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9,899
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48327
|
Discharge summary
|
report
|
Admission Date: [**2158-1-27**] Discharge Date: [**2158-2-24**]
Date of Birth: [**2103-11-3**] Sex: F
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: Patient is a 54-year-old female
with history of colon cancer and multiple metastases who
presented to the emergency room with a few days of nausea,
vomiting and abdominal distention. Patient has a history of
multiple ER visits and admits for abdominal pain, however she
never had documented small bowel obstruction. On
presentation, the patient reported increased nausea, vomiting
for about two weeks. Some epigastric pain. Nausea and
vomiting associated with eating. Emesis mostly bilious. Last
bowel movement a few days prior to presentation was loose.
Denies fever or chills.
PAST MEDICAL HISTORY:
1. Invasive colon cancer.
2. Hypertension.
3. Gastroesophageal reflux disease.
4. Deep venous thrombosis of right brachial vein.
PAST SURGICAL HISTORY: Status post exploratory laparotomy
ventral hernia repair [**5-19**].
2. Status post right colectomy.
3. Status post cholecystectomy.
4. Status post small bowel resection.
5. Status post Port-A-Cath placement.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Coumadin 1 mg q.d.
2. Multivitamin.
3. Protonix 40 mg q.d.
4. Oxycodone 5 mg t.i.d.
5. Celexa 40 mg q.d.
PHYSICAL EXAMINATION: Pleasant, cooperative in some
distress. Temperature 99.1 F, heart rate 108, blood pressure
100/55, respiratory rate of 20. Heart: Tachycardic, regular
rhythm, no murmurs. Chest clear to auscultation bilaterally.
Abdomen: Soft, nondistended, tender in epigastric and left
upper quadrant area. No rebound, no guarding. Rectal:
Guaiac positive. No bright red blood per rectum. No masses
palpable.
LABORATORY: White blood cell 5.9, hematocrit 36.8, platelets
191. Sodium 135, potassium 3.1, chloride 94, bicarbonate 25,
BUN 12, creatinine 0.9, glucose 105. Total bilirubin 0.4,
direct bilirubin 0.1.
HOSPITAL COURSE: Patient had a CT Scan which showed markedly
dilated loops of small bowel at transition point. The
patient was admitted to the Medicine Service. She was placed
NPO and G tube was placed. She was given IV fluids for
resuscitation. Over the next few days, the patient reported
minimal improvement of symptoms. Site of metastasis was also
noted in the small intestine.
On [**2158-2-1**], the patient was started on TPN given potential
for a long term problem. Repeat abdominal CT Scan showed no
improvement with dilated loops of small bowel. The patient
had a gastrografin enema that showed no obstruction at the
level of the sigmoid. Patient was taken to the Operating
Room on [**2158-2-3**] where lysis of adhesion and multiple small
bowel resection for perforation was performed (please see
operative note for details).
Patient was transferred to the SICU postoperatively. Patient
was extubated on postoperative day #2. The patient was
transferred to the floor in stable condition on [**2158-2-5**].
For the next few days patient was afebrile wit vital signs
stable. Postoperative antibiotics were discontinued. She
started to ambulate and slowly decreasing NG tube output.
Continued on TPN.
On postoperative day #9, the patient spiked a fever up to
104.0 F. She was started on Vancomycin and Cipro. Had a
PICC line placed to which she started complaining of swelling
and pain in the left arm. PICC line was removed. The
ultrasound of her upper extremity was performed which showed
no change from previous picture. MRI revealed no clot,
only stenosis with collaterals. The patient continued to
intermittently spike fevers. She started growing
enterococcus out of her blood cultures. Infectious Disease
consult was obtained. The patient was switched to Ampicillin
IV on [**2158-2-14**].
Repeat CT Scan on [**2158-2-15**] showed significantly improved
collection which was seen in the previous
films so decision was made not to drain the collection.
Patient's swelling of the left arm was going down. NG tube
was removed. The patient was started on clears which was
slowly advanced. Patient is tolerating a low residue diet
[**2158-2-10**]. The left arm swelling is significantly better.
The patient was started on Coumadin 1 mg per Oncology
recommendation (patient has a history of hypercoagulability
and was started on a low dose Coumadin to prevent clotting in
the Port-A-Cath).
On postoperative day #19, the patient is afebrile. Vital
signs stable. Tolerating a low residue diet. The left arm
swelling is down significantly. The patient had a total of
three cultures which were growing enterococcus which after
discussion with Infectious Disease, it was decided to
continue the patient on a total of four weeks of Ampicillin
(started on [**2158-2-14**]). The Ampicillin can be administered
through the Port-A-Cath. The patient will continue on 1 mg
of Coumadin per day to keep her Port-A-Cath open. The
patient will need a repeat echo to evaluate for endocarditis.
Her abdomen is soft, nontender, nondistended. Her wound is
clean, dry and intact. No concerns no active issues at this
time.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Patient will be discharged to rehabilitation
center for follow up and antibiotic administration. Patient
will need Ampicillin administration q. four hours for a total
of four weeks. Antibiotics can be given through her
Port-A-Cath. Patient will come back to follow up with Dr.
[**Last Name (STitle) **] in one week. Patient will need to have repeat
echocardiogram prior to finish of her antibiotic course.
Patient should follow up with Oncology as previously
scheduled.
MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Ampicillin 2 grams IV q. four hours.
3. OxyContin 10 mg p.o. b.i.d.
4. Oxycodone 5 mg q. four hours p.r.n.
5. Prilosec 20 mg p.o. q.d.
DISCHARGE DIAGNOSIS:
1. Colon cancer.
2. Small bowel obstruction status post lysis of adhesion.
3. Gastroesophageal reflux disease.
4. Hypertension.
5. Bacteremia.
6. Postoperative anemia.
7. Hypokalemia.
8. Hypomagnesemia.
9. Hypocalcemia.
10. Left extremity deep venous thrombosis.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2158-2-22**] 13:36
T: [**2158-2-22**] 13:46
JOB#: [**Job Number **]
1
1
1
DR
|
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"197.4",
"530.81",
"V10.05",
"560.9",
"197.6",
"453.8",
"285.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
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"54.23",
"38.93",
"54.51",
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] |
icd9pcs
|
[
[
[]
]
] |
5832, 6387
|
1972, 5102
|
942, 1321
|
1344, 1954
|
177, 762
|
784, 918
|
5127, 5811
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,247
| 102,148
|
41920
|
Discharge summary
|
report
|
Admission Date: [**2186-12-10**] Discharge Date: [**2186-12-14**]
Date of Birth: [**2100-3-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
Bleeding from mouth
Major Surgical or Invasive Procedure:
EGD, IR embolization
History of Present Illness:
Mrs[**Doctor Last Name **] is a pleasant 86 yo woman with dementia, hx CABG,
HTN, hyperthyroidism, DM, TIAs, who presented to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
after having been found by her daughter covered in blood, with
blood in her mouth, characterized as approximately 1 L of blood
lost. Daughter states that she left to do an errand and returned
to find her mother confused and bleeding from her mouth. She has
no known history of liver disease or GIB. She was transferred by
EMS to an outside hospital where crit was 24.7 she was started
on vasopressin for SBP of 94, protonix and given 1 unit of
PRBCs, 2 L of fluid, transferred to [**Hospital1 18**] for urgent EGD.
In our ED, on arrival her maps were in the 50s-60s, however
improved to 65-75 and pressors were weaned. She was febrile to
100.7 rectal, exam was notable for petichae in sublingual
region, blood crusting around mouth. ECHO showed appropriate
resp variation in IVC, fast was negative. A left subclavian was
placed and cvp was measured at 5-6. Crit was 23.5, INR was 1.4,
lactate 3.6 pt had a leukocytosis to 16.3. She was 2 U PRBCs
were ordered, 1 was given in the ED. CXR unremarkable, inf q
waves on EKG. She was producing urine, having an output of 50
ccs in last hr prior to ICU transfer. She was given Zosyn and
vanco for fever and continued on a PPI gtt. A left subclavian
was placed and she was transferred with 2 PIVs. CXR showed no
acute process.
.
On the floor, pt is conversant but confused. Denies shortness of
breath, CP, discomfort.
Past Medical History:
diabetes
CAD, s/p 4 v CABG
MI
a fib
arthritis
colitis
dementia
goiter, hyperthyroid, pt refused surgery in the past
HTN
TIA
pernicious anemia
appendectomy, cholecystectomy
Social History:
Lives with daughter, is functional with some supervision. No
EtOH, tob, illicits.
Family History:
Sister with brain cancer
Physical Exam:
On admission:
Vitals: T:96 BP:120/99 P:105 R: 20 O2: 100% RA
General: Interactive, responsive, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, large neck mass
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular rhythym, tachycardic, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, mildly 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
Neuro: unable to assess, sedated
Pertinent Results:
On admission:
.
[**2186-12-10**] 07:15PM BLOOD WBC-16.3* RBC-2.70* Hgb-7.6* Hct-23.5*
MCV-87 MCH-28.0 MCHC-32.2 RDW-12.8 Plt Ct-295
[**2186-12-10**] 07:15PM BLOOD PT-15.5* PTT-27.7 INR(PT)-1.4*
[**2186-12-11**] 02:14AM BLOOD Albumin-2.7* Calcium-6.7* Phos-5.2*
Mg-1.8
[**2186-12-11**] 07:02AM BLOOD Type-ART Rates-14/ Tidal V-450 PEEP-5
FiO2-40 pO2-191* pCO2-31* pH-7.44 calTCO2-22 Base XS--1
-ASSIST/CON Intubat-INTUBATED
.
[**2186-12-10**]
Urine Cx and Blood Cx: no growth
.
[**2186-12-10**] CXR
No acute cardiopulmonary abnormality.
.
[**2186-12-11**] CXR
Endotracheal tube ends in standard placement at the thoracic
inlet and the
trachea is shifted substantially to the right and prior to
intubation, one can see is severely narrowed, by a presumed huge
left-sided goiter or a mammoth arterial aneurysm.
.
Tip of the Left subclavian line ends at the origin of the SVC.
Moderate
cardiomegaly is stable. Lungs grossly clear. No pneumothorax or
pleural
effusion. Descending thoracic aorta is tortuous and may be
mildly dilated. Stomach is moderately distended with gas.
.
[**2186-12-11**]: Transcatheter embolization
FINDINGS:
1. Active extravasation from the branch of the GDA into the
proximal
duodenum.
2. Gelfoam slurry embolization and 2 cm x 3 mm coil embolization
of the
branch of SMA with no residual active extravasation.
3. Atherosclerotic aorta and mesenteric arteries.
IMPRESSION:
Successful embolization of the active bleeding focus from GDA
with no residual active extravasation post-procedure.
.
[**2186-12-12**]
R LE u/s of catheterization site
IMPRESSION: No evidence of a hematoma and no pseudoaneurysm
identified.
.
[**2186-12-14**]:
LUE u/s
.
IMPRESSION:
1. Thrombus seen in one of the superficial veins, the left
cephalic vein. No
evidence of deep vein thrombosis in the left arm.
2. Incidental left thyroid nodule.
.
Discharge
[**2186-12-14**] 06:13AM BLOOD WBC-7.1 RBC-2.79* Hgb-8.3* Hct-24.1*
MCV-86 MCH-29.7 MCHC-34.4 RDW-14.2 Plt Ct-149*
[**2186-12-14**] 06:13AM BLOOD Glucose-112* UreaN-10 Creat-0.6 Na-137
K-3.0* Cl-104 HCO3-26 AnGap-10
[**2186-12-14**] 06:13AM BLOOD Calcium-8.1* Phos-2.0* Mg-1.8
Brief Hospital Course:
Pleasant 86 yo female presenting from OSH with hypotension,
bleeding from mouth concerning for UGIB, found to have rapid
arterial bleed in the duodenal bulb, now s/p IR embolization.
.
# UGIB/dieulafoy's lesion: scoped on arrival to the unit, found
to have bleeding ulcer in the duodenal bulb which was bleeding
rapidly and unable to be intervened upon. Unclear cause of
ulcer, pt had been on naproxen/aspirin but had not been taking
recently, no hx of h. pylori. Unstable with pressures in the 90s
and tachycardia to the 120s, repeat crit of 16.4 after
transfusion of 2 units, therefore massive transfusion protocol
was initiated pt went for IR embolization, which was successful
and crits stabilized thereafter. In total, she was transfused 7
units. DNR/DNI status was reversed for the procedure. Procedure
was complicated by groin hematoma. US showed no evidence of
hematoma or aneurysm. On the floor pt remained hemodynamically
stable and hematocrit was stable at 24-25. She was started on
famotidine for GI prophylaxis, as PPIs increase risk of PNA,
specifically aspiration PNA. Her ASA was restarted as the
literature indicates those pt's with true cad, had lower all
cause mortality and fewer MI's when aspirin was continued and a
nonsignificant increased amount of bleeding from PUD. Her dose
was decreased from 325 to 81mg because women do not confer any
survival benefit from high dose asa.
.
# Fever: pt had one fever in the ED, with no clear source. Per
family, pt was asymptomatic prior to arrival. Abx were held and
she had no further fevers throughout the admission. Cxs did not
speciate.
.
# Hx CAD: s/p CABG, no recent CP or evidence of active coronary
disease. Her home aspirin, atenolol, amlodipine, and lisinopril
were held in the setting of active GI bleed. She was restarted
on home medications with the exception of amlodine because she
remained normotensive without it. As mentioned above, her asa
was decreased to 81mg.
.
# Elevated PTH in setting of Hypocalcemia: In ICU attributed to
citrate toxicity from blood transfusions, PTH was sent and found
to be elevated at 125. Of note, pt's was hyperphosphatemic at
the time which can cause elevated PTH secretion. Furthermore, a
free calcium was measured within normal limits and albumin was
low indicating that total Ca decreased due to hypoalbuminemia.
.
# Dementia: home namenda and aricept were held given pt unable
to take POs, restarted when regular diet resumed.
.
# Hyperthyroidism: methimazole was held given pt unable to take
POs, restarted when regular diet resumed. Of note, report from
LUE U/S notes a thyroid nodule, and it is unclear if this was
present earlier.
.
# Superficial Vein Clot: last day, had swelling in Left arm,
nontender. US revealed cephalic vein clot, but no DVT.
.
# DM: maintained on ISS
.
.
DNR/DNI
.
Transitional:
- follow up incidental solid thyroid nodule in L thyroid.
- follow up Ca+ and high PTH as outpt for furtherwork up if
indicated
Medications on Admission:
aspirin 325
Namenda 10 [**Hospital1 **]
aricept 10 q am
atenolol 50 mg
amlodipine 5 mg
lisinopril 10 mg q am
janumet 50/500 1 q AM
methimazole 10 mg daily
Discharge Medications:
1. Outpatient Lab Work
CBC
please fax to Dr. [**Last Name (STitle) 90016**] Office at ([**Telephone/Fax (1) 91019**]
please have labs drawn on [**2186-12-18**]
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO qAM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Bleeding Dieulafoy's Lesion
Hypovolemic Shock
Atrial fibrillation
alzheimer's dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs.[**Doctor Last Name **],
It was a pleasure taking care of you. You were admitted to the
hospital for a gastrointestinal bleed. We performed an exam
called an upper endoscopy and the bleeding source was identified
in your small intestine. A special procedure was performed
called an arterial embolization and the bleeding stopped. When
you were bleeding, your blood pressure dropped and your blood
counts were very low. Because of this, you were admitted to the
intensive care unit and you required multiple blood transfusions
and intravenous fluids. The bleeding has now stopped and we
believe that you are safe to go home.
.
We have made the following changes to your home medications:
1. START Famotidine 20mg tablet by mouth twice daily
2. CHANGE: Aspirin from 325 mg daily to 81mg daily
3. STOP: Amlodipine 5 mg daily
4. STOP: Naproxen 500 mg tablet twice daily. Please avoid all
NSAID medications (includes ibuprofen)
.
We have arranged a follow up appointment for you with your PCP,
[**Name10 (NameIs) **] information for this appointment is below. Prior to
following up with your primary care doctor, we would like you to
get lab work to make sure your blood counts are stable. Please
have this lab work done 2 days prior to your appointment.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Street Address(2) 4472**],[**Apartment Address(1) 24519**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 18325**]
Appointment: Friday [**2186-12-22**] 10:00am
|
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icd9cm
|
[
[
[]
]
] |
[
"88.47",
"44.44",
"44.43",
"38.91"
] |
icd9pcs
|
[
[
[]
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] |
9001, 9072
|
5028, 7996
|
294, 316
|
9202, 9202
|
2872, 2872
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2210, 2236
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8202, 8978
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235, 256
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9217, 9360
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1921, 2095
|
2111, 2194
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,570
| 158,118
|
29903
|
Discharge summary
|
report
|
Admission Date: [**2146-1-13**] Discharge Date: [**2146-1-15**]
Date of Birth: [**2068-5-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
77 y/o F presents with multiple medical problems including
CAD, MI, HTN, GERD and Type II DM with a one day history of
syncope at home.
Major Surgical or Invasive Procedure:
Angiography here at [**Hospital1 18**] on [**2146-1-14**]
History of Present Illness:
77 y/o F presents with multiple medical problems including
CAD, MI, HTN, GERD and Type II DM with a one day history of
syncope at home. While trying to prepare her lunch today, she
heard a bang in her head, on then realizing that she was on the
kitchen floor. She does not recall the event at all. She could
not describe any symptomatology such as chest pain, shortness of
breath, nausea, vomiting, etc. She denies ever having such an
event before. She believes she hit the right posterooccipital
area of her head on an open cabinet which initially caused a lot
of pain. Of note, the day after [**Holiday **], she had an
angioplasty/stenting? done at both [**Hospital3 15402**] and [**Location (un) 8973**]
hospitals and re cooperated well in rehab. Today, she had a non
contrast CT scan revealing the ill-defined increased attenuation
and occipital scalp hematoma. She was referred for further
workup.
She then went on to have several radiological studies here and
the reports are as follows:
MRA BRAIN W/O CONTRAST [**2146-1-13**] 7:32 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: eval: SAH noted on CT
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with SAH on CT
REASON FOR THIS EXAMINATION:
eval: SAH noted on CT
INDICATION: 77-year-old woman with subarachnoid hemorrhage on
CT, to evaluate for intracranial vascular lesions.
PRIOR STUDY: CT of the head done on [**2146-1-13**].
TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain
were obtained without IV contrast - including FLAIR,
susceptibility, and diffusion-weighted images. 3D TOF MR
angiogram of the circle of [**Location (un) 431**] was performed.
PRELIMINARY REPORT: "Approximately 4-mm anterior communicating
artery aneurysm; small sentinel SAH surrounding the aneurysm and
more superiorly in parafalcine location corresponding to areas
of hyperattenuation on prior CT. Findings communicated to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at approximately 9:45 p.m. on [**2146-1-13**] and immediate
neurosurgical consultation recommended. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24949**]."
FINDINGS: The posterior fossa structures are unremarkable. The
cerebral parenchyma has normal [**Doctor Last Name 352**] and white matter
differentiation. Parafalcine subarachnoid hemorrhage is noted
near the anterior interhemispheric fissure, on the
susceptibility images. The ventricles and extra-axial CSF spaces
are slightly prominent, consistent with age-appropriate
involutional changes. No abnormalities noted on the
diffusion-weighted images.
3D TOF MR ANGIOGRAM OF THE CIRCLE OF [**Location (un) **]: There is a 4-mm,
fusiform aneurysm at the anterior communicating artery, best
seen on the MIP images (series 706, Im 5). A1 segment of the
right ACA is not visualized. The A1 segment of the left ACA is
prominent. Rest of the vessels of the circle of [**Location (un) 431**] -
bilateral intracranial ICA, MCA, distal vertebral, basilar and
bilateral PCA are patent and normal in caliber. No evidence of
stenosis or occlusion.
IMPRESSION:
1. 4-mm fusiform anterior communicating artery aneurysm with
adjacent subarachnoid hemorrhage in the interhemispheric region.
To consider conventional catheter angiogram for further
evaluation.
DR. [**First Name (STitle) 10627**] PERI
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
RADIOLOGY Preliminary Report
MR HEAD W/O CONTRAST [**2146-1-13**] 7:32 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: eval: SAH noted on CT
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with SAH on CT
REASON FOR THIS EXAMINATION:
eval: SAH noted on CT
INDICATION: 77-year-old woman with subarachnoid hemorrhage on
CT, to evaluate for intracranial vascular lesions.
PRIOR STUDY: CT of the head done on [**2146-1-13**].
TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain
were obtained without IV contrast - including FLAIR,
susceptibility, and diffusion-weighted images. 3D TOF MR
angiogram of the circle of [**Location (un) 431**] was performed.
PRELIMINARY REPORT: "Approximately 4-mm anterior communicating
artery aneurysm; small sentinel SAH surrounding the aneurysm and
more superiorly in parafalcine location corresponding to areas
of hyperattenuation on prior CT. Findings communicated to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at approximately 9:45 p.m. on [**2146-1-13**] and immediate
neurosurgical consultation recommended. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24949**]."
FINDINGS: The posterior fossa structures are unremarkable. The
cerebral parenchyma has normal [**Doctor Last Name 352**] and white matter
differentiation. Parafalcine subarachnoid hemorrhage is noted
near the anterior interhemispheric fissure, on the
susceptibility images. The ventricles and extra-axial CSF spaces
are slightly prominent, consistent with age-appropriate
involutional changes. No abnormalities noted on the
diffusion-weighted images.
3D TOF MR ANGIOGRAM OF THE CIRCLE OF [**Location (un) **]: There is a 4-mm,
fusiform aneurysm at the anterior communicating artery, best
seen on the MIP images (series 706, Im 5). A1 segment of the
right ACA is not visualized. The A1 segment of the left ACA is
prominent. Rest of the vessels of the circle of [**Location (un) 431**] -
bilateral intracranial ICA, MCA, distal vertebral, basilar and
bilateral PCA are patent and normal in caliber. No evidence of
stenosis or occlusion.
IMPRESSION:
1. 4-mm fusiform anterior communicating artery aneurysm with
adjacent subarachnoid hemorrhage in the interhemispheric region.
To consider conventional catheter angiogram for further
evaluation.
RADIOLOGY Final Report
CT C-SPINE W/O CONTRAST [**2146-1-13**] 1:23 AM
CT C-SPINE W/O CONTRAST
Reason: PLEASE ASSES C-SPINE FOR FX.
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with ? SAH and R IPH s/p fall
REASON FOR THIS EXAMINATION:
please assess neck for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 77-year-old woman with question subarachnoid
hemorrhage and right intraparenchymal hemorrhage status post
fall. Assess for neck fracture.
CT NECK WITHOUT CONTRAST: No prior studies are available for
comparison. There is no prevertebral soft tissue swelling. No
acute fractures are visualized. There are multilevel
degenerative changes most severe between C5 through C7. There is
widening of the anterior intervertebral disc space between C3
and C4 with very minimal anterolisthesis of C3 over C4 and an
associated posterior disc bulge. These most likely represent
chronic degenerative changes; however, given the history of
trauma, injury of the anterior longitudinal ligament cannot be
excluded. There are two posterior disc bulges narrowing the
spinal canal at the level of C2/C3 and C3/C4.
Minimal scarring is seen at the lung apices.
An occipital subgaleal hematoma is better assessed on today's
head CT.
IMPRESSION:
1. Multilevel degenerative changes throughout the cervical spine
as described.
2. Slight widening of the anterior intervertebral disc space
between C3 and C4 and grade I anterolisthesis of C3 over C4,
most likely representing degenerative changes. However, if the
patient has pain in this location and ligamentous injury is
considered, then an MRI with STIR imaging should be performed.
3. Subgaleal hematoma better assessed on the accompanying head
CT.
RADIOLOGY Preliminary Report !! Wet Read !!
CTA HEAD W&W/O C & RECONS [**2146-1-14**] 1:07 PM
CTA HEAD W&W/O C & RECONS
Reason: ANUERYSM ANT. COMMUNICATING
fusiform 4x3 mm anterior communicating aneurysm with involvement
of the right A1 segment. Decreased areas of hyperdensity of SAH
seen on previous scan. No new intracranial hemorrhage
identified. Final read pending 3D reconstructions.
DR. [**First Name (STitle) 2618**] [**Doctor Last Name **]
CT HEAD W/O CONTRAST [**2146-1-14**] 5:57 AM
CT HEAD W/O CONTRAST
Reason: please evaluate for any new bleeding or masses
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with SAH, now with acute mental status changes
REASON FOR THIS EXAMINATION:
please evaluate for any new bleeding or masses
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 77-year-old woman with subarachnoid hemorrhage, now
with acute mental status changes. Evaluate for new bleeding or
masses.
Comparison is made to [**2146-1-13**] at 2:28 a.m.
CT HEAD WITHOUT CONTRAST: Again noted are multiple foci of
increased attenuation along several frontal gyri and parafalcine
right frontal lobe, all of which however are less apparent than
on the prior study suggesting resolving hemorrhage. No new foci
of hemorrhage are seen. Ventricles and basilar cisterns are
stable. Size of subgaleal hematoma has decreased in size.
IMPRESSION: No evidence of new hemorrhage or mass effect.
Multiple foci of presumed subarachnoid hemorrhage (note recent
MRI suggesting aneurysm as source of bleed) have partially
resolved.
NOTE ADDED AT ATTENDING REVIEW: There is also subarachnoid
hemorrhage in the interhemispheric fissue.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 46933**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: [**First Name9 (NamePattern2) **] [**2146-1-14**] 2:32 PM
Past Medical History:
CAD/MI
HTN
GERD
DM Type II
Cellulitis
Social History:
unknown
Family History:
lives at home
Physical Exam:
(**note, this is from her inital admission as she is intubated
and sedated now s/p angiography today. There were no deficits
on exam this morning.)
O: T: BP:150/55 HR: 82 R 18 O2Sats
Gen: WD/WN, comfortable, NAD. C-collar on.
HEENT: Pupils: R surgical pupil. Left corneal scar. Reactive
EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-26**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils: R>L round. Right surgical pupil. Left pupil 4 to 2.
Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-30**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right +2 +2 +2 0 +2
Left +2 +2 +2 0 +2
Babinsky indeterminate.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2146-1-13**] 07:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2146-1-13**] 07:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2146-1-13**] 05:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2146-1-13**] 05:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2146-1-13**] 12:45AM GLUCOSE-141* UREA N-13 CREAT-0.6 SODIUM-134
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-29 ANION GAP-11
[**2146-1-13**] 12:45AM ALBUMIN-3.9 CALCIUM-9.7 PHOSPHATE-2.0*
MAGNESIUM-2.0
[**2146-1-13**] 12:45AM WBC-6.8# RBC-4.23 HGB-13.4 HCT-38.0 MCV-90
MCH-31.6 MCHC-35.2* RDW-14.1
[**2146-1-13**] 12:45AM NEUTS-71.0* LYMPHS-20.5 MONOS-5.6 EOS-2.5
BASOS-0.4
[**2146-1-13**] 12:45AM PLT COUNT-234#
[**2146-1-13**] 12:45AM PT-11.2 PTT-26.3 INR(PT)-0.9
[**2146-1-13**] 12:30AM GLUCOSE-133* UREA N-13 CREAT-0.6 SODIUM-132*
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-23 ANION GAP-16
[**2146-1-13**] 12:30AM estGFR-Using this
[**2146-1-13**] 12:30AM CK-MB-NotDone
[**2146-1-13**] 12:30AM CK-MB-NotDone
[**2146-1-13**] 12:30AM CALCIUM-9.7 PHOSPHATE-2.2* MAGNESIUM-2.0
[**2146-1-13**] 12:30AM WBC-3.7* RBC-3.46* HGB-11.2* HCT-31.5* MCV-91
MCH-32.5* MCHC-35.6* RDW-14.1
[**2146-1-13**] 12:30AM NEUTS-68.6 LYMPHS-22.4 MONOS-5.7 EOS-2.7
BASOS-0.5
[**2146-1-13**] 12:30AM PLT COUNT-66*
Brief Hospital Course:
77 y/o F presents with multiple medical problemsincluding CAD,
MI, HTN, GERD and Type II DM with a one day history of syncope
at home. She was seen and evaluated by the neurosurgical intern
in the ED and had no focal signs on presentation. She was
admitted to the SICU and was looked after by the MICU team. She
underwent multiple imaging studies on [**2146-1-13**] demonstrating the
presence of an aneurysm. On [**2146-1-14**], the neuroradiology group
was consulted and they took the patient to the angiography suite
for imaging and +/- cloiling. Accoringing to the angio staff,
the aneurysm was too narrow to coil and she was brought to the
PACU and then to the SICU. Dr. [**Last Name (STitle) **] then facilitated a direct
transfer to [**Hospital1 112**] for potential clipping of the aneurysm.
The patient has 2 contact people:
[**Name (NI) **] (Daughter) [**Telephone/Fax (1) 71464**]
[**Name (NI) **] (son) [**Telephone/Fax (1) 71465**].
Thank you for accepting this paitient as a transfer for a higher
level of care.
Medications on Admission:
Plavix 75' qd
Asa 325' qd
lopressor 50' qd
Xanax 0.5' QOD
protonix 40' qd
glucovance 2.5'/500'
[**Doctor Last Name **] VR 1000' [**Hospital1 **]
HCTZ 12.5' qd.
Discharge Medications:
1. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
2. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
3. Propofol 10 mg/mL Emulsion Sig: One (1) Intravenous TITRATE
TO (titrate to desired clinical effect (please specify)).
4. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
5. Phenytoin Sodium 50 mg/mL Solution Sig: One (1) Intravenous
Q8H (every 8 hours).
6. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q6H (every 6 hours).
7. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 13753**] - [**Location (un) 86**]
Discharge Diagnosis:
4-mm, fusiform aneurysm at the anterior communicating artery.
small amount of subarachnoid
blood/hemorrhage.
Discharge Condition:
serious
Discharge Instructions:
Patient is being transfered to [**Hospital1 112**] for definitve management of
her aneurysm.
Followup Instructions:
Interventional neurovascular group at [**Hospital1 112**] for clipping. Dr.
[**Last Name (STitle) **] (attending at [**Hospital1 18**]) spoke with attending at [**Hospital1 112**] about
direct transfer for definitve care. Attempt at coiling today was
not attempted.
Completed by:[**2146-1-14**]
|
[
"412",
"250.00",
"430",
"530.81",
"414.01",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
15124, 15197
|
13212, 14250
|
456, 516
|
15351, 15361
|
11740, 13189
|
15502, 15799
|
10127, 10142
|
14461, 15101
|
8647, 8713
|
15218, 15330
|
14276, 14438
|
15385, 15479
|
10157, 10574
|
280, 418
|
8742, 10024
|
544, 1676
|
10867, 11721
|
10589, 10851
|
10046, 10086
|
10102, 10111
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,300
| 164,522
|
36336
|
Discharge summary
|
report
|
Admission Date: [**2113-5-8**] Discharge Date: [**2113-5-15**]
Date of Birth: [**2033-10-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Seizure activity/NSVT
Major Surgical or Invasive Procedure:
Pacemaker placment
History of Present Illness:
79 year old female with severe AS (valve area 0.8, peak gradient
75), afib on coumadin, dCHF (EF 60%), sinus bradycardia
(recently taken off of metoprolol), and hypertension who
presents from [**Hospital 100**] rehab for evaluation of seizure-like
activity. Per review of facility records, on [**5-7**] 7:45pm noted
to have "upper extremity tremors, eyes rolled back of head...
very confused and disoriented." At 9:30pm she was reported to
have a similar episode although a record of this event is not
available. Patient was free of headache, chest pain, shortness
of breath, tongue-biting.
.
Of note the patient was recently admitted to [**Hospital1 18**] [**Location (un) 620**] from
[**Date range (1) 82333**] with CHF, L femur fracture following reported
mechanical fall. She underwent ORIF on [**5-2**] by Dr. [**Last Name (STitle) **].
During the admission she was noted to be bradycardic (HR 40s)
with suspected junctional beats and per cardiology her
metoprolol was discontinued. Her HR remained 50-70. She also
presented with ARF with Cr 1.5, on discharge creatinine was 1.4.
Her INR was reversed for surgery and she was discharged to rehab
on coumadin with Lovenox bridge.
.
In the emergency department, initial vitals: T100-101.6, 140/80,
60, 20, 89 on RA, on 95% on 2L. No seizure activity of confusion
observed in ED (family at bedside and states patient at
baseline). Patient had been bradycardic in 50s maintaining BP.
At 11pm, patient was noted to have polymorphic NSVT ([**11-20**]
beats, x3 episodes) with torsades morphology. Labs were notable
for WBC 12.7 with 90.9% polys, negative CE, INR 2.8, lactate
2.3. UA was positive and she was given a dose of Cipro 400mg IV
at midnight for UTI. She was also given IVF - NS 800cc. CXR and
CT head were normal with no change from previous.
.
For NSVT, given bolus and gtt of lidocaine. Given 4mg IV mag for
mag of 1.9. Patient was evaluated by cardiology fellow and
decision was made to admit to CCU. On transfer from ED, vitals
were T98.6, HR50, BP150/38, RR16, 96% on 2L.
.
On arrival to the CCU, patient denies chest pain, palpitations.
She does not remember seizure-like activity. She reports
persistent dry cough. She denies dyspnea, abdominal pain,
diarrhea, dysuria, focal weakness or numbness.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- L femur fracture s/p ORIF on [**5-2**]
- AS, valve area 0.8 on TTE in [**4-15**]
- Diastolic CHF (chronic, EF 55%)
- Right knee problems
- Hx of Afib
- Carotid Artery stenosis 75% bilaterally
- Torn rotator cuff (left)
- pulmonary hypertension
- Hypertension
- Hyperlipidemia (recent diagnosis)
Social History:
The patient normally lives alone; she is currently in rehab
facility. At home, [**Date Range **] help with her medications. Retired
former state employee (worked at the state mental hospital). Has
2 [**Date Range **] and other family in the area. Denies smoking
history, no alcohol use.
Family History:
Noncontributory
Physical Exam:
Vitals: 98.9; HR 75; BP 155/38; 18 96%RA
GENERAL: Pleasant, fatigued appearing elderly woman in no
distress.
HEENT: Normocephalic. No scleral icterus. PERRL (although
constricted). Dry mucous membranes. Neck supple. No appreciable
JVD. Skin tear left cheek.
SKIN: Multiple eccymoses upper extremitites; dry, scaly,
hyperpigmented skin at dorsal surface of both hands
CHEST: dressing C/I/D
CARDIAC: Regular rhythm, normal rate. S1, S2. 3/6 SEM best
appreciated at LUSB, heard throughout, radiating to the carotids
LUNGS: CTA bilaterally; no wheezes, rales, or rhonchi
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: No edema or calf pain, good perfusion, 2+ radial,
dorsalis pedis, posterior tibial pulses
NEURO: A&Ox2. (oriented to person/place, but not time) CNII-XII
intact EXCEPT for right upward gaze palsy; upper and RLE
extremity strength 5/5 (unable to assess LLE strength 2/2 recent
surgery)
Pertinent Results:
CT head without contrast ([**2113-5-7**]):
IMPRESSION: No intracranial hemorrhage or edema.
CXR 2V ([**2113-5-7**]):
IMPRESSION: Cardiomegaly without acute cardiopulmonary process.
ECHO:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is 10-20mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The aortic valve leaflets are severely thickened/deformed. There
is severe aortic valve stenosis (valve area 0.8-1.0cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-9**]+) mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severe aortic valve stenosis. Severe pulmonary
artery systolic hypertension. Right ventricular cavity
enlargement with free wall hypokinesis. At least mild-moderate
mitral regurgitation. Normal left ventricular cavity size and
regional/global systolic function.
Carodtid U/S
IMPRESSION:
1. 80-99% stenosis in the right internal carotid artery with the
degree of
stenosis being more likely 80% than 99%.
2. 60-69% stenosis in the left internal carotid artery.
[**5-11**] Cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
no obstructive, flow-limiting disease. The LMCA, LAD, LCx, and
RCA were
all widely patent.
2. There was moderate arterial systolic hypertension with a
central
aortic SBP of 162mmHg.
FINAL DIAGNOSIS:
1. Coronary arteries are free of angiographically significant
disease.
CXR: [**5-13**]
Compared to the prior study, there is no significant interval
change in the pacemaker leads, the heart is mildly increased in
size, there is pulmonary vascular redistribution and patchy
areas of volume loss/infiltrate in both
lower lungs. There is no pneumothorax.
[**2113-5-7**] 10:10PM BLOOD WBC-12.7*# RBC-3.27* Hgb-9.5* Hct-28.4*
MCV-87 MCH-29.0 MCHC-33.4 RDW-15.6* Plt Ct-539*#
[**2113-5-7**] 10:10PM BLOOD Neuts-90.9* Lymphs-5.3* Monos-3.6 Eos-0.1
Baso-0.1
[**2113-5-7**] 10:10PM BLOOD PT-27.9* PTT-36.5* INR(PT)-2.8*
[**2113-5-7**] 10:10PM BLOOD Glucose-146* UreaN-21* Creat-1.1 Na-136
K-3.9 Cl-97 HCO3-24 AnGap-19
[**2113-5-7**] 10:10PM BLOOD CK-MB-NotDone
[**2113-5-7**] 10:10PM BLOOD cTropnT-0.01
[**2113-5-8**] 04:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2113-5-7**] 10:10PM BLOOD CK(CPK)-27
[**2113-5-8**] 04:20AM BLOOD CK(CPK)-24*
[**2113-5-7**] 10:10PM BLOOD Calcium-8.7 Phos-3.5# Mg-1.9
[**2113-5-9**] 11:44AM BLOOD calTIBC-221* Ferritn-472* TRF-170*
[**2113-5-11**] 05:07AM BLOOD Vanco-16.0
[**2113-5-15**] 05:30AM BLOOD WBC-6.7 RBC-3.39* Hgb-9.7* Hct-30.0*
MCV-89 MCH-28.6 MCHC-32.3 RDW-15.6* Plt Ct-487*
[**2113-5-15**] 05:30AM BLOOD Neuts-74.0* Lymphs-17.1* Monos-6.8
Eos-1.5 Baso-0.8
[**2113-5-15**] 05:30AM BLOOD PT-17.3* PTT-32.3 INR(PT)-1.6*
[**2113-5-15**] 05:30AM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-136
K-4.1 Cl-101 HCO3-25 AnGap-14
[**2113-5-8**] 07:22AM BLOOD ALT-15 AST-33 LD(LDH)-258* AlkPhos-85
TotBili-0.8
[**2113-5-15**] 05:30AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0
URINE CULTURE (Final [**2113-5-10**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
URINE CULTURE (Final [**2113-5-11**]): NO GROWTH.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2113-5-12**]):
Feces negative for C.difficile toxin A & B by EIA.
Blood Culture, Routine [**5-7**]:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
Blood Cx: [**5-7**], [**5-9**], 62, [**5-10**], [**5-10**], [**5-11**], [**5-11**] PENDING (NGTD)
Brief Hospital Course:
79 year-old female with severe AS, afib on coumadin, and HTN who
presents from rehab for evaluation of seizure-like activity,
found to have intermittent runs of NSVT and admitted to the CCU
for further management. Hospital course was as follows.
#. Torsade de pointes: Admitted to CCU for multiple runs of
polymorphic VT in ED, now on lidocaine gtt with no recurrent
runs since admission to the CCU. Has history of afib on
coumadin, therapeutic INR. Metoprolol d/c'd during recent
hospitalization due to bradycardia and suspected junctional
beats. Usual etiologies include valvular disease (patient with
severe AS), myocardial scar (although patient without documented
prior myocardial infarction or coronary heart disease, or
cardiomyopathy), myocardial ischemia. Patient with known
prolonged QT, unknown reason. The lidocaine gtt was weaned off.
She was monitored on tele and pacer pads were in place. She did
not have any further episodes during her admission. Her lytes
were aggressively repleted with goal Mg>2.2, K4.5-5.0. Her
mirtazapine was also held. The patient's coumadin was held.
Pacer placement was delayed by questionable bacteremia (1 bottle
of coag-neg staph) likey contamination given no further cultures
were positive. Additionally, the patient was treated with CTX
for UTI and switched to keflex when sensitivies returned K.
pneumo. The patient also underwent cardiac cath that did not
show significant disease. The patient underwent pacer placement
on [**2113-5-12**] without complication. Plan for device clinic follow-up
in 1 week after discharge.
#. A-fib: Pt coumadin was held prior to pacermaker placement.
It was restart after the procedure. She was also started on
metoprolol 12.5mg [**Hospital1 **] and can be titrated up as need for rate
control.
#. CORONARIES: No known history of CAD history. Cardiac enzymes
negative x2. Patient underwent cardiac cath on [**2113-5-11**] that did
not show significant disease. She was continued on simvastatin,
ASA 81mg and started on an ACE-I.
#. PUMP: Per review of records, has history of dCHF although
recent TTE without evidence of this. TTE on [**2113-5-8**] showed EF
>55%.She was continued on her home lasix 40mg. She was started
on metoprolol 12.5mg [**Hospital1 **] after pacer placement.
#. Valve: Severe AS: Pt underwent repeat ECHO that showed severe
AS (valve area 0.8-1.0cm2). She was evaluated by surgery with
plan for AVR within the next month. She underwent carotid U/S
that showed 80-99% stenosis in the right internal carotid artery
and 60-69% stenosis in the left internal carotid artery. She
will need vascular surgery follow-up prior to her AVR. She will
also have outpatient follow-up regarding workup and scheduling
of her AVR.
#. Delirium: Pt with multiple episodes of delirium during her
hospitialization. She was treated for a UTI that was likey
contributing to her mental status. Additionally,
hospitalization and CCU stay likely also contributing to her
delirium. She has episodes of being AAOx3, but also episodes of
confusion, especially occuring at night. She was not given
anti-psychotics due to concern for QT prolongation. She was
reoriented and sleep-wake cycles were attempted to be
maintained.
#. Seizure activity: Question of seizure at rehab. Her neuro
exam non-focal here and CT head negative for acute process. This
was likely due to her arrhythmia and not seizure activity. She
had no further episodes.
#. UTI: Pt with positve UA with culture that grew K. pneumo
pansensitive except intermediate to nitrofurantoin. She was
treated initally with CTX. She was switched to Keflex 500mg q6
for 10 day course (last day: [**2113-5-17**]). Her repeat UA and
culture were no growth.
#. HTN: The patient's amlodipine was held on admission. Her
blood pressure ranged SBP 130-150's in the CCU. Her blood
pressure remained elevated and she was started on lisinopril
that was titrated up to 40mg daily. Additionally, the patient
was also started on metoprolol 12.5mg [**Hospital1 **] after her pacer was
placed. This should be titrated up as needed.
#. Hyperlipidemia: stable, statin per home regimen
#. s/p recent ORIF: She remained stable and pain was controlled
with tylenol and oxycodone prn. She was seen by PT and is WBAT.
Additionally, [**Hospital1 **] removed her staples on [**2113-5-15**] and will need
to follow-up with [**Date Range **] 2 weeks after discharge for routine
follow-up.
**CODE STATUS: FULL CODE, confirmed with patient
**CONTACT:
[**Name (NI) 23835**]
[**Name2 (NI) **]: ([**Telephone/Fax (1) 82334**]
[**Name2 (NI) **]: ([**Telephone/Fax (1) 82335**]
Medications on Admission:
(from rehab records):
- Furosemide 40 mg PO DAILY
- Acetaminophen 650mg PO every 4-6 hours as needed for pain.
- Senna 8.6 mg PO BID
- Folic Acid 1 mg daily
- Aspirin 81 mg daily
- Calcium carbonate 650mg PO BID
- Cholecalciferol 1000 units daily
- Ferrous Sulfate 325 mg daily
- Mirtazapine 30mg PO HS
- Magnesium Oxide 400 mg PO BID
- Omeprazole 40mg PO BID
- Simvastatin 20 mg PO QHS
- Bisacodyl 10 mg daily prn
- Amlodipine 7.5mg PO DAILY
- Oxycodone 5mg 1-2 Tablets PO Q3H prn
- Warfarin 2mg PO daily, goal INR [**1-10**] (last INR 2.2 on [**5-7**])
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days: last day [**2113-5-17**].
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Calcium Carbonate 600 mg (1.5 gram) Tablet, Chewable Sig:
One (1) Tablet, Chewable PO twice a day.
18. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Polymorphic VT
UTI
Delirium
Severe AS
HTN
Secondary: CHF, A-fib, s/p ORIF, Hyperlipidemia
Discharge Condition:
stable, systolic blood pressures 140-150, AAOx2 (persone and
place)
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because your heart was
beating in a dangerous rhythm. You had a pacemaker placed and
tolerated the procedure without complication. You were also
treated for a urinary tract infection with antibiotics. You last
day will be [**2113-5-17**]. You also had your staples removed from
your surgery and will follow-up as an outpatient.
Please follow the medications prescribed below.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Electrophysiology:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2113-5-22**]
2:00. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**].
Proveder: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**6-2**] at 9:00 am. [**Hospital Ward Name 23**] Clinical Center
Orthopedics:
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2113-5-18**] 9:00
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2113-5-18**] 8:40
Vascular Surgery:
[**Last Name (LF) **],[**First Name3 (LF) **] Phone: ([**Telephone/Fax (1) 9393**] Date/time: [**6-8**] at
1:00pm. [**Hospital **] Medical Building [**Location (un) 442**] 5B.
.
Cardiology:
Provider: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**6-12**] at 9:00 am.
.
Cardiac Surgery:
Dr. [**Last Name (STitle) 914**] Phone: [**Telephone/Fax (1) 82336**] Date/time: [**5-30**] at 1:00pm.
[**Last Name (un) 6752**] [**Location (un) 1773**].
Completed by:[**2113-5-15**]
|
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"433.10",
"428.0",
"433.30",
"416.8",
"041.3",
"285.29",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.45",
"88.56",
"37.83",
"37.72",
"37.22"
] |
icd9pcs
|
[
[
[]
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|
16017, 16087
|
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3468, 3485
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14241, 15774
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15903, 15996
|
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|
6317, 9001
|
16111, 16817
|
3500, 4396
|
2745, 2818
|
276, 299
|
386, 2651
|
2849, 3148
|
2673, 2725
|
3164, 3452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,382
| 180,236
|
49406+49407+49408
|
Discharge summary
|
report+report+report
|
Admission Date: [**2184-6-11**] Discharge Date: [**2184-6-26**]
Date of Birth: [**2138-6-4**] Sex: M
Service: MICU-A
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
male with a past medical history of child's A cirrhosis,
status post radiation therapy for squamous cell carcinoma of
the tongue, in remission, whose chief complaint was
gastrointestinal bleeding.
The patient presented to the Emergency Room with a history of
spitting up blood times three episodes, about 100 cc each.
The patient also complained of a sore throat times one day,
as well as a sensation of something in his throat times a few
days, also increased hoarseness, no weight loss, fever or
chills, no shortness of breath. His alcohol use was two days
prior to admission. On evaluation, the patient coughed up
100 cc of blood with clots. The patient did not tolerate
nasogastric lavage and refused the procedure.
PHYSICAL EXAMINATION: On physical examination in the
Emergency Room, the patient had a temperature of 98.2, pulse
104, blood pressure 150/60, respiratory rate 18 and oxygen
saturation 98% in room air. He was awake and alert, in no
acute distress. Head, eyes, ears, nose and throat: Pupils
equal, round, and reactive to light, extraocular movements
intact, oropharynx dry. Neck: Without lymphadenopathy.
Lungs: Clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm without murmur, rub or gallop.
Abdomen: Soft, nontender, liver span palpated about 6 cm,
spleen tip palpable. Extremities: 1+ edema.
LABORATORY DATA: White blood cell count was 3.3, hematocrit
33. platelet count 57,000, sodium 139, potassium 4.2,
chloride 102, bicarbonate 26, BUN 2, creatinine 0.3, glucose
113, INR 1.9, partial thromboplastin time 41, ALT 35, AST
123, alkaline phosphatase 227, and total bilirubin 11.7.
HOSPITAL COURSE: The patient was given vitamin K and fresh
frozen plasma in the Emergency Room and was transfused two
units of packed red blood cells. Gastroenterology performed
an endoscopy and found grade II varices, banded three of
them.
The patient then continued a five day course of octreotide.
His hematocrit remained stable and no re-bleeding recurred.
Upon resolution of the gastrointestinal bleed, the patient
became increasingly somnolent and, one morning, was unable to
be aroused. The patient had stridor and anesthesia was
called for intubation, noting edema in the airway.
The patient was aggressively treated with lactulose. A CT
scan was within normal limits. An electroencephalogram
showed seizure activity. The patient was presumed to be in
status epilepticus, therefore was given Ativan and a loading
dose of phenytoin until he reached a therapeutic level.
Over a few days, with aggressive lactulose and Flagyl
therapy, the patient resumed his baseline mental status,
which includes Korsakoff. The patient was extubated when
ventilation and oxygenation were adequate and the patient was
more alert.
Upon extubation, the patient developed stridor, which his
wife said is somewhat evident at his normal baseline.
However, otolaryngology was consulted. There was noted to be
crust above the glottis, however, they did not note very much
edema. Therefore, dexamethasone originally incited was
tapered. The crust was soft and, with humidified air, the
patient did well.
A Dobbhoff tube was placed on the day of transfer to the
floor in order to administer lactulose and tube feeds.
Because the patient's ability to swallow is not at maximum
capacity we are waiting until his mental status is much more
improved for a swallowing study.
The patient is stable, doing well, and is to be transferred
to the floor.
MEDICATIONS ON TRANSFER:
Flovent and albuterol p.r.n. wheezing.
Lasix 20 mg i.v.b.i.d.
Phenytoin 2 mg i.v.q.a.m. followed by 100 mg times two.
Flagyl 500 mg p.o.q.d. when capable of oral intake.
Aldactone 100 mg p.o.q.d.
Aggressive treatment with lactulose.
Nadolol.
Sucralfate.
Protonix 40 mg b.i.d.
Note: There will be an addendum to his dictation upon
discharge out of the hospital from the floor.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 10038**]
Dictated By:[**Last Name (NamePattern1) 103443**]
MEDQUIST36
D: [**2184-6-26**] 12:45
T: [**2184-6-26**] 14:47
JOB#: [**Job Number 24985**]
Admission Date: [**2184-6-11**] Discharge Date: [**2184-7-8**]
Date of Birth: [**2138-6-4**] Sex: M
Service: [**Hospital1 212**]
STAT ADDENDUM:
The patient was transferred to the [**Hospital **] Medical service
on [**2184-7-3**] from the Medical Intensive Care Unit.
This is a continuation of the [**Hospital 228**] hospital course. The
previous dictation the Medical Intensive Care Unit course has
already been dictated.
CONTINUATION HOSPITAL COURSE: On the 13th, the patient was
transferred.
1. PULMONARY: Ears, nose and throat continued to follow the
patient. The patient was maintained on his original regimen,
humidified O2 via the face shovel mask and was encouraged to
have suction qid to the back of the pharynx and was continued
to be monitored.
2. GASTROINTESTINAL: 1. Swallow study: The patient had
failed swallow study previously in the Medical Intensive Care
Unit and was reevaluated. Reevaluation via oropharynx video
showed aspiration on both thick and thin liquids. However,
upon further discussion aspiration on nectar thick felt to be
one of patient's suboptimal efforts where the patient was
rushed using straw, therefore recommendation was made to
allow the patient to continue on a honey thick diet with
puree with careful supervision of all meals. No straws to be
used, encouraged the patient to go slowly with three swallows
per bite. The patient did well, was reevaluated and advanced
to nectar thick liquids. Recommendations were also made to
have medications crushed and placed in puree, although
patient did do well with small pills without being crushed.
The goal is for the patient to receive rehabilitation and
then have the swallow study repeated to monitor for
improvement.
For the patient's cirrhosis, hepatology service
recommendation was continue to swallow and make
recommendations. The patient was continued on his doses of
lactulose, spironolactone with a goal diuresis each day of
minus 500 cc. MRI of the abdomen was done to evaluate the
liver which showed moderate ascites, splenomegaly and a liver
contour consistent with cirrhosis. No abnormal liver masses
or enhancement were found and the portal vein was patent.
For the esophageal varices, the patient has a follow up
appointment on [**2184-7-16**] at 10 a.m. The patient is to
come at 9 to [**Hospital Ward Name 121**] Eight for a repeat
esophagogastroduodenoscopy with banding.
On the [**7-7**], the patient complained of pain per
rectum, thought it was reminiscent of patient's hemorrhoids.
Upon examination, it was found to have an approximately 1 cm
draining perirectal abscess. The abscess was tender, but
showed no signs of infection and was draining serosanguinous
fluid. Instructions were to keep the wound clean and dry,
follow patient's white count which did not rise and the
patient remained afebrile.
3. NEUROLOGY: Patient with hepatic encephalopathy versus
seizures. The repeat EEG was done which showed no signs of
seizure activity. The patient remained seizure free and was
continued on Neurontin 300 mg 3x a day and Dilantin 350 mg
broken up in 150 mg in the morning, 100 mg in the p.m. and
100 mg in the evening. The patient is to follow up with Dr.
[**Last Name (STitle) **] of neurology.
4. DECONDITIONING: Patient with a stage 1 decubitus sacral
ulcer noted recommending position change q2h with use of
barrier cream. Overall, the patient did well while in the
hospital, although complained of feeling weak secondary to
deconditioning.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: The patient is discharged to
rehabilitation today.
DISCHARGE DIAGNOSES:
1. Alcohol cirrhosis with esophageal variceal bleed
2. Hepatic encephalopathy
3. Seizures
4. Status post a laryngeal mask removal
5. Deconditioning
DISCHARGE MEDICATIONS:
1. Lactulose 30 ml po 4x day or lactulose 300 ml per rectum
4x a day prn if patient not tolerating po.
2. Spironolactone 100 mg po bid
3. Nadolol 200 mg po once a day, hold for systolic blood
pressure less than 90 or heart rate less than 60.
4. Lasix 40 mg po once a day
5. Albuterol nebulizer ............ 1 to 2 nebulizers q6h
prn
6. Atrovent nebulizers 1 to 2 nebulizers ih q6h prn
7. Neurontin 300 mg 3x a day
8. Dilantin 350 mg a day broken up into 150 mg a.m., 100 mg
p.m., 100 mg evening
9. Calcipotriene 0.[**Numeric Identifier **]% applied to skin twice a day for
psoriasis
10. Nystatin ointment 1 application to skin 4x a day as
needed.
11. Miconazole powder 2% one application to skin 4x a day prn
12. Protonix 40 mg po 2x a day
13. Vitamin C 500 mg twice a day
14. Multivitamin
15. Zinc sulfate 220 mg po once a day
DISCHARGE INSTRUCTIONS: The patient is also to receive
suctioning to the back of his throat 4x a day and to have
oxygen provided via humidified face shovel mask to prevent
dryness of his oropharynx. Diet is to be nectar thick
liquids with supervision during all meals. No straws to be
used. The patient is to take small bites and sips and
encouraged to go slowly, for example three swallows per bite.
Large medications are to be crushed and placed in puree for
administration. The patient is to have position changed q2h
and monitoring of the stage 1 sacral decubitus with use of
barrier cream. Perirectal abscess should be kept clean and
dry and monitored.
FOLLOW UP: The patient is to follow up with gastrointestinal
for esophagogastroduodenoscopy banding with banding on [**2184-7-16**], 10 a.m. at [**Hospital Ward Name 121**] Eight. The patient is to arrive
at 9 a.m. The patient is to follow up with ears, nose and
throat, Dr. [**Last Name (STitle) 103444**], and is to follow up with neurology, Dr.
[**Last Name (STitle) **] in one month.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4987**]
Dictated By:[**Last Name (NamePattern1) 25643**]
MEDQUIST36
D: [**2184-7-8**] 13:08
T: [**2184-7-8**] 14:28
JOB#: [**Job Number 103445**]
cc:[**Hospital3 **] Admission Date: [**2184-6-11**] Discharge Date: [**2184-7-8**]
Date of Birth: [**2138-6-4**] Sex: M
Service: [**Hospital1 212**]
STAT ADDENDUM:
The patient was transferred to the [**Hospital **] Medical service
on [**2184-7-3**] from the Medical Intensive Care Unit.
This is a continuation of the [**Hospital 228**] hospital course. The
previous dictation the Medical Intensive Care Unit course has
already been dictated.
CONTINUATION HOSPITAL COURSE: On the 13th, the patient was
transferred.
1. PULMONARY: Ears, nose and throat continued to follow the
patient. The patient was maintained on his original regimen,
humidified O2 via the face shovel mask and was encouraged to
have suction qid to the back of the pharynx and was continued
to be monitored.
2. GASTROINTESTINAL: 1. Swallow study: The patient had
failed swallow study previously in the Medical Intensive Care
Unit and was reevaluated. Reevaluation via oropharynx video
showed aspiration on both thick and thin liquids. However,
upon further discussion aspiration on nectar thick felt to be
one of patient's suboptimal efforts where the patient was
rushed using straw, therefore recommendation was made to
allow the patient to continue on a honey thick diet with
puree with careful supervision of all meals. No straws to be
used, encouraged the patient to go slowly with three swallows
per bite. The patient did well, was reevaluated and advanced
to nectar thick liquids. Recommendations were also made to
have medications crushed and placed in puree, although
patient did do well with small pills without being crushed.
The goal is for the patient to receive rehabilitation and
then have the swallow study repeated to monitor for
improvement.
For the patient's cirrhosis, hepatology service
recommendation was continue to swallow and make
recommendations. The patient was continued on his doses of
lactulose, spironolactone with a goal diuresis each day of
minus 500 cc. MRI of the abdomen was done to evaluate the
liver which showed moderate ascites, splenomegaly and a liver
contour consistent with cirrhosis. No abnormal liver masses
or enhancement were found and the portal vein was patent.
For the esophageal varices, the patient has a follow up
appointment on [**2184-7-16**] at 10 a.m. The patient is to
come at 9 to [**Hospital Ward Name 121**] Eight for a repeat
esophagogastroduodenoscopy with banding.
On the [**7-7**], the patient complained of pain per
rectum, thought it was reminiscent of patient's hemorrhoids.
Upon examination, it was found to have an approximately 1 cm
draining perirectal abscess. The abscess was tender, but
showed no signs of infection and was draining serosanguinous
fluid. Instructions were to keep the wound clean and dry,
follow patient's white count which did not rise and the
patient remained afebrile.
3. NEUROLOGY: Patient with hepatic encephalopathy versus
seizures. The repeat EEG was done which showed no signs of
seizure activity. The patient remained seizure free and was
continued on Neurontin 300 mg 3x a day and Dilantin 350 mg
broken up in 150 mg in the morning, 100 mg in the p.m. and
100 mg in the evening. The patient is to follow up with Dr.
[**Last Name (STitle) **] of neurology.
4. DECONDITIONING: Patient with a stage 1 decubitus sacral
ulcer noted recommending position change q2h with use of
barrier cream. Overall, the patient did well while in the
hospital, although complained of feeling weak secondary to
deconditioning.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: The patient is discharged to
rehabilitation today.
DISCHARGE DIAGNOSES:
1. Alcohol cirrhosis with esophageal variceal bleed
2. Hepatic encephalopathy
3. Seizures
4. Status post a laryngeal mask removal
5. Deconditioning
DISCHARGE MEDICATIONS:
1. Lactulose 30 ml po 4x day or lactulose 300 ml per rectum
4x a day prn if patient not tolerating po.
