2L
133/76 98.2 --> 132/76 p81 18 97%2L
.
Of note, per chart review it appears that pt had cath at BU in
[**2102**] in which re-do CABG was offered, but pt refused. Then,
admitted to [**Hospital1 18**] in [**4-/2110**] with NSTEMI and taken to cath, which
showed all SVG's occluded, and had 60% LMCA and a lot of
stenoses in his LCx system. He was deemed poor surgical
substrate, so maximal medical management was pursued with
increase in ASA to 325, started on Plavix and Lisinopril.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
- CABG: 25 yrs ago in [**State 108**] (SVG-RCA, SVG-LAD, SVG-OM1)
- Cath at BU [**2102**] (SVG-LAD occluded at origin, SVG-OM widely
patent, SVG-RCA occluded at origin, 50% LM disease, normal LVEF)
-> redo CABG offered pt and he refused
- [**4-/2110**]: Admitted to [**Hospital1 18**] with NSTEMI, cath showed distal LMCA
60% stenosis, LAD proximally totally occluded, LCx had several
large ramus branches with moderate disease and long 80% lesion
at mid LCx, RCA totally occluded at mid-segment with
right-to-right collaterals. The SVG-PDA, SVG-LAD, and SVG-OM
grafts were all occluded.
3. OTHER PAST MEDICAL HISTORY:
- GERD
- Prostate cancer with urinary incontinence
- Anxiety
- Esophageal stricture
- Severe athritis (motorized wheel chair)
- Spinal stenosis
Social History:
Lives in [**Hospital1 392**] in an [**Hospital3 **] facility. Drinks 1 scotch
per night. No tobacco. No illicts.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non contributory.
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. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
ON DISCHARGE:
T97.6, P 78, BP 104/78
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS
[**2110-10-8**] 10:05PM PTT-69.7*
[**2110-10-8**] 03:52PM PT-12.7 PTT-84.8* INR(PT)-1.1
[**2110-10-8**] 08:55AM GLUCOSE-120* UREA N-18 CREAT-1.1 SODIUM-143
POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-17* ANION GAP-17
[**2110-10-8**] 08:55AM CK-MB-23* cTropnT-0.22*
[**2110-10-8**] 08:55AM WBC-5.3 RBC-3.68* HGB-13.5* HCT-36.5* MCV-99*
MCH-36.6* MCHC-36.9* RDW-13.3
[**2110-10-8**] 02:20AM cTropnT-0.02*
CPK ISOENZYMES CK-MB cTropnT
[**2110-10-8**] 08:55 23* 0.22*
ADMISSION EKG
Regular narrow complex rhythm at a tachycardic
rate, probably non-sinus supraventricular rhythm or atrial
tachycardia. P wave
may be positive in lead aVR and negative in lead I. There is
leftward axis.
Possible Q waves in early precordial leads. There are marked ST
segment
depressions in leads I, II and aVL with reciprocal change in
lead aVR. There
are deep ST segment depressions in leads V3-V6. There are
occasional
ventricular premature beats. Compared to the previous tracing of
[**2110-5-2**]
the rate is much faster. ST-T wave abnormalities are more
marked. Ventricular
premature beat is new. Clinical correlation is suggested.
ADMISSION CXR:
Single portable chest radiograph excludes bilateral lung apices
from view. The patient is status post CABG with sternotomy
sutures midline
and intact. Heart size is top normal. There is a prominence of
the central
pulmonary vasculature which may indicate mild pulmonary edema.
Lungs are
clear. No pleural effusion or pneumothorax evident.
DISCHARGE EKG
robably non-sinus supraventricular rhythm with occasional
atrial premature beats. Since the previous tracing ST-T wave
abnormalities
are less prominent.
DISCHARGE LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV
MCH MCHC PL Ct
[**2110-10-9**] 04:18
6.5 3.54* 12.4* 35.2* 99* 35.1* 35.3* 174
[**2110-10-9**] 04:18AM BLOOD Glucose-110* UreaN-17 Creat-1.0 Na-140
K-3.8 Cl-109* HCO3-20* AnGap-15
[**2110-10-9**] 04:18AM BLOOD Calcium-10.3 Phos-3.1 Mg-2.2
Brief Hospital Course:
6 year-old Male with PMH CAD s/p CABG with known total graft
occlusion presents with chest pain and dynamic ECG changes.
.
#unstable angina: patient presented with anginal chest pain.
EKG showed sinus 122, normal axis/intervals, STE aVR STD in I,
II, aVL, and V3-6. GIven patient's previous history of failure
of his coronary grafts and an overall poor surgical candidate he
was medically managed with IV metoprolol and heparin. Patient
was not considered for cardiac cath given the demand nature of
his symptoms and degree of overall coronary disease. After rate
control with metoprolol patient's chest pain resolved and
patient's EKG changes resolved. Afterload reduction was further
achieved with isosorbide mononitrate. He was continued on
asprin, plavix and transitioned to 100 mg metoprolol succinate
prior to discharge. Patient should consider addition of
Ranolazine for chronic angina as an outpatient.
.
# CAD: Patient presented with known history of CAD s/p CABG with
occluded grafts. His CAD was medically managed with aspirin,
plavix and lisinopril at his home doses. While an inpatient he
was started on atorvostatin 80 mg and his metoprolol was changed
to 100 mg of succinate prior to discharge.
.
# HLD- Patient was changed from simvastatin to atorvastatin 80mg
and his ezetimibe discontinued prior to discharge.
.
# GERD- patient was treated with 40 mg pantoprazole daily while
inpatient and discharged on his home regimen.
.
# Prostate cancer with urinary incontinence: not an active
issue while inpatient.
.
# Anxiety: patient's diazepam was held while in the hospital
out of concern for precipitating delirium. Patient did receive
a dose of trazadone for difficulty sleeping.
.
# Esophageal stricture: not an active issue while inpatient.
.
#Severe athritis: patient uses a motorized wheel chair at home.
Prior to discharge he was evaluated by physical therapy who
recommended a visiting nurse visit him at home and did not
believe he needed additional rehab.
.
# Spinal stenosis: not an active issue while inpatient.
.
TRANSITIONAL ISSUES:
-patient's ezetimibe was discontinued prior to discharge
-patient was started on metoprolol succinate 100 mg daily
-patient was switched to atorvastatin 80 mg
-would recommend Ranolazine for chronic angina as an outpatient.
Medications on Admission:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. megestrol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
12. nitroglycerin 0.4 mg Tablet, Sublingual Sig: as directed
Sublingual as needed: If you experience chest pain place 1 pill
under your tongue. If the pain persists after [**Street Address(2) 90078**]
another pill under the tongue. [**Month (only) 116**] take a total of 3 pills
separated by 5 mins each. If pain persists call your doctor.
[**Last Name (Titles) **]:*30 tablets* Refills:*2*
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
- Unstable Angina
- Dyslipidemia
- GERD
- Prostate cancer with urinary incontinence
- Anxiety
- Esophageal stricture
- Severe athritis (motorized wheel chair)
- Spinal stenosis
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 with chest pain which was felt
to be from low blood flow to your heart. You were given
medications to help improve this blood flow which relieved your
pain. Several of your medications were changed while in the
hospital. You will need to follow up with your cardiologist Dr.
[**Last Name (STitle) 10543**] in the next week. Please weigh yourself daily and if you
notice that you gain more than 3 pounds in 3 days contact your
cardiologist immediately as this may be a sign of worsening
heart failure.
The following changes have been made to your medications:
- CHANGED metoprolol tartrate 50 mg Tablet PO BID to METOPROLOL
SUCCINATE 100 mg DAILY.
- STOP ezetimibe 10 mg DAILY
- STOP simvastatin 40 mg Tablet 1 Tablet DAILY
- START Atorvastatin 80 mg Tablet Daily
- CONTINUE megestrol 20 mg (1) Tablet 2 times a day.
- CONTINUE alprazolam 0.25 mg (1) Tablet 2 times a day
- CONTINUE isosorbide mononitrate 30 mg daily
- CONTINUE omeprazole 20 mg Daily
- CONTINUE aspirin 325 mg DAILY
- CONTINUE multivitamin Tablet DAILY
- CONTINUE Plavix 75 mg once a day
- CONTINUE lisinopril 5 mg once a day
- CONTINUE nitroglycerin 0.4 mg Tablet as needed: If you
experience chest pain place 1 pill under your tongue. If the
pain persists after [**Street Address(2) 90078**] another pill under the tongue.
[**Month (only) 116**] take a total of 3 pills.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt: [**10-17**] at 2:15pm
|
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"724.00",
"716.90",
"414.02",
"530.81",
"530.3",
"V46.3",
"272.4",
"300.00",
"V10.46",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11244, 11315
|
6859, 8915
|
310, 317
|
11536, 11536
|
4824, 6836
|
13130, 13428
|
3032, 3147
|
10584, 11221
|
11336, 11515
|
9188, 10561
|
11712, 13107
|
3162, 3162
|
2121, 2709
|
3986, 4805
|
8936, 9162
|
264, 272
|
345, 2041
|
3176, 3972
|
11551, 11688
|
2740, 2885
|
2063, 2101
|
2901, 3016
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,941
| 107,962
|
34099
|
Discharge summary
|
report
|
Admission Date: [**2144-7-16**] Discharge Date: [**2144-9-18**]
Date of Birth: [**2085-7-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
tachypnea, increased oxygen requirement
Major Surgical or Invasive Procedure:
Intubation
Extubation
Right sided thoracentesis
History of Present Illness:
59 year old female with mental retardation, anemia, ileus and
volvulus s/p resection and recent hospitalization with
pericardial effusion and new mediastinal mass with diffuse
lymphadenopathy presents with recurrent tachypnea and increased
oxygen requirement. Patient was discharged from [**Hospital1 18**]
approximately one week ago back to her group home. During her
last hospitalization she was found to have a pericardial
effusion with evidence of tamponade and this was drained. She
then developed a-fib with RVR that was suppressed with verapamil
and metoprolol. She was also noted to have a large mediastinal
mass and diffuse lymphadenopathy. Pericardial fluid and lymph
node FNA both did not show clear evidence of malignancy. She was
discharged to her group home acute care facility and recommended
to have entire excision of her egg-sized left axillary lymph
node for further diagnosis.
She now represents with tachypnea and increased oxygen
requirement. At her home she was noted to be more tachypnic with
slightly increased O2 requirement. She has needed intermittent
oxygen and occasionally refuses it. The patient has history of
tachypnea during her last hospitalization that resolved with
sitting up (may have been mechanical from her large
abdomen/ileus) and with nebulizer treatments. At
[**Hospital3 1196**] ED she received solumedrol 125mg once,
sasix 20mg IV once, zosyn 1 dose. CTA chest showed no evidence
of PE, small bilateral pleural effusion, moderate pericardial
effusion and large mediastinal mass encasing and narrowing the
SVC, extensive lymphadenopathy. No comment was made on a
consolidation. She was in normal sinus rhythm and had a negative
first set of cardiac enzymes. She was transferred to [**Hospital1 18**] for
further evaluation.
History is difficult to obtain from the patient. She often says
yes to all questions. When asked if she has pain, she does point
to her distended abdomen and to her chest.
Past Medical History:
- h/o mediastinal mass and diffuse lymphadenopathy; s/p FNA,
diagnosis unclear
- h/o pericardial effusion s/p drainage; path/cytology
inconclusive
- h/o paroxysmal a-fib w/ RVR s/p pericardiocentesis; no
anticoagulation 2/2 blood pericardial effusion
- Mental retardation of unknown etiology.
- h/o ileus requiring occasional rectal tube
- Status post volvulus and colonic resection.
- DJD.
- Bilateral knock knees (talus valgus, pes planus).
- Neurodermatitis.
- Psoriasis.
- History of obesity.
- Status post left oophorectomy.
- microcytic anemia 28.5
- GERD
Social History:
Patient lives at [**Location 18355**] Center for mentally disabled. Her HCP
is her brother [**Name (NI) **].
Family History:
Father died of prostate cancer, CABG, MIs; he also had colon CA.
maternal aunt with ovarian and breast cancer. MI and CAD
throughout family on both sides. Mother is still living.
Physical Exam:
VS: T 98.4 SBP 120/68 pulsus 6 HR70s RR30s 94% on 4L
GEN'L: pale, obese, talkative and fairly comfortable
HEENT: nc/at, MMM slightly dry, edentulous with poor dentition
NECK: no JVP appreciated
LN: no clear submandibular/anterior cervical or supraclavicular
LN noted; pt did not allow palpation of axillary LN (ticklish)
CVS: NR/RR, clear heart sounds, +s1/s2, no clear murmurs
PUL: soft expiratory wheezes, no clear [**First Name9 (NamePattern2) **]
[**Last Name (un) **]: +BS (normal), distended, soft, old abdominal surgical
scar, +tympany, no tenderness to deep palpation, no clear
masses, organs not palpated
EXT: marked edema to thighs, deformed feet, pulses not
appreciated LE, 2+ radial, lower extremities cool, no edema of
upper
GU: deferred; foley in place
NEURO: alert, oriented to name. Moves all four extremities. Has
difficulty complying with exam. Able to pull herself up to sit
on her own.
Pertinent Results:
OSH labs:
u/a trace blood, otherwise negative
trop <0.01
CK 7
total protein 6.1
T. bili 0.6, ast 24, alt 35, alk phos 281
BNP 153
ABG: 7.35/59/74/32 on 5L
IN-HOUSE LABORATORY RESULTS:
K:4.1
Lactate:1.2
HEMOLYZED SLIGHTLY
141 103 15
-------------< 155
4.3 29 0.4
Ca: 9.3 Mg: 1.8 P: 4.5
MCV 82
12.6 > 8.3 < 472
----------------
28.1
N:97.4 L:1.9 M:0.5 E:0.1 Bas:0.1
Labs at admission and discharge
[**2144-9-17**] 09:20AM BLOOD WBC-7.5 RBC-2.36*# Hgb-7.3*# Hct-22.3*#
MCV-94 MCH-30.9 MCHC-32.7 RDW-20.8* Plt Ct-524*#
[**2144-9-17**] 12:00AM BLOOD WBC-5.0# RBC-4.14*# Hgb-12.7# Hct-40.1#
MCV-97 MCH-30.7 MCHC-31.7 RDW-20.5* Plt Ct-273
[**2144-9-16**] 09:00AM BLOOD WBC-10.9 RBC-2.62* Hgb-8.2* Hct-25.6*
MCV-98 MCH-31.3 MCHC-32.1 RDW-21.0* Plt Ct-450*
[**2144-7-17**] 05:15AM BLOOD WBC-13.4* RBC-3.21* Hgb-7.6* Hct-26.7*
MCV-83 MCH-23.6* MCHC-28.4* RDW-16.3* Plt Ct-465*
[**2144-7-16**] 10:02AM BLOOD WBC-12.6* RBC-3.44* Hgb-8.3* Hct-28.1*
MCV-82 MCH-24.1* MCHC-29.5* RDW-16.3* Plt Ct-472*
[**2144-9-17**] 09:20AM BLOOD Neuts-94.5* Bands-0 Lymphs-2.6* Monos-2.2
Eos-0.6 Baso-0.2
[**2144-7-16**] 10:02AM BLOOD Neuts-97.4* Lymphs-1.9* Monos-0.5*
Eos-0.1 Baso-0.1
[**2144-9-17**] 09:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2144-9-16**] 09:00AM BLOOD Plt Ct-450*
[**2144-9-17**] 09:20AM BLOOD Plt Smr-NORMAL Plt Ct-524*#
[**2144-7-16**] 10:02AM BLOOD Plt Ct-472*
[**2144-7-17**] 05:15AM BLOOD PT-15.9* PTT-25.8 INR(PT)-1.4*
[**2144-9-17**] 12:00AM BLOOD PT-13.7* PTT-39.3* INR(PT)-1.1
[**2144-9-17**] 12:00AM BLOOD Fibrino-694*
[**2144-7-21**] 04:43AM BLOOD D-Dimer-752*
[**2144-9-16**] 01:49AM BLOOD Gran Ct-8330*
[**2144-9-15**] 12:00AM BLOOD Gran Ct-8325*
[**2144-7-28**] 12:00AM BLOOD Gran Ct-[**Numeric Identifier **]*
[**2144-7-20**] 05:30AM BLOOD ESR-107*
[**2144-9-16**] 04:15AM BLOOD Ret Aut-6.4*
[**2144-8-20**] 05:55AM BLOOD Ret Aut-0.6*
[**2144-9-17**] 12:00AM BLOOD Glucose-113* UreaN-14 Creat-0.3* Na-134
K-3.5 Cl-102 HCO3-27 AnGap-9
[**2144-9-16**] 01:49AM BLOOD Glucose-102 UreaN-12 Creat-0.3* Na-136
K-3.3 Cl-105 HCO3-25 AnGap-9
[**2144-7-17**] 05:15AM BLOOD Glucose-169* UreaN-21* Creat-0.4 Na-140
K-4.4 Cl-102 HCO3-32 AnGap-10
[**2144-7-16**] 10:02AM BLOOD Glucose-155* UreaN-15 Creat-0.4 Na-141
K-4.3 Cl-103 HCO3-29 AnGap-13
[**2144-9-14**] 12:00AM BLOOD estGFR-Using this
[**2144-9-17**] 12:00AM BLOOD ALT-24 AST-15 LD(LDH)-177 AlkPhos-130*
TotBili-0.3
[**2144-9-16**] 01:49AM BLOOD ALT-23 AST-15 LD(LDH)-170 AlkPhos-101
TotBili-0.4
[**2144-9-16**] 12:00AM BLOOD ALT-18 AST-10 LD(LDH)-136 AlkPhos-76
TotBili-0.2
[**2144-7-22**] 05:34AM BLOOD ALT-11 AST-10 LD(LDH)-264* CK(CPK)-6*
AlkPhos-138* TotBili-0.4
[**2144-7-20**] 05:30AM BLOOD LD(LDH)-264*
[**2144-9-6**] 12:01AM BLOOD proBNP-110
[**2144-7-22**] 05:34AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-1219*
[**2144-7-21**] 04:43AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3161*
[**2144-9-17**] 12:00AM BLOOD Albumin-2.3* Calcium-7.9* Phos-2.6*
Mg-2.0
[**2144-7-16**] 10:02AM BLOOD Calcium-9.3 Phos-4.5 Mg-1.8
[**2144-9-16**] 01:49AM BLOOD calTIBC-157* VitB12-1256* Folate-8.6
Hapto-248* Ferritn-632* TRF-121*
[**2144-9-4**] 12:00AM BLOOD Triglyc-115
[**2144-8-23**] 12:00AM BLOOD TSH-7.5*
[**2144-8-23**] 04:26AM BLOOD Free T4-1.5
[**2144-8-5**] 05:12AM BLOOD Digoxin-1.0
[**2144-8-25**] 04:08AM BLOOD Type-ART pO2-90 pCO2-46* pH-7.35
calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2144-7-18**] 06:39PM BLOOD Type-[**Last Name (un) **] pO2-60* pCO2-50* pH-7.43
calTCO2-34* Base XS-7 Comment-GREEN TOP
[**2144-8-25**] 04:08AM BLOOD freeCa-1.27
[**2144-8-24**] 07:36PM BLOOD freeCa-1.01*
[**2144-9-17**] 06:35AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2144-9-17**] 06:35AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2144-9-17**] 06:35AM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-OCC Epi-<1
[**2144-8-18**] 11:40AM URINE CastHy-1*
[**2144-9-12**] 05:11PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2144-9-12**] 05:11PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2144-9-12**] 05:11PM URINE RBC-3* WBC-178* Bacteri-MANY Yeast-NONE
Epi-0
[**2144-9-12**] 05:11PM URINE Mucous-FEW
[**2144-7-24**] 05:09PM PLEURAL WBC-600* RBC-5500* Polys-0 Lymphs-93*
Monos-1* Other-6*
[**2144-7-24**] 05:09PM PLEURAL TotProt-1.6 LD(LDH)-135
Todays Discharge labs-
K of 2.9
Na of 135
Cl of 102
Bicarb of 28
BUN of 11
Cr of 0.3
Glucose of 130
Hct 21.6- before receiving 2 units of blood
plts 445
wbc 19.2
Micro Studies-
[**2144-9-15**] 8:30 am URINE Source: Catheter.
**FINAL REPORT [**2144-9-16**]**
URINE CULTURE (Final [**2144-9-16**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
-------------
[**2144-9-13**] 1:46 pm URINE Source: Catheter.
**FINAL REPORT [**2144-9-15**]**
URINE CULTURE (Final [**2144-9-15**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final [**2144-9-13**]):
TEST CANCELLED, PATIENT CREDITED.
SPECIMEN UNACCEPTABLE FOR ANAEROBES.
IMPROPER SPECIMEN COLLECTION.
----------------
[**2144-9-9**] 6:13 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2144-9-11**]**
FECAL CULTURE (Final [**2144-9-11**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2144-9-11**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2144-9-10**]):
NO OVA AND PARASITES SEEN.
.
FEW MACROPHAGES.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
[**2144-9-8**] 6:00 pm Immunology (CMV)
**FINAL REPORT [**2144-9-10**]**
CMV Viral Load (Final [**2144-9-10**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
[**2144-9-8**] 12:20 pm URINE Source: Catheter.
**FINAL REPORT [**2144-9-13**]**
URINE CULTURE (Final [**2144-9-13**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
CEFAZOLIN CEFUROXIME sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2144-9-6**] 4:50 am URINE Source: Catheter.
**FINAL REPORT [**2144-9-8**]**
URINE CULTURE (Final [**2144-9-8**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2144-9-1**] 12:35 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2144-9-2**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2144-9-2**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2144-9-2**] AT 0700.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2144-8-9**] 12:40 pm URINE Source: Catheter.
**FINAL REPORT [**2144-8-10**]**
URINE CULTURE (Final [**2144-8-10**]):
GRAM POSITIVE BACTERIA. ~[**2136**]/ML.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
[**2144-8-8**] 7:19 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2144-8-9**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2144-8-9**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11596**] ON [**2144-8-9**] AT 3PM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2144-8-5**] 4:15 pm
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
**FINAL REPORT [**2144-8-11**]**
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
[**2144-8-6**]):
Positive for Herpes Simplex Virus Type 1 by direct antigen
staining..
REPORTED BY PHONE TO DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Numeric Identifier 78643**] [**2144-8-6**]
10:55AM.
Await culture results.
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2144-8-11**]):
HERPES SIMPLEX VIRUS TYPE 1.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
[**2144-8-3**] 7:57 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2144-8-4**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2144-8-4**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2144-7-31**] 9:15 am BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2144-8-6**]**
Blood Culture, Routine (Final [**2144-8-6**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
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.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROBACTER CLOACAE
| | KLEBSIELLA
PNEUMONIAE
| | |
KLEBSIELLA OXYTO
| | | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R <=2 S 4 S
CEFAZOLIN------------- =>64 R <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S <=1 S
CEFUROXIME------------ 16 I <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN---------- 32 I <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2144-8-1**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1:25A [**2144-8-1**].
GRAM NEGATIVE RODS.
Aerobic Bottle Gram Stain (Final [**2144-8-1**]): GRAM NEGATIVE
RODS.
[**2144-7-31**] 10:32 am URINE Source: CVS.
**FINAL REPORT [**2144-8-2**]**
URINE CULTURE (Final [**2144-8-2**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2144-7-24**] 5:09 pm PLEURAL FLUID #3.
**FINAL REPORT [**2144-8-1**]**
GRAM STAIN (Final [**2144-7-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final [**2144-7-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2144-8-1**]): NO GROWTH.
[**2144-7-17**] 5:08 pm TISSUE LEFT SUPRACLAVICULAR NODE.
GRAM STAIN (Final [**2144-7-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2144-7-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2144-7-23**]): NO GROWTH.
ACID FAST SMEAR (Final [**2144-7-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2144-7-31**]): NO FUNGUS ISOLATED.
EKG: NSR, normal axis, normal intervals, occasional PAC,
ST/T-wave changes, no Q waves
EKG #2: a-fib, rate 110, normal intervals, no ischemic changes
.
CTA CHEST at OSH:
1. no e/o pulmonary emboli
2. small bilateral pleural effusions. moderate pericardial
effusion.
3. large right superior mediastinal mass encasing adn narrowing
the SVC with insinuation around prevascular space structures and
hilar vasculature. multiple enlarged prevascular and epicardial
lymph nodes are present. Grossly enlarged subpectoral lymph
nodes measure up to 3.5cm in short axis diameter. There is
extensive supraclavicular lymphadenopathy. The appearance favors
lymphooma, although other tumor such as small cell lung cancer
should also be considered. The SVC diameter is narrowed from
20mm to 7mm.
.
CXR: large mediastinum, large heart, increased bilateral pleural
effusions
.
Abdominal XR:Small and large bowel dilatation with likely stool
ball demonstrated.
Axillary lymph node FNA [**7-4**]:
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B-cell
lymphoma are not seen in specimen. Review of cytospin slide
(1096V-[**7-1**]) shows predominantly blood with admixed lymphocytes
and numerous degenerated cells precluding definitive morphologic
assessment. Correlation with clinical findings and morphology
is recommended. Flow cytometry immunophenotyping may not detect
all lymphomas due to topography, sampling or artifacts of sample
preparation.
[**2144-7-21**] ECHO:
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. There are three aortic
valve leaflets. Significant aortic regurgitation is present, but
cannot be quantified. The pulmonary artery systolic pressure
could not be determined. There is a moderate sized pericardial
effusion. The effusion appears circumferential. The echo dense
portion of the effusion, consistent with blood, inflammation or
other cellular elements, is over both the right (1.3cm) and left
(0.8cm) ventricles. The echo lucent portion of the pericardial
effusion is most prominent around the right atrium and is small
in size elsewhere. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
Compared with the prior study (images reviewed) of [**2144-7-17**], the
pericardial effusion might be slightly more organized.
[**7-21**] BILATERAL LOWER EXTREMITY ULTRASOUND:
IMPRESSION: No evidence of DVT.
[**7-21**] LEFT UPPER EXTREMITY ULTRASOUND:
IMPRESSION: No left upper extremity DVT identified
[**7-27**] Pleural fluid cytology:
NEGATIVE FOR MALIGNANT CELLS. Many small lymphocytes and
scattered reactive mesothelial cells.
[**8-2**] CT Abdomen and Pelvis
IMPRESSION:
1. No acute abnormality identified.
2. Moderate predominantly gaseous distention of the stomach.
Also, mild
distention of the transverse colon is seen. Overall, the degree
of dilatation involving the colon is significantly decreased
since the prior exam.
3. Moderate bilateral pleural effusions and small pericardial
effusion.
4. Patient's known mediastinal lymphadenopathy is seen on the
superior most
images of this CT scan. These are seen to better detail on the
aforementioned prior exam.
[**8-3**] ECHO:
CONCLUSIONS:
LV systolic function appears depressed. with depressed free wall
contractility. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2144-7-21**],
the pericardial effusion appears smaller. The LV systolic
funciton appears worse (but the patient is significantly more
tachycardic - SVT?)
[**2144-8-5**] Direct Antigen Test for HSV Types 1 & 2 (lip):
Positive for Herpes Simplex Virus Type 1 by direct antigen
staining.
Torso CT [**2144-9-8**]
CT CHEST: Multiple enlarged supraclavicular and bilateral
axillary lymph
nodes are again seen. Largest left axillary node (2, 13)
currently measures 2.7 x 1.7 cm, decreased from 4.7 x 3.2 cm.
Largest right axillary lymph node (2, 11) currently measures 2.7
x 1.7 cm, slightly increased from previous, when it measured 2.1
x 1.5 cm.
Infiltrative soft tissue mass in the anterior mediastinum
extending from the supraclavicular region to the right atrium
has decreased in size, though it continues to encase and
slightly narrow the superior vena cava. Mass now measures
roughly 4.4 x 3.1 cm, decreased in size from previous exam when
it measured 6.8 x 4.1 cm.
Small pericardial effusion is slightly decreased. Small right
pleural
effusion and adjacent compressive atelectasis is unchanged.
Loculated small left pleural effusion is unchanged, with minimal
adjacent compressive atelectasis.
Small right hilar lymph node is unchanged. Evaluation of the
lung parenchyma is slightly limited by expiratory phase of scan
acquisition, with no focal nodules or consolidations identified.
CT ABDOMEN: Liver is unchanged in appearance, with multiple
subcentimeter
hypodensities which remain too small to definitively
characterize. Multiple gallstones within the gallbladder lumen
are unchanged. There is no gallbladder wall thickening or
pericholecystic fluid. Pancreas and adrenal glands and kidneys
remain unremarkable. Focal hypodensity in the superior aspect of
the spleen (2, 47) is slightly decreased in prominence. No new
splenic lesions are seen. Stomach and intra-abdominal loops of
bowel are normal. There is no free air, free fluid, or abnormal
intra-abdominal lymphadenopathy.
CT PELVIS: Degree of colonic distension has slightly improved.
However,
there is now marked bowel wall edema, and surrounding
inflammatory stranding in the region of the rectum and sigmoid
colon. This extends roughly to the region of apparent surgical
anastomosis in the left lower quadrant. Pelvic loops of large
and small bowel are otherwise unremarkable. There is a small
amount of free pelvic fluid, unchanged. Uterus is unchanged,
with small focal hyperattenuating focus anteriorly, which is
unchanged, and may represent a small exophytic fibroid. Diffuse
anasarca is unchanged.
There is no osseous lesion suspicious for malignancy.
IMPRESSION:
1. Slight interval improvement in patient's known anterior
mediastinal mass, and bilateral supraclavicular and axillary
lymphadenopathy.
2. Worsening of severe bowel wall thickening and inflammatory
stranding in
the rectum and sigmoid colon, most consistent with colitis,
presumably related to the patient's known C. difficile
infection.
3. Small bilateral pleural effusions and small pericardial
effusion, slightly improved.
4. Cholelithiasis, without evidence of cholecystitis.
5. Slight improvement in small hypodensity in the superior
aspect of the
spleen.
6. Unchanged appearance of tiny subcentimeter hepatic
hypodensities, too
small to definitively characterize.
CXR [**2144-9-8**]
HISTORY: Lymphoma, on chemotherapy, now with fever.
FINDINGS: In comparison with study of [**9-5**], an external device
greatly
obscures detail, as does some marked obliquity of the patient.
Areas of
increased opacification persists in the right lower zone,
consistent with some combination of pleural effusion and volume
loss. A repeat study is
recommended without overlying artifact for patient obliquity.
The study and the report were reviewed by the staff radiologist.
Echo [**2144-9-7**]
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. ?Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a small
(<1cm) pericardial effusion most prominent around the right
atrium and right ventricle without evidence for hemodynamic
compromise/tamponade physiology.
Compared with the prior pre-drainage study (images reviewed) of
[**2144-8-24**], the pericardial effusion is smaller and tamponade
physiology is no longer suggeted. Biventricular systolic
function and the severity of aortic regurgitation are similar.
Echo [**2144-9-15**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is mild global left ventricular
hypokinesis (LVEF = 45 %). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is a small (<1cm) anterior
pericardial effusion without evidence for tamponade physiology.
Compared with the prior study (images reviewed) of [**2144-9-7**],
there is mild global hypokinesis and a small anterior
pericardial effusion.
[**2144-9-15**] CXR
REASON FOR EXAM: Lymphoma, new O2 requirement.
Comparison is made to prior study [**2144-9-13**].
Mild pulmonary edema is stable as it does small to moderate
right pleural
effusion tracking towards the fissure. Cardiomediastinal
silhouette is
enlarged due to position of the patient and technique. Small
left pleural
effusion is unchanged. Left PICC tip is in unchanged position in
the
proximate SVC.
[**2144-9-15**] KUB
INDICATION: Patient is 59-year-old female with history of
non-Hodgkin's
lymphoma status post chemotherapy with recurrent problems of
ileus and C. diff
colitis, now presenting with increased abdominal distention and
no bowel
movement for the past 32 hours. Evaluate for obstruction.
EXAMINATION: Upright and supine portable abdominal radiographs
obtained.
COMPARISONS: Comparison to CT from [**2144-9-8**], and abdominal film
from [**2144-9-1**].
FINDINGS: There is marked gaseous distention of the bowel loops,
similar to previous study from [**2144-9-1**]. These loops are likely
colonic loops; however, this study is technically limited. There
is no intraperitoneal free air noted. There is no bowel wall
thickening noted. There is noted to be vascular calcifications
in the abdominal aorta. There is a pleural effusion noted at the
right base. There is a left subclavian central venous catheter
in place. The osseous structures are unchanged from previous
examinations.
IMPRESSION: Gaseous distention of bowel, likely colonic, that is
unchanged from previous examination from [**2144-9-1**].
[**2144-9-15**] EKG
Baseline artifact
Probable sinus tachycardia
Modest low amplitude T waves suggested
Q-Tc interval appears prolonged but is difficult to measure
Findings are nonspecific and baseline artifact makes assessment
difficult
Since previous tracing of [**2144-9-3**], tachycardia now present and
low amplitude T
wave changes suggested
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 158 100 356/440 61 51 40
[**2144-9-17**]
Preliminary Report
Uncomplicated PICC line replacement.
Brief Hospital Course:
59yoF with nodular sclerosing Hodgkin's lymphoma and multiple
medical problems including mental retardation, PAF with RVR, and
chronic ileus. She suffered from recurrent cardiac tamponade
with hemodynamic compromise recurrently during her long
hospitalization, ultimately requiring placement of a pericardial
window into the L pleural space. Because of her ongoing problems
with ileus she was placed on TPN. She also suffered from
infectious complications of C.Diff and a UTI with VRE which are
still being treated.
.
HODGKIN'S LYMPHOMA: patient has nodular sclerosing Hodgkin's
lymphoma with a mediastinal mass with extensive disease causing
compression of her L main stem bronchus, bilateral pulmonary
arteries and of her SVC (no evidence of SVC syndrome). Nodular
Sclerosing Hodgkin's, at least stage 2b. She underwent urgent
treatment with EACOP (no bleomycin due to low pulmonary reserve
and no vincristine due to GI toxicity in a patient w/ paralytic
ileus). Doxarubacin and Cytoxan on Day #1 ([**7-21**]) and Etoposide
on Day 1,2,3. 14 days of Dexamethasone 20mg daily. No evidence
of tumor lysis. R supraclavicular node decreasing in size (was
3cm, now difficult to palpate) with treatment. Also given
procarbazine ([**7-28**] and [**7-29**]) which was discontinued one day
early due to significant neutropenia and ileus with concern for
bowel obstruction. Patient became neutropenic on [**7-30**] and was
restarted on G-CSF for remaining two days of therapy.