2. Spironolactone 100 mg po bid
3. Nadolol 200 mg po once a day, hold for systolic blood
pressure less than 90 or heart rate less than 60.
4. Lasix 40 mg po once a day
5. Albuterol nebulizer ............ 1 to 2 nebulizers q6h
prn
6. Atrovent nebulizers 1 to 2 nebulizers ih q6h prn
7. Neurontin 300 mg 3x a day
8. Dilantin 350 mg a day broken up into 150 mg a.m., 100 mg
p.m., 100 mg evening
9. Calcipotriene 0.[**Numeric Identifier **]% applied to skin twice a day for
psoriasis
10. Nystatin ointment 1 application to skin 4x a day as
needed.
11. Miconazole powder 2% one application to skin 4x a day prn
12. Protonix 40 mg po 2x a day
13. Vitamin C 500 mg twice a day
14. Multivitamin
15. Zinc sulfate 220 mg po once a day
DISCHARGE INSTRUCTIONS: The patient is also to receive
suctioning to the back of his throat 4x a day and to have
oxygen provided via humidified face shovel mask to prevent
dryness of his oropharynx. Diet is to be nectar thick
liquids with supervision during all meals. No straws to be
used. The patient is to take small bites and sips and
encouraged to go slowly, for example three swallows per bite.
Large medications are to be crushed and placed in puree for
administration. The patient is to have position changed q2h
and monitoring of the stage 1 sacral decubitus with use of
barrier cream. Perirectal abscess should be kept clean and
dry and monitored.
FOLLOW UP: The patient is to follow up with gastrointestinal
for esophagogastroduodenoscopy banding with banding on [**2184-7-16**], 10 a.m. at [**Hospital Ward Name 121**] Eight. The patient is to arrive
at 9 a.m. The patient is to follow up with ears, nose and
throat, Dr. [**Last Name (STitle) 103444**], and is to follow up with neurology, Dr.
[**Last Name (STitle) **] in one month.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4987**]
Dictated By:[**Last Name (NamePattern1) 25643**]
MEDQUIST36
D: [**2184-7-8**] 13:08
T: [**2184-7-8**] 14:28
JOB#: [**Job Number 103445**]
rp07/19/2002mas
cc:[**Hospital3 **]
|
[
"518.82",
"571.2",
"572.2",
"482.41",
"464.31",
"780.39",
"507.0",
"789.5",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.72",
"38.91",
"96.07",
"98.14",
"42.33",
"87.69",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13962, 14041
|
14062, 14216
|
14239, 15077
|
10906, 13940
|
15102, 15743
|
15755, 16478
|
941, 1840
|
163, 918
|
3706, 4853
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,229
| 139,367
|
46666
|
Discharge summary
|
report
|
Admission Date: [**2143-5-7**] Discharge Date: [**2143-5-13**]
Date of Birth: [**2077-3-6**] Sex: F
Service: CCU
CHIEF COMPLAINT: Near syncope.
HISTORY OF PRESENT ILLNESS: This is a 66-year-old female
with multiple medical problems who was brought to the
Emergency Room after complaining of fatigue and slumping over
in the chair, although reportedly not losing consciousness
per her family.
She was last dialyzed on Saturday, and upon reaching the
Emergency Room, the patient was found to be in wide complex
bradycardia without discernable P-waves, question of complete
heart block with an increased potassium. She was treated
with Glucagon Insulin, D50, Bicarbonate, Atropine, and
Calcium Gluconate.
At the time of initial presentation, her heart rate was in
the 30s with a blood pressure of 70/30. After treatment, she
returned to narrow complex atrial rhythm at a rate of 50.
Her blood pressure remained low. Chest x-ray showed
congestive heart failure. Dopamine was started.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post coronary artery bypass grafting in [**2132**] with LIMA to
left anterior descending and saphenous vein graft to
posterior descending artery. She is also status post
catheterization with a stent to the left circumflex in [**2135**],
and is status post catheterization in [**2140**] showing patent
grafts. Most recent cardiac catheterization in [**2143-3-28**]
showed elevated right and left-sided filling pressures with
prominent V-wave and pulmonary capillary wedge pressure
tracing, preserved cardiac output, left main coronary artery
with a 95% hazy lesion extending into the proximal left
circumflex. It also showed secondary pulmonary hypertension,
hemiballismus. 2. History of ventricular tachycardia for
which Amiodarone was started. 3. Left ventricular thrombus.
4. Congestive heart failure with an ejection fraction of
25-30% which was recently decreased to 15%. Question of
apical akinesis as well. 5. Hypertension. 6.
Hyperlipidemia. 7. Severe mitral regurgitation. 8.
End-stage renal disease on hemodialysis times two months.
She is dialyzed Tuesday, Thursday and Saturday. 9. History
of cerebrovascular accident with questionable residual right
upper extremity weakness in the presence of hemiballismus in
the acute setting. Reportedly the cerebrovascular accident
is a 3 cm left parietal infarction. 10. Chronic obstructive
pulmonary disease. 11. Diabetes mellitus, dependent on
Insulin. 12. Meniere's disease. 13. Osteoarthritis.
MEDICATIONS ON ADMISSION: Amiodarone 400 gravida p.o. q.d.,
Warfarin 5 mg p.o. q.h.s., .................. 75 mg p.o.
t.i.d., Lipitor 40 mg p.o. q.h.s., Plavix 75 mg p.o. q.d.,
Losartan 50 mg p.o. q.d., Atenolol 25 mg p.o. q.d.,
Isosorbide Dinitrate 30 mg p.o. t.i.d., Elavil 10 mg p.o.
q.h.s., Albuterol inhaler p.r.n., Meclizine 25 mg p.o.
t.i.d., Gabapentin 100 mg p.o. q.h.s., Combivent inhaler
p.r.n., Remegel 800 mg p.o. q.d., Nephrocaps 1 tab p.o. q.d.,
Colace 100 mg p.o. b.i.d., Glargine 20 U q.a.m., 10 U q.h.s.,
regular Insulin sliding scale.
ALLERGIES: ASPIRIN, CAPTOPRIL; THE PATIENT CANNOT REMEMBER
HER REACTIONS TO THESE MEDICATIONS. MORPHINE SULFATE
REPORTEDLY CAUSES ANAPHYLAXIS.
SOCIAL HISTORY: She has a 60 pack-year of tobacco; the
patient has quit.
PHYSICAL EXAMINATION: Vital signs: On admission temperature
was 97.1??????, blood pressure 93/48, respirations 17, pulse 64,
oxygen saturation 97% on 2 L nasal cannula. General: The
patient was somnolent but arousable, barely coherent.
Cardiovascular: Regular, rate and rhythm. Barely audible
heart sounds. No peripheral edema. Positive jugular venous
distention. Pulmonary: Lungs coarse with diffuse rales.
Abdomen: Soft, nontender, nondistended. Neurological: No
focal or neurological deficits. Somnolent but arousable.
LABORATORY DATA: White blood cell count 10.1, hematocrit
33.8, platelet count 258; INR 2.8; potassium 5.0, this
potassium was obtained after treatment for a hemolyzed
potassium of 7.9, creatinine 10.1, BUN 66, glucose 194,
magnesium 2.7, calcium 9.2, sodium 135, CK 42, MB not
applicable.
Electrocardiogram showed non-sinus atrial rhythm.
Chest x-ray showed congestive heart failure with bilateral
effusions.
HOSPITAL COURSE: 1. Arrhythmia: His bradycardia and
hypertension was attributed to a combination of Amiodarone
and beta-blocker used in the setting of end-stage renal
disease with hyperkalemia. Withholding of Amiodarone and
beta-blocker together with treatment of hyperkalemia and
dialysis allowed the patient to return to normal sinus
rhythm.
Dopamine was initially required to maintain a heart rate
greater than 50 and to maintain an adequate blood pressure.
It should be noted that the patient has had in the recent
past a subclavian to subclavian graft constructed in her left
upper pectoral/anterior deltoid region. This anatomy results
in a falsely low blood pressure in the left arm, both by
manual cuff and by arterial line. Manual blood pressure
taken on the right arm is consistently about 20 points
systolic higher than a blood pressure taken on the left and
correlates better with clinical status. It is recommended
that in the future, the right arm be used for blood pressure
readings.
After return of heart rhythm to normal sinus at a normal
rate, the patient still required Dopamine for blood pressure
support. It is unclear how much of this blood pressure
support was necessary given that the story behind the blood
pressure discrepancy had not yet been discovered, and the
patient was likely in early sepsis, as described below.
After a couple of days of antibiotics and monitoring of her
blood pressure in the right arm, the patient was able to be
weaned off Dopamine without problem. Amiodarone and
beta-blocker were held throughout the hospitalization, and
she remained in sinus rhythm at a normal rate for the rest of
the duration of the hospitalization.
2. Fluid status: The patient is essentially aneuric. She
became hypoxic on the morning after admission secondary to
pulmonary edema failure. She was briefly intubated, both for
airway protection and to provide adequate oxygenation until
she can be dialyzed. After dialysis, she was weaned to
pressure support and extubated. She was continued on
hemodialysis while in-house every other day with removal of
2.0-2.5 L of fluid by ultrafiltrate at each dialysis session.
She was followed by Nephrology while in-house and was
continued on Nephrocaps while her Remegel was increased to
t.i.d. with meals, and she was also started on PhosLo. She
was also eventually placed on a 2 g sodium diet with a 1500
cc/day fluid restriction. She did have one other episode
prior to her dialysis on [**2143-5-11**], where she became very
dyspneic just prior to her dialysis. Dialysis with removal
of fluid allowed for complete resolution of these symptoms.
3. Sepsis: After the patient was able to maintain herself
in sinus rhythm at a normal rate, she required Dopamine for
blood pressure support as indicated above. During this time,
she spiked a temperature to 104?????? and developed a leukocytosis
to 18. She was empirically started on Vancomycin and
Levaquin, both dosed renally.
After about five days, her Vancomycin was discontinued, and
she was continued on Levaquin. There was marked clinical
improvement after 48 hours on antibiotics. A respiratory
source was suspected, as blood cultures remained negative,
urine cultures remained negative, and one respiratory culture
showed rare growth of .................. She will be
continued on renally dosed Levaquin through [**2143-5-18**], to
complete a 10-day course.
4. Anticoagulation: The patient is maintained on Coumadin
as an outpatient for her left ventricular thrombus. When
started on Levaquin, her INR became supratherapeutic. Her
Coumadin was intermittently held to allow return of her INR
to a therapeutic range.
On the day of discharge after holding her Coumadin for two
out of the three previous nights, her INR was still 4.1. She
is following up in two days with her primary care physician.
[**Name10 (NameIs) **] Coumadin will be held at discharge, and she will receive
5 mg p.o. Vitamin K prior to leaving the hospital.
5. Hyperkalemia: A Nutrition consult was called to discuss
a proper renal diet with the patient. She was advised to
stay away from foods that were high in potassium, given the
implication of hyperkalemia and the etiology of her symptoms
causing this hospitalization.
6. Coronary artery disease: Given that the patient is
allergic to Aspirin, she was started on ...................
Her Lipitor and Plavix were continued. Given that her blood
pressure remained on the low side of normal throughout her
hospitalization with a normal sterile fashion and rate, her
Atenolol, Isosorbide Dinitrate and Losartan were not
restarted.
7. Diabetes: Glucose control was initially difficult, and
while on the ventilator, the patient was maintained on an
Insulin drip. This was converted to a sliding scale and
eventually converted back to her home dose of Glargine 20 in
the morning and 10 at night with a sliding scale. Adequate
glucose control was achieved.
DISCHARGE STATUS: The patient is stable for discharge home
with visiting nurse and home physical therapy.
FOLLOW-UP: She will follow-up with her primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4251**] on Wednesday, [**2143-5-15**], at noon.
This appointment has been scheduled. She will also follow-up
with her cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2143-6-12**],
at 11:30; this appointment has also been scheduled. She was
last dialyzed on the day of discharge, [**2143-5-13**], and is
to resume her hemodialysis on Tuesday, [**2143-5-14**], as an
outpatient.
DISCHARGE INSTRUCTIONS: She is to be discharged on a 2 g/day
sodium-limited diet, as well as a 1500 cc/day fluid
restriction. She was also advised about avoiding high
potassium foods. She was advised not to restart her Elavil,
Gabapentin, Meclizine, ................., Isosorbide
Dinitrate, Atenolol or Losartan until authorized to do so by
Dr. [**Last Name (STitle) **] and/or Dr. [**Last Name (STitle) 4251**].
The patient was also advised not to restart her Amiodarone.
She will not resume taking her Coumadin until authorized to
do so by her primary care physician. [**Name10 (NameIs) **] is because her INR
was 4.1 on the day of discharge.
DISCHARGE MEDICATIONS: Lipitor 40 mg p.o. q.d., Plavix 75 mg
p.o. q.d., .................. 200 mg p.o. b.i.d., Remegel 800
mg p.o. t.i.d. with meals, PhosLo 2 tab p.o. t.i.d. with
meals, Nephrocaps 1 cap p.o. q.d., Colace 100 mg p.o. q.d.,
Albuterol inhalers p.r.n., Combivent inhalers p.r.n.,
Protonix 40 mg p.o. q.d., Levofloxacin 250 mg p.o. q.o.d., to
be started the evening of [**2143-5-14**], last dose to be
taken [**2143-5-18**].
DISCHARGE DIAGNOSIS:
1. Symptomatic bradycardia and hypotension secondary to
Amiodarone and beta-blocker use in the setting of end-stage
renal disease and hyperkalemia.
2. Sepsis of unknown etiology.
3. End-stage renal disease on hemodialysis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 99067**]
MEDQUIST36
D: [**2143-5-13**] 13:51
T: [**2143-5-13**] 15:02
JOB#: [**Job Number 99068**]
|
[
"V45.81",
"424.0",
"496",
"038.9",
"403.91",
"458.2",
"276.7",
"428.0",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"37.78",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10540, 10956
|
10977, 11484
|
2572, 3246
|
4289, 9865
|
9890, 10516
|
3344, 4271
|
152, 167
|
196, 1011
|
1034, 2545
|
3263, 3321
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,655
| 155,867
|
10889
|
Discharge summary
|
report
|
Admission Date: [**2197-4-9**] Discharge Date: [**2197-4-14**]
Date of Birth: [**2163-8-26**] Sex: F
Service: #58
CHIEF COMPLAINT: Infected AV graft.
HISTORY OF PRESENT ILLNESS: This is a 33 year-old woman with
a history of end stage renal disease who is currently being
dialyzed from a left upper arm AV graft. The patient
lethargy and mental status changes for the last 24 hours.
She was febrile to 102.7 Fahrenheit at home. She also noted
some episodes of feeling cold approximately a week ago. She
has been eating sporadically over the last couple of days,
but denies any nausea or decreased appetite. She denies any
neck stiffness or cough.
disease secondary to lithium toxicity. The patient had a
cadaveric kidney transplant in [**2196-6-17**] that was removed
in [**2196-12-17**]. She has post transplant lymphoma that has
been treated with Rituxan, hypertension,
history of bowel perforation likely secondary to her PTLD that
required a small bowel resection and bipolar
disorder.
MEDICATIONS ON ADMISSION: Depakote 1000 mg b.i.d.,
Olanzapine 10 mg b.i.d., Protonix 40 mg q.d., Nephrocaps one
q.d., Klonopin 1 mg q.h.s., folate 100 mg q.d., iron 325 mg
t.i.d., magnesium oxide 800 mg b.i.d., zinc 200 mg q day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: This is a ill appearing woman in mild
distress secondary to pain and rigors. Temperature 99
degrees. Pulse 124. Blood pressure 112/68. Oxygen
saturation 98% on room air. Examination of the head, eyes,
ears, nose and throat revealed pupils are equal, round and
reactive to light. Oropharynx was without lesion. neck was
supple without lymphadenopathy. Lungs were clear to
auscultation. Heart was tachycardic and regular with a 2 out
of 6 systolic ejection murmur. Examination of the abdomen
revealed it was mildly obese. There was mild tenderness to
palpation in the epigastrium and hypoactive bowel sounds.
There is a well healed midline scar. No masses or hernias
are noted. Examination of the extremities revealed erythema
and warmth over the left upper arm AV fistula with an eschar
present in the center of the erythematous area. There was an
intact thrill in the AV fistula and a left upper extremity
was neurovascularly intact. There was mild bilateral pedal
edema. A Port-a-cath was in place on the right side. On
neurological examination the patient was oriented, but
somewhat tangential. There were no focal findings.
LABORATORIES ON ADMISSION: White blood cell count4.3,
hematocrit 34, platelets 187, sodium 141, potassium 4.9,
chloride 104, bicarb 27, BUN 36, creatinine 68, glucose 97,
calcium 10.1, magnesium 1.8, phos .8. Chest x-ray showed no
infiltrate and abdominal x-ray and electrocardiogram were
unremarkable.
HOSPITAL COURSE: The patient was initially admitted to the
floor. She was treated with Vancomycin and Gentamycin in the
Emergency Department. She was taken to the Operating Room
shortly after admission for removal of the AV graft. This
was performed and a small residual cuff of Gortex was left in
place on the arterial and the venous side. A left IJ Quinton
catheter was also inserted. The wound was left open and
packed with Betadine soaked gauze. Postoperatively, the
patient was admitted to the MICU where she was
hemodynamically stable and afebrile with improved mental
status. The following day she was transferred to the regular
floor. Cultures from the resected AV graft revealed 4+ coag
positive staph. Blood cultures were negative. The patient
underwent dialysis via the left IJ Quinton catheter, however,
flow rates were very poor and eventually stopped completely.
Therefore the patient was taken to VIR on hospital day number
five and underwent placement of a tunneled dialysis catheter
in the right IJ. She remained afebrile and the erythema and
edema on the left upper extremity decreased each day.
Dressings changes were performed three times a day with
Betadine gauze.
The patient continued to have stable electrolytes. She was
dosed with Vancomycin as needed to maintain levels greater
then 15. Her psychiatric status also remained stable on her
current medication regimen. On hospital day number six the
patient had no evidence of active infection at the site of
the graft removal. She had been afebrile and hemodynamically
stable since the time of her operation and her dialysis was
working well through the VIR placed catheter and it was
decided that she was stable for discharge to home. It should
also be noted that she did undergo a duplex ultrasound
looking for a venous thrombosis in the left subclavian and
this was negative.
DISCHARGE DIAGNOSIS:
AV graft infection.
DISCHARGE PLAN: The patient will be discharged to home. She
will be discharged on her previous medications of folate one
tablet po q day, iron 325 mg t.i.d., magnesium oxide 800 mg
b.i.d., zinc 200 mg q.d., Divalproex sodium 1000 mg po
b.i.d., Olanzapine 10 mg b.i.d., Pantoprazole 40 mg q 24,
Nephrocaps one q.d., Clonazepam 1 mg po q.h.s. and
Vancomycin, which will be given in dialysis for a total two
week course. She will also receive twice a daily wet to dry
saline gauze dressing changes to the left upper arm until
healed and she will resume a regular renal diet.
CONDITION ON DISCHARGE: Stable.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Doctor Last Name 16885**]
MEDQUIST36
D: [**2197-4-14**] 09:59
T: [**2197-4-14**] 10:15
JOB#: [**Job Number 35436**]
cc:[**First Name (STitle) 35437**]
|
[
"272.0",
"401.9",
"038.9",
"585",
"285.21",
"296.7",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.43",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
4654, 4675
|
1043, 1286
|
2779, 4633
|
1309, 2468
|
148, 168
|
197, 1016
|
2483, 2761
|
4692, 5251
|
5276, 5589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,073
| 121,411
|
53577
|
Discharge summary
|
report
|
Admission Date: [**2159-4-30**] Discharge Date: [**2159-5-10**]
Date of Birth: [**2119-9-15**] Sex: F
Service: SURGERY
Allergies:
Vasotec
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted for weight reduction surgery.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Bypass
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 264.5 lbs as
of
[**2158-12-25**] (her initial screen weight on [**2158-8-15**] was 261.6 lbs),
height of 66 inches and BMI of 42.8. Her previous weight loss
efforts have included mostly her own diets and [**Street Address(1) 110097**]
at [**Last Name (un) **] Diabetes Center. She has not participated in formal
weight loss programs, commercial diet programs, used
prescription
weight loss medications or taken over-the-counter
ephedra-containing appetite suppressants or herbal supplements.
Her weight at age 21 was 130 lbs with her lowest adult weight
128 lbs and her highest weight being 266 lbs in [**Month (only) 404**] of this
year. She weighed 240 lbs one year ago. She stated that she
developed significant [**Last Name 4977**] problem at age 26 but has been
struggling hard with her weight past 8 years. Factors
contributing to her excess weight include large portions, too
many fats and lack of exercise. She denied history of eating
disorders or depression.
Past Medical History:
1)Nonalcoholic steatohepatitis
2)Insulin dependent DM: Questionable Type I or Type II. Patient
was diagnosed 6 years ago, but has had an episode of DKA.
3)Diabetitic nephropathy
4)HTN
5)Sleep Apnea
6)GERD
7)Psoriasis
8)Cholecystitis s/p lap chole [**2152-2-19**]
9)S/P ERCP and sphincterotomy
Social History:
Patient lives at home with her parents, husband, and two
children (age 4 and 1). Patient is a house wife, and her
husband is a waitor at a chinese restaurant. Patient denies
tobacco, alcohol or drug use.
Family History:
Family history of diabetes: father, paternal grandmother and
grandfather. Maternal grandmother with [**Name2 (NI) 499**] cancer.
Physical Exam:
Her blood pressure was 122/82, pulse 100 and O2 saturation 97%
on
room air. On physical examination [**Known firstname **] was casually dressed and
in no distress. Her skin was warm, dry, + acanthosis nigricans,
very mild hirsutism, mild acne and cushingoid appearance.
Sclerae
were anicteric, conjunctiva clear, pupils were equal round and
reactive to light, fundi with slightly blurry optic discs,
mucous
membranes were moist, tongue pink and the oropharynx was without
exudates or hyperemia. Trachea was in the midline and the neck
was supple with no adenopathy, thyromegaly or carotid bruits.
Chest was symmetric and the lungs were clear to auscultation
bilaterally with good air movement. Cardiac exam was slightly
tachycardic rate, normal rhythm, normal S1 and S2, no murmurs,
rubs or gallops. The abdomen was obese but soft and non-tender,
non-distended with normal bowel sounds, no masses or
organomegaly, no hernias, there were well-healed trocar scars.
Curvature of back was normal with no spinal tenderness or flank
pain. Lower extremities were without edema venous insufficiency
or clubbing. There was no evidence of swelling of the joints or
joint inflammation. There were no focal neurological deficits
except for very mild decrease sensation lower extremities, motor
and her gait were normal.
Pertinent Results:
[**2159-4-30**] 05:28PM BLOOD Hct-30.7*#
[**2159-5-1**] 07:30AM BLOOD WBC-11.0 RBC-3.45* Hgb-10.3* Hct-30.2*
MCV-87 MCH-29.8 MCHC-34.1 RDW-15.2 Plt Ct-194
[**2159-5-2**] 02:21AM BLOOD WBC-12.5* RBC-3.08* Hgb-9.1* Hct-26.6*
MCV-87 MCH-29.5 MCHC-34.1 RDW-15.0 Plt Ct-180
[**2159-5-3**] 02:58AM BLOOD WBC-12.0* RBC-3.15* Hgb-9.7* Hct-27.8*
MCV-88 MCH-30.9 MCHC-35.0 RDW-14.5 Plt Ct-197
[**2159-5-4**] 03:06AM BLOOD WBC-10.1 RBC-3.19* Hgb-9.6* Hct-28.0*
MCV-88 MCH-30.2 MCHC-34.4 RDW-14.0 Plt Ct-192
[**2159-5-1**] 01:12AM BLOOD Glucose-307* UreaN-17 Creat-0.8 Na-136
K-4.8 Cl-106 HCO3-22 AnGap-13
[**2159-5-4**] 03:06AM BLOOD Glucose-111* UreaN-7 Creat-0.4 Na-143
K-3.7 Cl-103 HCO3-32 AnGap-12
[**2159-5-1**] 01:12AM BLOOD Calcium-8.4 Phos-4.6* Mg-1.4*
[**2159-5-4**] 03:06AM BLOOD Calcium-8.3* Phos-1.7* Mg-2.1
[**2159-4-30**] 07:34AM BLOOD pO2-49* pCO2-46* pH-7.41 calTCO2-30 Base
XS-3 Intubat-NOT INTUBA
[**2159-5-3**] 04:26PM BLOOD Type-ART pO2-99 pCO2-57* pH-7.42
calTCO2-38* Base XS-9
[**2159-5-1**] 03:23PM BLOOD Glucose-121* Lactate-1.5 Na-137 K-4.2
Cl-102
[**2159-5-4**] 06:49AM BLOOD Lactate-1.1 Na-141 K-4.5 Cl-99*
[**2159-4-30**] 07:34AM BLOOD Hgb-13.9 calcHCT-42
[**2159-5-1**] 03:23PM BLOOD Hgb-10.5* calcHCT-32 O2 Sat-81
[**2159-4-30**] 07:34AM BLOOD freeCa-1.21
[**2159-5-3**] 04:26PM BLOOD freeCa-1.11*
Brief Hospital Course:
Patient admitted and underwent a laparoscopic gastric bypass.
Immediately postop, patient became hypotensive with heartrate in
the 140's. Patient was taken emergently back to the operating
room and exploratory laparotomy was performed with clot found
but no active bleeding noted. Postoperatively patient was taken
to the intensive care unit. [**Unit Number **] units of packed red blood cells
were given.
Patient remained intubated and closely monitored in the
intensive care unit for 3 days where she was extubated. Patient
had periods of confusion and delirium treated with haldol prn.
On postoperative day 5 patient attempted to get out of bed by
herself and fell. CT if the head was done with no active bleed
shown. Patient was also noted to have left upper extremity
weakness. Neurology consulted - MRI was done. It is thought this
is a probable brachial plexus injury.
On postoperative day 6 patient was transferred to the regular
floor. Physical therapy and occupational therapy was consulted.
There was some leakage from the bottom part of her incision that
was clear to pink. Dry dressings were applied and white count
was monitored. Patient was progressed to bariatric stage 3 with
good tolerability.
We will discharge to home today with VNA to check her wound and
PT/OT for ambulation and progressive strengthening of her left
arm. She will also follow up with her primary care provider and
with Dr. [**Last Name (STitle) 49**] in 2 weeks.
Medications on Admission:
Cozaar 150 mg daily for hypertension; NPH
insulin 100 units twice a day, Regular insulin 4 times a day per
sliding scale, Actos 45 mg daily for diabetes; Ursodiol 500 mg
twice a day for NASH; Omeprazole 20 mg twice a day for GERD;
Simvastatin 40 mg daily for dyslipidemia; Baby aspirin 81 mg
daily for cardiac prophylaxis; Multivitamins with minerals
daily,
Vitamin D and Folate/vitamin B12/vitamin B6 (METANX) twice daily
for nutritional supplementation; Ibuprofen and Tylenol as needed
Discharge Medications:
1. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: please
take for one month.
Disp:*600 ml* Refills:*0*
2. Roxicet 5-325 mg/5 mL Solution Sig: [**6-10**] ml PO every four (4)
hours as needed for pain.
Disp:*500 ml* Refills:*0*
3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as
needed for constipation.
Disp:*500 ml* Refills:*0*
4. Cozaar 100 mg Tablet Sig: 1.5 Tablets PO once a day: Please
crush.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
6. medication
resume multivits, check your blood sugars 4 x a day and take
only regular insulin per sliding scale provided, hold your
actos, aspirin and omeprazole.
Please follow up with your primary care provider/endocrinologist
in one week to review your blood sugars and medications.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis: Obesity
Discharge Condition:
Stable
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
5. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**11-15**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2159-5-16**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2159-5-16**] 2:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2159-6-27**] 3:00
Please follow up with your primary care provider in one week and
as needed to review all medications and make necessary
adjustments.
If your L upper extremity does not improve please feel free to
call your neurologist Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 541**].
Completed by:[**2159-5-10**]
|
[
"278.01",
"706.1",
"327.23",
"256.4",
"696.1",
"293.0",
"583.81",
"571.8",
"530.81",
"701.2",
"573.8",
"998.11",
"250.40",
"300.00",
"E878.2",
"285.1",
"353.0",
"518.5",
"V58.67",
"401.9",
"458.29",
"V85.4",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.38",
"54.21",
"54.11",
"54.4",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7599, 7656
|
4793, 6250
|
313, 355
|
7727, 7736
|
3452, 4770
|
9780, 10592
|
1978, 2109
|
6792, 7576
|
7677, 7677
|
6276, 6769
|
7784, 8350
|
2124, 3433
|
227, 275
|
9423, 9757
|
383, 1421
|
7696, 7706
|
8375, 9411
|
1443, 1738
|
1754, 1962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,252
| 167,437
|
18305
|
Discharge summary
|
report
|
Admission Date: [**2180-9-25**] Discharge Date: [**2180-9-29**]
Date of Birth: Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 50463**] was an 83-year-old
female with a history of polymyalgia rheumatica,
hypercholesterolemia, hypothyroidism, vertigo, postural
hypotension, and a history of syncope in the past who now is
on Florinef and presented to [**Hospital1 **] [**Location (un) 620**]
emergency department on [**2180-9-22**] after a syncopal episode
at home. She reported that she passed out after urinating
while on the toilet. She awoke and called her primary care
physician, [**Name10 (NameIs) 1023**] evaluated her in the office and suspected
dehydration, rehydrated her with fluids, and sent her home.
At home she continued to feel poorly, and her primary care
physician told her to return to the Emergency Department. At
[**Location (un) 620**] emergency department on [**2180-9-23**] EKG revealed
polymorphic ventricular tachycardia with rate in the 130s and
blood pressure in the 140s to 150s/60s. She was afebrile at
this time.
Labs in the Emergency Room revealed a potassium of 2.7 and
magnesium of 1.6. She was given electrolyte repletion and
her ventricular tachycardia spontaneously converted to sinus
rhythm. She had normal cardiac enzymes and a normal chest
x-ray. She was admitted on the morning after admission and
was seen by Electrophysiology, who recommended a Lidocaine
drip. Despite avid electrolyte repletion, her potassium
remained low, and a right internal jugular central line was
placed on [**2180-9-23**] for further resuscitation. Later that
evening her oxygen saturations dropped to the 60s or 70s, and
a post central line placement chest x-ray revealed no
evidence of pneumothorax but evidence of pulmonary edema.
She was placed on 100% non-rebreather and her sats improved
to 80 to 100%. An ABG at this time showed a pH of 7.36, CO2
of 54, and PA of 53. Potassium was 3.5 at this time.
A decision was made to give 20 mg of intravenous Lasix, and
she put out 620 cc of urine, but her sats continued to be 80
to 100%. Repeat ABG still revealed persistently low
oxygenation. Decision was made to intubate. The patient was
placed on AC at the rate of 10 with a tidal volume of 500 and
FIO2 of 100% and PEEP of 5. Recheck of an ABG still showed
poor oxygenation with [**MD Number(3) 50464**], and decision was made to
transfer her to [**Hospital6 256**] for
further management due to failure of oxygenation.
She was transferred, intubated, and a Lidocaine drip and
received 100 mg of Fentanyl and 50 mg of Versed.
BRIEF HOSPITAL COURSE: Ms. [**Known lastname 50463**] was transferred to [**Hospital1 18**]
on [**2180-9-25**]. The initial feeling was that she most likely
was in pulmonary edema, leading to poor oxygenation due to
aggressive fluid and electrolyte replacement at [**Location (un) 620**]. She
was ........... diuresed, and was successfully extubated on
[**2180-9-27**], however, became febrile with known MSSA in her
sputum, however, was persistently febrile despite treatment
with Levofloxacin, Vancomycin, and Flagyl. Call for concern
of aspiration pneumonia. She also had an elevated white
count with evidence of bandemia.
On [**2180-9-29**] she also developed a decreased urine output in
the setting of febrile illness, and there was concern for
sepsis. Her urine output continued to climb despite fluid
boluses. Her volume status was unclear but most likely
representative of total body fluid overload with decreased
intervascular volume, and plans were made for placement of a
PA catheter.
Despite concern for sepsis, her mental status continued to
improve from the time of admission. However, the house
officers called on [**2180-9-29**] in the afternoon due to
decreased mental status, tachypnea, bradycardia, and
hypotension. Passed away on [**2180-9-29**] at 15:50. She had
been made "Do Not Resuscitate"/ "Do Not Intubate" at the time
of admission. No resuscitative measures were done. Her
family was immediately [**Name (NI) 653**], and the Attending was
present. No autopsy was requested. Immediate cause of death
was pneumonia/adult respiratory distress syndrome with other
causes including renal failure and cardiac arrest.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**], M.D. [**MD Number(1) 1178**]
Dictated By:[**Last Name (NamePattern1) 9820**]
MEDQUIST36
D: [**2181-1-4**] 12:06
T: [**2181-1-4**] 15:18
JOB#: [**Job Number 50465**]
|
[
"482.41",
"518.81",
"276.6",
"427.5",
"276.0",
"584.9",
"263.9",
"427.89",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2642, 4538
|
157, 2618
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,709
| 170,283
|
8764+8765
|
Discharge summary
|
report+report
|
Admission Date: [**2110-7-4**] Discharge Date: [**2110-7-17**]
Date of Birth: [**2046-12-20**] Sex: M
Service:
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS:
1. Coumadin 4 mg q.d.
2. Lasix 80 mg q.d.; b.i.d.
3. Lasix 20 mEq to 40 mEq q.d.
4. Lopressor 25 mg b.i.d.
5. Glucophage 500 mg q.d.
6. Serzone 100 mg b.i.d.
7. BuSpar 5 mg q.three.
8. Zantac 150 mg b.i.d.
9. Ambien 5 mg q.h.s.
10. Lipitor 10 mg q.d.
11. Synacort one puff q.d.
12. Colace 100 mg b.i.d.
13. Flomax 0.4 mg q.d.
14. Oxycodone p.r.n.
15. Aspirin 85 mg q.d.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Chronic obstructive pulmonary disease.
3. Diabetes mellitus type 2.
4. Hypertension.
5. Depression.
PAST SURGICAL HISTORY:
1. Status post cholecystectomy, open.
2. Aortic valve replacement.
3. Mitral valve replacement, 5/[**2109**].
4. Permanent pacemaker placement, 5/[**2109**].
HISTORY OF THE PRESENT ILLNESS: The patient is a 63-year-old
gentleman, well known to Cardiothoracic Surgery status post
AVR and MVR (both mechanical on [**2110-3-10**] by Dr. [**Last Name (STitle) 70**].
The patient did well for a few weeks, but then developed
shortness of breath. The patient had bilateral pleural
effusions. He had talc pleurodesis six weeks to eight weeks
prior to admission by Dr. [**Last Name (STitle) 952**]. Prior to discharge, the
patient had increased shortness of breath. Echocardiogram,
on the date of admission, showed pericardial effusion. The
patient presented to [**Hospital1 69**] for
treatment.
PHYSICAL EXAMINATION: Examination revealed the vital signs
as follows: Temperature 97.9, pulse 101 and regular, blood
pressure 104/78, respiratory rate 20, saturation 96% on two
liters. NECK: Supple, no bruits. CARDIOVASCULAR: Regular
rate and rhythm. RESPIRATORY: Coarse breath sounds,
decreased breath sounds at bilateral bases. ABDOMEN: Soft
and nontender, nondistended. EXTREMITIES: 1+ bilateral
edema.
LABORATORY DATA: Labs on admission revealed the following:
White blood cells 7.4, hematocrit 37.8, platelet count
281,000, PT 21.5, PTT 34.2, [**Hospital1 263**] 3.2, sodium 135, potassium
4.0, chloride 96, bicarbonate 30, BUN 14, creatinine 11.0,
blood glucose 183.
HOSPITAL COURSE: The patient was admitted to the Thoracic
Surgery Department. On admission, the Coumadin was held and
the patient was started on heparin drip for anticoagulation.
On hospital day #2, the patient's condition was unchanged.
Some respiratory difficulties were as follows: Coarse sounds
bilaterally.
On hospital day #3, the patient was given vitamin K to
reverse the anticoagulation status. The patient still had
some shortness of breath.
On hospital day #4, the patient's condition remained
unchanged. The patient had heparin drip for anticoagulation.
On hospital day #5, the patient was taken to the operating
room, where left VADC and cardiac window was performed by
Dr. [**Last Name (STitle) 952**]. The operation went without complications; 450
cc of fluid was drained from the pericardium. One
pericardial and two chest tubes were placed in the operating
room. The patient was transported to the PACU in stable
condition. Overnight in the PACU the patient initially did
well, however, the patient started developing agitation. The
patient was taking swings at the nurse. He had to be
physical restrained and chemically restrained with Midazolam
to which he responded well. Also, on postoperative day #1,
the patient was taken for bronchoscopy. We found moderate
amount of thick, white secretions in both lungs and this was
suctioned to clear airway. The patient was in respiratory
distress and required Neo for his blood pressure. The
patient was transported to the SICU for further management
and observation.
On postoperative day #2, the patient remained agitated,
requiring chemical and physical restraints. The patient was
started on Coumadin and extensive diuresis.
On postoperative day #3, the patient was weaned off Neo and
started on Coumadin.
On postoperative day #4, the patient's postoperative delirium
almost resolved. He required minimal sedation and pain
medication. He was transferred to the floor in stable
condition.
The patient's mental status was back to normal, but he did
complain of feeling tired, weak, and sleepy. Also, on
postoperative day #5, the patient's PCA was discontinued.
The patient's chest tube was also removed without
complications. He was started on Percocet and Ibuprofen for
pain.
On postoperative day #6, the patient remained stable. [**Last Name (STitle) 263**]
increased to 3.4 and the heparin drip was discontinued. The
patient continued ambulation, exercise, and physical therapy.
On postoperative day #7, the patient remained stable while
exercising with PT. The [**Last Name (STitle) 263**] was 4.3 and he was discharged
home with a visiting nurse in stable condition.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg b.i.d..
2. Metformin 500 mg q.d.
3. Nefazodone 100 mg b.i.d.
4. BuSpar 5 mg t.i.d.
5. ....................5 mg q.h.s.p.r.n.
6. Atorvastatin 10 mg q.d.
7. Flovent 110 mcg two puffs b.i.d.
8. Tamsulosin 0.4 mg q.h.s.
9. Aspirin 81 mg q.d.
10. Milk of Magnesia 30 cc q.8.p.r.n.
11. Lasix 80 mg PO b.i.d.
12. Percocet 1 to 2 tablets PO q.4h.to 6h.p.r.n. pain.
13. Ibuprofen 600 mg PO q.6h.p.r.n.
14. Ranitidine 150 mg PO b.i.d.
15. Docusate 100 mg PO b.i.d.
16. Potassium chloride 20 mEq PO b.i.d.
17. Coumadin 2 mg PO q.d. (hold on [**2110-7-16**]).
18. Guaifenesin cough drops q.4h.p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged home with
[**Hospital6 **] for blood draws and wound check.
The patient should hold his Coumadin on the date of discharge
([**2110-7-16**]). The patient's [**Year (4 digits) 263**] should be drawn daily for a
week and results should be sent to the patient's primary care
physician (Dr. [**Last Name (STitle) 1159**]. The patient's potassium should be
checked on [**2110-7-18**]. The patient should be Dr. [**Last Name (STitle) 1159**] in 7 to
10 days for [**Last Name (STitle) 263**] and electrolyte check, as well Coumadin-dose
adjustment. The patient will followup with Dr. [**Last Name (STitle) 952**] in two
weeks in his clinic.
DISCHARGE DIAGNOSES: Coronary artery disease, chronic
obstructive pulmonary disease, DM2 depression started on AVR,
MVR pacemaker placement status post left pleural effusion.
Pericardial window.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern4) 28894**]
MEDQUIST36
D: [**2110-7-16**] 14:37
T: [**2110-7-16**] 15:19
JOB#: [**Job Number **]
Admission Date: [**2110-7-4**] Discharge Date: [**2110-7-17**]
Date of Birth: [**2046-12-20**] Sex: M
Service:
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS:
1. Coumadin 4 mg q.d.
2. Lasix 80 mg q.d.; b.i.d.
3. Lasix 20 mEq to 40 mEq q.d.
4. Lopressor 25 mg b.i.d.
5. Glucophage 500 mg q.d.
6. Serzone 100 mg b.i.d.
7. BuSpar 5 mg q.three.
8. Zantac 150 mg b.i.d.
9. Ambien 5 mg q.h.s.
10. Lipitor 10 mg q.d.
11. Synacort one puff q.d.
12. Colace 100 mg b.i.d.
13. Flomax 0.4 mg q.d.
14. Oxycodone p.r.n.
15. Aspirin 85 mg q.d.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Chronic obstructive pulmonary disease.
3. Diabetes mellitus type 2.
4. Hypertension.
5. Depression.
PAST SURGICAL HISTORY:
1. Status post cholecystectomy, open.
2. Aortic valve replacement.
3. Mitral valve replacement, 5/[**2109**].
4. Permanent pacemaker placement, 5/[**2109**].
HISTORY OF THE PRESENT ILLNESS: The patient is a 63-year-old
gentleman, well known to Cardiothoracic Surgery status post
AVR and MVR (both mechanical on [**2110-3-10**] by Dr. [**Last Name (STitle) 70**].
The patient did well for a few weeks, but then developed
shortness of breath. The patient had bilateral pleural
effusions. He had talc pleurodesis six weeks to eight weeks
prior to admission by Dr. [**Last Name (STitle) 952**]. Prior to discharge, the
patient had increased shortness of breath. Echocardiogram,
on the date of admission, showed pericardial effusion. The
patient presented to [**Hospital1 69**] for
treatment.
PHYSICAL EXAMINATION: Examination revealed the vital signs
as follows: Temperature 97.9, pulse 101 and regular, blood
pressure 104/78, respiratory rate 20, saturation 96% on two
liters. NECK: Supple, no bruits. CARDIOVASCULAR: Regular
rate and rhythm. RESPIRATORY: Coarse breath sounds,
decreased breath sounds at bilateral bases. ABDOMEN: Soft
and nontender, nondistended. EXTREMITIES: 1+ bilateral
edema.
LABORATORY DATA: Labs on admission revealed the following:
White blood cells 7.4, hematocrit 37.8, platelet count
281,000, PT 21.5, PTT 34.2, [**Hospital1 263**] 3.2, sodium 135, potassium
4.0, chloride 96, bicarbonate 30, BUN 14, creatinine 11.0,
blood glucose 183.
HOSPITAL COURSE: The patient was admitted to the Thoracic
Surgery Department. On admission, the Coumadin was held and
the patient was started on heparin drip for anticoagulation.
On hospital day #2, the patient's condition was unchanged.
Some respiratory difficulties were as follows: Coarse sounds
bilaterally.
On hospital day #3, the patient was given vitamin K to
reverse the anticoagulation status. The patient still had
some shortness of breath.
On hospital day #4, the patient's condition remained
unchanged. The patient had heparin drip for anticoagulation.
On hospital day #5, the patient was taken to the operating
room, where left VADC and cardiac window was performed by
Dr. [**Last Name (STitle) 952**]. The operation went without complications; 450
cc of fluid was drained from the pericardium. One
pericardial and two chest tubes were placed in the operating
room. The patient was transported to the PACU in stable
condition. Overnight in the PACU the patient initially did
well, however, the patient started developing agitation. The
patient was taking swings at the nurse. He had to be
physical restrained and chemically restrained with Midazolam
to which he responded well. Also, on postoperative day #1,
the patient was taken for bronchoscopy. We found moderate
amount of thick, white secretions in both lungs and this was
suctioned to clear airway. The patient was in respiratory
distress and required Neo for his blood pressure. The
patient was transported to the SICU for further management
and observation.
On postoperative day #2, the patient remained agitated,
requiring chemical and physical restraints. The patient was
started on Coumadin and extensive diuresis.
On postoperative day #3, the patient was weaned off Neo and
started on Coumadin.
On postoperative day #4, the patient's postoperative delirium
almost resolved. He required minimal sedation and pain
medication. He was transferred to the floor in stable
condition.
The patient's mental status was back to normal, but he did
complain of feeling tired, weak, and sleepy. Also, on
postoperative day #5, the patient's PCA was discontinued.
The patient's chest tube was also removed without
complications. He was started on Percocet and Ibuprofen for
pain.
On postoperative day #6, the patient remained stable. [**Last Name (STitle) 263**]
increased to 3.4 and the heparin drip was discontinued. The
patient continued ambulation, exercise, and physical therapy.
On postoperative day #7, the patient remained stable while
exercising with PT. The [**Last Name (STitle) 263**] was 4.3 and he was discharged
home with a visiting nurse in stable condition.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg b.i.d..
2. Metformin 500 mg q.d.
3. Nefazodone 100 mg b.i.d.
4. BuSpar 5 mg t.i.d.
5. ....................5 mg q.h.s.p.r.n.
6. Atorvastatin 10 mg q.d.
7. Flovent 110 mcg two puffs b.i.d.
8. Tamsulosin 0.4 mg q.h.s.
9. Aspirin 81 mg q.d.
10. Milk of Magnesia 30 cc q.8.p.r.n.
11. Lasix 80 mg PO b.i.d.
12. Percocet 1 to 2 tablets PO q.4h.to 6h.p.r.n. pain.
13. Ibuprofen 600 mg PO q.6h.p.r.n.
14. Ranitidine 150 mg PO b.i.d.
15. Docusate 100 mg PO b.i.d.
16. Potassium chloride 20 mEq PO b.i.d.
17. Coumadin 2 mg PO q.d. (hold on [**2110-7-16**]).
18. Guaifenesin cough drops q.4h.p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged home with
[**Hospital6 **] for blood draws and wound check.
The patient should hold his Coumadin on the date of discharge
([**2110-7-16**]). The patient's [**Year (4 digits) 263**] should be drawn daily for a
week and results should be sent to the patient's primary care
physician (Dr. [**Last Name (STitle) 1159**]. The patient's potassium should be
checked on [**2110-7-18**]. The patient should be Dr. [**Last Name (STitle) 1159**] in 7 to
10 days for [**Last Name (STitle) 263**] and electrolyte check, as well Coumadin-dose
adjustment. The patient will followup with Dr. [**Last Name (STitle) 952**] in two
weeks in his clinic.
DISCHARGE DIAGNOSES: Coronary artery disease, chronic
obstructive pulmonary disease, DM2 depression started on AVR,
MVR pacemaker placement status post left pleural effusion.
Pericardial window.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern4) 28894**]
MEDQUIST36
D: [**2110-7-16**] 14:37
T: [**2110-7-16**] 15:19
0JOB#: [**Numeric Identifier **]
|
[
"V43.3",
"496",
"293.9",
"401.9",
"250.00",
"V45.01",
"420.90",
"414.01",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"34.21",
"33.22",
"34.92",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
13037, 13496
|
11684, 12300
|
9011, 11661
|
7504, 8304
|
8327, 8993
|
7344, 7481
|
12325, 13015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,043
| 149,969
|
14223
|
Discharge summary
|
report
|
Admission Date: [**2176-6-3**] Discharge Date: [**2176-6-12**]
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol
Acetate / Remeron / Ritalin
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
87 yo man with history of prostate cancer s/p XRT, dementia,
prior bladder rupture, who was treated in the [**Hospital1 18**] MICU for a
new bladder rupture and urosepsis, transfered to SIRS 2
primarily for management of resolving urosepsis, peritonitis,
post-surgical pain, and delirium.
Major Surgical or Invasive Procedure:
Anterior bladder perforation closure, placement of suprapubic
catheter and peritoneal drain
History of Present Illness:
87 yo man with history of prostate CA in [**2156**] s/p XRT, prior
bladder rupture, indwelling foley, multiple UTIs, and recently
dx dementia who presented to ED from NH with weeks of lower
abdominal pain and groin pain. Bright red hematuria was seen at
his nursing home. His foley was changed 1 week prior to
admission with sm amount of blood that cleared at the time. He
was unable to give other ROS. His family reported that the pt
had been having abd pain and hematuria all week since foley
change, and he was brought to the ED because he was having
fevers, nausea/vomiting and worsening pain. Prior to this past
week, he had been at his best recent baseline (w/a h/o one year
of new onset dementia), totally recovered from prior stroke,
working with PT, alert and oriented although. After he
presentated to ED he had n/v and one episode of abd pain. He
triggered for tachycardia with HR 130s while vomiting. His
abdomen was soft on exam. He had gross hematuria noted and
urology was consulted. In line with their recs a CT with IV
contrast was ordered which showed the foley catheter balloon
dilated in urethra, urology came and replaced the foley. The pt
started to become hypotensive, with a lowest BP to 65/30, and he
received approximately 2-3L liters IVF with minimal response.
He had a RIJ line placed, and he was started on norepinephrine.
His labs were notable for lactate 2.4, WBC 7.7 with 15% bands.
His UA was positive with gram negative rods. He was thus
started on cefepime/gent/vanc.
The pt then had CT cystogram after foley replacement prior to
transfer to [**Hospital Unit Name 153**], notable for bladder rupture, this was believed
to have occured sometime in the past week either immediately or
some time after foley replacement. Urology saw the patient
again, at which point his abdomen was noted to be diffusely
tender but not hard. His BP was noted to be 100-120s while he
was being weaned off norepinephrine. After the pt was
appropriately stabilized, he was taken on [**2176-6-4**] to the OR for
repair of his bladder rupture and placement of a suprapubic
catheter. Post-op the pt was hemodynamically stable and c/o
abdominal pain. As the pt recovered from his sepsis w/ IV abx
and IV NS his serial CXRs showed worsening pulmonary edema,
which improved with diuresis with IV lasix. His SBP values also
went up to the 200s, at which point his home HTN regimen was
restarted. He also became delirious soon after surgery, likely
due to resolving urosepsis, pain, and pain medications. He was
transfered to the medical team for management of his resolving
urosepsis, post-op pain management, and delirium.
Past Medical History:
- DM II, on insulin
- Prostate CA s/p XRT. Diagnosed in [**2156**].
- Chronic urinary incontinence, s/p TURP [**10-6**].
- History of UTI's, including prior MRSA and pseudomonas growth.
(Has chronic indwelling foley, changed Q6 weeks, on ppx with
cephalexin per Dr. [**Last Name (STitle) 770**]
- S/p bladder rupture and repair [**2-8**]
- A Fib, not anticoagulated due to bleeding history.
- Hyperthyroidism.
- Depression.
- Hypertension.
- PVD.
- H/o CVA [**2172**]
- Severe chronic axonal neuropathy, radiculopathy and plexopathy
(due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many
years. Bed ridden.
- L3 compression fracture.
- Cataract s/p bilateral laser surgery, also with "macular
edema" s/p dexamethasone injxn.
- Hard of hearing
- L thyroid nodule, benign.
Social History:
[**Location (un) 1036**] resident. Smoked 2ppd tobacco x 24 years. Quit in
[**2137**]. Denies EtOH. Former WWII vet. Former Fire Fighter. Wife
is HCP. Daughter is RN, Son is engineer.
Family History:
No illnesses, strokes, DM or early heart attacks run in the
family.
Physical Exam:
Vitals: T:96.5 BP:132/68 P:103 (AF) R: 30 SaO2: 94% RA CVP 8
General: Awake, responds to command, marked speech latency,
minimal response to questions. Appears frail, uncomfortable and
fatigued.
HEENT: Pale sclera. MM dry.
Neck: Supple, no LAD. R CVL IJ in place.
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: Tachycardic, irregular, 2/6 systolic murmur
Abdomen: BS present. Abd soft. Diffusely tender w/tap
tenderness throughout but w/o rebound or guarding.
Extremities: Mild dependent edema in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**],
cool toes with evidence of PVD/dry gangrene of right 2nd/3rd
toes. Upper extremitites well perfused. Foley in place,
draining clear urine.
Skin: No ulcers noted. Scattered excoriated lesions on right
lower quadrant/groin area.
Neurologic:Awake, responds to commands, can give coherent
answers. Oriented to person and hospital, not to specific
hospital, or year, marked speech latency. EOMI. Slight right
facial droop and UE contracture, resolves with effort. Moving
all extremities, grip strength equal.
Pertinent Results:
Labs
Admission labs
[**2176-6-3**] 03:46PM BLOOD WBC-7.4 RBC-3.92* Hgb-11.6*# Hct-34.9*#
MCV-89 MCH-29.5 MCHC-33.1 RDW-16.1* Plt Ct-302
[**2176-6-3**] 03:46PM BLOOD PT-13.7* PTT-25.1 INR(PT)-1.2*
[**2176-6-3**] 03:46PM BLOOD Glucose-124* UreaN-28* Creat-0.9 Na-139
K-4.9 Cl-107 HCO3-21* AnGap-16
[**2176-6-3**] 03:46PM BLOOD Albumin-3.3*
[**2176-6-4**] 01:31AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.5*
[**2176-6-4**] 05:39AM BLOOD Type-ART pO2-70* pCO2-30* pH-7.37
calTCO2-18* Base XS--6
[**2176-6-3**] 03:47PM BLOOD Glucose-120* Lactate-2.4* Na-141 K-4.6
Cl-105 calHCO3-22
Discharge labs:
[**2176-6-12**] 06:04AM BLOOD WBC-11.2* RBC-3.34* Hgb-10.2* Hct-30.6*
MCV-92 MCH-30.5 MCHC-33.2 RDW-16.2* Plt Ct-331
[**2176-6-12**] 06:04AM BLOOD Glucose-133* UreaN-26* Creat-1.2 Na-139
K-4.2 Cl-108 HCO3-24 AnGap-11
[**2176-6-12**] 06:04AM BLOOD Calcium-7.3* Phos-2.3* Mg-2.2
[**2176-6-12**] 06:04AM BLOOD Genta-5.8
Microbiology:
[**2176-6-6**] 10:25 am URINE. URINE CULTURE (Final [**2176-6-7**]): NO
GROWTH.
[**2176-6-4**] 12:00 pm PERITONEAL FLUID
**FINAL REPORT [**2176-6-11**]**
GRAM STAIN (Final [**2176-6-4**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) **] @ 1822 ON [**2176-6-4**].
FLUID CULTURE (Final [**2176-6-11**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
DR. [**First Name (STitle) **] #[**Numeric Identifier 42293**] REQUESTED SENSITIVITIES [**2176-6-9**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2176-6-8**]): NO ANAEROBES ISOLATED.
[**2176-6-3**] 3:46 pm BLOOD CULTURE
FINAL REPORT [**2176-6-9**]** Blood Culture, Routine (Final
[**2176-6-9**]):NO GROWTH.
[**2176-6-3**] 3:46 pm URINE from CATHETER FINAL REPORT [**2176-6-5**]**
URINE CULTURE (Final [**2176-6-5**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
.
Imaging Studies:
CT abdomen/pelvis w/ contrast ([**6-3**])
1. Pyelonephritis of the left kidney. No abscess.
2. The Foley catheter balloon is inflated in the penile urethra.
Small amount of gas within the bladder and the left distal
ureter are most likely related to the catheterization.
3. Small amount of free fluid is noted within the pelvis.
CT abdomen/pelvis w/ contrast ([**6-9**])
IMPRESSIONS:
1. Small, 3.6 x 1.2 x 4 cm fluid collection at the
posterior-superior aspect
of the bladder dome, with an enhancing rim, concerning for
abscess. The right
pelvic catheter does not terminate within this collection.
2. Trace residual free fluid in the mesentery of the pelvis.
Interval
resolution of free contrast material in the pelvis.
CXR ([**6-7**])
The NG tube tip is in the stomach. The right internal jugular
line tip is at mid SVC. There is interval improvement up to
almost complete resolution of pulmonary edema. The left
retrocardiac opacity is still present, most likely consistent
with left lower lobe atelectasis. Pleural effusion, bilateral,
is small, left more than right.
Brief Hospital Course:
87 yo man with history of prostate cancer s/p XRT, prior bladder
rupture, and dementia who was treated in the [**Hospital1 18**] MICU for a
second bladder rupture, bladder rupture repair and suprapubic
catheter placement, UTI, sepsis, and peritonitis who was
transfered to the Medicine service for management of his
post-surgical pain, resolving peritonitis, delirium, and heart
rate control.
.
# Bladder rupture, urosepsis, peritonitis
.
The pt had a history of bladder rupture s/p repair in [**1-/2175**] and
presented to this admission with evidence of new rupture on CT
in setting of vague abdominal pain, nausea, vomiting and
evolving shock. He likely has friable bladder tissue in setting
of XRT for prostate CA and prior rupture. At admission it was
unclear how long the rupture had been present, but may have been
related temporally to recent foley catheter change one week
prior. He had a history of MRSA, proteus, klebsiella and
pseudomonas UTIs, and thus was started on broad spectrum
antibiotics (vancomycin, cefepime, and gentamicin) at admission.
.
He was bolused with IV fluids overnight in the MICU and went to
the OR on the first hospital day. In the OR, a perforation in
the anterior bladder wall was closed. A suprapubic catheter was
placed in a posterior bladder wall perforation, and a JP drain
was placed in the peritoneum. Cultures were taken from the
peritoneal fluid and urine that grew out Pseudomonas sensitive
to cefepime and gent, resistent to cipro. After the surgery,
the output from the JP drain continued to decrease. Chemical
analysis was consistent with serum, rather than urine, and on
the basis of this it was felt that the bladder perforations were
successfully sealed.
Post-operatively, he was treated with IV morphine and
acetaminophen for pain control. He was transfused 2 units PRBCs
for hematocrit 27, with appropriate bump.
The pt did go on to c/o some post-surgical pain. He continued to
drain clear urine from both the urethral and suprapubic
catheters. He had a CT scan on [**6-9**] to assess for a fluid
collection or abscess in the pelvic cavity, which showed a small
fluid collection that requires follow up CT. Thus he was cleared
for the removal of his JP drain. His surgical incision remained
clean, dry, and intact. He had two negative urine cx. The cx
of his peritoneal fluid sample taken on [**2176-6-4**] showed no growth
except for rare Pseudomonas Aeruginosa growth that were shown on
[**2176-6-12**] to be sensitive to Cefepim and Vancomycin. He was
continued on his regimen of IV Cefepim, Vancomycin, and
Gentamycin for 10 days to ensure adequate tx of his UTI and
peritonitis, but was switched to solely Cefepim coverage on
[**2176-6-12**] when the culture sensitivities returns. He had a PICC
line placed on [**2176-6-12**] for the completion of his 14 day course
of Cefepime. He did have mild urine leakage around his
suprapubic catheter, but this only lasted 3 days and Urology was
not concerned given that his catheters both continued to drain
clear urine. He is scheduled for a F/U pelvic CT scan to
reasscess the region concerning for a possible abscess, and he
is also scheduled for a F/U visit with his urologist Dr. [**Last Name (STitle) 770**]
for in 2 weeks.
.
# Delirium
W/R/T the pt's mental status, after his surgery, he became
increasingly agitated and disoriented. The delirium was felt to
be secondary to pain, recent surgery, infection, and narcotics
in the setting of baseline dementia. The pt. had been receiving
IV Dilaudid for pain. Overall the narcotics were used sparingly
and his infection was treated with [**Last Name (STitle) 17577**] broad spectrum abx.
Zyprexa was used in small doses for acute agitation with
adequate sedation. He was placed in soft restraints to protect
against the pt pulling out his NGT or either of his catheters or
drains. [**2176-6-7**] was the last time that the pt received Zyprexa
for agitation/delirium, and he became alert and oriented to
person, hospital name, and month/year since [**6-9**] and has been at
his baseline since then (he has some known dementia). He is
alert and oriented x3 on D/C.
.
# Anemia
W/R/T the pt's anemia as above, he received 2 units PRBCs
post-operatively for hematocrit of 27. His blood count then
stabilized and he did not require further transfusions. His
hemolytic work-up was negative. He stabilized in the low 30s
throughout his stay and has been stable.
.
# Atrial fibrillation
The pt has a h/o atrial fibrillation controlled only by
Metoprolol and has not been anticoagulated due to his h/o
hemorrhage on coumadin. While in the hospital he had multiple
episodes of atrial fibrillation with RVR to 130-160s, typically
related to pain and stress. His metoprolol had been held due to
hypotension at admission, but was restarted to manage his RVR
when his blood pressure tolerated. He continued to have such
episodes of afib with RVR throughout his stay, and thus his
Metoprolol dose was increased to 50 mg Q 8H up from 25 mg [**Hospital1 **],
which his BP tolerated. With this increase in the metoprolol
maintained an average HR in the 70s and stopped having episodes
of RVR. He will need outpt F/U to assess any need to adjust this
regimen.
.
# Diabetes mellitus II:
The pt was placed on a humalog sliding scale with 15U NPH in the
AM, however was taken off of the NPH due to hypoglycemia in the
MICU. on the floor, the pt developed hyperglycemia to the 200's
and was consistently over 180, at which point 4 [**Location **]
was added and his sliding scale was increased to maintain better
glycemic control. He subsequently had lower blood glucose
levels overall, but still has some levels in the 200s and now
that he is not infected and will be having decreasing levels of
pain and stress, his insulin regimen will likely need to be
adjusted at the rehab facility with [**Location 17577**] finger sticks and
his primary care should f/u on this as well.
.
# Volume status/Blood pressure
The pt has a h/o hypertension controlled on amlodipine and
metoprolol, but he was hypotensive at admission, at whcih point
he was hydrated aggressively with IV normal saline overnight and
post-operatively. As he recovered from hypotension and sepsis,
his blood pressure came up. Serial CXRs showed worsening
pulmonary edema and he was diuresed with boluses of IV Lasix,
which completely cleared his pulmonary edema. His outpatient
antihypertensives (except for Lisinopril) were restarted as
tolerated after he had recovered from peritonitis and urosepsis.
Lisinopril should be restarted as an outpatient as tolerated by
his blood pressure with the new adjustment to the metoprolol
levels.
.
# Nutrition:
W/R/T the pt's nutrition, given the pt's delirium, an NGT was
placed for tube feeds which were given continuously. He had a
speech and swallow consult with a swallow study and was noted to
be silently aspirating and was thus deemed unable to take POs
until he has rehab and a further evaluation. NGtube and PEG
were both considered, and it was decided to plan for discharge
with the NG tube with plans for speech and [**Hospital 42294**] with a goal of reachieving ability to take POs.
For now he has a feed rate of 40ml/hr but his goal is 60ml/hr.
The rate was slowed given recent NGT residuals, but he is on
Metoclopramide and and has recently begun a bowel regimen to
ensure that there is no backup causing these residuals.
Instrucitons are to hold for residuals over 150ml.
.
# Scrotal Edema and candidal infection
The pt also experienced extreme scrotal edema for being given
about 14 liters of IV fluid for his urospesis/hypotension. His
scrotum was elevated to decrease the edema, and has decreased
but is still an issue. He also developed a erythematous rash
around his scrotum and groin area which was treated with 2%
Miconazole powder. There is no warmth in this area or any
appearance of cellulitis. The plan is to continue to manage
with miconazole powder.
.
# Depression:
The pt has a h/o depression and had been on 10mg Lexapro per
night prior to admission. His home dose of Lexapro was held
during this admission given his delirium with the plan to
restart it as an outpatient.
.
The pt was known to be a full code status.
.
Signed:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42295**] (Sub-Intern) pager number [**Serial Number 11736**]
[**Last Name (LF) **], [**First Name3 (LF) 1439**] (Resident) [**Numeric Identifier 16045**]
[**Last Name (LF) **], [**First Name3 (LF) 518**] (Attending)
Medications on Admission:
Cephalexin daily UTI ppx
NPH 15 units QAM
RISS
Heparin SC TID
Azo cranberry 450mg daily
Bisoprolol 5mg daily
Norvasc 5mg daily
Aspirin 81mg daily
Florastor 250mg [**Hospital1 **]
Tylenol 500mg TID
MVI [**Hospital1 **]
Lisinopril 5mg daily
Simvastatin 10mg QHS
Prilosec 20mg daily
Lexapro 20mg daily
MOM PRN constipation
Bisacodyl PRN constipation
Fleet's enema PRN constipation
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for Pain/fever for 3 weeks.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 Appl* Refills:*2*
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for bladder pain.
Disp:*1 Tablet(s)* Refills:*0*
5. Ondansetron 4 mg IV Q8H:PRN nausea, vomiting
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
Disp:*1 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*1 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
Disp:*1 50 mg/5 ml* Refills:*2*
9. Insulin Glargine 100 unit/mL Solution Sig: Four (4) UNits
Subcutaneous at bedtime.
10. Cefepime 2 gram Recon Soln Sig: Two (2) g Intravenous twice
a day for 5 days.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
12. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Your primary Diagnoses Include:
Bladder rupture
Peritonitis
Urinary tract infection
sepsis
Secondary Diagnoses
Delirium
Diabetes mellitus
Atrial fibrillation with episodes of rapid ventricular rate
Discharge Condition:
Stable. Afebrile. At his baseline mental status. Pain adequately
controlled on standing Tylenol.
Discharge Instructions:
You were admitted to the hospital for treatment of bladder
rupture and infection. You underwent surgery to repair the leak
in the bladder. Afterwards, you were treated with intravenous
antibiotics for infection in the space around the bladder.
There have been changes to your medications as follows:
1. Metoprolol increased to 50 mg Q 8H. This level may need to be
decreased in the future as recommended at followup with your
primary care doctor given you heart rate in the future.
Scheduled appointments:
Please return to the [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical center on [**2176-6-17**]
for your scheduled follow-up CT scan of the pelvis.
Plan for returning to the [**Hospital1 18**] for a followup appointment with
your Urologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] on Monday [**2176-6-17**] at 3
PM.
The location of this appointment will be at the [**Hospital1 18**] [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Building [**Location (un) **] Surgical Specialities. Please
call the phone number: ([**Telephone/Fax (1) 7707**] with quesitons about this
appointment.
Please call your doctor or return to the emergency room for
fever > 101 deg F, worsening abdominal or bladder pain, or other
new symptoms concerning to you.
Followup Instructions:
Newly-scheduled follow-ups:
- F/U CT 1 week after discharge to re-assess for abscess. CT
scheduled for [**2176-6-17**] at 8:15 AM at [**Location (un) **], [**Hospital Ward Name 5074**] [**Location (un) 470**].
- F/U urology appointment: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD
Phone:[**Telephone/Fax (1) 5727**] Date/Time: [**2176-6-17**] 3:00PM.
|
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,512
| 176,208
|
18142
|
Discharge summary
|
report
|
Admission Date: [**2170-6-28**] Discharge Date: [**2170-7-11**]
Service: MEDICINE
Allergies:
Erythromycin Base / Sulfamethoxazole / Sulfa(Sulfonamide
Antibiotics) / azithromycin
Attending:[**First Name3 (LF) 50171**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a [**Age over 90 **] year old female with a PMH notable for atrial
fibrillation, sick sinus syndrome s/p pacemaker, annulocalcific
mitral valve disease, chronic kidney disease with recent
creatinine of 1.78 ([**2170-6-6**]) who is transferred from OSH for
management of fluid status and possible aspiration pneumonia.
Patient was transferred from [**Hospital6 28728**] Center. She
initially presented to OSH on [**2170-6-17**] with hematuria in the
setting of supratherapeutic INR (5). Urology was consulted who
recommended holding her coumadin briefly (later bridged with IV
heparin) with IV ceftriaxone X 3 days and her hematuria
resolved. She underwent cystoscopy on [**6-22**] which demonstrated
diffuse cystitis without active bleeding. She was found to have
a citrobacter UTI with sensitivity to zosyn and patient
completed a course of zosyn X 7 days (finished [**6-26**]). She was
transfused one unit prbcs. Cardiology was consulted on [**2170-6-27**]
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Houzen) due to intermittent episodes of dyspnea
thought to be multifactorial from acute on chronic diastolic
congestive heart failure superimposed on a aspiration vs.
hospital acquired pneumonia/pneumonitis.
A CT scan was suggestive of aspiration pneumonia as well as a
5x6mm nodular filling defect within the trachea at the carina
level. In addition to IV solumedrol and lengthening of zosyn
course to 10 days for possible pneumonia, patient had received
multiple doses of IV lasix (anywhere from 40-80mg IV boluses)
due to vascular congestion. Her weight on admission was 131 lbs
which dropped to 128.6 with diuresis (weight was 125lbs on
[**2170-6-6**] office visit). In the setting of her diuresis, her
creatinine has risen to 2.5 from a baseline of 1.8-2.0. Of note,
she has chronic lower extremity edema at baseline. Her
lisinopril, metformin, and glipizide were on hold in the setting
of renal failure.
On the floor, patient reports that she continues to feel short
of breath and is complaining of a nonproductive cough with
associated fits. She denies fevers, chills, nausea or vomtiing,
She denies pain or problems with swallowing. She has a foley in
place and denies any problems moving her bowels. She is
compliang of some right sided chest pain that is located under
her breast which has been hurting since a fall prior to her
previous admission.
Past Medical History:
Diastolic dysfunction
- Chronic kidney disease with recent creatinine 1.8-2.0
- Atrial fibrillation on coumadin
- Prior left bundle branch block
- Sick sinus syndrome s/p dual chamber pacemaker
- Annulocalcific mitral valve disease
- HTN
- Diabetes mellitus
- Hyperlipidemia
- Squamous cell skin cancer
- History of gallstones
- History of osteopenia
- Adenomatous polyps
- History of TIA
- History of breast cancer
- Hematuria
Social History:
Widowed, prior telephone operator, retired. Lives with daughter,
[**Name (NI) **] [**Last Name (NamePattern1) **] (who is HCP) [**Name (NI) **] two other sons who live
locally and are invovled. Independent to perform chores. Denies
any history of alcohol, tobacco (but did have significant second
hand smoke), or substance abuse. At baseline she walks around
her house with a walker
Family History:
Non-contributory to presenting illness
Physical Exam:
Physical Exam on Admission
Vitals- T: 98.3, 132/62, 72, 20, 97% 4L.
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, dry mmm, oropharynx clear
Neck- supple, JVP elevated at 13, no LAD
Lungs- Diffuse inspiratory crackles wet sounding to [**2-5**] way up.
Musical expiratory wheezing throughout the lungs
CV- Irregular rhythm, regular rate, with systolic murmu at the
LUSB, and blowing mumur at the Apex radiating to the axilla. no
tenderness to palpation of the right chest caudal to the breast
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, left anteior shin abrasion
of 1cm in diameter, no surounding erythema or fluctuance. 2+DP
pulses bilaterally no clubbing, cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal
.
Physical Exam on Discharge:
Pulseless, no spontaneous respirations, no pupillary or corneal
reflexes
Patient expired.
Pertinent Results:
Admission Labs:
[**2170-6-28**] 09:32PM BLOOD WBC-7.4 RBC-3.37* Hgb-10.1* Hct-31.7*
MCV-94 MCH-29.8 MCHC-31.8 RDW-17.2* Plt Ct-203
[**2170-6-28**] 09:32PM BLOOD Neuts-65.7 Lymphs-20.8 Monos-5.8 Eos-6.6*
Baso-1.1
[**2170-6-28**] 09:32PM BLOOD PT-24.5* PTT-39.0* INR(PT)-2.3*
[**2170-6-28**] 09:32PM BLOOD Glucose-278* UreaN-62* Creat-2.5* Na-137
K-4.0 Cl-94* HCO3-30 AnGap-17
[**2170-6-28**] 09:32PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.4
[**2170-6-29**] 05:20AM BLOOD Digoxin-1.1
Urine:
[**2170-7-1**] 12:00PM URINE Color-RED Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2170-7-1**] 12:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2170-7-1**] 12:00PM URINE RBC->182* WBC->182* Bacteri-NONE
Yeast-MANY Epi-0
Microbiology:
Blood cultures: all NGTD
Imaging:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2170-6-30**] 1:37
AM
FINDINGS: Comparison is made to the prior study from [**2167-4-20**].
There is a left-sided pacemaker with distal lead tips in the
right atrium and right ventricle. There is unchanged
cardiomegaly. There is prominence of the pulmonary interstitial
markings suggestive of mild fluid overload. This is within a
background of baseline interstitial lung disease. No confluent
areas of opacity are seen. There are no pneumothoraces.
Radiology Report RIB UNILAT, W/ AP CHEST RIGHT Study Date of
[**2170-6-30**] 1:20 PM
FINDINGS: Comparison is made to previous study from [**6-30**] at
1:43 a.m.
Heart size is enlarged but stable. There is a dual-lead
left-sided pacemaker with the distal lead tips in the right
atrium and right ventricle which have intact leads. There are
again seen airspace opacities throughout both lung fields which
may represent an element of fluid overload. Underlying
infection is not excluded. Markers have been placement at the
right lower ribcage. At this location, there are no displaced
rib fractures.
CHEST X-RAY ([**2170-7-2**]): There is a dual-lead left-sided pacemaker
with lead tips in the right atrium and right ventricle,
unchanged. There is stable cardiomegaly. There is improved
aeration and improvement of the airspace opacities throughout
both lung fields. There remains some coarsening of the
bronchovascular markings bilaterally, mostly in the perihilar
region and at the lung bases, likely represent some fluid
overload.
CT CHEST WITHOUT CONTRAST ([**2170-7-2**]):
1. Bilateral patchy airspace opacities with prominent with
interlobular
septal thickening may be related to congestive heart failure
versus a
multifocal pneumonia. Clinical correlation is recommended. No
definite
evidence for interstitial lung disease is identified.
2. Calcification along the pleura suggests prior granulomatous
disease.
3. Emphysematous changes in both lungs.
(TTE) ECHO: [**2170-7-3**]: The left atrium is elongated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is dilated with normal free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with trivial mitral
stenosis. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient was a [**Age over 90 **] yo F w/
PMH of diastolic heart failure, afib and sick sinus syndrome s/p
pacemaker placement and recent hematuria in the setting of an
elevated INR who developed a possible aspiration
pneumonia/pneumonitis and decompensated diastolic heart failure.
She underwent lasix diuresis to euvolemia and received
antibiotics. Speech and swallow eval revealed persistent
aspiration which was unavoidable with oral intake. The family
decided to allow the patient to eat despite this finding to make
the patient comfortable.
ACUTE CARE ISSUES ADDRESSED THIS STAY:
#Aspiration pneumonia- the patient had a suspected aspiration
pneumonia at the outside hospital which presented with worsening
shortness of breath and cough. She had a CT scan which showed
some opacities which were consistent with an aspiration event.
On further review of her history it was learned that she had
undergone a barium swallow during which she had aspirated and it
quite likely that the CT scan was showing this barium as the
aspiration. She came in on a [**8-14**] day course of IV Zosyn, and
completed this regimen during her stay. She was afebrile with
no leukocytosis during her hospital stay.
#Decompensated chronic diastolic heart failure- the patient had
become volume overloaded at the outside hospital and had been
agressively diuresed. Her home regimen included 10mg po lasix
qday. She was diuresed gently while at [**Hospital1 18**] given her acute on
chronic renal failure.
#Acute on chronic renal failure- patient has a baseline
creatinine of 1.8 at the beginning of [**2170-6-5**] and was 2.5 on
admission to [**Hospital1 18**]. This was likely [**3-8**] her diuresis at the
outside hospital. Nephrotoxic medications were held during her
hospital stay, including her metformin, glipizide and losartan.
#Diabetes mellitus- the patient had elevated blood sugars in the
setting of her pneumonia. Her oral agents were held and she was
started on ISS during her hospital stay.
#Sick-sinus syndrome/Atrial fibrillation- the patient was in
Afib during this admission without any episodes of RVR or
bradycardia while on monitor.
======================
MICU COURSE:
On HD #3, patient developed increased respiratory distress on
the floor with RR 40s (although satting in mid 90s on 3L NC).
She was started on Vanco + Levoquin to treat possible new HCAP
and IV Solumedrol (presumably due to increased wheezing on exam)
and transferred to the MICU for BiPAP and more intensive nursing
care. In the MICU, Solumedrol was tapered to 25mg IV BID, and
once patient more alert and taking POs was tapered to 40mg daily
on [**7-4**] (to complete one week taper). Vanco was DC'd on [**7-4**] due
to low suspicion for MRSA pneumonia. Levoquin was continued
(last day [**2170-7-7**]). CT chest was performed which showed BL patchy
airspace opacities c/w pulm edema vs. multifocal pneumonia, and
granular pleural opacities suggestive of prior granulomatous
disease. TTE was also performed which showed severe (3+ TR),
LVEF >55%, pulm HTN, all unchanged from prior. Patient remained
hemodynamically stable, except for an episode of
confusion/delirium overnight on [**7-2**] during which she desatted
(likely secondary to anxiety). Sats improved significantly with
Zydis 2.5mg PO x1. She was transferred back to the floor on
[**2170-7-4**] at which point she continued to express discomfort in
respect to her dyspnea. She remarked on numerous occasions about
how miserable she was and how she did not understand the point
of all of the tests or medications she was receiving as she was
just going to get sick again. On [**2170-7-6**], a palliative care
meeting was held, and the patient's family made the decision to
change her goals of care to comfort measures only.
========================
She expired with family at bedside on [**2170-7-11**] @ 1200. Autopsy
was declined.
Medications on Admission:
Medications confirmed with patient
- aspirin 81mg PO daily
- digoxin 0.125mg PO daily
- losartan 12.5mg PO daily
- lasix 10mg PO daily
- simvastatin 20mg PO daily
- glipizide 10mg PO daily
- metformin 1000mg PO daily
- albuterol inhaler PRN
- warfarin 1mg PO daily
- vitamins PO daily
- calcium
- vitamin D
- tylenol 325mg PO daily
Medications on Transfer:
- Aspirin 81mg PO daily
- Caltrate plus D 1tablet PO BID
- Coumadin 1mg PO daily
- Folic acid PO daily
- Lasix 40mg PO daily
- Digoxin 0.125mg PO daily
- Multivitamin 1 tablet PO daily
- Simvastatin 10mg PO daily
- Vitamin B12 1 tablet PO daily
- insulin sliding scale
- Zosyn 2.25mg TID for 3 more days......
- Mucomyst 10% four ml nebs TID
- Duonebs
- Tylenol 650mg PO q4h
- Lidoderm patch at RUQ daily 12 hours on
- Desenex powder
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Immediate cause of death: pneumonia
Antecedent cause of death: chronic renal insufficiency
Discharge Condition:
Expired.
Discharge Instructions:
Patient expired. Autopsy declined by family.
Followup Instructions:
Patient expired. Autopsy declined by family.
Completed by:[**2170-7-11**]
|
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icd9cm
|
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icd9pcs
|
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|
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78,076
| 133,326
|
10768
|
Discharge summary
|
report
|
Admission Date: [**2113-11-17**] Discharge Date: [**2113-12-5**]
Date of Birth: [**2043-3-24**] Sex: M
Service: SURGERY
Allergies:
Aspirin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
admission for skin graft
Major Surgical or Invasive Procedure:
STSG
History of Present Illness:
70M extensive surgical history presented for elective
split-thickness skin graft for abdominal wound coverage.
Past Medical History:
PMHx: asthma, HTN, basal cell carcinoma, DM, gallstone
pancreatitis c/b respiratory and renal failure, abdominal
compartment syndrome, necrotizing pancreatitis
PShx:
rib frx plating approx 5 years ago.
On last admission
[**2113-7-13**] closure, GJ tube
[**2113-7-8**] partial abd closure, drsg [**Name5 (PTitle) **]
[**2113-7-4**] Open abdomen dressing revision
[**2113-7-3**] Decompressive laparotomy, open abd
[**2113-7-8**] partial closure abdominal wound
[**2113-7-13**] formal closure GJ tube
[**2113-7-19**] Decompressive laparotomy, open abd
[**2113-7-24**] tracheostomy
[**2113-7-29**] abdominal closure with mesh
[**2113-8-13**] and [**2113-8-18**] -I&D of pancreatic fluid collection and
subsequent upsizing of drain by IR
[**2113-8-22**], [**2113-8-28**], [**2113-9-4**] -Laparoscopic pancreatic
necrosectomy
Social History:
Married for 45+ years. Three daughters, one son. Retired six
years ago, owned upholstery business. Never smoker, one glass of
wine per evening with dinner. No illicits.
Family History:
Sister died from breast cancer, another sister (deceased)
with CRF on HD
Brief Hospital Course:
[**11-17**]: admitted from nursing home
[**11-18**]: fever spiked to 102, OR cancelled.
[**11-19**]: L subclavian CVL removed, tip sent for culture, RIJ
placed ID recommended vanco+ceftaz while awaiting cultures and
TTE given h/o fungemia. febrile to 101.7.
[**11-20**] TPN stopped, OR postponed, central acces removed.
[**11-21**]: Afebrile, TF started
[**11-22**]: TF increased to 20, Hct dropped to 21
[**11-23**]: Vanc held. TF increased to 30.
[**11-24**]: PPN held, possible aspiration from tube feeds
[**11-25**]: tolerating TF @ 30, CXR clear, no more emesis episodes
[**11-26**]: TF advanced to 40cc/h tolerating well
[**11-27**]: TF to 45 residual TF in G-tube, held after 8pm npo after
midnight for OR
[**11-28**]: STSG from left thigh to Abdomen
[**11-29**]: trach mask trials, G-J study with leak, tube feeds held
due to abdominal pain.
[**11-30**]: lasix given for pleural effusions, on PPN
[**12-1**]: got J tube replaced by IR, TF restarted, 1 unit pRBCs
[**12-2**]: no event, TF increased to 35cc/h
[**12-3**]: TF increased to 40 and to 3/4 strength, attempted [**8-9**]
CPAP pt reported SOB so back to [**10-9**]
[**12-4**]: TF to goal of 60 (3/4 strength) + MCT for total of [**2052**]
kcal/day, rehab screen started.
Medications on Admission:
Caspofungin 50mg', Tobramycin 300'', RISS, Nexium, Zofran,
ipratropium, Olanzapine 5'', Zolpidem 5prn, Hydromorphone
0.5Q2prn
Discharge Medications:
1. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) mL
Injection Q8H (every 8 hours) as needed for nausea.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain / fever.
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO DAILY (Daily).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs
Miscellaneous Q6H (every 6 hours) as needed for secretion.
9. Nutrition
Please continue enteral feeds: Replete with fiber Full strength
40 mL/hr with 30 mL water flush q6h. Medium chain triglycerides
25 mL QID.
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-6**]
Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
11. BG regimen
resume previous insulin regimen.
12. Misc
Line care/oral hygiene per facility protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p STSG
Discharge Condition:
stable
Discharge Instructions:
dressing care as indicated on page 1.
Followup Instructions:
With Dr. [**First Name (STitle) **] in 1 week.
|
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icd9cm
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[
[
[]
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263, 289
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361, 473
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1334, 1505
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,260
| 105,146
|
15740
|
Discharge summary
|
report
|
Admission Date: [**2164-2-20**] Discharge Date: [**2164-3-11**]
Date of Birth: [**2120-8-12**] Sex: F
Service: MEDICINE
Allergies:
Topiramate / Aripiprazole / Shellfish / Bee Pollen
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
[**2164-2-20**] EGD without intervention
[**2164-2-29**] Diagnostic/therapeutic paracentesis
[**2164-3-1**] Diagnostic/therapeutic paracentesis
[**2164-3-4**] Diagnostic paracentesis
[**2164-3-7**] Diagnostic/therapeutic paracentesis
[**2164-3-8**] EGD with Dobhoff placement with sedation
[**2164-3-9**] Diagnostic/therapeutic paracentesis
History of Present Illness:
Ms. [**Known lastname 45209**] is a 43F with a history of alcoholic cirrhosis s/p
TIPS 6 weeks ago (gradient 17->10), active alcoholism, and
recect UGIB attributed to duodenal varix who was discharged
[**2164-1-16**] after IR guided embolization of a sentinel bleed from a
duodenal varix. During her most recent admission the pt was
tachycardic, hypotensive and required multiple blood
transfusions and underwent EGD that showed only mild portal
gastropathy and colonoscopy that showed a large volume of blood
in the colon and grade 1 external/internal hemorrhoids. She
subsequently underwent CTA that showed duodenal varicies that
were embolized.
Following this, patient was in her normal state of health until
she started having BRBPR as well as light-headedness and
presented to OSH where she had a crit of 18.8 blood [**Month/Day/Year **] of 279.
She was also found to be hypotensive to as low as 80/44 but was
said to be mentating well. She was given 1 unit of FFP, 1 unit
of pRBC's, started on an octreotide drip, and given 1 dose of
40mg IV pantoprazole and was transferred to [**Hospital1 18**] for further
evaluation and management.
.
In the ED, initial VS were: 98.9 118 84/55 12 100% RA
She was noted to have BRBPR on rectal exam as well as dark blood
from her vagina, pelvic exam was significant for dark red blood
from her cervical os, she was dosed with IV 2gram Ceftriaxone,
continued on her octreotide drip, and had blood from OSH
hanging. Her crit was 22.3 (baseline mid 20's), PLT ct of 44
(fluctuates between 40's and low 120's), lactate of 2.5, Serum
[**Hospital1 **] of 164, Cr of 0.7. Prior to transfer to the MICU her BP was
98/54.
On arrival to the MICU, patient is alert and confirms the above
history. She states that she had the sudden onset of BRBPR along
with the feeling of generalized weakness. She denies significant
abdominal pain although described mild abdominal discomfort such
as hunger cramps. No N/V/D, no hematemesis, states she has had a
few recent falls related to her generalized weakness and perhaps
her [**Hospital1 **] intake. She denies LOC but did hit her nose on her
coffee table and had a minor nose bleed. Otherwise describes no
blood in her urine but has had small amounts of dark blood from
her vagina but states that she hasn??????t had an ordinary period in
over a year. She denies fevers, chills, CP, SOB, focal numbness,
weakness, or tingling.
Past Medical History:
- Alcoholic cirrhosis s/p TIPS
- s/p cholecystectomy [**2153**]
- Gastroesophageal reflux disease
- Bipolar disorder
- HTN
- Depression/anxiety
- Recent burns to both hands [**11/2163**] (housefire) s/p skin
grafting from R thigh
Social History:
She lives with her husband and 2 children, ages 16 and 17.
Smokes 1 pack every few weeks. Used to be an accountant.
Describes a few beers daily. Denies other drug use.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress although appears
uncomfortable
HEENT: moderately icteric sclerae, dry MM, oropharynx clear,
EOMI, PERRL, no sinus tenderness
Neck: supple, JVP not elevated, no LAD
CV: Rapid rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: Foley with icteric urine
Ext: warm, well perfused, 2+ pulses, trace BLE edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
.
DISCHARGE PHYSICAL EXAM:
VS 97.6 (99.7) 117/74 (110-122/66-79) 113 (103-131) 20 97RA
(97-99RA)
I/O: PO 1500 + TF 1075 / UOP 1250 + BMx6
GENERAL: appears older than stated age, NAD, comfortable in bed
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: Tachycardic, SEM at RUSB. +S4.
LUNGS: Unlabored breathing, poor air movement. Decreased breath
sounds at right lung base to halfway up lungfields, with
bibasilar crackles.
ABDOMEN: Less distended and slightly tighter. Soft, non-tender.
EXTREMITIES: Warm and well perfused, trace edema
Pertinent Results:
ADMISSION LABS:
[**2164-2-20**] 11:00AM WBC-3.4* RBC-2.48* HGB-7.3* HCT-22.3* MCV-90
MCH-29.5 MCHC-32.9 RDW-19.0*
[**2164-2-20**] 11:00AM NEUTS-83.5* BANDS-0 LYMPHS-7.9* MONOS-7.4
EOS-0.7 BASOS-0.6
[**2164-2-20**] 11:00AM PLT COUNT-44*
[**2164-2-20**] 11:00AM GLUCOSE-167* UREA N-26* CREAT-0.7 SODIUM-126*
POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-23 ANION GAP-13
[**2164-2-20**] 11:00AM ALT(SGPT)-27 AST(SGOT)-67* ALK PHOS-112* TOT
BILI-6.3*
[**2164-2-20**] 11:00AM ALBUMIN-2.2* CALCIUM-6.9* PHOSPHATE-3.1
MAGNESIUM-1.3*
[**2164-2-20**] 11:00AM ASA-NEG ETHANOL-164* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-2-20**] 11:00AM PT-18.7* PTT-36.8* INR(PT)-1.8*
[**2164-2-20**] 11:00AM FIBRINOGE-113*
[**2164-2-20**] 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-2* PH-6.0
LEUK-NEG
[**2164-2-20**] 07:02PM URINE RBC-<1 WBC-14* BACTERIA-NONE YEAST-NONE
EPI-1
[**2164-2-20**] 11:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
DISCHARGE LABS:
[**2164-3-11**] 05:45AM BLOOD WBC-10.5 RBC-2.56* Hgb-7.8* Hct-25.3*
MCV-99* MCH-30.3 MCHC-30.7* RDW-21.9* Plt Ct-94*
[**2164-3-11**] 05:45AM BLOOD PT-31.1* PTT-44.9* INR(PT)-3.0*
[**2164-3-11**] 05:45AM BLOOD Glucose-123* UreaN-15 Creat-0.7 Na-137
K-4.2 Cl-104 HCO3-25 AnGap-12
[**2164-3-11**] 05:45AM BLOOD ALT-10 AST-30 AlkPhos-95 TotBili-3.7*
[**2164-3-11**] 05:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.5*
.
MICROBIOLOGY:
[**2164-2-20**] Blood cultures x2: no growth
[**2164-2-20**] Urine culture: no growth
[**2164-2-22**] Urine culture: no growth
[**2164-2-22**] Blood cultures x2: no growth
[**2164-2-24**] Blood cultures x2: no growth
[**2164-2-24**] Stool C. diff PCR: POSITIVE
[**2164-2-24**] Stool bacterial culture: no growth
[**2164-2-29**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-1**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-1**] Blood culture: no growth
[**2164-3-1**] Urine culture: YEAST
[**2164-3-4**] Urine culture: no growth
[**2164-3-4**] Blood cultures x2: no growth to date
[**2164-3-4**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-7**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-9**] Peritoneal fluid gram stain and culture: no growth
.
.
IMAGING:
[**2164-2-20**] RUQ US FINDINGS: The liver is diffusely echogenic,
consistent with chronic liver disease. There is a simple hepatic
cyst in the left lobe measuring 2.5 cm. The spleen is enlarged
measuring 15 cm. There is no ascites.
COLOR FLOW AND PULSE WAVE DOPPLER: The TIPS shunt is widely
patent with
wall-to-wall flow throughout. The flow velocities in the
proximal, mid and
distal portion of the TIPS shunt are 55.1, 180, and 116 cm/sec
respectively. These velocities previously were 133, 157 and 105
cm/sec respectively. The main portal vein has normal hepatopetal
flow. There is stable, expected reversal of flow within the left
portal vein. The right portal vein is patent. The hepatic veins
are patent.
IMPRESSION: Patent TIPS shunt with wall-to-wall flow throughout.
.
[**2164-2-20**] CXR:
FINDINGS: Endotracheal tube ends approximately 6.3 cm from the
carina, just above the level of medial heads of the clavicles.
Consider advancing the ET tube by another 2.5 cm for a better
seating. Bilateral lungs are remarkable for mild pulmonary
vascular congestion, prominent bilateral hila and azygos vein
which is likely from volume overload, given clinical setting.
Heart size is top normal. No pneumothorax or pleural effusion.
.
[**2164-2-21**] ABD CT:
CT ABDOMEN: There are small bilateral pleural effusions with
adjacent
compressive atelectasis and lingular atelectasis. No pericardial
effusion.
An echogenic focus at the hepatic dome (2B:97) is incompletely
imaged and
apparently new from [**2164-1-11**], too small to characterize. The
liver is
shrunken and nodular, compatible with known cirrhosis. A 2.1 cm
hypodensity in the left hepatic lobe is a cyst seen on prior
ultrasounds. A TIPS shunt is in place. The patency cannot be
assessed on this study, but it is patent on ultrasound [**2164-2-20**].
The gallbladder is absent. The spleen is enlarged to 13.8 cm.
The pancreas and bilateral adrenal glands are normal. The
kidneys enhance symmetrically and excrete contrast promptly
without hydronephrosis. A gastric diverticulum at the posterior
stomach (2A:18) is unchanged. High-density material in the
duodenum is likely related to coiling of duodenal varices,
performed [**2164-1-11**].
The small bowel is normal in course and caliber without
obstruction. There is large bowel wall thickening, predominantly
in the right colon with a large amount of adjacent stranding,
increased from [**2164-1-11**]. The findings are concerning for
colitis, probably infectious or inflammatory, less likely
ischemic given the distribution. There is a small amount of
perihepatic fluid. There is no free air. The aorta is of normal
caliber throughout. The main portal vein, splenic vein, and
proximal SMV are patent. Extensive portosystemic shunts are
again seen. The aorta is of normal caliber throughout. No
pathologically enlarged mesenteric or retroperitoneal lymph
nodes are identified.
CT PELVIS: The rectum and sigmoid colon are normal. The bladder
is normal,
with a Foley catheter in place. The uterus is normal. A small
amount of free fluid in the cul-de-sac is probably tracking down
from the abdomen. There is no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or
malignancy is seen.
IMPRESSION:
1. Findings concerning for colitis, likely infectious or
inflammatory, less likely ischemic given the distribution.
2. Cirrhosis with stigmata of portal hypertension including
ascites,
extensive portosystemic collaterals. A TIPS shunt is in place.
.
[**2164-2-20**] EGD
Findings: Esophagus:
Protruding Lesions 1 cords of grade I varices were seen in the
lower third of the esophagus.
Stomach:
Mucosa: Diffuse erythema and congestion of the mucosa were
noted in the stomach. These findings are compatible with portal
hypertensive gastropathy.
Other No active bleeding.
Duodenum:
Protruding Lesions Non bleeding varices were seen in the first
part of the duodenum.
Impression: Varices at the lower third of the esophagus
No active bleeding.
Erythema and congestion in the stomach compatible with portal
hypertensive gastropathy
Varices at the first part of the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: [**Hospital1 **] PPI
Octreotide drip
keep hct above 25
duplex for TIPS patency
If rebleeds, would get IR evaluation for TIPS pressure gradient
measurement and angioplasty if elevated gradient
.
[**2164-2-23**] CXR PA/lat: PA and lateral chest radiographs demonstrate
opacification of the left lower lobe with air bronchograms. The
patient has been entubated. There is also bibasilar atelectasis.
The heart size is mildly enlarged. Prominence of the azygos vein
and pulmonary vasculature is unchanged from [**2-20**].
IMPRESSION: Likely left lower lobe pneumonia.
.
[**2164-2-25**] CXR portable: Left PICC terminates in the mid superior
vena cava. The cardiac silhouette is enlarged and accompanied by
increased vascular pedicle width, increased pulmonary vascular
congestion, and bilateral perihilar haziness suggestive of
edema. Additionally, there persist opacities within the right
middle and right lower lobes suggestive of atelectasis.
Previously reported left lower lobe opacities have slightly
improved and could be due to either atelectasis or improving
infection.
.
[**2164-2-28**] EKG: Sinus rhythm. Prominent QRS voltage but does not
meet criteria for left ventricular hypertrophy. Since the
previous tracing of [**2164-2-20**] the rate is slower. Otherwise,
probably unchanged.
.
[**2164-2-29**] Abdominal ultrasound ascites search: A limited
examination of the four quadrants of the abdomen was performed.
A moderate amount of ascites is seen and a mark was made at the
right lower quadrant for a paracentesis to be performed by the
clinical staff.
IMPRESSION: Moderate ascites. The right lower quadrant was
marked for a
paracentesis to be performed by the clinical staff.
.
[**2164-2-29**] Portable abdominal x-ray: A single supine frontal view
of the abdomen demonstrates a non-specific bowel gas pattern
with gas in non-dilated loops of small bowel and large bowel. A
TIPS shunt is in place in the right upper quadrant of the
abdomen. Surgical clips adjacent to the TIPS shunt are
consistent with prior cholecystectomy. Evaluation for a small
amount of free air is limited due to supine positioning;
however, there is no evidence of a large amount of free
intraperitoneal air. Generalized increased opacification of the
abdomen is consistent with ascites. No portal venous gas is
appreciated.
IMPRESSION: Non-specific bowel gas pattern without evidence of
obstruction or ileus. No free air detected; however, a left
lateral decubitus film, upright film or CT would be more
sensitive for a small amount of free intraperitoneal air.
.
[**2164-2-29**] Portable chest x-ray: Single supine view was submitted
for review, this limits the evaluation of free air. There are
low lung volumes. Cardiac size is top normal. Left PICC tip is
in the mid SVC. There is no pneumothorax. If any, there is a
small right pleural effusion. Bibasilar atelectases, larger on
the right side. Streaky atelectases are also present in the left
upper lobe. There is mild vascular congestion. TIPS projects in
the right upper quadrant.
.
[**2164-2-29**] CT ABD/PELVIS W/O CONTRAST:
1. Resolution of colonic wall thickening, which was compatible
with colitis.
2. Slight increase in ascites, however likely due to fluid
overload given
interval development of anasarca and increased stranding of the
intra-abdominal fat.
3. No intra-abdominal abscess.
4. Bibasilar atelectasis, wedge-shaped volume loss at right lung
base may
indicate a small infiltrate.
5. Chronic findings including TIPS shunt (cannot assess patency
due to lack
of contrast), large gastric diverticulum, multiple secondary
findings
indication of cirrhosis and portal hypertension.
.
[**2164-3-1**] IR-guided diagnostic/therapeutic paracentesis:
Uneventful diagnostic and therapeutic ultrasound-guided
paracentesis yielding 2.35 liters of yellow ascitic fluid.
.
[**2164-3-4**] Portable abdominal x-ray: In comparison with the study
of [**2-29**], there is again generalized haziness of the abdomen
consistent with extensive peritoneal fluid. A TIPS shunt is in
place.
There is dilatation of gas-filled loops of small bowel that
appear to be out of proportion to the large bowel gas. This
raises the possibility of a
partial or early small-bowel obstruction. If this is a serious
clinical concern, CT would be the next imaging procedure.
Although there is no definite free intraperitoneal gas, though
this also could be evaluated on CT.
.
[**2164-3-4**] CT ABD W/O CONTRAST:
1. Cirrhotic liver with evidence of portal hypertension with
splenomegaly,
increased ascites, and extensive varices.
2. Bilateral small pleural effusions with overlying atelectasis.
3. Stable appearance of large gastric diverticulum.
4. Stable left paraaortic lymph node.
.
[**2164-3-6**] EKG: Sinus tachycardia. Consider left ventricular
hypertrophy by voltage. ST-T wave abnormalities of strain and/or
ischemia. Since the previous tracing of [**2164-2-28**] the rate is
faster. ST-T wave abnormalities are more prominent.
.
[**2164-3-6**] CT HEAD W/O CONTRAST: No evidence of hemorrhage or
infarction. Prominent ventricles and sulci for age.
.
[**2164-3-7**] EKG: Sinus tachycardia. Since the previous tracing ST
segment depressions may be less prominent. T wave abnormalities
persist.
.
[**2164-3-7**] IR-guided diagnostic/therapeutic paracentesis:
Ultrasound-guided therapeutic and diagnostic paracentesis with
removal of 2 L of straw-colored fluid.
.
[**2164-3-8**] EGD: A 10F nasojejunal feeding tube was placed in a
standard fashion. The tube was subsequently bridled. No
complication occured. The estimated blood loss was 2 cc.
Otherwise normal EGD to third part of the duodenum. Dobhoff is
okay to use.
.
[**2164-3-9**] CXR PA/lat: Persistent lower lung volume. Mild
cardiomegaly is accentuated by low lung volumes. Pulmonary edema
has improved, now mild. Large right lower opacity is a
combination of pleural effusion and atelectasis. This has
improved from prior study. The lower lung atelectasis has
improved. There is no pneumothorax or pleural effusion. Left
PICC tip is in the upper-to-mid SVC. NG tube is out of view
below the diaphragm. Of note, the opacity in the right lower
lobe could be due to atelectasis but superimposed infection
cannot be excluded in the appropriate clinic setting.
.
[**2164-3-9**] Abdominal ultrasound: Large amount of loculated ascites
is seen in the abdomen.
.
[**2164-3-9**] IR-guided paracentesis: Ultrasound-guided therapeutic
and diagnostic paracentesis with removal of 3L of blood tinged
ascitic fluid.
.
[**2164-3-10**] CXR (portable): Left-sided PICC line overlies mid/distal
SVC. An NG-type tube extends beneath the diaphragm beyond the
inferior edge of the film, likely extending into the duodenum.
Cardiomediastinal prominence, right effusion, underlying right
base collapse and/or consolidation, and diffuse increased
vascular markings are grossly unchanged.
.
[**2164-3-10**] LLE Ultrasound with Doppler: No DVT in the left lower
extremity.
Brief Hospital Course:
Ms. [**Known lastname 45209**] is a 43 year old lady with a hx of alcoholic
cirrhosis s/p TIPS 6 weeks prior to presentation, active
alcoholism, and recent duodenal varix bleed s/p IR guided
embolization, who was admitted with BRBPR and relative
hypotension, from a presumed upper GI bleed; she then developed
C. diff colitis, healthcare associated pneumonia and SBP.
Hospital course was also complicated by hyponatremia, a fall
without loss of consciousness, and tachycardia.
.
.
ACTIVE ISSUES:
# Upper GI bleed: Patient presented with hematochezia c/b
hypotension: Patient with prior history of gastrointestinal
bleeding from varices s/p IR-guided embolization ([**1-15**]) and EGD
with injection of glue to duodenal varix in third part of
duodenum ([**1-24**]) now presenting with BRBPR and relative
hypotension. Hematocrit was 18 at OSH and she received 2 units
PRBCS prior to transfer to [**Hospital1 18**]. Here she received two more
units of PRBCs. She was started on octreotide, pantoprazole and
ceftriaxone. She underwent liver US which showed a patent TIPS.
She then underwent EGD without clear source of bleeding. For the
rest of hospitalization, her hematocrit remained stable ~25.
.
# Colitis: While in the MICU, the patient had low grade fevers
and reent history of gastrenteritis-like illness. She complained
of severe abdominal pain, so a CT scan was obtained, showing
possible colitis. Her ceftriaxone was switched to ciprofloxacin
and Flagyl was also started for treatment of presumptive
infectious colitis. Soon after transfer to the floor, the
patient developed severe diarrhea, with stool sample positive
for C. diff. Ciprofloxacin was discontinued. She was treated
with vancomycin PO and Flagyl IV for the rest of her hospital
course. Even though the patient was counseled that opioids put
her at risk for developing toxic megacolon and could lead to
severe complications including death, she preferred receiving
low-dose opioids for pain control; these were tapered off. On
[**3-4**], she developed increasing abdominal distention with no
bowel movements overnight; x-ray and CT imaging were negative
for toxic megacolon. The patient's diarrhea and abdominal pain
improved. Stool studies for other infectious etiologies were
negative. The patient will need to continue vancomycin for a
4-week-long tapered course.
.
# HCAP: On arrival to the floor from the MICU, patient was noted
to have shortness of breath and chest discomfort, along with a
leukocytosis. CXR revealed a left lower lobe pneumonia. She was
treated with cefepime IV and vancomycin IV for healthcare
associated pneumonia. Dyspnea improved.
.
# Spontaneous bacterial peritonitis: After transfer from MICU to
the floor, patient developed increasing leukocytosis along with
worsening abdominal distention and pain. She underwent
diagnostic paracentesis on [**2-29**] that was consistent with SBP.
She continued cefepime and Flagyl IV, which had been started for
her HCAP and C. diff, respectively. When repeat
diagnostic/therapeutic tap on [**3-1**] showed worsening WBC count in
ascitic fluid, there was concern for translocation of bacteria
from the gut or from perforation. Abdominal CT from [**2-29**] did not
show obvious perforation or free air and did show an improving
colitis. She was transferred back to the MICU for closer
observation and management. In the MICU, fluconazole for
coverage of fungal infection of ascites was added to her
antimicrobial regimen. Transplant surgery was consulted who
felt this was not a perforation, and did not need surgical
intervention. Patient was watched in ICU until [**2164-3-3**] with
improvement of her abdominal exam. She was then transferred back
to the floor. She underwent three more paracenteses, which
showed signs of improving infection with resolving ascitic
leukocytosis. Abdominal pain improved.
.
# Hyponatremia: Patient has a history of hyponatremia related to
her cirrhosis. She presented with sodium of 126, which trended
down and nadired at 120. On presentation, she also had low
plasma Osm of 254 and appeared to be total body fluid
overloaded. She was place on fluid restriction, but did not want
to adhere to a low sodium diet. With reinstitution of her
diuretics and fluid restriction, sodium increased to the 130s
and remained stable.
.
# [**Last Name (un) **]: Patient's Cr trended up to peak at 4.5 during her
hospital stay from 0.7 on admisison. Etiology was prerenal
azotemia, but there was also concern for hepatorenal syndrome.
Patient was aggressively volume resuscitated with Albumin and
her Cr decreased to 0.7, where it stabilized.
.
# Tachycardia: On the day prior to discharge, patient developed
sinus tachycardia, along with a sensation of shortness of
breath. The rest of her physical exam was significant for volume
overload. CXR showed pulmonary edema. EKG was consistent with
sinus tachycardia, and LLE U/S showed no evidence of DVT. She
was diuresed with IV Lasix, and her tachycardia and dyspnea
resolved. There was also a high component of anxiety in her
symptoms.
.
.
CHRONIC ISSUES:
# Alcoholic Cirrhosis: Patient with chronic cirrhosis secondary
to alcohol ongoing alcohol abuse s/p TIPS with significant
esophageal and duodenal varices. No prior hx of esophageal
variceal bleed. MELD at discharge was 21. She continued
lactulose and rifaximin. She was counseled extensively regarding
necessity of a relapse prevention to maintain and document
sobriety after discharge in order to be considered a transplant
candidate. While in house, a Dobhoff was placed and tube feeds
started for supplemental nutrition.
.
# Active Alcoholism: Patient with [**Last Name (un) **] level of 274 at OSH. She
was placed on CIWA scale though she did not require
benzodiazepines during this admission. As above, she was
counseled extensively regarding need to maintain sobriety for
overall health and transplant consideration.
.
# Uterine Bleeding: Patient with low volume dark blood from her
cervical os per ED pelvic exam. Per ED, patient is otherwise
amenorrheic so they have raised concern for possible DIC. Since
hospitalization no further bleeding from vagina. Pelvic
ultrasound should be considered for further evaluation as an
outpatient.
.
.
TRANSITIONAL ISSUES:
# Patient should continue vancomycin PO for four weeks, tapered
as described.
# Commitment to a relapse prevention program, and documented
sobriety for three months is necessary for patient to be
considered a transplant candidate. This was discussed
extensively with the patient, her husband, and her [**Last Name (un) **].
# Please consider pelvic ultrasound for further evaluation of
uterine bleeding as an outpatient.
# PICC was left in place per request of rehab facility. Pt is
currently not on any IV medications. It should be removed as
soon as possible to reduce risk of line infection.
# Pt has Foley catheter in place currently. A voiding trial can
be attempted as pt gains strength to use a bedside
commode/bathroom.
# Code: full
# HCP: husband [**Name (NI) **] [**Telephone/Fax (1) 45334**]
Medications on Admission:
- furosemide 60 mg PO DAILY
- lactulose 10 gram/15 mL - 30 ML PO QID
- rifaximin 550 mg PO BID
- folic acid 1 mg PO DAILY
- thiamine HCl 100 mg PO DAILY
- multivitamin PO DAILY
- spironolactone 150 mg PO BID
- omeprazole 40 mg PO DAILY
- lorazepam 0.5 mg PO Q8H prn anxiety
Discharge Medications:
1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day: titrate to [**2-23**] BMs per day.
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. spironolactone 50 mg Tablet Sig: Three (3) 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. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Severe Anxiety.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
11. vancomycin 125 mg Capsule Sig: One (1) Capsule PO see taper:
-1 tab QID for 7 days ([**Date range (1) 30341**])
-1 tab [**Hospital1 **] for 7 days ([**Date range (1) 35542**])
-1 tab daily for 7 days ([**Date range (1) 45335**])
-1 tab every other day for 7 days ([**Date range (1) 45336**])
-1 tab every 3 days for 14 days ([**Date range (1) 45337**]).
Disp:*62 Capsule(s)* Refills:*0*
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
14. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary diagnosis:
Upper GI bleed
.
Secondary diagnoses:
Healthcare associated pneumonia
Severe C. diff colitis
Spontaneous bacterial peritonitis
Cirrhosis
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 45209**],
It was a pleasure to participate in your care here at [**Hospital1 1535**]. You were admitted with an upper
GI bleed, which stablized. You then developed several
infections, including a pneumonia, colitis and spontaneous
bacterial peritonitis. All these infections were treated with
appropriate antibiotics. You improved clinically and were then
discharged to a rehab facility so that you can continue to
regain your strength.
Please make the following changes to your medications:
START Vancomycin by mouth:
125 mg by mouth four times per day for 7 days ([**Date range (1) 30341**])
125 mg by mouth twice daily for 7 days ([**Date range (1) 35542**])
125 mg by mouth once daily for once 7 days ([**3-25**]-/12)
125 mg by mouth every other day for 7 days ([**Date range (1) 45336**])
125 mg by mouth every 3 days for 14 days ([**Date range (1) 45337**])
Continue to take all of your other medications as prescribed.
Please see below for your follow-up appointments.
Followup Instructions:
Department: LIVER CENTER
When: FRIDAY [**2164-3-30**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: FRIDAY [**2164-5-4**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"537.89",
"486",
"456.1",
"303.91",
"571.2",
"263.9",
"584.9",
"276.8",
"276.69",
"427.89",
"782.4",
"276.1",
"572.3",
"567.23",
"008.45",
"530.81",
"578.9",
"789.59",
"626.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.08",
"54.91",
"96.6",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
27181, 27326
|
18274, 18755
|
315, 658
|
27526, 27526
|
4818, 4818
|
28743, 29382
|
3546, 3564
|
25637, 27158
|
27347, 27347
|
25338, 25614
|
27709, 28204
|
5878, 18251
|
3604, 4240
|
27404, 27505
|
24506, 25312
|
28233, 28720
|
272, 277
|
18770, 23321
|
686, 3091
|
4834, 5862
|
27366, 27383
|
27541, 27685
|
23337, 24485
|
3113, 3345
|
3361, 3530
|
4265, 4799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,281
| 194,673
|
50988
|
Discharge summary
|
report
|
Admission Date: [**2123-9-23**] Discharge Date: [**2123-9-27**]
Date of Birth: [**2068-2-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Type B aortic Dissection
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 55 year old female transferred to the [**Hospital1 18**] for
management of a type B dissection. She developed acute onset of
back and chest pain and promptly presented to an outside
emergency department. The CT scan revealed an aortic dissection
distal to the left subclavian to 2cm below the renal arteries.
Past Medical History:
anxiety,
depression
hysterectomy,
tonsillectomy
Social History:
neg tobacco
neg alcohol
Family History:
non contributary
Physical Exam:
NEURO: Grossly intact
PULM: Clear
HEART: RRR
ABD: Benign
EXT: warm, no edema
Pertinent Results:
[**2123-9-23**] 02:20AM PT-12.8 PTT-25.7 INR(PT)-1.1
[**2123-9-23**] 02:20AM WBC-12.5* RBC-3.79* HGB-12.2 HCT-35.2* MCV-93
MCH-32.2* MCHC-34.7 RDW-13.1
[**2123-9-23**] 02:20AM ALT(SGPT)-10 AST(SGOT)-18 LD(LDH)-266*
CK(CPK)-44 ALK PHOS-70 TOT BILI-0.2
[**2123-9-23**] 02:20AM GLUCOSE-134* UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-20* ANION GAP-19
[**2123-9-23**] 03:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2123-9-26**] 06:50AM BLOOD WBC-6.4 RBC-3.54* Hgb-11.1* Hct-33.5*
MCV-95 MCH-31.5 MCHC-33.2 RDW-13.3 Plt Ct-205
[**2123-9-26**] 06:50AM BLOOD Plt Ct-205
[**2123-9-26**] 06:50AM BLOOD Glucose-106* UreaN-7 Creat-0.6 Na-142
K-3.6 Cl-109* HCO3-24 AnGap-13
CT scans:
[**2123-9-23**] - Type B aortic dissection, originating just distal to
the origin of left subclavian extending approximately 2 cm below
and below the origin of the renal arteries. The celiac, SMA and
the left renal artery appeared to be originating from the true
lumen. There appears to be a small flap extending into the right
renal artery.
[**2123-9-27**] - 1. Type B aortic dissection extending from the distal
arch to just below the level of the renal artery origins. No
interval progression.
2.Renal arteries and mesenteric arteries are patent.
The right renal artery origin is most likely opacified from the
false lumen. Selective renal CTA may be considered for more
definitive assessment.
Both left renal arteries from the true lumen.
2. Moderate left basal pleural effusion which has shown some
interval enlargement in size.Some dependent basal atelectasis.
[**2123-9-23**] EKG
Normal sinus rhythm with occasional atrial premature beats and
non-specific ST-T wave abnormalities. No previous tracing
available for comparison.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2123-9-23**] for further
management of her aortic dissection. Intravenous esmolol was
switched to oral labetalol. Her systolic blood pressure was
maintained less then 90 mmHg. A vascular surgery consult was
obtained. A repeat CT Scan was performed after 24 hours which
showed no interval progression of her dissection. She was seen
and worked-up by the cardiology service. A repeat CT scan at
another 24 hours again showed no progression of her dissection.
Ms. [**Known lastname **] continued to make steady progress and was discharged
home. She will follow-up with the vascular surgery service as an
outpatient.
Medications on Admission:
Zoloft
Ativan
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Labetalol 300 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Type B aortic dissection.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Monitor BP and make sure it is less than 120/80.
Call with any increase in back pain.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 2 weeks.
Completed by:[**2123-10-7**]
|
[
"511.9",
"441.02",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3752, 3810
|
2778, 3463
|
302, 310
|
3880, 3888
|
939, 2755
|
4068, 4241
|
809, 827
|
3527, 3729
|
3831, 3859
|
3489, 3504
|
3912, 4045
|
842, 920
|
238, 264
|
338, 679
|
701, 751
|
767, 793
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,695
| 139,641
|
6311
|
Discharge summary
|
report
|
Admission Date: [**2185-7-22**] Discharge Date: [**2185-8-10**]
Date of Birth: [**2119-1-7**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66yo F with h/o chronic pancreatitis s/p Puestow procedure
(lateral pancreaticojejunostomy)in [**9-20**], anorexia/depression,
COPD & anemia is presenting with epigastric pain radiating to
the back for 6 months. It has been worsening for the past few
days. It is dull in quality with occasional sharpness associated
with nausea and nonbilious/nonbloody vomiting. Pt states pain is
similar to her previous pancreatitis. + weight loss of 6 lbs
over ths past 2 month. Pain is worse with food. Denies any f/c.
Pt was seen by Dr. [**First Name (STitle) 679**] last week and was prescribed with bland
food without fat. Pt denies any ETOH use.
.
ROS: negative for exertional chest pain, dyspnea on exertion, LE
edema, jaundice, hematemasis, hematochezia, melena, diarrhea,
constipation.
.
Pt seen in ED, t 97, hr 62, bp 104/66, rr 18, 98% ra. Amylase
121, lipase 90. LFTs unremarkable. CBC with chronic anemia, but
o/w unremarkable. Lytes unremarkable. CT abd demonstrated
chronic pancreatitis. Given dilaudid, zofran and 1 L NS.
Transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for further management.
.
Past Medical History:
1. Chronic pancreatitis s/p Puestow procedure [**2182-9-25**]
2. Status post cholecystectomy.
3. Known renal infarction.
5. Anorexia and bulimia times 25 years.
6. Gastritis.
7. COPD
8. Pulmonary nodules LUL, LLL believed inflammatory etiology.
8. Bronchiectasis.
9. s/p ORIF in [**2172**] complicated by aspiration pneumonia and ARDS
requiring mechanical ventilation times six weeks.
10. Depression.
12. Spinal stenosis s/p two back surgeries
13. Hemorrhoids
14. Chronic headaches; MR in [**1-20**] microvascular ischemic
changes.
15. Anemia, baseline HCT 33-34.
16. s/p tubal ligation.
17. s/p appendectomy.
18. s/p bilateral varicose vein removal
19. Renal mass
20. Depression
Social History:
Social History:
Patient has 4 children, lives alone.
ETOH: quit many years ago, previously 2 drinks per night
TOB: started at age 11, 1 pack/d, about 50 pack-years quit cold
[**Country 1073**] few years ago
IVDU: none
Family History:
Unknown, adopted
Physical Exam:
on admission to floor
VS 98.3 100/68, 67, 20, 98% on RA
GEN - comfortable, pleasant, elderly female
HEENT - anicteric, PERRL, EOMI, dry mucous membrane. No OP
lesions.
Neck - No JVD, no cervical LAD
CV- RRR without m/r/g
PULM?????? CTA bilaterally, no wheezes
Abd ?????? BS present, no distension, mild epigastric tenderness, no
rebound or voluntary guarding. no palpable masses. no CVA
tenderness, no cullens, no [**Doctor Last Name 352**] turners
EXT ?????? Warm, well perfused, DP 2+ bilaterally, no edema
NEURO ?????? A&Ox3, CNII-XII intact, no focal deficits.
.
Pertinent Results:
CT ABD/Pelv [**2185-7-22**] IMPRESSION:
1. Unchanged enhancing lesion in the lower pole of the right
kidney,
previously characterized as a renal cell carcinoma.
2. Bilateral small renal hypodensities likely represent simple
cysts.
3. Small amount of ascites.
4. Chronic pancreatitis.
5. Severe degenerative changes of the lumbar spine with grade 1
anterolisthesis of L4 over L5.
.
Chest CTA [**7-26**]
IMPRESSION:
1. No pulmonary embolus.
2. Diffuse predominantly peripheral ground-glass opacities.
Primary considerations are ARDS and multifocal pneumonia.
3. Moderate sized bilateral pleural effusions right greater than
left.
.
Chest CT non contrast [**7-28**]
IMPRESSION:
1. Diffuse consolidations in both lungs have worsened compared
to [**7-26**], most likely reflecting severe pulmonary edema, and
multifocal pneumonia and/or hemorrhage.