Neutropenia resolved on [**8-3**]. Spiked temperature over 101 on
[**7-31**] and was started on Cefepime and Vancomycin (day 1=[**7-31**]).
Flagyl was started on [**7-31**] as pt was found to have GNR in [**2-14**]
blood cultures. Due to decreasing concern for gram positive
infection, Vancomycin was D/C'ed with last dose being on [**8-2**].
Patient was afebrile from [**8-1**] until transfer out of the ICU on
[**8-7**].At time of transfer out of the ICU, patient's blood culture
results were all pending (and showing NGTD) aside from GNR
growth on [**7-31**]. Stool was c. Diff toxin negative on [**8-3**]. Upper
lip ulcer was screened for HSV on [**8-5**] and proved positive by
DFA. With day 1 being [**8-6**], patient was initiated on Acyclovir
400 mg PO BID with plan for 10 total days followed by
suppressive regimen.
.
GND was started as a consolidation regimen on the BMT unit on
[**2144-8-17**]. The first two doses were tolerated well. However, on the
night of [**2144-8-23**] the pt developed hypotension and was found to
be in Afib with RVR again. She had pulses 160s and SBP to 80s,
and was transferred to the [**Hospital Unit Name 153**]. She was restarted on Amiodarone
IV and spontaneously converted to NSR. Her BP stabilized while
in sinus. Her pulsus was recorded as 4 but she did have
pulmonary congestion and distended neck veins. An echo was
obtained which showed RV and RA collapse w tamponade physiology.
On [**8-24**], cardiac surgery was urgently consulted following
the echo that revealed significant pericardial effusion and
right ventricular collapse. Given those findings, she was
brought to the operating room where Dr. [**Last Name (STitle) 2230**] performed urgent
pericardial window. She tolerated the procedure well and there
were no complications. Approximately 150 cc of clear fluid was
removed and sent for cytology. For further surgical details,
please see separate dictated operative note. Following the
operation she was brought to the CVICU for monitoring. Within 24
hours, she was extubated without incident. She was maintained on
Amiodarone and beta blockade for intermittent atrial
fibrillation. TPN was continued for her chronic ileus. Her CVICU
course was otherwise uneventful and she transferred to the SDU
on postoperative day one. She continued to experience atrial
fibrillation. Her mediastinal chest tube was eventually removed
on [**8-31**]. She eventually transferred back to the BMT service on
[**9-2**].
.
Her return to the BMT service was uneventful. She was maintained
on TPN and her cardiac medications. Her GI status continued to
be a concern, as well as her skin breakdown. A rectal tube was
placed on [**2144-9-5**] to help keep her sacral area dry and clean and
assist wound healing. She remained hemodynamically stable and
interacting at baseline. However, she is now confined to her bed
and has not walked this admission.
.
She had a CT scan on [**9-8**] of her torso that showed only mild
improvement in her lymphoma after chemo therapy. Therefore, she
underwent 3 days of ICE chemotherapy, and at discharge is on day
5 after ICE began. During her ICE treatment she became febrile
on Day 3, but they was afebrile till discharge. She also had a
decrease in the number of bowel movements, which increased in
number again once her treatment was complete. She will likely
need more cycles of treatment with this therapy about every 21
to 28 days.
.
TACHYPNEA AND HYPOXIA: Found on chest CT to have tumor causing
compression not only of her SVC but also of her pulmonary
arteries bilaterally which would cause the same V/Q mismatch as
a PE would by decreasing her perfusion. In addition she was
fluid overloaded and had bilateral pleural effusions and had
tumor compression of her L main stem bronchus. Treatment was
directed towards the underlying cause, she received chemotherapy
for her Hodgkin's lymphoma as above and underwent a R sided
thoracentesis 1.1 liters removed. She was intubated x 3 days
due to increased PaCO2 of 80 and somnolence- this increase in
PCO2 was possibly due to patient tiring versus L main stem
bronchus compression; however her mental status significantly
improved. After initiation of chemotherapy and thoracentesis
she was able to be extubated, her mental status was much
improved, her O2 requirement was down from 95% face mask to 6L
NC and her tachypnea resolved. As of [**8-7**] she was breathing
comfortably, free of tachypnea on 3L nasal cannula. She was
weaned from O2 and remained stable without O2 thereafter until
her treatment with ICE. She required 2L nasal canula for 2 days,
and then no longer required oxygen therapy.
.
TACHYCARDIA: Paroxysmal atrial fibrillation with RVR with rate
as high as 190s to low 200s; however, she was normotensive with
these rates. Treated initially with a dilt and esmolol drip;
subsequently she was loaded with IV amiodarone and dilt drip was
discontinued, her atrial fibrillation reverted to sinus rhythm
and the IV amiodarone was stopped. She was transitioned to po
Lopressor 12.5mg tid, which was uptitrated to 25mg TID due to
persistent and intermittent RVR. This can be uptitrated as
tolerated. She still has occasional very short self limited
episodes of paroxysmal atrial fibrillation. CTA negative for PE
but a fib with RVR more frequent and more difficult to control
prior to chemotherapy and may have been due to pulmonary artery
compression causing physiology similar to PE. She then
developed afib during her first neutropenic fever on [**7-31**] to
rates in the low 200s, reduced only to the 150s with 3 doses of
10mg IV diltiazem. As this resulted in hypotension, the patient
was transferred back to the ICU for rate control. She was
mentating at her baseline and with minimal oxygen requirement
throughout her RVR while on the medicine floor. On transfer to
the ICU the pt received 1L NS in setting of on-going diarrhea.
She converted to NSR spontaneous with IVF resuscitation. She was
started on an amiodarone gtt with the hope of maintaining NSR
however she developed bradycardia with the IV infusion and it
was stopped. She received 90mg total. After stopping the
amiodarone on [**7-31**] the pt reverted back to afib with HR
110s-120s but broke again with IVF. At this time she was found
to be bacteremic and her abx were broadened. Off of amiodarone
IV, patient's rate rose to 190 on [**8-4**]. IV amiodarone loading
was continued in separate sessions over the next several days.
Metoprolol 25mg QID was initiated on [**8-5**]. On night of [**8-5**]
patient converted to NSRat rate less than 90. Amiodarone IV
infusion was stopped on evening of [**8-6**] and patient was started
on amiodarone 400 mg PO BID. Patient remained in NSR with rate
less than 80 from [**8-6**] through [**8-7**].
.
She remained in sinus and stable until 7/13-14/08 as noted
elsewhere in this summary. In brief, at that time she became
hypotensive and tachycardia and was found to have Afib with RVR
as well as cardiac tamponade. Her rate and rhythm were
controlled with amiodarone and metoprolol and her tamponade was
treated with a pericardial window. She was eventually
transferred back to the BMT unit stable and in fair condition on
[**2144-9-2**]. She was initially monitored on telemetry, however, the
patient removed the leads, therefore, tele monitoring was not
feasible. She no longer had any more afib until discharge. Her
last EKG before discharge showed mild tachycardia but sinus
rhythm.
.
ILEUS AND ABDOMINAL DISTENTION: Patient has a history of
recurrent ileus. Upon admission to the ICU on [**7-31**], the patient
displayed a soft and non-tender abdomen. The enlarged bowel
segment was originally thought to be colon and typhlitis became
of concern; however, review of CT scan on [**8-2**] revealed that
distention was more related to gastric distention than colonic
distention. Rectal tube was inserted per surgery recs then
removed on [**8-5**] as patient began passing flatus and stooling
spontaneously. Distention of abdomen was followed by serial
exams. Abdominal distention was markedly improved, but still
present at time of patient transfer from ICU on [**8-7**].
.
Her ileus continued to be a problem after transfer to the BMT
unit. She was initially eating well, but developed abdominal
distension with diarrhea. She was switched to NPO and started on
TPN with tap water enemas per GI recommendations on [**2144-8-18**]. The
distension slowly resolved and she has continued TPN until
several days before discharge, at which time she is able to eat
small soft meals.
.
As of her discharge she still having diarrhea, that is sometimes
guaiac positive and sometimes a jelly like quality which GI
contribute to pseudomembrane from C. Diff. However, since
starting PO vancomycin (she is on Day 14 at discharge), her
diarrhea has become less frequent. She remains on TPN, but is
slowly tolerating more POs. GI did not recommend a endoscopy at
this time, but may pursue it in the future when her infection
has been treated. Her ileus has been previously relieved with
repositioning the patient and then rectal tube placement for a
short time.
.
R UPPER LIMB THOMBUS - patient assessed on floor and noted to
have swelling around the PICC; DVT found by US. US on [**8-31**]
showed superficial thrombus. Because the thrombus is superficial
no treatment was needed. However, given her many risk factors
for DVT she was maintained on PPx dose of heparin SC.
.
C. DIFF: Pt was noted to have diarrhea with leukocytosis on
[**2144-8-8**]. She was found to be C diff toxin positive and started
on metronidazole on [**2144-8-9**]. Her leukocytosis resolved within
days of treatment but her diarrhea continued. As of her transfer
back to the BMT unit on [**2144-9-2**] she was still C diff toxin
positive. She was switched to oral vancomycin on [**2144-9-5**] with ID
approval. She remains on PO vanco, which ID recommends a 14 day
course once her diarrhea is controlled and then a gradual
[**Doctor Last Name 2949**]. Her stools are still intermittently a bloody jelly
consistency (likely shedding of pseudomembrane), however, the
volume and number of stools have improved on this treatment,
until after her ICE treatment finished, at which time the number
of loose stools increased again. She may benefit from
probiotics.
.
SKIN BREAKDOWN: Pt has suffered from worsening skin breakdown
throughout her admission complicated by persistent diarrhea.
Wound care has followed closely. To assist in healing of her
sacral ulcer a rectal tube was placed on [**2144-9-5**]. Her vaginal
irritation improved with placement of a Foley catheter on
[**2144-8-17**]. She also suffered from very significant HSV of her
mouth, lips, and vagina. As of [**2144-8-20**] she was dramatically
improved and has since been maintained on suppressive acyclovir
with good effect. It is worth noting that the Pt obsessively
picks at her skin and need frequent reinforcement not to do so.
Finally, pneumoboots have repeatedly had to effect of causing
skin breakdown her calves. For that reason she was switched to
SC heparin. Her calf ulcers and rashes have not recurred now
that she is not on pneumoboots. As of discharge her skin
condition is improving. She still has a perineal ulcer for which
she needs wound care, but her sore on her hip has improved.
.
UTI: On [**2144-9-6**] she began having a leukocytosis (WBC to 18) and
was febrile. Her urine culture was positive for >100,000
enterococcus. She was initially started on amoxicillin for 1
day, then when sensitives returned was stated on linezolid for
VRE infection. Per ID, she is to have a 14 day course, which
will end on [**2144-9-22**]. She then had another urine culture showing
a UTI with E. coli and she was started on ceftriaxone. She is on
day 6 of this treatment. She will need treatment until [**2144-9-19**].
At which time, if the patient is clinically stable a repeat
urine culture should be checked. Of note, a UA was being
followed while on ICE therapy to monitor for hematuria, which
was negative.
DM: Patient is a type II diabetic and on SSI. While on TPN she
received insulin in her TPN. After her TPN was stopped she had
one episode of hypoglycemia with BG of 47, which was increased
to 147 after a [**2-12**] amp of dextrose. Her sliding scale has now
been changed to be less aggressive and she has no longer had
hypoglycemia.
She will be discharged to U [**Hospital **] Rehab Oncology unit for
continued care. In the past two days she has been having a
decrease in her Hct, was 22.3 yesterday and had 1 unit of RBCs,
was 21.6 today and received 2 units of rbcs. She had guaiac neg
stools today and yesterday. Was also given lasix 20mg extra with
her blood. Also had a potassium of 2.9 in AM, was given
repletion before transfer. Her retic count is pending and
haptoglobin was 320. She may need further transfusions. She was
started on G-CSF last night.
Medications on Admission:
calcium oyster 500mg [**Hospital1 **]
multivitamin
Celebrex 100mg [**Hospital1 **]
Iron 325mg [**Hospital1 **]
omeprazole 20mg daily
miralax 17g daily
toprol XL 125mg daily
verapamil 180mg q8H
Albuterol MDI neb PRN
Fleet enemal PRN
Maalox PRN
saline nasal spray PRN
chlorhexidine mouth wash
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for temperature >38.0: max dose 4g per day.
2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 3 days: Continue for three days for UTI.
3. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 1 days: Give for
one more day for UTI with Ecoli.
4. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day): hold if SBP<100.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H
(every 24 hours): Continue until absolute neurophil count is
>1000.
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
8. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): See flow sheet for scale.
9. Metoclopramide 5 mg/mL Solution Sig: Five (5) mg Injection
Q6H (every 6 hours) as needed for nausea/vomiting.
10. Simethicone 80 mg Tablet, Chewable Sig: 0.5 to 1 Tablet,
Chewable PO TID (3 times a day): for gas.
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold if SBP <100 or hr<60.
13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): can also use vancomycin liquid same dose.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
16. Acyclovir Sodium 500 mg Recon Soln Sig: 400mg Recon Solns
Intravenous Q8H (every 8 hours).
17. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for Nausea.
19. IVF
Please give 75ml/hr [**2-12**] normal saline IVF
20. Outpatient Lab Work
Please check CBC and Chem 10 on [**2144-9-19**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-Non-Sclerosing Hodgkins Disease
-Pericardial Effusion/Pleural Effusion - s/p Pericardial Window
-Mental Retardation
-Chronic Ileus
-C. difficile colitis
-Urinary tract infection with vancomycin resistant entercoccous
and E. coli
-Sacral Decubitus Ulcer
-Atrial fibrillation with rapid ventricular response
-Type II diabetes, insulin dependent
Discharge Condition:
Hemodynamically stable, afebrile, unable to ambulate
Discharge Instructions:
You were admitted to [**Hospital1 69**] to
treat your Hodgkin's Disease. You were given mulitple cycles of
chemotherapy for your cancer. You most recently had ICE
cheomotherapy and are on day 5 of treatment. Prior to that you
had 3 cycles of GND and one cycle of modified EACoPP. You had
complications from your cancer including having fluid in your
lungs and around your heart. You had to have the fluid revomed
from around your heart with a pericardial window. The fluid from
your lungs was removed with a thoracentisis. Also for your heart
you had an irregular rhythm for which you were started on
amiodarone.
You also had problems with your colon and at times required a
rectal tube. You also have an infection with C. Diff colitis,
which is was first treated with Flagyl and now you have to take
Vancomycin to treat the infection.
You have have bladder infections, for which you are on
antibiotics. You are taking Linezolid and Ceftriaxone.
You have skin sores that are being taken care of with wound care
that will continue after discharge.
You are weak from your long hospital stay and will require more
intensive physical therapy at rehab.
Followup Instructions:
Heme/onc follow up
Dr. [**First Name (STitle) **] Wed. [**2144-9-23**] at 11:30AM [**Telephone/Fax (1) 3237**], [**Hospital Ward Name 23**] Building
Completed by:[**2144-9-19**]
|
[
"788.30",
"696.1",
"715.90",
"782.3",
"569.89",
"423.8",
"041.3",
"319",
"E942.0",
"996.74",
"008.45",
"707.03",
"201.58",
"054.9",
"790.7",
"280.9",
"458.9",
"041.4",
"E879.8",
"560.1",
"496",
"250.80",
"698.3",
"427.89",
"201.52",
"518.81",
"599.0",
"787.3",
"427.31",
"041.04",
"423.0",
"054.10",
"459.2",
"V09.80",
"278.00",
"041.85",
"276.4",
"423.3",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"99.25",
"88.72",
"38.93",
"96.71",
"99.15",
"34.91",
"96.09",
"34.04",
"99.10",
"96.04",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
48133, 48212
|
31235, 45579
|
362, 411
|
48600, 48655
|
4243, 19540
|
49855, 50035
|
3116, 3296
|
45920, 48110
|
48233, 48579
|
45605, 45897
|
48679, 49832
|
3311, 4224
|
19576, 31212
|
283, 324
|
439, 2388
|
2410, 2974
|
2990, 3100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,121
| 179,295
|
25811
|
Discharge summary
|
report
|
Admission Date: [**2145-6-30**] Discharge Date: [**2145-7-6**]
Date of Birth: [**2074-10-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70yo Chinese speaking man with history of previous IMI [**2134**],
hypertension, and borderline diabetes, recent admission for
dyspnea found to have CAD with 3VD, EF of 20% and 3+MR and 2+AR
with plan for medical management of CAD/CHF.
He presented with SOB. In ED initially felt to be in CHF and
siuresed. THen found to have several subsegmental PE's. He
required a NRB for a time. He was transferred to the CCU with
hypotension. Given his poor cardiac function, it was felt he was
hemodynamically unstable and would benefit from lysis of PE. TPA
and heparin administered. Afterwards, he developed a hematoma on
L groin site in area of prior catheterization. This responded to
pressure. He remained hemodynamically stable with several small
IVF boluses.
Past Medical History:
CAD s/p inferior MI [**2134**], 3 vessel CAD
3+ MR
Hypertension
Borderline diabetes mellitus; untreated
Social History:
Patient lives in [**Country 651**], visiting son in the US. Denies tob,
EtOH, illicit drug use. Poor English with need for interpreter.
Family History:
Brother MI 75yrs, Mother MI 80s
Physical Exam:
Afebrile, 100-120, 90/60, 24, 90% initially on 4 L (went down to
65% in ED->NRB improved to 90%)
GENL: mild respiratory distress
HEENT: OP clear, PERL,
CV: RRR, +systolic murmur
LUNGS: crackles 3/4 up
Abd: soft, nt, nd, +bs
Ext: trace pedal edema
Pertinent Results:
[**2145-6-30**] 07:40PM HCT-32.8*
[**2145-6-30**] 07:40PM PTT-91.2*
[**2145-6-30**] 04:15PM FIBRINOGE-242
[**2145-6-30**] 03:46PM WBC-15.0* RBC-4.15* HGB-12.1* HCT-35.6*
MCV-86 MCH-29.1 MCHC-34.0 RDW-13.6
[**2145-6-30**] 03:46PM PLT COUNT-237
[**2145-6-30**] 08:54AM TYPE-ART RATES-/30 PO2-171* PCO2-45 PH-7.44
TOTAL CO2-32* BASE XS-6 INTUBATED-NOT INTUBA VENT-SPONTANEOU
COMMENTS-NON-REBREA
[**2145-6-30**] 08:00AM GLUCOSE-170* UREA N-18 CREAT-1.2 SODIUM-139
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
[**2145-6-30**] 08:00AM CK(CPK)-38
[**2145-6-30**] 08:00AM cTropnT-0.06*
[**2145-6-30**] 08:00AM CK-MB-NotDone
[**2145-6-30**] 03:54AM CK(CPK)-35*
[**2145-6-30**] 03:54AM cTropnT-0.10*
[**2145-6-29**] 07:56PM LACTATE-2.2*
[**2145-6-29**] 07:30PM CK-MB-NotDone cTropnT-0.13*
[**2145-6-29**] 07:30PM ALBUMIN-4.4
[**2145-7-6**] INR 2.6
PTT 19.8
[**2145-6-29**]
ABD CT
INDICATION: Right upper quadrant pain
IMPRESSION: Technically limited exam with no gallstones
identified. There is apparent mild/moderate bilateral
hydronephrosis, right greater than left and likley due to high
post-void residual.
EKG: Baseline artifact. Sinus tachycardia. Left axis deviation.
Non-specific
intraventricular conduction delay. Left atrial abnormality. Q
waves in the
inferior leads with possible ST segment elevation. Non-specific
lateral
ST-T wave changes. Compared to the previous tracing of [**2145-6-26**]
possible
inferior ST segment elevation is new. If ischemia is a clinical
concern, a
repeat tracing is recommended.
[**2145-6-29**]
CXR: IMPRESSION:
1. Persistent CHF.
2. Stable left lower lobe opacity, probably representing
atelectasis.
6/22/05CT reconstruction
IMPRESSION:
1. Bilateral pulmonary emboli as described above.
2. Multiple right-sided lung nodules. In the absence of known
malignancy, followup CT scan in 12 months may be performed. In
the presence of primary malignancy, followup scan in 3 months
may be performed.
3. Multiple likely bilateral renal cysts.
4. Small hypodense lesion in the inferior portion of the spleen,
too small to characterize, that may represent a small
hemangioma.
5. Aneyrusmal dilatation of the common iliac arteries
[**2145-7-4**]
EKGSinus rhythm. Left axis deviation. Non-specific
intraventricular conduction
delay. Left atrial abnormality. Q waves in the inferior leads
consistent with
prior inferior myocardial infarction. Non-specific anterior and
lateral
ST-T wave changes. Compared to the previous tracing of [**2145-6-30**]
ST-T wave
changes are more extensive.
Brief Hospital Course:
1) Pulmonary Emboli - As stated in the HPI, the patient
presented with SOB and some right epigastric vs. pleuritic chest
pain. A CTA was done with showed multiple bilateral pulmonary
emboli, and due to the patients SOB and hypotension in the
setting of severe ischemic cardiomyopathy, the patient given
lysis treatment with tPA. He was started on Heparin for
anticoagulation and transitioned to coumadin by discharge. His
symptoms of SOB improved daily and his breathing was baseline at
discharge.
2) CHF - The patient has known ischemic cardiomyopathy with NYHA
Class III CHF. Initially many of his medications were held due
to hypotension, but as the patient's BP stabalized and he
clinically improved, he was placed back on all of the
medications from prior hospitalization, including lasix,
sprinolactone, lisinopril, and carvedilol, and imdur.
3) CAD - known 2 VD, not surgical candidate, s/p failure of PTCA
attempt. EKG c/w pulmonary emboli with no evidence of acute or
ongoing ischemia during hospitalization. Continued to optimize
medical management of patient with ASA, plavix, atrovastatin,
carvedilol, lisinopril, imdur, SL nitro PRN, and above
medications.
4) Hyperglycemia - the patient showed evidence of glucose
intolerance. A converstaion was had regarding the need to
treat, and it was decided that while the patient was inhospital
with sickness that could elevate blood sugars, treatment was not
felt to be necessary. However, this decision was made with the
idea that the patient would have the issued addressed more fully
as an outpt.
5) FEN - SBP remained 90-100's. Ate a cardiac/heart healthy
diet. Received daily potassium.
6) PPX - heparin to prevent DVT's and PPI to prevent stress
ulcer
7) Dispo - discharged home to son's place in [**Location (un) **], wife
accompanying. F/U scheduled with Dr. [**Last Name (STitle) **] on Friday [**7-9**] at 2:30 pm at [**Hospital6 733**] in [**Hospital Ward Name 23**] 6.
Additional f/u on [**7-19**] with Dr. [**Last Name (STitle) **] of cardiology and [**7-26**]
with Dr. [**First Name (STitle) 3037**] in [**Hospital 191**] clinic. VNA will follow patient's INR in
meantime and call Dr. [**First Name (STitle) 3037**] to make decision regarding coumadin
dosing.
Medications on Admission:
Meds (from recent d/c summary)
Aspirin 325 mg Tablet QD
Atorvastatin Calcium 80 mg QD
Clopidogrel 75 mg QD
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg PRN
Nitroglycerin 0.3 mg PRN chest pain
Lisinopril 30 mg QD
Isosorbide Mononitrate 30 mg QD
Furosemide 40 mg QD
Spironolactone 25 mg QD
Toprol XL 50 mg QD
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel 75 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. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. 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*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
15. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CHF
PE
CAD
T2DM
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters.
Please return to the emergency room if you have severe shortness
of breath, chest pain, palpitations or any other symptom that
bothers you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on Friday [**7-9**] at 2:30
pm at [**Hospital6 733**] in [**Hospital Ward Name 23**] 6.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3037**] on [**7-26**] at 1:30 pm
at [**Hospital6 733**] in [**Hospital Ward Name 23**] 6.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**7-19**] at 3:15pm at
[**Hospital Ward Name 23**] [**Location (un) 436**].
|
[
"E879.0",
"396.3",
"311",
"458.29",
"415.19",
"414.8",
"V45.82",
"398.91",
"414.01",
"427.1",
"401.9",
"922.2",
"276.2",
"285.9",
"591",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.43",
"99.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8790, 8848
|
4322, 6571
|
335, 341
|
8908, 8917
|
1741, 4299
|
9236, 9731
|
1426, 1459
|
6948, 8767
|
8869, 8887
|
6597, 6925
|
8941, 9213
|
1474, 1722
|
276, 297
|
369, 1127
|
1149, 1254
|
1270, 1410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,564
| 156,221
|
14345
|
Discharge summary
|
report
|
Admission Date: [**2127-7-28**] Discharge Date: [**2127-8-10**]
Date of Birth: [**2057-2-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Remeron
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic with dilated aorta
Major Surgical or Invasive Procedure:
[**7-28**] Replacement of ascending aorta and hemi-arch using 28-mm
Vascutek Gelweave dacron graft
[**8-4**] Rigid bronchoscopy with the yellow Dumon tracheoscope,
Y-stent placement, BAL left lower lobe.
History of Present Illness:
70 yo female with metastatic breast cancer noted to have
enlarged aorta over the past several years (followed since
[**2121**]). Recent CT showed continuing enlargement of ascending
aorta now at 5.4cm. Echo showed asc. aorta at 5.4cm. Referred
for surgery.
Past Medical History:
Ascending aortic aneurysm
Aortic insufficiency
Right breast CA [**2120**], recurrence in lymph node [**2121**]
Hyperlipidemia
Meningitis vs. viral encephalitis at age 25
Polymalgia rheumatica x 2
Polio at age 16 - mild muscle weakness
Gastroesophageal reflux disease
Bilateral peripheral neuropathy
Depression
s/p ight breast lumpectomy [**2120**], Left lumpectomy - benign
s/p Right knee arthroscopy
Social History:
Patient is married with one son. Lives with husband. [**Name (NI) **] son
lives in [**Name (NI) 42542**] but has come back to the United States.
Occupation: not employed
Tobacco: [**2-7**] ppd x 50 years. Actively smoking.
ETOH: 1.5 ounces of vodka/water per night
Family History:
Father died of ruptured abd. aortic aneurysm at age 61
Physical Exam:
Pulse: 74
B/P 104/68
Height: 5'5" Weight: 120 lbs
General: WDWN female in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X] with wheezes R base,
well-healed lumpectomy scars
Heart: RRR [X] Irregular [] Murmur [X]- 1/6 systolic with
quiet
diastolic component
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2127-7-28**] Echo: PRE BYPASS 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 thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a subtle focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
markedly dilated There are simple atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild to moderate ([**2-7**]+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric and directed
away from the anterior mitral leaflet.. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified
in person of the results in the operating room at the time of
the study.
POST BYPASS Normal right ventricular systolic function. Low
normal left ventricular systolic function (EF = 50%). There is
graft material in situ in the ascending aorta. There is now
trace to mild aortic regurgitation. Mild mitral regurgitation
remains. No other significant changes from the pre bypass study.
[**2127-8-8**] 05:41AM BLOOD WBC-9.6 RBC-3.03* Hgb-8.8* Hct-27.3*
MCV-90 MCH-29.0 MCHC-32.2 RDW-15.9* Plt Ct-773*
[**2127-8-7**] 05:51AM BLOOD WBC-9.3 RBC-3.16* Hgb-9.2* Hct-28.8*
MCV-91 MCH-29.0 MCHC-31.8 RDW-16.1* Plt Ct-664*
[**2127-8-10**] 05:17AM BLOOD PT-14.9* PTT-24.0 INR(PT)-1.3*
[**2127-8-8**] 05:41AM BLOOD Glucose-94 UreaN-14 Creat-0.6 Na-139
K-3.8 Cl-104 HCO3-27 AnGap-12
[**2127-8-10**] 05:17AM BLOOD PT-14.9* PTT-24.0 INR(PT)-1.3*
[**2127-8-9**] 04:33AM BLOOD PT-15.7* INR(PT)-1.4*
[**2127-8-8**] 05:41AM BLOOD PT-20.9* INR(PT)-1.9*
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit after undergoing complete
pre-operative work-up as an outpatient. On [**7-28**] she was brought
directly to the operating room where she underwent a ascending
aorta and hemi-arch replacement. Please see operative note for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition. On
post-operative day one she was weaned from sedation, awoke
neurologically intact and extubated. She was transferred to the
floor on POD 1, however, returned to the CVICU for hypoxia and
atrial fibrillation. Amiodarone and diltiazem were started for
atrial fibrillation. The patient was electively reintubated for
ARDS. She failed many weaning trials and the interventional
pulmonary service was consulted. She was found to have
tracheo-bronchial malacia. On [**8-4**] she underwent bronchial
Y-stent placement under rigid bronchoscopy with the IP team.
Diamox was started for metabolic acidosis, which did improve.
The patient was subsequently weaned from the ventillator again.
She developed an intractable cough initially and was planned to
have removal of the bronchial stent. However, this cough
improved with tessalon perles as well as codeine and it was
decided to give the stent the full two week trial that IP
suggested. The patient was cleared by physical therapy. She
was cleared by Dr. [**Last Name (STitle) 914**] for discharge to home with VNA
services. She will be discharged on coumadin for atrial
fibrillation. Dr. [**First Name (STitle) 916**] (PCP) will be called and requested to
manage INR/coumadin dosing. The patient is discharged home with
appropriate follow up instructions.
Medications on Admission:
Atenolol 25mg half a tablet every evening, Zetia 10mg daily at
12pm, Femara 2.5mg daily at 12pm, Lorazepam 1mg, two tablets
every evening, Herceptin Infusion 300mg every three weeks,
Effexor XR 75mg daily every morning, Aspirin 81mg daily every
evening, Oscal Plus 600mg + D twice a day, Folic acid daily
Citrucel prn, MVI qhs, Aciphex 20mg daily every morning
Discharge Medications:
1. nebulizer machine
nebulizer machine and equipment
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).
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week,
then 200mg/day until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
8. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
9. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for cough.
Disp:*60 Tablet(s)* Refills:*0*
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheezing.
Disp:*qs * Refills:*0*
11. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO daily ().
12. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
Disp:*40 Tablet(s)* Refills:*0*
15. Trastuzumab 440 mg Recon Soln Sig: as directed Intravenous
as directed.
16. Rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation TID (3 times a day).
Disp:*qs * Refills:*2*
18. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous TID (3 times a day).
Disp:*90 ML(s)* Refills:*2*
19. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
20. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Dose
will change daily based on goal INR [**3-11**], Dr. [**First Name (STitle) 916**] to manage,
Have INR drawn Tues. [**2127-8-12**].
Disp:*30 Tablet(s)* Refills:*2*
21. Outpatient Lab Work
Serial PT/INR
dx: atrial fibrillation
Goal INR [**3-11**]
Results to Dr. [**First Name (STitle) 916**] [**Telephone/Fax (1) 42543**]
22. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for acid reflux.
Disp:*qs ML(s)* Refills:*0*
23. Radiology
PA/lateral chest x-ray
f/u effusions/atx
s/p repair of ascending aortic aneurysm with subsequent
respiratory failure/tracheomalacia with placement of Y stent
results to Dr. [**Last Name (STitle) 914**]
24. cardiology
12-lead EKG
dx: post-op atrial fibrillation
s/p repair of ascending aortic aneurysm [**2127-7-28**]
results to Dr. [**Last Name (STitle) 914**]
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Ascending aortic aneurysm s/p Ascending aorta and Hemi-arch
replacement
Aortic insufficiency
Right breast CA [**2120**], recurrence in lymph node [**2121**]
Hyperlipidemia
Meningitis vs. viral encephalitis at age 25
Polymalgia rheumatica x 2
Polio at age 16 - mild muscle weakness
Gastroesophageal reflux disease
Bilateral peripheral neuropathy
Depression
s/p ight breast lumpectomy [**2120**], Left lumpectomy - benign
s/p Right knee arthroscopy
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 from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
VNA to draw INR [**2127-8-12**] with results to Dr. [**First Name (STitle) 916**] ([**Telephone/Fax (1) 42543**])
Dr. [**Last Name (STitle) 914**] in 3 weeks
Dr.[**Doctor Last Name 3733**] in [**2-7**] weeks
Dr. [**First Name (STitle) 916**] in [**2-7**] weeks
Dr. [**Last Name (STitle) **] (interventional pulmonology)- they will call you to
make appt. in 1 week.
Completed by:[**2127-8-10**]
|
[
"272.4",
"799.02",
"997.39",
"356.9",
"V10.3",
"496",
"427.31",
"276.2",
"725",
"424.1",
"519.19",
"V58.66",
"441.2",
"518.81",
"530.81",
"138"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"39.61",
"96.05",
"96.04",
"96.72",
"96.6",
"38.45",
"38.93",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
9654, 9762
|
4326, 6025
|
304, 510
|
10253, 10259
|
2306, 4303
|
11057, 11453
|
1518, 1575
|
6436, 9631
|
9783, 10232
|
6051, 6413
|
10283, 11034
|
1590, 2287
|
233, 266
|
538, 796
|
818, 1220
|
1236, 1502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,194
| 190,448
|
29
|
Discharge summary
|
report
|
Admission Date: [**2157-5-31**] Discharge Date: [**2157-6-1**]
Date of Birth: [**2106-1-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
tremors, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50 y/o M w/ h/o ETOH abuse, who p/w tremors, tachycardia,
nausea, vomiting x 2 days. These symptoms started after he
stopped drinking ETOH 2 days prior to admission. He notes that
he threw up multiple times, including a small amount of bright
red hematemesis. He reports associated abdominal pain and
tremulousness. +VH's, AH's. Denies seizure activity. Denies SI.