2. Enlarging non-transudative pleural effuisions.
3. Left hilar lymphadenopathy, probably related to the acute
process.
4. Small lingular nodule increased in density on [**2185-7-26**]
compared to [**2182-9-8**]. This finding should be reassessed
after resolution of the acute disease, for possible
bronchoalveolar carcinoma.
.
CXR on [**2185-8-7**] IMPRESSION: Improving interstitial opacities
since the prior chest x-ray.
.
[**2185-8-10**] 04:57AM BLOOD WBC-11.2* RBC-2.75* Hgb-8.8* Hct-27.3*
MCV-99* MCH-32.0 MCHC-32.2 RDW-15.4 Plt Ct-634*
[**2185-7-29**] 02:44PM BLOOD Ret Aut-1.7
[**2185-8-10**] 04:57AM BLOOD Glucose-75 UreaN-30* Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-33* AnGap-11
[**2185-8-8**] 05:36AM BLOOD ALT-108* AST-33 AlkPhos-82 Amylase-56
TotBili-0.2
[**2185-8-8**] 05:36AM BLOOD Lipase-39
[**2185-7-28**] 04:55AM BLOOD proBNP-2736*
[**2185-8-9**] 06:12AM BLOOD CYSTIC FIBROSIS, DNA PROBE ANALYSIS-PND
[**2185-7-31**] 10:53AM BLOOD ANTI-GBM-Test
Brief Hospital Course:
Pt was initially admitted for pain control of acute on chronic
pancreatitis. However, after aggressive fluid resuscitation the
pt developped significant respiratory distress. CXR demonstrated
mild copd and mild b/l effusions. EKG at the time was without
evidence of ischemia. Pt was ruled out for MI by enzymes. Given
persistent O2 requirement, CTA checked on [**7-26**] which
demonstrated no PE, but "diffuse predominantly peripheral
ground-glass opacities consistent with multifocal pneumonia; the
differential diagnosis would include pulmonary
edema from ARDS," and moderate b/l effusions. Pt was started on
levofloxacin for empirical coverage on [**7-27**]. Pt had been having
intermittent low-grade temps to 100. On [**7-28**] at 4 am, pt had
spike to 101.2. Abx switched to from levoflox to vanc/zosyn.
.
Pt triggered on the floor for resp rate>30 & sats down to low
80s, she was started on a NRB and sats came up to high 80s. CXR
showed evidence of new pulm edema, pt was given lasix 20 mg iv
x3 and had good urine out-put though repeat cxr showed worsened
edema. Pt was transferred to the MICU for continued respiratory
distress and hypoxia.
.
In the MICU, pt diuresed but she continued to be hypoxic and was
managed with non invasive ventilation. Pt had significant
difficulty weaning and was eventually started on high dose
steroids for treatment of possible BOOP/ARDS or eosinophilic
pna. Pt showed significant clinical improvement with high dose
steroids and was weaned down to 3LNC over 3days. She was
transfered back to the floor on [**8-7**] for continued management.
.
Pt did well on the floor, her PO intake improved and TPN was
discontinued. Her abd pain was well controlled with PO pain
medications and was not limiting intake. Pt was weaned to RA
and was sating well (94%) on RA. Pt worked with PT and was
cleared to complete all ADLs independantly. Pt was followed by
pulmonology and they recommended a four week steroid taper as
well as follow up with Dr. [**Last Name (STitle) 1632**] in [**Hospital **] clinic. Pt was
discharged in stable condition with plan of VNA services to help
with home pain medications. Insulin regimen was d/c'd per PCP
recommendations and pt will be followed closely in the next few
weeks by Dr. [**Last Name (STitle) 16258**].
Medications on Admission:
Prozac 40mg qday
Lipram 2 talbets with meals and 2-3 tablets with snack
Mellaril 25mg qday
Trazodone 150mg qday
Discharge Medications:
1. Prozac 40 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
2. Trazodone 150 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Thioridazine 25 mg Tablet Sig: One (1) Tablet PO once daily
().
Disp:*30 Tablet(s)* Refills:*0*
4. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*90 * Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain for 7 days.
Disp:*24 Tablet(s)* Refills:*0*
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
take four pills each day for 5days, then take three pills each
day for 7days, then take 2 pills each morning for 7days, then
take 1 pill each day for 7 days then stop.
Disp:*62 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
- acute on chronic pancreatitis
- steroid responsive lung injury
Secondary:
- Anorexia/Bulimia
- COPD
- Chronic Pancreatitis s/p peustow procedure
- hx pulm nodules
- major depression
- chronic headaches
- anemia (baseline hct 33)
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with an acute on chronic pancreatitis flare.
Your abdominal scan showed no evidence of issues requiring
surgical intervention. However, your hospital course was
complicated by difficulty breathing that has improved
significantly with steroids. You should continue taking
Prednisone 10mg by mouth as described in the taper (4pills per
day for 5 days, then 3pills per day for 7days, then 2pills per
day for 7 days then 1 pill per day for 7days then stop.)
Please take all of the rest of your medications as you were
prescribed prior to admission to the hospital. We will also
give you medication to take for abdominal pain and a visitng
nurse will help to educate you on how to take these pills at
home. Please contact your PCP if your symptoms worsen or if you
experience severe abdominal pain, chest pain, shortness of
breath, fever, chills or any other general worsening of
condition you should go directly to the emergency room.
Followup Instructions:
Dr. [**Last Name (STitle) 16258**] would like you to call and make a follow up appt to
see him in the next 7 days.
You have a follow up appt on [**9-6**] at 9:30am with Dr.
[**Last Name (STitle) 1632**] (Pulmonary) You should come into the hospital about
30min before this appointment, go into the [**Hospital Ward Name 23**] building up
to the fourth floor to get a chest x-ray in radiology, then
continue to the [**Location (un) 436**] for a breathing test and a follow up
appt with Dr. [**Last Name (STitle) 1632**].
|
[
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"285.29",
"263.9",
"507.0",
"496",
"189.0",
"296.30",
"E932.0",
"518.81",
"790.5",
"275.42",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"93.90",
"99.05",
"99.07",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
8516, 8565
|
4847, 7136
|
286, 292
|
8849, 8858
|
3022, 4824
|
9860, 10383
|
2402, 2420
|
7298, 8493
|
8586, 8828
|
7162, 7275
|
8882, 9837
|
2435, 3003
|
231, 248
|
320, 1448
|
1470, 2151
|
2183, 2386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,634
| 197,412
|
53500
|
Discharge summary
|
report
|
Admission Date: [**2137-4-23**] Discharge Date: [**2137-5-10**]
Date of Birth: [**2075-9-7**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Glyburide
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Sypmtomatic AAA
Major Surgical or Invasive Procedure:
s/p pararenal AAA repair with aortobifem bypass & R renal artery
reimplantation.
History of Present Illness:
This 61-year-old gentleman has a 5.1 cm aneurysm of the
infrarenal aorta which is tender on examination. He is not a
candidate for endovascular repair
based on the quality of his proximal neck. He has a high grade
stenosis at the origin of his right renal artery.
Past Medical History:
PMH: CAD s/p MI [**2124**], HTN, h/o perforated diverticulitis, benign
vocal cord polyps [**2108**], depression, polysubstance abuse
PSH: 4V CABG [**2124**], bone graft L wrist mid-70s, colectomy &
colostomy [**2127**], colostomy reversal [**2128**], hernia repair, open CCY
Social History:
Pt states he alone lives in an apartment for "elderly and
disabled" people in [**Location (un) 7913**], and had not been receiving
any home services there prior to admission. He states he does
have a large group of friends including a long
relationship with a deacon.
Denies alcohol and tobacco
Family History:
He denies having any family (no children or siblings, and
parents are deceased).
Physical Exam:
afvss
alert / oriented
supple / farom
cta
rrr
benign abdomen with surgicla inc healing well
distal pulses palp
Pertinent Results:
[**2137-5-8**] 06:20AM BLOOD
WBC-9.0 RBC-3.34* Hgb-10.1* Hct-30.4* MCV-91 MCH-30.3 MCHC-33.3
RDW-14.7 Plt Ct-479*
[**2137-5-8**] 06:20AM BLOOD
PT-15.1* PTT-84.5* INR(PT)-1.3*
[**2137-5-8**] 06:20AM BLOOD
Glucose-130* UreaN-22* Creat-1.4* Na-136 K-3.9 Cl-105 HCO3-24
AnGap-11
[**2137-4-29**] 09:56AM BLOOD
ALT-26 AST-14 LD(LDH)-535* AlkPhos-73 TotBili-0.5
[**2137-5-8**] 06:20AM BLOOD
Calcium-7.6* Phos-2.8 Mg-2.0
[**2137-5-1**] 02:49AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2137-5-1**] 2:34 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2137-5-1**]):
[**10-19**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2137-5-3**]):
OROPHARYNGEAL FLORA ABSENT.
SERRATIA MARCESCENS. MODERATE GROWTH.
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
RADIOLOGY Final Report
[**2137-5-8**] 5:15 PM
CT HEAD W/O CONTRAST
Reason: Assess for intracranial processes/bleed
INDICATION: 61-year-old man with repair of aortic aneurysm and
confusion and dementia. Please evaluate for intracranial
processes.
No comparison is available.
TECHNIQUE: Non-contrast head CT.
FINDINGS: No edema, masses, mass effect, hemorrhage, or
infarction is noted. The ventricles and sulci are mildly
prominent consistent with age-appropriate involutional changes.
The periventricular white matter hypodensities are consistent
with small vessel disease. The visualized portion of paranasal
sinuses are clear. The mastoid air cells are filled with fluid
most likely related to the recent intubation. Note is also made
of calcification within the intrapetrosal and intracavernosal
portion of the both carotid arteries and in the vertebral
arteries.
IMPRESSION: No acute intracranial pathology including no
hemorrhage.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 109987**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 109988**]Portable TTE
(Focused
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.48 >= 0.29
Left Ventricle - Ejection Fraction: 70% to 80% >= 55%
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
TR Gradient (+ RA = PASP): *24 to 26 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Hyperdynamic LVEF >75%.
RIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity.
Borderline normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS. Normal
PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views.
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF 70-80%). The right ventricular cavity is borderline dilated
with borderline normal free wall function. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2137-4-29**], the left ventricle is now hyperdynamic. Right
ventricular size and function appear similar grossly, but the
right ventricle is suboptimally visualized in both studies,
precluding definitive assessment and comparison.
[**2137-5-6**] 9:29 PM
CHEST (PORTABLE AP)INDICATION: Shortness of breath
As compared to the previous examination, the nasogastric tube
and the central venous access line has been removed. The cardiac
silhouette is of unchanged size. The pre-existing subtle left
basal opacities have cleared; the right basal opacities are
slightly more extensive than on the previous examination. There
is no evidence of pleural effusion. No other relevant changes.
[**2137-4-27**] 2:48 pm STOOL CONSISTENCY: WATERY Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2137-4-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Brief Hospital Course:
Pt admiited and preop'd for AAA repair
Abdominal aortic aneurysm with right renal artery stenosis and
bilateral iliac artery
occlusive disease.
PROCEDURE:
Resection and repair of abdominal aortic aneurysm.
Eversion endarterectomy and reimplantation of right renal artery
into graft.
Repair of aneurysm with 20 x 10 aortobifemoral bypass.
Tolerated the procedure well.. No complications.
Transfered to the [**Year/Month/Day 42137**] in stable condition
While in the [**Name (NI) **] pt was weaned from pressure support. It was
noticed that the patient had loose stool with rising lactate.
Stat GS consult for endoscopy, high suspicion for ischemic
colitis.
Imaging: Colonoscopy - 30cc from anal verge - no signs of
ischemia
followed lactates and base excess, all trending down. Pt
stablalizes.
Pt also recieved Blood products for blood loss in the OR.
Pt had runs of V tach and paroxysmal atrial fibrillation.
Contolled wwith amiodarone. On DC amiodarone to be weaned to 200
qd. Pt to follow-up with PCP. [**Name10 (NameIs) **] was seen by cardiology here at
the hospital. Medically treated. he did recieve a echo, with
preserved EF. Pt als had increase BMP during this time frame.
This was thought to be related to CHF exaserbation from fluids.
Pt diuresed aggressively. BNP improved. Pt also had increase in
Troponins secondary to demand ischemia from the CHF
exaserbation.
Pt lumbar drain removed - no sequele
Pt had hard time weaning from vent / febrile / diagnosed with
pna, broad spectrum AB. CX's obtained. Currently on Cipro. Pt
was pan cx'd. all other cx's negative.
Pt finally extubated POD # 10 - On extubation. pt confused. Non
focal nuerological work-up, Head Ct negative Confusion thought
to be from post op psycosis. ON Dc pt is cleared. Does not
require 1:1 sitter.
During the time in the [**Name (NI) 42137**] pt had ARF - this was thought to
related to aggressive diuresis. Once his CHF resolved from the
diuresis. His creat improved. On Dc his creat is 1.4.
In the interim pt did get TF for nutrition.
Pt transfered to the [**Name (NI) **] in stable condition.
In the [**Name (NI) **] pt progressed with PT / his confusion cleared. He
was then transfered to the floor in stable condition.
His tele was DC, his foley removed. On DC he is taking PO and
urinating
Medications on Admission:
[**Last Name (un) 1724**]: Atenolol 50', Lipitor 40', Cyclobenzaprine 10''', clonidine
0.2", Imdur 30', Lisinopril 40', Lorazepam 1-prn, Meclazine
25''', Metformin 1000", Niacin SR 1000-hs, Nifedipine 90',
Pantoprazole 40', Seroquel 25''', Tramadol 50-100-prn, Buspirone
10''', Motrin 800'''
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
12. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
15. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
16. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
19. Insulin
Insulin SC Fixed Dose Orders
Lunch
Glargine 10 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-60 oj and cracker
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-200 mg/dL 4 Units 4 Units 4 Units 4 Units
201-240 mg/dL 6 Units 6 Units 6 Units 6 Units
241-280 mg/dL 8 Units 8 Units 8 Units 8 Units
281-320 mg/dL 10 Units 10 Units 10 Units 10 Units
321-360 mg/dL 12 Units 12 Units 12 Units 12 Units
> 360 mg/dL Notify M.D.
20. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): taper as follows
400 [**Hospital1 **] x 7 days
then
200 [**Hospital1 **] x 7 days
then 200 qd therafter.
21. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed.
22. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehab and Nursing Center
Discharge Diagnosis:
aaa
anemia secondary to AAA repair requiring blood products
post op phsycosis
V-tac postoperative
afib post operative
r/i for MI - demand ischemia, treated medically
ARF
CHF systolic acute - resolved / preserved EF
depression, polysubstance abuse
Discharge Condition:
good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-2**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**1-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2137-5-23**] 1:15
Call PCP and schedule an appointment immedialty
Completed by:[**2137-5-10**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
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12444, 12514
|
7249, 9550
|
307, 390
|
12807, 12814
|
1544, 7226
|
15553, 15789
|
1314, 1396
|
9892, 12421
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12535, 12786
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9576, 9869
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12838, 15100
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15126, 15530
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1411, 1525
|
252, 269
|
418, 684
|
706, 984
|
1000, 1298
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,478
| 113,289
|
47132
|
Discharge summary
|
report
|
Admission Date: [**2130-9-1**] Discharge Date: [**2130-9-5**]
Service: MEDICINE
Allergies:
Vioxx / Bactrim / Codeine / Aspirin / Ranitidine
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
s/p cardiac catheterization
History of Present Illness:
88 year old female with PMH significant for HTN, DM who was
brought by EMS to [**Hospital1 18**] ER for chest pain and diaphoresis. Per
ED intake BP in field 68/p, ASA given. Patient's presenting
vitals in ED were HR 92, BP 148/91, 100 NRB, however shortly
after presentation patient became hypotensive with BP 50/30. EKG
demonstrated ST elevations lead I, lead aVL, V1, V2; ST
depression lead III, aVR. Patient was taken emergently to
cardiac cath which demonstrated thrombus with occlusion in
proximal LAD; wiring of this lesion restored flow, export
removed clot, however it traveled to LCx. Patient then began
having recurrent chest pain, respiratory distress, and
hypotension. She was intubated and an IABP was placed. A small
amount of residual thrombus remained in the LCx near the OM1. No
stents were placed as no underlying plaque apparent. Patient was
started on integrilin and heparin and transferred to the CCU for
further care.
.
While in the CCU RN noticed blood in the oropharynx, while
placing an OG patient regurgitated approximately 25 cc of bright
red blood with clots. Upon placement of OG approximately 10 cc
of bright red blood was suctioned. Patient was transfused 2
units pRBC, started on IV PPI and GI consulted. EGD demonstrated
diffuse friable mucosa with clotted blood in the lower third of
esophagus and GE junction. Blood clot felt to be partially
tamponading the bleed. For full report please see reports below.
GI recommended conservative care unless clinical picture changes
overnight.
.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes insulin dependent, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2116-6-18**]
1.)Coronary angiography of this codominant system showed single
vessel coronary artery disease. The left main was without
significant stenosis, and the LAD was also without stenosis, but
the first diagonal had an ostial 50% lesion. The circumflex had
no
significant disease. The RCA was also without any significant
stenoses.
2.) Resting hemodynamics showed normal right and left sided
filling
pressures (RVEDP 7, LVEDP 5) with a mean PCWP of 6. The cardiac
output was normal at 5.5 with an SVR of 1207 and a PVR of 58.
3.) Left ventriculograpy revealed a normal ejection fraction of
62%
with mild mitral regurgitation and no significant wall motion
abnormalities.
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- diverticulosis [**2127**] requiring 8 units transfusion with
negative angiogram.
- grade 1 internal hemorrhoids
- sigmoid diverticulitis with an adjacent abscess [**9-/2129**]
- Afib: not on coumadin
- Chronic diarrhea
- Asthma
- Gout
- Recurrent urinary tract infections
- gastroesphogeal reflux
- Tremor: essential tremor, followed previously by Dr. [**Last Name (STitle) 17281**]
- Chronic Renal Failure
- Choledocholithiases/cholangitis ([**2126-4-20**]): found to have
pseudomonas bacteremia, treated with ceftazidime and flagyl, and
referred for cholecystectomy but patient refused
- Neuropathic pain
- Right hip fracture
- bilateral knee replacements
- right leg pins
- cataract repair
Social History:
No alcohol, tobacco, or other drugs. Currently living with her
daughter in [**Location (un) 686**]. From [**State 2690**] originally. Three children,
six grandkids, 7 greatgrandkids
Family History:
Father died of MI at 43 yo. Maternal history of breast cancer.
Uncle with stomach cancer, uncle with liver cancer, brother with
prostate cancer. Brother and 2 daughters with diabetes.
Physical Exam:
VS: T=92.9 BP=118/39 HR=88 RR=vent O2 sat=100% on FiO2 1
GENERAL: Opens eyes to name. Intubated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Blood surrounding ET
tube.
NECK: No JVP appreciated.
CARDIAC: RRR, IABP noises, unable to appreciate murmurs, rubs,
gallops.
LUNGS: Coarse breath sounds bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Cold feet, pulses not palpable.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2130-9-1**] 08:45AM BLOOD WBC-9.8# RBC-2.75* Hgb-8.5* Hct-25.1*
MCV-91 MCH-30.8 MCHC-33.8 RDW-16.2* Plt Ct-193
[**2130-9-1**] 08:45AM BLOOD PT-19.2* PTT-43.3* INR(PT)-1.8*
[**2130-9-1**] 10:00AM BLOOD Glucose-273* UreaN-61* Creat-1.9* Na-134
K-3.8 Cl-107 HCO3-16* AnGap-15
[**2130-9-1**] 03:05PM BLOOD Calcium-8.0* Phos-4.0 Mg-1.8
Brief Hospital Course:
In summary, this is a 88 year old female with DM, HTN who
presented with STEMI and was brought emergently to cath lab, was
transferred to the CCU following procedure with IABP given
hypotension. Hospital course was complicated by upper GI bleed,
slow afib requiring cardiopulmonary resusitation. The pt was
made DNR during the admission and passed on [**2130-9-5**] at 12:08 AM
while in the CCU, cause of death noted to be cardiogenic shock
following STEMI.
.
# CORONARIES: Patient presented with STEMI. During cath patient
had successful thrombectomy of proximal LAD occlusion with 20%
residual stenosis. However, developed acute occlusion of OM (due
to an embolus) treated with thrombectomy and PTCA (2.5x12mm
balloon) with a 60% residual thrombotic occlusion but
restoration of flow. Patient was unstable during procedure and
consequently was intubated and IABP placed. No stent was placed
during procedure. She was transferred to the CCU on IABM,
integrillin, hepain. Attempts were made to wean the balloon
pump but were unsuccessful due to hypotension. On day 3 of the
hospitalization, family meeting was held and pt was made CMO,
IABP weaned, pt started on morphine gtt.
.
# PUMP: ECHO performed on the [**9-2**] showed EF of 30% to 35% with
mild regional left ventricular systolic dysfunction and dilated
right ventricle with moderate regional systolic dysfunction. New
changes secondary to ACS.
.
# RHYTHM: Sinus. Patient has history of A Fib, patient
presumably on Verapamil for rate control. No anti-coagulation
had been given in the past due to prior history of GI bleed.
During this admission, she developed slow afib and the family
was called and decided to make DNR after the first code, no
escalation of care.
.
# Upper GI bleed: EGD demonstrates friable esophagus with blood
clot at GE junction. Patient's HCT and hemodynamics currently
stable. Due to ballon pump patient was initially placed on
heparin, started on IV PPI. Crits were followed.
.
# Diabetes: Insulin sliding scale
.
# Hypertension: Outpatient Lisinopril, Lasix and Verapamil were
held due to hypotension after cath
.
# Chronic Renal Failure: Recent creatinine range as outpatient
1.3 - 1.9. During this admission, pt developed [**Last Name (un) **] with
creatinine rising to 2.3, unclear etiology but concerning for
pre-renal vs cholesterol emboli vs contrast-induced nephropathy
(less likely due to timing of onset).
.
# Shock: on day 2 of the admission, pt developed mixed
cardiogenic/septic shock, 2 blood cxs growing gram + cocci, was
started on vanc/cefepime for broad coverage.
.
# Coagulopathy: Pt with declining platelets, hct, concerning for
DIC, platelet distruction in the setting of IABP.
.
# Asthma: Patient intubated.
.
# Gout: Hold Allopurinol in acute setting.
.
# GERD: IV PPI given UGI bleed.
Medications on Admission:
MEDICATIONS: per OMR - unable to obtain from patient
ACETAMINOPHEN - 500 MG CAPLET - 2 TABS BY MOUTH Q 8 HRS
ALBUTEROL SULFATE [PROVENTIL HFA] - 90 mcg HFA Aerosol Inhaler -
2 puffs(s) inhaled tid prn
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth twice a day
ATORVASTATIN - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
FUROSEMIDE - 20 mg Tablet - one Tablet(s) by mouth every day
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet
IPRATROPIUM BROMIDE [ATROVENT]
LISINOPRIL - 10 mg Tablet - one Tablet(s) by mouth daily
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 (One) Tablet, Delayed Release (E.C.)(s) by mouth twice a day
TRAMADOL - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - 50 mg
Tablet - one Tablet(s) by mouth once a day as needed for prn
pain
VERAPAMIL - 120 mg Cap,24 hr Sust Release Pellets - 1 Cap(s) by
mouth once a day
ZAFIRLUKAST [ACCOLATE] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth twice a day
.
Medications - OTC
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) - 500
mg Tablet, Chewable - Tablet(s) by mouth
DIPHENHYDRAMINE HCL [BENADRYL] - (OTC) - Dosage uncertain
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
14 units subcutaneous every morning and 10 units subcutaneous
every evening
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE] - 25 gauge X
1"
Syringe - as directed twice a day one ml syringe, brand name med
necessary, no substitutions - No Substitution
LACTASE [LACTAID] - (Prescribed by Other Provider) - Dosage
uncertain
LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) - 2
mg
Tablet - 4 Tablet(s) by mouth every other day
MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Tablet -
1 Tablet(s) by mouth once a
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
STEMI/cardiogenic shock
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"585.9",
"403.90",
"V43.64",
"410.01",
"274.9",
"530.7",
"562.10",
"493.90",
"427.31",
"V58.67",
"584.9",
"250.00",
"276.2",
"785.51",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.61",
"99.20",
"96.71",
"00.41",
"00.66",
"37.22",
"88.55",
"88.52",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9394, 9403
|
4742, 7545
|
265, 294
|
9470, 9479
|
4384, 4719
|
9532, 9539
|
3652, 3837
|
9365, 9371
|
9424, 9449
|
7571, 9342
|
9503, 9509
|
3852, 4365
|
1957, 2708
|
215, 227
|
322, 1845
|
2739, 3436
|
1867, 1937
|
3452, 3636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,569
| 169,655
|
11943
|
Discharge summary
|
report
|
Admission Date: [**2134-2-22**] Discharge Date: [**2134-3-3**]
Date of Birth: [**2063-4-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lopid / Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2-22**] Intubation and line placement
[**2-24**] Mitral Valve Repair (28mm Physio ring)
History of Present Illness:
70 year old male with history of myocardial bridge with
progressively worsening chest pain and dyspnea over the last 6
months
Past Medical History:
Elevated cholesterol
Sleep apnea
Mitral valve prolapse
Mitral regurgitation
depression
anxiety
lipoma
celiac sprue
Social History:
works as architect and painter
20 pack year history
3 drinks daily
lives with spouse
Family History:
mother had MI
father deceased at 97
Physical Exam:
Skin unremarkable
HEENT unremarkable
Neck supple full ROM
Chest CTA bilat
Heart RRR 3/6 SEM
Abd soft, NT, ND
Extremeties warm well perfused no edema
Varicosities none
neuro grossly intact
Pertinent Results:
[**2134-3-3**] 09:55AM BLOOD WBC-7.9 RBC-3.53* Hgb-10.3* Hct-31.5*
MCV-89 MCH-29.2 MCHC-32.6 RDW-13.9 Plt Ct-381
[**2134-2-22**] 03:42PM BLOOD WBC-4.8 RBC-4.49* Hgb-13.1* Hct-37.8*
MCV-84 MCH-29.2 MCHC-34.7 RDW-14.5 Plt Ct-158
[**2134-2-24**] 12:46PM BLOOD Neuts-84.5* Bands-0 Lymphs-13.1*
Monos-1.0* Eos-1.3 Baso-0.1
[**2134-3-3**] 09:55AM BLOOD Plt Ct-381
[**2134-2-24**] 02:09PM BLOOD PT-13.7* PTT-32.7 INR(PT)-1.2*
[**2134-2-22**] 03:42PM BLOOD Plt Ct-158
[**2134-2-22**] 03:42PM BLOOD PT-13.9* PTT-150* INR(PT)-1.2*
[**2134-2-24**] 12:46PM BLOOD Fibrino-301
[**2134-3-3**] 05:00AM BLOOD Glucose-90 UreaN-29* Creat-1.2 Na-142
K-4.6 Cl-104 HCO3-26 AnGap-17
[**2134-2-22**] 05:29PM BLOOD Glucose-93 UreaN-21* Creat-1.0 Na-139
K-4.0 Cl-107 HCO3-22 AnGap-14
[**2134-3-1**] 05:10AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.6
CHEST (PA & LAT) [**2134-3-3**] 9:48 AM
CHEST (PA & LAT)
Reason: evaluate rt ptx
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with s/p mv repair
REASON FOR THIS EXAMINATION:
evaluate rt ptx
PA AND LATERAL CHEST [**3-3**]:
HISTORY: Mitral valve repair. Evaluate pneumothorax.
IMPRESSION: PA and lateral chest compared to [**3-1**] and 15:
Small right pneumothorax with apical and anterior components has
decreased minimally since [**3-2**]. Small bilateral pleural
effusions, right greater than left, have also decreased
slightly. Postoperative cardiomediastinal silhouette is mildly
enlarged but unchanged. Aside from mild bibasilar atelectasis,
lungs are clear. There is no pulmonary edema.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 37595**] (Complete)
Done [**2134-2-24**] at 1:57:38 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2063-4-13**]
Age (years): 70 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for mitral valve repair
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2134-2-24**] at 13:57 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 65% to 70% >= 55%
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.0 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA. Mild
spontaneous echo contrast in the body of the LA. No
mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness, cavity size,
and global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in aortic arch. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Partial
mitral leaflet flail. Mild mitral annular calcification.
Eccentric MR jet. Moderate to severe (3+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-CPB The left atrium is moderately dilated. The left atrium
is elongated. Mild spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in 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%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
partial mitral leaflet flail involving the P2 scallop is seen.
An eccentric, anteriorly directed jet of moderate to severe (3+)
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results in the operating room at the time of the study.
POST-CPB Normal biventricular systolic function. A mitral valve
annuloplasty ring is in situ. It appears well seated. No mitral
regurgitation is appreciated. The mean pressure gradient across
the mitral valve is 8 mm Hg with a maximum pressure of 13 mm Hg
at a time when the cardiac output was about 7.5 liters/min. No
other changes from the pre-CPB study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2134-2-24**] 14:
Brief Hospital Course:
On [**2-22**] went to operating room for minimally invasive valve
repair. After lines were placed he received heparin bolus and
was found to have hematoma at line site in right neck. Surgery
was cancelled, he remained intubated, vascular surgery was
consulted, and he was transferred to the intensive care unit.
He was also noted to have hematuria that was treated with
irrigation and resolved. He underwent CTA of neck that showed
no bleeding or fistulas. He remained intubated over night. On
[**2-23**] his neck was ecchymotic but soft. He was weaned from
sedation, awoke neurologically intact, and was extubated without
complications. After discussion with Dr [**Last Name (STitle) 914**], he decided to
have a conventional mitral valve repair. On [**2-24**] he went to the
operating room and underwent mitral valve repair via sternotomy.
See operative report for further details. He was transferred
to the intensive care unit for hemodynamic monitoring. In the
first 24 hours he was weaned from sedation, awoke neurologically
intact, and was extubated. He remained in the unit for blood
pressure management and was ready for transfer to floor on POD
2. Physical therapy worked with him for strength and mobility.
He continued to progress, his narcotics were discontinued due to
confusion. He had a chest xray the revealed a pneumothorax that
was monitored by serial CXR. The pneumothorax remained stable
and was decreasing. In addition his confusion resolved and he
was ready for discharge home with services. Plan for follow up
visit with Dr [**Last Name (STitle) 914**] in 2 weeks with CXR prior to office visit.
Medications on Admission:
Celexa 10 daily
Volaran 50
Centrum silver
ASA 81
Cialis prn
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. radiology
CXR - clinical center building
[**Location (un) 10043**]
please get xray 1 hour prior to office visit
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Mitral valve prolapse s/p MV repair
Mitral regurgitation
depression
anxiety
lipoma
Elevated cholesterol
Sleep apnea
Celiac spruce
s/p hernia repair
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
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] tuesday [**3-16**] at 130pm [**Hospital Unit Name **] [**Hospital Unit Name **]([**Telephone/Fax (1) 170**])
Please get CXR prior to office visit at clinical center building
Dr [**Last Name (STitle) 1007**] in 1 week ([**Telephone/Fax (1) 10492**]) please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2134-3-3**]
|
[
"424.0",
"998.12",
"E878.8",
"512.1",
"780.57",
"599.7",
"300.4",
"579.0",
"518.0",
"416.8",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"96.71",
"38.93",
"39.61",
"88.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10098, 10148
|
7412, 9049
|
292, 385
|
10340, 10347
|
1059, 1960
|
10859, 11310
|
798, 835
|
9159, 10075
|
1997, 2032
|
10169, 10319
|
9075, 9136
|
10371, 10836
|
850, 1040
|
242, 254
|
2061, 7389
|
413, 540
|
562, 679
|
695, 782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,250
| 126,410
|
9201
|
Discharge summary
|
report
|
Admission Date: [**2133-6-16**] Discharge Date: [**2133-6-22**]
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
EGD on [**2133-6-16**] and [**2133-6-18**]
History of Present Illness:
79 yo man admitted with acute onset of large-volume melena and
n/v (non-bloody) on night prior to admission Pt subsequently
felt weak and lightheaded, phoned son, was brought to [**Name (NI) **]. Had
some reflux last night. Patient with history of upper GI
bleed/subsequent finding of duodenal ulcer on EGD in [**5-30**].
Patient was H. pylori positive at that time, treated for 2 weeks
with triple therapy, never followed up with GI doc again for
eradication testing. Sees PCP once every 3 months but has not
seen gastroenterolgist since [**5-30**].
Denies chest pain, palpitations, shortness of breath, fevers,
chills, abdomnal pain, weight loss, fatigue. No history smoking,
significant NSAIDs.
In ED initial BP 84/58, guaiac positive melena on exam, NG
lavage negative. Given two liters IVF, one unit pRBC,
pantoprazole 40 mg iv.
Past Medical History:
PMHx: antral bulb duodenal ulcer and duodenitis on EGD [**5-30**],
presumed [**12-29**] NSAID use and c/b iron deficiency anemia, positive
H pylori (treated), HTN, CRF, grade I internal hemorrhoids,
colonic adenoma, L inguinal hernia s/p repair [**5-29**], R inguinal
hernia s/p repair [**5-30**], cataract surgery
Social History:
No smoking, limited alcohol.
Family History:
non-contributory
Physical Exam:
VS: 97.6/BP 110-126/68-70 HR 80-84 RR 18 98%rm air
PE HEENT; PERLLA, EOMI, MMM, no JVD
lung: cTA b/l heart: RR, S1 and S2 wnl, no murmur
abdomen: +b/s, soft, non-tender, no masses
extr: -cyanosis, clubbing, edema
neuro: AAOx3, no focal deficits.
Pertinent Results:
Admission labs:
[**2133-6-15**] 10:10PM PT-13.9* PTT-22.7 INR(PT)-1.3
[**2133-6-15**] 10:10PM PLT COUNT-187
[**2133-6-15**] 10:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2133-6-15**] 10:10PM NEUTS-76* BANDS-2 LYMPHS-14* MONOS-6 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2133-6-15**] 10:10PM WBC-11.2*# RBC-2.97*# HGB-9.3*# HCT-26.3*#
MCV-89 MCH-31.2 MCHC-35.2* RDW-12.5
[**2133-6-15**] 10:10PM ALBUMIN-3.5
[**2133-6-15**] 10:10PM LIPASE-32
[**2133-6-15**] 10:10PM ALT(SGPT)-16 AST(SGOT)-14 LD(LDH)-180 ALK
PHOS-65 AMYLASE-66 TOT BILI-0.3
[**2133-6-15**] 10:10PM GLUCOSE-229* UREA N-79* CREAT-2.3* SODIUM-143
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-29 ANION GAP-17
[**2133-6-15**] 10:27PM HGB-10.0* calcHCT-30
NG lavage negative
EGD: [**6-16**] duodenal ulcer-clip placed with hemostasis
[**6-18**] active bleeding of duodenal ulcer-clip off, hemostasis
obtained with epinephrine and cautery.
Discharge labs:
[**2133-6-22**] 07:45AM BLOOD WBC-10.0 RBC-3.87* Hgb-12.0* Hct-34.7*
MCV-90 MCH-31.0 MCHC-34.6 RDW-15.2 Plt Ct-159
[**2133-6-22**] 07:45AM BLOOD Glucose-131* UreaN-27* Creat-1.9* Na-141
K-3.6 Cl-108 HCO3-22 AnGap-15
Cardiac enzymes:[**2133-6-16**] 08:00PM BLOOD CK(CPK)-142
[**2133-6-16**] 07:03AM BLOOD CK(CPK)-144
[**2133-6-16**] 08:00PM BLOOD CK-MB-5 cTropnT-0.02*
[**2133-6-16**] 07:03AM BLOOD CK-MB-4 cTropnT-0.03*
EKGs: [**6-15**]: Sinus rhythm with atrial premature complex
Left axis deviation
Right bundle branch block
Left axis deviation with left anterior fascicular block
Late precordial QRS transition -is nonspecific
Since previous tracing of [**2133-2-6**], atrial premature complex seen
[**6-16**]
Sinus rhythm
Left axis deviation
Left axis deviation - left anterior fascicular block
Modest lateral ST-T wave changes - are probably primary and
nonspecific -
clinical correlation is suggested
Late precordial QRS transition - is nonspecific
Since previous tracing of [**2133-6-15**], Modest lateral ST-T wave
changes present
[**6-17**]
Sinus rhythm
Borderline first degree A-V block
Left atrial abnormality
Marked left axis deviation
RBBB with left anterior fascicular block
Late precordial QRS transition - is nonspecific
Modest lateral ST-T wave changes - are probably primary and
nonspecific
Clinical correlation is suggested
Since previous tracing of [**2133-6-16**], no significant change
7/23Sinus arrhythmia
Marked left axis deviation
RBBB with left anterior fascicular block
Since previous tracing of [**2133-6-17**], no significant change
Brief Hospital Course:
This is a 79 year-old man with a history of duodenal ulcer in
[**5-30**] admitted now with GI bleeding. On admission, his
hematocrit had fallen to 24.5 with stable coags and he was NG
lavage negative.
Concerning his GI bleeding, his hospital course was as follows:
The patient was transfused two units on [**7-31**] with a
resultant crit of 29.3 EGD was performed on [**2133-6-16**] which showed
a duodenal ulcer. Hemostasis was obtained with a clip and the
patient returned to the floor for further monitoring. Serial
crits over the next day and a half revealed a drop to 21.7 and
the patient was transfused two more units of blood. He was
taken for repeat EGD where the clip was found to be detached,
with active bleeding of the patient's duodenal ulcer. The
patient's ulcer was cauterized and injected with epinephrine to
obtain hemostasis. The patient was then transferred to the ICU
given his significant bleed and low blood pressures. He was
again transfused 2 units and his hematocrit began to stabilize.
After spending 1 say in the ICU, with stabilizing crit and blood
pressure, he was transferred back to the floor. His crit on
[**6-20**] was stable at 31.7. On the evening of [**6-20**] a crit of 29.9
was obtained and he was transfused one additional unit for a
total of seven. At the time of discharge his crit was 34.7.
The patient's diet was gradually advanced and he was tolerating
solids by discharge. His stool over [**6-20**] through [**6-22**] became
less black and tarry and the patient had a brown bowel movement
on the morning of discharge.
Throughout his course, the patient was maintained on a PPI. He
was discharged with follow-up in three days, on a PPI.
Regarding H. pylori testing, patient has been treated in past
for H. pylori ([**5-30**]). Could consider urea breath test as an
outpatient. Further evaluation by gastroenterology. Advised to
avoid all NSAIDs.
Concerning the patient's pre-syncopal episode prior to
admission: This was likely due to his acute GI bleeding.
Consideration of cardiac causes given. [**6-15**] EKG showed sinus
rhythm with atrial premature complex, left axis deviation, right
bundle branch block and non-specific late precordial QRS
transition. Repeat EKG's obtained on [**6-16**] and 23 showed no
new changes. Cardiac enzymes revealed normal CK-MB's with
troponins below 0.10 (0.02 and 0.03). The patient had no chest
pain and was discharged without light-headedness, dizziness. He
had no syncopal episodes during his stay.
Concerning his fever on this admission: The patient developed
fevers on [**6-21**] with a fever to as high as 102 during the night
of [**6-21**]. U/A on [**6-21**] was within normal limits, CXR showed
atelectasis. There was no other evidence of infection. On
discharge he was afebrile.
Additionally, the patient has a long history of paroxysmal leg
swelling for which extensive work-ups have been performed
without definitive diagnosis. On [**6-20**] through [**6-22**] the patient
experienced increased lower extremity swelling worse in his
right leg. Given his fevers and recent decreased ambulation,
consideration of DVT was given. The patient, however, was
insistent that this was his typical swelling. He was without
other complaints including shortness of breath, chest pain or
leg pain. The patient reported being unable to stay in the
hospital for lower extremity dopplers or further work-up because
he had to leave to take care of his wife. [**Name (NI) **] is the primary
care-taker of his wife who has [**Name (NI) 5895**]. Given his long
history of leg swelling, of which this is typical, and
atelectasis as a probable explanation of his low grade fevers,
the patient was discharged with careful instructions to return
immediately if the fevers continued, if the leg swelling
worsened, if there was leg pain, or if he developed any
shortness of breath or chest pain. He will follow-up on [**6-25**]
and take fevers until then. Patient was given subcutaneous
heparin prophylactically.
Concerning his hypertension: Anti-hypertensives were held duirng
this admission, due to his hypotensive episodes.
Hydrochlorothiazide was re-started on discharge.
Concerning his chronic renal failure: The etilogy of this is not
completely clear. It is presumed secondary to hypertensive
nephropathy. The patient was likely dehydrated secondary to GI
bleed. With blood and fluids, his initial creatinine of 2.3 on
admission (baseline around 1.7) fell to 1.9 on discharge. This
appears to be slightly above his baseline. Encouraged copious
fluids on discharge. Will need repeat labs on follow-up on
[**6-25**].
Concerning his history of dyslipidemia: The patient was
continued on atorvastatin 10-follow up as outpatient.
The patient was discharged in stable condition. He is a
pleasant gentleman but was insistent on leaving to care for his
wife with [**Name (NI) 5895**], as he is her primary caretaker and his
recent hospital stay was causing overwhelming burden. He will
follow-up with Dr. [**Last Name (STitle) **] on [**6-25**].
Medications on Admission:
hydrochlorothiazedie-25
lipitor 10
Discharge Disposition:
Home
Discharge Diagnosis:
1. GI bleed
2. acute blood loss anemia
3. chronic RLE edema
4. fever
5. acute on chronic renal failure
Discharge Condition:
Hematocrit stable for 48 hours. Febrile to 102 on night prior to
discharge, but afebrile at time of discharge. Creatinine
slightly elevated to 1.9 in setting of likely intravascular
volume depletion. RLE edematous without change from chronic,
intermittent RLE edema per the patient. Tolerating full diet.
Eager for d/c home to care for wife with [**Name (NI) 5895**]; has f/u
appt. scheduled with Dr. [**Last Name (STitle) **] on Thursday [**6-25**].
Discharge Instructions:
1. Take all medications as prescribed.
2. Do not take any products containing ibuprofen.
3. Be certain to return to the emergency department or call Dr. [**Name (NI) 31617**] office with any bright red or black stools, vomiting
of blood or coffee-grounds material, fevers, cough, shortness of
breath, or increased lower extremity swelling, warmth, redness,
or tenderness.
4. Be certain to keep your appointment with Dr. [**Last Name (STitle) **] on Thursday
[**6-25**] at 1:30.
5. Be certain to drink at least [**5-5**] glasses of water daily.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2133-6-25**] 1:30
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2133-7-1**] 8:30
3. Provider: [**Last Name (NamePattern4) **]/EYE LIST HMFP- EYE Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2133-7-8**] 3:30
|
[
"276.5",
"584.9",
"403.91",
"E935.9",
"532.41",
"287.5",
"518.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
9566, 9572
|
4422, 9480
|
222, 267
|
9719, 10171
|
1834, 1834
|
10763, 11353
|
1535, 1553
|
9593, 9698
|
9506, 9543
|
10195, 10740
|
2826, 3043
|
1568, 1815
|
3059, 4399
|
176, 184
|
295, 1134
|
1850, 2810
|
1156, 1473
|
1489, 1519
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,376
| 172,781
|
23977
|
Discharge summary
|
report
|
Admission Date: [**2188-4-16**] Discharge Date: [**2188-4-29**]
Date of Birth: [**2111-3-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2188-4-18**], Off pump coronary artery bypass graft x 2(LIMA->LAD,
SVG->Diag)
History of Present Illness:
This 77 year old male patient presented to an OSH [**2188-4-14**] with
c/o chest tightness off and on for one week. His cardiac
enzymes were negative x 2. On [**2188-4-16**] he had a cardiac cath
showing two vessel disease; with LAD 40-50% origin, 70-75% mid,
100% distal; RCA occluded; EF 60%.
He was transferred to the [**Hospital1 69**]
on [**2188-4-16**] for eval for coronary artery bypass grafting.
Past Medical History:
Diabetes
Arthritis
Migraine
Hyperlipidimia
Hypertension
Anxiety
Hernia repair
Hemorrhoids
Social History:
Denies ETOH use.
15 pack year smoking history -- quit 40 years ago.
Lives alone in [**Hospital1 487**], AM.
Family History:
Father and brother with CAD -- unknown ages.
Physical Exam:
On presentation:
VS: 97.8 88 134/72 93% on RA
General: NAD, alert.
Neck: soft, no bruits, no JVD.
CV: RRR, no murmurs.
Resp: CTAB
Abd: soft, NT, ND.
Ext: no edema.
Pertinent Results:
[**2188-4-29**] 06:54AM BLOOD WBC-10.1 RBC-4.19* Hgb-11.6* Hct-35.8*
MCV-85 MCH-27.6 MCHC-32.4 RDW-13.9 Plt Ct-580*
[**2188-4-29**] 06:54AM BLOOD Plt Ct-580*
[**2188-4-24**] 09:35AM BLOOD PT-12.8 PTT-25.5 INR(PT)-1.0
[**2188-4-29**] 06:54AM BLOOD Glucose-134* UreaN-22* Creat-1.1 Na-139
K-4.7 Cl-105 HCO3-27 AnGap-12
[**2188-4-26**] 06:00AM BLOOD ALT-29 AST-22 AlkPhos-64 Amylase-56
TotBili-0.7
[**2188-4-23**] 04:59PM BLOOD Calcium-8.2* Phos-1.8* Mg-1.9
Brief Hospital Course:
Patient was admitted [**2188-4-16**] and underwent eval for bypass
grafting. On [**2188-4-18**] he went to the OR and underwent an
off-pump CABG x 2 with Dr. [**Last Name (STitle) **] with LIMA to the LAD and SVG
to the Diag. Please see op note for full details.
He was unable to extubate on his operative day due to an low
SVO2, anxiety and agitation.
On POD one he was successfully weened and extubated. He
remained in the ICU post-operative days two through four for
hemodynamic monitoring.
On POD five he was transferred to the telemetry floor for
ongoing management.
He remained anxious and agitated throughout these days with
haldol PRN and a 1:1 sitter. A psych eval was obtained with a
diagnosis of delerium and recommendations to treat underlying
causes of this. They also recommended continuation of haldol
PRN, avoidance of benzos, and constant redirection and
distraction.
On POD seven, he had bursts of atrial fibrillation on and off
throughout the day with electrolyte repletion.
On POD eight he continued with bursts of afib; he received an
amiodarone bolus and was started on PO amiodarone. On this same
day, he was also noted to have a urinary tract infection and was
started on levofloxacin.
He continued to be agitated throughout his stay here and was
felt to be withdrawn and minimally interactive by the staff. He
was followed by the psychiatry team throughout his admission and
it is their feeling that his primary diagnosis is delerium and
that in this state of delerium he can not be assessed for
underlying depression.
On POD ten it was decided that he was safe for disharge to
rehabilitation and on POD eleven he was discharged.
Medications on Admission:
Aspirin 160 daily.
Cozaar 50 [**Hospital1 **].
Glyburide 1.25 daily.
Pravachol 80 daily.
Protonix 40 [**Hospital1 **].
Colace 100 [**Hospital1 **].
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO twice a
day for 7 days: Then decrease to 400 mg PO daily for 1 week,
then decrease to 200 mg PO qd.
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
Coronary artery disease.
NIDDM
HTN
Anxiety disorder
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 4783**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2188-4-29**]
|
[
"272.0",
"V17.0",
"414.01",
"401.9",
"293.9",
"E878.2",
"427.31",
"997.5",
"V15.82",
"041.7",
"997.1",
"041.09",
"V17.3",
"530.81",
"250.00",
"599.0",
"346.90",
"411.1",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.64",
"36.11",
"89.68",
"34.04",
"38.91",
"89.64",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5006, 5094
|
1857, 3520
|
356, 439
|
5190, 5197
|
1378, 1834
|
5441, 5684
|
1129, 1175
|
3718, 4983
|
5115, 5169
|
3546, 3695
|
5221, 5418
|
1190, 1359
|
282, 318
|
467, 875
|
897, 988
|
1004, 1113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,121
| 154,700
|
24628
|
Discharge summary
|
report
|
Admission Date: [**2167-11-9**] Discharge Date: [**2167-11-18**]
Date of Birth: [**2125-4-11**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
PEG tube malfunction, seizure while in ED
Major Surgical or Invasive Procedure:
- Reprogramming of VP shunt
History of Present Illness:
42y F bed-bound, non-verbal woman seen previously for GTC
seizures by our Neurology service; followed in [**Hospital 875**] clinic
by Dr. [**First Name (STitle) **] for recent-onset seizure disorder thought to be
in general secondary to severe traumatic brain injury suffered
in MVC (car-on-pedestrian) in [**2164**]. Please see prior notes from
myself ([**2-/2167**]), Dr. [**Last Name (STitle) 19825**] (mid-[**2167**]), and Dr. [**First Name (STitle) **] ([**10/2167**]
clinic follow-up) for detailed information. Pt has a VP-shunt in
her L-lat ventricle (placed earlier this year). She is on Keppra
(currently 1500mg/d) and valproate (started earlier this year,
and subsequently increased to 2250mg/d as 750mg TID dosing). In
other recent events, she had a tracheostomy revision here at
[**Hospital1 18**] earlier this month, apparently without complication. I
have no information that she has been infected or ill in any way
recently. The last known report of seizure activity, mentioned
in Dr.[**Name (NI) 7029**] [**10/2167**] clinic note, was at her nursing home and
was prolonged and generalized, treated there (without hospital
evaluation) using benzodiazepine medication. Her seizure onset
is unclear, but may be secondary/generalized and is likely a
Right-frontal onset consistent with her Right-frontal
encephalomalacia and her [**4-/2167**] presentation with LUE twitching.
**********
She was transferred to our ED today from her nursing home due to
malfunction of her PEG feeding tube. By verbal report, it is
unclear whether she actually missed any doses of medications; no
missed doses are charted, but she was brought because of leakage
and difficulty pushing fluids through the PEG, so this seems to
be the case although it is unclear how long it has been a
problem
(to be clarified in the AM if possible).
Shortly after arrival in our ED, she exhibited clonic seizure
activity. I do not have information regarding the onset or exact
semiology, but Dr. [**Last Name (STitle) 62184**] thinks that convulsions involved
primarily her left arm and possibly leg, and that she had
left-[**Hospital1 **] eye deviation at that time. An IV hadn't been placed
yet, so i.m. Ativan was given without seizure resolution
initially, so i.v. Ativan was added, up to a total dose of 6mg
by combined routes (?2 im + ?4 iv) before her movements stopped
over a period of roughly 40 minutes total (I was not present and
did not observe the duration of any individual bouts). On our
recommendation, she was then loaded with a dose each of IV VPA
and IV LEV (1 gram each).
Review of Systems: unable (non-verbal pt)
Past Medical History:
1. Traumatic brain injury (struck by motor vehicle on [**2164-7-13**]) causing right SDH, right frontal SAH and IPH, left
subfalcine herniation and uncal herniation; status post
right-sided hemicraniectomy, right SDH evacuation, right frontal
lobectomy and right temporal lobectomy and VP shunt.
2. Status post revision of VP shunt with placement of a
programmable valve on [**2167-3-30**].
3. History of seizure in [**2167-2-11**] and second seizure in
[**2167-4-12**].
4. Remote history of OxyContin abuse, alcohol abuse, and
question heroin abuse.
5. History of Hypothyroidism without need for present treatment
6. Remote history of anxiety and back pain.
Social History:
[**Hospital 4820**] Nursing Home resident @ [**Location 24442**] HN. Father is the
guardian, [**Name (NI) **], 87yo, his phone number is [**Telephone/Fax (1) 62180**]. Her
sister is [**Name (NI) 62181**] [**Name (NI) **], phone number is [**Telephone/Fax (1) 62182**]. PCP
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 45347**]. Has a remote history of opioid abuse
prior to MVA in [**2164**].
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital signs: see ED VS sheet (initially mild tachycardia
resolved; no other pertinent abnormalities, afebrile and
normotensive)
General Exam: Lying in bed in NAD. Trach with 15L O2 running,
balloon with appropriate pressure. Awakens to voice, appears
displeased or angry. Non-verbal, does not follow any commands.
HEENT: Depressed R frontal/supraorbital ridge, as before.
Anicteric. Mucous membranes are moist.
Neck: Supple. Trach, CDI. No gross cervical lymphadenopathy.
Pulmonary: Good air movement bilaterally. No wheezes or loud
crackles. Non-labored breathing.
Cardiac: RRR, no loud M/R/G appreciated.
Abdomen: Soft, non-distended. Pt moves R arm on palpation, but
not exquisitely tender. PEG site non-tender and mildly
erythematous.
Extremities: RUE and RLE withdraw to pain and move spontaneously
to resist some aspects of exam (but not on command). Warm and
well-perfused x4. Intact radial, DP pulses bilaterally.
Skin: RUE in restraint (mitt). On removal of mitt, hand and
mitt
are mildly malodorous. Lateral dorsum of wrist has erythematous
abrasions, seems mildly tender to palpation. [**Doctor Last Name **] mild rash on
chest, similar to appearance in [**Month (only) **] (see note from that time).
*****************
Neurologic examination:
Mental Status:
Opens eyes to voice. Mildly lethargic, but by end of exam
maintains eyes open. Does not follow commands, but does resist
exam intermittently with angry facial expression, RUE/RLE
movements (swats at me with mitt/RUE external rotation,
withdraws
and arm/leg, kicks RLE). Seems to attempt vocalization on two
occasions, with mouth movements and attendant respiratory
changes.
-Cranial Nerves:
II: PERRL, 4 to 3mm and brisk. Blinks to threat in both eyes,
possibly only from the right side of each visual field (also
closes eyes and resists exam frequently, limiting conclusions).
Not cooperative with fundoscopy.
III, IV, VI: EOMs conjugate with spontaneous saccades. No
spontaneous nystagmus. Does not track. Reliably looks to Right,
not to left on my exam. Suppresses OCRs and closes eyes, so
cannot examine smooth pursuits.
V: Facial sensation intact and subjectively symmetric to eyelash
stimulation (blinks) and nasopharyngeal stimulation (grimaces).
Bites tongue depressor and will not open mouth on command.
VII: No ptosis. [**Month (only) 116**] have mild facial assymetry (left edge of
lips
slightly less elevation than right), but this is subtle. Does
not
smile or raise brows on command. Symmetric eye closure.
VIII: Hearing grossly intact (opens eyes to voice). Suppresses
OCRs and closes eyes, limits vestibular testing. No nystagmus
observed.
IX, X: Does not open mouth or swallow on command.
[**Doctor First Name 81**]: Cannot assess.
XII: Cannot assess.
-Motor:
Increased tone in RUE>LLE (I cannot extend RUE past 90deg at
elbow) and RLE (hyperextended), with easily evoked
non-sutstained
clonus at R knee (also intermittently @ L ankle). Tone in LLE is
low vs. normal. Spontaneous/purposeful movements observed in RUE
(swats at me, withdraws briskly) and RLE (withdraws) only, not
in
LUE or LLE at this time. R wrist held in pronation with thumb
adducted. No tremor. Does not comply with power testing; RUE
and
RLE seem grossly strong, but limited exam (lift at delt, pull at
biceps, IP, hams).
-Sensory: grimaces and increases activity to mild pinch x4.
Withdraws on R, not on L.
-Reflexes (left; right):
Biceps (++;++) brisker on L (tone already increased on R)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++++;+)
Gastroc-soleus / achilles (++;++++) intermittently evokes clonus
on L
Plantar response was withdraw on R and UPgoing with clonus on L.
-Coordination & Gait: cannot assess.
DISCHARGE PHYSICAL EXAM: unchanged
Pertinent Results:
[**2167-11-9**] 03:50PM BLOOD WBC-7.9 RBC-4.66 Hgb-14.5 Hct-41.8 MCV-90
MCH-31.2 MCHC-34.8 RDW-13.1 Plt Ct-208
[**2167-11-9**] 03:50PM BLOOD Neuts-71.1* Lymphs-17.0* Monos-9.5
Eos-2.0 Baso-0.3
[**2167-11-9**] 03:50PM BLOOD PT-10.6 PTT-37.5* INR(PT)-1.0
[**2167-11-9**] 03:50PM BLOOD Glucose-97 UreaN-9 Creat-0.4 Na-136 K-4.0
Cl-97 HCO3-28 AnGap-15
[**2167-11-9**] 03:50PM BLOOD ALT-89* AST-88* AlkPhos-82 TotBili-0.3
[**2167-11-9**] 03:50PM BLOOD Calcium-9.1 Phos-4.2 Mg-1.9
[**2167-11-9**] 03:50PM BLOOD Valproa-29*
[**2167-11-9**] 03:50PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2167-11-10**] 07:05PM BLOOD TSH-2.9
ANTI-EPILEPTIC DRUG LEVELS:
[**2167-11-9**] 03:50PM BLOOD Valproate-29*
[**2167-11-10**] 07:05PM BLOOD Valproate-58
[**2167-11-12**] 04:15AM BLOOD Valproate-103*
[**2167-11-14**] 04:20AM BLOOD Valproate-105*
[**2167-11-9**] 06:10PM BLOOD LEVETIRACETAM (KEPPRA)-21.1 mcg/mL
ANTI-EPILEPTIC DRUG LEVELS ON DISCHARGE:
[**2167-11-17**] 04:20AM BLOOD Valproate-113*
[**2167-11-17**] 04:20AM BLOOD LAMOTRIGINE-PND
[**2167-11-17**] 04:20AM BLOOD LEVETIRACETAM (KEPPRA)-PND
NCHCT ([**11-9**]):
1. Acute-on-chronic left subdural hematoma, as described above
with some
effacement of underlying sulci and decrease in size of the left
lateral
ventricle.
2. Stable in position left frontal approach ventriculostomy
catheter which
again terminates in the third ventricle.
VP SHUNT SERIES ([**11-9**]):
1. Left-sided VP shunt without evidence of discontinuity or
sharp kink, from a left frontal approach continues over the left
neck, left hemithorax, into the left upper quadrant and
terminates in the right lower quadrant.
2. Patchy right base opacity new since [**2167-10-13**], partially
obscured by
overlying leads, may be due to atelectasis or consolidation from
infection
and/or aspiration. Dedicated PA and lateral views of the chest
would be
helpful for further evaluation.
AP CHEST X-RAY ([**11-9**]): A tracheostomy tube is in place, 4.8 cm
from the carina. A VP shunt catheter is seen overlying the left
chest, unchanged from prior exams. The lung volumes are low. A
linear opacity at the right base and mild volume loss is
consistent with atelectasis. Left basilar atelectasis is also
present. This is similar in appearance to the prior chest
radiograph in [**2167-4-12**]. There is no pulmonary edema,
pleural effusion, or pneumothorax. The cardiomediastinal
silhouette is normal.
IMPRESSION: Bibasilar atelectasis.
EEG ([**11-10**]): At baseline, the recording showed periodic
lateralized
epileptiform discharges (PLEDs) especially in the right frontal
central area. In addition, there were three electrographic
seizures with very rapid, rhythmic [**8-21**] Hz sharp wave activity
just posterior to the frontal sharp waves on the right side. The
seizures lasted about a minute. On video, there was no clear or
major change in behavior. There was a bit of blinking. In one,
in the right hand quivered a bit of the left was patent by
blankets. There was no convulsion.