He normally drinks [**1-19**] to 1 liter of wine per day, but stopped
on sunday. He has a h/o w/d seizures. Because of his ongoing
symptoms he presented to the ED for evaluation. In the ED, he
recieved a total of 40mg IV valium, 3L NS, Anzemet 12.5mg IV,
Banana bag, and was transferred to the [**Hospital Unit Name 153**] for monitoring.
*
On arrival to the [**Hospital Unit Name 153**], he was noted to be tremulous with VH's.
Cognition was intact and he was HD stable. He was started on
valium CIWA monitoring.
Past Medical History:
EtOH abuse-hx of DT's requiring ICU admission with heavy benzo
needs in past and WD sz's
HTN
?pna with empyema?
UGI bleed-admitted to [**Hospital1 18**] [**Date range (1) 331**] but no GI workup done for
risk of DT's
Social History:
Pt is homeless. Denies IVDA. Smokes 2 packs a day. Drinks [**1-19**] to
1 liter of wine/day. No other ETOH use. No other illicit drug
use. has one daughter [**Name (NI) 339**] at [**Telephone/Fax (1) 340**] who lives w/ her
mother.
Family History:
non-contributory
Physical Exam:
wt 130 lb. T 97.4, BP 139/93, HR 95, RR 16, 100% RA
gen- tremulous. non-diaphoretic. NAD
heent- EOMI/PERRLA. muddy sclera. non-icteric. no nystagmus. op
w/ poor dentition. no thrush.
chest- lungs CTA. no r/r/w. R scapula well-healed scar. +
gynecomastia
cv- RRR. normal S1/S2. no m/r/g1
abd- soft, mild mid-epigastric tenderness to palpation. no
rebound or guarding. no HSM. no caput or telangiectasias.
ext- no c/c/e.
neuro- CN II-XII intact. communication appropriate. [**5-19**] motor
strength 5/5 LE's. poor f->n b/l. coarse tremor, but no
asterixis.
Pertinent Results:
Labs:
-----
CHEM: Na 138, K 3.8, Cl 77, CO2 37, BUN 22, Cr 2.6, Glu 147. AG
=24
CBC: WBC 7.5, Hct 47.6, Plt 107, MCV 92
Coags- INR 1.1, PTT 26.9
Amylase 110, Lipase 41
*
CT chest [**4-19**]- RLL lung mass, spiculated. fatty liver.
*
EKG: sinus tach, QTc 450, J-pt elevation in V1-V3 c/w early
repolarizations
*
U/A: negative
*
Serum ETOH neg, Tylenol neg, ASA neg, benzo neg.
*
Serum Acetone small, Osm 304
Brief Hospital Course:
50 y/o M w/ h/o ETOH abuse, chronic pancreatitis, who presented
with signs and symptoms of ETOH withdrawal
1. ETOH w/d: Presented with tachycardia, hallucinations,
tremulousness. Given 40mg Valium in ED. Admitted to [**Hospital Unit Name 153**] and
started on valium CIWA scale. Started on Folate, Thiamine, MVI.
Monitored on telemetry overnight. He had no evidence of seizure
or HD instabilitiy o/n. His CIWA was [**8-23**], mainly based on
agitation and tremulousness, and he recieved an additional 120mg
valium overnight. Early on HD 2 the patient demanded to leave.
It was explained to the patient that he has a high probability
of withdrawal seizure or DT's and that he needed continued ICU
monitoring. The patient reported that he understood this but
still wished to leave against medical advice. He was felt to
have capacity to make this decision since he had no evidence of
delirium and clearly understood his situation and risks
involved. The case was discussed with the on call psychiatry
resident, ICU medicine resident and ICU staff attending.
Therefore the patient signed out AMA on hospital day 2. Prior to
discharge we did have him ambulate around the intensive care
unit and he was able to do this without too much difficuluty,
although he was still a bit tremulous upon discharge. He had no
other evidence of active w/d symptoms.
2. Anion-gap Acidosis: Suspected secondary to ketoacidosis,
likely from poor PO intake. ETOH was negative suggesting against
ETOH related cause. Serum acetone was positive, with a normal
serum osm. His gap closed with IVF hydration.
3. Hypochloremic Metabolic Alkalosis: Secondary to HCL loss from
vomiting. Improved with IVF hydration.
4. Hematemesis: Limited hematemesis early the morning of
admission. He had no further episodes of blood loss and he was
guaiac negative on admission. Hematocrit remained stable
overnight.
5. Abd pain: Suspect secondary to chronic pancreatitis.
Amylase/Lipase unchanged from previous levels. AST/ALT 2:1 in
setting of h/o ETOH abuse. Recent CT ([**4-19**]) negative for liver
or GB dx, only fatty liver.
6. RLL lung mass: Seen on Chest CT from [**4-19**], concerning for
primary lung CA. Has not been worked up further. Not able to set
up follow-up as patient left AMA.
Medications on Admission:
none recently
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH withdrawal
Discharge Condition:
fair
|
[
"403.91",
"303.01",
"291.0",
"276.5",
"578.0",
"577.1",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5108, 5114
|
2754, 5015
|
295, 301
|
5173, 5180
|
2323, 2731
|
1714, 1732
|
5079, 5085
|
5135, 5152
|
5041, 5056
|
1747, 2304
|
230, 257
|
329, 1209
|
1231, 1449
|
1465, 1698
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,250
| 138,381
|
50028
|
Discharge summary
|
report
|
Admission Date: [**2113-7-10**] Discharge Date: [**2113-7-14**]
Date of Birth: [**2030-7-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 F with history of neurofibromatosis, PVD, [**First Name3 (LF) **], recent
admission for humeral fracture in setting of mechanical fall
treated conservatively (discharged 5 days ago, [**2113-7-4**]) who
presents with acute SOB. Evening of [**2113-7-9**], patient reports dry
cough. 1 hr prior to presentation accutely SOB.
Per EMS, patient was satting mid 80s on non-rebreather. In the
ED, VITALS: T 97.2, HR 94, 220/124, 99% non rebreather. On exam,
negative JVP, no pedal edema, looked dry. Labs notable for:
Bicarb 13, K 6.4 (hemolyzed), AG 22, Phos 6, BNP 17,500, PLT
500, WBC 17, HCT 42, Hb 13, trop 0.02, Lactate 7.0. ABG: 7.42,
CO2 30, O2 130, Bicarb 20. CXR: LLL pna and some pulmonary
edema. For lactate 7, gave 750cc IVF, lactate improved to 2.1, K
4.5. As pt was given fluids, breathing improved.
ABG on non rebreather: pH 7.40, CO2 34, O2 81, HCO3 22,
Temp 100.2 rectally.
Pt was given: zosyn and levofloxacin 750mg.
Vitals on transfer: RR 24, 98.2 axillary, HR 75, 185/93
(150-160s SBP), 100% on non rebreather.
On arrival to the MICU, patient is comfortable on a
non-rebreather at 70%. She denies any chest pressure or
pleuritic component chest pain. She also denies any headache.
She is 79% on Room Air when checked.
Past Medical History:
- [**Date Range **]
- HLD
- DCIS s/p excision/XRT, on tamoxifen in past but d/c'd due to
side effects
- Osteoporosis
- Neurofibromatosis type II
- Lichen sclerosis
- Left hip fracture s/p hemiarthroplasty
- Carotid stenosis s/p CEA of left ICA in [**2106**]. Right ICA with
80% stenosis as of [**2110**]
- PVD
- Cataracts s/p removal ([**2109**])
Social History:
Occupation: Former homemaker.
Marital: Married.
Home Situation: Lives with husband in [**Name (NI) 3146**].
Religion: Catholic.
Tobacco: 50 years of one-half pack a day. Quit circa [**2100**].
Alcohol: Occasional. No prior difficulty.
Other Drugs: None.
Family History:
Mother: Deceased, unknown reason.
Father: Deceased, TB.
Cancer History: Sister with breast cancer in her 70s.
Coronary Artery Disease History: None.
Diabetes Mellitus History: None.
Physical Exam:
Admission Exam:
79% on room air.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at bases, otherwise, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Right leg is tender to palpation in calf
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam:
Vitals: T:98.1 BP 118/61 P:72 R:18 97% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at bases, scattered rhonchi, no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Right leg is tender to palpation in calf
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2113-7-10**] 03:36PM GLUCOSE-87 UREA N-40* CREAT-1.1 SODIUM-139
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-22 ANION GAP-21*
[**2113-7-10**] 03:36PM cTropnT-0.03*
[**2113-7-10**] 03:36PM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-1.7
[**2113-7-10**] 04:13AM LACTATE-1.5
[**2113-7-10**] 02:55AM GLUCOSE-123* UREA N-42* CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-20* ANION GAP-17
[**2113-7-10**] 02:55AM cTropnT-0.06*
[**2113-7-10**] 02:55AM CALCIUM-8.3* PHOSPHATE-4.1# MAGNESIUM-1.7
[**2113-7-10**] 02:55AM WBC-13.1* RBC-3.99* HGB-11.5* HCT-35.6*
MCV-89 MCH-28.8 MCHC-32.2 RDW-15.3
[**2113-7-10**] 02:55AM PLT COUNT-396
[**2113-7-10**] 12:20AM TYPE-[**Last Name (un) **] PO2-81* PCO2-34* PH-7.40 TOTAL
CO2-22 BASE XS--2 COMMENTS-GREEN TOP
[**2113-7-10**] 12:20AM LACTATE-2.1* K+-4.5
[**2113-7-9**] 11:04PM TYPE-ART TEMP-37.9 PO2-130* PCO2-30* PH-7.42
TOTAL CO2-20* BASE XS--3 INTUBATED-NOT INTUBA COMMENTS-O2
DELIVER
[**2113-7-9**] 11:04PM K+-4.5
[**2113-7-9**] 10:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2113-7-9**] 10:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5
LEUK-NEG
[**2113-7-9**] 10:50PM URINE RBC-5* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-2
[**2113-7-9**] 10:50PM URINE HYALINE-17*
[**2113-7-9**] 10:50PM URINE MUCOUS-RARE
[**2113-7-9**] 09:40PM GLUCOSE-152* UREA N-36* CREAT-1.0 SODIUM-138
POTASSIUM-6.4* CHLORIDE-103 TOTAL CO2-13* ANION GAP-28*
[**2113-7-9**] 09:40PM estGFR-Using this
[**2113-7-9**] 09:40PM ALT(SGPT)-143* AST(SGOT)-272* ALK PHOS-209*
TOT BILI-0.8
[**2113-7-9**] 09:40PM cTropnT-0.02*
[**2113-7-9**] 09:40PM proBNP-[**Numeric Identifier **]*
[**2113-7-9**] 09:40PM CALCIUM-9.0 PHOSPHATE-6.0*# MAGNESIUM-2.1
[**2113-7-9**] 09:40PM WBC-17.4*# RBC-4.46 HGB-13.2 HCT-42.4 MCV-95
MCH-29.7 MCHC-31.2 RDW-15.2
[**2113-7-9**] 09:40PM NEUTS-82.7* LYMPHS-13.1* MONOS-3.3 EOS-0.3
BASOS-0.5
[**2113-7-9**] 09:40PM PLT COUNT-500*
[**2113-7-9**] 09:40PM [**Name (NI) 8255**] TO PTT-UNABLE TO INR(PT)-UNABLE
TO
[**2113-7-9**] 09:23PM LACTATE-7.0* K+-5.2*
.
Discharge Labs:
[**2113-7-14**] 07:05AM BLOOD WBC-7.7 RBC-4.15* Hgb-11.9* Hct-37.4
MCV-90 MCH-28.6 MCHC-31.7 RDW-15.4 Plt Ct-350
[**2113-7-14**] 07:05AM BLOOD Glucose-102* UreaN-36* Creat-1.0 Na-140
K-3.8 Cl-97 HCO3-33* AnGap-14
[**2113-7-14**] 07:05AM BLOOD ALT-137* AST-48* LD(LDH)-228 AlkPhos-96
TotBili-0.5
[**2113-7-14**] 07:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9
CTA Chest [**7-10**]
1. No pulmonary embolus.
2. Bilateral pleural effusions with centrilobular emphysema and
ground glass opacities, the appearance may be due to fluid
overload. Focal punctate areas of consolidation are noted in
the right upper lobe only.
3. Multivessel coronary artery calcifications and progression
of extensive ulcerating plaques in the aortic arch.
.
EKG [**7-10**]: HR 96, PR 104, QTc 390, nl axis, a in III, flat T in
III
Shoulder Films:
Three views of the right humerus show a comminuted fracture of
the neck of the
proximal humerus with displaced associated fractures of the
tuberosities of
the humeral head. No dislocation and the visualized right lung
is grossly
normal. Little position change from previous exam [**2113-7-1**].
RUQ ultrasound [**7-11**]:
IMPRESSION:
1. No liver pathology and no biliary dilatation seen.
2. Cholelithiasis with no sign of cholecystitis.
3. Bilateral pleural effusions.
4. Small non-obstructing stone in the right kidney and small
simple right
renal cyst.
Echo [**7-12**]
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
normal free wall contractility. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion
CXR [**7-13**] FINDINGS: In comparison with the study of [**7-11**], there
is some continued enlargement of the cardiac silhouette with
little change in the degree of pulmonary vascular congestion.
Continued opacification of the right hemidiaphragm, consistent
with pleural effusion and atelectasis at the left base. Again
supervening pneumonia would be difficult to exclude in the
appropriate clinical setting.
Brief Hospital Course:
82F with history of neurofibromatosis, PVD, [**Date Range **], recent
admission for humeral fracture in setting of mechanical fall
treated conservatively (discharged 5 days prior to this
admission) who presented with acute SOB.
.
# Shortness of breath: Pt met 2 SIRS criteria on presentation:
leukocytosis (WBC 17), tachypnea, possible sources include
pulmonary (?LLL opacity) or GI (diarrhea). Given 750cc IVF in
the ED and started on zosyn and levofloxacin empirically for
possible infectious process. Differential for SOB also includes:
PE (considered in pt with recent humeral fracture) and recent
immobility and right calf tenderness. ACS (trop 0.02, but no
chest pain or EKG changes), acute heart failure (BNP 17,500 (no
prior), pulmonary edema on CXR). Aa gradient of 590 assuming
100% FiO2 on non-rebreather. Heparin drip was started
empirically, but was discontinued when the pt's CT chest showed
no PE. The patient was but on empiric PNA coverage with
vanc/Zosyn/levo. Blood cultures were sent (NG at discharge). The
patient was transferred to the MICU for close monitoring. The
patient had a foley placed and was diuresed with good response.
She remained afebrile and abx were stopped. She was downgraded
to NC and transferred to the floor. She continued to have
difficulty acheiving O2 sat >90% on room air and required O2 NC.
A repeat CXR showed persistent pleural effusions and the patient
was diuresed with moderate improvement She was started on 20mg
PO lasix daily. Additionally, she received chest PT and was
started on inhaled steroids in setting of emphysema and
persistent cough with sputum production. She remained afebrile
following transfer to floor. At discharge, she is saturating
88-90% on RA, 97% on 3L, and 94-95% on 3L with ambulation.
.
# [**Date Range **]: Hypertensive to 200s in the ED. Pt has history of BP in
200s on prior admissions in setting of med non compliance. She
states she missed several doses prior to this admission.
Patient without evidence of end organ dysfunction, no chest
pain. BP was controlled with hydralazine and amlodipine in the
unit. In the MICU, the patient's BP was controlled with
hydralazine. Her dose of lisinopril was increased from 20mg to
40mg daily. A beta-blocker was held in the setting of possible
bacterial etiology to SOB and elevated lactate. Upon transfer to
the floor, the patient was started on home atenalol for SBP of
180. Atenolol failed to successfully control BP so pt was
transitioned to labetalol [**Hospital1 **]. BP is now well controlled. She
has also been started on lasix 20mg daily.
# Metabolic Acidosis/Lactate: AG 22, Lactate 7.0-->2.1 after
750cc IVF. AG closed. Lactate normalized on transfer to the
floor. Still uncertain etiology. Most likely [**1-19**] to hypertensive
emergency
# Tachycardia: Patient had a run of supraventricular
tachycardia that self-resolves and did not return after
restarting beta-blockers.
# Right humeral fracture s/p fall: s/p comminuted fracture in
setting of mechanical fall.Ortho saw patient and noted fracture
healing well. Shoulder films show proper healing. Follow up in 2
months.
.
Chronic issues:
# HLD. Continued home simvastatin.
.
# Osteoporosis. Continued calcium/vitamin D daily.
.
# Neurofibromatosis type II. Stable no acute issues
.
# Lichen sclerosis. Continued clobetasol cream.
.
# Carotid stenosis s/p CEA of left ICA in [**2106**]. Right ICA with
80% stenosis as of [**2110**]. No acute issues.
.
# PVD. Not on any medications, no acute issues.
.
# Cataracts. Stable no acute issues.
Transition of Care:
# Follow lytes in in [**12-19**] weeks after starting lasix
# Trend blood pressures to ensure goal 110-140/60-80
# Follow up with Ortho in 2 months
# Communication: [**First Name8 (NamePattern2) **] [**Known lastname 83141**], Relationship: husband. Phone
number: [**Telephone/Fax (1) 104461**]
# Code: DNR/DNI confirmed
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN
itching
7. Acetaminophen 1000 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
hold for SBP<100
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN
itching
4. Acetaminophen 1000 mg PO Q6H:PRN pain
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Furosemide 20 mg PO DAILY
hold for sbp<100
7. Guaifenesin 10 mL PO Q6H
8. Labetalol 200 mg PO BID
hold for SBP <100 and HR <60
9. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
10. Docusate Sodium 100 mg PO DAILY:PRN constipation
11. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Hypertensive Emergency with Secondary Pulmonary Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 83141**],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You came in due to shortness of breath and were found to have
high blood pressure. We believe your high blood pressure caused
your shortness of breath. We controlled your blood pressure and
gave you medicine to decrease fluid in your lungs. Your
shortness of breath is now improving, but you still require some
oxygen.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: WEDNESDAY [**2113-7-19**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ORTHOPEDICS
When: THURSDAY [**2113-8-17**] at 5:00 PM
With: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"427.1",
"V54.11",
"401.0",
"443.9",
"237.72",
"272.4",
"433.30",
"V15.82",
"V49.86",
"701.0",
"518.4",
"276.2",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13576, 13662
|
8646, 11769
|
324, 330
|
13760, 13760
|
3820, 5936
|
14401, 15036
|
2262, 2451
|
13001, 13553
|
13683, 13739
|
12563, 12978
|
13943, 14378
|
5952, 8623
|
2466, 3126
|
3142, 3801
|
265, 286
|
358, 1594
|
13775, 13919
|
11786, 12537
|
1616, 1966
|
1982, 2246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,730
| 125,695
|
32327
|
Discharge summary
|
report
|
Admission Date: [**2187-10-29**] Discharge Date: [**2187-11-22**]
Date of Birth: [**2107-10-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP with stones at the lower third of the common bile duct - a
biliary stent was placed.
History of Present Illness:
This is a 80 year old female with a history of A-fib, who was
med-flighted here from [**Hospital 1562**] Hospital. She was admitted to
[**Hospital 1562**] Hosp on [**10-23**] with pancreatitis complicated by
respiratory arrest with bradycardic rhythm requiring chest
compressions, intubation and ICU on [**10-25**]. She was R/O for MI
and etiology unclear. CT head negative, however, repeat CT ABD
c/w increasing pancreatic necrosis/pseudocyst/hemorrhage. Pt
transferred to [**Hospital1 18**] on [**10-29**] for further management of
gallstone pancreatitis.
Past Medical History:
A-fib w/ hx of failed cardioversion [**4-8**], Syncope, glaucoma,
HTN, IDDM, tonsillectomy and adenoidectomy
TIA w/out residual deficits
Social History:
Lives in [**Hospital3 **]
Physical Exam:
VS: 98.7, 99 A-fib, 137/63, 14, 100%
Gen: Intubated and sedated
CV: A-fib.
Resp: intubated, ventilator
Abd: abdominal pain, epigastric tenderness. +BS
Ext: no clubbing, cyanosis or edema.
Pertinent Results:
[**2187-10-29**] 08:57PM BLOOD WBC-12.5* RBC-3.43* Hgb-10.5* Hct-30.5*
MCV-89 MCH-30.5 MCHC-34.3 RDW-15.9* Plt Ct-136*
[**2187-11-1**] 04:11AM BLOOD WBC-24.4* RBC-3.38* Hgb-10.3* Hct-30.7*
MCV-91 MCH-30.6 MCHC-33.7 RDW-15.9* Plt Ct-339
[**2187-11-8**] 01:30PM BLOOD WBC-15.1* RBC-3.19* Hgb-9.8* Hct-30.1*
MCV-94 MCH-30.6 MCHC-32.5 RDW-17.1* Plt Ct-582*
[**2187-11-13**] 04:38AM BLOOD WBC-12.4* RBC-3.13* Hgb-9.5* Hct-30.0*
MCV-96 MCH-30.4 MCHC-31.8 RDW-16.8* Plt Ct-538*
[**2187-10-29**] 08:57PM BLOOD Glucose-187* UreaN-31* Creat-0.8 Na-143
K-4.1 Cl-109* HCO3-27 AnGap-11
[**2187-11-5**] 04:00AM BLOOD Glucose-166* UreaN-20 Creat-0.9 Na-143
K-3.2* Cl-108 HCO3-27 AnGap-11
[**2187-11-13**] 04:38AM BLOOD Glucose-207* UreaN-18 Creat-0.6 Na-139
K-3.6 Cl-102 HCO3-28 AnGap-13
[**2187-10-29**] 08:57PM BLOOD ALT-16 AST-23 LD(LDH)-569* AlkPhos-67
Amylase-64 TotBili-1.2
[**2187-11-3**] 01:33AM BLOOD ALT-12 AST-20 LD(LDH)-332* AlkPhos-189*
Amylase-88 TotBili-0.6
[**2187-11-10**] 03:14AM BLOOD ALT-89* AST-149* AlkPhos-180* Amylase-54
TotBili-0.5
[**2187-11-13**] 04:38AM BLOOD ALT-70* AST-58* AlkPhos-191* Amylase-43
TotBili-0.5
[**2187-10-29**] 08:57PM BLOOD Lipase-16
[**2187-11-6**] 05:00PM BLOOD Lipase-18
[**2187-11-13**] 04:38AM BLOOD Lipase-35
[**2187-10-29**] 08:57PM BLOOD Albumin-2.4* Calcium-7.4* Phos-4.0 Mg-2.3
[**2187-11-6**] 02:30AM BLOOD Albumin-2.1* Calcium-8.3* Phos-3.8 Mg-2.2
[**2187-11-13**] 04:38AM BLOOD Albumin-2.1* Calcium-7.9* Phos-2.9 Mg-2.3
.
ERCP BILIARY ONLY PORTABLY BY TECH [**2187-10-31**] 12:34 PM
IMPRESSION: ERCP with cholangiogram reveals filling defects in
the common bile duct consistent with stones. For procedure
details, please refer to the ERCP note on CareWeb.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree: Three stones ranging in size from 3mm to 8mm that
were causing partial obstruction were seen at the lower third of
the common bile duct. Given suspicious of cholangitis, full
cholangiogram was not obtained.
Procedures: A 7 cm by 10 French Cotton-[**Doctor Last Name **] biliary stent was
placed successfully using a Oasis system stent introducer kit.
Impression: Stones at the lower third of the common bile duct -
a biliary stent was placed.
Otherwise normal ercp to second part of the duodenum
Recommendations: Repeat ERCP in 3 months for stent removal,
sphincterotomy and stone extraction - this was discussed with
patient's family. They have my office number and will call to
schedule ERCP..
Further recommendations per ICU team.
.
CHEST (PORTABLE AP) [**2187-11-5**] 3:45 PM
IMPRESSION:
1. Improvement of bilateral pleural effusions, now small on the
right and small to moderate on the left.
2. Left lower lung opacity likely represents atelectasis;
however, pneumonia cannot be excluded.
.
UNILAT UP EXT VEINS US LEFT [**2187-11-9**] 6:22 PM
IMPRESSION: No evidence of deep vein thrombosis in the left
upper extremity
.
UNILAT UP EXT VEINS US LEFT [**2187-11-13**] 8:48 PM
IMPRESSION: No evidence of DVT involving the left upper
extremity.
.
MR HEAD W/O CONTRAST [**2187-11-16**] 11:40 PM
IMPRESSION:
Acute infarctions in the right occipital lobe, parietal lobe and
in the centrum semiovale, which could be secondary to emboli
from central source. There is no mass effect or midline shift.
.
CT ABD W&W/O C [**2187-11-17**] 6:34 PM
IMPRESSION:
1. Multiple cysts arising from the pancreatic parenchyma, the
largest measures up to 15 cm.The small amount of remaining
pancreas appears to enhance normally.
2. Pneumobilia with a biliary stent in place.
3. Bilateral moderate pleural effusions and associated
atelectasis, incompletely evaluated.
4. Body wall edema.
5. Air within the bladder lumen. Please correlate with recent
catheterization or instrumentation.
.
ECHO [**11-19**]
Findings
LEFT ATRIUM: Elongated LA. No LA mass/thrombus (best excluded by
TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral
annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Left pleural effusion.
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension. No definite structural
cardiac source of embolism identified.
CLINICAL IMPLICATIONS:
Based on [**2187**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
CAROTID SERIES COMPLETE [**2187-11-19**] 8:57 AM
REASON: Acute cerebral infarct on MRI.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries. There is mild plaque seen in the proximal ICA
bilaterally.
On the right, peak velocities are 59, 49, and 58 cm/sec in the
ICA, CCA, and ECA respectively. This is consistent with less
than 40% stenosis.
On the left, peak velocities are 58, 48, and 53 cm/sec in the
ICA, CCA, and ECA respectively. This is consistent with less
than 40% stenosis.
There is antegrade vertebral flow bilaterally.
IMPRESSION: Bilateral less than 40% carotid stenosis.
.
Brief Hospital Course:
This is a 80 year old female who was transferred to [**Hospital1 18**]
intubated in A-fib for severe gallstone pancreatitis.
She had an ERCP on [**10-31**] and this showed Three stones ranging in
size from 3mm to 8mm that were causing partial obstruction were
seen at the lower third of the common bile duct. Given
suspicious of cholangitis, full cholangiogram was not obtained.
Procedures: A 7 cm by 10 French Cotton-[**Doctor Last Name **] biliary stent was
placed successfully.
She remained intubated in the ICU while she continued to recover
for the pancreatitis.
She will need a CCY and cystgastrostomy in the future and will
return for a CT scan in 3 weeks.
Neuro: Once extubated, she was confused. Her confusion continued
to improve and by time of discharge, she was A+O x 3.
We noticed left UE weakness on examination. Neurology was
following along. She had an MRA Brain and this showed acute
infarctions in the right occipital lobe, parietal lobe and in
the centrum semiovale, which could be secondary to emboli from
central source. There is no mass effect or midline shift.
She continued on her Coumadin, with a INR goal of [**2-10**]. The left
UE weakness continued to improve and PT/OT was following along.
We obtained an Echo and carotid US. The ECHO showed No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%)
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension. No definite structural
cardiac source of embolism identified.
The carotid US showed Bilateral less than 40% carotid stenosis.
CV: She continued in A-fib. She had a rate as high as 180 when
agitate. She received Lopressor PRN. She then received diltiazem
drip for HR control. Once able to take PO's, she was switched to
PO diltiazem.
She was restarted on her Coumadin for her chronic A-fib.
Continue to monitor INR and dose Coumadin. Most recently, she
was supertherapeutic with an INR of 7.1. This has been coming
down slowly and today was 4.0. Please continue Coumadin on
[**11-23**].
Resp: She was vented. The ICU team was able to wean her off the
vent was she improved.
GI: She was NPO. She had a flexisealin place draining loose
brown stool. She had a NGT in place.
When the NGT was removed, she was seen by the Swallow specialist
and eventually clears to eat nectar thick liquids and ground
consistency solids. She was then cleared for regular food.
Unfortunately, her PO nutrition intake was very poor, only about
~300kcals/day, and she required a NJ feeding tube. She will
receive Replete with fiber at 50cc/hr.
GU/Renal: Foley in place. She had a UTI and this was being
covered by the Unasyn. After aggressive fluid resuscitation, she
then received Lasix for diuresis for overall body edema.
It was also noted that she had a fungal infection to her
vaginal/perineum area. She was ordered for Nystatin cream and
also a one-time dose of Diflucan.
ID: She was on Unasyn for a short course s/p ERCP.
Medications on Admission:
Coumadin, Metformin 500", Glyburide'
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for SBP < 100, HR<60.
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP<100 or HR<60.
7. Insulin Glargine 100 unit/mL Solution Sig: See sliding scale
Subcutaneous at bedtime.
8. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust Coumadin per the INR. Start [**11-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] and Islands
Discharge Diagnosis:
Gallstone Pancreatits
Atrial Fibrillation - Chronic
Delirium
Left UE weakness
Acute infarctions in the right occipital lobe, parietal lobe and
in the centrum semiovale.
Malnutrition
Hyperglycemia
Discharge Condition:
Good
Deconditioned
Continue with Coumadin. INR goal [**2-10**].
Good
Deconditioned
Continue with Coumadin. INR goal [**2-10**].
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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 take any new meds as ordered.
* Continue to amubulate several times per day.
* Continue a regular diet and tube feedings.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. You will have a CT
at this time.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-12-14**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2187-12-14**] 11:15
.
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2188-1-31**] 9:00
.
Completed by:[**2187-11-22**]
|
[
"250.00",
"577.0",
"434.91",
"427.31",
"574.51",
"263.9",
"285.9",
"511.9",
"518.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"51.87",
"96.6",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
12260, 12347
|
8159, 11366
|
331, 423
|
12587, 12718
|
1436, 7265
|
13813, 14346
|
11455, 12237
|
12368, 12566
|
11392, 11430
|
12742, 13790
|
1228, 1417
|
7288, 8136
|
277, 293
|
451, 1010
|
1032, 1170
|
1186, 1213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,075
| 190,552
|
9745+56060+56061
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2175-2-10**] Discharge Date: [**2149-1-27**]
pending
Service: MEDICAL INTENSIVE CARE UNIT
CHIEF COMPLAINT: 84 year old woman with a history of atrial
fibrillation on Coumadin who was transferred from New
[**Location (un) 30389**] [**Hospital **] Hospital to [**Hospital1 188**] for management of subdural hematoma.
HISTORY OF PRESENT ILLNESS: The patient was admitted to [**Hospital6 14475**] on [**2175-2-1**], for chronic
obstructive pulmonary disease exacerbation treatment. She
was found on the ground on [**2175-2-9**]. Initial CT scan was
noted for bleed but she subsequently developed decreased
mental status. Repeat CT scan on [**2175-2-10**], revealed left
subdural hematoma with midline shift.
She was transferred to [**Hospital1 69**]
where, on presentation, she was somewhat awake and was able
to squeeze the left hand on command, but was not able to move
the right side of her body at all. She developed increasing
somnolence and was taken to the Operating Room for a
craniotomy and evacuation.
She was initially transferred to the Surgical Intensive Care
Unit. There, she continued to have very poor mental status.
She occasionally appeared able to follow commands, but was
not displaying purposeful movements of the upper or lower
extremities. She was transferred to the Medical Intensive
Care Unit on [**2175-2-22**], for management of recurrent fevers
to a temperature of 101.0 F, to 102.0 F., as well as for a
failure to wean off the ventilator.
She had a tracheostomy in place and while in the Medical
Intensive Care Unit received trials where she was allowed to
breathe on her own off the ventilator. She usually was only
able to breathe for several hours before she would fatigue
and would have to be put back on the ventilator.
She continued to spike temperatures to 101.0 F., to 102.0 F.
The source of these fevers were unclear. [**Name2 (NI) **] sputum, blood
and urine were cultured multiple times and were always
negative. A CT scan of the chest did not reveal any obvious
source of infection.
Her mental status continued to be poor; she was unable to
speak. She did not appear able to make purposeful movements
and in general did not display any improvement in her
neurologic status. Given her overall poor prognosis and her
very low probability for a meaningful recovery, the family
decided on [**2175-3-3**], that they wished to withdraw care for
her on the evening of [**2175-3-4**].
Addendum to Discharge Summary to follow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2175-3-4**] 15:23
T: [**2175-3-6**] 11:46
JOB#: [**Job Number 9286**]
Name: [**Known lastname 5704**], [**Known firstname **] Unit No: [**Numeric Identifier 5705**]
Admission Date: [**2149-1-27**] Discharge Date:
Date of Birth: Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM: The patient was started on
Morphine drip for comfort on the evening of [**2175-3-5**].
She was taken off the ventilator. She expired in the early
evening of [**2175-3-6**].
CAUSE OF DEATH: Subdural hematoma.
IMMEDIATE CAUSE OF DEATH: Respiratory failure.
DR.[**Last Name (STitle) 5706**],[**First Name3 (LF) 126**] 11-685
Dictated By:[**Name8 (MD) 2984**]
MEDQUIST36
D: [**2175-3-6**] 15:02
T: [**2175-3-8**] 09:02
JOB#: [**Job Number 5707**]
Name: [**Known lastname 5704**], [**Known firstname **] Unit No: [**Numeric Identifier 5705**]
Admission Date: [**2149-1-27**] Discharge Date:
Date of Birth: [**2090-11-25**] Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM CORRECTION: The patient was
started on Morphine drip and the ventilator was continued the
evening of [**2175-3-4**] (not [**2175-3-5**]), she expired during the
early evening of [**2175-3-5**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 126**] 11-685
Dictated By:[**Name8 (MD) 2984**]
MEDQUIST36
D: [**2175-3-6**] 15:07
T: [**2175-3-8**] 09:06
JOB#: [**Job Number 5708**]
|
[
"852.20",
"E888.9",
"238.4",
"427.31",
"707.0",
"428.0",
"496",
"518.5",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.56",
"03.31",
"38.91",
"96.72",
"31.1",
"38.93",
"34.91",
"01.31",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
187, 396
|
426, 4231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,956
| 194,360
|
52538
|
Discharge summary
|
report
|
Admission Date: [**2187-8-25**] Discharge Date: [**2187-9-2**]
Date of Birth: [**2127-10-6**] Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Revision of R charcot joint
Major Surgical or Invasive Procedure:
Right Charcot Joint Reconstruction
History of Present Illness:
This is a 59 yo male with a complicated PMH who was previously
admitted to the hospitalist service for R LE cellulitis and
Charcot joint revision. He tolerated the surgery well and was
dicharged on [**2187-7-26**]. Since then, he has been feeling well, no
complaints of chest pain, SOB, abdominal pain, f/c/ns/weight
loss, headache, cough, increasing LE edema, PND, orthopnea. He
has come in today for heparin bridge prior to his surgery
scheduled for afternoon of [**2187-8-28**]. He reports that he has not
had any significant complaints from his RLE, but 2 days ago
slipped and his 2nd toenail was removed. Of note, he has not
had any woound care of the external casing or pin care since the
last discharge. No increasing LE erythema or pain.
Past Medical History:
1)Type 2 diabetes with complications including neuropathy
2)Charcot deformity of RLE s/p reconstruction and multiple
revisions
3)Hypertension
4)A fib on coumadin
5)Systolic CHF EF 25%
6)s/p ICD placement in [**2-2**] at [**Hospital1 2025**]
7)h/o VT
8)GERD
9)Barrett's esophagus
10)osteoarthritis
11)OSA- uses CPAP
12)obesity
13)umbillical hernia
14)s/p gastric bypass
15)s/p CCY
16)s/p left rotator cuff tear and repair
Social History:
The patient is married. He has a 40 pack year smoking history
but quit. He has occasional alcohol use, but denies illicit drug
use.
Family History:
Father with CAD, Brother with DM
Physical Exam:
98.5, 116/80, 93, 15, 96% RA
Gen: obese, well appearing, NAD
HEENT: PERRLA, EOMI, throat clear
CV: +s1s2, irreg irreg, no mrg appreciated (heart sounds were
difficult to auscultate), JVP flat
Lungs: ctab
Abd: obese, reducible umbilical hernia
Ext: RLE with external casing by podiatry, pins in place, 2nd
toenail is removed with erythema, decreased sensation over LLE,
trace LE edema, chronic venous stasis changes noted on LLE.
Neuro: nonfocal, CN 2-12 intact, able to move all 4 extremities
Pertinent Results:
[**2187-8-25**]
Na 139 / K 4.4 / Cl 99 / CO2 29 / BUN 27 / Cr 1.3 / BG 100
Ca 9.3/ Mg 2.1 / Phos 3.6
WBC 11.1 / Hct 40 / Plt 253
INR 2.5 / PTT 29.8
[**2187-9-2**] - 7:23am
Na 134 / K 5.3 / Cl 97 / CO2 24 / BUN 24 / Cr 1.4 / BG 184
Ca [**88**] / Mg 2.3 / Phos 4.7
WBC 8.3 / Hct 44.3 / Plt 237
Vanco trough 13.6
INR 1.1
PTT 87.2 on heparin drip at 3550 units
MICROBIOLOGY:
[**2187-8-28**] Right Ankle Swab - Gram stain with no PMNs or organisms
seen
[**2187-8-28**] Right Ankle Swab Culture - Final - No growth
[**2187-8-28**] Blood Culture - preliminary - no growth to date as of
[**2187-9-2**]
[**2187-8-29**] Urine Culture - Final - No growth
RADIOLOGY:
[**2187-8-25**] Portable CXR - Lordotic positioning. A pacemaker is in
place with lead tips over right atrium and right ventricle.
There is moderate cardiomegaly and minimal unfolding of the
aorta. There is upper zone redistribution, but no overt CHF. No
focal infiltrate or effusion
is identified. Probable left base atelectasis. Extreme left
costophrenic
angle excluded from the film. ? subcutaneous emphysema adjacent
to right
clavicle versus film artifact.
Brief Hospital Course:
59yo male with multiple medical problems was admitted to [**Hospital1 18**]
for heparin bridge before and after R foot charcot joint
revision.
.
1. RLE Charcot joint
Patient had successful charcot joint reconstruction on [**2187-8-28**].
His post-operative course was complicated by transient
hypotension and was monitored in the ICU overnight after his
procedure. This was thought likely related to prolonged
sedation. Blood cultures were sent and are negative. Wound
cultures were also sent and are preliminarily no growth to date.
He was treated with IV vancomycin while hospitalized and can be
transitioned to PO linezolid for two weeks upon discharge. His
vancomycin dose was titrated to 1250mg IV bid, and his most
recent trough on that dosage was 13.6. He should follow-up with
podiatry as an outpatient on [**2187-9-3**] (appointment already
scheduled).
.
2. Chronic systolic heart failure EF 25%
He remained asymptomatic throughout his hospital course. His
antihypertensive and diuretic medications were briefly held with
his brief post-operative hypotension but most were restarted.
His creatinine increased slightly from 1.3 to 1.5. Due to this
slight creatinine bump, his lisinopril and spironolactone have
been held and his torsemide dose was decreased to 20mg [**Hospital1 **] from
40mg [**Hospital1 **]. His lisinopril and spironolactone should be restarted
and his torsemide should be increased back to his home dose when
appropriate.
.
3. Chronic atrial fibrillation
Due to his high risk of blood clots with CHADS-2 score of 3, he
was kept on heparin bridge prior and post-podiatry procedure.
His coumadin was restarted on the evening of his surgery, and
his dose was increased from 12.5mg daily to 15mg daily due to
difficulty achieving therapeutic levels. Please continue the
heparin bridge until his INR is therapeutic. He is not an ideal
candidate for lovenox due to his renal insufficiency and his
obesity. His heparin drip was at 3550 units upon discharge from
[**Hospital1 18**] and his most recent PTT at 7am on [**2187-9-2**] was 87.2.
.
4. Diabetes Mellitus
He was discharged on his last hospitalization with lantus 75 U
[**Hospital1 **], but now has increased to 85 units [**Hospital1 **] with home dose
sliding scale. HbA1C was checked to be 6.9. Sugars were
adequately controlled during the hospitalization.
.
5. OSA - patient on home CPAP machine.
.
6. Hyperkalemia
Patient's potassium was slightly elevated on the morning of
transfer at 5.3. We would recommend rechecking potassium on the
evening of transfer. Spironolactone can be restarted once
potassium levels are stable.
Medications on Admission:
per patient's wife
ASA 325
Bupropion 150 tid
coreg 6.25 [**Hospital1 **]
digoxin 250 mcg qdaily
gabapentin [**Telephone/Fax (3) 86673**] AM/PM/HS
lisinopril 5 qdaily
lorazepam 1 prn(rarely takes)
colace 100 [**Hospital1 **]
simvastatin 20 hs
spironolactone 25 qdaily
torsemide 40 [**Hospital1 **]
coumadin 12.5 qdialy
oxycodone 5 prn
lantus 85 [**Hospital1 **]
humalog SS
omeprazole 40 qdaily
fioricet prn
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
9. Insulin Glargine 100 unit/mL Cartridge Sig: 85 units
Subcutaneous twice a day: .
10. Humalog Insulin Sig: According to sliding scale four
times a day: Please administer according to attached sliding
scale. .
11. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
12. Warfarin 5 mg Tablet Sig: Three (3) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
13. Vancomycin 500 mg Recon Soln Sig: 1250 mg Recon Solns
Intravenous Q 12H (Every 12 Hours) as needed for pin site
infection for 2 weeks.
14. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Heparin (Porcine) in NS 10 unit/mL Kit Sig: As directed per
sliding scale. Intravenous Continuous: Please administer per
sliding scale. Please continue at 3550 units. .
16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Charcot Joint
Secondary:
Atrial fibrillation
Hypertension
Congestive heart failure
Type II Diabetes Mellitus
Discharge Condition:
Stable.
Discharge Instructions:
You were hospitalized for heparin bridge for the days
surrounding your right charcot joint reconstruction. Your INR is
taking somewhat longer than expected to return to a therapeutic
level, and you are on a heparin bridge while awaiting a
therapeutic INR. Per your request, we are transferring you to
[**Hospital3 3765**] to be closer to your family while you are on a
heparin bridge.
We made the following changes while you were hospitalized:
- Heparin - This is an anticoagulant that we started to keep you
anticoagulated until your coumadin levels are therapeutic.
- Vancomycin - This is an antibiotics to treat your foot
infection.
- Lisinopril - We have held this medication while your kidney
function is slightly abnormal. Your doctors [**Name5 (PTitle) **] restart this
medication at [**Hospital3 3765**].
- Torsemide - We decreased your dose from 40mg twice daily to
20mg twice daily due to your slightly abnormal kidney function.
- Spironolactone - We held this medication due to your slightly
abnormal kidney function and slightly elevated potassium. This
medication can be restarted while at [**Hospital3 3765**].
Please seek immediate medical attention if you develop fevers,
shaking chills, night sweats, worsened pain in your right foot,
abdominal pain, nausea, or vomiting.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2187-9-3**] 10:50
Please follow up with your endocrinologist and cardiologist
after discharge.
|
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66,613
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42648
|
Discharge summary
|
report
|
Admission Date: [**2106-1-10**] Discharge Date: [**2106-1-14**]
Date of Birth: [**2034-6-4**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
ICD discharges
Major Surgical or Invasive Procedure:
VT ablation
Generator change
History of Present Illness:
71 y/o M h/o HTN, CAD, NIDD, pacemaker/defibrillator, CABG in
[**2086**] who presents after receiving multiple shocks from
pacer/AICD. Pt had CABG in [**2086**] at [**Hospital1 112**]. [**2098**] experienced
episodes of falling asleep constantly and had an accident while
driving which prompted placement of pacer/AICD (unclear medical
reasons per pt and wife). in [**2103**] experienced 1 shock without
subsequent issues.
.
This evening, pt was sitting at home watching tv this evening
when he experienced the first shock. Prior to this he felt fine
only c/o some dizzy episodes earlier in the day but did not lose
consciousness and went about his normal activities without issue
including driving. He denies having SOB/CP, f/n/v. No recent med
changes, or illness. Wife was with pt, they state that he
recieved his second shock 3 minutes later. Per wife, pt received
a total of 10 shocks between those at home and the shocks that
occurred subsequently in the ambulance on the way to [**Hospital 39437**].
.
On arrival to the [**Name (NI) 26615**] [**Name (NI) **] pt had multiple episodes of VT
which were successfully defibrillated by the pts own
defibrillator. BP 156/82, went down to 137/78, HR 80, RR 18,
O2sat 99%. Initially given amio 150mg followed by infusion.
Episodes increased in frequency, received lido bolus 200mg and
drip initiated at 3mg/min with some improvement but again
increased frequency. Defibrillator was not going off so required
ED defibrillation. Twice defibrillated into Vfib which appeared
as polymorphic VT/torsades for roughly 10 seconds, at which
point internal defibrillator fired and pt converted to sinus
rhythm. received another bolus of lido 100mg and drip increased
to 4mg/min. Received oral K 40meq and drip of 10meq/hr along
with Mg 1g IV. Labs at OSH notable for WBC of 11.5, PLT 128, 20%
monocytes 70% PMNs. K was 3.1 with BUN/cr 32/1.3. CK 103 CKMB
4.1, trop <0.03
.
IN [**Hospital1 18**] [**Name (NI) **] Pt was in VT with HR in 160s, received 20mg bolus
procainamide. Trop 0.07, K 4.3, Cr 1.3 WBC 12.3. Was in VT with
rate around 160s. ------------------
________________________
.
On the floor, pt very sleepy after receiving fentanyl at OSH.
Other than some nausea pt has no complaints. Continued on
procainamide drip at 4mcg/min. EP following, pt now being
A-paced and is in sinus. Pt received a total of 40 shocks this
evening.
Past Medical History:
1. CARDIAC RISK FACTORS: + NIDDM, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: [**2086**] at [**Hospital1 112**]
- PACING/ICD: [**Company **] placed in [**2098**] for episdoes of falling
asleep one of which occured while driving
3. OTHER PAST MEDICAL HISTORY:
NIDDM
hypertension
Social History:
- Tobacco history: previous smoker
- ETOH:
- Illicit drugs: none
Physical Exam:
On admission:
PHYSICAL EXAMINATION:
VS: T= AF BP= 140/85 HR=80 RR= O2 sat= 94% 3-4L
GENERAL: NAD. Oriented x3. Affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: lower extremities with significant changes of
venous stasis and ulcerations on forelegs covered by bandaging.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
On Discharge:
VS: 98.6-60-18-113/72 O2 sat 99% RA
.
GENERAL: 71 yo male in no acute distress
HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated
CHEST: LS clear throughout, no wheezes, no rales, no rhonchi
CV: RRR, NL S1S2, no murmurs rubs or gallops, exam limited r/t
body habitus
ABD: Obese, soft, non-tender, non-distended, BS normoactive.
EXT: Venous stasis bilateral lower extremities, 2+ pedal edema,
2+ DP/PTs
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Amb
with walker
SKIN: no rashes or open sores
PSYCH: alert, oriented, much calmer and less tearful today. Able
to sleep overnight.
Pertinent Results:
[**2106-1-10**] 01:50AM BLOOD WBC-12.3* RBC-5.08 Hgb-15.1 Hct-45.0
MCV-89 MCH-29.8 MCHC-33.6 RDW-14.2 Plt Ct-148*
[**2106-1-10**] 05:52AM BLOOD WBC-10.5 RBC-4.54* Hgb-13.7* Hct-40.6
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.3 Plt Ct-111*
[**2106-1-11**] 04:40AM BLOOD WBC-8.6 RBC-4.58* Hgb-14.0 Hct-41.0
MCV-90 MCH-30.5 MCHC-34.1 RDW-14.3 Plt Ct-105*
[**2106-1-12**] 05:39AM BLOOD WBC-8.6 RBC-4.75 Hgb-14.5 Hct-42.5 MCV-90
MCH-30.5 MCHC-34.1 RDW-14.4 Plt Ct-107*
[**2106-1-13**] 06:45AM BLOOD WBC-7.3 RBC-4.77 Hgb-14.3 Hct-43.5 MCV-91
MCH-30.1 MCHC-33.0 RDW-14.0 Plt Ct-103*
[**2106-1-13**] 06:45AM BLOOD PT-11.8 PTT-27.9 INR(PT)-1.1
[**2106-1-11**] 04:40AM BLOOD Glucose-181* UreaN-25* Creat-1.2 Na-144
K-4.6 Cl-106 HCO3-29 AnGap-14
[**2106-1-11**] 05:35PM BLOOD UreaN-22* Creat-1.3* Na-146* K-3.7 Cl-105
HCO3-31 AnGap-14
[**2106-1-12**] 05:39AM BLOOD Glucose-144* UreaN-24* Creat-1.1 Na-144
K-4.0 Cl-106 HCO3-31 AnGap-11
[**2106-1-13**] 06:45AM BLOOD Glucose-158* UreaN-31* Creat-1.2 Na-146*
K-3.9 Cl-105 HCO3-35* AnGap-10
[**2106-1-10**] 01:50AM BLOOD cTropnT-0.07*
[**2106-1-10**] 05:52AM BLOOD CK-MB-6 cTropnT-0.07*
[**2106-1-11**] 04:40AM BLOOD CK-MB-6 cTropnT-0.04*
[**2106-1-11**] 05:35PM BLOOD CK-MB-7 cTropnT-0.32*
[**2106-1-12**] 05:39AM BLOOD VitB12-724
[**2106-1-12**] 05:39AM BLOOD TSH-3.3
[**2106-1-10**] 05:19PM BLOOD PROCAINAMIDE AND
N-ACETYLPROCAINAMIDE-Test
[**2106-1-11**] ECHO
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with akinesis of the inferior wall and hypokinesis
of the inferolateral and inferoseptal walls. The remaining
segments contract normally, though technical quality is
suboptimal (LVEF = 40%). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The ascending aorta and aortic arch are
mildly dilated. 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 mildly thickened. Trivial mitral
regurgitation is seen. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
dilation with regional systolic dysfunction c/w CAD (PDA
distribution). Dilated thoracic aorta.
[**2106-1-10**] CXR
IMPRESSION:
1. Dual-lead left-sided AICD is again seen with its leads intact
and
terminating over the expected location of the right atrium and
right ventricle
respectively. Status post median sternotomy for CABG with
overall stable
post-operative contours. Interval resolution of the pulmonary
edema with
persistent elevation of the left hemidiaphragm of uncertain
etiology. Linear
opacity in the left mid lung is felt to most likely represent
subsegmental
atelectasis or scarring. No pleural effusions or pneumothoraces.
Brief Hospital Course:
71 y/o M h/o NIDDM, HTN/HLD s/p CABG [**2086**] with pacer/AICD
placement [**2098**] presents after receiving multiple recurrent
shocks from his AICD this evening. Found to be in persistent VT,
pt stable throughout, received amio, lido, on procainamide with
return of sinus rhythm.
.
#VT - pt with persistent VT resulting in approximately 42 shocks
from both implanted ICD and external defibrillation within a
24-48 hour period. Most likely [**1-21**] prior myocardial injury with
resultant scar and now with CHF causing structural abnormalities
and arrhythmia. Differential also includes MI vs electrolyte
imbalance. K and Mg repleted, enzymes flat. Given
amio/lido/procainamide, continued on maintenance procainamide.
Was taken to the EP lab where multiple (at least 5) VT foci were
mapped. There was one culprit focus with recurrent PVCs which
was ablated. A circumferential ablation around his ventricular
scar was attempted and half completed, unfortunately the
procedure was stopped due to worsening pulmonary edema and
respiratory distress. He was maintained on quinidine after the
procedure and had no further episodes of VT which was
discontinued in favor of beta-blockade at the time of discharge.
He had a generator change on [**1-13**] which went without
complication. He will follow-up in device clinic here and with
Dr. [**Last Name (STitle) **] for follow-up.
.
# CHF: unclear whether pt has documented history of CHF
although states on a diuretic at home. Echo here with EF 40%,
however this echo was performed after his recurrent VT/ICD
discharges. He required minimal diuretics and was transitioned
to his home dose of torsemide at the time of discharge. He was
also started on low-dose ACE and aldactone for further
optimization of his CHF status.
.
# CAD: s/p CABG [**2086**], anatomy not defined as [**Hospital1 112**] records unable
to be obtained. His enzymes remained flat throughout the
hospitalization. Ischemia was ruled out as a cause for his VT
via enzymes. He was maintained on optimal medications for his
CAD.
Medications on Admission:
toprol xl 100mg daily
allopurinol 300 mg daily
ASA 325 daily
vit D 3000mg daily
torsemide 40mg [**Hospital1 **]
imdur 30 mg daily
potassium 20 mEq daily
zocor 40 mg daily
omeprazole 20mg daily
metformin XL 750mg daily
Discharge Medications:
1. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Vitamin D 1,000 unit Capsule Sig: Three (3) Capsule PO once a
day.
5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. metformin 750 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please check chem-7 on Monday [**2106-1-19**] with results to [**First Name4 (NamePattern1) 1258**]
[**Last Name (NamePattern1) 69336**] NP
Location: [**Hospital1 18**]
Address: [**Location (un) **], [**Location (un) 86**]
Fax: [**Telephone/Fax (1) 32656**]
Phone: [**Telephone/Fax (1) 79809**]
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Ventricular tachycardia
Acute on Chronic systolic Congestive heart failure
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia
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:
It was a pleasure caring for you during your stay at [**Hospital1 771**].
You were admitted to the hospital after your ICD fired multiple
times for ventricular tachycardia (VT).
You had a successful VT ablation to treat this abnormal rhythm
and hopefully your defibrillator will not fire again.
You also had a generator change because your battery ran low
after shocking you so many times. You should keep the original
dressing in place for 72 hours. You can remove the dressing and
shower on [**2106-1-19**]. Do not remove the steristrips, they will fall
off on their own.
You have swelling that has worsened somewhat that is due because
of a heart muscle that is weakened. This is called congestive
heart failure. You were started on some new medicines to help
your heart pump better and to remove the fluid.
Medication changes:
START Keflex 500mg every 6 hours for 5 days to prevent infection
at the incision site.
START Lisinopril to help your heart pump better
START Spironolactone to help your heart remove the extra fluid
START Lorazepam as needed for anxiety
STOP taking potassium for now
Followup Instructions:
Device clinic:
Department: CARDIAC SERVICES
When: THURSDAY [**2106-1-21**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 17811**]
When: Wednesday [**2106-1-27**] at 11:10
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 2 [**Location (un) **] CENTER DR, [**Location (un) **],[**Numeric Identifier 29936**]
Phone: [**Telephone/Fax (1) 79695**]
.
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4455**]
When: Tuesday [**2106-2-2**] at 10:30 AM
Address: [**Last Name (un) **] [**Apartment Address(1) 40744**], [**Hospital1 420**],[**Numeric Identifier 26668**]
Phone: [**Telephone/Fax (1) 45578**]
.
Department: CARDIAC SERVICES
When: THURSDAY [**Month (only) **] [**2106**] at 9:00 AM
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2106-1-14**]
|
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,291
| 189,260
|
42461
|
Discharge summary
|
report
|
Admission Date: [**2174-2-19**] Discharge Date: [**2174-3-11**]
Date of Birth: [**2107-6-19**] Sex: M
Service: MEDICINE
Allergies:
Lithium
Attending:[**Doctor First Name 2080**]
Chief Complaint:
"bilious vomiting [pancreatitis]."
Major Surgical or Invasive Procedure:
G-tube placement
EGD
colonoscopy
History of Present Illness:
66 y/o man with mental retardation v GDD (unknown), minimally
verbal baseline, resident of a 'group home' brought to an osh by
his caregivers for hours of bilious, non bloody, emesis at home
yesterday. Found at osh to have pancreatitis by labs - no
gallstones, no lab evidence of biliary obstruction, sent to our
ED for ? ERCP
In our [**Name (NI) **], pt AF and HD stable, labs sl improved, but notable
for ongoing hypernatremia, pancreatitis (by lipase) - emesis
stopped, rectal exam guaiac NEGATIVE. CTAP done revealing
bibasilar infiltrates v atelectasis, pancreatitis, no gallstones
or obstruction or other acute abnormality on prelimiary ('wet')
read.
ROS: pt unable to respond given baseline cognitive impairment -
repeats questions back to me in echolalic fashion only.
Past Medical History:
-mental delay (etiology unclear at this time but documented in
record we have
-hx. pna
-hx seizures (type unknown)
-mention in record of recent rt clavicular fracture (etiology
unknown, but I suspect a fall)
Social History:
lives in group home, brother [**Name (NI) **] [**Name (NI) 410**] is HCP but wishes to
have guardianship established because he lives 300 miles away-he
was made guardian when their father died
Family History:
pt. unable to answer
Physical Exam:
AF and VSS
NAD, somnolent but arousable
Face symmetric
Speech fluent - repeats spoken words back to me (echolalia)
RRR, no MRG
Bibasilar rales, otherwise clear to auscultation, no wheezes
Abdomen distended, tender to deep palpation by grimacing and
vocalization, BS diminished, no rebound, no guarding
Moves all extremities symmetrically - did not comply with formal
neuro exam, so assisted (by two persons) to sitting and then
standing in lieu of formalized testing - pt. able to do this
with assist of two, once standing, able to stand with
contact-guard assistance of two persons to min assist. Bears
weight and moves both sides symmetrically.
Has no rash
Trace bt LE edema, Lt very slightly greater than rt, however, no
ertythema or tenderness to suggest a DVT
Pertinent Results:
[**2174-2-19**] 01:07AM GLUCOSE-116* UREA N-42* CREAT-2.2*
SODIUM-154* POTASSIUM-5.0 CHLORIDE-117* TOTAL CO2-26 ANION
GAP-16
[**2174-2-19**] 01:07AM PLT SMR-LOW PLT COUNT-138*
[**2174-2-19**] 01:07AM WBC-3.9* RBC-3.65* HGB-11.7* HCT-36.8*
MCV-101* MCH-31.9 MCHC-31.7 RDW-16.6*
[**2174-2-19**] 01:15AM LACTATE-2.2*
[**2174-2-19**] 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2174-2-19**] 01:07AM LIPASE-1146*
.
EGD [**2174-3-4**]
Normal mucosa in the esophagus
Normal mucosa in the stomach
Friability and erythema in the duodenal bulb and first part of
the duodenum compatible with duodenitis (biopsy)
(PEG)
Otherwise normal EGD to third part of the duodenum
.
[**2174-2-19**] CT AP
IMPRESSION:
1. Peripancreatic stranding, consistent with known pancreatitis
without
evidence for pseudocyst formation.
2. Bilateral lower lobe consolidations, which may represent
aspiration or
pneumonia.
3. Liver hypodensities may represent cysts or hemangiomas, but
are not
further characterized. Consider ultrasound for further
characterization.
.
CXR [**2174-2-19**]
IMPRESSION: Bilateral lower lung opacities, which may represent
pneumonia. Continued radiographic follow up is recommended.
.
[**2174-2-19**] right clavicle XR
There is cortical step-off of the inferior margin of the
clavicle, worrisome for fracture.
Colonoscopy:
Impression: Melanosis coli was noted scattered in the cecum.
Otherwise normal colonoscopy to cecum
Recommendations: No etiology of the anemia could be found.
Given fair prep would repeat colonosocpy in [**4-18**] years for
screening purposes. Further work-up for anemia per inpatient GI
team.
Brief Hospital Course:
Mr. [**Known lastname 410**] is a 66 y.o man with a history of global
developmental delay vs. mental retardation, CKD III-VI, bipolar
disorder, and ? seizure disorder, who presented with
pancreatitis, and whose course has been complicated by course of
pancreatitis, treated conservatively, persistent hypernatremia,
HCAP, critically high hyperglycemia and inability to
consistently tolerate po liquids and solids.
.
# DM2/Hyperosmolar hyperglycemic state: As suggested by serum BG
critically high, >600, serum bicarb >18, osms elevated (379 this
am). Difficult to assess mental status given baseline
non-communicative. It was unclear exactly what precipitated this
hyperglycemic state given no known history of diabetes. Pt had
been receiving essentially continuous D5W for tx of
hypernatremia, but this should not have caused blood glucose
that high if pt is not diabetic. HgbA1c 6.9. D5W in setting of
recent infection (see below) could precipitate hyperglycemia,
but would not expect levels to be >300. Possible that given
recent pancreatitis episode, pt could have burnout and
essentially no insulin production at this time. Patient was
transferred to the ICU for further management. Insulin gtt with
D5 was started and BG was monitored closely. Endocrine was
consulted, and pt was transitioned to insulin SC once BG
improved. Pt's A1c returned as 6.9. He was started on Lantus was
ISS. Endocrine followed on the medicine floor and uptitrate his
basal lantus as needed. His FSBG improved significantly.
- Discharged on Lantus 15 units with HISS. Further titration as
deemed necessary. WIll need uptitration of Lantus. FSBG in
200s on discharge
.
# Hypernatremia/Nephrogenic DI: Ddx included DI from
nephrogenic or central process vs. [**3-17**] osmotic diuresis and
insensible losses with fever. From previous notes, pt appears to
have possible nephrogenic DI from Lithium in the past. Pt was
hypernatremic on presentation, though not improving even with
free water, which is likely tied in with the hyperglycemia and
osmotic diuresis as above. Pt has been putting out over 6L per
day, and continues to be volume down. Pt's Na on admission was
154, and on transfer to the ICU, it was 166 (corrected for
elevated glucose). Patient's free water deficit was calculated
and he was given D5W with a goal of decreased corrected Na+ by
0.5meq/hr. Chem 7 was checked q3-4hrs and IVF rate was adjusted
accordingly. Endocrine was consulted as above. He was continued
on D5W while in the ICU. He was encouraged to take free water po
but was unable to do so on his own. His free water deficit was
calculated as 3.6L per day. This was initially via D5W and then
a G-tube was placed. Following this he was started on free
water flushes 600 cc Q4H and his blood sugars were much easlier
to control.
- As tube feeds were initiated, his water intake was decreased
slightly to 500ml q4 hrs, but resumed at 600ml
- He REQUIRES constant free water to maintain normal Na levels,
via his G tube. If this has to be stopped for some reason,
please monitor his sodium closely. PLEASE give 600ml free water
q4 through G tube
.
# Sinus Bradycardia: Pt arrived to the ICU bradycardic to 40s,
and hypertensive to 180s systolic. When looking back in the
chart, pt has been intermittently bradycardic and then
tachycardic. DDx for this includes hypothyroidism, hypothermia,
electrolyte abnormalities, sick sinus syndrome, MI or increased
intracranial pressure. Initially concerned about cerebral edema
given worsening hypernatremia, however, pt is agitated, but not
somnolent, and per nursing staff on the medicine floors, his
mental status has been relatively unchanged. He was monitored on
telemetry and HR improved to 70s with treatment of hyperglycemia
and sodium. TSH 2.8, trop negative x1.
.
# Hypothermia: DDx includes infection vs. hypothyroidism vs.
central process. Pt has known infection, and being treated with
HCAP coverage. Pt has ?seizure disorder, and neuroleptics
recently changed. TSH WNL. Temperature improved with resolution
of hyperglycemia and hypernatremia while in the ICU.
.
# HCAP: As evidenced by fever, infiltrates on CXR. Pt has been
on Vanc/Ceftazidime since [**2174-2-22**]. Blood cultures remained
negative while in the ICU and were resulted as negative when on
the floor. The patients vanco was renally dose with somewhat
variable renal function. He completed his antibiotic course in
house.
.
# Acute Pancreatitis: Pt had lipase >[**2162**] at OSH, ? CBD
dilatation, sent here for evaluation, no ERCP done given no
stone seen. Pt has been treated conservatively with pain
management, IVF's. Etiology unclear since no stone seen and
alcohol not thought to be the etiology. Per primary team,
depakote suspected, and thus discontinued. TGs 289. Monitored
while in ICU.
.
# Bipolar disorder: Pt has continued on his home dose of
Risperidal. Unclear if Trazodone is standing or prn qhs order.
Per OMR notes from admitting team, Depakote was more for mood
stabilization than known seizures. As above, depakote has been
discontinued, and keppra started. No changes were made during
ICU stay. He had been on keppra in the past for mood
stabalization.
- Cont Trazodone and Risperdal qHS standing as this helps his
mood
.
# CKD stage III-IV: Cr on admission 2.2, and has been relatively
stable this admission.
.
# Clavicular fracture: Noted on admission films, admitting
attending has discussed this with group home. Group home
director, who is aware, and who has initiated a DPPC
investigation into possible abuse, given that he did not have a
known fall.
PT consulted.
.
# Anemia: Macrocytic, no evidence of bleeding. Low retic count.
No evidence of DIC with normal plts and coags. No evidence of
hemolysis with normal haptoglobin and Tbili. Vitamin B12, folate
normal. Iron low at 10, but ferritin normal. Hct has been
stable. PEP has been sent this admission and normal. Given low
retic count, would be concerned about acute inflammatory process
or infiltration of bone marrow preventing reticulocytosis, or
chronic malnutrition. Monitored while in the ICU, unchanged.
When on the floor the patients Hgb steadily dropped. While
getting a G-tube placed the patient had a concurrent EGD which
showed duodenitis. He was placed on lansoprazole for this.
Colonoscopy was normal. His Hct stabilized.
- Recommend colonsocopy in [**4-18**] years
- Would repeat Hct in next few weeks and refer to Hematology if
still with significant anemia
##? of hypodensities in the liver
-a ruq u/s can be done as outpatient vs. while in house
After discharge:
F/U with pcp (request made in care connection), psychiatrist, ?
epileptologist
[**Month (only) 116**] need rehabilitation convalescence vs. home with RN/PT
services (pending)
Medications on Admission:
Reviewed list that accompanied pt:
vitamin c and iron (500/324 daily)
depakote 750 mg [**Hospital1 **]
colace/senna (standing)
proscar
zocor 10 mg daily
Fosamax/Os-cal
Trazodone 50 mg hs
Risperdal 3 mg hs
Discharge Medications:
1. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
3. finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. risperidone 1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO HS (at
bedtime).
6. trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Five (5) mL PO BID (2
times a day).
10. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Fifteen (15) units
Subcutaneous once a day.
11. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: 1-15 units Subcutaneous
qACHS: per sliding scale.
12. trazodone 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
13. Zofran 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Pancreatitis, acute, depakote related
Healthcare associated pneumonia
Anemia, multifactorial
Hypernatremia
Nephrogenic diabetes insipidus
Rt. clavicular fracture
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
During this admission you were diagnosed with:
1. Pancreatitis, most likely due to depakote (valproic acid)
that was prescribed for seizures. This improved with stopping
depakote and IV fluids.
2. Anemia, multifactorial, WITHOUT vitamin B12 or Iron
deficiency, may also be due to depakote. You had an EGD which
showed no obvious causes. You also had a colonoscopy which
showed no cause of bleeding
3. Thrombocytopenia, mild, possibly also due to depakote
4. Hypernatremia (free water deficit) most likely due to limited
intake in setting of known nephrogenic diabetes insipidus from
prior lithium use
5. Rt. clavicular fracture, sub-acute, present on admission,
etiology unknown
6. (possible) seizure disorder, for which keppra has been
prescribed
7. Diabetes, type II-now controlled on long and short acting
insulin
Please take medications as prescribed.
Followup Instructions:
Follow up with physicians at you Rehab facility. Follow this
you should have routine follow up with your:
1) PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 45950**]-please call to arrange
2) Renal physician-[**Last Name (NamePattern4) **]. [**Last Name (STitle) 3112**] ([**Telephone/Fax (1) 91914**]
3) GI: should anemia continue
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40,370
| 199,999
|
2652
|
Discharge summary
|
report
|
Admission Date: [**2136-4-4**] Discharge Date: [**2136-4-10**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
88 y/o M with hx of Crohn's and CAD who presents with 4 days of
feeling badly and a new temp to 103 this afternoon. He saw his
PCP yesterday and had no localizing symptoms were noted and
workup was unremarkable. Today he spent all day in bed and just
continued to feel poorly with shaking fevers and chills. He had
a slight cough, but did not really think much of it. No sputum
production. Had a mild backache, but no chest pain. He notes he
had some diarrhea, but only once or twice a day and also had
some darker urine. He was not eating and drinking because he
felt poorly. His wife kept bringing him fluids but he just
didn't feel like drinking.