ABNORMALITY #2: Background activity was of very low voltage
broadly over the left side.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: The patient appeared to be awake between seizures, but no
normal
waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal EEG due to the rightsided PLEDs, especially
frontally,
with the three electrographic seizures described above, with
minimal clinical signs.
EEG ([**11-11**]): Began just after midnight on the night of the 31st
and continued through 9:00 the next morning. Throughout the
record, it showed extremely frequent sharp wave and following
slow wave discharges widely over the right hemisphere and
particularly in frontal regions, but the periodic appearance had
diminished. The electrographic seizures, on the other hand,
increased in frequency. Bursts of spikes and sharp waves were
frequent sometimes for just two to three seconds but often in
longer runs constituting electrographic seizures. These seizures
occurred about three times an hour and were not diminishing by
the time of the end of the recording. They usually remained
restricted to the right hemisphere. On video, there was usually
no movement evident but, on one occasion, there was turning of
her eyes to the left.
SPIKE DETECTION PROGRAMS: Showed extremely frequent rightsided
spikes and
sharp waves.
SEIZURE DETECTION PROGRAMS: Showed the same electrographic
seizures described above.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry showed a disorganized background
throughout with
extremely frequent epileptiform discharges broadly over the
right hemisphere. Periodic discharges were no longer evident,
but there were extremely frequent bursts of more rapid
epileptiform discharges for a few seconds at a time and also
electrographic seizures lasting a minute or more, about three
times an hour, possibly increasing toward the end of the record.
EEG ([**2167-11-13**]): Began at 7:01 on the morning of [**11-13**] and
showed a low voltage fast pattern in all areas, likely
reflecting medication use. There continued somewhat periodic
polysharp wave discharges broadly over the right hemisphere,
appearing every three seconds or so. On the first morning, the
sharp waves progressed to rapid, [**12-26**] Hz sharp and spike
activity especially in the right temporal region, spreading more
broadly over the right hemisphere and becoming seizures lasting
three to four minutes at a time. Typically, on video, there was
no motor phenomena. The seizures occurred about three times an
hour in the morning. By the afternoon, seizures were occurring a
bit more than once an hour and, after 2:00, there were three
seizures until the end of the recording at 7:00.
SPIKE DETECTION PROGRAMS: Showed the same innumerable right
hemisphere spikes and sharp waves.
SEIZURE DETECTION PROGRAMS: Showed the same seizures described
above.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry showed continued right hemisphere
periodic sharp
wave discharges throughout, often at about one every two
seconds. There were also very frequent three to four minute long
electrographic seizures beginning in the same area and spreading
through most of the right hemisphere but usually with no motor
findings on video. Over the course of the recording, seizures
decreased markedly in frequency.
EEG ([**2167-11-14**]): Began at 7:01 on the morning of [**11-14**] and
continued until 8 the next morning. For much of the record, it
showed less
frequent blood rate hemisphere sharp waves with some following
slowing than it had shown on earlier recordings. These sharp
waves did not appear
periodically. There were 13 electrographic seizures recorded.
The first was
at 7:29 on the first morning. It began in the same area as the
right temporal sharp waves, maximal at T4-T6, with a "PLEDs
plus" onset and rapid sharp activity following the larger sharp
wave. This rhythmic sharp activity remained restricted to the
right temporal region for about 12 seconds, and then there was
sharp and very irregular [**12-25**] Hz activity in all areas for
about one minute. On video, there was no clear left facial
twitching or other movement. Very similar seizures occurred
later. They were somewhat less frequent beginning on the evening
of the 23rd. A few were associated with facial twitching.
SPIKE DETECTION PROGRAMS: Showed the same very frequent right
hemisphere
discharges.
SEIZURE DETECTION PROGRAMS: Showed the same seizures described
above.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry showed a disorganized background
throughout with
very frequent right hemisphere sharp and slow wave discharges,
maximal in the right anterior to mid temporal region. These
discharges occurred at least every few seconds but were not
rhythmic or periodic. The same area was associated with the
onset of all the electrographic and clinical seizures described
above. Seizures lasted for a minute or so and often had no
clinical correlate. They were far less frequent than they were a
few days earlier.
EEG ([**2167-11-15**]): Began at 7:01 on the morning of [**11-15**] and
continued
for 24 hours. At the onset, it showed a very low voltage
background in all
areas. Frequencies were generally faster, but there was
widespread slowing
over the right hemisphere, and there were area frequent moderate
voltage
polymorphic sharp waves seen broadly over the right side
particularly in
central and temporal areas. These sharp waves were not rhythmic
or periodic. The record also showed three electrographic
seizures, all beginning in the same area as the sharp waves just
described. Typically, the sharp waves became more periodic, at
about 1 Hz, four minutes before the seizure. On video, there was
no facial twitching or other clear motor sign of the seizure.
They lasted about a minute.
SPIKE DETECTION PROGRAMS: Showed the same very frequent right
hemisphere
especially central temporal, polymorphic sharp wave discharges.
Overall, they became less frequent over the course of the
recording and gave way to
irregular slowing. There were exceptions with more rapid and
periodic
discharges for short periods.
SEIZURE DETECTION PROGRAMS: Showed the same seizures described
above at other periods of more rhythmic rightsided sharp waves.
PUSHBUTTON ACTIVATIONS: There was a single activation for
movement or
technical reasons, likely a mistake in activation. There were
none for
clinical events.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry showed a lower voltage fast
background, likely
indicative of medication effect. There continued to be prominent
slowing
broadly over the right side, and there were very frequent right
central
temporal sharp wave discharges. These are far less rhythmic than
on earlier
recordings. In the same area was involved three clinical
seizures, around
noon, at 7 in the evening, and just before midnight. The seizure
frequency
was markedly reduced from that on earlier days.
Brief Hospital Course:
Ms. [**Known lastname 62183**] is a 42 yo bed-bound, non-verbal F with seizure
disorder [**2-12**] TBI ([**2164**]) s/p R hemicraniectomy and SDH
evacuation, R frontal lobectomy and VP shunt who initially
presented to [**Hospital1 18**] ED on [**11-9**] with malfunctioning PEG tube.
# NEURO: While in the ED, patient had a witnessed seizure,
semiology apparently convulsions of LLE and ?LUE with possible L
eye deviation, requiring ativan 6mg IV. VPA level was found to
be 29 despite recent dose increase to 750mg TID, so most likely
reason for her seizure was suspected missed doses of AEDs (VPA +
Keppra) secondary to blocked PEG tube. She was loaded with IV
VPA and Keppra in the ED. NCHCT also showed acute on chronic L
SDH and [**Month/Year (2) 62185**] of L lateral ventricle, so VPS [**Month/Year (2) 62185**]
causing SDH could have been contributing. Toxic-metabolic workup
was otherwise negative.
20-minute EEG subsequently showed multiple right-sided PLEDs and
3 electrographic seizures, so patient was admitted to the
Epilepsy Monitoring Unit for closer monitoring.
In the hospital, patient remained on bedside EEG for five days.
On EEG she initially was found to be having extremely frequent
epileptiform discharges and electrographic seizures located over
the right hemisphere with few clinical correlates (except for
occasional left facial twitching and left hand twitching):
diagnosis was non-convulsive status epilepticus. Accordingly,
her anti-epileptics were aggressively uptitrated. First her
Keppra was increased to 2000mg IV BID. Then she was started on
standing lorazepam. Next, she was started on trial of Lacosamide
for non-convulsive status. Her seizure frequency improved
greatly after uptitration of these meds, and her mental status
seemed to improve slightly in that she was more responsive to
examiners with fewer nystagmoid eye movements on day of
discharge. Her discharge AED regimen is as follows: VPA 750mg
TID (home dose), Keppra 2000mg [**Hospital1 **], Lacosamide 150mg [**Hospital1 **], and
lorazepam 0.5mg TID. Plan is for her to taper the lorazepam to
off over the next 15 days: 0.5mg TID x5 days, then 0.5mg [**Hospital1 **] x5
days (starting [**11-22**]), then 0.5mg daily x5 days (starting
[**11-27**]), then STOP.
# VP SHUNT: NCHCT in the ED revealed VPS [**Last Name (LF) 62185**], [**First Name3 (LF) **] VPS
was reprogrammed by neurosurgery. Patient will follow up with
neurosurgery (Dr. [**Last Name (STitle) 62186**] in 2 weeks for repeat NCHCT
and evaluation of VPS.
# GI: On HD #2 patient's damaged PEG tube was replaced under
flouroscopy by Interventional Radiology. After this it
functioned without any further issues. She will follow up with
IR q3 months for routine replacement of PEG tube (to be
scheduled by IR).
# ID: no active issues during hospitalization.
# CV: continued home metoprolol for HTN.
# CHRONIC PROBLEMS
- s/p TBI: continued home Baclofen (for muscle contractures) and
Amantadine (for arousal) + Percocet PRN pain
- Depression: continued home sertraline
- s/p tracheostomy: continued home albuterol + ipratropium nebs
PRN
- GI ppx: continue home ranitidine
- DVT ppx: SC heparin, pneumoboots
- Precautions: seizures and falls
=================================
TRANSITIONS OF CARE:
- Patient should taper lorazepam on the following schedule:
0.5mg TID x5 days, then 0.5mg [**Hospital1 **] x5 days (starting [**11-22**]), then
0.5mg daily x5 days (starting [**11-27**]), then STOP.
- If patient has behavioral issues in the future, should
consider TAPERING keppra as she is currently on high dose
(2000mg [**Hospital1 **]).
- Studies pending on discharge = Lacosamide level and
Levetiracetam level from [**11-17**]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Amantadine 100 mg PO TID
3. Baclofen 10 mg PO TID:PRN muscle spasm
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea
5. LeVETiracetam Oral Solution 750 mg PO BID
per G tube
6. Metoprolol Tartrate 12.5 mg PO BID
7. Endocet *NF* (oxyCODONE-acetaminophen) 5-325 mg Oral q4 hrs:
PRN pain
8. Ranitidine (Liquid) 150 mg PO BID
9. valproic acid (as sodium salt) *NF* 250mg/5mL (15 mL total)
mL Oral TID
Take 15 mL (750mg) three times daily per G tube
10. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
11. Bisacodyl 10 mg PR EVERY OTHER DAY
12. Docusate Sodium (Liquid) 100 mg PO BID
13. polysorbate 80-glycerin *NF* dosage unknown OU unknown
14. Loperamide 2 mg PO BID:PRN loose stools
15. Psyllium 1 PKT PO Frequency is Unknown
16. Sodium Chloride Nasal [**1-12**] SPRY NU [**Hospital1 **]
17. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
3. Amantadine 100 mg PO TID
4. Baclofen 10 mg PO TID:PRN muscle spasm
5. Bisacodyl 10 mg PR EVERY OTHER DAY
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea
8. Metoprolol Tartrate 12.5 mg PO BID
9. Ranitidine (Liquid) 150 mg PO BID
10. Sodium Chloride Nasal [**1-12**] SPRY NU [**Hospital1 **]
11. Endocet *NF* (oxyCODONE-acetaminophen) 5-325 mg Oral q4 hrs:
PRN pain
12. Loperamide 2 mg PO BID:PRN loose stools
13. polysorbate 80-glycerin *NF* 1 application OU Frequency is
Unknown
14. Psyllium 1 PKT PO BID:PRN constipation
15. Sertraline 50 mg PO DAILY
16. LeVETiracetam Oral Solution [**2155**] mg PO BID
RX *levetiracetam 500 mg/5 mL (5 mL) 20 mL by mouth twice a day
Disp #*1 Bottle Refills:*3
17. valproic acid (as sodium salt) *NF* 750 mg ORAL TID Reason
for Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
18. Lacosamide 150 mg NG [**Hospital1 **]
RX *lacosamide [Vimpat] 10 mg/mL 15 mL by mouth twice a day Disp
#*1 Bottle Refills:*3
19. Lorazepam 0.5 mg NG Q8H
RX *lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth as directed
Disp #*50 Tablet Refills:*0
20. Outpatient Lab Work
Please check valproate (depakote) level and liver function tests
(AST, ALT, Tbili, alkaline phosphatase) in one week and fax
results to Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] (fax #[**Telephone/Fax (1) 7020**]).
Discharge Disposition:
Extended Care
Facility:
[**Location 24442**]
Discharge Diagnosis:
ACUTE PROBLEMS:
1. Nonconvulsive status epilepticus
2. Blocked PEG tube
3. VP shunt over-drainage
CHRONIC PROBLEMS:
1. Status-post traumatic brain injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
NEURO EXAM: eyes open spontaneously. Nystagmus on leftward gaze,
eyes move in all directions but left gaze preference. Right arm
contracted, left arm and leg extensor posturing. Toes upgoing
bilaterally.
Discharge Instructions:
Dear Ms. [**Known lastname 62183**],
You were brought to the hospital after developing a blockage in
your PEG tube. In the Emergency Department, you had a seizure
which was likely caused by missing doses of your anti-epileptic
medications. You received ativan and and extra IV dose of keppra
and depakote in the ED and your seizure stopped. You also had a
VP shunt study which showed that your shunt was probably
draining too much, so Neurosurgery reprogrammed the shunt so it
would drain less. You were then admitted to the hospital, where
your PEG tube was replaced by Interventional Radiology. However,
an EEG then revealed that you were having very frequent, long
seizures on the right side of your brain (not associated with
actually physical . Therefore you were started on long-term EEG
monitoring and your anti-epileptic drugs were increased to treat
the seizures. Over time, the frequency of the seizures
decreased. You are being discharged back to your long-term care
facility and will follow up with neurology to make sure your
seizures have continued to improve.
.
Please attend the outpatient appointments listed below with
Neurosurgery (to follow up on your VP shunt adjustment) and
Neurology (to follow up on your seizures).
.
We made the following changes to your medications:
1. INCREASED keppra (levetiracetam) from 750mg twice daily per
G-tube to 2000mg twice daily per G-tube
2. STARTED vimpat (lacosamide) 150mg twice daily per G-tube
3. STARTED ativan (lorazepam) 0.5mg three times daily per
G-tube. Lorazepam should be TAPERED as follows:
-- Decrease to 0.5mg twice daily starting in five days
([**2167-11-22**])
-- Decrease to 0.5mg once daily five days after that ([**2167-11-27**])
Followup Instructions:
Check Liver function tests and valproate level 1 week after
discharge.
You will be contact[**Name (NI) **] by Interventional Radiology to schedule
routine PEG tube replacement in the next 3 months.
Department: NEUROLOGY
When: FRIDAY [**2168-2-12**] 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: NEUROLOGY
When: FRIDAY [**2168-2-12**] 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: RADIOLOGY
When: WEDNESDAY [**2167-12-2**] at 8:45 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2167-12-2**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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48,239
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Discharge summary
|
report
|
Admission Date: [**2175-4-23**] Discharge Date: [**2175-5-2**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Helicopter transfer for right thalamic hemorrhage
Major Surgical or Invasive Procedure:
Tracheal intubation and extubation
History of Present Illness:
[**Age over 90 **]yo right handed woman with history significant for
hypertension, atrial fibrillation on coumadin, GERD, presented
from OSH with RIGHT thalamic hemorrhage, transferred to [**Hospital1 18**] ED
via helicopter. She was in her normal state of health at an
[**Hospital3 **] facility when she was noted to be slumped, with
LEFT facial droop, left hemiparesis. [**Hospital3 **] personnel
were notified and she was taken to an OSH where head CT showed a
2.5cm acute intraparenchymal hemorrhage in the RIGHT basal
ganglia with surrounding edema, no midline shift. VS were:
afebrile, HR 80 BP 180/90 97% on RA. On exam, she was
dysarthric, following commands, disoriented, with LEFT facial
and hemiparesis. INR was 2.35, so she was given 4 units FFP, Vit
K 10mg, [**Last Name (un) **] 7 90mEq/kg = 54000mcg IV. GCS changed from 14 at
presentation to 12 just prior to CareFlight.
In the [**Hospital1 18**] ER, VS 98.7 74 NSR 185/70s 16 98% on RA. She became
more unresponsive and somolent. She was intubated with Propofol.
VS were: afebrile, HR 74 BP 268/92 RR 16 SaO2 100% directly
after intubation. She was started on a
Propofol drip and her BP slowly decreased to 149/58 with HR 55s.
She was given 4 units FFP. Neurosurgery was consulted. Repeat
Head CT was obtained. Neurosurgery reviewed this and deemed no
benefit from surgery at this time.
Past Medical History:
hypertension
atrial fibrillation
gastroesophageal reflux disease
peripheral vascular disease
glaucoma
Social History:
Lived in [**Hospital3 **] facility near [**Location (un) **]. No children. Has
2 sisters [**First Name8 (NamePattern2) 11320**] [**Name (NI) **] and [**First Name8 (NamePattern2) 1743**] [**Name (NI) **]) that live out of
state. Has a [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) **] that lives in the nearby
vicinity. Pt does NOT have a Healthcare Proxy or known advanced
directives.
Family History:
not elicited
Physical Exam:
On admission:
T: 99.4 HR: 55 NSR BP: 148/58 R 16 100 O2Sats on mech
vent
Gen: Sponateous movement of lower extremities. Intubated and
sedated with propofol in 2 point restraints
HEENT: Pupils: 2->1mm, No dolls eyes, Intubated, NGT draining
bilous fluid
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated with propofol
Cranial Nerves: Pupils 3->2mm. No dolls eyes, no BTT, grimace
only on right to noxious stimulation, intubated with gag reflex.
Unable to identify if tongue was midline.
MOTOR/Sensation: actively and purposefully withdrew in all
extremities yet Left arm only tonic motioin with noxious
stimulation, LEFT ARM hypertonic, Able to grasp with RIGHT hand,
Sponataneous movement of LE with talking and noxious stim equal
movement
Reflexes: Difficult to illicit in UE, Brisk in LE B/L, B/L
upgoing toes
On discharge, somnolent, looks to voice. Breathing comfortably.
Dysarthric with inappropriate answers to questions at times,
left hemiplegia.
Pertinent Results:
On admission:
[**2175-4-23**] 05:19PM PT-8.5* PTT-20.1* INR(PT)-0.7*
[**2175-4-23**] 05:19PM PLT COUNT-270
[**2175-4-23**] 05:19PM NEUTS-70.8* LYMPHS-20.2 MONOS-6.5 EOS-2.0
BASOS-0.4
[**2175-4-23**] 05:19PM WBC-7.6 RBC-3.55* HGB-9.9* HCT-30.9* MCV-87
MCH-27.9 MCHC-32.0 RDW-16.0*
[**2175-4-23**] 05:19PM CALCIUM-8.2* PHOSPHATE-3.6 MAGNESIUM-1.7
[**2175-4-23**] 05:19PM CK-MB-NotDone
[**2175-4-23**] 05:19PM cTropnT-<0.01
[**2175-4-23**] 05:19PM CK(CPK)-27
[**2175-4-23**] 05:19PM estGFR-Using this
[**2175-4-23**] 05:19PM GLUCOSE-115* UREA N-24* CREAT-1.3* SODIUM-138
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-21* ANION GAP-14
[**2175-4-23**] 05:26PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2175-4-23**] 05:26PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2175-4-23**] 05:26PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2175-4-23**] 07:35PM TYPE-ART RATES-14/ TIDAL VOL-450 PEEP-15
O2-100 PO2-87 PCO2-47* PH-7.32* TOTAL CO2-25 BASE XS--2
AADO2-605 REQ O2-95 -ASSIST/CON INTUBATED-INTUBATED
[**2175-4-23**] 11:47PM URINE MUCOUS-RARE
[**2175-4-23**] 11:47PM URINE HYALINE-4*
[**2175-4-23**] 11:47PM URINE RBC-11* WBC-26* BACTERIA-FEW YEAST-NONE
EPI-1
[**2175-4-23**] 11:47PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2175-4-23**] 11:47PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2175-4-23**] 11:47PM PT-12.6 PTT-25.1 INR(PT)-1.1
[**2175-4-23**] 11:47PM PLT COUNT-211
[**2175-4-23**] 11:47PM NEUTS-70.9* LYMPHS-20.4 MONOS-6.8 EOS-1.6
BASOS-0.2
[**2175-4-23**] 11:47PM WBC-7.3 RBC-3.08* HGB-8.5* HCT-26.2* MCV-85
MCH-27.6 MCHC-32.5 RDW-16.1*
Head CT:
1. 2.5 cm intraparenchymal hemorrhage centered in the right
thalamus with mild mass effect on the third ventricle and
extension into the posterior [**Doctor Last Name 534**] of the right lateral
ventricle.
2. Chronic ischemic microvascular disease.
3. Ethmoid sinus disease.
MRI Brain:
The MRA is severely limited by motion artifact. No vascular
abnormalities are detected on this limited study. Specifically,
there is no evidence of an aneurysm.
CONCLUSION: Right thalamic hematoma without evidence of new
hemorrhage since [**2175-4-24**]. No findings to suggest amyloid
angiopathy.
CXR: IMPRESSION: AP chest compared to [**4-27**]:
Mild pulmonary edema and mall bilateral pleural effusions have
increased.
Upper lungs are clear. Lung bases are partially obscured by the
cardiac
silhouette and could [**Hospital1 **] pneumonia, though opacification at
the lung bases is more likely atelectasis. Nasogastric tube ends
in the stomach. Heart size top normal. No pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname 1511**] had a right thalamic hemorrhage thought secondary to
hypertension. She was transferred from an OSH with a worsening
mental status. She received 4 units FFP, Vit K 10mg, [**Last Name (un) **] 7
5400mcg to reverse her INR of 2.3. In the [**Hospital1 18**] ER, pt received
2 units FPP and was intubated secondary decreased mental status.
She was admitted to the ICU, but extubated on hospital day 1 and
transitioned to face mask. Hospital course was notable for:
1. Right thalamic hemorrhage status post reversal - her
neurologic examination remained stable, with decreased
interaction, somnolence, and severe left hemiparesis.
2. Infection: She had a UTI treated with bactrim, then a
pneumonia treated with vancomycin and levofloxacin.
3. Respiratory distress: She had pulmonary edema, treated with
lasix, and pneumonia, treated as above.
4. Renal failure: Creatinine worsened after lasix treatment, but
improved with hydration.
5. Tachycardia: Treated with metoprolol.
6. Hypertension: Treated with metoprolol and hydralazine, as
high as 220s systolic.
7. Nutrition: She required an NG tube for nutrition and
medications.
***8. Goals of care: Given her poor progress and functional
limitations, her family decided to make her goals of care
comfort. She was treated with morphine, scopolamine, and ativan
as needed. She needs frequent assessments for adjustments of
these medications to minimize discomfort and distress.
Medications on Admission:
Coumatin, HCTZ, Cozaar, Amlopidine, Alphagan, Xalatan, Prilosec,
Diltazem, Vitamin B12
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO
Q2H (every 2 hours) as needed for dyspnea, pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5503**] [**Hospital1 **] Convalescent Home - [**Location (un) 5503**]
Discharge Diagnosis:
right thalamic intracerebral hemorrhage
pulmonary edema
acute renal failure
hypertension
atrial fibrillation with rapid ventricular rate
Discharge Condition:
Somnolent, looks to voice. Breathing comfortably. Dysarthric
with inappropriate answers to questions at times, left
hemiplegia.
Discharge Instructions:
You were admitted to the hospital for a bleed in your brain. You
have been discharged to a facility to keep your pain controlled
under close supervision.
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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23,201
| 163,373
|
714
|
Discharge summary
|
report
|
Admission Date: [**2180-2-2**] Discharge Date: [**2180-2-5**]
Date of Birth: [**2106-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
transfer from cath lab for acute pulmonary edema s/p cath
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Drug Eluting Stent Placement.
History of Present Illness:
73 yo male with past medical history significant for CAD s/p
CABG, insulin-dependent diabetes mellitus, hypertension,
hypercholesterolemia, and peripheral vascular disease PVD was
admitted to [**Hospital1 18**] from [**Hospital3 3583**] with after having had
[**6-23**] substernal chest pain. Patient was initially admitted to
[**Hospital3 3583**] on [**2180-1-30**] with a COPD exacerbation and a right
lower lobe pneumonia, being treated with IV antibiotics,
steroids, and nebulizer treatment. On [**2180-2-1**], patient
experienced [**6-23**] substernal chest pain with associated bilateral
arm numbness and troponin I of 11. He initially received
morphine and ativan without relief and then received 5mg IV
metoprolol and IV nitroglycerine with relief. On 12.20, patient
found to have troponin I with 83.41 and was transferred to [**Hospital1 18**]
for cardiac catheterization.
.
At cardiac cath, patient found to have the following: 3 vessel
native coronary artery disease; LMCA 50% distal in-stent
restenosis; LAD occluded proximally; LCX 60% at its origin with
occluded OM branches except for OM3 which was occluded distally;
RCA known to be occluded and not selectively engaged; LIMA-LAD
widely patent to distal LAD. SVG-RCA was known to be occluded
and was not engaged selectively.
The SVG-D-OM had an ulcerated 80% stenosis at the diagnoal
origin and
widely patent OM stent. Patient had a drug eluting stent placed
(Cypher 3.5 x 18) to the SVG-Diag-OM. 170cc dye used during
procedure and hemodynamics not performed (Aortic pressure 145/74
with HR 73). Post cath course complicated by development of
acute shortness of breath, diaphoresis, and respiratory
distress, thought likely secondary to flash pulmonary edema.
Patient started on a NRB and received 60mg furosemide IV total
(20 then 40), morphine 5mg, and was started on a nitro drip for
elevated blood pressures to SBPs to 190s.
.
Upon arrival to the floor, patient was started on BiPap but had
persistent respiratory distress with use of accessory muscles
and increased CO2 retention, as seen on ABG (7.29 / 59 / 160).
Patient was intubated with anesthesia and started on propafol
for sedation. With increased sedation, patient also became
hypotensive to SBPs 70s-80s and was started on dopamine for
blood pressure support.
Past Medical History:
- Hypertension
- Hypercholesterolemia
- IDDM, c/b ?diabetic neuropathy, retinopathy
- CAD with 5-vessel CABG in [**2166**] (LIMA->LAD, SVG->PDA,
SVG->D1->OM1)
- Carotid Artery Stenosis: [**2177-10-28**] carotid u/s: diffuse
calcified bilateral plaque making a technically difficult study,
however, this was most consistent with bilateral 40-59%
stenosis.
- PVD: disease of the right common iliac, anterior tibial and
posterior tibial.
- [**2165**] CVA- loss of vision in right field of eyes, diminished
memory and attention
- Back pain due to compressed vertebrae
- CRI (Cr was in )
- h/o nephrolithiasis
Social History:
Tobacco - Quit smoking 30 years ago; 80-100 PPY smoking history
28 year history with 6 PPD
EtOH - occasional, once a year
Denies illicit drug use
Retired Electrical Engineer
Lives with wife, daughter, and two grandchildren (ages 3 and
7yo)
Family History:
Mother & Father, both deceased secondary to cancer
Physical Exam:
T 95.6 / HR 73 / BP 112/54 / PO2 97%
Dopa 5 / Propafol 20
Vent Settings - AC - FiO2 .6 / TV 550 / Set RR 14 / Total RR 16
/ PEEP 5
Gen: lying in bed, sedated
HEENT: MMM
NECK: Supple, thick neck, difficult to assess JVD
CV: RRR with normal S1 and S2; [**3-22**] harsh, late-peaking systolic
murmur
LUNGS: diffuse bilateral crackles, increased at the bases
bilaterally, diffuse expiratory wheezes throughout
ABD: obese, soft, NT, ND. NL BS.
EXT: 1+ edema to mid-shins bilaterally with 2+ DP/PT dopplerable
pulses BL; right femoral sheath in place with 1+ left femoral
pulse; no hematoma, ecchymoses, or bruising
SKIN: No lesions
NEURO: Alert and oriented to time and person
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2180-2-2**] 04:17PM HGB-13.7* calcHCT-41 O2 SAT-98
[**2180-2-2**] 04:17PM GLUCOSE-205* K+-4.3
[**2180-2-2**] 04:17PM TYPE-ART O2 FLOW-15 PO2-165* PCO2-54*
PH-7.34* TOTAL CO2-30 BASE XS-2
[**2180-2-2**] 04:56PM PT-19.4* PTT-68.6* INR(PT)-1.8*
[**2180-2-2**] 04:56PM PLT SMR-HIGH PLT COUNT-469*#
[**2180-2-2**] 04:56PM NEUTS-89.6* BANDS-0 LYMPHS-6.8* MONOS-3.2
EOS-0.1 BASOS-0.2
[**2180-2-2**] 04:56PM WBC-17.6*# RBC-4.39* HGB-13.0* HCT-39.3*
MCV-90 MCH-29.7 MCHC-33.2 RDW-14.4
[**2180-2-2**] 04:56PM CALCIUM-8.8 PHOSPHATE-5.4*# MAGNESIUM-2.3
[**2180-2-2**] 04:56PM CK-MB-60* MB INDX-8.6* cTropnT-4.20*
proBNP-2687*
[**2180-2-2**] 04:56PM CK(CPK)-701*
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2180-2-2**] 9:17 PM
CHEST (PORTABLE AP)
Reason: please re-eval postition of ngt and ett (was ~ 6cm above
cor
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with IDDM and COPD who was admitted to the CCU
after presumed flash pulmonary edema , intubated, s/p tube
repositioning
REASON FOR THIS EXAMINATION:
please re-eval postition of ngt and ett (was ~ 6cm above [**Female First Name (un) 5309**])
CHEST: Status post intubation for flash pulmonary edema. Check
endotracheal tube position.
COMPARISON: Film performed at 18:45 same day.
Tip of the endotracheal tube is in good position, 4.5 cm above
the carina. There is blunting of both costophrenic angles which
is new consistent with bilateral pleural effusions. There is new
focal opacity behind the left side of the heart consistent with
atelectasis or infiltrate. Tip of the NG tube is in the stomach.
IMPRESSION: Tubes in good position.
Interval development of new bilateral pleural effusions and new
left lower lobe opacity. There is moderate pulmonary vascular
redistribution, likely due to the supine technique.
CARDIAC CATH - [**2180-2-2**]
BRIEF HISTORY:
This 72 year old gentleman with known coronary artery disease
status
post CABG with LIMA to LAD, SVG to D and OM, SVG to RCA. He
subsequently
had cypher stents placement to the LMCA/LAD and SVG to D and OM.
He is
transferred from outside hospital following admission for
pneumonia and
was noted to have NSTEMI after complaining of chest pain.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, NSTEMI
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Graft Angiography: of 1 saphenous vein bypass grafts was
performed using
a 5 French left amplatz catheter, with manual contrast
injections.
Arterial Conduit Angiography: of a left internal mammary artery
graft
was performed using a preformed [**Female First Name (un) 899**] catheter, with manual
contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
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} 145/74/105
**CARDIAC OUTPUT
HEART RATE {beats/min} 75
RHYTHM SINUS
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DIFFUSELY DISEASED 100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN TUBULAR 50
6) PROXIMAL LAD DIFFUSELY DISEASED 100
12) PROXIMAL CX TUBULAR 60
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 DIFFUSELY DISEASED 100
29) SVBG #2 TUBULAR 80
32) LIMA NORMAL
**PTCA RESULTS
SVG-D-OM
**BASELINE
STENOSIS PRE-PTCA [**53**]
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH 6AL-1
GUIDEWIRES FILTER
INITIAL BALLOON (mm) 3.5
FINAL BALLOON (mm) 3.75
# INFLATIONS 2
MAX PRESSURE (PSI) 300
**RESULT
STENOSIS POST-PTCA 0
SUCCESS? (Y/N) Y
PTCA COMMENTS: Initial angiography revealed an ulcerated,
hazy
lesion in the SVG to Diagonal with jump OM at the takeoff of the
diagonal. The initial strategy was to direct stent after
thrombectomy
with distal protection. An [**Doctor Last Name **]-1 Guide provided good support.
Bivalirudin was used. The 4 French RX Angioject catheter was
used with
two passes in an antegrade fashion with moderate debulking of
the
lesion. A 3.5 x 18 mm Cypher stent was deployed at 18 ATM. A
3.75 x
13 mm Powersail balloon was inflated twice at 20 ATM. Final
angiography
revealed normal flow, no dissection and 0% residual stenosis in
the
stent. The patient tolerated the procedure well and developed
transient
chest pain with balloon inflations. He complained of dyspnea
during the
case and was administered furosemide. Despite diuresis, he
developed
increased shortness of breath in the holding area and was then
transferred to the CCU for further management of volume overload
CHF.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 13 minutes.
Arterial time = 1 hour 13 minutes.
Fluoro time = 25 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 170
ml, Indications - Renal
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Bivalirudin bolus 80mg iv
Bivalirudin drip 105 mg/hr iv
Fentanyl 50 mcg iv
Furosemide 20 mg iv
Nitroglycerine bolus 200mcg ic
Versed 0.5 mg iv
Cardiac Cath Supplies Used:
3.75 GUIDANT, POWERSAIL, 13
6F CORDIS, [**Doctor Last Name **] 1 (90CM)
4F POSSIS, ANGIOJET XMI RX, 135CM
.014 [**Company **], FILTER WIRE EZ 190 CM
3.5 CORDIS, CYPHER RX, 18
- ALLEGIANCE, CUSTOM STERILE PACK
- POSSIS, ANGIOJET PUMPSET
- GUIDANT, PRIORITY PACK 20/30
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated 3 vessel native coronary artery disease. The LMCA
had 50%
distal in-stent restenosis. The LAD was occluded proximally. The
LCX had
60% at its origin with occluded OM branches except for OM3 which
was
occluded disteally. The RCA was known to be occluded and
therefore was
not selectively engaged. The LIMA-LAD was widely patent to
distal LAD.
The SVG-RCA was known to be occluded and was not engaged
selectively.
The SVG-D-OM had an ulcerated 80% stenosis at the diagnoal
origin and
widely patent OM stent.
2. Limited resting hemodynamics were performed. The systemic
arterial
pressures were elevated measuring 145/74mmHg.
3. Successful PTCA and Stenting of the SVG to Diagonal-OM were
performed
with distal protection using a 3.5 x 18 mm Cypher stent
(postdilated to
3.75 mm) . Final angiography revealed normal flow, no
dissection and 0%
residual stenosis. (See PTCA Comments).
FINAL DIAGNOSIS:
1. Native 3 vessel coronary artery disease with patent LIMA-LAD,
known
occluded SVG-RCA and known 80% stenosis in SVG-D-OM.
2. Mildly elevated systemic arterial pressures.
3. Successful PTCA and Stenting of the SVG-D-OM with Cypher [**Company **].
TTE - [**2180-2-3**]
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease.
Height: (in) 72
Weight (lb): 280
BSA (m2): 2.46 m2
BP (mm Hg): 79/43
HR (bpm): 62
Status: Inpatient
Date/Time: [**2180-2-3**] at 10:51
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W050-0:17
Test Location: West Echo Lab
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 251**] [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.6 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: 0.32 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.88
Mitral Valve - E Wave Deceleration Time: 366 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
Eccentric AR jet directed toward the anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips
of papillary muscles. No MS. Trivial MR. Prolonged (>250ms)
transmitral E-wave
decel time. LV inflow pattern c/w impaired relaxation.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views.
Conclusions:
Acoustic windows were technically suboptimal. The left atrium is
dilated. The
right atrium is moderately dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild
(1+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric,
directed toward the anterior mitral leaflet. The mitral valve
leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired
relaxation. There is no pericardial effusion.
Brief Hospital Course:
ASSESSMENT:
73 yo male with known coronary artery disease, hypertension,
hyperlipidemia, tobacco abuse, and obesity s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5175**] to
SVG-Diag-OM, complicated by congestive heart failure, acute
pulmonary edema, hypotension, and respiratory failure s/p
intubation.
.
1. CARDIAC
Coronary Artery Disease
Patient was found to have an 80% ulcerated SVG-D-OM lesion which
was stented with a Cypher 3.5 x 18. Patient was chest pain free
for the duration of his hospitalization. Patient was placed on
aspirin, plavix, high-dose statin, and started back on his home
dose of valsartan 160mg daily and hydrochlorothiazide 25mg PO
daily. Patient was also started on Toprol XL 50 mg daily.
Patient had previously been taking atenolol 25mg PO bid but was
switched to metoprolol given patient's chronic renal
insufficiency. Patient recommended to discuss this change with
his primary care physician and primary cardiologist.
.
Pump
Patient's initial presentation of acute pulmonary edema during
catheterization was thought likely secondary to his hypertension
and diastolic heart failure. He was initially hypertensive and
started on a nitro drip. As he was sedated and intubated, his
blood pressure decreased and hwas started on dopamine for
pressure support. Once extubated, patient again developed
hypertension and he was re-started on his home medicines of
valsartan 160mg and hydrochlorothiazide 25mg daily. He was also
started on Toprol XL 50 mg QD. Patient was noted in previous
records to have an EF of 45%, by report from prior cardiology
notes. TTE during this admission demonstrated EF of 55% with 1+
AR. Patient was on [**Last Name (un) **] upon admission, unclear from our records
or patient history whether he has been tried on an ACE inhibitor
such as ramipril. Patient recommended to discuss with his
primary care physician and primary cardiologist whether he
should be on an ACE inhibitor such as ramipril.
.
Rhythm
Patient remained in normal sinus rhythm for the duration of his
admission and was monitored with telemetry.
.
2. Respiratory Failure
Patient initially with respiratory distress after cath, likely
secondary to flash pulmonary edema secondary to hypertension and
congestive heart failure. Patient was initially intubated for
respiratory distress and received lasix for aggressive diuresis
and was extubated one day later without complication. Upon
discharge, patient was stable on room air.
.
3. Hypercholesterolemia
Patient was initiated on high dose statin therapy with
atorvastatin 80mg PO daily. He should have another lipid panel
checked in 30 days and his liver function and CK followed by his
PCP.
.
4. Pneumonia
Patient was transferred from OSH with findings of right lower
lobe pneumonia, per report. Patient received a 5 day course of
antibiotic therapy with ceftriaxone/ azithromycin for 3 days
then 2 days of levofloxacin. Patient symptomatically improved
with decreased cough and sputum production by discharge.
.
5. Diabetes Mellitus
Patient received insulin drip for a short time while he was
intubated and was quickly transitioned to his outpatient insulin
regimen of 25U NPH in the morning, 25U at bedtime, and sliding
scale at meals. It was noted that patient also required high
doses of insulin on the sliding scale in addition to his NPH
dosing and pt also reports that he often takes greater than 18
units per day on his own sliding scale. No adjustments were
made to his regimen while he was an inpatient here, but this
issue should be addressed as an outpatient.
.
6. Acute on Chronic Renal Insufficiency with Mild Proteinuria
Patient noted to have chronic renal insufficiency with baseline
Cr ~1.5, likely secondary to diabetes mellitus. During this
admission, his creatinine bumped slightly to 1.8, thought likely
secondary to prerenal causes with diuresis and decreased forward
flow. Upon discharge, patient's creatinine had improved to 1.4.
.
Patient also noted to have mild proteinuria with a
protein/creatinine ratio of .3. His chronic renal insufficiency
and mild proteinuria are thought to be likely secondary to his
diabetes mellitus but he was recommended to have a further
work-up of his renal insufficiency by his primary care
physician.
.
Patient will follow up with his PCP and his cardiologist Dr.
[**Last Name (STitle) 5310**].
Medications on Admission:
Home Meds:
Imdur 30mg PO daily
Lipitor 20mg PO daily
Diovan - 160/25 PO daily
Nexium 40mg PO daily
Pletal 100mg PO bid
Atenolol 25mg PO bid
NPH 25U in the AM - 20U at suppertime - 20U qhs
10U Humalog in the morning + sliding scale
.
Transfer Meds:
Aspirin 325mg PO daily
Atenolol 50mg PO bid
Atorvastatin 20mg PO daily
Azithromycin 500mg IV qAM
Cilostazol 100mg PO bid
Clopidogrel 75mg PO qAM
Docusate 100mg PO bid
Enoxaparin 110mg SC q12h
Insulin
Methylprednisolone 60mg I q12h
Pantoprazole 40mg PO daily
Valsartan 160mg PO qAM
Zolpidem 5mg PO qhs
Fluticasone/Salmeterol 1inh [**Hospital1 **]
Tiotropium 1 inh qAM
Ceftriaxone 1mg IV qAM
Nitro gtt @ 20mcg
Discharge Medications:
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. Coronary artery disease
- [**2166**] - CABG (LIMA-LAD; SVG-PDA; SVG-D1-OM1)
.
SECONDARY:
1. Chronic Renal Insufficiency (baseline Cr 1.4)
2. Peripheral Vascular Disease
3. Obesity
4. IDDM complicated neuropathy and retinopathy
5. Hypertension
6. Hypercholesterolemia
7. Carotid Stenosis
8. CVA in [**2165**] with residual loss of vision in right field of
eyes, diminished memory and attention
9. Back pain r/t compressed vertebral
10. Nephrolithiasis
Discharge Condition:
Good - Patient is ambulating, tolerating oral intake, and back
to his baseline condition.
Discharge Instructions:
Please take all medications as prescribed. While it is important
for you to take all of your medications, it will be especially
important for you to take your aspirin and plavix every day. You
are recommended to take plavix for one year after your discharge
from the hospital.
.
If you have any symptoms of fevers, chills, night sweats,
light-headedness, chest pressure or pain, shortness of breath,
calf pain, or calf swelling, please go to the nearest emergency
room.
.
Due to your high blood pressure and heart disease, please try to
adhere to a heart-healthy, low sodium diet.
Followup Instructions:
Please go to your follow-up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5311**] on Monday [**2-21**] at 3:30pm. His phone number is
[**Telephone/Fax (1) 5312**].
.
Please also follow-up with your cardiologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5310**] on [**2-16**] at 11:20am. His phone number is
[**Telephone/Fax (1) 5313**].
.
When you meet with your primary cardiologist and your primary
care physician, [**Name10 (NameIs) **] discuss the following issues with them:
- evaluation of your sleep apnea and scheduling for a sleep
study
- further evaluation and work-up for your renal insufficiency
and mild proteinuria (small amounts of protein in your urine).
- taking a medication such as ramipril for your blood pressure
and kidney protection
- please note that pt is on NPH 25 [**Hospital1 **], but as per pt report,
requires nearly 18 units at home on his sliding scale and also
required additional doses while an inpatient. Due to his short
length of stay, no changes were made to his regimen. A better
outpatient regimen is needed for Mr. [**Known lastname 5314**] to control his
diabetes.
Completed by:[**2180-2-5**]
|
[
"403.90",
"V45.81",
"272.0",
"428.0",
"414.01",
"362.01",
"250.50",
"250.40",
"486",
"518.81",
"357.2",
"V58.67",
"250.60",
"428.31",
"585.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"37.22",
"00.40",
"96.71",
"88.55",
"00.66",
"00.45",
"00.17",
"88.52",
"36.07",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
20376, 20382
|
15273, 19644
|
372, 433
|
20890, 20982
|
4485, 5322
|
21612, 22814
|
3659, 3711
|
20353, 20353
|
5359, 5495
|
20404, 20869
|
19670, 20328
|
11522, 11793
|
21006, 21588
|
11819, 15250
|
3726, 4466
|
9611, 11505
|
6715, 9592
|
275, 334
|
5524, 6682
|
461, 2755
|
2777, 3384
|
3401, 3643
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,086
| 186,682
|
50171+59229
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-12-2**] Discharge Date: [**2182-12-10**]
Date of Birth: [**2099-9-24**] Sex: F
Service: SURGERY
Allergies:
Demerol / Erythromycin Base / Amoxicillin / Bactrim / Codeine /
Lipitor / Penicillins / Plavix / Linezolid / Keflex / Cipro /
Protamine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
non healing infected ulcers, LLE
Major Surgical or Invasive Procedure:
[**2182-12-4**] OPERATION:
1. Ultrasound-guided puncture of the right common femoral
artery.
2. Contralateral third-order catheterization of the left
superficial femoral artery.
3. Abdominal aortogram.
4. Serial arteriogram of left lower extremity.
5. Balloon angioplasty of left superficial femoral artery.
6. Stent placement at left superficial femoral artery.
7. Perclose closure of right common femoral arteriotomy.
History of Present Illness:
This is an 83-year-old female with a
nonhealing ulceration of the left medial malleolus, admitted
through Dr.[**Name (NI) 5695**] clinic and planned for angiogram and
possible angioplasty and
stenting.
Past Medical History:
PMH: HTN, asthma, COPD, hypothyroidism, CAD, and diabetes
PSH: [**2179-11-3**] Contralateral third order arteriography with
abdominal aortogram and unilateral extremity runoff,
angioplasty of left popliteal artery, angioplasty of left
peroneal artery, CABG [**73**], TAH, appy
Social History:
Denies smoking and ETOH use. Lives with husband.
Family History:
N/C
Physical Exam:
98.7 115/50 70 100%RA
gen- NAD, AxOx3
heart- RRR
lungs- CTA b/l
abd- soft, NT/ND
ext- nonhealing left lower extremity ulcers,
Pulses:
RT [**Name (NI) 6024**]
LT PT/DP dop
Pertinent Results:
[**2182-12-9**] 07:20AM BLOOD WBC-10.5 RBC-4.15* Hgb-9.3* Hct-31.7*
MCV-76* MCH-22.4* MCHC-29.3* RDW-20.3* Plt Ct-216
[**2182-12-2**] 09:10PM BLOOD WBC-9.1 RBC-4.31 Hgb-9.2* Hct-32.4*
MCV-75* MCH-21.4*# MCHC-28.4*# RDW-18.5* Plt Ct-271
[**2182-12-9**] 07:20AM BLOOD Plt Ct-216
[**2182-12-2**] 09:10PM BLOOD PT-42.1* PTT-34.7 INR(PT)-4.5*
[**2182-12-5**] 06:21PM BLOOD CK(CPK)-46
[**2182-12-8**] 07:30AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
[**2182-12-2**] 09:10PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.5 Mg-2.5
Brief Hospital Course:
[**2182-12-2**] Admitted thorugh Dr.[**Name (NI) 5695**] office with infected
LLE ulcers. Started IV ABX-Vanco (MRSA), wound care and planned
for angio. Home medications continued. Coumadin on hold.
[**2182-12-3**] Coninued wound care and ABX. Made NPO with IVF and
consented for angio on [**2182-12-4**] Underwent serial arteriogram of
left lower extremity, Balloon angioplasty of left superficial
femoral artery, Stent placement at left superficial femoral
artery. At completion of case-right common femoral perclosed.
Case complicated by hypotension requiring intubation. Transfered
to CVICU.
[**Date range (1) 93043**] Remained in CVICU with ICU level montioring.
Continued wound care
[**Date range (1) 101553**] Stable, tolerating diet. Loose stools- X4, cdiff
negative. Continued wound care and IV anitbiotics (Vanco).
Physical therapy working with patient and spouse for home safety
evaluation. Nutrition consulted for teaching. Coccyx area with
stage1 ulcer, monitoring and following repostioning protocol
[**12-10**]: Discharged with picc line for 2 additional weeks of
vancomycin per ID. Follow up with ID to be decided after
vascular clinic appointment. PT to work with patient and family
regarding home safety.
To note pt vanco trough was 22, her creat was 1.4, Vanco changed
from 750 q 24 to 500 q 24. Creat in down trend to 1.3. Labs
will be checked at home and faxed to her PCP and [**Name9 (PRE) 104687**]
office.
Medications on Admission:
Warfarin, Levemir 15 units', Humalog SS, Dig 0.125', carvedilol
3.125 [**Hospital1 **], mirtazapine 15', Furosemide 60 [**Hospital1 **], Folic acid 1',
levothyroxine 75mcg', omeprazole 20', sertraline 25', trusopt 1
gtt each eye [**Hospital1 **], alphagan 1 drop each eye [**Hospital1 **], fluticasone 50
mcg 2 sprays each nostril [**Hospital1 **], senna, colace
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
4. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain or fever .
15. Levemir 100 unit/mL Solution Sig: 15 units daily
Subcutaneous at bedtime.
16. Humalog scale
resume home sliding scale
17. Vancomycin 500 mg IV Q 24H
18. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous once a day for 2 weeks.
Disp:*14 * Refills:*0*
19. Outpatient Lab Work
Please check cbc, chem 7, vancomycin trough q week and fax to
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 51996**].
Also please check PT/INR twice weekly and PRN and send results
to Dr. [**Last Name (STitle) **]
Phone: [**Telephone/Fax (1) 6699**]
Fax: [**Telephone/Fax (1) 99894**]
20. PICC CARE
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.
21. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
adjust for INR to [**2-13**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
83F DM with infected, NHU LLE s/p L LE angiogram; PTA L SFA c
Stent c/b hypotensive episode required brief intubation
PMH: HTN, asthma, COPD, hypothyroidism, CAD, and diabetes
PSH: [**2179-11-3**] Contralateral third order arteriography with
abdominal aortogram and unilateral extremity runoff,
angioplasty of left popliteal artery, angioplasty of left
peroneal artery, CABG [**73**], TAH, appy
[**2180-2-22**] STSG to medial Malleolus of Left ankle
[**2180-4-6**] I&D left foot
[**4-19**] RT [**Month/Year (2) 6024**] ([**Hospital3 **])
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:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-13**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-14**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2182-12-23**] 10:30
Completed by:[**2182-12-10**] Name: [**Known lastname 5405**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 16993**]
Admission Date: [**2182-12-2**] Discharge Date: [**2182-12-10**]
Date of Birth: [**2099-9-24**] Sex: F
Service: SURGERY
Allergies:
Demerol / Erythromycin Base / Amoxicillin / Bactrim / Codeine /
Lipitor / Penicillins / Plavix / Linezolid / Keflex / Cipro
Cystitis / Protamine
Attending:[**First Name3 (LF) 1546**]
Addendum:
Pt became hypotensive during the procedure
EMERGENCY TEE PERFORMED AFTER SEVERE HEMODYNAMIC INSTABILITY IN
THE ENDOVASCULAR SUITE The left atrium is dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. No thrombus/mass is seen in the body of the left atrium.
Mild spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. The right atrium is markedly dilated. The interatrial
septum is bowed into the left atrium consistent with
significantly elevated right atrial pressure. No atrial septal
defect is seen by 2D or color Doppler. No thrombus or mass is
seen in the right heart or pulmonary artery. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). The right ventricular cavity is
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is likely
moderate to severe aortic valve stenosis (valve area around 0.8
cm2) but low cardiac output makes determination of actual area
difficult (i.e. pseudo aortic stenosis). Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is moderate valvular mitral stenosis (area
1.0-1.5cm2). Mild to moderate ([**1-12**]+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen.
Dr.[**Last Name (STitle) **] was notified in person of the results in the
procedure room at the time of the study.
Pt intubated sent to the CVICU for monitering
Pt Acute on chronic diastolic heart failure
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2182-12-31**]
|
[
"459.81",
"682.6",
"244.9",
"V45.81",
"041.12",
"401.9",
"707.03",
"416.8",
"427.89",
"493.20",
"440.23",
"458.29",
"285.9",
"428.23",
"707.13",
"V49.75",
"707.21",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"89.64",
"96.04",
"00.45",
"88.72",
"39.90",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
12197, 12409
|
2219, 3653
|
430, 860
|
6790, 6790
|
1687, 2196
|
9553, 12174
|
1475, 1480
|
4066, 6130
|
6229, 6769
|
3679, 4043
|
6966, 8956
|
8982, 9530
|
1495, 1668
|
357, 392
|
888, 1092
|
6805, 6942
|
1114, 1392
|
1408, 1459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,641
| 131,760
|
7845
|
Discharge summary
|
report
|
Admission Date: [**2121-10-7**] Discharge Date: [**2121-11-11**]
Date of Birth: [**2041-5-24**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 28286**]
Chief Complaint:
"anasarca" -per cardiology
Major Surgical or Invasive Procedure:
[**10-8**] left sided thoracentesis
[**10-9**] right sided thoracentesis
History of Present Illness:
80 year old male s/p CABG, AVR and MV
repair on [**2121-9-8**] that was discharged to rehab on [**2121-9-18**].
He
had worsening Creatinine 2.2 from 1 at discharge, as noted by
rehab. His diuretics were stopped and lisinopril held, and
continued to be monitored at rehab. He was readmitted to [**Hospital1 18**]
on [**2121-9-26**] and aggressively diuresed and underwent bilateral
thoracentesis for 2 liters of serous fluid per side.
He was discharged back to rehab on [**2121-10-1**].
He was sent from rehab to PCP's office and directly admitted to
[**Hospital1 18**] for total body anasarca and renal failure with reported
creat of 2.4. Mr. [**Known lastname **] [**Last Name (Titles) **] SOB, states he was ambulating
around the rehab without issues.
Past Medical History:
Aortic Stenosis, Coronary Artery Disease, Diabetes,
Dyslipidemia, Hypertension, PPM, DM II, retinopathy, neuropathy,
gastroparesis, Obesity, peripheral vascular disease with RLE
stent placed [**4-/2121**], Presyncope, BPH, Ulcerative colitis, b/l
cataract extraction
Social History:
Lives with 2 grandchildren in a large house. Has a girlfriend.
Pt has a dry cleaning business that's closing down soon due to
the poor economy. Major source of stress.
-Tobacco history: None
-ETOH: Occasional
-Illicit drugs: None
Family History:
FAMILY HISTORY:
Mother died of breast cancer at age 59, does not know father.
Daughter has thyroid cancer, currently on treatment.
Physical Exam:
Admission Physical Exam:
vs: 97-85-123/73-18 95% on RA
General: No acute distress, well nourished
Skin: Dry [x] intact [x] small area of redness right second toe,
Dime sized Stage II decub on this coccyx
HEENT: PERRLA [x] EOMI [x]R eyelid droop
Neck: Supple [x] Full ROM [x]
Chest: increased work of breathing with forced exhallation and
dyspnea. Lungs clear- no rales/rhonchi, +wheezes
Heart: RRR [x] Irregular [] Murmur []
Abdomen: obese Soft [x] non-distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm, 1+ pitting edema to knees
Neuro: Alert and oriented x3 non focal
Pulses:
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: +1 Left: +1
Sternal incision healing well, no erythema or drainage, sternum
stable. Chest tube sites C/C/I.
L leg endoscopic vein harvest sites draining scant serous
drainage.
R leg medial thigh open vein harvest site with minimal erythema
along incision, no drainage. Distal leg endscopic
harvest sites with no drainage or erythema.
.
Discharge Physical exam:
PHYSICAL EXAM:
Vitals - Tmax/current: 97.9/97.5 BP 100-131/46-61 HR 76-87 RR 18
98% RA
WEight 78.2 (78)
Last 24H: 900/350
Last 8H: 150/none
.
GENERAL: No acute distress, pleasant elderly gentleman sitting
comfortably in chair
HEENT: PERRLA, no pharyngeal erythemia, mucous membs dry, no
lymphadenopathy, JVP non elevated sitting in chair
CHEST: Decreased bs at bases Left > right, no rhonchi, no
crackles. Incision well approximated.
CV: S1 S2, audible S3, no murmurs
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: wwp, 1+ edema to shin. DPs, PTs 2+. Left and right
incisional scars with no drainage.
NEURO: grossly intact
SKIN: no rash, has sore bottom and using cream.
Pertinent Results:
ADMISSION LABS:
[**2121-10-7**] 07:05PM BLOOD WBC-9.6 RBC-3.53* Hgb-10.7* Hct-33.3*
MCV-94 MCH-30.3 MCHC-32.1 RDW-17.8* Plt Ct-153
[**2121-10-8**] 12:07AM BLOOD PT-14.5* PTT-29.1 INR(PT)-1.3*
[**2121-10-8**] 12:07AM BLOOD Glucose-149* UreaN-57* Creat-2.3* Na-129*
K-4.7 Cl-91* HCO3-29 AnGap-14
[**2121-10-11**] 03:37AM BLOOD ALT-18 AST-31 AlkPhos-104 Amylase-31
TotBili-0.5
[**2121-10-11**] 03:37AM BLOOD Lipase-19
[**2121-10-8**] 12:07AM BLOOD Phos-4.7* Mg-3.2*
[**2121-10-15**] 03:04AM BLOOD Albumin-3.1* Mg-2.9*
.
DISVCHARGE LABS:
[**2121-11-11**] 05:35AM BLOOD WBC-7.5 RBC-3.03* Hgb-9.2* Hct-29.3*
MCV-97 MCH-30.6 MCHC-31.6 RDW-17.5* Plt Ct-236
[**2121-11-11**] 05:35AM BLOOD Glucose-30* UreaN-19 Creat-1.0 Na-141
K-3.7 Cl-107 HCO3-30 AnGap-8
[**2121-11-11**] 05:35AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2
[**2121-11-10**] 09:54AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.026
[**2121-11-10**] 09:54AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
.
MICRO/PATH:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2121-11-10**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
WOUND CULTURE (Final [**2121-11-6**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 4 S
VANCOMYCIN------------ 1 S
.
[**2121-10-9**] ECHO: The left atrium is mildly dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is
moderately depressed (LVEF= 35 %) with akinesis of the basal and
mid inferior and inferolateral segments. Due to suboptimal image
quality additional wall motion abnormalities cannot be fully
excluded. Right ventricular chamber size is normal with moderate
global free wall hypokinesis. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. A bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis leaflets appear to move normally.
The transaortic gradient is normal for this prosthesis. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. A mitral valve
annuloplasty ring is present. The mitral annular ring appears
well seated with normal gradient. Trivial mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] Moderate
[2+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Biatrial enlargment. Normal left ventricular cavity
size with moderately depressed left ventricular systolic
function and regional wall motion abnormalities as described
above. Normally functioning bioprosthetic aortic valve with
trace aortic regurgitation. Well-seated, normally functioning
mitral valve annuloplasty ring. Moderate tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2121-9-27**],
the pulmonary artery systolic pressure has increased from 38
mmHg to at least 44 mmHg.
.
[**2121-10-12**] RENAL U.S. PORT: The right kidney measures 11.3 cm in
its long axis. In the mid pole of right kidney is a 1.8 x 0.9 x
1.2 cm, anechoic, well-circumscribed region compatible with a
simple cyst. The left kidney measures 12.1 cm in its long axis.
Neither kidney demonstrates stones or hydronephrosis. Both
kidneys demonstrate global color Doppler flow. Transverse and
sagittal views of the bladder demonstrate it to be decompressed
around a Foley balloon. There is no ascites seen in the lower
quadrants. A small amount of right upper quadrant ascites and
right pleural fluid is demonstrated. IMPRESSION: No evidence of
hydronephrosis. Small right renal cyst. Small amount of right
upper quadrant ascites and right pleural effusion.
.
[**2121-10-29**] ECHO: The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Overall left ventricular systolic function is mildly
depressed. Diastolic function could not be assessed. The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. A bioprosthetic aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. A mitral valve annuloplasty ring is
present. There is moderate thickening of the mitral valve
chordae. Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
[Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric LVH. There is at least mild LV
systolic dysfunction. There appears to be significant
dyssynchrony present - as a result LV cardiac ouput is further
impaired. Dilated and hypokinetic right ventricle with moderate
tricuspid regurgitation and moderate pulmonary artery
hypertension. Normally functioning aortic bioprosthesis.