.
In the ED, initial vitals were 99.9, 80, 133/52, 20, 92% on RA.
He desatted to 88% and a CXR showed a new pneumonia. He received
2L of IVFs. He was noted to be unable to urinate, so a foley
catheter was placed.
Past Medical History:
# Crohn's disease. Diagnosed [**5-/2132**] with abdominal pain &
partial SBO. Initially managed with prednisone, colonoscopy
[**7-/2132**] and biopsy were negative, tapered to pentasa tid
# Diverticulosis
# CAD s/p stent
# HTN
# hyperlipidemia
Social History:
Lives in [**Hospital1 392**] with his wife. The patient is married, is
currently a nonsmoker (1ppd x5 yrs while in the Navy, quit 60
yrs ago), has a rare occasional glass of wine with dinner, is a
retired chemical engineer. no IVDU or illicit drug use.
Family History:
no known family members with IBD. son w/ ? gas issues.
Physical Exam:
On admission:
Vitals - 97.7, 151/71, 80, 20, 94% on 2L
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, mildly short of
breath when talking for long period of time.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-5**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait.
.
On discharge:
GEN: NAD
HEENT: Oral mucosa moist
NECK: Supple, no [**Doctor First Name **], no appreciable JVP elevation
PULM: Diminished anterior breath sounds and crackles of left
anterior lung field with left axillary egophony
CARD: RR, nl S1, nl S2, no M/R/G
ABD: Thin, BS+, soft, NT, ND
EXT: No C/C/E
SKIN: Erythematous appearance of cheeks and neck
NEURO: Patient oriented x 3, hearing impairment, non-focal motor
exam
PSYCH: Mood and affect appropriate
Pertinent Results:
Admission labs:
===============
[**2136-4-4**] 08:45PM BLOOD WBC-17.9*# RBC-3.96* Hgb-12.5* Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.3* RDW-13.7 Plt Ct-250
[**2136-4-4**] 08:45PM BLOOD Neuts-92.1* Lymphs-4.0* Monos-3.4 Eos-0.4
Baso-0.1
[**2136-4-4**] 08:45PM BLOOD Plt Ct-250
[**2136-4-5**] 03:20AM BLOOD PT-14.2* PTT-31.3 INR(PT)-1.2*
[**2136-4-4**] 08:45PM BLOOD Glucose-164* UreaN-21* Creat-1.3* Na-128*
K-3.9 Cl-96 HCO3-20* AnGap-16
[**2136-4-6**] 06:40AM BLOOD LD(LDH)-251* CK(CPK)-118
[**2136-4-6**] 06:40AM BLOOD CK-MB-7 cTropnT-<0.01
[**2136-4-5**] 03:20AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.9
[**2136-4-4**] 08:55PM BLOOD Lactate-1.9
.
Discharge labs:
===============
[**2136-4-9**] 02:08AM BLOOD WBC-8.0 RBC-4.09* Hgb-12.5* Hct-37.2*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.3 Plt Ct-417
[**2136-4-9**] 02:08AM BLOOD Glucose-106* UreaN-12 Creat-0.8 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
[**2136-4-9**] 02:08AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0
.
Imaging:
========
CXR [**4-4**]: Diffuse opacities involving the left lung is compatible
with pneumonia.
.
CT chest [**4-6**]: Extensive left upper and lateral segment of left
lower lobe consolidation with surrounding septal thickening and
ground-glass. Given the clinical features of fever and acute
hypoxia, this most likely represents an extensive bacterial
pneumonia.
.
CXR [**4-9**]: As compared to the previous radiograph, there is mild
improvement of the left-sided pneumonia. The opacities
pre-existing in the left lung has mildly decreased in extent.
Unchanged normal appearance of the right lung. Unchanged
appearance of the cardiac silhouette.
.
Brief Hospital Course:
88 yo M with limited past medical history, who ultimately
presented to [**Hospital1 18**] ED on afternoon of [**4-4**] after 4 days of
malaise and chills. Found to have legionella pneumonia.
.
#. Legionella pneumonia: patient was admitted with fevers and
hypoxia and found to have positive Legionella assay. He was
treated on the floor with azithromycin and levofloxacin but
continued to develop worsening oxygen requirment necessitating
transfer to the MICU. In the MICU, he was maintained on facemask
with high flow oxygen and transitioned to nasal cannula but
continued to have mild respiratory distress. He did not require
intubation. CT chest and CXR confirmed involvement of both the
left upper and left lower lobe. He was provided with chest PT.
After some clinical improvement, azithromycin was discontinued
and he was continued on levofloxacin monotherapy for a total of
14 day course (at time of transfer was on day [**5-15**]). He was
transferred to an LTAC to continue his antibiotic course, to
wean down oxygen, and to continue pulmonary therapy. He should
follow up with his geriatric NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 715**] after discharge from
rehab.
.
#. Left pleural effusion: patient had a thoracentesis with IP on
[**2136-4-6**]. Given elevated pleural fluid LDH to 461, is most
consistent with a parapneumonic effusion. CXR post-thoracentesis
on the floor was without concern for pneumothorax. Pleural fluid
gram stain was negative and culture showed no growth on [**4-9**].
Pleural fluid pH was 7.44 and no indication for chest tube
placement.
.
#. Crohn's disease: Reportedly asymptomatic at this time.
Continue homed pentasa 1000 mg [**Hospital1 **].
.
#. Anemia: HCT stable at 37.2, up from 35.5 at admission.
Baseline anemia likely from chronic GI losses from Crohn's
disease, though not microcytic. Will need further outpatient
work-up.
Medications on Admission:
ASA 81 mg daily
Pentasa 1000 mg ER [**Hospital1 **]
Troprol XL 50 mg daily
Lisinopril 20 mg daily
Simvastatin 20 mg daily
MVI daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. mesalamine 250 mg Capsule, Extended Release Sig: Four (4)
Capsule, Extended Release PO BID (2 times a day).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for desat, wheeze.
8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 8 days: LAST DAY = [**2136-4-17**].
9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
Legionella pneumonia
Left pleural effusion (parapneumonic)
Secondary:
Anemia
Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 13284**],
You were admitted to [**Hospital1 18**] and found to have a Legionella
pneumonia. We started you on antibiotics for this and your
breathing improved but you were still requiring oxygen therapy
at time of transfer to the rehab facility. It may take some time
for your lungs to clear the infection and your oxygen will be
weaned down at the rehab. You also had a build up of fluid
around your left lung which was likely due to your pneumonia and
we took a sample of this. You should continue antibiotics for
your pneumonia for a total of 2 weeks (last day will be on
[**2136-4-17**]).
After you are discharge from your rehab facility, please [**Name6 (MD) 138**]
your NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 715**] at the geriatric clinic to schedule a follow
up. You should also discuss with [**Doctor First Name 717**] further evaluation of
your anemia.
We have not made any changes to your other home medications.
Followup Instructions:
After you are discharge from your rehab facility, please call
our geriatric clinic to schedule a follow up (Phone:
[**Telephone/Fax (1) 719**]). You should also discuss with your PCP further
evaluation of your anemia.
The following appointment was already scheduled for you:
Department: GASTROENTEROLOGY
When: MONDAY [**2136-4-16**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"276.1",
"482.84",
"285.29",
"584.9",
"518.81",
"429.3",
"786.06",
"799.02",
"511.9",
"V45.82",
"788.20",
"414.01",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7584, 7649
|
4621, 6518
|
264, 279
|
7796, 7796
|
3001, 3001
|
8982, 9704
|
1727, 1783
|
6701, 7561
|
7670, 7775
|
6544, 6678
|
7979, 8959
|
3654, 4598
|
1798, 1798
|
2535, 2982
|
218, 226
|
307, 1172
|
3017, 3638
|
1812, 2521
|
7811, 7955
|
1194, 1440
|
1456, 1711
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,438
| 197,760
|
34389
|
Discharge summary
|
report
|
Admission Date: [**2154-10-3**] Discharge Date: [**2154-10-7**]
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
complete occlusion of infrarenal aorta
Major Surgical or Invasive Procedure:
OPERATION PERFORMED:
1. Bilateral femoral artery exposure via cutdown balloon
thrombectomy of iliofemoral and femoral popliteal system.
2. CFA endarterectomy Patch angioplasty of left common femoral
artery.
History of Present Illness:
HPI:
83 year old woman with h/o Stage IV ovarian cancer with mets to
lung and liver presents with back pain and paraplegia. She was
awakended from sleep this morning at 1am due to sudden onset
"constant, dull" lumbar pain. When she tried to get up from bed
she was unable to do so. She was taken to an OSH and later
transferred to [**Hospital1 18**]. Here she has continued low back pain,
foley
has already been placed and it is unclear if she is continent of
urine. No bowel incontinence. She feels her legs are numb,
denies
paresthesias. Legs are notably violaceous to her knees which she
relates to having ever since she broke her ankles in the [**2116**]'s.
She denies any HA, speech difficulty, diplopia, dysphagia.
Past Medical History:
PMH:
met ovarian cancer
malignant plerual effusions
Social History:
SH: Lives in [**Hospital1 11851**] [**Hospital3 **], nonsmoker, no ETOH or
illicits.
Family History:
FH: not elicited.
Physical Exam:
Pt deceased on this admission
Pertinent Results:
[**2154-10-4**] 02:33AM BLOOD
WBC-14.9*# RBC-3.59* Hgb-11.2* Hct-32.0* MCV-89 MCH-31.1
MCHC-34.9 RDW-20.2* Plt Ct-70*
[**2154-10-4**] 02:33AM BLOOD
PT-20.0* PTT-69.7* INR(PT)-1.9*
[**2154-10-4**] 02:33AM BLOOD
Glucose-163* UreaN-25* Creat-1.6* Na-137 K-5.9* Cl-108 HCO3-17*
AnGap-18
[**2154-10-4**] 02:33AM BLOOD
CK(CPK)-4567*
[**2154-10-3**] 02:28PM BLOOD
CK(CPK)-1513*
[**2154-10-4**] 05:36AM BLOOD
Type-ART pO2-106* pCO2-37 pH-7.34* calTCO2-21 Base XS--5
Brief Hospital Course:
83 F presented with bilateral lower extremity paralysis at 4am
in ED now with pulseless bilateral lower extremities
fem/[**Doctor Last Name **]/dp/pt and cold mottled legs. Pt had work up in ed for
r/o of cord compression which showed some canal narrowing.
Vascular consulted emergently at 8:00am for increasingly mottled
legs.
Emergently Taken to OR:
OPERATION PERFORMED:
1. Bilateral femoral artery exposure via cutdown balloon
thrombectomy of iliofemoral and femoral popliteal system.
2. CFA endarterectomy Patch angioplasty of left common femoral
artery.
Pt developed dead leg.
family was informed that she needed AKA and that the pt
condition was dire
The family decided to make pt [**Name (NI) 3225**]
Pt diseased on [**10-7**] cause of death respiratory failure
Medications on Admission:
[**Last Name (un) 1724**]:
Fosamax 70'
Citalopram 20'
Timolol 0.5 % Eye Drops Ophthalmic
1 Drops(s) both eyes Once Daily
Vitamin D-3 400"
Alphagan P 0.15 % Eye Drops Ophthalmic
1 Drops(s) both eyes once daily
Labetalol 300 mg Tab Oral
1 Tablet(s) Twice Daily
Oyst-Cal-500 500 mg (1,250 mg) Tab Oral
1 Tablet(s) Twice Daily
Hydralazine 50 mg Tab Oral
1 Tablet(s) Three times daily
Alprazolam 0.25 mg Tab Oral
1 Tablet(s) Once Daily
Simvastatin 20 mg Tab Oral
1 Tablet(s) Once Daily
Coumadin -- Unknown Strength
Lasix 40 mg Tab Oral
1 Tablet(s) Twice Daily
Debrox 6.5 % Ear Drops Otic
4 Drops(s) L ear three times a day for 3 days
Potassium Chloride SR 20 mEq Tab, Particles/Crystals Oral
1 Tab Sust.Rel. Particle/Crystal(s) Once Daily
Discharge Medications:
Pt deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Complete occlussion of aorta
Discharge Condition:
deseased
Discharge Instructions:
deseased
Followup Instructions:
deseased
Completed by:[**2154-10-15**]
|
[
"584.5",
"444.81",
"198.5",
"197.7",
"444.0",
"344.1",
"197.0",
"287.5",
"285.9",
"197.2",
"V10.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.08",
"38.06",
"00.40",
"38.18"
] |
icd9pcs
|
[
[
[]
]
] |
3619, 3628
|
2016, 2798
|
280, 493
|
3701, 3711
|
1523, 1993
|
3768, 3808
|
1438, 1458
|
3583, 3596
|
3649, 3680
|
2824, 3560
|
3735, 3745
|
1473, 1504
|
202, 242
|
521, 1244
|
1266, 1319
|
1335, 1422
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,584
| 163,018
|
19161
|
Discharge summary
|
report
|
Admission Date: [**2130-8-19**] Discharge Date: [**2130-9-1**]
Date of Birth: Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: This is a 60 year old female,
recently diagnosed with transient ischemic attack and
diabetes mellitus type II and increased cholesterol. She
presents with a three day history of left lower extremity
weakness. She also had left upper extremity weakness and
left sided visual fields. The patient was visiting
[**State 350**] from [**State **]. She was at home working in her
garden on [**2130-7-21**], when she fell and tripped in the
garden. She felt generally weak later on in her house. She
sat down and slumped backwards in a chair. She had trouble,
per her husband, understanding him and what she was saying
was not making sense. The episode lasted approximately 30
seconds. The patient was felt to be okay except for
persistent left lower extremity weakness.
She went and saw her primary care physician and was told that
she had transient ischemic attacks and was sent to a
cardiologist who discovered right carotid total occlusion on
[**2130-8-16**]. The patient drove to [**Location (un) 86**] to visit her son on
[**2130-8-17**] and was in a store and again had an episode of her
legs hurting and a headache and then she noticed that her
left arm was weaker. She also described that she was unable
to see anything on her left side. She denied bowel problems.
She has an occasional incontinence over the last two months.
She denies recent illnesses, no diplopia, no numbness or
tingling. She was started on Lipitor and Plavix in [**Month (only) **]
after that episode that occurred in her garden. She does not
have any treatment for diabetes mellitus.
PAST MEDICAL HISTORY: Transient ischemic attack which was
diagnosed in [**7-18**]. Diabetes mellitus, type II. Pacemaker
placement for conductive defect that was in [**2127-4-16**]. She
is status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy in [**2087**]. Status post appendectomy.
ALLERGIES: There is a question of a codeine allergy.
MEDICATIONS:
Lipitor 20 mg q. day.
Plavix 75 mg q. day.
Primatene mist one puff several times a day.
SOCIAL HISTORY: She does smoke one to two packs per day
times 35 years. She does not drink alcohol or use
intravenous drugs.
FAMILY HISTORY: Father is 83 with stroke and diabetes
mellitus. Siblings are healthy.
PHYSICAL EXAMINATION: Vital signs 99.1; 120/96; 72; 16; 91%
on room air. General: She is no acute distress, appears
comfortable; gaze is to the right. HEAD, EYES, EARS, NOSE
AND THROAT: No scleral icterus. Mucous membranes are moist.
Neck is supple. Positive right carotid bruit. Chest:
Positive fine rales, bibasilar. CV: Regular rate and
rhythm, normal S1 and S2. Abdomen soft, nontender,
nondistended. Extremities had no edema bilaterally.
Neurologic: Mini mental examination was 30/30. Speech was
fluent. Repetition and naming were intact. [**Location (un) **] and
writing are intact. Pupils are equal, round, and reactive to
light and accommodation. 3.5 to 2.5 on the right and the
left. The extraocular movements were full. She also has
left sided anonymas hemiopia on the left side. Facial
sensation was intact. Facial movement was symmetrical. No
weakness. Sternocleidomastoids were full strength
bilaterally. Palate elevates midline and symmetrically.
Tongue protrudes midline without deviation. Motor was good
bulk and tone throughout. Right biceps was 4+. Triceps was
4+. Deltoids were five. IP's were 4. AT was 5.
Gastrocnemius were 5. Left side was 4+ for the biceps, 4-
for triceps; deltoid was 4+; IP was 4-; AT was 4- and
gastrocnemius was 4. She had a left pronator drift.
Reflexes were 2+ on the right except for the knee and ankle
and left was 2+ throughout. Coordination: Finger to nose
was intact. Positive intention tremor. Sensation was
decreased to vibration and temperature, worse on the left
than on the right. JPS joint position was somewhat decreased
bilaterally. She has positive Romberg. Gait was unsteady.
Flow was falling to the left side.
LABORATORY DATA: Sodium 135; potassium of 3.9; chloride 101.
C02 23; BUN 13; creatinine .8; 253 for blood glucose. White
count was 12; hematocrit was 43.7; platelets were 284; PT was
12.6; PTT was 24; INR was 1.1. Head CT showed several
prominent old lacunar infarcts on the right, one by the
internal capsule could be a developing extension. That is
what was thought. No prominent ventricles. Positive
peri-ventricular white matter changes.
HOSPITAL COURSE: The patient was admitted to the
neurosurgery service. The patient was started on a heparin
drip and was continued on her aspirin and Plavix. Goal PTT of
50 to 70. The patient was preopped for an angiogram and was
followed on telemetry. Chest x-ray was done, showing likely
chronic obstructive pulmonary disease and fingersticks were
done for her diabetes mellitus.
On the [**4-20**], the patient was seen by the neurologic
resident who felt, on examination, she had an incongruous
left homonomous hemianopia and a subtle left hemiparesis with
some hemi-anesthesia. There was also evidence of decreased
cortical sensation on the left. They felt that it was an
anterior choroidal infarction on the right side. They
recommended to continue on aspirin p.o. q. day for stroke
prophylaxis, carotid ultrasound, a repeat non contrast head
CT, to start her on Lipitor, to check cholesterol panel.
On the [**4-23**], the patient did have a transesophageal
echocardiogram done which showed the left atrium to be mildly
dilated. The left ventricular cavity size was normal. The
left ventricular systolic function was normal. An ejection
fraction of greater than 55% was noted. The right
ventricular chamber size was normal. Aortic valve was not
seen. No aortic regurgitation was seen. The mitral valve
leaflets were mildly thickened. There was +1 mitral
regurgitation and no source of embolism was noted.
On the [**4-23**], the patient was brought to the angio
suite where had a cerebral angiogram done. She was found to
have right internal carotid artery occlusion with left
subclavian steel syndrome. The patient was brought back to
the surgical floor where she continued on her aspirin, Plavix
and she was scheduled for an angioplasty of her left
subclavian. Postoperatively, she had no complications. She
was continued on the heparin drip. She continued with a left
pronator drift and some left sided weakness. The findings on
the diagnostic angiogram were a right internal carotid artery
occlusion with minimal artery involvement; right hemisphere
was supplied with collateral from the right vertebral artery
and right PCOM artery and left subclavian stenosis for steel
syndrome, involving the right vertebral artery and in addition
the patient had a left subclavian steal phenomenon because of a
left subclavian artery origin stenosis.
On [**8-28**], the patient did have an angioplasty of her
subclavian artery. There were no postoperative complications.
She was monitored overnight in the Intensive Care Unit where
her blood pressure was kept in the 140 to 160 range. She
required Nipride to maintain good blood pressure. The
sheaths were kept in overnight.
On the 15th, the sheaths were removed. The patient continued
to have a slight left pronator drift and finger to nose
movements were slightly decreased on the left. Her left IP
was a four out of five. PTT was five out of five and
gastrocnemius was five out of five. Her groin was intact with
no hematoma, had a good pulse. She had complained of some
back pain while in Intensive Care Unit. She was kept
overnight and was ruled out for a myocardial infarction. Her
enzymes were normal. She was also seen by medicine to have a
consult to assist us with her blood pressure control. They
recommended continuing her on Lopressor, which had been
started the day before and Captopril, increasing in
increments until her blood pressure was in the 140 to 160
range.
The patient was transferred out of the Intensive Care Unit on
[**2130-8-30**]. She was seen by physical therapy on the 16th. It
was noted that her IP's were 4 out of 5; AT was four out of
five and gastrocnemius was [**6-19**] on the left side. On the
16th, medicine made some changing recommendations for her
blood pressure control. They changed her Captopril to
Lisinopril. They recommended 5 mg q. a.m. and also they
stopped her Lopressor and changed it to Atenolol 50 mg q.
day. She was seen by physical therapy and was recommended to
have transfer training, balance training and gait training.
On the 17th, it was felt that the patient needed one more day
of hospitalization to continue with physical therapy.
The patient was discharged home, back to [**State **] on [**2130-9-1**]
with the following medications:
Lisinopril 5 mg q. a.m.
Atenolol 50 mg q. day.
Pravastatin 20 mg.
Propanolol 40 mg q. 24 hours.
Ipratropium bromide MDI, two puffs four times a day.
Plavix 75 mg q. day.
Aspirin 325 mg q. day.
DISCHARGE INSTRUCTIONS: The patient should be seen by
primary care physician on return to [**State **] to monitor her
blood pressure. She will need to follow-up with a local
neurosurgeon in [**State **] and should continue follow-up with her
cardiologist. The patient was discharged neurologically
stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 52281**]
MEDQUIST36
D: [**2130-8-31**] 11:55
T: [**2130-8-31**] 11:02
JOB#: [**Job Number 52282**]
|
[
"272.0",
"250.00",
"V45.01",
"435.2",
"424.0",
"433.10",
"434.91",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"88.72",
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
2351, 2423
|
4599, 9062
|
9087, 9626
|
2446, 4581
|
166, 1737
|
1760, 2207
|
2224, 2335
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
945
| 101,713
|
4406
|
Discharge summary
|
report
|
Admission Date: [**2156-9-19**] Discharge Date: [**2156-9-27**]
Date of Birth: [**2095-5-7**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides) / Percocet
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Fever, neutropenia, and swollen, painful left elbow
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
61-year-old right-handed woman with glioblastoma multiforme, s/p
subtotal resection on [**2156-7-2**], involved-field cranial XRT, and
chemotherapy (last taken on [**2156-9-10**]). She developed a fever to
102 F, hypotension to SBP 90s today, and came to our emergency
room. Husband first noted left elbow 3-4 weeks ago which
resolved in 2 days after application of neosporin (there was a
question of spider bite). Then 3 days ago she noted erythema
which increased and associated with increasing edema and
tenderness. Today, the patient was practically unable to move
elbow due to pain. She experienced fever and chills that began
yesterday, but she did not take her temperature. Her Review of
System is notable for a new dry cough x 6 days. She also
developed diarrhea but stopped 3 days ago when she stopped
taking Colace. She has fatigue but no SOB, congestion,
abdominal pain, dysuria, bright red blood per rectum, or melena.
There was no trauma to elbow. There was no recent sick
contacts or travel.
Regarding her oncologic history, her symptoms began in late [**Month (only) 205**]
[**2155**] with headache, word-finding difficulties, memory loss, and
confusion. She was found to have a left parietal brain lesion.
After subtotal resection on [**2156-7-2**], underwent involved-field
XRT with concurrent temozolomid. She also received 1 treatment
with CyberKnife radiosurgery to an enhancing lesion in the right
occipital lobe, together with temozolomide.
In the emergency room, her temperature was 102.6 F, HR 130s
(sinus tachycardia), and systolic BP 90s-100s (baseline SBP
120s-130s). Her WBC was 0.3 with no neutrophils or bands. Her
U/A showed no WBC but there was nitrates and bacteria. Her
serum lactate was 3.9. Blood and urine cultures were sent. Her
chest CTA was negative for pulmonary embolism, but there was
mild left lung apical patchy ground-glass opacity; there was a
question of atelectasis versus pneumonia. She received oxygen
at 7 liters via nasal cannula in the emergency room but her
systolic BP persisted in 90s-100s. Emergency Department did not
start on sepsis protocol because her serum lactate was not > 4
and she was responsive to fluid, despite the elevated
temperature, heart rate, and WBC.
Past Medical History:
Glioblastoma multiforme of left temporoparietal lobe
Anxiety
Social History:
Never smoked, drinks alcohol on rare occasions. Lives with
husband. Worked as secretary.
Family History:
Father had lung cancer. Mother had [**Name (NI) 2481**] disease. Her
siblings are all healthy. She has 1 son and 1 daughter, and
both of them are healthy.
Physical Exam:
Physical Examination:
Vital Signs: Temperature 102.6 F in Emergency Department;
Current Temperature 100.2 F; Heart Rate 108; Blood Pressure
106/56; Respiratory Rate 16; Oxygen Saturation 99% on 2 Liters.
Gen: Cushingnoid faced woman, fatigued appearing, otherwise in
no acute distress lying in bed
HEENT: PERRLA, EOMI, anicteric, pale conjunctival membranes, dry
mucous membranes, +scars on scalp from prior neurosurgery
Neck: No LAD
CV: RRR tachycardic, nl S1, S2 no m/r/g
Pulmonary: CTA bilaterally
Abdomen: NABS, soft, NT/ND, well-healed vertical [**Doctor First Name **] incision
Extremities: LUE elbow has 5-cm area of erythema, warmth, mild
fluctuance, and tenderness to palpation. She is unable to
abduct at elbow more than 5 degrees secondary to pain. Her
lower extremities are cool, without c/c/e. She has 2+ dorsalis
pedis pulses bilaterally
Neurologic Examination: Her mental status is intact. She is
awake, alert, and oriented x 3. Her language is fluent with
good comprehension. CN II-XII are intact. Her motor strength
is [**4-15**] motor in RUE; LUE examination limited due to pain at
elbow. In the lower extremities, she has 4-/5 strength
bilaterally at thigh flexors, 5/5 strength at quadriceps,
hamstrings, foot dorsiflexion, and plantar flexion. Her
reflexes are 2- but her ankle jerks are absent. She has
downgoing toes. Sensory examination reveals normal sensory
examination. Coordination examination does not reveal
dysmetria. Her gait is steady. She does not have a Romberg.
Pertinent Results:
[**2156-9-19**] 12:10PM WBC-0.3* RBC-4.61 HGB-14.8 HCT-41.3 MCV-90
MCH-32.1* MCHC-35.8* RDW-13.9
[**2156-9-19**] 12:10PM NEUTS-0* BANDS-0 LYMPHS-65* MONOS-35* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2156-9-19**] 12:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-OCCASIONAL
[**2156-9-19**] 12:10PM PLT SMR-LOW PLT COUNT-140*
[**2156-9-19**] 12:10PM PT-13.5* PTT-24.5 INR(PT)-1.2
[**2156-9-19**] 12:10PM SED RATE-70*
[**2156-9-19**] 12:10PM GLUCOSE-114* UREA N-14 CREAT-0.6 SODIUM-138
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
[**2156-9-19**] 12:10PM ALT(SGPT)-35 AST(SGOT)-22 ALK PHOS-88 TOT
BILI-0.6
[**2156-9-19**] 01:05PM LACTATE-3.9*
[**2156-9-19**] 01:07PM CK-MB-NotDone cTropnT-<0.01
[**2156-9-19**] 01:07PM CRP-67.5*
[**2156-9-19**] 01:07PM CK(CPK)-11*
[**2156-9-19**] 02:08PM URINE RBC-0 WBC-0 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2156-9-19**] 02:08PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-9-19**] 02:08PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
L elbow Xray [**2156-9-19**]: Four radiographs of the left elbow
demonstrate no joint effusion. No fracture. No cortical
fragmentation to suggest osteomyelitis. Regional soft tissues
are unremarkable.
IMPRESSION:
Unremarkable radiographs, left elbow.
MRI of L elbow: MR LEFT ELBOW WITHOUT CONTRAST: There is a
moderate elbow joint effusion. The bone marrow appears normal in
signal intensity characteristics. There is circumferential edema
within the subcutaneous tissues about the elbow. There is fluid
signal intensity in the region of the olecranon bursa,
suggestive of bursitis. There is more confluent high signal
intensity surrounding the musculature at the elbow joint. It is
not clear if this represents dense edema or frank fluid, as this
study is limited without intravenous contrast. Also noted is
diffuse increased signal intensity within the musculature about
the elbow, suggestive of myositis.
IMPRESSION:
1. Moderate elbow joint effusion.
2. Diffuse increased signal intensity within the musculature
about the elbow, consistent with nonmyositis.
3. Olecranon bursitis.
4. Edema within the subcutaneous tissues about the elbow,
suggestive of cellulitis.
CT OF THE CHEST: There are no significant axillary, mediastinal,
or hilar lymph nodes. There is a small hypodense area in the
left lobe of the thyroid measuring 1.2 x 0.8 cm. Ultrasound
could be performed for further evaluation.
There is no pericardial effusion. The heart is of normal size.
The great vessels are unremarkable. There is no evidence of
aortic dissection. There is fluid in the pericardial recess
anterior to the aorta, which is unchanged when compared to prior
study. The pulmonary artery is normal size. There are no filling
defects in the pulmonary artery branches. There is no evidence
of pulmonary embolism. The airway is patent to level of
subsegmental bronchi. There are subsegmental atelectasis in the
right middle lobe and lower lobes. There are emphysematous
changes in the lungs. There is a patchy ground-glass opacity in
the left upper lobe near the apex that is new when compared to
the prior study and of unclear significance. It most likely
represents an area of pneumonia. There are no pleural effusions.
Limited images of the upper abdomen do not reveal significant
abnormality.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Emphysema.
3. Subsegmental atelectasis.
4. Small patchy ground-glass opacity in the left apex of unknown
clinical significance. It could representa small focus of
pneumonia. It is new when compared to the prior study from [**6-30**], [**2155**]. Attention on follow to confirm resolution is
recommended.
EKG [**2156-9-25**]: Sinus tachycardia
Modest diffuse nonspecific ST-T wave abnormalities
Since previous tracing of [**2156-9-19**], sinus tachycardia rate
slower and ST-T wave abnormalities are less prominent
[**2156-9-26**] 1:20 pm SWAB Source: Left elbow bursa pus.
**FINAL REPORT [**2156-10-5**]**
GRAM STAIN (Final [**2156-9-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2156-9-30**]):
STAPH AUREUS COAG +. RARE GROWTH.
Please contact the Microbiology Laboratory ([**6-/2457**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
ANAEROBIC CULTURE (Final [**2156-10-5**]): NO ANAEROBES ISOLATED.
BCX [**2156-9-19**]: No growth (final)
BCX [**2156-9-20**]: No growth (final)
Brief Hospital Course:
This is a 61-year-old woman with glioblastoma multiforme, s/p
involved-field XRT, surgery, involved-field cranial irradiation,
and chemotherapy presented with neutropenic fever, left elbow
bursitis/cellulitis, UTI, and possible pneumonia on chest CT.
1. Neutropenic Fever/Hypotension: In the [**Hospital Unit Name 153**], the patient was
aggressively fluid resuscitated, and her blood pressure
responded without any pressor. Sources of infection included
left elbow bursitis/cellulitis, pneumonia, and UTI. In the
setting of neutropenic fever, the patient was started on broad
spectrum antibiotics with vancomycin, ceftazidime, and
azithromycin (for atypical pneumonia), as well as gentamicin x 1
dose in context of continued destabilization and need for double
gram negative coverage. Central venous pressure improved to
[**6-23**] over the course of 48 hours, and blood pressures
stabilized. Patient had no more fever. Patient received stress
dose steroids as well as Neupogen. Orthopedics was consulted
for her left elbow bursitis/cellulitis. X-ray and MRI did not
reveal osteomyelitis. Orthopedics felt that possible bursitis;
however, symptoms improved with antibiotics.
On transfer to the OMED service, the patient was afebrile and
hemodynamically stable. She was continued on Neupogen,
vancomycin, ceftazidime, and azythromycin. On [**2156-9-23**], given
her enterococcal UTI is pansensitive and the patient no longer
neutropenic, vancomycin and ceftazidime were discontinued and
cefazolin IV was started to cover both enteroccocus and left
elbow cellulitis. Neupogen was discontinued on [**2156-9-24**].
Azythromycin was discontinued after completion of 7 day course
on [**2156-9-26**]. Also, on [**2156-9-26**], the left elbow had increased
warmth and erythema as well as enlargement of fluid sac. Also,
patient's WBC increased despite the discontinuation of Neupogen
was disproportionately high with a presence of dohl bodies and
toxic granulations on smears suggestive of undertreated or
persistant infection. Thus, cefazolin was discontinued, and
vancomycin was restarted on [**2156-9-26**]. The left elbow responded
well to vancomycin and the fluid sac broke open spontaneously,
draining pus. The patient had a PICC line placed in her right
arm and was discharged with 10 more days of vancomycin to finish
a 2 week course.
2. Hypoxia: The paitnet required O2 supplement temporarily. CXR
showed small bilateral pleural effusions and atelectasis. With
incentive spirometry use, the patient's sat improved to 95% on
RA.
3. Glioblastoma Multiforme: Chemotherapy was held. Continued on
Keppra and Decadron. Given on steroids, FS blood glucose was
checked 4 times daily and they were mostly in the 100's, not
requiring a long acting insulin.
4. Transaminitis: She had elevated AST and ALT from [**2156-7-12**].
Rechecked and was normal.
5. Anxiety: Lorazepam prn helped.
6. Prophylaxis: Sliding scale insulin and finger stick blood
glucose given on steroids; PPI, subcutaneous heparin, and bowel
regimen were administered as well.
7. FEN: Regular diet
8. Full code: Patient does not want prolonged intubation if
M.D.s think poor recovery.
Medications on Admission:
Decadron 4 mg p.o. TID
Keppra 1000 mg p.o. [**Hospital1 **]
Protonix 40 mg p.o. [**Hospital1 **]
Colace 100 mg p.o. [**Hospital1 **]
Lorazepam 1 mg p.o. p.r.n.
Percocet 1-2 tablets p.o. p.r.n.
G-CSF 300 mcg x 10d, started 2d ago
Pentamidine, aerosolized
Temodar chemotherapy
Discharge Medications:
1. Saline Flush 0.9 % Syringe Sig: Five (5) ml Injection SASH as
needed for flushing for 10 days.
Disp:*qs for 10 days * Refills:*0*
2. Heparin Flush 100 unit/mL Kit Sig: Three (3) ml Intravenous
SASH as needed for iv abx therapy for 10 days.