Compared with the prior study (images reviewed) of [**2121-10-9**],
the right ventricle appears more dilated/hypokinetic. There is
probably increased dyssynchrony present.
.
[**2121-10-30**] UNILAT LOWER EXT VEINS: Grayscale, color and Doppler
images were obtained of the left common femoral, superficial
femoral, popliteal and tibial veins. Normal flow, compression
and augmentation is seen in all of the vessels. There is an
elongated complex fluid collection which extends from the left
popliteal fossa region upward to the lower third of the medial
left thigh. This structure could represent a hematoma from the
patient's recent saphenous vein harvest site. IMPRESSION: No
deep vein thrombosis seen in the left leg. Avascular complex
fluid collection in the medial left distal thigh and [**Doctor Last Name **] fossa
could represent a hematoma from recent saphenous vein harvest
site.
Brief Hospital Course:
ACTIVE ISSUES:
# Congestive heart failure: Acute on chronic systolic congestive
heart failure, with most recent EF 35%. Mr. [**Known lastname **] was admitted
and diuresed with IV Lasix with milrinone for blood pressure
support. He underwent a left sided thoracentesis by the
Interventional Pulmonology service on [**2121-10-8**] for a yield of
1600cc of fluid. Right sided thoracentesis on [**2121-10-9**] yielded
1600cc of fluid. It was attempted to transition back to PO
torsemide however he was not effectively diuresing with this
regimen so he was restarted on a lasix drip with dopamine for
pressure support. He did well with this and was transferred to
the floor on PO furosemide. He was felt to be euvolemic and
ready for discharge. ACEI should be restarted as an outpatient.
Carvedilol was resumed at 3.125 mg [**Hospital1 **] at discharge.
.
#Sepsis: After Mr [**Known lastname **] was transferred back to the floor he had
an episode of hypotension with SBPs in the 80s as well as
abdominal pain, diarrhea and fever, he was taken back to the CCU
where pressors were re-initiated. He was started on vancomycin
and zosyn. Blood and urine cultures were negative however his
midline catheter tip grew coagulase negative staph. He was
treated with vanc/zosyn for one week. His stool studies were
negative and his diarrhea slowly resolved.
.
# Acute kidney injury: His creatinine has been rising over the
past two months secondary to diuresis for repeat acute episodes
of heart failure. At the time of admission, his creatinine had
been 2.3, rose to a peak of 2.9, and was 2.4 at the time of
transfer to the CCU. Dopamine was used to increase kidney
perfusion. With successful diuresis, the patient's creatinine
improved to 1.0 on discharge.
.
# Diabetes mellitus, type 2: The patient's blood glucose was
initially poorly controlled, ranging up to 300 upon transfer to
the CCU. He was followed by the [**Last Name (un) **] consulting team who
adjusted his standing and sliding scale doses of insulin with
resulting better blood gluocose control. At the time of
discharge, his regimen included glargine and HISS
.
# BPH: Has had difficulty voiding while in the hospital. Because
he had been hypotensive his tamsulosin had been held and later
restarted. On the day of discharge he had succesfully urinated
without a foley catheter.
.
CHRONIC ISSUES:
# Rhythm: The patient is AV- and V-paced at 85 bpm. He was
monitored on telemtry during this admission without any issues.
.
# Hypertension: During this admission, the patient was
hypotensive from aggressive diurese, so his home
antihypertensives (hydralazine and isosorbide) were held
accordingly.
.
# Hyperlipidemia: Documented history of this problem, for which
the patient was continued on his home atorvastatin.
.
# CAD: s/p 3-vessel CABG [**2121-9-8**], with moderately decreased LV
systolic function (EF 35%). The patient was chest pain-free
during this admission, and continued on his aspirin adn
atorvastatin. His beta blocker and ACEi were initially held
secondary to hypotension. At the time of discharge, he was
restarted on carvedilol 3.125 mg [**Hospital1 **]. ACEI should be resumed as
an outpatient
.
# Inflammatory bowel disease: Documented history of this
problem, for which the patient was continued on his mesalamine
800 mg PO QID.
.
Medications on Admission:
1. aspirin 81 mg daily
2. acetaminophen 325 mg PO Q4H prn pain
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Q4H prn SOB/wheezing
4. mesalamine 750 mg Capsule, Extended Release PO QID
5. multivitamin PO daily
6. atorvastatin 80 mg PO daily
7. finasteride 5 mg PO daily
8. trazodone 25 mg PO qHS PRN insomnia
9. tamsulosin 0.4 mg, extended release, PO qHS
10. loperamide 2 mg PO QID prn for diarrhea.
11. metoprolol succinate 25 mg PO daily
12. sulfamethoxazole-trimethoprim 800-160 mg PO BID for 6 days
13. ranitidine HCl 150 mg PO daily
14. nystatin 100,000 unit/mL Susp Sig: Five (5) ML PO QID
15. lidocaine 5 %(700 mg/patch) Adhesive Patch, daily
16. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-12**] Sprays Nasal
QID (4 times a day) prn nasal congestion.
17. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous twice a day: 4 Units at breakfast and bedtime.
18. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: per sliding scale.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q2H (every 2 hours) as
needed for wheezing/SOB .
4. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
10. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-12**] Sprays Nasal
TID (3 times a day) as needed for nasal congestion.
11. zinc oxide-cod liver oil 40 % Ointment Sig: One (1)
application Topical [**Hospital1 **] (2 times a day): apply to rectal area.
12. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Hold SBP < 90, HR <55.
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous once a day: 5 units before breakfast, 4 units at
hs. .
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Chronic Systolic Heart Failure
Coronary Artery Disease, s/p CABG x 3 on [**2121-9-8**]
Diabetes
Dyslipidemia
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right- serosanguinous drainage without signs of infection
Edema [**1-12**]+
Discharge Instructions:
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
You had a long course here at [**Hospital1 18**] and was treated for
congestive heart failure, acute kidney injury and sepsis. You
finished a course of antibiotics yesterday and required
intravenous fluid for low blood pressure. You have fluid
collections in your lungs called pleural effusions that were
tapped and have reaccumulated but are stable. As of now, your
kidney function is normal and you are likely at your ideal
weight of 78.2 kg or 172 pounds. Please weigh yourself every
morning, call Dr. [**Last Name (STitle) 4541**] if weight goes up more than 3 lbs in 1
day oer 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. STOP taking lisinopril as your blood pressures are somewhat
low, this can be restarted soon.
2. Increase your lantus to 5 units in the morning and 4 units at
night.
3. STOP taking trazadone, bactrim, nystatin and lidoderm patch
4. Change metoprolol to carvedilol to help your heart pump
better
5. Change ranitidine to pantoprazole to protect your stomach
6. START nasal spray as needed for dry nose
7. START desitin ointment for a sore rectal area
8. START Digoxin to help your heart pump better
9. START Furosemide to get rid of extra fluid
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Cardiology)
Location: [**Hospital 20086**] MEDICAL GROUP
Address: [**Street Address(2) 20087**], STE 3A, [**Hospital1 **],[**Numeric Identifier 10727**]
Phone: [**Telephone/Fax (1) 7164**]
Fax: [**Telephone/Fax (1) 28287**]
Date/Time: [**11-25**] at 11:00am.
|
[
"362.01",
"278.00",
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"600.00",
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"443.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"89.64",
"34.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
16843, 16898
|
10892, 10892
|
303, 378
|
17064, 17263
|
3652, 3652
|
18672, 19062
|
1734, 1851
|
15236, 16820
|
16919, 17043
|
14237, 15213
|
17287, 18649
|
2942, 3633
|
237, 265
|
10907, 13235
|
406, 1163
|
3668, 10869
|
13251, 14210
|
1185, 1454
|
1470, 1702
|
2927, 2927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,509
| 153,908
|
11372
|
Discharge summary
|
report
|
Admission Date: [**2130-10-19**] Discharge Date: [**2130-10-24**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
woman with a history of chronic obstructive pulmonary
disease, congestive heart failure and hypertension, who was
admitted to the medical intensive care unit on [**2130-10-18**].
She initially presented to [**Last Name (un) 36412**]
mental status; the patient was extremely confused, with
slurred speech and diaphoresis. She had gone to her primary
care physician earlier in the day secondary to a headache
with possible subacute confusion, i.e. not feeling herself,
for several days prior.
At [**Hospital 26200**] Hospital, the patient was intubated on
protection. She was transferred to [**Hospital1 190**] for medical intensive care unit care. Workup
included an unremarkable CT scan of the head, MRI, lumbar
puncture and electroencephalogram. The [**Hospital 26200**]
Hospital course was notable for a blood pressure of 210/100
as well.
On the day of admission after a visit to her primary care
physician's office, the patient went into the bathroom and
had a bowel movement. She needed her husband to help her
walk and sit down when coming out of the bathroom. She then
seemed confused, not knowing family names, repeating "Who is
that?". She was on the phone when there was no one on the
other end. Her husband commented that her speech seemed
slurred and was not making sense, but there were no clear
word substitutions. The patient also appeared diaphoretic at
that time. By the time that the EMS arrived, the patient had
lost consciousness. Her subsequent course was as noted
above.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Congestive heart failure.
3. Hypertension.
4. Question of history of hallucinations.
MEDICATIONS ON TRANSFER TO FLOOR:
1. Atenolol 50 mg p.o. q.d.
2. Digoxin 0.25 mg p.o. q.d.
3. Prednisone 60 mg p.o. q.d.
4. Dilantin 300 mg p.o. q.d.
5. Levofloxacin 250 mg p.o. q.d.
6. Subcutaneous heparin.
ALLERGIES: There were no known drug allergies.
SOCIAL HISTORY: The patient had a history of tobacco use,
quitting five years ago.
PHYSICAL EXAMINATION: On admission to the medical intensive
care unit, vital signs revealed a temperature of 98.6??????F, a
pulse of 55, a blood pressure of 162/48 and a pulse oximetry
of 98% on 50% FiO2 with pressure of 12 and 5. In general,
the patient was lying in bed, intubated and sedated, in no
acute distress. On HEENT examination, the head was
normocephalic and atraumatic. The pupils were 2 mm
bilaterally.
The cardiovascular examination was a regular rate and rhythm
with a normal S1 and S2 and a positive II/VI systolic murmur
at the right upper sternal border, radiating to the apex. On
lung examination, there were coarse breath sounds throughout.
The abdomen was soft, nontender and nondistended. The
extremities had no clubbing, cyanosis or edema.
SIGNIFICANT STUDIES: An MRI/MRA revealed no gross
abnormalities. An electroencephalogram revealed no evidence
of seizure activity. A lumbar puncture was unremarkable.
HOSPITAL COURSE: The patient was extubated on the morning of
the second hospital day. She did have desaturations in the
mid 70s status post extubation when she took off her nasal
cannula. Her oxygen saturation returned to 92% when four
liters O2 via nasal cannula were instituted. The patient was
also hypercarbic before transfer to the floor with a pCO2 of 83.
However, it was thought that her likely baseline pCO2 of 60 to
65, given her history of chronic obstructive pulmonary disease.
The patient was found to have pneumonia in the right lower
lobe by chest x-ray and was started on Levaquin on the third
hospital day. She was transferred to the floor on the third
hospital day for further management of her pneumonia. The
patient did well after transfer to the floor with continued
improvement in her mental status back to baseline.
CONDITION/DISPOSITION: The patient was discharged to short
term rehabilitation in improved and stable condition.
DISCHARGE MEDICATIONS:
1. Captopril 12.5 mg p.o. t.i.d.
2. Digoxin 0.25 mg p.o. q.d.
3. Prednisone 50 mg p.o. q.d. with plan for rapid taper.
4. Dilantin 300 mg p.o. q.d.
5. Levofloxacin 250 mg p.o. q.d. with plan for ten day total
course.
DISCHARGE DIAGNOSES:
1. Question of seizure.
2. Pneumonia.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**]
Dictated By:[**Name8 (MD) 2061**]
MEDQUIST36
D: [**2130-10-24**] 08:34
T: [**2130-10-24**] 08:49
JOB#: [**Job Number **]
|
[
"496",
"486",
"401.9",
"427.89",
"593.9",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
4336, 4604
|
4092, 4315
|
3126, 4069
|
2189, 3108
|
124, 1660
|
1682, 2081
|
2098, 2166
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,364
| 151,038
|
49487
|
Discharge summary
|
report
|
Admission Date: [**2168-10-5**] Discharge Date: [**2168-10-11**]
Date of Birth: [**2091-2-18**] Sex: M
Service: MEDICINE
Allergies:
Nsaids/Anti-Inflammatory Classifier / Vancomycin / Flagyl
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Septic Shock, UTI, GI Bleed due to Gastic Ulcers, Obstructing
Ureteral Stone, Hypokalemia
Major Surgical or Invasive Procedure:
Left nephrostomy on [**2168-10-5**]
EGD on [**2168-10-5**]
EGD on [**2168-10-7**]
History of Present Illness:
77 year old Male with h/o CAD s/p CABG and stent placement,
pacemaker, hemorrhagic frontal CVA [**2152**] with residual effects,
prior DVT and PE (20 years ago), BPH, Type 2 DM, benign
hypertension, ulcerative colitis (with h/o of admissions for GI
bleeding) transferred from [**Hospital1 **] [**Location (un) 620**] due to GI bleed and
septic shock due to UTI with obstructive kidney stone.
Patient is homebound at baseline but ambulates with walker and
requires assitance with ADL's. He has recent history of
recurrent UTI and had a cystoscopy on [**9-30**] for work-up of
persistent hematuria. He initially presented to [**Hospital1 18**] [**Location (un) 620**] ED
after an unwitnessed fall at home on [**10-4**] in the PM, unclear if
there was LOC, he was found by his wife on the floor, fully
concsious and with no signs of trauma. He was able to be helped
up and walk with his walker. Following the fall he had a
persistent cough and then developed large amounts of dark
vomitus. He is on ASA, not on coumadin or plavix.
At [**Hospital1 18**] [**Location (un) 620**] was HD stable with SBP in the 140's, found to
have positive NG lavage that did not clear, was noted febrile to
102, with positive UA and CT abdomen/pelvis showing 1cm
obstructing left kidney stone at the UPJ. CT head and CXR showed
no acute processes. 16g and 18g PIVs were placed, He was started
on ceftriaxone and protonix drip. He was guiac neg with stable
Hct. He was transferred to [**Hospital1 18**]-[**Location (un) 86**] per urology for
placement of drainage nephrostomy.
Patient was last admitted to our institution in [**2168-5-4**] for
UTI with pan-sensitive e.coli. Per his last PCP note from [**8-/2168**]
he was since treated twice for UTI and had persistent
microscopic hematuria despite completion of treatment. He does
have known prostatic enlargement and some lower urinary tract
symptoms and he is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] at NWH for this.
He had cystoscopy on [**9-30**] followed by 3 day course of cipro.
ED Course
- Initial Vitals: 08:27 0 100. 73 147/69 12 99% 1L NP
- A+O X2, benign abdomen, non focal neuroexam.
- EKG showed afib HR 70s, had asymptomatic nonsustained VT with
pulse.
- labs: WBC = 8.3, Hct = 35.6 (from 37 at [**Location (un) **]), PLT = 105.
Lactate = 3.7, Cr 1.1: 31 (from 0.7:14 baseline), K = 3.3, Mg =
1.6, P = 1.2, Normal LFT and coags, Dirty urine with Mod
bacteria.
He was in a wide complex tachycardia, and EP was consulted, who
felt this was his usual atrial tachycardia with abberency. A
repeat lavage posivice for cofee-grounds. Recieved IV Mg 2g + K
40mg, continued protonix drip, got early goal directed therapy.
IV Ceftriaxone given in OSH. A Nephrostomy tube was inserted
with good drainage, with relief of the obstructing Left Ureteral
stone. Patient was initally placed on levophed in the ICU. The
EP team reprogrammed his pacer to address his aberent
conduction.
He was stabilized and transferred to the floor on [**2168-10-6**].
Past Medical History:
- hemorrhagic frontal CVA [**1-6**] heparin about ~16 years ago
- CAD s/p quadruple bypass [**2152**] (LIMA-LAD, SVG PL/PDA, SVG-OM)
and later BMS to ostial SVG-PL/PDA and PTCA of LIMA-LAD.
- s/p dual chamber [**Company 1543**] pacemaker in [**2157**]
- Depression
- Anxiety
- h/o body dysmorphia, controlled on medication
- Type 2 DM ~ 20 years with peripheral neuropathy
- H/o DVT complicated by PE about 19 years ago
- H/o PNA
- HTN
- Ulcerative colitis, last colonoscopy in [**2162**] showing erythema
and ulcers in the rectum and sigmoid
- BPH
- s/p neck surgery
- h/o thrombocytopenia
Social History:
Lives with wife who helps with ADLs in [**Location (un) 37666**].
Homebound but ambulates with walker. Wife says she makes him
walk 50 laps around the house daily. Ex smoker 25 pack-year but
quit 25 yrs ago. Denies ETOH and drug use. Former contractor. No
kids.
Family History:
- Father died in 80s [**1-6**] DM
- Mother died in 70s [**1-6**] alcoholism
- Brother died in 40s of esophageal hemorrhage
- Otherwise h/o mental illness
Physical Exam:
ADMISSION EXAM:
Vitals: T: 100.0, 156/73, 69, 20, 97%
General: AlertX3, no acute distress.
HEENT: pale, anicteric, MMM
Skin: warm and dry
Neck: supple, JVP not elevated, no LAD, surgical scar right
neck.
Lungs: CTAB, no wheezes, rales, ronchi
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, normal BS, non-tender, no rebound tenderness or
guarding, no organomegaly, No CVA tenderness
GU: foley in place with hazy concentrated urine
Ext: 2+ pulses, no clubbing, cyanosis or edema
Back: Left Nephrostomy in place
Pertinent Results:
[**2168-10-11**] 04:48AM BLOOD WBC-6.5 RBC-3.78* Hgb-10.2* Hct-30.9*
MCV-82 MCH-27.1 MCHC-33.1 RDW-15.7* Plt Ct-82*
[**2168-10-6**] 03:24AM BLOOD WBC-12.2* RBC-3.68* Hgb-10.3* Hct-29.3*
MCV-80* MCH-28.1 MCHC-35.2* RDW-15.0 Plt Ct-78*
[**2168-10-5**] 05:29PM BLOOD WBC-10.5# RBC-3.88* Hgb-11.1* Hct-31.2*
MCV-80* MCH-28.5 MCHC-35.4* RDW-14.9 Plt Ct-81*
[**2168-10-5**] 09:00AM BLOOD WBC-8.3# RBC-4.30* Hgb-12.2* Hct-35.6*
MCV-83 MCH-28.4 MCHC-34.3 RDW-14.6 Plt Ct-105*
[**2168-10-5**] 09:30PM BLOOD Neuts-76* Bands-12* Lymphs-6* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2168-10-5**] 09:00AM BLOOD Neuts-77* Bands-17* Lymphs-4* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-10-6**] 03:24AM BLOOD PTT-36.7*
[**2168-10-5**] 01:07PM BLOOD PT-13.4 PTT-22.1 INR(PT)-1.1
[**2168-10-5**] 09:00AM BLOOD PT-13.5* PTT-22.6 INR(PT)-1.1
[**2168-10-5**] 09:00AM BLOOD PT-13.5* PTT-22.6 INR(PT)-1.1
[**2168-10-11**] 04:48AM BLOOD Glucose-114* UreaN-7 Creat-0.6 Na-140
K-3.0* Cl-110* HCO3-24 AnGap-9
[**2168-10-10**] 07:05AM BLOOD Glucose-119* UreaN-8 Creat-0.7 Na-143
K-2.9* Cl-113* HCO3-24 AnGap-9
[**2168-10-9**] 06:00AM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-142
K-2.7* Cl-110* HCO3-24 AnGap-11
[**2168-10-7**] 06:45AM BLOOD Glucose-84 UreaN-30* Creat-1.1 Na-145
K-3.2* Cl-114* HCO3-24 AnGap-10
[**2168-10-5**] 09:37PM BLOOD Glucose-132* UreaN-31* Creat-1.2 Na-145
K-3.2* Cl-116* HCO3-17* AnGap-15
[**2168-10-5**] 01:07PM BLOOD Glucose-218* UreaN-28* Creat-1.2 Na-143
K-3.9 Cl-111* HCO3-20* AnGap-16
[**2168-10-5**] 09:00AM BLOOD Glucose-207* UreaN-31* Creat-1.1 Na-143
K-3.3 Cl-107 HCO3-26 AnGap-13
[**2168-10-5**] 09:00AM BLOOD ALT-18 AST-27 CK(CPK)-50 TotBili-0.5
[**2168-10-5**] 09:00AM BLOOD Lipase-31
[**2168-10-5**] 09:00AM BLOOD cTropnT-<0.01
[**2168-10-11**] 04:48AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.6
[**2168-10-10**] 07:05AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.8
[**2168-10-9**] 06:00AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.5*
[**2168-10-7**] 06:45AM BLOOD Calcium-8.8 Phos-2.3* Mg-2.0
[**2168-10-5**] 09:37PM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2168-10-5**] 09:00AM BLOOD Albumin-3.6 Calcium-9.5 Phos-1.2* Mg-1.6
[**2168-10-6**] 09:02AM BLOOD Type-ART Temp-36.3 pO2-96 pCO2-34*
pH-7.38 calTCO2-21 Base XS--3
[**2168-10-5**] 09:53PM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-44 pH-7.28*
calTCO2-22 Base XS--5 Comment-GREEN TOP
[**2168-10-5**] 09:22AM BLOOD pH-7.30*
[**2168-10-6**] 09:02AM BLOOD Lactate-1.3 Na-142 Cl-3.4*
[**2168-10-5**] 09:22AM BLOOD Glucose-187* Lactate-3.7* Na-143 K-3.3
Cl-104 calHCO3-24
[**2168-10-5**] 09:22AM BLOOD Hgb-11.9* calcHCT-36
[**2168-10-5**] 09:22AM BLOOD freeCa-1.23
[**2168-10-5**] 09:00AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.042*
[**2168-10-5**] 09:00AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2168-10-5**] 09:00AM URINE RBC-92* WBC->182* Bacteri-MOD Yeast-FEW
Epi-0
[**2168-10-5**] 09:20AM URINE Hours-RANDOM UreaN-447 Creat-32 Na-88
K-35 Cl-100
[**2168-10-5**] 09:20AM URINE Osmolal-528
ECG Study Date of [**2168-10-5**] 8:39:46 AM
Sinus arrhythmia. Inferoposterior myocardial infarction of
indeterminate
age. Non-specific anterior T wave changes. Compared to the
previous tracing of [**2168-5-18**] the precordial ST segments are
flatter.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 140 118 412/440 70 28 -29
INTRO CATH RENAL PELVIS FOR DRAINAGE Study Date of [**2168-10-5**] 2:50
PM
IMPRESSION: Uncomplicated placement of an 8 French percutaneous
left
nephrostomy catheter with its retention pigtail loop within the
renal pelvis. Small amount of urine sample sent for laboratory
analysis.
RENAL U.S. Study Date of [**2168-10-10**] 1:25 PM
IMPRESSION: Left nephrostomy tube in expected location. No
hydronephrosis or hydroureter. Multiple echogenic foci, which
may represent air or less likely nonobstructive left renal
calculi.
EGD Wednesday, [**2168-10-5**]
Findings: Esophagus:
Contents: Digested food was found in the distal esophagus.
Stomach:
Lumen: A small size hiatal hernia was seen.
Contents: A food bezoar was found in the fundus.
Other Multiple red circular lesions of the same diameter were
noted in the stomach body. The three most distal lesions were
entirely flat and located along lines of linear erythema.
Proximally, along the greater curvature, there were two circular
lesions that were raised and almost polypoid. The final two
lesions were flat with apparent submucosal hemorrhage. Taken
together, these lesions appeared consistent with significant NG
trauma. This is plausible since the patient's NG tube was to
suction for some time. Nevertheless, we have no obvious
explanation for his reported coffee ground emesis.
Duodenum: Normal duodenum.
Impression: Gastric bezoar
Circular lesions likely NGT trauma as noted above
Food in the Distal esophagus
Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
EGD Friday, [**2168-10-7**]
Findings: Esophagus:
Mucosa: A salmon colored mucosa suggestive of short segment
(about 2cm) Barrett's Esophagus was found. The Z-line was at 37
cm from the incisors. Biopsies were not taken given recent Upper
GI bleed.
Stomach:
Excavated Lesions A single superficial 3-4 mm ulcer was found
in the stomach body. There was no high risk associated stimgata.
Duodenum:
Contents: Pills were found in the third part of the duodenum.
Impression: Mucosa suggestive of short segment Barrett's
esophagus
Ulcer in the stomach body
Pills in the duodenum
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
77M with h/o CAD s/p CABG and stent placement, pacemaker,
hemorrhagic frontal CVA [**2152**], prior DVT and PE, BPH, type 2 DM,
Hypertension, ulcerative colitis (with h/o of admissions for GI
bleeding) transferred from [**Hospital1 **] [**Location (un) 620**] with GI bleed and septic
shock due to UTI with obstructive kidney stone.
# Septic Shock from Bacterial UTI with Proteous, infected
ureteral stone:
admitted with fevers and positive UA in the setting of
obstructive kidney stone and recent cystoscopy. Blood cultures
showed gram negative rods. Urine culture grew Proteus.
- Zosyn empirically for gram negative and anaerobe coverage in
the setting of recent instrumentation/hospitalization, which was
changed on [**10-8**] to ceftriaxone with sensitivities.
- Pt was initially hypotensive to 70s on admission so gave fluid
boluses and started on levophed, with good result, patient
transferred to the floor on [**10-6**].
- CT A/P at [**Location (un) 620**] showed multiple left renal calculi with mild
left hydronephrosis and delayed nephrogram c/w acute obstruction
as well as cystitis. Concern was for infected fluid collection
behind stone so he underwent nephrostomy tube placement by IR to
drain renal pelvic space behind stone. They recommended leaving
nephrostomy tube in place until definitive stone treatment can
be done, which is to be arranged when patient is stabilized with
Dr. [**Last Name (STitle) 986**] at NWH.
# Hypokalemia, Hypomagnesemia
- Patient has required almost daily supplementation. At the
rehab he should have a daily potassium check, and
supplementation as needed. His wife reports that at home he
consumes many bannanas and he has a normal K at home, so this is
likely some self-supplementation. He may require chronic oral
supplementation, but would not initiate this until he is
clinically stable.
# Upper GI bleed due to gastric ulcers:
Initially presented to outside hospital with coffee-ground
emesis. GI was consulted and performed EGD on [**2168-10-5**] which
showed multiple circular lesions consistent with NG trauma, as
well as large bezoar, with no evidence of recent or active
bleeding. GI recommended placing patient on IV PPI [**Hospital1 **] and
Erythromycin to help propagate the bezoar. A repeat EGD was
performed on [**2168-10-7**], which showed a superficial ulcer in the
stomach body and short-segment Barrett's esophagus. He received
1Unit PRBC while in the ICU. Hct remained stable thereafter in
the 30's. He was transitioned to PO PPI. He will remain on both
the PPI and erythromycin until presenting to his followup GI
appointment
# Fall:
Patient had fall at home prior to presentation. The etiology was
unclear. EP was consulted to interrogate his pacemaker and found
that he had an episode of asymptomatic wide-complex tachycardia.
EP described it as an atrial tachy-arrhythmia with aberrancy and
subsequently re-programmed the pacer to detect it at 135bpm. CT
head showed no acute intracranial process.
# Atrial Tachycardia with Abberency
- The patient frequently goes into a wide complex rhythm. This
is abberent conduction, and was evaluated by the EP service with
his primary cardiologist, Dr. [**Last Name (STitle) **], who concurred that
there is no need for urgent intervention.
# Acute renal failure:
This was thought to result from a combination of septic shock as
well as the obstructing calculus. Improved with hydration,
treatment of sepsis, and nephrostomy placement. Discharge Cr was
0.6.
# Extrapyramidal syndrome:
The patient was noted to have tremor and bilateral cogwheel
rigidity. Most likely parkinson's or vascular EP syndrome but in
the setting of enlarged ventricles on CT head, urinary
incontinence and his h/o recurrent fall. Patient may benefit
from outpatient followup on this when not acutely ill.
# Thrombocytopenia:
This is chronic and was relatively at his baseline.
# CAD s/p CABG / chronic systolic CHF / Benign Hypertension:
ischemic cardiomyopathy with EF 35-45% at baseline. held ACE-I
and BB initially in the setting of bleeding and sepsis. These
were later reintroduced once his BP was stable. ASA was held and
remains held until the lithotripsy.
# Ulcerative colitis:
Continued asacol.
# Type 2 Diabetes Controlled without Complications:
Continued standing NPH and sliding scale
# Depression
- continued lexapro, seroquel, ritalin
# Constipation
- patient became highly constipated, but was succesfully treated
with PEG over 3 days.
Full Code
Medications on Admission:
ATENOLOL - 25 mg Tablet - 1 (One) Tablet(s) by mouth QAM
DIPHENOXYLATE-ATROPINE [LOMOTIL] - 2.5 mg-0.025 mg Tablet - 1
Tablet(s) by mouth twice a day as needed for Diarrhea
ESCITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day
MESALAMINE [ASACOL] - 400 mg Tablet, Delayed Release (E.C.) - 4
(Four) Tablet(s) by mouth four times a day
QUETIAPINE [SEROQUEL] - 25 mg Tablet - 1 Tablet(s) by mouth
daily
RAMIPRIL - 5 mg Capsule - 2 Capsule(s) by mouth once a day
RITALIN - 20MG Tablet - ONE TWICE A DAY
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime
TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Ext Release 24 hr - 1
Capsule(s) by mouth once a day
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - Test
twice a day
CHOLECALCIFEROL ([**Last Name (STitle) **] D3) [[**Last Name (STitle) **] D] - (OTC) - Dosage
uncertain
CRANBERRY - 500mg Cap - Dosage uncertain
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
Inject 6 units qam
Discharge Medications:
1. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO QID (4 times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
4. sodium chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
5. methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. insulin regular human 100 unit/mL Solution Sig: One (1)
sliding scale Injection QACHS: Standard insulin sliding scale.
9. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
14. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours): until
lithotripsy procedure.
15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Septic shock
GI bleed due to Gastic Ulcers
Barrett's esophagus
Obstructive nephrolithiasis
Acute kidney injury
Bacteremia
Urinary Tract Infection
Hypokalemia
Hypomagnesemia
Constipation
Chronic Systolic CHF
CAD Bypass Vessle
Depression
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 for treatment of your blood in your vomit, an
infected kidney stone, and urinary tract infection with septic
shock. You had an upper endoscopy which showed a large
collection of undigested food in your stomach. Repeat endoscopy
showed a small ulcer in your stomach and abnormal lining of your
esophagus called barrets esophagus. Your infection was treated
with IV antibiotics and medicine to support your blood pressure
in the Intensive Care Unit. You will need to complete
antibiotics until you have your lithotripsy with Dr. [**Last Name (STitle) 103548**].
You have also had low potassium levels, which the rehab will
continue to monitor, and they can give you potassium as needed.
MEDICATION CHANGES:
-
Followup Instructions:
Please call today to make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
office at [**Telephone/Fax (1) 103549**] to arrange for your lithotripsy procedure
Department: CARDIAC SERVICES
When: FRIDAY [**2168-10-21**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2168-11-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
|
[
"276.8",
"287.49",
"428.22",
"592.1",
"333.90",
"V58.67",
"530.85",
"414.00",
"995.92",
"553.3",
"038.49",
"V12.51",
"428.0",
"592.0",
"785.52",
"250.60",
"584.9",
"E849.8",
"564.00",
"275.2",
"285.9",
"357.2",
"556.9",
"599.0",
"V45.01",
"531.40",
"E928.8",
"427.1",
"311",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"55.03",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
17876, 17953
|
10764, 15230
|
409, 493
|
18232, 18232
|
5205, 10741
|
19158, 20012
|
4463, 4618
|
16349, 17853
|
17974, 18211
|
15256, 16326
|
18407, 19112
|
4633, 5186
|
19132, 19135
|
280, 371
|
521, 3552
|
18247, 18383
|
3574, 4167
|
4183, 4447
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,180
| 159,166
|
22522
|
Discharge summary
|
report
|
Admission Date: [**2184-7-5**] Discharge Date: [**2184-7-11**]
Date of Birth: [**2114-9-18**] Sex: M
Service: HEPATOBILIARY SURGERY
HISTORY OF PRESENT ILLNESS: This is a 69 year old male who
underwent a left colon, right colon resection, and partial
gastric wall resection on [**2180-9-19**] for a T2, N0, M0,
moderately well-differentiated adenocarcinoma of the colon
with 12 lymph nodes all negative for tumor. He was recently
noted to have a rise of his CEA and on [**2184-6-4**] underwent a
CT scan of the abdomen and pelvis which demonstrated
metastatic disease in segments 4 and 5 of the liver. He was
admitted for segmental resection.
PAST MEDICAL HISTORY: Hypertension.
Colon adenocarcinoma as above.
MEDICATIONS AT HOME: Cardura 16 mg p.o. q.day
Atenolol 50 mg p.o. q.day.
ALLERGIES: No known drug allergies.
EXAMINATION ON ADMISSION: Alert, obese male in no acute
distress. No scleral icterus. Neck: No lymphadenopathy or
thyromegaly. Lungs clear to auscultation. Cardiac: Regular
in rate and rhythm, no murmurs. Abdominal exam is benign.
Periphery is warm with no edema.
LABORATORY STUDIES ON ADMISSION: Hematocrit 46.5, white
count 7.5, platelets 196, PT 12.9, INR 1.1, sodium 141,
potassium 3.8, chloride 104, bicarb 26, BUN 11, creatinine
0.8, albumin 4.3, AST 16, ALT 18, alkaline phosphatase 73, T-
bili 1, glucose 94, AFP 3.5, CEA 41.
HOSPITAL COURSE: On the day of admission, [**2184-7-5**], he
underwent hepatic resection of segments 4, 5, and part of
segment 6. He tolerated the procedure well. Post-op he was
transferred to the Intensive Care Unit for close followup
because of significant blood loss, which was 2700 cc.
Altogether during his procedure here, he required 8 units of
blood and several liters of fluid. His postoperative course
is summarized as follows:
NEURO: Initially his pain was controlled with an epidural
which was removed on postoperative day 3. His pain is now
well-controlled on Percocet.
CARDIOVASCULAR: On post-op day 2 in the evening, he
developed rapid atrial fibrillation. His rate was controlled
with calcium channel blockers, conversion with amiodarone
drip failed, and he was electrically cardioverted on
postoperative day 3. He has remained in sinus since and is
now taking amiodarone p.o. According to the cardiology
consult, he will be maintained on amiodarone 200 mg p.o.
q.day, and this will be re-evaluated in six weeks and, if
stable, will probably be discontinued then.
RESPIRATORY: Remained stable throughout his hospitalization
with good saturations on room air.
GASTROINTESTINAL: His diet was gradually advanced. He is
now tolerating a regular diet and having normal bowel
movements.
GENITOURINARY: His urine output was good throughout his
hospitalization. His renal functions remained within normal
limits. He was voiding with no difficulty after removal of
the Foley.
INFECTIOUS DISEASE: His wound is healing well with no signs
of infection. His white count is normal and he has remained
afebrile. His two [**Location (un) 1661**]-[**Location (un) 1662**] drains which were placed
during surgery were found to drain slightly bilious fluid on
postoperative day 3. The bilirubin on these drains was 7 and
14. They are therefore left in place and will there and be
removed when followed up in clinic in the future. He has
been taught how to empty these drains and will be discharged
home with VNA to follow up on the wound and assist him with
drain care.
He is discharged home in stable condition with the following
recommendations:
DISCHARGE RECOMMENDATIONS: Follow up in [**Hospital 52796**] Clinic
as scheduled on Wednesday.
Continue medications as listed in the discharge form.
Follow up with cardiologist in six weeks to reassess need for
amiodarone treatment.
DISCHARGE DIAGNOSES: Metastatic colon cancer.
Status post segmental liver resection, segments 4, 5 and 6.
Hypertension.
Atrial fibrillation, status post cardioversion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (Titles) 58461**]
MEDQUIST36
D: [**2184-7-11**] 09:29:53
T: [**2184-7-11**] 10:30:15
Job#: [**Job Number 58462**]
|
[
"197.7",
"518.89",
"427.32",
"997.1",
"V10.05",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.22",
"99.61",
"50.12",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3827, 4249
|
1412, 3805
|
758, 861
|
182, 667
|
1156, 1394
|
690, 736
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,988
| 165,323
|
4065
|
Discharge summary
|
report
|
Admission Date: [**2128-7-15**] Discharge Date: [**2128-8-3**]
Date of Birth: [**2072-9-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dizziness, diarrhea
Major Surgical or Invasive Procedure:
attempted SVC thrombectomy/venoplasty
History of Present Illness:
55 year-old female with a history of ESRD secondary to
hypertensive nephropathy, transitioning from HD to PD, SVC
syndrome [**12-27**] clots on anticoagulation, recent line infection
with E.cloacae on ceftazidime admitted with hypotension and
diarrhea found to have C.diff colitis now somewhat improved on
PO vanco and IV flagyl. The patient was admitted to the MICU on
[**7-15**] [**12-27**] hypotension in the ED. In the MICU, the patient was
fluid repleted, given peripheral dopamine, and ruled out for MI.
Renal is following and managing her HD and PD.
.
Patient was recently hospitalized at [**Hospital1 18**] [**Date range (1) 17901**]
enterobacter bacteremia, and began treatment with ceftazidime at
HD and empirically in peritoneal diasylate with plans for 3 week
course starting [**6-28**] (last day would be [**7-18**]). She states that
she began having very frequent liquid diarrhea after discharge
from the hospital with slight blood, mucous in stool. Reports
dizziness and a presyncopal episode, especially with standing
over past 2 weeks. Pt was seen by Dr. [**First Name (STitle) 805**] on [**7-8**] and had
stool culture sent at that time that was negative, no c. diff
was sent.
.
She has denied abd pain, SOB, chills, CP. States appetite has
been normal, no N/V. Reported her dry weight at 78Kg, was 78Kg
at HD prior to HD on Monday. Gets HD M and F at [**Location (un) **] in
[**Location (un) **]. On other days does PD at home, reports using extra
diasylate day prior to admission as she was concerned that she
was retaining water because her face was "puffy." Reports her
normal BPS 100-120s. Has noted her BPs have been low, has been
holding her lisinopril and taking half dose of her atenolol.
.
Past Medical History:
-ESRD on HD: proliferative glomerulonephritis. ? hx of lupus
On steroids several years ago. Diagnosed in [**2122-10-25**] ([**Doctor First Name **]
1:160)
-Bilateral total knee replacement in [**2125-1-23**]
-CAD
-Rheumatic fever
-HTN
-Left shoulder OA
-Left rotator cuff tear
-Hyperparathyroidism
-Iron deficiency anemia
-Hypercholesterolemia
-Hysterectomy; fibroids
-Bilateral knee replacements [**1-28**]
-Herpes Zoster prior history with resulting post-herpetic
neuralgia right side
Social History:
Lives with housemates in [**Location (un) 669**]. Worked as social worker for
DSS, currently not working. Smoked [**11-26**] pack per day x 30 years,
now down to 1-2 cigarettes a day. Former cocaine user. Last
drink 1/[**2127**]. Denies recent cocaine use. Denies IVDU.
Family History:
Father myocardial infarction in his 40s. Uncle with a
myocardial infarction in his 40s. Brother with a myocardial
infarction in his 40s. There is no family history of connective
tissue disease. Sister with [**Name (NI) **]. Uncle with prostate ca.
Physical Exam:
Vitals: T: 96.7 BP:90/67 P:85 R:20 SaO2:94% on RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP. Periorbital edema.
Neck: thick, supple, + JVP. multiple prior line placement scars.
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Chest: RSC HD tunneled line, no expressible fluid. dressing
c/d/i, non-tender. B/l breast edema R>L
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, ND, normoactive bowel sounds, no masses or
organomegaly noted. Mimimally TTP in LLQ. No rebound or
guarding. PD catheter in place, c/d/i, non-tender.
Extremities: [**11-26**]+ dependent upper extremity pitting edema b/l.
No LE edema.
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor.
Pertinent Results:
[**2128-7-15**] 02:10PM PLT COUNT-584*
[**2128-7-15**] 02:10PM NEUTS-67.6 LYMPHS-14.9* MONOS-8.6 EOS-8.3*
BASOS-0.7
[**2128-7-15**] 02:10PM WBC-8.7 RBC-3.09* HGB-9.4* HCT-30.4* MCV-99*
MCH-30.6 MCHC-31.0 RDW-15.5
[**2128-7-15**] 02:10PM proBNP-5588*
[**2128-7-15**] 02:10PM estGFR-Using this
[**2128-7-15**] 02:10PM GLUCOSE-87 UREA N-25* CREAT-9.7*# SODIUM-136
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16
[**2128-7-15**] 02:22PM LACTATE-2.4*
[**2128-7-15**] 02:22PM COMMENTS-GREEN TOP
[**2128-7-15**] 08:28PM LACTATE-2.2*
.
CT Abdomen/Pelvis ([**2128-7-29**]): 1. There is expansion and
hyperdensity involving the right gluteus musculature, consistent
with an acute hematoma. 2. Diffuse anasarca, with marked edema
of the subcutaneous tissues. Intra-abdominal fluid is likely
related to peritoneal dialysis.
3. Mild interval increase in nodes about the right inguinal
region.
4. Left renal cyst, with a questionable thin rim of enhancement
posteriorly. MRI is recommended to exclude a solid component in
this lesion.
Brief Hospital Course:
55 year-old female with ESRD, transitioning from HD to PD, SVC
syndrome [**12-27**] clots on anticoagulation, recent line infection
with E.cloacae, admitted with hypotension and diarrhea found to
have C.diff colitis, treated with oral vancomycin, subsequently
developed R. gluteal bleed likely from heparin gtt, transfused 2
units, Hct stable since, to be placed on warfarin and
discharged.
.
.
## Functional SVC syndrome: Patient's face and upper extremities
are diffusely anasarcic due to SVC clot, thought to be from
indwelling catheter. IR attempted multiple times to perform
venoplasty and alleviate the clot in some manner, but was
unsuccessful, and concluded that further intervention would not
be warranted in light of HD catheter presence. Additionally,
given that the patient was on heparin gtt for most of these
procedures, she developed a spontaneous R. gluteal bleed seen
via CT scan. Heparin was discontinued, and the patient received
2 units of PRBC's through dialysis catheter, and another 2 units
two days later. Hct has been stable since.
.
## Asthma: patient had an episode of shortness of breath with
expiratory wheezes on exam. Desaturated to 90-92 percent on RA,
lower than baseline of 97-100 percent on RA. Given albuterol
nebulizers which alleviated the problem, will be discharged on
this medication.
.
## Hypotension/syncope: pt had hypotension and syncope, was
fluid responsive, on dialysis, no events after initial episode
since, patient had all antihypertensive medications held.
.
## C.diff colitis: pt. admitted for colitis and treated
successfully with 14 day course of PO vancomycin. No fevers
once on Abx, and cultures have since been negative to date.
.
## ESRD: Was in a period of transition from Hemodialysis to
Peritoneal Dialysis, unable to dialyze peritoneally adquately,
so patient had her HD catheter continually in place and is
having a prolonged transition period. IR replaced old HD
catheter, which may have been source for SVC clot, with new one
on [**2128-7-29**]. The patient also had a CT scan of the abdomen and
pelvis which showed a small atrophic cyst of the L. kidney which
may warrant a future MRI.
.
## OSA: CPAP was in use throughout stay.
.
## H/O GNR bacteremia: Blood cultures were monitored, patient
was placed on ceftazidime and finished course with no blood
culture growth to date.
.
## Depression: Continued celexa
.
## Anemia: Continued EPO and Iron infusions with dialysis.
.
## Post-herpetic neuralgia: Continued gabapentin
.
## CAD: No active symptoms or ecg changes during this admission.
.
## GERD: continued PPI
Medications on Admission:
1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
10. Paricalcitol
Paricalcitol 6.5 mcg IV QHD
11. Ferric gluconate
Ferric Gluconate 125 mg IV QWEEK AT HD
12. ceftazidime
CeftazIDIME 1 g IV 3X/WEEK (MO,WE,FR) Duration: 3 Weeks with
start date [**2128-6-28**]
13. Outpatient Lab Work
Please check INR at next HD session
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
16. Ferric Gluconate 125 mg IV QWEEK AT HD
17. CPAP
CPAP with 2L O2
Auto CPAP range 4-20
Diagnosis: OSA
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Aspirin 325 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. Nursing Care
-Heparin flushes PRN HD Catheter per protocol
-Peritoneal Dialysis care as per Peritoneal protocol
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO ONCE (Once) as needed for dyspepsia .
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-26**] Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*3*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed.
Disp:*90 Tablet(s)* Refills:*0*
13. Paricalcitol 6.5 mcg IV QHD
14. Ferric Gluconate 125 mg IV QWEEK WITH HD
15. Potassium Chloride 7.5 mEq IV PRN
Please add to 2.5L PD bag (3 mEq/liter).
16. CPAP
CPAP with 2L O2
Auto CPAP range 4-20
Diagnosis: OSA
17. Warfarin 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:
Primary:
End Stage Renal Disease, Dialysis Dependent
Superior Vena Cava Syndrome
Clostridium Difficile Colitis
Enterobacter Cloacae Bacteremia
Secondary:
Hypertension
Discharge Condition:
stable, still with r. gluteal pain on motion, eating and
drinking without complaint.
Discharge Instructions:
You were admitted to the hospital for management of your
diarrhea. You were found to have a bacteria named C.diff in your
colon which was causing your diarrhea. You were treated for this
infection with antibiotics. You also had the clot in your upper
chest looked at and operated on by interventional [**Location (un) **] over
3 times, without any success. What they were able to do is
replace your old hemodialysis catheter line with a new one.
However, given that you were on the anticoagulant medication
heparin, you had a spontaneous bleed into your R. buttock area.
We stopped the heparin, and gave you 2 units of blood via your
hemodialysis catheter. Since that time, your blood count has
stabilized. Given your history of having this clot, we are
placing you on an anticoagulant called coumadin and you will be
discharged on that medication. You will need to be followed up
in a coumadin clinic to monitor your blood levels and in a
hematology oncology clinic.
Because you were very dehydrated when you came to the hospital,
your blood pressure was very low and you resultingly received
copious fluids. Because you do not make urine, this additional
fluid caused a worsening of your SVC (superior vena cava)
syndrome. In order to remove this fluid, you had daily
hemodialyisis with overlapping peritoneal dialysis. Because of
low blood pressures and a longterm goal of converting to PD
alone, HD was stopped while PD was continued several times per
day -- you are now to have HD and PD at different times during
the week.
If you have any severe shortness of breath, chest pain,
lightheadedness, sudden and instoppable bleeding, please call
your primary care provider and come to the emergency department.
Followup Instructions:
-Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2128-8-11**] 9:30
-Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2128-8-11**] 10:45
-Provider: [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 17898**]
Date/Time:[**2128-8-12**] 1:20
-Please follow up your coagulation studies (INR) with your
primary care provider [**Name9 (PRE) **] [**Name10 (NameIs) **] visiting nurse should draw them
for you, you simply need to have him/her fax them to your PCP.
[**Name10 (NameIs) 2172**] INR will also be checked at Dialysis, so if you cannot fax
the results to your PCP, [**Name10 (NameIs) **] should also be done at dialysis.
-Please make an appointment with the Hemostasis and [**Hospital 17902**]
clinic as soon as you can: ([**Telephone/Fax (1) 17903**]
Completed by:[**2128-8-3**]
|
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"458.9",
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"276.51",
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"008.45",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"54.98",
"88.51",
"38.95"
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icd9pcs
|
[
[
[]
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10958, 11015
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5345, 7937
|
333, 373
|
11226, 11313
|
4276, 5322
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13083, 13962
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2935, 3186
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9419, 10935
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11036, 11205
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7963, 9396
|
11337, 13060
|
3201, 4257
|
273, 295
|
401, 2120
|
2142, 2631
|
2647, 2919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,574
| 148,147
|
45245+45246+45247
|
Discharge summary
|
report+report+report
|
Admission Date: [**2158-11-2**] Discharge Date: [**2158-11-10**]
Date of Birth: [**2095-4-11**] Sex: F
Service: INTERNAL MEDICINE/[**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old
woman with multiple medical problems including pancreatic
cancer, type 2 diabetes, hypertension, gastroesophageal
reflux disease, nausea, constipation, hemorrhoids, Crohn's
disease in remission. ....................
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 96692**]
MEDQUIST36
D: [**2158-11-10**] 08:28
T: [**2158-11-10**] 08:30
JOB#: [**Job Number 96693**]
Admission Date: [**2158-11-2**] Discharge Date: [**2158-11-11**]
Date of Birth: [**2095-4-11**] Sex: F
Service:
ADDENDUM:
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
(CONTINUED):
1. OLIGURIC RENAL FAILURE ISSUES: The patient experienced
total body overload secondary to aggressive fluid and blood
resuscitation during her hospitalization, but she remained
intravascularly depleted. Her urine output throughout her
hospitalization, up until the time of discharge, was marginal
and could be characterized as oliguric renal failure in the
range of approximately 20 cc to 30 cc per hour despite
attempts to expand her intravascular volume with fluids and
blood. Some component of this reflects renal failure itself;
although, there was likely a significant contribution of her
propound malnutrition as her oral intake had been minimal.
Her blood urea nitrogen was 10, and her albumin was in the
middle 2.
We were also concerned that there may be some hemodynamic
compromise with poor renal perfusion secondary to her clot
burden; although, she remained otherwise hemodynamically
stable with a normal blood pressure (although off her
antihypertensive medications).
Given the patient's wishes to return home, and the fact that
we were not currently in a hospice mode, will transition home
with close followup and visiting nurses who can follow her
blood pressure and her respiratory status.
I explained to her that over the coming weeks she may be at
more risk for total body overload including congestive heart
failure, and she knew to return to the hospital for those
reasons. In the meantime, we will discontinue any renal
toxic medications and carefully monitor her urine output as
can best be done from home.
2. HEMATOLOGIC ISSUES: Bilateral deep venous thromboses and
bilateral pulmonary emboli were likely secondary to her
hypercoagulability secondary to metastatic pancreatic
carcinoma. The patient was to be discharged on Lovenox 80 mg
subcutaneously twice per day for an unlimited duration. The
patient remained hemodynamically stable at the time of
discharge (as noted).
3. GASTROINTESTINAL ISSUES: The patient with some mild
diarrhea during the latter week of her hospitalization. This
had decreased in frequency at the time of discharge. She was
written for Lomotil as needed. Clostridium difficile
cultures were negative.
4. INFECTIOUS DISEASE ISSUES: The patient with evidence of
a urinary tract infection versus Foley catheter
contamination. The patient received three days of by mouth
Levaquin and had her Foley catheter changed. She was to
complete a 7-day course of Levaquin.
5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
profoundly malnourished. Will encourage by mouth and not
limit the patient to a diabetic diet. The patient was
started on Megace during her hospitalization. Her
electrolytes were repleted.
6. ONCOLOGIC ISSUES: The patient with metastatic pancreatic
carcinoma. Chemotherapy was being held for now. The patient
was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately three
days.
7. ENDOCRINE ISSUES: For the patient's diabetes, she was
maintained on her home dose of Glyburide and a regular
insulin sliding-scale during her hospitalization. Her
Glyburide was held for several days prior to discharge given
her poor oral intake. Should her oral intake improve at
home, she may resume her Glyburide per [**Hospital6 1587**].
8. CODE STATUS ISSUES: The patient is do not resuscitate/do
not intubate. Will defer further discussion of re-initiation
of chemotherapy to her oncologist.
DISCHARGE DISPOSITION: The patient was to return to home
with services which include physical therapy, visiting
nurses, as well as her home private nursing service.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE DIAGNOSES:
1. Metastatic pancreatic cancer.
2. Oliguric renal failure.
3. Total body volume overload.
4. Malnutrition.
5. Bilateral deep venous thromboses.
6. Bilateral large pulmonary emboli.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg by mouth twice per day.
2. Sertraline 50 mg by mouth once per day.
3. Hydromorphone 2 mg q.8h. as needed.
4. Multivitamin one tablet by mouth once per day.
5. Glyburide 5 mg by mouth in the evening.
6. Glyburide 7.5 mg by mouth in the morning.
7. Compazine as needed.
8. Ambien at hour of sleep as needed.
9. Prevacid 15 mg by mouth twice per day.
10. Lovenox 80 mg subcutaneously twice per day indefinitely.
11. Lactulose as needed.
12. Levaquin (to complete a 7-day course for a urinary tract
infection).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2158-11-11**] 12:24
T: [**2158-11-11**] 12:38
JOB#: [**Job Number 96694**]
Admission Date: [**2158-11-2**] Discharge Date: [**2158-11-11**]
Date of Birth: [**2095-4-11**] Sex: F
Service: IM-[**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 63 year old woman
with multiple medical problems including pancreas divisum,
diabetes mellitus type 2, transaminitis, hypertension,
gastroesophageal reflux disease, nausea, vomiting,
constipation, hemorrhoids, Crohn's Disease in remission,
metastatic pancreatic cancer to liver. She was in her usual
state of health until seven days prior to admission, when she
noticed a swelling of her left foot. Three days later, there
was swelling noted on the right foot as well as right leg and
thigh.
Over the following day, her swelling increased and coolness
and discoloration were noted in the lower extremities causing
pain on ambulation especially with dorsiflexion. There was
no associated shortness of breath, chest pain, dizziness,
headache, change in vision or change in mental status.
The patient called her primary care physician who scheduled [**Name Initial (PRE) **]
lower extremity venous duplex at [**Hospital1 190**] which showed bilateral deep venous thromboses.
The patient was given 80 mg of Lovenox subcutaneously there
and was directly admitted for treatment of lower extremity
deep venous thrombosis.
PAST MEDICAL HISTORY: As per History of Present Illness.
PAST SURGICAL HISTORY:
1. Status post stent placement, biliary stent, in [**2158-9-30**].
2. Total abdominal hysterectomy / bilateral
salpingo-oophorectomy.
REVIEW OF SYSTEMS: The patient has complained of recent dry
mouth, loss of taste and weakness. Denies any recent weight
loss, chest pain, dizziness, fever, chills or night sweats.
PHYSICAL EXAMINATION: Temperature 97.9 F.; blood pressure
85/47; pulse 110; respiratory rate 20; O2 saturation on room
air 97%. In general, chronically ill appearing in no acute
distress. HEENT: Normocephalic, atraumatic. Extraocular
muscles are intact. Pupils equally round and reactive to
light and accommodation. Mucous membranes were moist; no
adenopathy, no jugular venous distention. Chest clear to
auscultation bilaterally, no wheezes or rhonchi, breath
sounds normal. Cardiovascular examination: S1, S2, no
murmurs, gallops or rubs. Regular rate and rhythm;
tachycardic at 110 beats per minute. Abdomen soft,
distended, positive hepatomegaly three fingerbreadths below
the costal margin. Ill defined immobile mass in the left
lower quadrant, nontender, nondistended, no rebound, guarding
or rigidity, bowel sounds normal. Extremities with bilateral
pitting edema to knees, plus four, right lower extremity
greater than left. Right extremity cooler than left,
positive [**Last Name (un) 5813**] sign on the right. Bilateral discoloration,
right greater than left. Distal pulses present and strong.
LABORATORY: White blood cell count 17.6, hemoglobin 10.7,
hematocrit 33.7, platelets 99. Sodium 129, potassium 4.7,
chloride 93, bicarbonate 24, BUN 39, creatinine 1.6 with
baseline 0.4 to 0.7; glucose 403 (corrected sodium 133).
Coags with PT 30, PTT 150, INR 6. Repeat coags with PT 24,
PTT 47.6, INR 3.8.
Venous duplex: Extensive deep venous thrombosis from common
femoral vein to popliteal veins bilaterally.
CONCISE SUMMARY OF HOSPITAL COURSE:
1. Assessment: [**First Name8 (NamePattern2) **] [**Known lastname **] is a 63 year old woman with
multiple medical problems, of note, metastatic pancreatic
cancer to the liver, who presents with increased lower
extremity swelling for one week, subsequently found to
represent bilateral deep venous thromboses.
On arrival to the Floor, the patient was noted to be
hypotensive, tachycardic and did not respond appropriately to
three liters of normal saline fluid boluses. Given the high
index of suspicion for pulmonary embolism in the setting of
metastatic cancer, it was decided to order a CT angiogram to
evaluate the possibility of pulmonary emboli. Subsequent CT
showed significant filling defects in the pulmonary
circulation representing massive bilateral pulmonary emboli.
The patient was taken to the Intensive Care Unit where the
patient arrived to the Medical Intensive Care Unit alert and
oriented in no apparent distress. She was in sinus
tachycardia with heart rate in the low 100s with no ectopy
seen at the time. Her blood pressure continued to be in the
low 80s and respiratory rate between 12 and 16 breaths per
minute. There were no complaints of shortness of breath or
chest pain. She remained afebrile.
It was subsequently decided that based on the patient's
massive pulmonary embolism, the most appropriate intervention
at that time was for an IVC filter placement. In the
interim, however, the patient was started on a heparin drip
which was discontinued temporarily before the IVC filter
placement to then resume subsequently. Following placement
of the filter, the patient remained on bed rest with pulse
and groin checks every one hour. Her pulses remained
Dopplerable and palpable. Her groin site was intact with no
signs of hematoma or bleeding.
Her heparin was subsequently restarted at 1150 units per
hour. She continued having bilateral lower extremity edema
however. Her O2 saturation remained in the high 90s on two
liters of nasal cannula; lungs remained clear. By that time,
the patient was stable to be transferred back to floor.
Upon arrival to the regular medicine floor, the patient
continued to be tachycardic and hypotensive. Intravenous
fluids were continued as needed to maintain blood pressure.
The patient was preload dependent and needed boluses to
maintain her blood pressure. A trial off of intravenous
fluids was attempted which the patient tolerated. She
remained normotensive.
During the rest of her hospital stay, she continued in sinus
tachycardia with no arrhythmias noted on Telemetry.
Respiratory she remained comfortable saturating in the 90s on
room air with no desaturation.
She was started on Lovenox 80 mg subcutaneously q. 12 to
treat her thromboembolism. She will need to remain on
Lovenox indefinitely.
The rest of her hospital stay was complicated by oliguria
followed by anuria. The patient was provided with
intravenous fluids in the form of normal saline through
boluses and normal infusion, however, urine output did not
respond appropriately.
Urinalysis was sent which results were consistent with a
urinary tract infection. Of note, her urinalysis showed
nitrites, leukocyte esterase, 6 to 10 red blood cells, 21 to
50 white blood cells, many bacteria, 11 to 20 transitional
epithelial cells. She was subsequently started on Levaquin
for therapy at 500 mg q. day by mouth, however, urine output
remained minimal. A fractional excretion of sodium
determined the patient to be prerenal indicating a need for
further hydration.
Despite encouraging p.o. intake, the patient persisted with
poor appetite. At this time, it was decided to transfuse the
patient with two units of packed red blood cells to try to
maintain her fluid intravascular. It was apparent that she
was third spacing and the fluids that she was receiving were
going into the extravascular space. The patient received two
units of packed red blood cells without incident. She
remained afebrile afterwards, however, she remained anuric.