Disp:*qs for 10 days * Refills:*0*
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous Q
12H (Every 12 Hours) as needed for for cellulitis/bursitis for
10 days.
Disp:*qs for 10 days gm* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Left elbow bursititis/cellulitis
Urinary tract infection
Dehydration
Glioblastoma multiforme
Discharge Condition:
Afebrile, no longer neutropenic, improved left elbow and feeling
good.
Discharge Instructions:
Return to the emergency department or call Dr. [**Last Name (STitle) 724**] if you
develop fever, chills, nausea, vomiting, worsening pain or
redness in your left elbow, chest pain, shortness of breath, or
any other concerning symtpoms.
Take your medications as instructed.
Keep your follow up appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-10-11**]
12:15
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2156-10-11**]
2:00
|
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"518.0",
"682.3",
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"288.0",
"041.4",
"300.00",
"255.4",
"599.0",
"995.91",
"191.3",
"E933.1",
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icd9cm
|
[
[
[]
]
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[
"38.93"
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icd9pcs
|
[
[
[]
]
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14258, 14319
|
9888, 13061
|
344, 366
|
14456, 14529
|
4561, 9865
|
14888, 15154
|
2851, 3011
|
13387, 14235
|
14340, 14435
|
13087, 13364
|
14553, 14865
|
3026, 3026
|
3048, 3882
|
253, 306
|
394, 2643
|
3907, 4542
|
2665, 2728
|
2744, 2835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,823
| 115,599
|
12987
|
Discharge summary
|
report
|
Admission Date: [**2184-3-15**] Discharge Date: [**2184-3-18**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transferred to cath
Major Surgical or Invasive Procedure:
Coronary angioplasty
Bare metal stent to LAD
History of Present Illness:
88 year old female with PMH of HTN, colon cancer s/p resection,
presents from OSH for cardiac catheterization. Patient states
she has been having left back/scapular pain intermittently for
over 2 years. It occurs about once per week and lasts for up to
an hour. She describes this pain as an ache that feels
muscular. It worsens with movement but also comes on with
exertion after walking for a block or two. She denies SOB,
palpitations, N/V, chest pain, or radiating pain to neck or left
arm. Ms. [**Known lastname 1018**] also describes DOE to one to two blocks. Because
of her scapula pain, she was referred for a stress test in late
[**2184-2-3**] which showed some 'changes'. Per note from NEBH,
patient had inferolateral ischemia on ETT (4minutes) with
reproduction of symptoms. Because of these changes she was sent
for cardiac catheterization at [**Hospital6 **] which showed
90% stenosis to the LAD and she is being transferred to [**Hospital1 18**]
for intervention with cath in the AM. At NEBH, WBC 9.8, HCT
37.6, PLT 152, Na 141, K 5.0, Cl 102, CO2 32, Glucose 88, BUN
30, Cr 0.9, Ca 8.9. On arrival, the patient was sent to the
cath lab holding area and had her cath sheath removed
successfully.
On arrival to [**Hospital Unit Name 196**] floor, patient was asymptomatic. She denied
chest pain, back pain, scapular pain, SOB, palpitations, or N/V.
She had no other complaints.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
*** Cardiac review of systems is notable for absence of chest
pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Hypertension
Colon Ca [**2170**] s/p resection
Tonsillectomy at age 9
B/L Hip replacements
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, +
Hypertension
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient drinks a
glass or two of wine per week. She still works as a Dental
Hygienist.
Family History:
Mother with MI, Father with Prostate Ca and MI.
Physical Exam:
VS - BP 122/65 HR 78 RR 12 O2ssat 98% RA
Gen: WDWN middle aged 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 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Irregular rhythm
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+, Femoral not taken
as pt is s/p cath sheath removal.
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2184-3-15**] 09:14PM BLOOD WBC-8.4 RBC-3.44* Hgb-11.1* Hct-32.6*
MCV-95 MCH-32.3* MCHC-34.1 RDW-12.8 Plt Ct-130*
[**2184-3-15**] 09:14PM BLOOD PT-12.2 PTT-26.3 INR(PT)-1.0
[**2184-3-15**] 09:14PM BLOOD Glucose-163* UreaN-23* Creat-1.0 Na-141
K-4.2 Cl-107 HCO3-26 AnGap-12
[**2184-3-15**] 09:14PM BLOOD Mg-2.1
MEDICAL DECISION MAKING
EKG demonstrated
.
ETT performed on [**2-/2184**] demonstrated inferolateral ischemia on
ETT (4minutes) with reproduction of symptoms.
CARDIAC CATH performed on [**2184-3-15**] demonstrated: 90% stenosis of
LAD.
Brief Hospital Course:
Patient is an 88 year old female with PMH of HTN, colon cancer
s/p resection, presents from NEBH s/p cardiac catheterization
which demonstrated 90% stenosis of [**Hospital **] transferred to [**Hospital1 18**] for
cardiac catheterization and intervention of LAD.
CAD - Patient has no prior history of CAD. She describes
intermittent left scapular/back pain which has been ongoing for
2 years. She also describes some DOE to one block. Stress test
done 2-3 weeks ago showed inferolateral ischemia with
reproduction of symptoms. Cardiac cath showed 90% occlusion of
LAD. Patient transferred to our institution where intervention
was performed with BMS to LAD. Patient experienced hypotensive
episode after femoral sheath was pulled, and she developed a
large groin hematoma and transiently lost lower extremity
pulses, for details see below.
Patient transfused one unit of pack red cells and medical
regimen adjusted. She was closely monitored in the CCU. Patient
remained hemodynamically stable overnight and did not require
any further blood products. Follow up was arranged with her
primary cardiologist. For discharge regimen, please see
medications section.
.
# Groin hematoma: As above, catheterization complicated by groin
bleed with estimated blood loss of approximately 1 liter.
Serial hematocrits were obtained and no further drops were
observed. Hematoma remained stable and no further intervention
was necessary.
.
# Possible limb ischemia: loss of DP pulse most likely secondary
to holding pressure on femoral artery. Vascular surgery
evaluated and recommended checking serial pulses hourly. Patient
remained with good pulses via doppler, no intervention was
necessary.
# Delerium: Likely in the setting of receieving sedation for
catheterization. Patients mental status returned to baseline at
time of discharge.
.
#. Hypertension: Regimen adjusted secondary to hypotension post
procedure. Please refer to medication section for details.
#. Colon Ca - Patient is s/p resection, no history of
recurrence.
.
#. FEN - Cardiac heart healthy diet, replete lytes
.
#. Access: PIV
.
#. PPx: Heparin SQ, Bowel regimen
.
#. Code: Full Code
.
Medications on Admission:
ASA 81mg daily
Amlodipine 2.5mg daily
Diovan 160mg daily
Preserve Vision one tab daily
Nasonex [**Hospital1 **]
Ocean spray nasal
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Angina
2. Coronary artery disease
Secondary
1. Hypertension
Discharge Condition:
Hemodynamically stable, afebrile, ambulatory
Discharge Instructions:
You were admitted to the hospital for a cardiac catheterization
and received a stent to one of your arteries. The procedure was
complicated by some bleeding. Your ultrasound did not show any
further bleeding.
Please take all of your medications as directed. The following
changes have been made to your medications.
1. You are no longer taking your Amlodipine
2. You are now taking Metoprolol 12.5mg twice daily
3. Please take Aspirin and Plavix EVERY DAY.
If you develop any chest pain, shortness of breath, pain in your
groin or back, bleeding from your procedure site or any other
concerning symptoms, you should call your doctor or come to the
emergency room.
Followup Instructions:
You have a follow up appointment with Dr [**Last Name (STitle) 14522**], ([**Telephone/Fax (1) 39803**]
[**3-25**] at 1 pm. At that time, you should have your hematocrit
checked.
|
[
"411.1",
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"E879.0",
"998.12",
"V43.64",
"285.1",
"414.01",
"V10.05",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"00.45",
"00.41",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
7129, 7135
|
4207, 6358
|
236, 283
|
7250, 7297
|
3631, 4184
|
8014, 8196
|
2633, 2682
|
6538, 7106
|
7156, 7229
|
6384, 6515
|
7321, 7991
|
2697, 3612
|
176, 198
|
311, 2218
|
2240, 2400
|
2416, 2617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,477
| 165,406
|
50097
|
Discharge summary
|
report
|
Admission Date: [**2105-2-22**] Discharge Date: [**2105-3-7**]
Date of Birth: [**2039-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
ICU stay, Intubation, Mechanical Ventilation
CT guided biopsy of liver.
History of Present Illness:
65 yo M with h/o duodenal ulcer and GERD p/w BRBPR who was
recently diagnosed with a splenic flexure mass, most likely
originating from the kidney who presents with fatigue, chills,
shortness of breath and decreased appetite. The pt reports that
for about one week now he has had decreased appetite and has
only been able to soft foods and liquids. Last Friday he started
to notice worsening SOB but only with ambulation associated with
a mild, dry cough. Today in the afternoon he started to note
chills and rigors and decided to come into the hospital.
.
In the ED, VS were 101.9, HR 124, BP 139/61, RR30, O2Sat 93RA. A
CXR showed b/l LL infiltrates R>L. The patient was given
Levofloxacin and Ceftriaxone for PNA. Lactate was found to be
elevated at 7.8. He was given 4L of NS. Lactate decreased to
2.7. A CT abdomen was done whihc confirmed the large LUQ mass
but did not show signs of other pathology, specifically an
ischemic bowel. The patient continued to be tachycardic but was
never hypotensive in the ED (lowest BP 92/66). His O2
requirements remained at 3L with O2 sats 96-99.
.
ROS: positive for about 15lb weight loss in last 2 weeks. The
patient also reports intermittent abdominal pain, present for
weeks, but worsening since discharge from the hospital. He
reports that the pain is worse when lying on the R side and
about 15-20min after eating especially cold foods. Pt denies HA,
vision changes, CP, N, V, D, changes in the color of his stool
or urine and specifically melena or BRBPR. He also denies
myalgias or arthralgias.
.
Past Medical History:
GERD
Duodenal ulcer, [**10-7**] yrs ago
Borderline diabetes
.
Social History:
Drinks 1-7 beers/week (last drink was 6 days ago during
superbowl), 45 pky smoking hx, no illicit drugs. At one point
was a heavy drinker, quit liquor 27 years ago but denies abuse
now. Retired, lives in senior citizen apartment complex because
of permanent disability.
Family History:
No family history of heart disease, cancers (including colon
cancer) or bleeding disorders.
Physical Exam:
VS: Temp:97.9 BP: 103/53 HR: 98 RR: 20 O2sat 93 2LNC
GEN: pleasant, comfortable, NAD, speaking in full sentences
HEENT: PERRL, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: moderate air movement throughout, decreased breath sounds
at the bases, mild crackles in R base
CV: RR, S1 and S2 wnl, no m/r/g, PMI non-displaced
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly,
positive for blood in ED, brown stool
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. moving all extremities
Pertinent Results:
[**2105-2-22**] 04:30PM BLOOD WBC-16.3*# RBC-3.21* Hgb-9.7* Hct-29.1*
MCV-91 MCH-30.2 MCHC-33.3 RDW-13.8 Plt Ct-266
[**2105-2-22**] 09:30PM BLOOD WBC-15.2* RBC-2.58* Hgb-7.6* Hct-23.4*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.7 Plt Ct-206
[**2105-3-5**] 03:24AM BLOOD WBC-48.9* RBC-2.47* Hgb-7.3* Hct-23.1*
MCV-93 MCH-29.4 MCHC-31.5 RDW-15.4 Plt Ct-106*
[**2105-3-6**] 03:06AM BLOOD WBC-62.3* RBC-2.54* Hgb-7.6* Hct-23.7*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.7* Plt Ct-107*
[**2105-3-6**] 03:06AM BLOOD Neuts-72* Bands-9* Lymphs-10* Monos-2
Eos-4 Baso-0 Atyps-0 Metas-2* Myelos-1* NRBC-5*
[**2105-2-22**] 04:30PM BLOOD Glucose-177* UreaN-27* Creat-1.2 Na-138
K-4.2 Cl-101 HCO3-18* AnGap-23*
[**2105-3-6**] 02:44PM BLOOD Glucose-158* UreaN-82* Creat-2.1* Na-148*
K-5.1 Cl-111* HCO3-26 AnGap-16
[**2105-2-22**] 04:30PM BLOOD ALT-39 AST-29 LD(LDH)-323* AlkPhos-169*
Amylase-26 TotBili-0.6
[**2105-2-23**] 05:32AM BLOOD ALT-35 AST-42* LD(LDH)-445* AlkPhos-128*
TotBili-0.3
[**2105-3-2**] 02:56AM BLOOD ALT-57* AST-35 LD(LDH)-441* AlkPhos-189*
TotBili-0.9
[**2105-3-3**] 03:16AM BLOOD ALT-112* AST-194* LD(LDH)-[**2093**]*
AlkPhos-201* TotBili-0.8
[**2105-2-22**] 04:30PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.3
[**2105-2-24**] 07:20AM BLOOD calTIBC-169* Ferritn-616* TRF-130*
[**2105-2-24**] 11:54AM BLOOD Hapto-338*
BLOOD CULTURES:
[**2105-2-22**] 4:30 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2105-3-1**]):
ANAEROBIC GRAM POSITIVE ROD(S).
NOT CLOSTRIDIUM PERFRINGENS OR CLOSTRIDIUM SEPTICUM.
SPUTUM CULTURE:
GRAM STAIN (Final [**2105-3-2**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
CT ABDOMEN
1. Marked short-interval progression of extremely large and
aggressive left upper quadrant mass that appears to arise from
the tail of the pancreas with new compression of the stomach and
near-complete encasement of the splenic flexure of the colon.
Frank infiltration of the stomach and colon cannot be excluded.
2. Previously reported splenic vein thrombus now extends to the
portal venous confluence and there are now new enlarged
collateral vessels present within the anterior abdomen. The
presence of splenic thrombosis at time of presentation also
favors a pancreatic origin of this mass.
3. Innumerable new liver metastasis with interval growth of two
dominant metastases compared to CT of only two weeks ago.
Multiple lung metastases and left hilar nodal masses, as
described.
4. No CT evidence of mesenteric ischemia.
CTA CHEST
1. No pulmonary embolus.
2. Multiple nodules/masses scattered throughout the lungs
consistent with metastases. Mediastinal and hilar
lymphadenopathy.
3. Small bilateral pleural effusions and adjacent atelectasis.
Scattered ground-glass opacities seen throughout both lungs with
more focal consolidative process within the right lower lobe
which may represent infection.
4. Diffuse hepatic metastatic lesions and splenic flexure mass,
better evaluated on CT abdomen and pelvis of [**2105-2-22**].
5. Asymmetric enlargement of the left lobe of the thyroid.
BIOPSY: CYTOLOGY
POSITIVE FOR MALIGNANT CELLS
consistent with poorly-differentiated malignant neoplasm,
see note.
Brief Hospital Course:
PNEUMONIA / GRAM POSITIVE ROD BACTEREMIA:
The patient was admitted to the MICU from the ED for an elevated
lactate and concern for early/evolving sepsis, with new RLL
pneumonia. He was fluid resussitated and empirically started on
vanco, cipro, and cefepime for antimicrobial coverage. His
lactate level dropped over the course of several hours. Imaging
showed interval progression of his flank mass, including more
hepatic lesions and extension of his splenic vein thrombosis,
previously seen but not anticoagulated given his admission for
GIB. Blood cultures grew out gram positive rods, and he was
continued on his empiric antibiotics. Overall, he was
hemodynamically stable, lactate cleared, and he was transferred
to the floor.
He was later readmitted to the medical intensive care unit with
respiratory distress. He was intubated for respiratory distress.
He had low negative inspiratory pressures. He was extubated but
required high oxygen amounts, including non-rebreather. His CXR
was consistent with aspiration or hemorrhage, along with several
metastatic desposits.
METASTATIC CARCINOMA, UNKNOWN PRIMARY
The patient was found to have a malignant lesion, large in size
and diffusely metastatic to liver, peritoneum, and lung, on
prior admission last month. On admission, he had interval
progression and increase in number of his liver lesions. He
underwent CT guided biopsy of one liver lesion. Final pathology
was pending at time of discharge, but consistent with a very
poorly differentiated carcinoma.
Given the patient's extensive tumor burden, and in conjunction
with palliative care consultation and help from the patient's
primary care physician, [**Name10 (NameIs) **] decision was ultimately reached by
his health care proxy and family to make the patient comfort
measures/comfort care only. He was transferred to the floor of
the hospital where he expired.
METABOLIC ACIDOSIS
The patient had an increase in lactate, likely reflective of
anaerobic metabolism from his extensive tumor burden.
ACUTE RENAL FAILURE
Pre-renal etiology by low FENa, possibly contrast induced
nephropathy.
Continued to have elevated creatinine toward end of course.
SPLENIC VEIN THROMBOSIS
No active management given recent large GI bleed.
Medications on Admission:
Ranitidine 150mg PO BID
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Metastatic Carcinoma, Unknown Primary
Acute Renal Failure
Sepsis/ Gram Positive Rod Bacteremia
Pneumonia, Aspiration, Bacterial
Splenic Vein Thrombosis.
Secondary:
Gastroesophageal Reflux Disorder
Discharge Condition:
Expired
|
[
"038.9",
"199.1",
"507.0",
"197.7",
"276.2",
"197.0",
"995.92",
"289.59",
"785.52",
"530.81",
"493.20",
"197.6",
"518.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"50.11",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8640, 8649
|
6293, 8537
|
322, 395
|
8899, 8909
|
3061, 6270
|
2362, 2455
|
8611, 8617
|
8670, 8878
|
8563, 8588
|
2470, 3042
|
275, 284
|
423, 1972
|
1994, 2058
|
2074, 2346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,010
| 198,933
|
1093
|
Discharge summary
|
report
|
Admission Date: [**2131-1-15**] Discharge Date: [**2131-1-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Colon cancer
Major Surgical or Invasive Procedure:
1. Laparoscopy converted to laparotomy.
2. Transverse colectomy.
3. Small bowel resection
History of Present Illness:
Mrs. [**Known lastname **] is an 87-year-old female Jehovah's Witness with a
significant cardiovascular history who was diagnosed with a
poorly differentiated carcinoma in the left colon after
presenting with a hematocrit of 10. Preoperative staging with a
CT scan revealed a large mass in the transverse colon and
possible pulmonary nodules. Because of the profound nature of
the anemia induced by the tumor,surgical resection was indicated
even in the face of metastasis. She was referred to Dr. [**Last Name (STitle) 1120**],
evaluated, and scheduled for surgical resection of the mass.
Past Medical History:
PMH: CAD, HTN, DM2, hyperlipidemia, , h/o CVA, h/o MI, h/o TIA
PSH; CABGx 4, hysterectomy
Social History:
Jehovah's Witness. Lives with daughter.Does not smoke. Denies
using Etoh or illegal drugs.
Family History:
noncontributory
Physical Exam:
Post-Stroke Neuro Exam per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
VS: Tc 98.3 BP 126/68 P 98 R 20 02 99% on 3
liters
Gen: WD/WN
Heent: supple neck, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: regular rate and rhythm, no murmurs,
Abd: soft
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert, non-verbal, able to show right thumb upon
command but not able to show two fingers, able to name
"glasses",
eyes open spontaneously
CN: pupils equal, round, and reactive,
extraocular movements intact, mild right lower facial droop,
intact t/u/p, [**6-10**] SCM and trapezius
Motor: normal tone and bulk of all four extremities, no tremor
mild drift of the left arm
both deltoids were 4 - 4+ bilaterally
both iliopsoas were 5/5 Strength
Sensory: intact light touch of both arms
Reflex: BR B K A toes
Left 1 2 2 2 mute
Right 1 1 2 2 down
Coord: deferred
Pertinent Results:
RADIOLOGY Final Report
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2131-1-22**] 4:06 AM
Reason: Evaluate for infiltrate/edema
INDICATION: Shortness of breath.
Right subclavian catheter is unchanged in position. Congestive
heart failure has slightly improved with decreasing perihilar
edema but residual diffuse interstitial edema remaining.
Small-to-moderate left pleural effusion is also slightly
improved. Small right pleural effusion is unchanged.
.
CHEST (PORTABLE AP) [**2131-1-20**] 5:36 AM
Reason: Change in resp status?
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with Colectomy and post op MI.
IMPRESSION: Stable parenchymal opacities, likely reflecting
moderate pulmonary edema. Bibasilar effusions and associated
atelectasis, left greater than right. Cardiomegaly.
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2131-1-16**] 8:13 AM
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with lap assist Left colon resection for mass.
H/O TIA's. No with aphasia.
REASON FOR THIS EXAMINATION:
Evaluate for acute intracranial process.
IMPRESSION: No acute intracranial process.
.
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2131-1-17**] 10:57 PM
Reason: tlc placement
IMPRESSION:
1. Standard position of right subclavian line.
2. New bilateral parenchymal opacities as described, which in
the presence of known cardiac disease most likely represent
pulmonary edema.
3. Interval minimal increased in heart size.
4. Bilateral pleural effusion most likely related to same
process.
5. Nodules demonstrated on the torso CT cannot be assessed on
the current study in the presence of pulmonary edema.
.
Portable TTE (Complete) Done [**2131-1-18**] at 10:00:00 AM
FINAL
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO
by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Moderate regional LV systolic dysfunction. No LV mass/thrombus.
No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR. Severe PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast at
rest. Left ventricular wall thicknesses and cavity size are
normal. There is moderate regional left ventricular systolic
dysfunction with severe hypokinesis/akinesis of the inferior
wall, as well as distal septum and apex (c/w multivessel
coronary artery disease). Quantitative LVEF = 39%. No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No PFO seen. Moderate regional left ventricular
systolic dysfunction, c/w multivessel CAD. Moderate mitral
regurgitation. Moderate-to-severe tricuspid regurgitation.
Severe pulmonary hypertension.
.
[**2131-1-23**] 05:45AM BLOOD WBC-12.4* RBC-4.24 Hgb-10.2* Hct-31.8*
MCV-75* MCH-24.2* MCHC-32.2 RDW-23.2* Plt Ct-275
[**2131-1-19**] 03:04AM BLOOD WBC-9.6 RBC-3.64* Hgb-7.8* Hct-25.4*
MCV-70* MCH-21.4* MCHC-30.6* RDW-20.8* Plt Ct-307
[**2131-1-17**] 08:50AM BLOOD WBC-20.7* RBC-4.25 Hgb-9.5* Hct-30.1*
MCV-71* MCH-22.4* MCHC-31.6 RDW-22.2* Plt Ct-414
[**2131-1-16**] 03:52AM BLOOD WBC-17.4* RBC-4.89 Hgb-10.6* Hct-34.7*
MCV-71* MCH-21.8* MCHC-30.6* RDW-20.8* Plt Ct-445*
[**2131-1-23**] 05:45AM BLOOD Plt Ct-275
[**2131-1-23**] 05:45AM BLOOD PT-13.5* PTT-31.5 INR(PT)-1.2*
[**2131-1-21**] 03:10AM BLOOD PT-34.9* PTT-42.1* INR(PT)-3.7*
[**2131-1-18**] 03:23AM BLOOD PT-22.9* PTT-78.6* INR(PT)-2.2*
[**2131-1-16**] 03:52AM BLOOD Plt Ct-445*
[**2131-1-23**] 05:45AM BLOOD Glucose-84 UreaN-21* Creat-0.7 Na-145
K-3.5 Cl-111* HCO3-28 AnGap-10
[**2131-1-15**] 03:29PM BLOOD Glucose-177* UreaN-11 Creat-0.8 Na-142
K-4.0 Cl-108 HCO3-26 AnGap-12
[**2131-1-23**] 05:45AM BLOOD CK(CPK)-84
[**2131-1-21**] 03:10AM BLOOD ALT-25 AST-53* LD(LDH)-386* CK(CPK)-115
AlkPhos-60 TotBili-2.5*
[**2131-1-17**] 08:50AM BLOOD ALT-34 AST-134* CK(CPK)-667* AlkPhos-64
TotBili-0.6
[**2131-1-23**] 05:45AM BLOOD CK-MB-NotDone cTropnT-5.22*
[**2131-1-21**] 09:25PM BLOOD CK-MB-6 cTropnT-3.81*
[**2131-1-20**] 02:30AM BLOOD CK-MB-12* MB Indx-9.4* cTropnT-2.42*
[**2131-1-18**] 12:10PM BLOOD CK-MB-45* cTropnT-1.64* proBNP-[**Numeric Identifier 7105**]*
[**2131-1-17**] 03:08PM BLOOD CK-MB-145* MB Indx-20.9* cTropnT-1.36*
[**2131-1-17**] 08:50AM BLOOD CK-MB-142* MB Indx-21.3* cTropnT-0.93*
[**2131-1-23**] 05:45AM BLOOD Calcium-7.4* Phos-3.5 Mg-1.9
[**2131-1-15**] 03:29PM BLOOD Calcium-8.4 Phos-4.6*# Mg-2.3
[**2131-1-17**] 05:40AM BLOOD %HbA1c-6.2*
[**2131-1-17**] 05:40AM BLOOD Triglyc-102 HDL-29 CHOL/HD-2.8 LDLcalc-33
Brief Hospital Course:
Mrs.[**Doctor Last Name 7106**] operative course was uncomplicated. She was
routinely evaluated in the PACU, and transferred to [**Hospital Ward Name **] for
post-op care.
.
POD1: She became aphasic in the morning of POD1. She was able to
respond to "Yes/No" questions appropriately. She appeared
slightly lethargic, but easily aroused. Her upper and lower
extremity strength remained equal. She was able to follow
commands. She made attempts to speak, but with difficulty
formulating comprehendable words. Her writing was not legible.
She underwent a Head CT, MRI/MRA, and bilateral carotid
ultrasounds. By 7pm her speech had improved. See below for
further workup
.
POD2: Her aphasia was somewhat worse on POD#2 and her cardiac
enzymes were positive. She was transferred to the ICU for
closer monitoring and care.
.
Neuro: She was seen by the Neurology Stroke team who
recommeneded ROMI, Tele, carotid ultrasound, MRA/MRI, ASA, and
TTE with buble study. The MRI/MRA revealed an acute left
frontal lobe embolic stroke. The carotid U/S showed 80-99% right
ICA stenosis. 40-59% left ICA stenosis. Per pt she was offered
carotid endarterectomy in the past but did not want to persue
this any further. Her speech improved throughout her hospital
stay and on discharge was close to baseline. She will follow up
in [**4-9**] weeks with Dr. [**Last Name (STitle) **] and drink as much fluids as
possible.
.
Cardiac: She was seen by Cardiology in ICU due to elevated
troponin levels indicating a myocardial infarction who
recommended following cardiac enzymes. If Cardiac cath and/or
nuclear MRI study were considered according to enzymes. Her
troponins continued to rise which indicated a Cardiac Cath. She
declined cath. She was managed with heparin gtt, asa,
metoprolol, & lipitor was increased to 80 mg daily.She was
diuresed in the ICU with monitoring of lytes and renal function.
Upon discharge, cardiology felt Rehab appropriate. Risks and
benefits of participating given recent NSTEMI discussed with
patient. She will follow-up with Cardiology outpatient.
.
RESP: She has continued on oxygen via nasal cannula throughout
admission. Her oxygen demand increased slightly in ICU,
intubation was not required. Her LS were decreased with crackles
early during admission. They are presently diminshed, and clear.
She should continue to wean from oxygen as long as cardiac
function remains stable during rest & activity. Refer to results
section for Chest XRAY results.
.
GI: Her abdomen is, soft, NT/ND. Her abdominal incision is OTA.
She has active bowel sounds with loose stools. She has been
incontinent of stool leading to erythema of skin. Provide
continued assessment of skin to prevent further breakdown. She
was NPO for some time. She was evaluated per Speech & Swallow.
She regained almost complete ability to swallow, and has been
tolerating a regular diet with nectar thick liquids.
.
RENAL: A foley was inserted intra-op, and removed on [**2131-1-23**].
She has been urinating adequate amounts of urine. She maintained
adequate urine output throughout her hospital course with an
increase in BUN requiring diuresis with IV Lasix. The BUN level
returned to baseline.
.
ID: A rectal and nasal swab was collected in ICU on [**2131-1-22**].
Results are pending presently.
.
HEME: She is a Jehovah's Witness, but agreed to tranfusion with
PRBC due to a drop in hematocrit. Her HCT's have remained
stable. No further transfusion required.
.
EXTREM: She appears to have baseline use of upper extremeties
with mild left sided weakness. She was evaluated per PT & OT.
She required a [**3-11**] person assist from bed to chair. She is a
FALL risk, and will benefit from Rehabilitation. She was able to
ambulate independently prior to hospitalization.
Medications on Admission:
lipitor 80', Protonix 40', Atenolol 25', Ferrous Sulfate 650''',
ASA 81', Temazepam 30 qhs prn
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
Colon mass
Left frontal lobe embolic stroke
Myocardial infarction
.
Secondary:
CAD, HTN, DM2, hyperlipidemia, , h/o CVA, h/o MI, h/o TIA, CABGx
4, hysterectomy
Discharge Condition:
Stable
Tolerating a Regular diet with nectar thick liquids
Pain control managed with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
*Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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.
* Continue to amubulate several times per day.
.
Incision Care:
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Please make a follow-up with Dr. [**Last Name (STitle) 1120**] ([**Telephone/Fax (1) 3378**] in 2
weeks.
2. Please follow-up with a primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 7107**]
[**Name (STitle) 7108**], [**Telephone/Fax (1) 7109**] in 1 week or as needed.
3. Neurology: Please follow-up in [**4-9**] weeks with Dr. [**First Name (STitle) **]
[**Name (STitle) **]
4. Cardiology: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],([**Telephone/Fax (1) 7110**] in [**2-7**] weeks.
Completed by:[**2131-1-24**]
|
[
"997.1",
"414.00",
"434.91",
"784.3",
"401.9",
"V64.41",
"428.21",
"153.1",
"428.0",
"V45.81",
"272.4",
"285.22",
"E849.7",
"276.0",
"997.02",
"E878.2",
"250.00",
"196.2",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"45.62",
"99.04",
"45.91",
"45.74"
] |
icd9pcs
|
[
[
[]
]
] |
12618, 12692
|
8045, 11802
|
274, 366
|
12905, 13008
|
2325, 2859
|
14328, 14931
|
1226, 1243
|
11947, 12595
|
3228, 3321
|
12713, 12884
|
11828, 11924
|
13032, 14075
|
14090, 14305
|
5050, 8022
|
1258, 2306
|
222, 236
|
3350, 5006
|
394, 987
|
1009, 1101
|
1117, 1210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,167
| 118,463
|
9401
|
Discharge summary
|
report
|
Admission Date: [**2121-9-29**] Discharge Date: [**2121-10-10**]
Date of Birth: [**2074-8-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
male with chronic hepatitis C, alcohol abuse, and cirrhosis.
After a few weeks of heavy drinking, he was found unconscious
on the beach vomiting large amounts of bright red blood. He
was admitted to [**Hospital 3320**] Hospital, where he underwent an EGD
the distal esophagus. Bleeding initially was stopped, but
resumed again at which time 1 liter of blood was removed via
nasogastric tube.
At the outside hospital, he received 6 units of pack red
blood cells, 5 units of fresh-frozen plasma, and 6 units of
platelets, and is transferred to [**Hospital1 **]
outside hospital for airway protection. He arrives at [**Hospital3 **] intubated. Condition is stable.
TIPS was attempted on the night of admission, on [**2121-9-30**] for
technical reasons. Over that night, the patient received an
additional 8 units of packed red blood cells, 6 units of
fresh-frozen plasma, and 1 unit of platelets, as well as put
on an octreotide drip and received electrolyte replacement.
This was successfully completed on [**2121-8-31**] and the patient
was transferred to the MICU.
Over the next days, the patient's bleeding slowly resolved.
EGD was repeated with no new bleeding sources and he was
bronchoscoped secondary to blood removed from ET tube. This
revealed clots thought to be secondary to aspiration during
primary bleeding event. He was started on Levaquin and
Flagyl for treatment of aspiration pneumonia as well as
spontaneous bacterial peritonitis prophylaxis.
While he was going through the past procedure, Interventional
Radiology tapped his ascites, but no studies were done.
Ultrasound currently done for possible diagnostic
paracentesis shows little fluid in the abdomen. Patient was
extubated on [**2121-9-4**] without event. He only had trace to mild
ascites on ultrasound
On [**2121-9-5**] he reported hallucinations of mice and babies.
These resolved with 1 mg of Haldol. This is felt to be
alcoholic withdrawal hallucinosis. He was not tachycardic or
febrile at the time there were no seizures. He was stable
and taking medications, and food, liquids po on [**2121-10-7**] and
was transferred out of the unit on to the floor.
Physical examination on admission to the hospital on [**9-29**]:
Temperature 100.4 F, 94, blood pressure 113/54. HCV:
750/14/40% 5 mm PEEP. HEEN: Sclerae are anicteric. Patient
was intubated with a nasogastric tube, ET tube to 28 cm,
Foley, rectal tube. Right IJ line in place. Neck showed
right IJ line, no palpable hematoma. Lungs: Coarse lung
sounds bilaterally. Decreased sound at right lung base.
Heart: Regular, rate, and rhythm, no murmur appreciated at
this time. Extremities were warm with distal pulses positive
+1. Neurologic examination was sedated.
Laboratories on admission from an outside hospital: An
albumin of 2.2, PT of 20, INR 1.9, bilirubin 3.4, alk 104,
AST 116, ALT 283, amylase 81. White blood cells 8,
hematocrit 27.5, platelets 54,000. Sodium 140, potassium
3.6, chloride 105, CO2 29, BUN 22, creatinine 0.8, glucose
168. CO is 6.7, magnesium 1.5, PO 4.16.
Soon after hospitalization, laboratories were repeated which
was found that his hematocrit had dropped to 22.6 prompting
retransfusion.
HOSPITAL COURSE AFTER REACHING THE FLOOR: On acceptance to
the General Medicine Floor, the patient's hematocrit was 31.0
and platelets of 72,000, both are within the normal range for
this patient's baseline. His coagulation studies have not
changed dramatically with an INR of 2.0. Electrolytes were
unremarkable. Albumin is consistently low at 2.1. This
patient did have persistently mild elevations of amylase and
lipase. These were felt to be from fluid contraction leading
to mild leak of pancreatic enzymes. He was found to be
Clostridium difficile negative.
Chest x-ray repeated for low-grade fevers was found to be
clear. The patient's IJ line on inspection was read as
erythematous and warm compared to contralateral neck. IJ
line was removed and a second peripheral IV was placed.
After removal of the IJ catheter, fevers resolved
spontaneously. The patient was continued on Levo/Flagyl for
the remainder of his course for prevention of aspiration
pneumonia. These medications were stopped on [**2121-10-9**].
Patient remained noncephalopathic. Did not have any
complications following TIPS procedure. He did not have any
rebleed.
For his lower extremitye edema, this patient was placed on 25
mg qd of aldactone and as well as
lactulose titrated to [**1-29**] loose stools per day to prevent
encephalopathy. The patient was not started on beta blockers for
secondary prophylaxis of variceal bleed due to persistently low
blood pressure and low heart rate dipping into the 40s and
occasionally high 30s at night during sleep which is
asymptomatic.
Cardiac: The systolic ejection murmur and was also noted to
have a brief run of supraventricular tachycardia on Tele the
night of [**10-6**]. He had a cardiac echocardiogram done on
[**10-7**] which showed moderate dilation with normal ejection
fraction. There are no valvular abnormalities.
Renal function remained stable throughout hospitalization.
After TIPS procedure, hematocrit and white blood cell count
remained stable. Electrolytes were repleted throughout
hospitalization, most prominently potassium and magnesium
needed repletion.
Neuropsych: Except for that single episode of
hallucinations, this patient showed no signs of alcohol
withdrawal. He was counseled extensively by Social Work, the
medical team and his family on the need to abstain from
alcohol from here on. He has agreed to be transferred to an
alcohol rehab program after discharge.
The patient is discharged in good condition.
DISCHARGE DIAGNOSES:
1. Alcohol abuse.
2. Hepatitis C.
3. Cirrhosis.
4. Variceal bleed requiring TIPS placement.
5. Gastroesophageal reflux disease.
6. Thrombocytopenia.
7. Anemia.
8. splenomegaly
DISCHARGE MEDICATIONS:
1. Spironolactone 25 mg po q day
2. Lactulose 30 mg po tid titrate to [**1-29**] loose stools per
day.
4. Endoprazole 40 mg po q day.
5. Multivitamins one po q day.
He is recommended to keep on a low-salt diet. He will follow
up with his hepatologist next month.
[**Known firstname **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2121-10-9**] 15:59
T: [**2121-10-9**] 16:06
JOB#: [**Job Number 32101**]
|
[
"303.91",
"291.3",
"507.0",
"571.2",
"789.5",
"456.20",
"070.54",
"518.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13",
"33.23",
"39.1",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5890, 6067
|
6090, 6654
|
160, 5869
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,016
| 112,955
|
23173
|
Discharge summary
|
report
|
Admission Date: [**2173-1-19**] Discharge Date: [**2173-1-24**]
Date of Birth: [**2099-9-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
hyperglycemia noted at [**Hospital1 1501**]
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
73M, h/o seizures, CVA with L sided deficits, HTN, PEG for
dysphagia, EMS reported that mental status is near baseline
according to [**Hospital1 1501**] (localizes to pain), DNR/DNI, sent to ED
because at [**Hospital1 1501**], noted to be lethargic and had fsbg of 800. Not a
known diabetic and no treatment for this was given at [**Hospital1 1501**]. Chem7
showed elevated Cr, Na, Glc, and WBC, so he was sent to [**Hospital1 18**].
EMS witnessed a tonic clonic seizure, 2-3 minutes, seizure
activity broke by the time IV access was obtained, and then
brought him to ED.
On arrival to ED, did not open eyes, now moves arms somewhat and
opens eyes. Blood sugar 774, given insulin 10 IV x2, then on
drip at 10 for first hour, now on 15, b/c sugar is still
critically high. 3rd L of NS hanging now. Also febrile to 102.6
on arrival. CXR clean, Urine clear. Abd soft, nontender. Blood
and urine cultures sent. Given vanc and CTX empirically. At time
of transfer, T102, HR 120s (sinus), BP 110s, O2 sats 95-97% on
2L RR 18.
ROS: pt unable to provide
Past Medical History:
strokes from ruptured intracerebral aneurysms in [**2160**] and [**2162**]
or [**2163**] with residual left sided deficits (has not been able to
walk since the stroke in '[**63**]) and aphasia, PEG for dysphagia
h/o seizure do
dementia
HTN
h/o HepC hepatitis, apparently not active
h/o neurosyphilis, treated in [**2163**]
hypothyroidism
Social History:
Nursing home resident ([**Hospital3 2558**]) since [**2163**]. Sent here
with no personal belongings.
Family History:
Noncontributory
Physical Exam:
Vitals: T: 98.1 BP:113/66 HR:114 RR:23 O2Sat:99%2L
GEN: chronically ill appearing elderly African American man
HEENT: EOMI, surgical pupils with gaze fixed to patient's right,
sclera anicteric, no epistaxis or rhinorrhea, MM dry, OP Clear
NECK: Supple, able to passively touch chin to chest. No JVD,
carotid pulses brisk, no bruits, no cervical lymphadenopathy,
trachea midline
COR: II/VI early systolic murmur at RUSB, normal S1 S2, radial
pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Neg Kernig's and Brudzinski. nonverbal. CN II ?????? XII
grossly intact. Moves R arm, L hand contractured. muscle wasting
throughout.
SKIN: Spotchy hypopigmentation on chest. No jaundice, cyanosis,
or gross dermatitis. No ecchymoses.
Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2173-1-19**]:
UPRIGHT AP VIEW OF THE CHEST: The heart size is normal. The
aorta is mildly unfolded. Pulmonary vascularity is normal. Hilar
contours are within normal limits. The lungs demonstrate low
inspiratory volumes, but otherwise are clear. No pleural
effusions or pneumothorax. Thoracic scoliosis convex to the
right is again demonstrated.
IMPRESSION: No acute cardiopulmonary abnormality.
CT HEAD W/O CONTRAST Study Date of [**2173-1-19**]:
FINDINGS: There is no hemorrhage, hydrocephalus, shift of
normally midline structures, or evidence of acute major vascular
territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. Hypodensities in the periventricular and subcortical
white matter reflect chronic microvascular ischemic change.
Right frontal and left parieto-occipital lobe encephalomalacia
is compatible with old infarcts. Tiny hypodensities in the right
subinsular region is consistent with lacunes. The ventricles and
sulci are prominent, compatible with age- related involutional
change. There has been a right frontal craniotomy. The
visualized paranasal sinuses and mastoid air cells are normally
aerated. The surrounding soft tissues are unremarkable.
IMPRESSION: No intracranial hemorrhage.
CHEST (PORTABLE AP) Study Date of [**2173-1-21**]:
Low lung volumes. The tip of the PICC line remains unchanged. No
failure or infiltrates are seen.
IMPRESSION: No pneumonia.
ADMISSION LABORATORY WORK:
[**2173-1-19**] 07:20PM BLOOD WBC-16.3* RBC-5.04 Hgb-15.0 Hct-46.5
MCV-92 MCH-29.8 MCHC-32.3 RDW-12.6 Plt Ct-175
[**2173-1-19**] 07:20PM BLOOD Neuts-80.2* Lymphs-11.2* Monos-7.8
Eos-0.1 Baso-0.5
[**2173-1-19**] 07:20PM BLOOD Glucose-774* UreaN-48* Creat-2.1* Na-158*
K-3.6 Cl-120* HCO3-20* AnGap-22*
[**2173-1-19**] 07:20PM BLOOD PT-15.5* PTT-33.8 INR(PT)-1.4*
[**2173-1-19**] 07:20PM BLOOD Calcium-10.1 Phos-5.3* Mg-2.4
[**2173-1-19**] 07:20PM BLOOD Phenyto-3.8*
[**2173-1-19**] 07:14PM BLOOD Glucose-GREATER TH Lactate-9.5*
CARDIAC ENZYMES:
[**2173-1-20**] 01:00AM BLOOD CK-MB-7 cTropnT-0.04*
[**2173-1-20**] 05:00AM BLOOD CK-MB-8 cTropnT-0.04*
[**2173-1-20**] 11:23AM BLOOD CK-MB-10 MB Indx-0.2 cTropnT-0.02*
[**2173-1-20**] 06:07PM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-0.02*
CPKs:
[**2173-1-20**] 01:00AM BLOOD CK(CPK)-1754*
[**2173-1-20**] 05:00AM BLOOD CK(CPK)-2635*
[**2173-1-20**] 11:23AM BLOOD CK(CPK)-5212*
[**2173-1-20**] 06:07PM BLOOD CK(CPK)-6733*
[**2173-1-21**] 04:00AM BLOOD CK(CPK)-5812*
MICROBIOLOGY:
[**2173-1-21**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING
[**2173-1-20**] MRSA SCREEN MRSA SCREEN-PENDING
[**2173-1-19**] URINE URINE CULTURE-FINAL (NO GROWTH)
[**2173-1-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2173-1-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
Brief Hospital Course:
MICU COURSE:
# Fevers/elevated WBC:
CXR clear at presentation. Urine clear except for high glucose.
Abdomen was soft and non-tender with no rebound at presentation.
No signs of RUQ pathology/cholecystitis on LFTs. History of
seizures raised suspicion for CNS infection, although no signs
of meningismus on exam; family refused LP to conclusively rule
out meningitis. Regardless, patient was treated empirically in
first 24 hours with Acyclovir, Vancomycin, Ampicillin, and
Ceftriaxone at meningitis dosing. On morning of [**2173-1-21**],
culture data and clinical signs remained unrevealing, and with
no specific source of infection identified, on [**2173-1-22**],
ceftriaxone was stopped as well.
# Hyperosmolar Hyperglycemic State:
Hyperglycemic to 774 at presentation with hypernatremia to 158
(corrected for elevated glc, corrNa was 169). Likely HHS (no
ketones in urine, so unlikely DKA). Catalyst is likely
infectious process. Hyperglycemia resolved within 12 hours of
presentation. Initially treated with insulin gtt, and given his
high insulin requirement, D5 1/2NS as well, and then
transitioned to subcutaneous insulin on [**2173-1-21**]. Nutren Pulmonary
Full strength tube feedings were started on [**2173-1-22**], at
nutrition's recommendation, and although pt had been on
nocturnal cycled tube feeds at his nursing home, [**Last Name (un) **] and
nutrition consults recommended round the clock tube feedings to
simplify blood sugar management. He will therefore receive
lantus + RISS for euglycemic control.
# Hypernatremia: Goal was to decrease sodium 12 mEQ in 24 hrs.
From evening presentation on [**2173-1-19**] to evening of
[**2173-1-20**], sodium went from 158 to 162. On morning of [**2173-1-21**],
patient's fluids. He continued to receive tube feeds with Q6H
250 mL free water flushes, and Na was down to 148 on [**2173-1-22**].
# Acute renal failure:
Cr was 1.8 on arrival. Likely was prerenal. Creatinine resolved
quickly to 0.7 by morning of [**2173-1-21**].
# Hypertension:
Antihypertensives held at presentation due to concern for
dehydration and impending sepsis, but since he has been stable,
on [**1-21**], lisinopril 5mg (home dose was 40mg) and metoprolol 50mg
[**Hospital1 **] (was on 100mg [**Hospital1 **] at home).
# Seizure disorder:
Has history of seizures and upon admission had seizure in
setting of fever and dilantin level of 3.8; not clear when last
seizure was. Still unsure if meningitis was present but without
LP cannot know this. Reloaded with 500mg dilantin IV x 2 and AM
dilantin level on [**2173-1-21**] was supratherapeutic at 28; however,
this was not a trough level. A true trough was taken on morning
of [**2173-1-22**] and was 13.8.
# Constipation:
Patient was without BM from admission to morning of [**2173-1-21**] and
had evidence of stool-filled colon on CXR. Lactulose was given
on [**2173-1-21**] until patient stooled in the afternoon.
Medicine Floor course:
The patient was evaluated by the [**Last Name (un) **] service and his insulin
regimen was titrated. New [**Last Name (un) **] service recs recommended
reverting his tube feeds back to his nocturnal tube feeds and
titrating his insulin regimen to that schedule. The patient's
lantus was titrated to 10 units qAM with a lispro sliding scale.
The patient will need close further insulin titration on an
outpatient basis. No clear etiology for the patient's fevers
and leukocystosis was discovered (family had refused LP).
Perhaps there was a viral infection.
The patient's bp meds were uptitrated to his home regimen with
strict holding parameters on discharge.
Would continue prior TF regimen.
Medications on Admission:
lisinopril 40mg daily
metoprolol 100mg [**Hospital1 **]
hydralazine 50mg qid
milk of magnesia
dilantin 25mg [**Hospital1 **]
colace liquid 100mg [**Hospital1 **]
Discharge Medications:
1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) cc
PO qMWF: Resume prior dosage and frequency of this med.
3. Phenytoin 50 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day): Increased from 25 mg po bid.
4. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold FOR SBP< 100, HR<55.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day): HOLD FOR DIARRHEA.
6. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a
day: Hold for SBP<100.
7. Acetaminophen 160 mg/5 mL Solution Sig: Ten (10) ml PO Q6H
(every 6 hours) as needed for pain.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
qAM.
10. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
at meals: Administer per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Hyperosmolar Hyerglycemic State
Seizure
Acute Renal Failure
Fevers, Leukocytosis
Hypernatremia
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Patient to retrun to ED if he is having consistently elevated
blood sugars>500 that do not improve with sliding scale insulin,
fevers, rigors, hypotension, seizures.
Followup Instructions:
Patient to f/u with Urban Med PCP [**Last Name (NamePattern4) **] 1 week. Will be followed
at [**Hospital3 2558**].
|
[
"438.11",
"438.82",
"345.90",
"288.60",
"287.5",
"244.9",
"401.9",
"276.0",
"787.20",
"V44.1",
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"250.02",
"564.00",
"584.5",
"070.54",
"294.8",
"728.88",
"695.9",
"794.31",
"438.20"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10450, 10520
|
5631, 9260
|
359, 380
|
10658, 10678
|
2801, 4820
|
10892, 11011
|
1955, 1972
|
9473, 10427
|
10541, 10637
|
9286, 9450
|
10702, 10869
|
1987, 2782
|
4837, 5608
|
276, 321
|
408, 1458
|
1480, 1820
|
1836, 1939
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,015
| 143,648
|
23582
|
Discharge summary
|
report
|
Admission Date: [**2140-4-14**] Discharge Date: [**2140-4-17**]
Date of Birth: [**2099-9-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
call out from MICU where he was admitted for acute liver failure
and evaluation for liver transplant
Major Surgical or Invasive Procedure:
.
History of Present Illness:
40 yo M w/ hx HCV, EtOH cirrhosis, [**First Name3 (LF) 2320**] s/p recent d/c from
[**Hospital3 3583**] [**2140-4-3**] presented to clinic [**2140-4-13**] c/o
worsening leg and arm cramps x months and was referred to [**Hospital1 3325**] ED for evaluation.
.
Pt was recently admitted to [**Hospital3 3583**] w/ EtOH cirrhosis,
d/c'ed on [**2140-4-3**] after being started on spironolactone. He
reports the spironolactone was a new medication for him. He
reports no F/C, but + N/V "foamy stuff" w/out coffee grounds or
bright red blood. No hematochezia or melena w/ usual color "dark
brown" stool. No increased pruritis, no cough or other
complaints. He reports increasing abdominal girth x ~ 1 month.
He reports his baseline wt is 175 lbs. Per pt no prior hx of
UGIB, vomiting up red blood or coffee grounds. Pt reports his
last Tylenol intake was 1 month ago and reports no further
tylenol injestion.
.
In [**Hospital3 3583**] ED he received morphine and D5W for glu 30,
1L IVNS and D5 NS @ 200cc/hr and was transferred to [**Hospital1 18**] for
further evaluation and treatment.
.
In [**Hospital1 18**] ED s/p 2U FFP, 30ml lactulose PO, 1L IV NS.
paracentesis of 1000cc serous fluid (lab: wbc 323, 74% pmns, rbc
10). Admission labs included Na 116, K6.5, lactate 2.7, creat
1.5, INR 2.1, alt 300, ast 600, alk phos 243, tbili 23,
acetaminophen 8, urine tox +opiates (s/p morphine at OSH). He
was found to have a large bladder and s/p foley placement
drained 500cc dark urine. S/P
.
Past Medical History:
IVDA
HCV
cirrhosis [**2-24**] HCV and EtOH
[**Month/Day (2) 2320**]
leg cramps
Social History:
single, lives w/ sister, not working x 2 yrs; per pt no hx of
IVDA, but hx of EtOH abuse d/c'ed EtOH/tobacco [**11-25**]; prev +
tobacco 1ppd x 30 yrs;
Family History:
[**Name (NI) 2320**] father, DMI mother;
Physical Exam:
AF 97.2 106 110/47 (96-125/30-70) RR 14 98% 2L NC
Gen: jaundiced cauc M lying in bed on his R side in NAD
HEENT: pupils constricted 1mm b/l, reactive, sclerae icteric, OP
clear, MM dry
Heart: RRR, S1, S2, flow murmur
Lungs: CTBLA, no wheezing, no rales or crackles
Abd: distended, NT, large ascites
Ext: 2+ pitting edema b/l
Neuro: Awake, somnolent, O x 3, + asterixis
Rectal: Guaiac Positive per ED.
Pertinent Results:
paracentesis: wbc 323 74% PMN's (240 PMNs) RBC 10
SAAG 2.1 - <1.0 >= 1.1
.
wbc 17 hct 40 plt 86
.
Na 116 (up from 114 on admission) K 6.5 Lact 2.7
Ser Osm 283 Ser Osm Gap 20 (calc ser osm 264)
AG 8
creat 1.5 INR 2.1
ALT/AST 300/600 AlkPhos 243 Tbili 23
acetaminophen 8, ser tox o/w negative
U/A negative for infection
U tox + opiates (s/p morphine @ OSH) o/w negative;
.
[**2140-4-13**] [**Hospital3 3583**]
wbc 18.7 hct 40.7 plt 79
+ toxic granulations & basophilic stippling
.
[**2140-4-3**]
Na 129 (baseline 120-130's) K (4.5-4.6) Cl 99-100 glu 162 BUN 20
(19-20) creat 0.8 Bili 6.9 dir 3.8 alk phos 213 (200's) AST/ALT
112 (100-110's)/87 (@ baseline)
.
[**2140-4-1**] INR 1.27
[**2140-4-3**] alb 2.1
[**2140-3-31**] [**Doctor First Name **]/lip <30/352
[**2140-4-3**] plt 54 (@ baseline 40-50's) hct 39.1 (baseline @ 40's)
.
NH4 74 [ref 9-33]
Na 117 K 5.5 Cl 86 CO2 11 BUN 68 creat 2.0 glu 30! Ca 7.5
alb 2.1 T.bili 18.8 Alkphos 240 ALT/AST 273/677 [**Doctor First Name **]/lip 129/742
INR 1.54
.
OSH CTAbd splenomegaly, small cirrhotic liver, + varices.
.
RAD:
CXR: low lung volumes, sm effusion on lateral XR, no pna or CHF.
.
RUQ U/S: prelim read "Large amount of ascitis. cirrhotic liver.
question of focal thrombus in the right PV. Main PV and hepatic
veins are patent. GB not seen.
.
Per OSH record 2 yrs ago by Dr. [**Last Name (STitle) 2455**] @ [**Location (un) 47**]: hx c-scope w/
hemorrhoids, EGD w/ varices, + HCV Ab, o/w negative; high iron
sat, [**Last Name (un) **] high; Alpha 1 antitripsin 132, cerruloplasmin 29,
TTG 5; s/p liver Bx @ [**Location (un) 47**]
.
EKG: NSR @ 100bpm, ? peaked T in V2 no baseline available for
comparison; no other STTW changes, q in III.
Brief Hospital Course:
He was admitted w/ hyponatremia, worsening liver failure and
ARF. His hyponatremia corrected w/ volume repletion and he was
sent out to the floor. He was also started on ceftriaxone and
received albumin for 240PMN's in his peritoneal fluid.
.
He was c/o to the floor. He had a dry tap on [**2140-4-15**]. Overnight
he became more hypoxic. He was diuresed ~ 3L w/ IV lasix over
the past 12-18hrs and his respiratory status improved, however
he continued to need a face mask and NRB. He also dropped his
pressure to 89/40 on the floor and was transferred to the ICU
for closer monitoring. From [**2059-4-13**], he experience increasing
respiratory distress and increasing abdominal girth likely
secondary to increasing abdominal gas. He was tried briefly on
BiPAP, but he did not tolerate it. He requested that he be made
comfort measure only. Extensive discussion took place between
Dr. [**Last Name (STitle) **] of hepatology, Dr. [**Last Name (STitle) **] of MICU and the rest of the
MICU service staff. It was determined that the patient was clear
and understand what was going on. He was aware of the
consequence of his decision. He also wanted to be made
comfortable. He also decline an organ transplant. He was started
on morphine drip on the afternoon of [**4-14**]. He passed without
much event on [**4-14**] around 6pm
Medications on Admission:
quinine 324mg qhs
metformin 500mg po bid
protonix 40mg po q24h
spironolactone 25mg po tid
hydroxyzine 25mg po tid
MgO 400mg po q24h
Discharge Disposition:
Expired
Discharge Diagnosis:
liver cirrhosis
hepatitic C
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"571.2",
"572.2",
"584.9",
"789.5",
"567.2",
"250.00",
"070.41",
"276.7",
"276.1",
"486",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.07",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
5924, 5933
|
4414, 5742
|
416, 419
|
6004, 6013
|
2698, 4391
|
6066, 6073
|
2220, 2262
|
5954, 5983
|
5768, 5901
|
6037, 6043
|
2277, 2679
|
276, 378
|
447, 1933
|
1955, 2035
|
2051, 2204
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,727
| 146,259
|
39607
|
Discharge summary
|
report
|
Admission Date: [**2173-6-29**] Discharge Date: [**2173-7-2**]
Date of Birth: [**2087-10-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest Pain
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname 13998**] is a 85 year old woman has a history of coronary
artery disease s/p drug-eluting stents in ostium as well as
proximal and mid segments of the RCA in [**6-/2173**], CHF ([**5-/2171**] EF
20%) who presented to the CCU for continued management of
stuttering chest pain and respiratory distress.
.
The patient presented to the cardiology clinic with symptoms
concerning for a decline in her functional capacity (DOE,
orthopnea) and the patient was referred to cardiac
catheterization on [**2173-6-1**].
.
Angiography revealed a 60% eccentric LAD lesion after the D1
bifurcation. There was a small circumflex with diffuse proximal
60-70% stenosis. There was also right coronary artery, which
was a large and dominant vessel having an 80-90% ostial lesion
and diffuse proximal mid 50% and mid 70% lesions with
left-to-right collaterals present. Drug-eluting stents were
placed in the ostium as well as the proximal and mid segments of
the RCA with good results.
.
Post-PCI, the patient reported improvement in her symptoms so
much so she was able to discontinue use of home oxygen.
.
The patient had been in USOH when developed gradual onset
malaise 4days days prior to admission. Per report since Friday
of last week patient has felt unwell. She reports episodes of
intermittent chest pressure, which is not new for her. However,
for the last couple of days she has been concerned that her SL
NTG is 'expired' because it doesn't have the same effect as
usual. On day prior to admission she had persistent chest
pressure that lasted a couple of hours and did not respond to
her SL NTG. Patient reports associated DOE, dizziness,
?orthopnea and ?PND.
.
On review of systems, she complains of a mild dysuria and
continues to take all medications as prescribed. She does not
have fever, chills, cough, nausea, vomiting and diarrhea.
.
The constellation of symptoms prompted presentation to
cardiology clinic. In clinic patient found to be diaphretic,
dyspneic and tachypneic with SBPs in 80s, HR in 100s with weight
129.8lb. A decision was made to refer patient to the ED for
further evaluation.
.
In the ED, 98.2 85 100/65 18 97% 2L NC, ABG: pH 7.37 pCO2 41 pO2
63 HCO3 25. Labs notable for flat biomarkers (trop <0.01, MB:
3), proBNP: 4557, + UA. CXR with florid pulmonary edema. In ED
patient appeared very uncomfortable with O2 Sats in the 80s on
RA. She was started on BiPAP and received Lasix 10 mg IV with a
total 600cc diuresis in the ED. Patient also given [**Year (4 digits) **]
suppository and started on heparin bolus + gtt for potential
ischemic trigger in setting of known LAD lesion. She was also
given SL nitro x 2 followed by nitro gtt with complete relief of
chest pain. UA was markedly positive, and she was given 400 mg
IV ciprofloxacin x 1. Prior to transfer, patient remained on
Bipap at 10/5, 50% O2, reportedly looked more comfortable. VS
prior to transfer: HR 80, BP 100/60, RR 18, 100% on facemask
.
On arrival in the CCU, VSS with O2 saturations >95% on 5-6L
facemask. Patient without complaint denying active chest pain
and reports improved SOB.
.
Current cardiac review of systems is notable improved, yet still
present SOB; resolved chest pain; lack of paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Cardiomyopathy, LVEF 20%
- Prior MI in [**2156**] by patient report
- CHF ([**5-/2171**], EF 20%)
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: DES in ostium and
proximal and mid segments of RCA ([**6-/2173**])
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Carotid artery stenosis, reported "mini stoke" in [**2166**];
carotid u/s in [**2169**] showed 60-80% right ICA stenosis, repeat u/s
in [**2171**] with no changes
- Normocytic Anemia baseline 32
- Recurrent UTI's (no cx data in our system)
- Vertigo/Dizziness
- Osteoarthritis
- Chronic leukocytosis, bone marrow biopsy negative
- Pancreatitis
- Hiatal hernia/GERD
Social History:
Occupation: Retired
Drugs: denies
Tobacco: one pack of cigarettes per day for 40 years; stopped in
[**2156**]
Alcohol: denies
Other:
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
On Admission:
VITALS: HR 79 BP 104/39 RR 21 SpO2 95% on aerosol-cool
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Speaking in
full sentences with dyspnea
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP elevated to earlobe.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2, + s3. 2/6 SEM. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Moderate dyspnea, occassional belly breathing, decreased bs at
bilateral bases, crackles [**2-7**] - 2/3 up bilateral lung fields, no
wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
.
On Discharge:
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Speaking in
full sentences with dyspnea
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with improved JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 SEM. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Mild
decreased bs at bilateral bases with scant overlying crackles,
no wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
CBC trend:
[**2173-6-29**] 05:55PM BLOOD WBC-9.7 RBC-3.47* Hgb-10.4* Hct-30.3*
MCV-87 MCH-29.9 MCHC-34.2 RDW-14.7 Plt Ct-232
[**2173-6-30**] 04:12AM BLOOD WBC-14.5* RBC-3.28* Hgb-10.0* Hct-28.7*
MCV-88 MCH-30.5 MCHC-34.9 RDW-14.9 Plt Ct-226
[**2173-7-1**] 07:00AM BLOOD WBC-10.8 RBC-3.42* Hgb-10.4* Hct-30.4*
MCV-89 MCH-30.3 MCHC-34.1 RDW-15.0 Plt Ct-246
[**2173-7-2**] 10:26AM BLOOD WBC-9.7 RBC-3.64* Hgb-11.1* Hct-32.2*
MCV-88 MCH-30.4 MCHC-34.4 RDW-15.1 Plt Ct-251
.
Coags:
[**2173-6-29**] 05:55PM BLOOD Plt Ct-232
[**2173-6-30**] 04:12AM BLOOD PT-14.4* PTT-121.9* INR(PT)-1.2*
[**2173-6-30**] 04:12AM BLOOD Plt Ct-226
[**2173-6-30**] 02:15PM BLOOD PTT-57.3*
[**2173-7-1**] 07:00AM BLOOD Plt Ct-246
[**2173-7-2**] 10:26AM BLOOD Plt Ct-251
.
Chemistry panel:
[**2173-6-29**] 05:55PM BLOOD Glucose-86 UreaN-30* Creat-1.2* Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
[**2173-6-30**] 04:12AM BLOOD Glucose-128* UreaN-28* Creat-1.2* Na-139
K-3.6 Cl-101 HCO3-27 AnGap-15
[**2173-6-30**] 02:15PM BLOOD Glucose-91 UreaN-22* Creat-0.9 Na-143
K-3.0* Cl-110* HCO3-25 AnGap-11
[**2173-6-30**] 10:50PM BLOOD Glucose-113* UreaN-24* Creat-0.8 Na-141
K-3.7 Cl-110* HCO3-23 AnGap-12
[**2173-7-1**] 07:00AM BLOOD Glucose-107* UreaN-27* Creat-1.1 Na-140
K-5.2* Cl-107 HCO3-28 AnGap-10
[**2173-7-2**] 10:26AM BLOOD Glucose-84 UreaN-22* Creat-1.2* Na-139
K-3.9 Cl-102 HCO3-30 AnGap-11
.
Biomarkers:
[**2173-6-29**] 05:55PM BLOOD CK-MB-3 proBNP-4557*
[**2173-6-29**] 05:55PM BLOOD cTropnT-<0.01
[**2173-6-30**] 04:12AM BLOOD CK-MB-3 cTropnT-<0.01
.
TSH
[**2173-6-29**] 05:55PM BLOOD TSH-2.8
.
UA:
RBC WBC Bacteri Yeast Epi TransE RenalEp
[**2173-6-29**] 20:45 <1 88* FEW NONE <1
[**2173-6-29**] 16:50 0 >182* FEW NONE 3
.
[**2173-6-29**] 4:50 pm URINE
**FINAL REPORT [**2173-6-30**]**
URINE CULTURE (Final [**2173-6-30**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging:
CXR [**6-29**]
IMPRESSION: Mild-to-moderate pulmonary edema with small
bilateral pleural
effusions and bibasilar atelectasis.
.
TTE:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe global left ventricular hypokinesis (LVEF= <20 %). No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal. with
normal free wall contractility. There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mildly dilated left ventricle with severe global
hypokinesis. Elevated estimated PCWP. Moderate mitral
regurgitation. Mild pulmonary hypertension.
.
Cardiology Report Stress Study Date of [**2173-6-30**]
EXERCISE RESULTS
RESTING DATA
EKG: SINUS WITH AV DELAY, LAA, LBBB
HEART RATE: 88 BLOOD PRESSURE: 104/60
PROTOCOL /
STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
1 0-4 0.142MG/ KG/MIN 99 90/60 8910
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 73
SYMPTOMS: NONE
INTERPRETATION: This 85 year old woman with a PMH of MI '[**56**],
PCIs
[**2173-5-7**] was referred to the lab following an acute bout of
systolic
CHF associated with chest discomfort. The patient was infused
with
0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck,
back or
chest discomfort was reported by the patient throughout the
study. The
ST segments are uninterpretable for ischemia in the setting of
the
baseline LBBB. The rhythm was sinus with rare isolated vpbs.
Appropriate hemodynamic response to the infusion and recovery.
The
dipyridamole was reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or interpretable ST
segments
(LBBB). Nuclear report sent separately.
.
S-MIBI:
Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
Following resting images and two minutes following intravenous
dipyridamole, approximately three times the resting dose of
Tc-99m sestamibi was administered intravenously. Stress images
were obtained approximately 30 minutes following tracer
injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is adequate but limited due to soft tissue and
breast
attenuation.
Left ventricular cavity size is increased
Rest and stress perfusion images reveal a fixed, moderate
reduction in photon counts involving the mid and distal anterior
wall, distal septum, distal inferior wall and the apex.
Gated images reveal akinesis in the territory of the defect. The
remaining
segments are hypokinetic.
The calculated left ventricular ejection fraction is 21% with an
EDV of 232.
IMPRESSION:
1. Fixed, large, moderate severity perfusion defect involving
the LAD
territory.
2. Increased left ventricular cavity size. Severe systolic
dysfunction with akinesis in the LAD territory and hypokinesis
of the remaining segments.
Brief Hospital Course:
Ms [**Known lastname 13998**] is a 85 year old woman has a history carotid
artery disease s/p drug-eluting stents in ostium as well as
proximal and mid segments of the RCA in [**6-/2173**], CHF ([**5-/2171**] EF
20%) presenting with gradual onset chest discomfort, hypoxia
likely secondary to acute CHF exacerbation.
.
# Hypoxia. Initial differential diagnosis included CHF, ACS, PE,
pneumonia. Patient with low risk for PE via [**Doctor Last Name 3012**] Score. CXR
without focal infiltrate suggestive of infection moreso plain
film with evidence of extensive vascular congestion. Hypoxia
likely secondary to acute CHF exacerbation in patient with last
known EF 20% as of 4/[**2171**]. Exam (bilateral crackles), labs
(elevated BNP) and imaging (CXR c/w vascular congestion)
supportive of diagnosis. Classic triggers to CHF exacerbation
include: med/dietary non-complaince, ischemia,
arrhythmias/valvular abnl, systemic infection, primary lung
processes: COPD, PE. Regarding our patients decompensation
etiology she was without h/o medication indiscretion though
endorses increased salt intake in recent weeks; No known h/o of
valvular abnl; no arrhythmia documented in history or seen on
prior or current EKG/telemetry. On admission ample concern for
ischemia in setting of known LAD lesions however biomarkers flat
and EKG uninterpretable in setting of LBBB. Surmised that likely
acute infection (UTI) as well as dietary indiscretion +/-
ischemic component resulted in presentation.
On admission heart failure treated with aggressive diuresis with
IV lasix (40mg IV) and nitro gtt to decrease preload. Possible
ischemic trigger was treated with heparin gtt, full dose [**Year (4 digits) **] and
statin. Patient diuresised with good response and subjective
improvement in symptoms. Patient was transitioned to PO
toresimide on HD2 with adequate UOP. Daily weights followed.