A Lasix trial was initiated at which time the patient
appeared to respond somewhat.
At this point, the patient appears somewhat stabilized
hemodynamically. As far as her other medical problems, they
remained relatively stable. The patient's hypertension was
an indication of her hemodynamic instability in light of the
thromboembolism. While initially she had low blood pressure
throughout the course of her hospital stay, she became
normotensive. She remained off of her blood pressure
medications and off of intravenous fluids towards the tail
end of her hospital stay.
For her thromboembolic disease, the patient was thought to
have an element of mild DIC, in light of the low platelets
and high INR and presence of thromboembolic disease in the
lower extremities and in the pulmonary vasculature. While
the patient is on a chemotherapy regimen with Taxotere, the
possibility of a low grade DIC could not be excluded in this
setting. Her fibrinogen was found to be low; on repeat check
it was normal.
For her malignancy, her end stage pancreatic cancer, again
being treated with Taxotere palliatively, but will be held
for the time being as per oncologist.
During the course of her hospital stay, the patient's blood
glucose remained within normal limits using Glyburide and
insulin sliding scale. Her electrolytes were noted to be
low, specifically magnesium and potassium. These
electrolytes were subsequently replaced with normal values
and filling.
For prophylaxis, the patient was placed on Protonix 40 q.
day.
The patient is "DO NOT RESUSCITATE" and "DO NOT INTUBATE"
The other issues of note in the [**Hospital 228**] hospital course
were difficulty ambulating and transferring from bed to
commode or bed to chair. She was evaluated by Physical
Therapy who determined that the patient was a candidate for
home Physical Therapy and she will be discharged with this
service.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Home with Physical Therapy.
DISCHARGE DIAGNOSES:
1. Pulmonary embolism / infarction.
2. Deep venous thrombosis.
3. Hypotension as a result of thromboembolic disease.
4 Tachycardia as a result of thromboembolic disease.
5. Deconditioning.
6. Azotemia in the setting of oliguria and subsequent
anuria.
7. Type 2 diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Docusate sodium 100 mg p.o. twice a day.
2. Sertraline 50 mg q. day.
3. Hydromorphone 2 mg q. 8 p.r.n.
4. Multivitamins q. day.
5. Glyburide 5 mg q. p.m. and a.m.
6. Prochlorperazine 10 mg p.o. q. six hours p.r.n.
7. Ambien 5 mg p.o. q. h.s.
8. Lansoprazole 15 mg p.o. twice a day.
9. Enoxaparin sodium 80 mg subcutaneously q. 12 hours.
10. Lactulose 10 grams in ml syrup, p.o. twice a day p.r.n.
DISCHARGE INSTRUCTIONS:
1. The patient to follow-up with her primary care physician
/ oncologist, Dr. [**First Name (STitle) **], on [**11-14**], at 10:45 a.m. in
the [**Hospital Ward Name 23**] Building.
2. The patient to be discharged with home Physical Therapy
and other hospital supplies necessary for her comfort in her
home, i.e., hospital bed, commode.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 96695**]
MEDQUIST36
D: [**2158-11-10**] 10:57
T: [**2158-11-13**] 17:04
JOB#: [**Job Number 96696**]
|
[
"584.9",
"250.00",
"599.0",
"453.8",
"415.19",
"197.7",
"276.1",
"157.8",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
4403, 4556
|
14949, 15238
|
15261, 15671
|
4842, 5795
|
15695, 16285
|
7039, 7176
|
8938, 14855
|
7382, 8910
|
14871, 14928
|
7196, 7359
|
5825, 6956
|
6980, 7016
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,539
| 147,775
|
6981+6982
|
Discharge summary
|
report+report
|
Admission Date: [**2106-2-25**] Discharge Date:
Date of Birth: [**2045-4-14**] Sex: M
Service: MEDICAL ICU/CARDIOLOGY SERVICE
CHIEF COMPLAINT: The patient was admitted to the MICU
service after a code.
HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old
male with diabetes, borderline hypertension, with a three
week history of nocturnal cough elicited when supine as well
as recent peripheral edema who presented to the Emergency
Room with the complaint of fatigue, malaise, and collapse in
the Triage Area.
After collapse, the patient was found to be ashen in color,
unresponsive. Paddle showed questionable artifact versus
ventricular fibrillation. The patient was shocked and went
into sinus bradycardia and was given epinephrine and
Atropine. She went into wide complex tachycardia that seemed
to be a left bundle branch block supraventricular
tachycardia. He was shocked three times. He was given
Amiodarone 300 mg. He went into sinus tachycardia. The
patient was intubated after the first shock. D50 was given
during the code. The ABG was 7.20, 49, 93, 16. After
intubation, the ABG improved to 7.31, 37, 242, and 20.
The family reports a three week history of dry cough at night
when supine. No paroxysmal nocturnal dyspnea. He slept on
two pillows. He has had recent leg edema bilaterally for the
last several days. He also had shortness of breath on the
morning of admission. He denied any fevers or chills, no
nausea, vomiting, or chest pain.
After the code, the patient's heart rate was 110, blood
pressure 232/110, glucose 451. Cardiology did a bedside
echocardiogram that showed good wall motion. The patient was
taken to the Cardiac Catheterization Laboratory emergently
which showed moderate elevated right and left-sided filling
pressures, high-normal cardiac index, mild anterolateral
hypokinesis of the LV. No mitral regurgitation. EF of about
50%. Pulmonary wedge pressure was 25. There was 80%
stenosis in the small third diagonal and 80% in the ostium of
the oblique marginal II, but otherwise diffuse disease. PA
pressures were 40 systolic, 18 diastolic, with a mean of 28.
The pulmonary capillary wedge pressure was again 25.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Borderline hypertension.
3. Recent peripheral edema.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Amaryl 400 q.d.
2. Glucophage 500 mg p.o. b.i.d.
FAMILY HISTORY: The patient's mother had [**Name (NI) 2481**]. No
other known family history. He is a former smoker, quit 30
years ago. Occasional alcohol. He is a retired tailor. He
is married with several children.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile on admission. Temperature 98.2, blood pressure
115/59, heart rate 47, respiratory rate 20, assist control of
60%, tidal volume of 750, rate 20, PEEP 5 with ABG
7.47/24/165/18, saturating 99%. He was sedated and
intubated. HEENT: The pupils were equally round and
reactive to light. The conjunctivae were pale. No
lymphadenopathy. No JVD. Neck: He had tinea on the neck.
Lungs: Bronchial sounds at the left base, otherwise his PMI
was in the midclavicular line in the fifth intercostal space.
Cardiovascular: He was bradycardiac, regular rhythm, S1, S2,
a soft I/VI systolic murmur, split S2. Abdomen: Soft, no
hepatomegaly, nontender. Extremities: He had 1+ edema
bilaterally in the lower extremities. No clubbing or
cyanosis. He had 1+ DP pulses bilaterally, palpable PT
pulses bilaterally. He had fungal nail infections. He had
four peripheral IVs, right femoral venous, and arterial
sheaths. Neurological: He had positive Babinski's
bilaterally. He was sedated.
LABORATORY DATA ON ADMISSION: Chemistries: Sodium 135,
potassium 4.8, chloride 104, bicarbonate 19, BUN and
creatinine 29 and 1.5, glucose 451. Corrected sodium was
141. ALT and AST 19 and 22. CK 163, troponin less than 0.3,
amylase 63. He had a white count of 18.6, hematocrit 31.0,
platelets 251,000. He had a left shift, 93% neutrophils.
The EKG showed a normal sinus rhythm at 66 beats per minute,
normal axis, normal PR interval. He had a left bundle branch
block with T wave inversion in V5 and V6, T wave inversion in
aVL and I.
Chest x-ray showed increased interstitial markings,
cardiomegaly. Air bronchogram right greater than left. No
focal consolidations at that time.
HOSPITAL COURSE: The patient was treated for presumed
pneumonia. He was started on levofloxacin on [**2106-2-25**] and
proceeded to have increased thick tannish secretions. He
continued to spike fevers despite levofloxacin and was
started on vancomycin on [**2106-2-28**] to cover for line
infection. His central line was changed at that time and
vancomycin was also to cover for any resistant strains of
Streptococcus that might have caused his pneumonia.
The patient continued to spike fevers despite vancomycin and
levofloxacin. The levofloxacin was changed to Zosyn on
[**2106-3-3**] and the patient defervesced after that.
Vancomycin was stopped on [**2106-3-5**] due to lack of
any resistant organisms growing from the cultures. All
cultures were essentially negative or pending at the time of
transfer from the MICU.
In terms of the patient's respiratory status, the patient
maintained good 02 saturation with good ABG on pressure
support, decreased secretions. He was extubated. He had a
sympathetic surge. He became tachycardiac and hypertensive
and then had flash pulmonary edema and was hypoxic to the 70s
and had to be reintubated on [**2106-2-26**].
The patient was then aggressively diuresed and continued on
IV antibiotics and was extubated on [**2106-3-4**].
In terms of the patient's congestive heart failure, an
echocardiogram was done on the night of [**2106-2-25**] showing
moderate to severe depressed LV function with an EF of 30%.
However, a Swan-Ganz catheter was placed to assess the
patient's hemodynamics and it revealed a high wedge with
cardiac output of [**9-22**]. A systemic vascular resistance of
about 500-550 with a mixed venous 02 saturation of 76-79%.
It was consistent with a more distributive picture. It
showed good cardiac output. The Swan-Ganz catheter was
discontinued. The patient continued to be aggressively
diuresed to bring his wedge pressure down.
The patient diuresed well to IV Lasix but needed increasing
doses of up to 80 mg IV b.i.d. The patient was also started
on nitroglycerin and hydralazine for preload and afterload
reduction and for blood pressure control. He continued to be
hypertensive at times. He was also started on metoprolol
after significant diuresis for rate control and for his heart
failure and coronary artery disease.
When his renal function improved, he was started on Captopril
to transition from Hydralazine to Captopril. The
nitroglycerin drip was discontinued.
In terms of his acute renal failure, his urinalysis revealed
muddy brown casts consistent with acute tubular necrosis
which was thought to be secondary to the hypotensive episode
on presentation to the Emergency Room as well as to the large
dye load during cardiac catheterization. His creatinine
continued to improve despite aggressive diuresis, proving
good cardiac flow to the kidneys. His Zosyn dose was
increased with improving creatinine clearance.
Other issues during the hospital course were his anemia. The
patient was found to have a drop in hematocrit from 33 to 27
post catheterization. He was given a total of [**2-15**] units of
packed red blood cells throughout the hospital stay.
Hemolysis workup was negative. A CAT scan of the abdomen
ruled out any retroperitoneal bleed. The patient's
hematocrit remained stable throughout the rest of the
hospital course.
The patient was transferred to the floor on [**2106-3-6**]
to the Cardiology Service to be followed-up. The plan was
also to get an Electrophysiology evaluation to assess for any
possible tachycardiac/bradycardiac arrhythmias.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2106-3-6**] 12:18
T: [**2106-3-6**] 14:02
JOB#: [**Job Number 26175**]
Admission Date: [**2106-2-25**] Discharge Date: [**2106-3-9**]
Date of Birth: [**2045-4-14**] Sex: M
Service:
ADDENDUM TO HOSPITAL COUSRE: The patient was transferred to
the [**Hospital Unit Name 196**] Service on [**3-6**] of [**2106**] and remained in
stable condition. He was continued on Zosyn for presumptive
pneumonia and remained afebrile. His white blood cells
counts also went down to 10 on the day prior to discharge.
He had no signs of active infection on the day of discharge.
Given his cardiac arrest on presentation he also had been
evaluated by the Electric Physiology Consult Service in the
hospital. It was thought that his initial cardiac arrest was
most likely secondary to pulmonary causes. Since the initial
stress was most likely sinus bradycardia. He had a repeat
echocardiogram on the day prior to his discharge. The full
reports will follow. The left atrium is normal in size. The
right atrium is moderately dilated. A small secundum, atrial
septal defect is present. There is mild symmetrical left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is
moderately depressed, ejection fraction estimated to be 345
to 40%. Resting regional wall motion abnormalities include
septal inferolateral and inferior hypokinesis. Right
ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated. The ascending aorta
is mildly dilated. The aortic valve leaflets are mildly
thickened. 1+ aortic regurgitation is seen. Mitral valve
leaflets are mildly thickened, 1+ mitral regurgitation is
seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. He also
went for EP study on the day prior to his discharge, which
showed only 9% polymorphic ventricular tachycardia.
Therefore there is no indication for defibrillator placement.
Given his persistently high blood pressure in the hospital
antihypertensive medication had been titrated up. He was
discharged on Metoprolol 50 mg po b.i.d., Lisinopril 20 mg po
q day and Norvasc 5 mg po q day for blood pressure control.
Since he suffered acute renal failure on presentation it is
important to follow his creatinine level until it returns to
normal. On the day prior to discharge his creatinine level
was down to 1.8. During this hospital stay his creatinine
level was up to 2.5 on [**3-3**].
The day prior to discharge the patient also complained of
frequent bowel movements, however, C-diff was still pending
on the day of discharge. Since the patient is also on
multiple laxatives it would be wise to hold the bowel regimen
while the patient has diarrhea.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Rehab.
DISCHARGE DIAGNOSES:
1. Status post cardiac arrest.
2. Status post intubation.
3. Pneumonia.
4. Urinary tract infection.
5. Congestive heart failure.
6. Hypertension.
7. Diabetes.
DISCHARGE MEDICATIONS: Augmentin 500/125 po b.i.d. for four
more days for a total of a ten day course, Metoprolol 50 mg
po b.i.d. held for systolic blood pressure less then 100 and
heart rate less then 55. Lisinopril 20 mg po q day held for
systolic blood pressure less then 100. Norvasc 5 mg po q day
hold for systolic blood pressure less then 100. Aspirin 325
mg po q day, Colace 100 mg po b.i.d. held for bowel movements
greater then twice a day, Dulcolax 10 mg po q day hold for
bowel movement greater then twice a day. Protonix 40 mg po q
day, regular insulin sliding scale. Tylenol prn, Albuterol
inhaler prn.
DIET: Diabetic and cardiac healthy diet.
DISCHARGE FOLLOW UP: The patient will see Dr. [**Last Name (STitle) **] in
congestive heart failure clinic on [**3-29**] of [**2106**] at 10:00
a.m. The patient will also follow up at the [**Hospital 191**] clinic in
one month. The patient will call for an appointment. The
phone number is [**Telephone/Fax (1) 250**] was given. Other follow up
instructions the rehab facility was asked to check the BUN
and creatinine level and titrate up blood pressure medication
as needed for a goal systolic blood pressure 120 to 130. The
patient's daily weight and ins and outs should also be
followed up closely. Po daily Lasix may be needed if the
patient appeared to be fluid overloaded. The patient's
previous oral hypoglycemics may also be restarted once the
renal function improved.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**First Name8 (NamePattern2) 26176**]
MEDQUIST36
D: [**2106-3-9**] 12:07
T: [**2106-3-9**] 12:15
JOB#: [**Job Number 26177**]
|
[
"427.5",
"996.62",
"518.81",
"038.9",
"276.2",
"486",
"584.5",
"402.91",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.53",
"38.93",
"99.60",
"96.04",
"96.6",
"96.71",
"37.23",
"89.64",
"37.26",
"38.91",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11001, 11037
|
2448, 2676
|
11058, 11225
|
11249, 11901
|
4429, 10979
|
2376, 2431
|
11913, 12942
|
160, 2204
|
3748, 4411
|
2226, 2353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,377
| 131,239
|
39212+58270
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-5-6**] Discharge Date: [**2150-6-9**]
Date of Birth: [**2096-12-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cerebral Angiogram
External Ventricular Drain
History of Present Illness:
Pt is 53 y/o healthy M who presents with severe global
headache with onset at 4 pm today. Pt stated that he had just
finished working on his truck at the time. He describes the
headache as throbbing and is accompanied by dizziness. Pt
states
that his vision from both eyes gets blurry at times. When pt
developed his headache, he laid himself into his car, but was
able to walk and find his wife who took him to the hospital. At
OSH, pt had a non-contrast head CT scan which showed a left
sided
SAH. Pt was transferred to [**Hospital1 18**] for further management.
Past Medical History:
thumb surgery
Social History:
no tobacco or alcohol
Family History:
NC
Physical Exam:
T 97 P 82 BP 137/67 R 16 SaO2 100% RA
Gen: conversant, comfortable, NAD.
HEENT: NCAT, EOMI
Pupils: [**3-31**] b/l
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. Mild dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to2
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 [**6-3**] throughout. No pronator drift
Sensation: Intact to light touch
On Discharge:
awake, alert, and oriented to person, place, and time. Pupils
equal and reactive to light 4mm to 3mm bilaterally. extraocular
movements are full without evidence of nystagmus. He did not
have a pronator drift. His motor exam showed RUE 4+bicep
otherwise [**6-3**], LUE [**6-3**], RLE IP 4+/5, [**Last Name (un) 938**] 0-1/5, gastroc [**5-4**], LLE
[**6-3**]. right femoral angio groin sit slightly full, positive 2+
pedal pulse RLE, + clonus on right.
Pertinent Results:
[**2150-5-6**] 07:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50
BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-NEG
RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2
GRANULAR-0-2 GLUCOSE-119* UREA N-7 CREAT-1.0 SODIUM-143
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-20* ANION GAP-21*
estGFR-Using this WBC-12.6* RBC-5.25 HGB-15.3 HCT-42.9 MCV-82
MCH-29.2 MCHC-35.8* RDW-13.5 NEUTS-89.1* LYMPHS-6.2* MONOS-3.0
EOS-1.2 BASOS-0.5
PLT COUNT-188 PT-12.1 PTT-24.6 INR(PT)-1.0
CTA head Neck [**2150-5-6**]:
1. Large anterior communicating artery aneurysm whose rupture
appears to be the cause of the increasing subarachnoid
hemorrhage noted within the brain, compared to the prior
non-contrast head CT.
2. Markedly narrow A1 segment of the right anterior cerebral
artery may be
due to congenital hypoplasia or less likely due to spasm (given
time
duration).
CT head [**2150-5-7**]:
1. Redemonstration of extensive subarachnoid hemorrhage, as
described above. Of note, there is increased blood seen layering
within the occipital horns of the lateral ventricles.
2. Interval placement of a right frontal approach
ventriculostomy catheter, terminating in the left lateral
ventricle.
3. New aneurysm coils in the region of the anterior
communicating artery.
4. Stable hydrocephalus.
CT Head [**2150-5-7**]:
The patient is status post aneurysm coiling in the vascular
territory of the anterior communicating artery, unchanged
subarachnoid
hemorrhage and intraventricular hemorrhage with ventricular
shunt via right frontal burr hole, the tip terminating on the
left ventricular [**Doctor Last Name 534**] as described above. There is no
significant change in the size and configuration of the
ventricles since the prior study.
No evidence of low attenuation areas or significant edema to
indicate
subacute ischemic changes.
The CTA demonstrates persistent lobulated aspect of the aneurysm
in the
superior dome with no significant change since the prior
cerebral angiogram, and coil embolization. These findings were
discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**5-7**] at 12:10 hrs.
Again hypoplasia of the A1 segment is redemonstrated, both
anterior cerebral arteries are filling from the left. No
flow-stenotic lesions are identified or vasospasm.
CTA Head [**2150-5-7**]:
The patient is status post aneurysm coiling in the vascular
territory of the anterior communicating artery, unchanged
subarachnoid
hemorrhage and intraventricular hemorrhage with ventricular
shunt via right frontal burr hole, the tip terminating on the
left ventricular [**Doctor Last Name 534**] as described above. There is no
significant change in the size and configuration of the
ventricles since the prior study.
No evidence of low attenuation areas or significant edema to
indicate
subacute ischemic changes.
The CTA demonstrates persistent lobulated aspect of the aneurysm
in the
superior dome with no significant change since the prior
cerebral angiogram, and coil embolization. These findings were
discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**5-7**] at 12:10 hrs.
Again hypoplasia of the A1 segment is redemonstrated, both
anterior cerebral arteries are filling from the left. No
flow-stenotic lesions are identified or vasospasm.
CTA Head [**2150-6-4**]
1. No intracranial hemorrhage.
2. Interval improvement of the vasospasm involving the left
middle cerebral artery, anterior cerebral arteries, posterior
cerebral arteries, and basilar artery.
3. Unchanged residual aneurysm filling at the base of the coil
pack of the
anterior communicating artery aneurysm.
Brief Hospital Course:
Patient presented on [**2150-5-6**] with severe headache and dizziness
after working on his truck. He also reported some blurred
vision. His wife took him to [**Hospital1 18**] where a [**Name (NI) 72787**] was performed
and found a left side SAH. Patient was then sent for a CTA where
an ACOM aneurysm was found. Patient became lethargic and less
responsive, angiogram was performed to coil aneurysm and an EVD
was placed to relieve ICP. His drain was leveled at 15 and was
observed to be draining well. Post angiogram check it was noted
that patient was moving his L>R. CTA/P was ordered and was
stable. He was then extubated. On [**5-8**], his exam improved, he was
a&ox3, full strength on L and antigravity with both upper and
lower extremities on the R side.
On [**5-12**], patient continues to be alert and oriented x3 and full
strength on L. RUE remains antigravity and RLE, he is only able
to wiggle toes. He was taken to angiogram where mild vasospasm
was seen and he received 10mg of verapamil intrathecally. His
SBP will be pushed to 180 and we will repeat angio on [**5-14**]. In
the afternoon, patient failed a clamping trial and drain was
reopened to relieve ICP. Overnight the drain was observed to be
draining less and a poor waveform was also noted. The drain was
flushed with normal saline, but continued to have poor waveform
and ouptut. TPA was administered to flush the drain proximally.
Patient remains stable. Overnight he also had a Tmax of 101.9,
he was pancultured and a CXR was ordered. CSF samples have been
negative to this date.
Over the weekend of [**5-16**] and [**5-17**], the patient's blood pressure
was liberalized by the SICu team to less than 140. The patient
subsequently had a change in his neurological status. He had
mental status changes and no command following. A stat head
CT/CTA was performed , which showed persistent but not new
vasospasm. He was kept at a strict 160-180 following this
incident. He was started on a 3% HTS for chronic hyponatremia
(na 12) at 10cc an hour, titrating up to 30cc/hour.
On [**5-20**], patient's blood pressure was liberalized to 140-160.
CTA on [**5-19**] showed vasospasm and hypertonic saline is being
weaned to off. MRI of the lumbar spine was ordered due to
patient's complaint of back pain. MRI results show some SAH
blood within the thecal sac. It also showed an intradural
hematoma at L2 with mild cord compression. EVD still in place at
20 and open to drainage.
On [**5-23**] overnight patient became confused, but over time began
to was more alert and oriented. Drain was sluggish and was
flushed x2 in AM. Blood pressure parameters continue to be
140-160. Patient was taken to angiogram where he was seen to be
in vasospasm and treated with verapamil. We continue to keep his
pressures between 140-160. There was a question of seizure
activity and patient was then transitioned to Keppra from
dilantin. On [**5-24**], patient was stable and his EVD was removed.
He has episodes where he does not speak, but will after constant
prompting. He also spiked fevers 103 and was pancultured. Lenis
showed a R dvt from the proximal SFV. CTA of chest showed a R
subsegmental PE. Heparin gtt was started with a goal PTT 40-60.
An IVC filter was also placed. Patient was observed to have RUE
weakness which was improved on [**5-27**] and SSRI restarted for his
depression.
His neurological exam improved and his blood pressure remained
well controlled; therefore he was transferred out of the ICU to
the floor on [**2150-5-30**].
Patient's neurologic exam continued to improved, RLE [**5-4**] in IPs
and RUE 5-/5. CTA was done on [**6-4**] which was stable and patient
was taken to angiogram for coiling of his aneurysm. His
angiogram and coiling was completed without difficulty and he
was placed on a heparin gtt overnight which was stopped on the
morning of [**6-5**]. On [**6-6**] he was transferred to the floor and
subcutaneous heparin was restarted. He remained stable on the
floor [**6-7**] and on [**6-8**] was deemed fit to be discharged to rehab.
Medications on Admission:
MVI
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-31**]
Tablets PO Q6H (every 6 hours) as needed for headache.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ibuprofen 100 mg/5 mL Suspension Sig: [**1-31**] PO Q8H (every 8
hours) as needed for fever.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing Rehab & Skilled Nursing Center
Discharge Diagnosis:
Subarachnoid Hemorrhage
fever
right hemiparesis
left frontal infarct
communicating hydrocephalus
cerebral vasospasm
subarachnoid hemorrhage
respiratory failure
deep vein thrombosis
pulmonary embolism
fever
diplopia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks. without imaging
??????You will need an MRI of the Brain with and without contrast in
6 months. you can make this appointment at the same time that
you make you're 4 week follow up
?????? You need to follow up with Opthamology for a dilatation
exam. Please call [**Telephone/Fax (1) 253**] to set up this appointment within
2-4 weeks.
Completed by:[**2150-6-8**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 13738**]
Admission Date: [**2150-5-6**] Discharge Date: [**2150-6-9**]
Date of Birth: [**2096-12-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 40**]
Addendum:
see hosiptal course addendum
Brief Hospital Course:
This is an addendum to the hospital course.
On the day of discharge (while the ambulance team was arriving)
- the pt attempted to get oob without assistance and without the
use of his walker. He fell predominently onto his buttocks and
then into the wall. His primary and secondary surveys were
benign except he was pale and diaphoretic. His VS and FSBS were
stable. Follow up labs/ekg and cxr were WNL. He remained
stable overnight and agrees with the plan to be discharged today
to rehab.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Landing Rehab & Skilled Nursing Center
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2150-6-9**]
|
[
"430",
"331.3",
"453.40",
"415.11",
"434.91",
"348.5",
"276.1",
"435.8",
"780.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"02.39",
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
14765, 14985
|
14244, 14742
|
325, 373
|
11731, 11731
|
2567, 6249
|
13266, 14221
|
1066, 1070
|
10378, 11361
|
11493, 11710
|
10350, 10355
|
11914, 13243
|
1085, 1224
|
2092, 2548
|
277, 287
|
401, 974
|
1457, 2078
|
11746, 11890
|
996, 1011
|
1027, 1050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,763
| 141,344
|
29979
|
Discharge summary
|
report
|
Admission Date: [**2157-10-18**] Discharge Date: [**2157-10-19**]
Date of Birth: [**2092-7-11**] Sex: M
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Intraoperative hypotension
Major Surgical or Invasive Procedure:
Electrophysiological study
History of Present Illness:
This 65 year old male has non-ischemic cardiomyopathy and an
LVEF between 20-30%. He has a biventricular ICD and has
recurrent ventricular tachycardia despite being treated with
Sotalol. He received a shock from his ICD, last was [**2157-9-8**] for
sustained ventricular tachycardia associated with loss of
conciousness. Multiple morphologies of VT in EP procedure
thought to be [**1-11**] epicardial source. Had labile pressures to
70's systolic that was responsive to pressors (Dopa and Neo),
felt to be secondary to anesthesia. CT Abdomen/Pelvis
preliminary negative for bleed.
On arrival to floor patient was extubated and responsive.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Non-ischemic cardiomyopathy
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: Cath at [**2154**]
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
None
Social History:
-Tobacco history: Quit 1.5 years ago. 40 pack years prior
-ETOH: None in 3 years. Occasional prior.
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam
VS: BP=112/52 HR= 82
GENERAL: WDWN [**Male First Name (un) 4746**] in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1 < S2 with physiologic splitting. 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.
EXTREMITIES: No c/c/e. Femoral and venous sheaths in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+
Left: Radial 2+ DP 2+
Pertinent Results:
CT abd:
IMPRESSION:
1. No radiologic evidence to suggest a cause for sudden
hypotension. In
particular, there is no retroperitoneal bleed seen or hematoma
in the region
of the access site in the right groin.
2. These findings were conveyed to Dr. [**Last Name (STitle) **] at 11 a.m. on
[**2157-10-18**].
[**10-18**] Echo:
LV systolic function appears depressed. The right ventricular
free wall may be hypertrophied. Right ventricular chamber size
is normal. with normal free wall contractility. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
Brief Hospital Course:
65 YO gentleman with non-ischemic cardiomyopathy s/p ICD with
multiple runs of VT despite sotalol therapy transferred from EP
lab to CCU for labile intraoperative bloop pressures.
.
# PUMP: Hypotension felt to be secondary to anesthesia
medications received during the procedure. Intrabadominal/RP
bleed and pericardial effusion were ruled out by imaging. Pt
initially put on neo drip which was weaned. His pressures
improved and he was hemodynamically stabled by time of
discharge. Lisinopril and carvedilol was initially held and then
resumed.
.
# RHYTHM: Per EP study, VT focus thought to be epicardial. While
epicardial ablation is a possibility, pt clearly has intolerance
to anesthestic medications and would likely need a bypass via
tandem heart to maintain adequate pressures during the surgery.
Thus, pt will be medically managed for now. Medical management
was optimized and patient's sotolol dose was increased from 80mg
[**Hospital1 **] to 120mg [**Hospital1 **]. Pt told to follow up with his outpatient EP
cardiologist.
Medications on Admission:
Carvedilol 3.125 mg twice a day
Lisinopril 5mg Tab once daily
Sotalol 80 mg
Aspirin 81mg Once daily
Calcium carbonate 500mg
MTV
Omega-3-fatty acid
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ischemic cardiomyopathy
Systolic congestive heart failure
Episodes of ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 19219**],
You came to [**Hospital1 **] for a study of your heart to
determine why you were having some dangerous heart rhythms. The
study ruled out one area of your heart causing these rhythms.
Unfortunately, your blood pressure became very low, probably
because of your reaction to the anesthesia. The low blood
pressure meant that one area of your heart could not be checked
to see if it is the source of the dangerous rhythm. To help
control your heart rate and rhythm, we have increased the dose
of your sotalol.
Please increase the dose of sotalol to 120 mg two times a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Patient should follow up with his cardiologist in [**12-11**] weeks.
|
[
"458.29",
"428.22",
"427.1",
"V45.02",
"428.0",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
4584, 4590
|
3037, 4074
|
301, 330
|
4732, 4732
|
2395, 3014
|
5601, 5673
|
1482, 1597
|
4272, 4561
|
4611, 4711
|
4100, 4249
|
4883, 5578
|
1612, 2376
|
1180, 1289
|
235, 263
|
358, 1086
|
4747, 4859
|
1320, 1327
|
1108, 1160
|
1343, 1466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,364
| 125,088
|
53696+59546
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-9-13**] Discharge Date: [**2138-9-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
BRBPR, tachycardia
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
84M with h/o AF s/p ablation, HTN, admitted with syncope x 2 and
BRBPR. He states he was in his USOH until the night of [**9-12**] when
he had 1 episode of BRBPR and 1 episode of vomiting. He felt
very weak after getting up from the toilet. He fell and hit his
head on the floor but denies LOC. He denies associated
fever/chills, abdominal pain, lightheadedness, diaphoresis,
headache, visual changes, palpitations, CP, SOB. He denies
melena in the preceding days, stating he had normal BMs. He
states he had [**1-10**] more episodes of BRBPR during the night. He
woke up this AM feeling very week and fell again in the kitchen.
He denies head trauma and LOC with this episode. He again denies
lightheadedness, N/V, CP, SOB, headache, urinary incontinence,
and tongue-biting.
.
In the ED, his BP was stable but his HR was 110s-140s. He
received IVF and 1U PRBC. Abdominal exam was benign, but rectal
showed frank blood. His ECG showed lateral ST depressions, 1st
set of enzymes negative. CT head and C-spine were negative, and
his C-collar was removed. GI was consulted. He was admitted to
the MICU for close monitoring.
.
Currently, he states he feels well. He denies lightheadedness,
abdominal pain, N/V, CP, SOB. Occasionally uses Excedrin (1x/wk
per pt), no aspirin. No history of liver disease. Has never had
a colonoscopy.
Past Medical History:
1. Atrial fibrillation- s/p TEE-CV in [**11-9**], s/p isthmus
ablation in [**1-11**]
2. CHF- by report, EF 55% on TTE [**2134**]
3. Hypertension
4. ASD- small secundum defect, mild L-to-R shunting on [**2134**] TEE
5. Asthma
Social History:
- Rare alcohol use.
- Never smoked
- No illicit drug use
- Lives alone in his apartment, no family or close friends in
the area. Has some housekeeping services but cooks for himself,
admits he has not been able to cook regular meals at home for
some time.
- Divorced, no children; was in the Navy for 9 years, retired in
the [**2111**]'s after working in housekeeping for a hospital.
Family History:
-Father: died in his 80's - not sure of cause
-Mother: died at age [**Age over 90 **] - from natural causes
-Siblings: 1 brother and 6 sisters. [**Name (NI) **] is the oldest.
- 2 siblings deceased, 4 still living. One sister with heart
problems
-[**Name (NI) **] children
Physical Exam:
Vitals- T 98.1, HR 89, BP 152/60, RR 18, O2sat 98% on 2L NC
General- elderly man sitting up in bed, NAD, pleasant, A&Ox3
HEENT- small abrasions on R frontal area and bridge of nose,
PERRL, sclerae anicteric, dry MM, OP clear
Neck- no JVD
Pulm- poor respiratory effort, ?decreased breath sounds at L
base
CV- RRR, [**2-10**] HSM at apex radiating to axilla
Abd- +BS, distended but soft, tympanitic, nontender, no
organomegaly
Rectal- frank blood per ER
Extrem- no LE edema, pnemaboots in place
Pertinent Results:
[**2138-9-13**] 10:35AM PT-12.9 PTT-27.8 INR(PT)-1.1
[**2138-9-13**] 10:35AM PLT COUNT-368
[**2138-9-13**] 10:35AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
STIPPLED-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2138-9-13**] 10:35AM NEUTS-88.0* BANDS-0 LYMPHS-8.6* MONOS-2.5
EOS-0.3 BASOS-0.5
[**2138-9-13**] 10:35AM WBC-13.5* RBC-3.10*# HGB-9.9*# HCT-29.6*#
MCV-96 MCH-31.9 MCHC-33.5 RDW-14.7
[**2138-9-13**] 10:35AM CK-MB-NotDone
[**2138-9-13**] 10:35AM cTropnT-0.01
[**2138-9-13**] 10:35AM CK(CPK)-59
[**2138-9-13**] 10:35AM GLUCOSE-226* UREA N-34* CREAT-1.4* SODIUM-136
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
[**2138-9-13**] 10:50AM LACTATE-2.1*
[**2138-9-13**] 02:25PM URINE AMORPH-FEW
[**2138-9-13**] 02:25PM URINE RBC-0-2 WBC-[**5-17**]* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2138-9-13**] 02:25PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2138-9-13**] 02:25PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2138-9-13**] 02:25PM URINE GR HOLD-HOLD
[**2138-9-13**] 02:25PM URINE HOURS-RANDOM
[**2138-9-13**] 05:16PM HCT-26.2*
[**2138-9-13**] 05:16PM CK-MB-14* MB INDX-12.5* cTropnT-0.14*
[**2138-9-13**] 05:16PM CK(CPK)-112
[**2138-9-13**] 11:46PM CK-MB-NotDone cTropnT-0.32*
[**2138-9-13**] 11:46PM CK(CPK)-99
.
[**9-13**] CT C-spine
CT C-SPINE: No fracture is identified. No subluxation is seen.
There is degenerative change, including anterior and posterior
osteophyte formation, predominantly at the C5/6 levels. There is
slight anterior widening of the C4/5 intervertebral disc space,
without any evidence of prevertebral soft tissue swelling. There
is limited evaluation of intrathecal contents on CT, however,
the contour of the thecal sacs is within normal limits.
Within the lung apices, there is fibrotic change bilaterally,
without any evidence of pneumothorax or pleural effusion.
There is an 8 mm focus of soft tissue adjacent to the posterior
wall of the trachea (series 2, image 58). This is approximately
5 cm below the glottis.
IMPRESSION:
1. No fracture or subluxation is seen. Degenerative changes are
seen at several levels.
2. There is an 8 mm soft tissue density adjacent to the
posterior wall of the trachea, approximately 5 cm below the
glottis. This may represent mucous, though this could also
represent a polypoid lesion arising off the wall, and further
nonemergent evaluation is recommended.
.
[**9-13**] CXR
SINGLE VIEW OF THE CHEST: Cardiac and mediastinal contours
appear stable. Again seen is evidence of vascular engorgement
with prominent interstitial opacities bilaterally, improved from
prior. No focal consolidations identified. No evidence of
pleural effusion.
IMPRESSION: Improving interstitial opacities again seen
consistent with improving CHF. No focal consolidations
identified.
.
[**9-13**] CT Head
CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is
identified. The ventricles are symmetric, and there is no shift
of normally midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. There is linear hyperdensity
within the right frontal region, which likely represents streak
artifact. No intracranial mass effect is seen. The soft tissues
are within normal limits. The paranasal sinuses are well
aerated. No fractures are identified.
IMPRESSION: No intracranial hemorrhage or mass effect is
identified.
.
[**9-13**] XR abdomen
FINDINGS:
Bowel gas pattern is nonspecific and nonobstructed with no
evidence for free air, ascites or pneumatosis. Calcifications in
left pelvis are most consistent with phleboliths.
.
[**9-16**] ECHO
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%), without regional wall
motion abnormalities. Tissue velocity imaging demonstrates an
E/e' <8
suggesting a normal left ventricular filling pressure (<12mmHg).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
.
[**9-17**] CT sCT CHEST WITH IV CONTRAST: The previously identified
soft tissue density in the posterior aspect of the trachea near
the thoracic inlet is not seen today, however, there is a focus
of slight tracheal wall thickening in the right posterolateral
aspect.
Multiple small lung nodules are seen throughout the lungs; the
largest is in the posterior right lower lobe (series 3, image
30), which has a hazy and distinct halo measuring approximately
8 mm. A similar finding is seen in the left lower lobe
posteromedial aspect, measuring 6 mm. No pleural effusion or
pericardial effusion is seen. There are calcified right hilar
lymph nodes. Both lung apices show mild scarring.
CT ABDOMEN WITH IV CONTRAST: There are radiopaque gallstones in
the gallbladder. The spleen and liver are normal. Left kidney
and proximal ureter are within normal limits. The right kidney
shows marked hydronephrosis with hydroureter and delayed
excretion. Adrenals are normal. Pancreas is normal. The
abdominal aorta below the level of the left renal vein is
notable for prominence to a maximum of 27 x 25 mm; there is
marked stranding surrounding the aorta and retroperitoneum, with
several prominent but nonpathologically enlarged lymph nodes.
Marked circumferential atherosclerotic calcification and
atheroma is in the aorta; additionally, inflammatory stranding
surrounds it from the level of the renal veins to approximately
the bifurcation. There is no free air. Bowel loops are grossly
normal, given lack of oral contrast.
CT PELVIS WITH IV CONTRAST: There are several enlarged lymph
nodes in the pelvis, for example, a left external iliac chain
node measures 17 mm in short axis diameter. The right ureter is
dilated proximally to near the common iliac artery bifurcation.
No definite stone is seen. There is a Foley in the bladder. The
left ureter appears normal, given the lack of good contrast
opacification. The prostate is enlarged with a central
calcification. There are diverticula in the sigmoid, without
diverticulitis. No free air is seen. There is no free fluid.
Bone windows show multiple sclerotic foci for example, in the
left scapula, left T1 transverse process, T3 vertebral body,
right lateral process T6, T8 vertebral body, L3 vertebral body,
S1 vertebral body, with a moth-eaten appearance to the bony
pelvis.
Multiplanar reformats were essential in delineating the findings
above.
IMPRESSION:
1. Abdominal aorta with marked atheromatous changes and
inflammatory stranding surrounding it, raising possibility of
inflammatory aneurysm or retroperitoneal fibrosis. CT angiogram
of the aorta is recommended for further characterization.
2. Severe right hydronephrosis and hydroureter without
obstructive lesion identified.
3. Multiple enlarged lymph nodes and several sclerotic foci in
the bones. Does the patient have a history of malignancy?
4. Soft tissue lesion in trachea seen on previous CT scan not
identified today, however, small focus of thickening in same
region may be better evaluated with direct visualization.
5. Multiple small lung nodules, which may be evaluated with
repeat chest CT without contrast in six months to ensure
stability.
.
Brief Hospital Course:
84M with h/o atrial fribillation s/p isthmus ablation and HTN,
admitted with lower GI bleed.
#) GI bleed: Mr. [**Known lastname **] was admitted to the ICU after presenting
with BRBPR and receiving 3 units PRBC in the emergency
department. He remained hemodynamically stable in the ICU so
was transferred to the medicine floor after 24 hours. He had
several episodes of melana during his time on the medicine floor
but no hematochezia. He was, however, transfused 2 additional
units PRBC while on the medicine floor for HCT drop (lowest HCT
on floor = 27.6). The most likely source of bleeding was
diverticular, although colonoscopy showed no clear source (blood
throughout the colon, multiple diverticula). His hematocrit
remained stable for >48 hours prior to discharge. His aspirin
was held throughout his hospital course. This can be restarted
upon follow-up with his new PCP if his hematocrit remains
stable.
#) NSTEMI: Mr. [**Known lastname **] was found to have an elevated troponin
(peak 0.33 on [**9-14**]) with V5-V6 st depressions in the setting of
tachycardia. He denied CP or SOB. Cardiology was consulted and
they felt that he was having demand ischemia in the setting of a
GI bleed and did not recommend an intervention. They recommend
an outpatient stress test and continuing b-blocker that had been
started. They also recommend [**Last Name (un) 2557**] ASA when safe from a GIB
standpoint.
#) H/o Atrial fibrillation: s/p isthmus ablation. Currently in
NSR. No anticoagulation was purused given recent GI bleed.
#) UTI: He was found to have a UTI on [**9-13**]. He was asymptomatic
but the decision was made to treat nonetheless. Sensitivities
revealed resistance to cipro and this antibiotic was changed to
ceftriaxone on [**9-17**]. He will be changed to Cefuroxime PO for a
total 10-day course (also [**Last Name (un) 36**] to cefuroxime). Per Urology, Mr.
[**Known lastname **] had a moderately enlarged, somewhat firm prostate on exam
with a small midline nodule, but a PSA has not be done. He will
be followed by Urology as an outpatient were a PSA test will be
done and prostate biopsy will be considerd.
#) Hydronephrosis & hydroureter: CT w/contrast revealed Right
hydronephrosis and hydroureter w/o obstructive lesion and
possible retroperitoneal fibrosis. Mr. [**Known lastname **] has had no
urinary symptoms (no flank pain, no urinary incontinence,
retention or urgency). Urology was consulted and felt that no
intervention was necessary at this time. He will have follow-up
with Urology with Dr. [**Last Name (STitle) 4229**] in 2 weeks. He will need CT-guided
biopsy to confirm the diagnosis of retroperitoneal fibrosis and
to determine the etiology (idiopathic vs [**1-9**] lymphoma). Despite
intensive discussion regarding the benefits and risks, the
patient declined to have this done while in-house.
#) Inflammation Abd Aorta: CT w/contrast revealed inflammation
of abdominal aorta with marked atheromatous changes, possible
inflammatory aneurysm or retroperitoneal fibrosis. As mentioned
above, he will need outpatient CT-guided biopsy to the determine
etiology. Diagnosis must be confirmed (to rule out cancer) prior
to initiating therapy (such as prednisone). He will have a
repeat abdominal CT scan in 3 months to evaluate for change and
will follow-up with rheumatology as an outpatient. A malignancy
work-up was initiated, with a normal CEA, PSA to be checked as
an outpatient. SPEP/UPEP pending at time of discharge.
#) HTN: Metoprolol was titrated up for improved blood pressure
control, and his blood pressure will need to be closely
monitored as an outpatient. Consider starting ACEi as
outpatient, after contrast dye is not a threat to renal function
#) Chronic renal insuficiency: Likely has some renal
insufficiency secondary to hydronephrosis. Creatinine at
discharge was 1.5. Given CT w/contrast [**9-17**], his creatinine
will need to be closely monitored as an outpatient to ensure
stability.
#) Multiple small lung nodules: - follow up CT in 6 months
#) Code status: FULL CODE, discussed with patient
Medications on Admission:
Multivitamin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day: for anemia.
6. Cefuroxime Axetil 250 mg Tablet Sig: One (1) Tablet PO twice
a day for 8 days: Through [**2138-9-27**].
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Outpatient Lab Work
Chem 7
CBC
on [**9-22**] and then every 3 days while in rehab. Please fax lab
values to Dr. [**First Name (STitle) **]. Fax ([**Telephone/Fax (1) 110253**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Lower GI bleed
NSTEMI
UTI
Hypertension
ASD
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
Please take all medications as instructed. There were several
changes made to your current medications regimen.
If you experience any fever, bleeding from your rectum, black
stool, nausea, vomiting, lightheadedness, chest pain, shortness
of breath, or any other concerning symptoms please seek medical
attention immediately.
We have set you up with appointments with Urology and new PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) **]. It is very important that you make this
appointments for appropriate medical follow up.
Followup Instructions:
An appointment with [**Hospital3 **] has been setup for
Tuesday [**2138-9-30**] at 1:30 pm with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
For any information call ([**Telephone/Fax (1) 1300**].
An appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] in Urology is setup for
Friday [**2138-10-3**] at 8 am. For any information call ([**Telephone/Fax (1) 18591**].
.
You will need a CT-guided biopsy to determine the reason for
your retroperitoneal fibrosis. Please call ([**Telephone/Fax (1) 6713**] to
schedule your appointment.
.
You will need a repeat CT abdomen in 3 months to follow your
retroperitoneal fibrosis.
.
You will need another CT chest in 6 months to evaluate your lung
nodules for progression.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 18070**]
Admission Date: [**2138-9-13**] Discharge Date: [**2138-9-19**]
Date of Birth: [**2053-12-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9532**]
Addendum:
It may be helpful to set-up an appointment with Dr. [**First Name8 (NamePattern2) 1626**] [**Name (STitle) 1627**]
who has several other pts with RP fibrosis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 163**] - [**Location (un) 164**]
Followup Instructions:
An appointment with [**Hospital3 **] has been setup for
Tuesday [**2138-9-30**] at 1:30 pm with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
For any information call ([**Telephone/Fax (1) 14840**].
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. (Urology) Phone:[**Telephone/Fax (1) 7907**]
Date/Time:[**2138-9-30**] 8:45
.
You will need a CT-guided biopsy to determine the reason for
your retroperitoneal fibrosis. Please call ([**Telephone/Fax (1) 18071**] to
schedule your appointment.
.
You will need a repeat CT abdomen to follow your retroperitoneal
fibrosis.
.
You will need another CT chest in 6 months to evaluate your lung
nodules for progression.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 9533**]
Completed by:[**2138-9-19**]
|
[
"599.0",
"410.71",
"403.90",
"585.9",
"285.1",
"493.90",
"593.4",
"780.2",
"518.89",
"745.5",
"562.12",
"428.0",
"591",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
18037, 18109
|
10782, 14868
|
281, 295
|
15950, 15988
|
3127, 10759
|
18132, 19006
|
2320, 2598
|
14931, 15767
|
15884, 15929
|
14894, 14908
|
16012, 16553
|
2613, 3108
|
223, 243
|
323, 1654
|
1676, 1902
|
1918, 2304
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,179
| 199,112
|
8149
|
Discharge summary
|
report
|
Admission Date: [**2163-3-18**] Discharge Date: [**2163-4-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Respiratory distress/failure
Major Surgical or Invasive Procedure:
ETT intubation
Dobhoff tube
PICC line
R IJ CVL
History of Present Illness:
Mr. [**Known lastname 6352**] is an 89 YO male with HTN, mild dementia presenting
with fever and hypoxia with 02 sats in the 80's at NH. Noted to
very fatigued and delirious at [**Hospital1 **], with "acute respiratory
distress". Suctioned with large purulent sputum. 40 mg IV lasix
given at 1700 hrs. NH reported mental status changes over 2
days. Recent admission [**Date range (1) 29030**] for delirium, shortness of
breath, cough, fever to 102. Found to be influenza positive.
Treated for superimposed bacterial infection with vanc and zosyn
[**3-5**] and completed course on [**3-15**]. Required MICU stay given
hypoxia and increased secretions. At time of discharge patient
was requiring frequent suctioning, satting in the mid- to upper
90's on 3 - 4 L NC; breathing comfortably with an NG tube for
feeding given failed speech and swallow.
.
In ED temp to 103, HR 101, RR 40's, 90% non rebreather. Crackles
bases. Intubated with etomidate and succinylcholine. Cr to 1.8
from baseline 0.7. HCT to 22.8 baseline above 30. ABG post
intubation 7.33
47/106. Right IJ placed, BP ~110 systolic throughout stay. Given
concern for sepsis, right IJ placed. ~3 L IV fluid given.
Ordered for 2 units PRBC. Admitted to the [**Hospital Unit Name 153**].
Past Medical History:
Influenza A
BPH
HTN
hx of hip fracture
Social History:
Patient lives at home with his wife. A nurse [**First Name (Titles) **] [**Last Name (Titles) 29028**]
Alliance sees the couple twice a week on Mondays and Wednesdays.
He denies tobacco use and drug use,but does drink [**2-6**] glasses
of wine/day.
Family History:
NC
Physical Exam:
97.8, 108, 112/63, 74 100% AC Fi02 50% RR 15, PEEP 5
Gen: intubated elderly male with OG tube
HEENT: thick secretions noted in mouth. Atramatic. No neck
stiffness. PEERL. Difficult to assess JVP. RIJ with scant
bleeding adjacent.
CV: tachycardic, no murmurs noted
Resp: exp wheeze, crackles basilar.
Abd: hypoactive bowel sounds, non distended. No grimace to touch
Guaiac: negative in ED prior to arrival
Neuro: intubated, sedated. Not responding
skin: cool LE, no mottling. 2+ DP,PT pulses
Pertinent Results:
[**2163-3-19**] 05:00PM BLOOD WBC-26.7* RBC-2.64* Hgb-8.3* Hct-24.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-15.5 Plt Ct-376
[**2163-3-19**] 08:58AM BLOOD WBC-26.5* RBC-2.26* Hgb-7.0* Hct-21.3*
MCV-94 MCH-31.1 MCHC-33.1 RDW-15.0 Plt Ct-426
[**2163-3-18**] 05:55PM BLOOD WBC-27.5*# RBC-2.43*# Hgb-7.7*#
Hct-22.8*# MCV-94 MCH-31.7 MCHC-33.8 RDW-15.0 Plt Ct-694*
[**2163-3-19**] 04:00AM BLOOD Ret Aut-6.5*
[**2163-3-19**] 04:00AM BLOOD Glucose-93 UreaN-46* Creat-1.3* Na-142
K-3.9 Cl-110* HCO3-24 AnGap-12
[**2163-3-18**] 05:55PM BLOOD Glucose-132* UreaN-53* Creat-1.8*# Na-138
K-4.8 Cl-102 HCO3-26 AnGap-15
[**2163-3-19**] 04:00AM BLOOD ALT-21 AST-23 LD(LDH)-202 AlkPhos-60
TotBili-0.9 DirBili-0.4* IndBili-0.5
[**2163-3-18**] 05:55PM BLOOD ALT-34 AST-31 CK(CPK)-40 AlkPhos-78
TotBili-0.4
[**2163-3-18**] 05:55PM BLOOD Lipase-41
[**2163-3-19**] 08:58AM BLOOD CK-MB-3 cTropnT-0.05*
[**2163-3-19**] 04:00AM BLOOD cTropnT-0.04* proBNP-1687*
[**2163-3-18**] 05:55PM BLOOD cTropnT-0.05*
[**2163-3-19**] 04:00AM BLOOD Albumin-2.1* Phos-2.9 Mg-1.9 Iron-22*
[**2163-3-18**] 05:55PM BLOOD Albumin-2.8* Calcium-8.6 Phos-4.1 Mg-2.4
[**2163-3-19**] 08:58AM BLOOD Hapto-238*
[**2163-3-19**] 04:00AM BLOOD calTIBC-137* Ferritn-497* TRF-105*
[**2163-3-19**] 05:56PM BLOOD Type-ART Temp-37.2 Rates-/17 FiO2-50
pO2-120* pCO2-48* pH-7.36 calTCO2-28 Base XS-1 Intubat-INTUBATED
Vent-SPONTANEOU
[**2163-3-19**] 07:33AM BLOOD Type-ART Temp-36.6 Rates-/25 Tidal V-495
PEEP-5 FiO2-50 pO2-86 pCO2-47* pH-7.39 calTCO2-30 Base XS-2
Intubat-INTUBATED Vent-SPONTANEOU
[**2163-3-19**] 02:16AM BLOOD Type-ART PEEP-5 pO2-122* pCO2-34*
pH-7.48* calTCO2-26 Base XS-3 -ASSIST/CON Intubat-INTUBATED
[**2163-3-18**] 07:38PM BLOOD Type-MIX PEEP-5 pO2-106* pCO2-47*
pH-7.33* calTCO2-26 Base XS--1 -ASSIST/CON Intubat-INTUBATED
Comment-GREEN TOP
[**2163-3-18**] 07:36PM BLOOD PEEP-5 pO2-395* pCO2-43 pH-7.39
calTCO2-27 Base XS-1 Intubat-INTUBATED
[**2163-3-18**] 06:13PM BLOOD Lactate-2.8*
[**2163-3-19**] 05:56PM BLOOD Lactate-1.1
[**2163-3-20**] 04:35AM BLOOD WBC-26.2* RBC-3.33* Hgb-10.4* Hct-30.4*
MCV-91 MCH-31.3 MCHC-34.3 RDW-15.3 Plt Ct-375
[**2163-3-27**] 04:04AM BLOOD WBC-13.1* RBC-3.28* Hgb-10.1* Hct-30.3*
MCV-93 MCH-30.9 MCHC-33.4 RDW-14.6 Plt Ct-382
[**2163-4-1**] 06:00AM BLOOD WBC-13.5* RBC-3.28* Hgb-9.9* Hct-31.2*
MCV-95 MCH-30.3 MCHC-31.9 RDW-14.1 Plt Ct-611*
[**2163-3-21**] 11:22AM BLOOD ESR-62*
[**2163-3-21**] 03:32PM BLOOD Ret Aut-2.8
[**2163-3-19**] 04:00AM BLOOD Ret Aut-6.5*
[**2163-3-19**] 04:00AM BLOOD Glucose-93 UreaN-46* Creat-1.3* Na-142
K-3.9 Cl-110* HCO3-24 AnGap-12
[**2163-3-26**] 04:41AM BLOOD Glucose-117* UreaN-26* Creat-0.8 Na-148*
K-3.3 Cl-106 HCO3-37* AnGap-8
[**2163-4-1**] 06:00AM BLOOD Glucose-70 UreaN-20 Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-28 AnGap-12
[**2163-3-19**] 04:00AM BLOOD cTropnT-0.04* proBNP-1687*
[**2163-3-20**] 04:35AM BLOOD CK-MB-4 cTropnT-0.04*
[**2163-3-21**] 03:32PM BLOOD Hapto-199
[**2163-3-20**] 04:35AM BLOOD Hapto-229*
[**2163-3-19**] 04:00AM BLOOD calTIBC-137* Ferritn-497* TRF-105*
[**2163-3-21**] 11:22AM BLOOD ANCA-NEGATIVE B
[**2163-3-21**] 11:22AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2163-3-21**] 11:22AM BLOOD RheuFac-13
[**2163-3-19**] 07:33AM BLOOD Type-ART Temp-36.6 Rates-/25 Tidal V-495
PEEP-5 FiO2-50 pO2-86 pCO2-47* pH-7.39 calTCO2-30 Base XS-2
Intubat-INTUBATED Vent-SPONTANEOU
[**2163-3-19**] 05:56PM BLOOD Type-ART Temp-37.2 Rates-/17 FiO2-50
pO2-120* pCO2-48* pH-7.36 calTCO2-28 Base XS-1 Intubat-INTUBATED
Vent-SPONTANEOU
[**2163-3-21**] 09:40AM BLOOD Type-ART Temp-36.6 PEEP-5 pO2-111*
pCO2-56* pH-7.42 calTCO2-38* Base XS-10 Intubat-INTUBATED
[**2163-3-22**] 10:31AM BLOOD Type-ART pO2-84* pCO2-52* pH-7.44
calTCO2-36* Base XS-9
.
Micro:
------
[**2163-3-19**] 12:00 pm ASPIRATE WITH SWAB.
VIC ADD ON PER DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PG# [**Serial Number 29031**] [**2163-3-20**] AT 1639.
VIC TO R/O ALL RESPIRATORY VIRUS.
**FINAL REPORT [**2163-3-23**]**
VIRAL CULTURE (Final [**2163-3-23**]):
HERPES SIMPLEX VIRUS TYPE 1.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2163-3-19**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2163-3-19**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
.
Studies:
--------
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2163-3-29**] 4:44 PM
FINDINGS: Three axial series were obtained through the paranasal
sinuses, two of which are significantly degraded by motion
artifact. The third axial series and the coronal reformats are
of diagnostic quality. The paranasal sinuses are clear. The
bilateral ostiomeatal complexes are patent. Nasoendotracheal and
nasoenteric tubes are present with their tips out of view. The
left mastoid is fully included in the field of view. The right
mastoid is nearly completely included with a small portion of
the lateral temporal bone not included. Compared to the
non-contrast head CT, [**2163-3-21**], there has been interval increase
in fluid within the bilateral middle ear cavities as well as
worsening of opacification of bilateral mastoid air cells. There
is no focal fluid collection or abscess identified and no
evidence of bone destruction.
IMPRESSION:
1. No paranasal sinus disease.
2. Compared to [**2163-3-21**], interval worsening in amount of fluid
within the bilateral middle ear cavities as well as worsening of
bilateral mastoid air cell opacification without evidence of
focal fluid collection, abscess, or bone destruction. Findings
could represent sterile effusions related to intubation,
although otomastoiditis is possible.
.
CHEST (PORTABLE AP) [**2163-3-28**] 9:00 AM
SINGLE SUPINE VIEW OF THE CHEST AT 9:20 A.M.: Again seen are a
right central venous catheter terminating at the cavo-atrial
junction, and a post-pyloric nasogastric tube. Multiple air
space opacities through both lungs are unchanged, consistent
with multifocal pneumonia. Again, the heart is enlarged and the
pulmonary vasculature is engorged. There are small bilateral
pleural effusions.
IMPRESSION: No interval change in multifocal pneumonia with
bilateral pleural effusions and congestive heart failure, but
without frank edema
.
UNILAT UP EXT VEINS US RIGHT [**2163-3-24**] 5:24 PM
FINDINGS: Grayscale, color, and pulsed wave Doppler son[**Name (NI) 1417**]
were performed on the right subclavian, axillary, brachial,
basilic, and cephalic veins. Right IJ could not be evaluated due
to dressing overlying the indwelling central venous catheter.
Echogenic noncompressible thrombus is seen within a portion of
the cephalic vein, but only in the antecubital fossa. Visualized
portions of the cephalic vein more proximally demonstrate normal
flow and compressibility. Other visualized veins in the right
upper extremity demonstrate normal flow, waveforms, and
compressibility. No other intraluminal thrombus is identified.