Regarding ischemic etiology patient underwent stress MIBI which
demonstrated fixed, large, moderate severity perfusion defect
involving the LAD. In light of findings cardiac catheterization
deferred. Decision made to pursue CRT with possible BiV pacing
as an outpatient in [**State 108**] vs [**Hospital1 18**]. At time of discharge
patient continued on BB (transitioned from carvedilol
->metoprolol to facilitate BP room), ACEI (lisinopril 2.5mg) and
diuretic (lasix 40mg PO QD -> toresimide 10mg PO QD).
OUTPATIENT ISSUES:
-- Continue to discuss CRT and desire to have procedure
performed at [**Hospital1 18**] vs [**State 108**].
-- Monitor weight and adjust diuretic regimen as needed
.
# CAD: Concern for ischemic cause of new heart failure given
known multi-vessel CAD that was not intervened on in recent
cath. Patient with description of worsening chest pressure
occuring at rest and with exertion concerning for unstable
angina in setting of flat biomarkers. EKG difficult to interpret
given left bundle branch block. Per record LBBB not new. Patient
initially anticoagulated on heparin drip as anticoagulation with
goal PTT 60-100, started on high dose statin, continued on SA
325 mg PO daily and clopidogrel 75 mg PO daily. Patient was
started on a nitro gtt and home ranexa was held. in setting of
nitro gtt administration. Biomarkers were negative. Stress Mibi
demonstrated fixed, large, moderate severity perfusion defect
involving the LAD. In light of findings cardiac catheterization
deferred. Patient without further episodes of chest pain in
house. Patient discharged on [**Last Name (LF) **], [**First Name3 (LF) **] 325 in setting of
recent stent placement as well as BB, ACEI and statin.
.
# RHYTHM:. Currently patient in normal sinus with evidence of
intraventricular conduction delay/LBBB. Per review of [**State 108**]
record, LBBB is not new. Patient was monitored on telemetry
without event.
.
# Hyperlipidemia. Patient continued on lipitor which was
increased to 80mg on admission. After active ischemia ruled out
lipitor decreased to home dose of 40mg daily.
.
# UTI. Patient with markedly positive UA in ED. No cx data in
our system. Started on Ciprofloxacin in ED (day one [**6-29**]).
Transitioned to Ceftriaxone on HD2 and completed 3 day course
for uncomplicated UTI.
.
# Hypothyroid. Patient continued on home levothyroxine 50mcg QD.
TSH in house wnl.
.
# GERD. Continued on home ranitidine
.
CODE: DNI/DNR
COMM: [**Name (NI) **]
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE [VENTOLIN HFA] - (Prescribed by Other
Provider) - 90 mcg HFA Aerosol Inhaler - 2 puffs four times per
day as needed
ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet - 1
(One) Tablet(s) by mouth once a week (Wednesdays)
ALPRAZOLAM - (Prescribed by Other Provider) - 0.25 mg Tablet -
1
Tablet(s) by mouth once a day as needed
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
Tablet - 0.5 (One half) Tablet(s) by mouth once a day (at night)
CARVEDILOL - 6.25 mg Tablet - 1 Tablet(s) by mouth once a day
CLOPIDOGREL [[**Name (NI) **]] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
LEVOTHYROXINE - 50 mcg Tablet - 1 (One) Tablet(s) by mouth once
a
day
LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
(One) Tablet(s) by mouth once a day QHS
MECLIZINE - (Prescribed by Other Provider) - Dosage uncertain
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually up to 3 tablets every 5
min
as needed for for chest pain/angina Sx
OXYGEN 2 LITERS PRN - (Prescribed by Other Provider) - Dosage
uncertain
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq
Tablet, ER Particles/Crystals - 1 Tab(s) by mouth once a day
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet
- 1 Tablet(s) by mouth twice a day
RANOLAZINE [RANEXA] - (Prescribed by Other Provider) - 500 mg
Tablet Extended Release 12 hr - 1 Tablet(s) by mouth twice a day
ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 0.5
(One half) Tablet(s) by mouth at bedtime
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day (taken at
night)
BISACODYL [DULCOLAX] - (OTC) - 5 mg Tablet, Delayed Release
(E.C.) - 2 Tablet(s) by mouth 3 times/week as needed
CALCIUM CARBONATE [CALTRATE 600] - (Prescribed by Other
Provider) - 600 mg (1,500 mg) Tablet - 1 Tablet(s) by mouth
twice
a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - 1 Capsule(s) by mouth at bedtime
DOCUSATE SODIUM - (OTC) - 100 mg Tablet - 1 Tablet(s) by mouth
at bedtime
MULTIVITAMIN WITH MINERALS - (OTC) - Capsule - 1 Capsule(s)
by
mouth once a day
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day
as needed for anxiety.
4. atorvastatin 80 mg Tablet Sig: 0.5 Tablet PO once a day.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. meclizine Oral
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation: 3 times per week .
17. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Outpatient Lab Work
Please check CBC and Chem-7 on Tuesday [**7-6**] with results to Dr.
[**Last Name (STitle) **] or [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 715**] at [**Telephone/Fax (1) 719**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on chronic congestive heart failure exacerbation
Coronary artery disease
Hypertension
chronic obstructive pulmonary disease on home oxygen
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had trouble breathing and needed to be admitted to the
intensive care unit to have intravenous medicine to remove the
excess fluid. It is possible that too much salt in your diet
lead to the fluid accumulation. In the future, you will need to
avoid all salt in your diet. Information about a low salt diet
was given to your caretakers and yourself. You were seen by Dr.
[**Last Name (STitle) **], [**First Name3 (LF) **] electrophysiology cardiologist who recommended
that you have a special type of pacemaker implanted that helps
your heart beat more efficiently and may help you avoid fluid
overload in the future. You will see Dr. [**Last Name (STitle) **] soon to
discuss this further. You had chest pain but did not have a
heart attack. You had a urinary tract infection as well and was
on antibiotics to treat this, these antibiotics are done now.
Weigh yourself every morning, call Dr.[**Last Name (STitle) **] if weight
increases more than 3 pounds in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Stop taking Ranexa
2. Stop taking Carvedilol and take Metoprolol instead to slow
your heart rate
3. Stop taking Furosemide and take Torsemide instead to remove
extra fluid.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2173-7-20**] at 2:00 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-Electrophysiology
When: FRIDAY [**2173-7-9**] at 4:00 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
Department: GERONTOLOGY
When: MONDAY [**2173-7-12**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES-General Cardiology
When: MONDAY [**2173-8-2**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2173-7-3**]
|
[
"428.0",
"288.60",
"V49.86",
"733.90",
"V13.02",
"426.9",
"433.10",
"599.0",
"715.90",
"V45.82",
"428.23",
"V46.2",
"300.00",
"530.81",
"414.01",
"244.9",
"V12.54",
"799.02",
"733.00",
"425.4",
"781.2",
"416.8",
"412",
"553.3",
"493.20",
"424.0",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20708, 20766
|
11890, 16233
|
291, 298
|
20955, 20955
|
6406, 11867
|
22382, 23643
|
4541, 4655
|
18685, 20685
|
20787, 20934
|
16259, 18662
|
21138, 22359
|
4670, 4670
|
3733, 3971
|
5610, 6387
|
233, 253
|
326, 3628
|
4684, 5596
|
20970, 21114
|
4002, 4370
|
3650, 3713
|
4386, 4525
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,369
| 129,235
|
25979
|
Discharge summary
|
report
|
Admission Date: [**2111-1-8**] Discharge Date: [**2111-1-25**]
Date of Birth: [**2080-7-13**] Sex: M
Service: SURGERY
Allergies:
Pertussis Vaccine,Fluid
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Bowel obstruction
Major Surgical or Invasive Procedure:
Exploratory laparotomy, Lysis of Adhesions, Small bowel
resection, Feeding jejunostomy, Closure ventral hernia with
Alloderm
History of Present Illness:
The patient is an extremely complex 30-year-old male with mental
retardation who has superior mesenteric artery syndrome. He was
treated with a Roux-en-Y
jejunostomy, duodenojejunostomy last [**Month (only) 404**]. This Roux-Y loop
obstructed and perforated requiring repeat operation and open
abdomen. The patient had a GJ-tube placed but this has not
worked out as he continues to reflux feedings up into the
stomach. The decision was made to take him to the operating
room and place a formal feeding jejunostomy.
Past Medical History:
1) Cerebral palsy with mental retardation
2) Seizure disorder
3) History of H. pylori gastritis
4) Recent right clavicular fracture on [**2109-9-14**]
5) History of multiple surgeries to the lower extremities for
flexion contractures
6) Recurrent Klebsiella UTI, treated with Bactrim, Rocephin and
Tequin.
7) SMA Syndrome
8) ARDS [**9-/2109**]
9) Left LE DVT, diagnosed on [**2109-12-5**], initially treated with
lovenox, then switched to coumadin.
10) Pancreatic Head Cystic Lesion, followed q1 year
Social History:
Mr. [**Known lastname 6164**] is a resident of [**Hospital1 **] Meadows in [**Location (un) **].
Patient reportedly ambulates with assist and wears a helmet for
safety in the nursing home.
Family History:
N/C
Physical Exam:
T 99.0 HR 115 BP 100/40 RR 15 SaO2 95% trach mask
NAD
Diffuse coarse breath sounds b/l
RRR
Soft, +BS
Ext warm
Pertinent Results:
[**2111-1-8**] 03:44PM HCT-25.5*
Brief Hospital Course:
Patient underwent operation described above on [**2111-1-8**] and was
transferred to the TICU postoperatively for close monitoring
after post-op hypoxia and tachycardia. He was treated with
antibiotics for pneumonia and eventually underwent tracheostomy
for failure to wean from the ventilator. He gradually improved
and was transferred out of the TICU on [**2111-1-16**]. His wound began
draining bilious fluid and a CT scan revealed an enterocutaneous
fistula. On [**2111-1-20**], he went into respiratory distress requiring
mechanical ventilation and transfer to the SICU. He was placed
on pressor support for hypotension. After careful consideration,
his family decided to make him CMO and he expired on [**2111-1-25**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Bowel obstruction
Discharge Condition:
Expired
Followup Instructions:
n/a
Completed by:[**2111-1-25**]
|
[
"318.1",
"557.1",
"553.21",
"560.81",
"569.62",
"518.5",
"998.2",
"E879.8",
"486",
"343.9",
"584.9",
"569.81",
"482.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.93",
"96.04",
"31.1",
"53.61",
"99.15",
"54.59",
"46.39",
"99.04",
"45.62",
"33.24",
"46.73",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
2682, 2691
|
1933, 2659
|
300, 426
|
2753, 2763
|
1874, 1910
|
2786, 2821
|
1720, 1725
|
2712, 2732
|
1740, 1855
|
243, 262
|
454, 972
|
994, 1497
|
1513, 1704
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,339
| 181,790
|
40102
|
Discharge summary
|
report
|
Admission Date: [**2140-11-1**] Discharge Date: [**2140-11-6**]
Date of Birth: [**2066-2-24**] Sex: M
Service: NEUROLOGY
Allergies:
Levaquin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 yo M with hx afib on coumadin, HTN, DM, bladder CA, renal
insufficiency, and gout, transferred from OSH for L BG IPH.
As per OSH records around 10:30 PM while sitting and watching TV
he was noted to have slurred speech. Upon EMS arrival BP 202/92
P 68 FS 218 and GCS 15. He was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital
and
CT head as per report showed 3 areas of acute hemorrhage in left
basal ganglia and internal capsule 6-13mm in diameter with small
amount of surrounding edema. Labs were notable for INR 2.2.
While getting his first unit FFP (at 00:10) he was noted to have
decreasing LOC and increasing weakness on right. He received a
total of 3 units FFP and 10 mg vitamin K. As he became less
responsive he was intubatged, receiving succinylcholine and
etomidate and started on a propofol drip. Minor trauma during
intubation was noted with slight bleeding anterior to
epiglottis.
He was transferred to [**Hospital1 18**] for further care.
Past Medical History:
-afib on coumadin
-HTN
-DM2
-gout
-bladder CA
-renal insufficiency
Social History:
n/a
Family History:
n/a
Physical Exam:
VS; BP 161/77 P 53 RR 14 on vent
Gen; intubated, agitated when sedation is held
CV; irregularly irregular
Pulm; CTA anteriorly
Abd; soft, distended, nontender
Extr; no edema
Neuro;
MS; Off sedation, patient grimaces and moves somewhat
purposefully but does not open eyes or follow any commands.
CN; Eyes conjugate in midposition, pupils 2.5 mm and minimally
reactive, strong corneal on left, minimal on right. Face
obscured by ET tube. + cough and gag.
Motor; normal tone. spontaneous movement in LUE, LLE,
diminished
at RLE, extensor posturing in RUE
Sensory; withdraws to noxious in all extremities, less in RLE vs
LLE
Reflexes; upgoing toe on right
Pertinent Results:
[**2140-11-1**] 06:06PM TYPE-ART PO2-117* PCO2-32* PH-7.47* TOTAL
CO2-24 BASE XS-1
[**2140-11-1**] 04:56PM GLUCOSE-163* UREA N-33* CREAT-1.8* SODIUM-138
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12
[**2140-11-1**] 04:56PM CK(CPK)-170
[**2140-11-1**] 04:56PM CK-MB-5 cTropnT-0.02*
[**2140-11-1**] 04:56PM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.9
[**2140-11-1**] 04:56PM WBC-9.6 RBC-3.39* HGB-9.8* HCT-29.7* MCV-88
MCH-28.9 MCHC-33.0 RDW-15.8*
[**2140-11-1**] 04:56PM PLT COUNT-187
[**2140-11-1**] 04:56PM PT-14.0* PTT-29.3 INR(PT)-1.2*
[**2140-11-1**] 03:51AM TYPE-ART RATES-/16 TIDAL VOL-550 PEEP-5
O2-100 PO2-175* PCO2-44 PH-7.39 TOTAL CO2-28 BASE XS-1 AADO2-498
REQ O2-83 -ASSIST/CON INTUBATED-INTUBATED
[**2140-11-1**] 03:00AM GLUCOSE-224* UREA N-42* CREAT-1.9* SODIUM-136
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2140-11-1**] 03:00AM estGFR-Using this
[**2140-11-1**] 03:00AM cTropnT-0.02*
[**2140-11-1**] 03:00AM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-2.2
[**2140-11-1**] 03:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-11-1**] 03:00AM URINE HOURS-RANDOM
[**2140-11-1**] 03:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2140-11-1**] 03:00AM WBC-9.1 RBC-3.33* HGB-10.3* HCT-29.8* MCV-89
MCH-30.9 MCHC-34.6 RDW-15.4
[**2140-11-1**] 03:00AM NEUTS-75.4* LYMPHS-17.8* MONOS-3.7 EOS-2.5
BASOS-0.6
[**2140-11-1**] 03:00AM PLT COUNT-210
[**2140-11-1**] 03:00AM PT-18.9* PTT-29.6 INR(PT)-1.7*
Brief Hospital Course:
74 yo M with hx afib on coumadin transferred
from OSH for L BG IPH in setting of INR 2.2. Initially he had
mild deficits with slurred speech and possible R NLF flattening,
but decompensated prior to transfer, becoming confused,
difficult
to arouse, and with RUE plegia. Repeat CT head revealed
significant expansion of bleed with intraventricular hemorrhage
and small amount of midline shift. Based on location, etiology
is most likely hypertensive in setting of anti-coagulation. For
now we recommend; given profilnine in [**Hospital **]
HOSPITAL COURSE
Neuro-
patient was given profinine and INR reversed in the ED. Patient
was kept comfortable. On [**2140-11-2**] patient was having shaking of
his left upper extremity. Difficult to say whether seizure. EEG
demonstrated no current seizure activity but areas of slowing.
Patient was given initially dose of 750 mg of Keppra, and was
then stopped. End of life options were discussed with family.
He was made CMO and patient was made comfortable. He passed on
[**2140-11-6**]
Risk factor reduction : TG 173 HDL 29 LDL58. HGBA1c 7.5
RECS-HOB > 30,-SBP < 160, repeat head CT head if change in exam
Resp
-cont current vent settings.
ID
-check CXR, UA. has continued to spike temps as of [**11-4**]. Re
cultured.
CV- patient was monitored on cardiac telemetry. neg enzymes.
Nicardipine gtt transitioned to amolodipine.
Endocrine
-FS QID. BG in 300s on tubefeeds on [**11-4**]. Started lantus.
GI
-PPI g tube initially had blood. Most likely from traumatic
intubation. Was initially placed on protonix gtt which was
changed to famotidine.
Renal
- patient's creatinine is slightly upwards trending, but
good UOP. His urine is fairly bland. Although this may be ATN,
it could be pre-renal or post renal as well. it is unlikely this
is any type of glomerulonephritis without an active sediment.
FENA is 0.17 making pre renal likely. Will give 500 mL bolus and
another 1 L overnight. Renal stated that it is unlikely that his
uremia is contributing to his mental status.
Nutrition
-gentle hydration. Was started on tube feeds on [**2140-11-2**].
PPx
-H2-blocker, pneumoboots. Will start SC heparin on [**2140-11-4**]
Medications on Admission:
-coumadin 5/2.5
-aspirin 81 mg daily
-allopurinol 150 mg daily
-atenolol 25 mg daily
-pravastatin 40 mg daily
-norvasc 5 mg daily
-lasix 40 mg daily
-fish oil 1200 mg daily
-vitamin D
-FeSO4 375 mg [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
stroke
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2140-11-7**]
|
[
"V43.64",
"784.3",
"599.0",
"790.92",
"584.5",
"431",
"250.00",
"507.0",
"781.94",
"427.31",
"585.3",
"V10.51",
"274.9",
"342.90",
"V49.86",
"403.90",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6155, 6164
|
3691, 5860
|
274, 280
|
6214, 6224
|
2135, 3667
|
6277, 6427
|
1439, 1444
|
6126, 6132
|
6185, 6193
|
5886, 6103
|
6248, 6254
|
1459, 2116
|
231, 236
|
308, 1311
|
1333, 1402
|
1418, 1423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,135
| 178,923
|
29623
|
Discharge summary
|
report
|
Admission Date: [**2154-1-6**] Discharge Date: [**2154-1-14**]
Date of Birth: [**2091-10-25**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Admit to MICU for increased tachypnea
Major Surgical or Invasive Procedure:
Replacement of tracheostomy with tracheostomy "button"
decanulation
History of Present Illness:
Patient is a 62 yo man with hypercholesterolemia, hypertension,
recent admission from [**12-22**]- [**1-2**] for PNA s/p trach, STEMI
(treated primarily in [**State **] with CABG), who presents from
nursing home with tachypnea for 2 days, intermittent fevers.
.
He was transferred from [**State 108**] (where pt was visiting) to [**Hospital1 18**]
on [**2153-12-22**]. On [**2153-12-7**], he had had a STEMI s/p 6v CABG, was
extubated [**2153-12-9**], and then shortly went into PEA arrest. He
was found to have an embolic stroke in left parietal, left
internal capsule region. During post op period he was diagnosed
with HIT and Afib. He was trached on [**2153-12-18**] and started on
dialysis [**2153-12-21**]. While in house he developed fevers 100-101
with neg cultures but +LLL pna. He was treated with Cefepime,
Linezolid, and changed to Nafcillin prior to d/c with treatment
ending [**2154-1-6**].
.
On admission patient endorses pnd, orthopnea, and loose stool x
2 d. Denies chest pain, palpitations, nausea/vomiting/urinary
sx.
Past Medical History:
Hypercholesterolemia
Hypertension
CAD s/p CABG in Fl (6 grafts placed, left main, prox lad and
right post descending artery)
Afib w/ hx of embolic stroke, L parietal and L external capsule
w/ right sided hemiplegia in [**12-5**]
h/o heparin induced thrombocytopenia
PNA s/p trach [**2153-12-18**]
ARF s/p Dialysis [**2153-12-21**]
New type II diabetes mellitus
Social History:
Worked as the director at [**Hospital3 **] Health center. Married. no
smoking/drinking history
Family History:
Non-contributory.
Physical Exam:
T99.8 BP 120/70 HR 95 RR 22 O2 100% on 40% TM, FS 161
Gen: NAD,
HEENT: PERRLA, EOMI, trach in place
no obvious jvd
Lungs: bibasilar rhonchi, no wheezes, chest with cabg scar
Heart: RRR, s1 s2
Abd: Soft NT/ND +bs
Ext: 1+ edema, cool with 1+ pulses, left vein graft scar, left
quarter sized stage 2 ulcer on lower shin, right LE>Left LE,
strength 2/5 on right upper and lower ext, [**5-4**] on left
Guaiac neg in ed
AOx3
Pertinent Results:
EKG- NSR, no ischemic changes
15.4> <538
32.7
89 pmns/ 0 bands/ 3 lymphs
131 | 92 | 29 < 115
5.7 | 30 | 1.4
Trop .57
Lactate 1.4
abg 7.44/44/81 on 100% trach mask
Admit CXR: Unchanged radiograph from previous with stable
bilateral
moderate-to-large pleural effusions and stable vascular
congestion.
.
[**2154-1-6**] 04:20PM CK(CPK)-75
[**2154-1-6**] 04:20PM CK-MB-NotDone cTropnT-0.46*
[**2154-1-6**] 10:46AM TYPE-ART PO2-81* PCO2-44 PH-7.44 TOTAL
CO2-31* BASE XS-4
[**2154-1-6**] 10:41AM TYPE-ART PO2-16* PCO2-59* PH-7.36 TOTAL
CO2-35* BASE XS-4
[**2154-1-6**] 10:34AM LACTATE-1.4 K+-5.6*
[**2154-1-6**] 10:25AM GLUCOSE-115* UREA N-29* CREAT-1.4*
SODIUM-131* POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-30 ANION
GAP-15
[**2154-1-6**] 10:25AM estGFR-Using this
[**2154-1-6**] 10:25AM CK(CPK)-108
[**2154-1-6**] 10:25AM cTropnT-0.57*
[**2154-1-6**] 10:25AM CK-MB-7 proBNP-7500*
[**2154-1-6**] 10:25AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2154-1-6**] 10:25AM WBC-15.4*# RBC-3.51*# HGB-10.8*# HCT-32.7*#
MCV-93 MCH-30.7 MCHC-32.9 RDW-18.4*
[**2154-1-6**] 10:25AM NEUTS-89* BANDS-0 LYMPHS-3* MONOS-7 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2154-1-6**] 10:25AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ STIPPLED-2+
[**2154-1-6**] 10:25AM PLT COUNT-538*#
[**2154-1-6**] 10:25AM PT-30.2* PTT-37.5* INR(PT)-3.2*
[**2154-1-6**] 10:25AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2154-1-6**] 10:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2154-1-6**] 10:25AM URINE RBC->50 WBC-[**3-4**] BACTERIA-MOD YEAST-NONE
EPI-0-2\
.
CXR [**2154-1-11**]:
IMPRESSION: Stable large bilateral pleural effusions. Mild
hydrostatic
edema.
Brief Hospital Course:
This is a 62 year man with coronary artery disease status 6
vessel CABG [**2153-12-7**] that was complicated by stroke (on
anticoagulation), CHF (EF 25%), pneumonia and respiratory
failure. He is status post tracheostomy placement. He was
readmitted to [**Hospital1 18**] with tachypnea from a rehabilitation
facilty. Initial differential was chiefly CHF vs. PNA. PE
appeared less likely as INR therapeutic. Of note the patient
had a recent pna with coag + staph, with hypoxia, tachypnea,
increased wbc. There was concern that he acquired noscomial
pneumonia. His presentation over the next few days appeared
more consistent with a CHF exacerbation rather than a pneumonia
so the chief goal was to optimize his volume status. A
cardiology consult was called to assist in this process.
Repeat echo revealed
EF of 40%, and a small loculated pericardial effusion, no sign
of tamponade. The patient was started on aldactone and diuresed
aggressively with furosemide. He had lost 7 kg in weight by
time of discharge and was negative 9L. His lisinopril and
Toprol doses were adjusted for low BP; he was continued on
minimal doses for secondary prevention of CHF. He will have a
repeat echocardiogram and then follow-up with Dr. [**Last Name (STitle) 171**] in
cardiology at [**Hospital1 18**] upon discharge. He should see Dr. [**Last Name (STitle) 171**]
one week after discharge. Additionally, he remained in normal
sinus rhythm. Amiodarone was discontinued. His INR was
supratherapeutic on discharge at 4.0. Coumadin was held for the
two days prior ot discharge, and INR trending down. Plan to
resume warfarin 2mg qHS when INR <3.
.
His respiratory status remained relatively stable on admission,
requiring only intermittent pressure support through the
tracheostomy. He soon was maintain good saturation on 40% trach
mask. His tracheostomy was closed with a "trach button" and he
continued to saturate well on 2L nasal cannula. On [**2154-1-13**] his
trach was decannulated. He is tolerating this well at the time
of discharge and continues to oxygenate well on 2Lnc.
.
In summary, this is a 62 year old gentleman with CHF (EF now
40%), CAD s/p recent CABG complicated by respiratory failure
requiring tracheostomy and complicated by CVA on
anticoagulation. He was admitted for tachypnea/respiratory
distress likely secondary to CHF exacerbation. Currently with
good respiratory status after diuresis and optimization of heart
failure medications. Also in the process of gettting
tracheostomy reversed. He is being transferred to
rehabilitation hospital at this time.
.
Communication is with the patient and his wife, [**Name (NI) **] [**Name (NI) 23203**] [**Telephone/Fax (1) 71007**] cell [**Telephone/Fax (1) 71008**]. He is a full code.
Medications on Admission:
Aspirin
Coumadin
Beta Blocker
Lasix
Niacin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
7. Niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. insulin
10 NPH qAM, 5 NPH qPM
During day use sliding scale of HUMALOG, at 151-200 give 2
units, 201-250 4 units, 251-300 6 unitS, 301-350 8 units,
351-400 10 units.
At night, dont start sliding scale until 251-300, at which point
give 2 units, 4 units for 301-350, 6 units for 351-400
14. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime: Hold
until INR falls to 2.3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Congestive Heart Failure exacerbation
Secondary: Status post tracheostomy for respiratory failure
Status post CABG for 6 vessel coronary artery disease
Diabetes type II
Discharge Condition:
Good, breathing normally on 2 L nasal cannula. Still with some
volume overload but vastly improved compared to presentation.
Hemodynamically stable on congestive heart failure medications.
No signs of infection.
No signs of ischemia.
Discharge Instructions:
Please return pt to hospital if patient experiences chest pain,
shortness of breath or develops high fever.
Return pt to hospital for any mental status change.
Weigh pt every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc per day
Check daily INRs - hold coumadin until INR falls to 2.3, then
restart coumadin at 3mg PO qHS
Followup Instructions:
We are sending you to a [**Hospital 4487**] hospital.
Please follow up with your new cardiologist, Dr. [**Last Name (STitle) 171**], on
[**2154-1-17**].
|
[
"585.9",
"V55.0",
"357.2",
"428.0",
"410.92",
"438.20",
"411.0",
"428.23",
"V45.81",
"707.09",
"518.83",
"403.90",
"272.0",
"427.31",
"285.9",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8559, 8638
|
4247, 7013
|
312, 381
|
8860, 9096
|
2436, 4224
|
9529, 9684
|
1962, 1981
|
7106, 8536
|
8659, 8839
|
7039, 7083
|
9120, 9506
|
1996, 2417
|
235, 274
|
409, 1449
|
1471, 1834
|
1850, 1946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,598
| 122,649
|
53998+53999
|
Discharge summary
|
report+report
|
Admission Date: [**2104-11-7**] Discharge Date: [**2104-11-12**]
Date of Birth: [**2049-1-2**] Sex: M
Service: CARDIOTHOR
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 110709**]
MEDQUIST36
D: [**2104-11-12**] 14:01
T: [**2104-11-12**] 15:49
JOB#: [**Job Number **]
Admission Date: [**2104-11-7**] Discharge Date: [**2104-11-12**]
Date of Birth: [**2049-1-2**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This 55 year old gentleman had
the recent onset of chest pressure. He developed chest pain
on [**11-7**], took one sublingual Nitroglycerin at this time with
temporary improvement of chest pain that returned. He came
in to the [**Hospital1 69**] to be
evaluated.
PAST MEDICAL HISTORY:
1. In [**2089**], the patient developed a large cell gastric
lymphoma. He was treated with surgery, chemotherapy and
radiation to the lower mediastinum.
2. In [**2099-7-12**], the patient underwent an echocardiogram.
Ejection fraction at that time was 55 with plus one mitral
regurgitation. There was a question of mobile aortic
atheroma. Subsequent transesophageal echocardiogram revealed
some atherosclerosis in the aorta and a strand in one of the
aortic cusps of unknown significance. The patient remained
asymptomatic.
3. In [**2104-2-12**], the patient began to use his
treadmill at home to exercise and did well.
4. In [**2104-7-12**], after a vacation in [**Country 6607**], the patient
noted decrease in his exercise tolerance when using his
treadmill and he stopped exercising at that time and remained
asymptomatic. Recently, when he was walking after eating, he
reports classical angina pressure which abated after two
minutes of rest. He went to his primary care practitioner
[**First Name (Titles) **] [**Last Name (Titles) 2742**] of this new onset angina and was started on
aspirin and atenolol at that time. He underwent a stress
test that was strongly positive for multi-vessel disease and
was recommended for cardiac catheterization follow-up.
The patient denied anemia, asthma, congestive heart failure,
chronic obstructive pulmonary disease, stroke, diabetes
mellitus, GI bleed, hepatitis, hypertension, liver failure,
prior stroke, pancreatitis. The patient does have a history
of high cholesterol.
SOCIAL HISTORY: The patient is married and lives with wife.
[**Name (NI) **] denies smoking.
FAMILY HISTORY: Father died of an myocardial infarction at
81. Mother and siblings have no identifiable cardiac risk
factors.
MEDICATIONS UPON ADMISSION:
1. Atenolol.
2. Aspirin.
3. Lipitor.
4. Vitamin E.
REVIEW OF SYSTEMS: On admission were unremarkable.
PHYSICAL EXAMINATION: On admission revealed a blood pressure
of 112/70; a heart rate of 65. HEENT were benign. Neck were
without carotid bruits. Chest: Heart was regular. No
murmurs. Respiratory: Lungs were clear. Abdomen was soft,
nontender, no masses. Extremities were warm with normal
pulses.
LABORATORY: The patient underwent a cardiac catheterization
on [**11-7**]; please refer to catheterization report for specific
details. In summary findings revealed severe left main
disease with a two-vessel coronary artery disease,
biventricular diastolic dysfunction, moderate pulmonary
arterial hypertension. An intra-aortic balloon pump was
placed and the patient went for emergent coronary artery
revascularization times five with a left internal mammary
artery and a saphenous vein graft. Please refer to the
operative report for details of surgery.
The patient was transferred to the Intensive Care Unit
postoperative with the preoperative intra-aortic balloon pump
in place on Nitroglycerin and Propofol. The patient remained
hemodynamically stable.
On [**11-8**], the patient's balloon pump was weaned and
discontinued and the intravenous Nitroglycerin was weaned
off. On [**11-9**], the patient was extubated, beta blockade
initiated and he transferred out to the Floor on
postoperative day two.
On postoperative day three, the patient began increasing his
activity and remained hemodynamically stable. At that time,
his epicardial wires and Foley catheter were discontinued.
Ambulation and pulmonary toilet was encouraged. On
postoperative day five, the patient remains hemodynamically
stable. He is ambulating successfully and able to climb a
flight of stairs and is being evaluated for discharge.
The patient is hemodynamically stable.
DISCHARGE PHYSICAL EXAMINATION: Temperature 99.5 F.; heart
rate 71 and regular; blood pressure 118/65; respiratory rate
20 with a saturation of 93 on room air. HEENT: Grossly
intact. Neurologic: Alert and oriented times three and
moving equally with steady gait. Cardiac: S1, S2 regular.
No rub, no murmur appreciated. Respiratory: No dyspnea,
respiratory rate 20's. He does present with rales 2 cm down
on the left and PA down on the right. He denies dyspnea.
There is no wheezing, no cough. He was treated with Lasix 40
intravenously times one prior to discharge. Vascular: He is
warm and dry. He has palpable pulses bilaterally. Wound,
chest and right leg incisions are open to air and they are
dry and intact with Steri-Strips. There is no erythema and
there is no drainage. On GI assessment, the patient has had
no nausea or vomiting. Abdomen was soft, positive bowel
sounds, nontender.
DISCHARGE STATUS: The patient's discharge status is stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times five.
MEDICATIONS UPON DISCHARGE:
1. Lopressor 50 mg p.o. twice a day.
2. Enteric coated aspirin 325 mg p.o. q. day.
3. Lasix 40 mg q. a.m. times two weeks; Lasix 20 mg p.o. q.
p.m. times two weeks.
4. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day times two weeks.
5. Ibuprofen 400 mg p.o. q. six p.r.n. pain and discomfort.
DISCHARGE MEDICATIONS:
Note, preoperative Lipitor was not resumed due to an elevated
ALT on [**11-7**] of 88 and an AST of 138 and a total bilirubin of
1.9. The patient is to follow-up with his primary care
provider in three weeks.
Further, labs from [**11-3**], white blood cell count was 13.6
with a hemoglobin of 9.1, and hematocrit of 26.5 with a
platelet count of 110.
Labs on [**11-11**], sodium of 139, potassium of 4.1, BUN of 28 and
a creatinine of 1.2 which remained stable and a glucose of
112.
DISCHARGE INSTRUCTIONS:
1. The patient will increase activity.
2. He will follow-up in the [**Hospital 409**] Clinic in two weeks.
3. He will follow-up with his primary care physician in
three weeks post discharge and he will be re-evaluated by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] four weeks postoperatively.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 110709**]
MEDQUIST36
D: [**2104-11-12**] 14:01
T: [**2104-11-12**] 15:49
JOB#: [**Job Number **]
|
[
"414.01",
"410.71",
"V10.79",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"99.20",
"36.14",
"37.61",
"39.61",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
2558, 2684
|
5573, 5670
|
6057, 6544
|
6568, 7194
|
4610, 5552
|
2774, 2807
|
5686, 6034
|
623, 889
|
2698, 2754
|
911, 2446
|
2463, 2541
|
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