Note is made of diffuse edema throughout the right arm.
IMPRESSION: Superficial thrombosis of the right cephalic vein in
the antecubital fossa. No evidence of deep venous thrombosis in
the right upper extremity.
.
TTE ([**3-22**]):
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is regional left ventricular
systolic dysfunction with mild focal hypokinesis of the apex and
the mid to apical septum, anterior, and lateral walls. The
remaining segments contract normally (LVEF = 45-50 %). Right
ventricular chamber size and free wall motion are difficult to
assess due to suboptimal technical quality, but are probably
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Regional left ventricular
dysfunction consistent with coronary artery disease or other
focal myopathic process. Borderline pulmonary hypertension.
Resting tachycardia.
Compared with the prior study (images reviewed) of [**2163-3-7**],
left ventricular function appears more vigorous. Resting heart
rate is now faster.
.
KNEE (2 VIEWS) RIGHT PORT [**2163-3-21**] 2:28 PM
FINDINGS: Two views show no evidence of joint effusion. The bony
structures are quite well maintained without evidence of
narrowing or spurring. Of incidental note is an intramedullary
device in the femur.
.
CT HEAD W/O CONTRAST [**2163-3-21**] 7:09 PM
FINDINGS: No evidence of acute hemorrhage, mass lesion, shift of
normally midline structures, hydrocephalus or evidence of major
territorial infarction. There is again noted moderate diffuse
global cerebral atrophy. There is moderate-to-severe
periventricular white matter hypoattenuation consistent with
chronic microvascular infarction. The major intracranial
cisterns are preserved. There is new opacification of the
mastoid air cells bilaterally. The remaining paranasal sinuses
visualized are clear. There has been a right orbital lens
replacement.
IMPRESSION:
1. No evidence of acute hemorrhage or mass effect.
2. New opacification of the mastoid air cells which may be
compatible with acute mastoiditis.
3. Moderate-to-severe chronic periventricular white matter
ischemia/infarction, unchanged.
.
CT PELVIS W/CONTRAST [**2163-3-21**] 7:10 PM
CT ABDOMEN WITH CONTRAST: Bibasilar opacities are present with
associated small pleural effusions. Nodular opacities are also
noted within the parenchyma of the right and left lower lobes.
Bilateral calcific pleural plaque is present suggesting previous
asbestos exposure. No pericardial effusion or cardiomegaly is
present.
Evaluation of the upper abdomen is limited given streak artifact
from arms within the field of view. There is a round
hypoattenuated lesion within segment IV of the liver measuring
1.3 cm in greatest axial dimension, consistent with a simple
cyst. An adjacent hypoattenuating lesion is too small to
adequately characterize. The gallbladder is distended without
definite intraluminal stone. A trace amount of ascitic fluid is
present surrounding the liver. Limited views of the pancreas
suggest mild pancreatic ductal prominece and a probable 8 mm
hypoattenuating lesion within the body (2:27). No gross
abnormalities are detected within the adrenal glands, which are
not well evaluated given artifact. There is a heterogenous
appearence to the left kidney which may be secondary to
considerable streak artifact in this region. An NG tube courses
through the mediastinum with tip terminating in the stomach.
CT PELVIS WITH CONTRAST: There is a mild amount of ascites
within the pelvis. A rectal tube is present in the rectum. There
is no small-bowel obstruction. A Foley catheter is noted within
the bladder with a small amount of intraluminal air. There is
calcific atherosclerotic plaque within the descending abdominal
aorta with a very mild aneurysmal dilatation in an infrarenal
location measuring 2.6 cm in greatest axial dimension. The iliac
vessels are tortuous.
There is a large intramuscular hematoma in the anterior
compartment of the right thigh. No arterial blush is identified
to suggest active extravasation of contrast material. Bilateral
knee effusions are only partially imaged. There is a right
femoral intramedullary rod with dynamic screw in the right
femoral neck and head. Coarse calcifications are detected in the
region of the scrotum bilaterally.
IMPRESSION:
1. Large intramuscular hematoma in the anterior compartment of
the right thigh.
2. Bibasilar consolidation with small pleural effusions.
Aspiration must be considered.
3. Bilateral knee effusions.
4. Small amount of ascitic fluid.
5. Calcific atherosclerotic plaque within the descending
abdominal aorta and iliac branches with very mild infrarenal
aneurysmal dilatation.
6. Suggestion of mild pancreatic ductal prominence and a rounded
cystic lesion within the body. The differential includes a
pancreatic cyst vs side branch IPMN. This region is considerably
degraded by streak artifact and further evaluation is
recommended in 3 months time.
7. Subcutaneous edema in bilateral lower extremities.
.
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN
[**Name Initial (PRE) **]: Supine portable AP chest radiograph is obtained. A new
right IJ central line is seen with its tip in the distal SVC.
Endotracheal tube and NG tube are unchanged. The lungs are
unchanged from prior study with stable multifocal pulmonary
consolidation again noted. Cardiomediastinal silhouette is
stable. Diffuse osteopenia is noted. No pneumothorax.
IMPRESSION:
New right IJ central line in good position. Otherwise, no
change.
Brief Hospital Course:
89 y/o male recent discharged after MICU stay for influenza
pneumonitis, representing with respiratory failure, fever,
altered mental status & hct drop, concern for onogoing
superimposed bacterial pneumonia.
MICU course: EGD performed and upper GI tract clear without
evidence of bleed. As it turns out, patient has large hematoma
in right thigh. Patient was seen by wascular surgery who
recommended ACE wrap. The patient's hematocrit stabilized after
a total of 9 unitd pRBCS. Patient also had head CT on arrival
secondary to mental status change. Was found to have acute
bilateral mastoiditis for which he was started on ceftriaxone.
Respiratory work-up was unrevealing though there was evidence of
a a possible right lower lobe infiltrate, however, his primary
pathology seemed to involve peripheral paranchyma suggestive of
a possible interstitial lung disease. He does have a history of
work in a shipyard and the CT was noted to be consist with
asbestosis in the past. At first, he was treated with Meropenem
and Linezolid for question of failure of previous antiibotics
treatment (Vanc/Zosyn) during his last hospitalization (was d/c
3 days prior to this admission).
#Anemia: hct drop on adm from 31 to 22%. Hemolysis labs WNL. Pt
received 9units pRBCs, hct did not rise appropriately until
after 3rd unit. Hct finally went to 30, no e/o hemodynamic
instability. Guaiac negative from golytely BM, reported coffee
grounds in NG lavage performed in ED, bile currently present
when OG suctioned, EGD on [**3-21**] showed clean upper GI tract
without evidence of bleeding. Colonosocpy not perfromed with
guaiac negative schools and intubated. Nursing noted swelling
of right knee and right lower extremity. Plain films of right
knee negative. Seen by rheum no blood on tap, no crystals.
LENI of right lower extremity revealed hematoma. Vascular
consulted recommended CTA of RLE. Patient premedicated with
acetylcysteine and and bicarb. Scan showed large hematoma with
no evidence of active extravation of contrast.
After transfer to the floor, hematocrit remained stable, and
thigh size improved with ACE wraps.
# Respiratory failure/#likely aspiration pneumonia: etiology
unclear, possibly aspiration versus inability to clear
secretions causing respiration pneumonitis vs. acute flare up of
what appears to be underlying interstital lung disease.
Respiratory viral screen positive for HSV 1, but felt to be an
oral contaminant. CXR and prior CT seem consistent with
underlying interstitial ling disease, making reserve lower.
Patient successfully extubated, transferred to floor.
He required intermittent suctioning for thick secretions on
transfer, but remained stable on 50% humidified face tent.
Subsequently transitioned to face mask and then nasal canula.
He was maintained on Ceftriaxone and then Flagyl was later added
for better anaerobic coverage. A course was completed. Pt.
continued to have delerium, inability to eat safely, ultimately,
after many disucssions with family, pt. was sent home with
hospice care.
# mastoiditis/#leukocytosis: Ceftriaxone therapy initiated, and
impressive admission leukocytosis improved gradually, though
remained elevated. He was not febrile while on the floor.
#Altered mental status/#dementia: Delerium in the setting of
acute illness, ICU stay and intubation with associated sedating
meds. Upon transfer to floor, he interacted with tracking and
unintelligible vocalization. He has a history of dementia, but
prior to recent hospitalizations was ambulatory and interactive,
although disoriented to all but self. He subsequently was quite
lethargic with minimal interaction. Later, he was alert again
and more interactive, even recognizing his son and conversing,
however, only intermittantly. He did not improve overall, and
was sent home with hospice care.
# ARF: Baseline creatinin 0.7. Improved with hydration.
premedicated with acetylcysteine and bicarb for CTA with no bump
in Cr.
# anasarca -- in the setting of fluid resucitation and acute
illness. Improved with gentle diuresis. Right upper ext felt to
be larger than left, so U/S doppler done with no evidence of DVT
(only superficial clot).
# flexible feeding tube placement -- placed by IR for nutrition
and fluids on the day of transfer to the floor, [**3-23**]. Initiated
on tube feeds without difficulty. Family was informed this does
not decrease his risk for aspiration. Dobhoff tube fell out on
[**3-29**] when patient vomited small amount.
.
# Goals of care
Prior to dobhoff tube falling out, overall goals of care
discussed with family (sons [**Name (NI) **] and [**Name (NI) **]). Initial thought
was to allow a course of antibiotics (at least one week more)
and then re-assess. Decision on PEG deferred. However, after
dobhoff tube came out, issue was revisited. Palliative care
also consulted. After much discussion, decision made to make
patient DNR/DNI, not pursue replacement of dobhoff or PEG, but
consider IV nutrition. Immediately after this, decision made to
make patient CMO. This was done on night of [**3-30**] (including
cessation of antibiotics). However, on morning of [**3-31**], patient
was much more alert. Decision then made to reverse CMO status,
however keeping DNR/DNI status and not pursuing aggressive
measures. Antibiotics were restarted. Patient was also seen by
speech/swallow. Though at high risk for aspiration, family
willing to take risk to allow patient to eat since patient
seemed to want to eat. TPN also initiated for brief period of
time to provide minimal nutrition. Plan is to assess for any
improvement in overall mental status and respiratory status and
then re-assess goals of care. Pt. subsequently aspirated again,
and the above discussion and family meeting again done. Family
decided not to feed him, to pursue further parenteral nutrition
and to complete his antibiotic course. He fluctuated from this
point forward, with two episodes of mucous plugging with
desaturations to the 60s, requiring invasive nasotracheal
suctioning to clear the secretions. He slowly became more alert
and interacitive, but was unable to comply with PT or speech
evaluations.
After numerous further dicussions with the patient's sons,
palliative care and the medical team, the decision was made by
the sons (and HCP son [**Name2 (NI) 3979**]) to send the patient home with
hospice (no TPN, no saline, no abx, no PICC line) with CMO
status.
The patient was discharged on [**4-11**] to home with hospice.
Medications on Admission:
ASA 81 mg
Metoprolol Tartrate 25 mg [**Hospital1 **]
Vancomycin 750 mg [**Hospital1 **] ended [**3-15**]
Zosyn 4.5 q 8 ended [**3-15**]
Ipratropium bromide 0.02% q6
Prevacid 30 mg daily
senna
colace oral
Dulcolax
Tylenol 325 mg q6
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 1-10 mg PO Q2H
(every 2 hours) as needed for pain, increased secretions.
Disp:*60 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary: Possible aspiration pneumonia
Secondary: Dementia
Secondary: 276.0 HYPERNATREMIA
Secondary: 383.9 UNSPECIFIED MASTOIDITIS
Secondary: 263.0 MALNUTRITION, MODERATE
Secondary: 293.0 DELIRIUM, NOS
Secondary: 600.01 BPH W/ URINARY OBSTRUCTION
Secondary: 428.20 HEART FAILURE, (A3) CHRONIC SYSTOLIC
Secondary: Thigh hematoma
Secondary: Acute blood loss anemia
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Patient going home with hospice.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2163-4-26**] 9:55
Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2163-4-26**]
10:15
|
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"263.0",
"518.81",
"924.00",
"453.8",
"584.9",
"428.0",
"428.22",
"600.01",
"507.0",
"401.9",
"782.1",
"383.9",
"E928.9",
"285.1",
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icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93",
"96.6",
"96.72",
"96.04",
"99.15"
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icd9pcs
|
[
[
[]
]
] |
22289, 22367
|
15324, 21835
|
291, 339
|
22774, 22795
|
2496, 15301
|
22876, 23122
|
1965, 1969
|
22119, 22266
|
22388, 22753
|
21861, 22096
|
22819, 22853
|
1984, 2477
|
223, 253
|
367, 1617
|
1639, 1680
|
1696, 1949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,110
| 172,644
|
2592
|
Discharge summary
|
report
|
Admission Date: [**2145-8-24**] Discharge Date: [**2145-9-5**]
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old
Russian female with coronary artery disease, hypertension,
diabetes mellitus type 2 and hypercholesterolemia, who
presented with chest pain and dyspnea on exertion. The
patient had known three vessel disease diagnosed on cardiac
catheterization in [**2138**] and managed medically since that
time.
During a preoperative workup for a hemicolectomy last year,
the patient had an exercise tolerance test that was
significant for a limited exercise tolerance and ischemic ST
segment changes with focal left ventricular systolic
dysfunction in the absence of anginal type symptoms, thought
to be consistent with inducible ischemia. She was admitted
and ruled out for a myocardial infarction in [**2144-7-21**].
Her angina equivalent was dyspnea on exertion and her
exercise tolerance was about one quarter of a mile walking
before needing to stop and rest. Prior to that admission,
she had only occasional chest pain on exertion, usually brief
and responsive to rest or one sublingual nitroglycerin.
Since then, she had no chest pain but worsening dyspnea on
exertion.
Approximately three days prior to admission, the patient
experienced her usual shortness of breath accompanied by
nonradiating chest discomfort described as a tightness with
pressure but not necessarily pain, which lasted approximately
two hours. She took two sublingual nitroglycerin tablets,
which helped alleviate the symptoms. The episode was not
associated with diaphoresis, nausea, vomiting, syncope or
lightheadedness. Since then, she had two additional episodes
of the shortness of breath, but not with the associated chest
discomfort. The patient had three pillow orthopnea for many
years, as well as chronically edematous ankles. The review
of systems was otherwise unremarkable.
The patient was referred to the [**Hospital1 188**] emergency department by her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 9346**], for presumed unstable angina. In the emergency
department, the patient was not experiencing shortness of
breath or chest discomfort. An electrocardiogram done at
that time was unremarkable for ischemic changes. The patient
was subsequently admitted for suspicion of a myocardial
infarction.
PAST MEDICAL HISTORY:
1. Coronary artery disease, as described.
2. Diabetes mellitus times one year, treated with Glyburide.
3. Chronic hypertension.
4. Chronic hypercholesterolemia.
5. Hypothyroidism.
6. Gout.
7. Colon cancer, status post hemicolectomy.
MEDICATIONS ON ADMISSION:
1. Nadolol 80 mg p.o. b.i.d.
2. Allopurinol 300 mg p.o. q.d.
3. Synthroid 0.150 mg p.o. q.d.
4. Accupril 40 mg p.o. q.d.
5. Glyburide 2.5 mg p.o. q.d.
6. Lipitor 10 mg p.o. q.d.
7. Nifedipine 30 mg p.o. q.d.
8. Nitrodisc 0.6 mg/hr transdermal patch q.d.
9. Lasix 20 mg p.o. q.o.d.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile
with a heart rate of 60, a blood pressure of 150/80, a
respiratory rate of 16 and an oxygen saturation of 96% on
room air. The jugular venous pressure was normal. Carotid
pulses had a normal upstroke without bruit. The lungs were
clear. The heart had a regular rate and rhythm with a II/VI
systolic murmur at the left sternal border. The abdomen was
soft, nontender and nondistended. The extremities were warm
and well perfused with mild edema bilaterally at the ankles.
HOSPITAL COURSE: The patient was admitted to the medical
service and was subsequently ruled out for a myocardial
infarction. A cardiology consultation was obtained and the
consultant recommended a new cardiac catheterization to
assess the patient's coronary artery disease. The results of
that study demonstrated a calcified aorta and coronary
arteries with an ejection fraction of approximately 60%. The
results of that study demonstrated a 100% occlusion of the
mid right coronary artery, a 60% stenosis of the left main
coronary artery, a 100% stenosis of the distal left anterior
descending artery, a 50% stenosis of the proximal left
anterior descending artery, a 90% stenosis of the mid
circumflex coronary artery and an 80% stenosis of the third
obtuse marginal artery. Based on these results, the
cardiothoracic surgery service was consulted and it was
recommended that the patient undergo coronary artery bypass
surgery.
There was a complication from the cardiac catheterization
done on [**2145-8-26**] that consisted of a suspected right
groin hematoma. The patient went down for an ultrasound of
the right groin at the same time that she was having her
carotid arteries studies. There was no evidence of a
hematoma, arteriovenous fistula or pseudoaneurysm in her
right groin. Her carotid ultrasound results were significant
for a 60-70% stenosis of both the right and left internal
carotid arteries. She was noted to have normal antegrade
flow in her right and left vertebral arteries.
The [**Hospital 228**] hospital course prior to surgery was
complicated by a declining hematocrit, requiring transfusions
of packed red blood cells. Her surgery was delayed,
therefore, until the medical team could stabilize her
hematocrit and determine the etiology of her blood
requirement.
On [**2145-8-21**], she underwent an abdominal CT scan
which demonstrated a 5 x 12 cm right pelvic hematoma. The
patient was managed medically for her retroperitoneal bleed
with serial transfusions of packed red blood cells in order
to maintain a hematocrit above 30. By [**2145-8-30**],
the vascular surgery service had been consulted and deemed
her retroperitoneal hematoma to be stable and deemed it to be
safe to heparinize the patient for her coronary artery bypass
grafting.
On [**2145-9-2**], the patient underwent an uncomplicated
off pump coronary artery bypass grafting times three with a
left internal mammary artery graft to the first diagonal
artery, a saphenous vein graft to the second diagonal artery
and a saphenous vein graft to the obtuse marginal artery.
The patient tolerated the procedure well and was transported
to the cardiac surgery recovery room, intubated and in good,
stable condition. Overnight, she required two units of
packed red blood cells and remained intubated.
On postoperative day #1, the patient was afebrile and
hemodynamically stable, making good urine. She was extubated
and subsequently transferred to the floor. Once on the
floor, the patient remained stable.
On postoperative day #2, the patient was tolerating p.o.
intake as well as oral pain medication. She was still making
adequate amounts of urine. She was out of bed and ambulating
around her room. Her Foley catheter and her antecubital
intravenous lines were removed. On postoperative day #4, the
patient was deemed to be in stable condition and ready for
discharge to a rehabilitation center.
PHYSICAL EXAMINATION ON DISCHARGE: The patient was afebrile
with stable vital signs. The neck was supple. There were no
bruits. The lungs were clear with slightly diminished breath
sounds bilaterally. The sternum was stable. The incision
was clean, dry and intact. The heart had a regular rate and
rhythm with a II/VI systolic ejection murmur at the left
sternal border. The abdomen was soft, nontender and
nondistended. The extremities were warm and well perfused.
The incision was clean, dry and intact.
DISCHARGE MEDICATIONS:
Lopressor 25 mg p.o. b.i.d.
Lasix 20 mg p.o. b.i.d. times one week.
Potassium chloride 20 mEq p.o. b.i.d. times one week.
Aspirin 81 mg p.o. q.d.
Plavix 75 mg p.o. q.d.
Synthroid 0.150 mg p.o. q.d.
Glyburide 2.5 mg p.o. q.d.
Lipitor 10 mg p.o. q.d.
Percocet one to two tablets p.o. every three to four hours
p.r.n. for pain.
Colace 100 mg p.o. b.i.d.
Allopurinol 300 mg p.o. q.d.
DISCHARGE DIAGNOSES:
Coronary artery disease, status post coronary artery bypass
grafting times three.
CONDITION/DISPOSITION: The patient was discharged to
rehabilitation insertion table condition.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2145-9-5**] 15:11
T: [**2145-9-5**] 15:32
JOB#: [**Job Number 13081**]
|
[
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"998.12",
"440.0",
"414.01",
"285.9",
"780.2",
"411.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.15",
"36.12",
"88.53",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7875, 8335
|
7473, 7854
|
2691, 3003
|
3539, 6955
|
6970, 7450
|
144, 2402
|
3018, 3521
|
2424, 2665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,553
| 101,085
|
12180
|
Discharge summary
|
report
|
Admission Date: [**2193-11-21**] Discharge Date: [**2193-11-25**]
Date of Birth: [**2145-6-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2193-11-21**] Coronary Artery Bypass Graft x 2 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal)
History of Present Illness:
Mr. [**Known lastname **] is a 48-year-old, with end-stage renal disease, who
was recently diagnosed with coronary artery disease of his left
anterior descending
artery and diagonal artery. Because of his end-stage renal
disease, it was deemed appropriate for a coronary bypass. After
risks, benefits and alternatives were explained to the patient,
he agreed to proceed to surgery.
Past Medical History:
DM Type I x 30 years
HTN
S/p L vitrectomy and R vitrectomy (diabetic loss of vision)
ESRD on PD (recent baseline 6)
Gallstones
s/p arthroscopic knee surgery
Diveriticulosis
Social History:
He used to work as a medical assistant at [**Last Name (un) **], but quit in
order to avoid infectious exposures, and now works in real
estate. He lives with his partner who is HIV+; his partner has
recently been sick with cancer and Zoster secondary to HIV. He
practices safe sex and is HIV- as of [**5-26**], smokes tobacco (40-50
pack years), drinks EtOH socially, and denies IVDU
Family History:
His mother has diabetes, as does maternal aunt and uncle. There
is also history of gastric cancer in his father's side
Physical Exam:
Exam:
Well developed man in no acute distress
Vitals: WT 183# BP 152/96 P 84 bpm reg
HEENT: Rt cheek minimal induration, small central ulceration
present on most posterior lesion, other closed
Lt cheek multiple healing ulcerations
Neck: no JVD
Lungs: good air movement, no crackles or wheezes
Cardiac: RRR, no s3, s4 or murmurs
Ext: 1+ edema bilaterally
Pertinent Results:
[**2193-11-21**] ECHO
PRE-CPB: 1. The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. A left atrial appendage
thrombus cannot be excluded.
2. No thrombus is seen in the right atrial appendage
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is mildly dilated. No left ventricular
aneurysm is seen. Overall left ventricular systolic function is
mildly depressed (LVEF= 40 %).
5. The right ventricular free wall is hypertrophied. Right
ventricular chamber size is normal. with borderline normal free
wall function.
6. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. The NCC is calcified and
nonmobile. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen.
8. Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine, a-pacing. Preserved
biventricular systolic function. LVEF is now 50%. MR remains
mild. The aortic contour is normal post decannulation.
[**2193-11-24**] 06:50PM BLOOD WBC-12.4* RBC-2.73* Hgb-7.9* Hct-23.3*
MCV-85 MCH-28.8 MCHC-33.9 RDW-17.4* Plt Ct-276
[**2193-11-24**] 01:11AM BLOOD WBC-13.4* RBC-2.87* Hgb-8.4* Hct-24.4*
MCV-85 MCH-29.2 MCHC-34.4 RDW-17.7* Plt Ct-263
[**2193-11-23**] 06:07AM BLOOD WBC-16.4* RBC-2.74* Hgb-7.9* Hct-23.6*
MCV-86 MCH-28.8 MCHC-33.4 RDW-17.4* Plt Ct-279
[**2193-11-21**] 11:00AM BLOOD WBC-6.5 RBC-2.39*# Hgb-6.8*# Hct-20.1*#
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.8* Plt Ct-188
[**2193-11-21**] 06:07PM BLOOD PT-14.8* PTT-32.1 INR(PT)-1.3*
[**2193-11-21**] 11:00AM BLOOD PT-16.9* PTT-43.5* INR(PT)-1.5*
[**2193-11-24**] 06:50PM BLOOD Glucose-59* UreaN-51* Creat-10.2* Na-135
K-4.1 Cl-95* HCO3-27 AnGap-17
[**2193-11-24**] 01:11AM BLOOD Glucose-113* UreaN-46* Creat-10.4* Na-134
K-4.2 Cl-95* HCO3-24 AnGap-19
[**2193-11-23**] 06:07AM BLOOD Glucose-84 UreaN-42* Creat-10.5* Na-137
K-4.6 Cl-98 HCO3-26 AnGap-18
[**2193-11-22**] 04:17AM BLOOD Glucose-72 UreaN-42* Creat-11.2* Na-137
K-4.8 Cl-103 HCO3-22 AnGap-17
[**2193-11-21**] 12:43PM BLOOD UreaN-40* Creat-10.9*# Cl-104 HCO3-23
[**2193-11-24**] 06:50PM BLOOD Mg-1.9
[**2193-11-24**] 01:11AM BLOOD Calcium-8.2* Phos-7.4* Mg-2.0
[**2193-11-23**] 06:07AM BLOOD Calcium-8.4 Phos-7.5* Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2193-11-21**] for elective
surgical management of his coronary artery disease. He was
admitted as a same day surgery and taken to the operating room
where he underwent coronary artery bypass grafting to two
vessels. Please see operative note for details. Postoperatively
he was taken to the intensive care unit for invasive hemodynamic
monitoring. Within 24 hours, Mr. [**Known lastname **] had awoke neurologically
intact and was extubated. On postoperative day one, he was
transferred to the step down unit for further recovery. Mr.
[**Known lastname **] was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility.
He continued his peritoneal dialysis as per usual routine. Some
serous and serosangeuenous drainage was noted on POD 4 and he
was started on 7 days of prophylactic Keflex. He progressed well
and on POD 4 he was stable and was discharged to home.
Medications on Admission:
Norvasc 10', calcitrol 0.25', phoslo 666", lasix 80", gabapentin
600",
B-complex, folic acid, cinacalet 30', lantus, humalog, labetolol
200", asa 81', mvi
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take as long as you take narcotics for
pain.
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*0*
5. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
Disp:*30 Cap(s)* Refills:*0*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH:
-DM Type I x 30 years
-HTN
-S/p L vitrectomy and R vitrectomy (diabetic loss of vision)
-ESRD on PD (recent baseline 6)
-Gallstones
-s/p arthroscopic knee surgery
-Diveriticulosis
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
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**1-20**] weeks
Please schedule appointments
Completed by:[**2193-11-25**]
|
[
"585.6",
"562.10",
"403.91",
"250.41",
"285.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"54.98",
"36.11",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7224, 7282
|
4657, 5691
|
294, 439
|
7572, 7579
|
2000, 4634
|
8090, 8245
|
1465, 1587
|
5896, 7201
|
7303, 7551
|
5717, 5873
|
7603, 8067
|
1602, 1981
|
235, 256
|
467, 850
|
872, 1046
|
1062, 1449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,581
| 195,215
|
54799
|
Discharge summary
|
report
|
Admission Date: [**2138-7-19**] Discharge Date: [**2138-7-20**]
Date of Birth: [**2094-8-18**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reason for MICU transfer: opiate od requiring naloxone gtt
History of Present Illness:
43 y/o F HepC, HIV, polysubstance abuse, recent dx of anaplastic
Tcell lymphoma s/p 2 month hospitalzation on BMT (on cycle 2 of
[**Hospital1 **], received PRBC and neupogen on [**7-17**]). DC'd home few days
ago. Left hospital on Wed, staying w/ her son. [**Name (NI) **] thinks she
overdosed on street drugs and her own prescriptions that he gave
her. He found her lying on the bathroom floor unresponsive. He
took her to the car and drove to the [**Location (un) **] ED. Her sister
says that she has overdosed frequently. Son [**Name (NI) 112003**]drugs plus methadone and oxycodone. Pt admits to using cocaine
yesterday, but denies any other illicit drug use or taking more
methadone than proscribed. Went to [**Hospital **] hospital. Cocaine
positive. 0.4mg x5 naloxone at OSH, then placed on naloxone gtt
prior to transfer. HeadCT negative at [**Location (un) **]. Loaded into
PACS. Empiric abx given prior to records from OSH. No LP after
getting history. HDS, no fevers, no respiratory distress. PIV in
foot and hand. Rouses to voice. Oriented to 'hospital' and
'president'. BMT aware.
In the ED, initial VS were: P:105 RR:18 BP:113/65 O2Sat: 99
EKG:Sinus Tachycardia QTC 484. She was given ceftriaxone, vanc,
and acycolvir IV for AMS ?meningitis, no LP performed after
receving hx.
On arrival to the MICU, patient's VS. T:97.6, HR: 101, BP 129/75
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- anaplastic T cell lymphoma
- VRE and coag neg staph bacteremia
- HIV (CD4 372 [**2138-6-21**]),
- History of hepatitis C
- Asthma
- Bipolar disorder
- Polysubstance abuse (including opiates and coaine)
- Dysplasia on PAP smear
- Umbilical herniography
- Caesarean section
- Tubal ligation
- GERD
- History fo nephrolithiasis.
- Denies TB but apparently does have a PPD with an unclear prior
treatment for latent TB.
- CNS toxoplasmosis - many years ago in the [**Country 13622**] Republic
Past surgical history:
3 c-sections, hernia repair in [**2124**].
-opiate/cocaine abuse
Social History:
Originally from [**Country 13622**] Republic. Lives with her daughter and
granddaughters. Incarcerated at [**Location (un) 47**] jail, released
[**2138-5-4**]. Has 5 children. Patient admits to active smoking [**1-13**]
pack daily. Uses IV heroin drugs (last use was [**2138-3-13**]),
crack cocaine which she smokes. Went through rehab and is on
clonidine and percocet until she can start Suboxone. Formerly
used marijuana. Admits to alcohol but last drink was about 5 or
six months ago. Has not had a sexual partner in many months.
Was formerly imprisoned in the [**Country 13622**] Republic 2 years ago
for about 7 months. During that imprisonement she got sick and
was hospitalized for 3 months and treated for toxoplasmosis.
Already had been diagnosed with HIV by then
Family History:
Negative for colon cancer, stomach cancer or liver disease.
Mother with diabetes, father healthy. [**Name2 (NI) **] father with substance
abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:T: 97.6, HR: 101 BP 126/75 RR 14 97%RA
General: Alert, oriented to person and place, no acute distress
[**Name2 (NI) 4459**]: 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: L base crackles, no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
P105, 99% RA, BP 113/65,
I/O even
Alert and awake, uncooperative with exam/questioning, demanding
to go home
Rales at left base with scattered wheezing
CV: RRR
Abd: soft, nt +bs
Pertinent Results:
ADMISSION LABS
--------------
[**2138-7-19**] 05:00PM BLOOD WBC-5.9 RBC-4.22# Hgb-10.8*# Hct-34.3*#
MCV-81* MCH-25.7* MCHC-31.6 RDW-20.0* Plt Ct-351
[**2138-7-19**] 05:00PM BLOOD Neuts-51 Bands-4 Lymphs-13* Monos-23*
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-6* NRBC-1*
[**2138-7-19**] 05:00PM BLOOD PT-12.0 PTT-33.4 INR(PT)-1.1
[**2138-7-19**] 05:00PM BLOOD Glucose-77 UreaN-11 Creat-0.7 Na-140
K-4.5 Cl-105 HCO3-20* AnGap-20
[**2138-7-19**] 05:00PM BLOOD ALT-75* AST-125* AlkPhos-93 TotBili-0.5
[**2138-7-19**] 05:00PM BLOOD Albumin-4.2 Calcium-9.6 Phos-5.1* Mg-2.1
[**2138-7-19**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2138-7-19**] 04:49PM BLOOD Type-[**Last Name (un) **] Temp-37.2 Rates-/18 pO2-90
pCO2-41 pH-7.36 calTCO2-24 Base XS--1 Intubat-NOT INTUBA
DISCHARGE LABS
--------------
[**2138-7-20**] 04:05AM BLOOD WBC-4.9 RBC-3.99* Hgb-10.2* Hct-32.0*
MCV-80* MCH-25.6* MCHC-32.0 RDW-19.6* Plt Ct-344
[**2138-7-20**] 04:05AM BLOOD Neuts-60 Bands-2 Lymphs-19 Monos-17*
Eos-0 Baso-1 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2138-7-20**] 04:05AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-138 K-3.6
Cl-107 HCO3-18* AnGap-17
[**2138-7-20**] 04:05AM BLOOD ALT-56* AST-75* LD(LDH)-314* AlkPhos-72
TotBili-0.3
[**2138-7-20**] 04:05AM BLOOD Calcium-8.4 Phos-3.4# Mg-1.9
IMAGING
-------
Chest X-ray on admission:
Increased opacity at the left lung base, which may be due to
increase in existing atelectasis at the site rather than
pneumonia. However, particularly if clinical concern for
pneumonia persists, standard PA and lateral radiographs may be
helpful to evaluate further and directly compare to earlier
studies when clinically feasible.
MICROBIOLOGY
------------
Blood culture x 2: pending
Brief Hospital Course:
[**Hospital 112004**] COURSE
43 year old female with hepatitis C, HIV, polysubstance abuse,
recent diagnosis of anaplastic T-cell lymphoma s/p 2 month
hospitalzation on BMT (on cycle 2 of [**Hospital1 **]) course complicated
by VRE and coag neg staph bacteremia admitted to ICU for opiate
toxicity requiring naloxone gtt.
ACUTE ISSUES:
-------------
#Altered mental status: The most likely etiology was thought to
be opiate toxicity given positive tox screen and immediate
response to naloxone. Most likely source of opiate intoxication
is dilaudid that she was prescribed on discharge. Patient's
mental status improved after naloxone gtt was discontinued.
#Anion gap metabolic acidosis: Pt. was found to have an elevated
AG at 15 with a normal lactate and ketones in the urine. The gap
closed to 13 on the day following admission and the patient was
taking good PO.
CHRONIC ISSUES:
---------------
#Anaplastic T-cell lymphoma on [**Hospital1 **] cycle 2. Bone marrow
transplant was notified that she was in the ICU. This issue
remained stable during her course and the patient will follow up
with her outpatient provider.
#HIV ((CD4 372 [**2138-6-21**]) with history of toxoplasmosis, on
darunavir 400 mg Tablet 2 tab po daily, emtricitabine-tenofovir
200-300 mg 1 tab po daily and ritonavir 100 mg Tablet 1 tab po
daily. The patient was continued on her home medications during
the hospitalization.
#GERD: The patient was continued on her home famotidine.
#Bipolar Disorder: The patient was continued on home
lamotrigine, ativan and risperdal prn.
#Asthma: The patient was continued on her home asthma
medications.
Medications on Admission:
-darunavir 400 mg Tablet 2 tab po daily
-emtricitabine-tenofovir 200-300 mg 1 tab po daily
-ritonavir 100 mg Tablet 1 tab po daily
-Risperdal 0.5 mg Tablet 1 tab [**Hospital1 **] PRN anxiety
-acyclovir 400 mg Tablet 1 tab TID
-Ativan 1 mg tab PO BID prn anxiety
-lamotrigine 150 mg 1 tab po daily
-methadone 5 mg Tablet 3 tabs TID
-gabapentin 300 mg 3 tab TID.
-Dilaudid 4 mg Tablet 1 Tablet PO q4H
-atovaquone 750 mg/5 mL Suspension Sig: 1500 mg PO daily
-multivitamin
-albuterol sulfate 90 mcg/actuation
-famotidine 20 mg Tablet 1 tab po daily
Discharge Medications:
-darunavir 400 mg Tablet 2 tab po daily
-emtricitabine-tenofovir 200-300 mg 1 tab po daily
-ritonavir 100 mg Tablet 1 tab po daily
-Risperdal 0.5 mg Tablet 1 tab [**Hospital1 **] PRN anxiety
-acyclovir 400 mg Tablet 1 tab TID
-Ativan 1 mg tab PO BID prn anxiety
-lamotrigine 150 mg 1 tab po daily
-methadone 5 mg Tablet 3 tabs TID
-gabapentin 300 mg 3 tab TID.
-Dilaudid 4 mg Tablet 1 Tablet PO q4H
-atovaquone 750 mg/5 mL Suspension Sig: 1500 mg PO daily
-multivitamin
-albuterol sulfate 90 mcg/actuation
-famotidine 20 mg Tablet 1 tab po daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Opiate overdose
Secondary diagnosis:
Anaplastic T-cell lymphoma
HIV
Gastroesophageal reflux disease
Asthma
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 2427**],
It was a pleasure caring for you at [**Hospital1 18**]. You came for further
evaluation of altered mental status and confusion. Further
work-up showed that you had likely taken too much of some of
your medications, namely methadone and Dilaudid. We reversed
the effects of these medications, and you are now back to your
usual self. It is important that you take your medications only
as they are prescribed and no more than that. It is also
important that you do not drink alcohol, drive, or operate heavy
machinery while on methadone and Dilaudid. You should also not
use other illicit drugs, as they could kill you. Please follow
up with your appointments, as listed below.
The following changes have been made to your medications:
No changes
Followup Instructions:
Department: HEMATOLOGY/BMT
When: TUESDAY [**2138-7-22**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2138-7-22**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23455**], NP [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2138-7-22**] at 1:30 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN [**Telephone/Fax (1) 14665**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You have an appointment with Pain Management (Dr. [**Last Name (STitle) **] on
[**2138-8-12**] at 9:20 am in the Pain Management Center at [**Hospital1 18**].
|
[
"305.60",
"296.80",
"E850.2",
"200.60",
"305.1",
"070.70",
"E850.1",
"276.2",
"V58.69",
"530.81",
"965.09",
"493.90",
"042",
"965.02",
"304.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9274, 9280
|
6477, 6838
|
290, 296
|
9470, 9470
|
4720, 6051
|
10437, 11567
|
3627, 3774
|
8702, 9251
|
9301, 9301
|
8130, 8679
|
9621, 10414
|
2752, 2820
|
3815, 4494
|
1795, 2215
|
229, 252
|
412, 1776
|
9360, 9449
|
9321, 9338
|
6065, 6454
|
9485, 9597
|
7364, 8104
|
2237, 2729
|
2836, 3611
|
4519, 4701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,796
| 178,045
|
4505
|
Discharge summary
|
report
|
Admission Date: [**2120-4-20**] Discharge Date: [**2120-4-23**]
Date of Birth: [**2058-12-29**] Sex: F
Service:
CHIEF COMPLAINT: Status post myocardial infarction and RCA
stent placement.
HISTORY OF THE PRESENT ILLNESS: The patient is a 61-year-old
female with a history of coronary artery disease, status post
stenting times two in the past with hypertension,
hypercholesterolemia, GERD, and family history of coronary
artery disease, who has had stuttering chest pain
approximately 20 minutes in duration and dyspnea on exertion
over the past two weeks. She has been taking aspirin up to
six times per day and sublingual nitroglycerin and dyspnea on
exertion which would occur after walking a few blocks. At
7:00 p.m. the night prior to admission, she developed
substernal chest pain which did not radiate along with
dyspnea on exertion but no nausea, vomiting, or diaphoresis.
She went to sleep after the pain resolved until 11:00 p.m.
At 5:00 a.m., the chest pain recurred and she was taken to an
outside hospital. At the outside hospital, she was found to
have ST elevations in leads II, III, and aVF, and ST
depressions in I, aVL and V1 and V2. She received heparin,
aspirin, beta blocker, and Aggrastat and was transferred to
[**Hospital1 18**] for further care.
On the floor, on arrival, she had one episode of nausea and
vomiting and 1/10 chest pain without EKG changes. The chest
pain resolved with 3 mcg nitroglycerin drip.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post stenting of the
diagonal in [**2114**], distal RCA also in [**2114**].
2. GERD, known since [**9-26**].
3. Shingles.
4. Measles.
5. [**Doctor First Name 533**] measles.
6. Chicken pox.
7. History of endometriosis.
8. Tonsillectomy.
9. History of a left arm fracture and right arm fracture.
10. History of bilateral patellar bursitis.
11. Hypertension times five years.
12. Hypercholesterolemia.
13. Laryngotomy.
14. Question of asthma.
MEDICATIONS AT HOME:
1. Aspirin 325 q.d.
2. Senokot 1.5 q.h.s.
3. Nitroglycerin p.r.n.
4. Toprol XL 100 q.d.
5. Ativan p.r.n.
ALLERGIES: The patient has an allergy to penicillin,
tetracycline, Rhinocort, and iodine.
FAMILY HISTORY: Significant for coronary artery disease in
both parents and also diabetes.
SOCIAL HISTORY: No tobacco. No drugs. Positive alcohol
use, one to two drinks per day. Works as an attorney.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient
appears fatigued, otherwise in no apparent distress. Vital
signs: Heart rate 68, blood pressure 111/65, respiratory
rate 17, 98% on 2 liters. HEENT: PERRL. EOMI. The
oropharynx was clear and moist. Neck: No carotid bruits,
JVP to 8 cm. Chest: Bilateral expiratory upper airway
sounds. No rales. Heart: Regular S1, S2. Abdomen: Soft,
nontender, nondistended. Bowel sounds positive.
Extremities: No lower extremity edema, 2+ right dorsalis
pedis pulse, 1+ left dorsalis pedis pulse.
LABORATORY DATA ON ADMISSION: White blood cell count 8.1,
hematocrit 35.3, platelets 240,000. INR 1.1, Na 138, K 3.4,
Cl 206, C02 21, BUN 14, creatinine 0.5, glucose 148, AST 91,
total bilirubin 0.6, alkaline phosphatase 67, CK 993, MB 178,
calcium 7.8, magnesium 1.7, phosphorus 3.4.
The patient underwent cardiac catheterization on arrival with
results of a total occlusion of the OM1 which appeared
chronic and collateralized and total occlusion of the distal
RCA. She had successful primary angioplasty with stenting of
the RCA. The OM1 treatment was deferred to a future date.
HOSPITAL COURSE: 1. CARDIAC: The patient did well after
cardiac catheterization with no recurrent chest pain.
Cardiac enzymes trended down and she tolerated her
medications well. There was no significant arrhythmias post
MI. She was kept on telemetry throughout hospitalization.
She did have some post catheterization nausea which was
treated successfully with Zofran. She has follow-up arranged
with her cardiologist, Dr. [**Last Name (STitle) **] within 10-14 days. She was
explained the importance of exercise and reporting any
worrisome symptoms.
Over the course of admission, her Lopressor was kept at 12.5
mg b.i.d. but lisinopril was increased to 5 mg q.d. as her
blood pressure tolerated. These can be titrated up further
as an outpatient. She will also need a repeat echocardiogram
in the future to assess the residual loss of cardiac function
from this inferior myocardial infarction.
2. PULMONARY: The patient had no pulmonary issues during
the hospitalization and no evidence of pulmonary edema or
reactive airway disease.
3. RENAL: The patient's renal function was stable post
catheterization with a creatinine remaining approximately
0.06.
4. HEMATOLOGY: The patient's hematocrit was stable as were
platelets on heparin.
5. GASTROINTESTINAL: The patient was continued on Protonix
for GERD.
DISPOSITION: The patient was discharged to home in good
condition.
FOLLOW-UP: She is to have follow-up with her cardiologist,
Dr. [**Last Name (STitle) **], and her primary care physician.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg q.d. for 30 days.
3. Lipitor 10 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
5. Lopressor 0.5 mg b.i.d.
6. Lisinopril 5 mg p.o. q.d.
DISCHARGE DIAGNOSIS:
1. Acute myocardial infarction secondary to total occlusion
of the distal right coronary artery.
2. Chronic coronary artery disease.
3. Gastroesophageal reflux disease.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2120-4-22**] 08:16
T: [**2120-4-27**] 10:41
JOB#: [**Job Number 19234**]
|
[
"458.2",
"410.31",
"414.01",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.01",
"88.56",
"36.07",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
2211, 2287
|
5088, 5268
|
5289, 5741
|
3563, 5065
|
1991, 2194
|
146, 1462
|
2988, 3545
|
1484, 1970
|
2304, 2422
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,208
| 139,248
|
9415
|
Discharge summary
|
report
|
Admission Date: [**2140-1-11**] Discharge Date: [**2140-1-15**]
Service: MEDICINE
Allergies:
Celebrex
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
[**First Name3 (LF) **] of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo F with hx of CAD s/p PCI in [**2138**], CVA x2, diastolic
dysfunction with mod-severe AS (mean gradient 35 mm Hg [**10-10**]),
and PAF presents from rehab in acute respiratory distress now
intubated for hypoxic resp failure. Pt seen this AM urgently
for c/o acute SOB - RR 40's, O2sat 80's on 4-6L NC (HR 120, BP
170/100) with diffuse rhonchi/exp wheeze. EMS unable to obtain
IV access with cont tachypnea in 36, 86% 10L NC -> 92% on 100%
NRB. In [**Name (NI) **], pt intubated emergently for hypoxic respiratory
failure. Pt received IV lasix 80 mg, propofol started
hypotensed to SBP 80's. Received 250 cc IVF bolus and started
on dopamine, titrated to 20 mcg/kg/min with SBP in 90's.
Initial CVP 6 subsequently received additional 1 L NS. Initial
CXR c/w CHF. Per family report, with exception of chronic LBP
with LLE sciatica, pt has no new issues including complaint of
CP, SOB, abd pain, papitation. Pt recently admitted to [**Hospital1 18**]
[**Date range (1) 32136**] s/p fall with L ankle fracture and delirium. At that
time, she underwent cardiac evaluation including TTE, ROMI, and
PMIBI without evidence of perfusion defect, ischemia, or new
wall motion abnormalities. Howerever, newly noted mod-severe AS
(tricuspid sclerotic) with mean gradient of 35 mm Hg.
Past Medical History:
1) CVA [**2135**], [**2138**]- right frontal (with right visual field loss)
2) Hypertension
3) Hypercholesterolemia
4) DJD/spinal stenosis,
5) Mitral regurg 1+, mild Mitral stenosis [**10-10**]
6) Depression
7) s/p TKR
8) Hx of retroperitoneal bleed
9) Tonic-clonic seizure: likely in setting of CVA
[**45**]) CAD s/p PTCA stent [**2138**]. negative mibi in [**10-10**]
11) +PPD
12) CHF: EF 55%
13) A-fib
14) Ankle Fracture; bimalleolar, left ankle
15) [**2-6**]+ TR [**10-10**]
16) Severe AS [**10-10**]
17) s/p Appendectomy
18) MRSA bacteremia: [**10-9**]
19) Brain aneuryms
20) ?bilateral adrenal masses seen on CT. needs outpatient MRI
Social History:
Living at [**Hospital 100**] Rehab for the last 15 weeks. No EtOH or
tobacco. Has aide that helps with bathing, dressing. Son handles
finances. She has 3 sons. [**Name (NI) **] [**Name (NI) **] is the HCP.
Family History:
NC
Physical Exam:
Exam: VS: T 96.3 BP 97/54 HR 89 WT 79.9 kg, CVP 6->14.
GEN: Inutbated
HEENT: NC/AT, pin-point pupil bilaterally, +intubated, neck
supple
COR: Initially irregular/later regular rhythm, S1, S2, crescendo
III/VI systolic murmur at R2nd ICS, LSB.
PULM: +coarse breath sounds bilaterally
ABD: [**Month (only) **] BS, soft, NTND, no-guarding
EXT: +left leg brace, no edema.
NEURO: Pt sedated and intubated. No asymmetric posturing.
Pertinent Results:
EKG: 8:28 am A-fib 101 BPM LBBBm L axis.
8:39 sinus LBBB, 3 mm discordant STE V2-V3, no changes.
ECHO:
Left Atrium - Long Axis Dimension: *5.9 cm (nl <= 4.0 cm)
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: *3.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 43 mm Hg
Aortic Valve - Mean Gradient: 25 mm Hg
Mitral Valve - Peak Velocity: 1.5 m/sec
Mitral Valve - Mean Gradient: 5 mm Hg
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.5 m/sec
Mitral Valve - E/A Ratio: 0.87
Mitral Valve - E Wave Deceleration Time: 270 msec
TR Gradient (+ RA = PASP): *38 mm Hg (nl <= 25 mm Hg)
Brief Hospital Course:
80 yo F with hx of CAD s/p PCI [**2138**], diastolic dysfunction with
mod-severe AS, PAF, presented with hypoxic respiratory failure.
Most likely flash pulmonary edema with etiology: rapid afib ->
flash vs. medical noncompliance -> CHF-> rapid a-fib. Unlikely
acute ischemia since CE's were negative on admission. However,
the echo during this admission showed worsening EF and recent
changes in wall motion with hypokiesis suggesting recent
ischemic event. Pt had a recent admission with similar
presentation with CHF w/ rapid a-fib. CHF was managed with IV
lasix with goal CVP of <10. On [**1-12**], pt went into rapid a-fib
on two occasion (11am, 6pm) with hypotension requiring DC
cardioversion & IV amiodarone bolus plus continuous drip. Rapid
a-fib most likely in a setting of overdiuresis as the CVP was
low after diuresis with IV lasix. A-fib may be the trigger of
her frequent flash pulmonary edema as she has an outflow
obstruction and requires adequate atrial contraction during
diastole. She remained Dopamine dependent mostly since she had
to be heavily sedated for agitation. On [**1-13**] pt was briefly
extubated and off Dopamine, but had to be re-intubated after
being severely agitated and desaturation. While she was
extubated, she was extremely disoriented, agitated, minimally
responsive to Haldol. She has underlying pain issue from spinal
stenosis which precipitated the dramatic changes in her BP while
she was awake. Once re-intubated and pt became hypotensive and
Dopamine was re-started. Then, pt went into another rapid a-fib
with hypotension requiring 200 J x1. After long family meeting,
family decided to make her DNR but continue the current
management until her son from [**Name2 (NI) **] arrived. When all of her sons
were at the scene, family decdied to make her CMO. All of the
medications were removed except for fentanyl and versed drip,
and she was breathing on PS 5/0. Pt expired on [**2140-1-15**] 5:01
am.
Medications on Admission:
Amiodarone 200 mg po qd, Fentanyl TD 25 mg q72, Isosorbide MN 30
mg po qd, metoprolol 50 mg po bid, simvastatin 40 mg po qd,
lasix 40 mg po qd, synthroid 125 mcg po qd, risperdal 75 mg po
qd, sertraline 100 mg po qd, colace 100 mg po bid, CaCO3 650 mg
po tid, lidoderm TD q12, vit D 800 u qd, prevacid, desipramine
50 mg po qhs, tylenol 650 mg po q6, heparin sq.
Discharge Disposition:
Expired
Discharge Diagnosis:
Congestive heart failure
Atrial fibrillation
Coronary Artery Disease
Spinal stenosis
Hypothyroid
Discharge Condition:
Pt expired
Completed by:[**2140-1-15**]
|
[
"V09.0",
"414.01",
"785.51",
"427.31",
"402.91",
"041.11",
"518.0",
"599.0",
"518.81",
"041.3",
"428.0",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.62",
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6030, 6039
|
3655, 5617
|
250, 256
|
6179, 6220
|
2946, 3632
|
2480, 2484
|
6060, 6158
|
5643, 6007
|
2499, 2927
|
177, 212
|
284, 1573
|
1595, 2238
|
2254, 2464
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,708
| 102,505
|
37510
|
Discharge summary
|
report
|
Admission Date: [**2131-1-26**] Discharge Date: [**2131-2-5**]
Date of Birth: [**2056-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine / Sulfa (Sulfonamide Antibiotics) / Parnate
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dyspnea and hiatel hernia
Major Surgical or Invasive Procedure:
[**2131-1-26**] Laparoscopic hiatal hernia repair with fundoplication
History of Present Illness:
74 year old woman with interstitial lung disease and severe
respiratory impairment. She underwent a bronchoscopy and review
of her thoracic imaging by Dr. [**Last Name (STitle) **]. Based on the CT images,
there was evidence of ongoing inflammation and therefore she was
treated empirically for
non-specific interstitial pneumonitis (NSIP) as there was no
readily identifiable inciting [**Doctor Last Name 360**] for hypersensitivity
pneumonitis. It was thought that the trigger for the NSIP is the
aspiration and as such, she was evaluated for repair of her
sizable hiatal hernia. She recently completed a Prednisone taper
course prior to the surgery and presented this time for an
elective laparoscopic hiatal hernia repair repair and nissen
fundoplication.
Past Medical History:
- COPD
- CHF
- Pulmonary fibrosis diagnosed CT [**2126**]
- Osteoporosis with compression fractures
- Hypercholesterolemia
- Hypertension
- GERD
- Anxiety/Depression
- Insomnia
- Post-surgical hypothyroidism
- Melanoma removed from back, left axillary lymph node
dissection [**2107**].
- Right knee and hip replacement.
Social History:
Widowed. Has one child. Worked as a quality inspector for
[**Company 2892**],
retired [**2116**]. Denies ETOH. Quit smoking in [**2119**] and was a
45ppy
smoker. Does not have any pets. No birds in house. No recent
travels. No molds in house. Currently lives in [**Hospital3 **]
facility.
Family History:
Mother deceased from complications related to RA. Father
deceased age 52 from MI. Brother has CAD. Sister deceased from
traumatic fall.
Physical Exam:
VS: Temp 98.4, HR 92SR, BP 119/49, RR 18, pulse oximetry 94% on
3LNC
Physical Exam:
Gen: pleasant in NAD
Resp: slight rales t/o
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: no pressure sores, trace BLE edema
Pertinent Results:
[**2131-1-27**] Barium swallow study:
IMPRESSION: No evidence of leak. Contrast passes through the
duodenum and
into the small bowel.
[**2131-2-2**] US BLE duplex: neg DVT
[**2131-1-30**] CTA C/A/P:
IMPRESSION:
1. Known pulmonary fibrosis, roughly stable in appearance since
recent
examination from [**2130-11-24**]. New interval development of
bilateral, left
greater than right, superimposed parenchymal consolidation
concerning for
pneumonia.
2. No evidence of pulmonary embolism to the subsegmental levels,
though
evaluation of the lower lobes is limited by respiratory motion.
3. Dynamic abnormal concave bowing of trachea that is suggestive
of
tracheomalacia and dedicated imaging examination can be
performed as
indicated.
4. Prominent mediastinal lymph nodes, with some enlarged since a
recent exam from [**2130-11-24**], likely reactive in nature, though
given history of known melanoma, metastasis cannot be entirely
excluded, and attention could be paid on followup imaging as
indicated.
5. No abnormal fluid collections within the abdomen that would
be concerning for abscess formation.
6. Incompletely characterized 1.6 cm liver lesion in segment
III, recommend correlation with prior imaging or if not
available, ultrasound can be considered for further evaluation.
[**2131-2-4**] 05:00AM BLOOD WBC-6.3 RBC-3.59* Hgb-10.1* Hct-31.7*
MCV-88 MCH-28.1 MCHC-31.8 RDW-15.6* Plt Ct-307
[**2131-2-3**] 02:37AM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-138
K-3.5 Cl-102 HCO3-28 AnGap-12
[**2131-2-1**] 03:07AM BLOOD ALT-28 AST-34 AlkPhos-105 TotBili-0.4
[**2131-2-3**] 02:37AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0
[**2131-2-3**] 02:47AM BLOOD Type-ART pO2-82* pCO2-43 pH-7.46*
calTCO2-32* Base XS-5
[**2131-1-29**] 9:07 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2131-2-1**]**
GRAM STAIN (Final [**2131-1-29**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2131-2-1**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2427**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Ms. [**Known lastname 84254**] was taken to the operating room by Dr. [**First Name (STitle) **] on [**2131-1-26**]
for her paraesophageal hernia with laparoscopic Nissen. She
recovered in usual fashion. A barium swallow study was done on
[**2131-1-27**] which did not show any leak. She had some coughing on
[**2131-1-27**], at which time she was resumed on home meds, and given
aggressive pulmonary toilet. Pulmonology evaluated her and did
not feel she warranted bronchoscopy at that time. The patient
remained on her home oxygen. She was evaluated by PT/OT on
[**2131-1-29**] who determined she would best benefit from pulmonary
rehab. Her cough worsened and chest xray revealed CHF. She was
diuresed well, however on [**2131-1-30**] developed 102 fever, was
pancultured and started on vancomycin and zosyn. She required
transfer to the ICU for sepsis on [**2131-1-31**]. She required low dose
neosynephrine. She was found to have MRSA pneumonia which
resolved on IV vancomycin. Her last vancomycin trough level was
18 on [**2131-2-2**]. ID consulted and recommended PICC line with IV
vancomycin to continue until [**2131-2-14**] with CBC, Chem panel and
vanco trough [**2131-2-6**]. The patient was transfered to the floor on
[**2131-2-4**]. She has been medically stable without fevers or
hypotension on the floor and is stable for pulmonary rehab. It
is noted we do not have a recent echo documenting LV function,
and the patient did not come in with beta blockers or ace
inhibitors. She should have close outpatient follow up with her
primary care physician regarding initiation of these meds if
tolerated.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider; Pt
reports taking.) - 40 mg Tablet - 1 (One) Tablet(s) by mouth
once
a day.
CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider; Pt
reports taking.) - 1 mg Tablet - 1 (One) Tablet(s) by mouth
three
times a day.
DULOXETINE [CYMBALTA] - (Prescribed by Other Provider; Pt
reports taking.) - 30 mg Capsule, Delayed Release(E.C.) - 3
(Three) Capsule(s) by mouth Once a day.
FUROSEMIDE [LASIX] - (Prescribed by Other Provider; Pt reports
taking.) - 40 mg Tablet - 1 (One) Tablet(s) by mouth Once a day.
LEVOTHYROXINE - (Prescribed by Other Provider; Pt reports
taking.) - 75 mcg Tablet - 1 (One) Tablet(s) by mouth Once a
day.
OMEPRAZOLE - (Prescribed by Other Provider; Pt reports taking.)
- 40 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by
mouth Once a day.
ONDANSETRON HCL [ZOFRAN] - (Prescribed by Other Provider; Pt
reports taking.) - Dosage uncertain
ZOLPIDEM [AMBIEN CR] - (Prescribed by Other Provider; Pt
reports
taking.) - 12.5 mg Tablet, Multiphasic Release - 1 (One)
Tablet(s) by mouth At bedtime.
Medications - OTC
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider; Pt reports taking.,) - Dosage uncertain
POTASSIUM - (Prescribed by Other Provider; Pt reports taking.)
-
Dosage uncertain
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL
Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain .
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
15. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
once a day: end [**2131-2-14**].
17. 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.
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
21. Doxepin 25 mg Capsule Sig: Eight (8) Capsule PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
[**2131-1-26**]
1. Laparoscopic repair of giant paraesophageal hernia.
2. Laparoscopic Nissen fundoplication.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills or shakes
-Increased shortness of breath, cough, chest pains
-Difficulty or painful swallowing.
-Diarrhea or vomiting
-redness, drainage or swelling near lap sites
Followup Instructions:
Follow up with [**Last Name (NamePattern4) 4113**]; call for directions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2131-2-21**] 2:00 [**Hospital1 18**] [**Hospital Ward Name **] [**Hospital1 **] 116 CDC
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2131-2-21**] 1:00 [**Hospital1 18**] [**Hospital Ward Name **] [**Hospital1 **] 116 CDC
Completed by:[**2131-2-5**]
|
[
"244.0",
"V13.51",
"311",
"553.3",
"272.0",
"300.00",
"516.3",
"V43.64",
"530.81",
"401.9",
"428.0",
"V43.65",
"482.42",
"V10.82",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"44.67",
"53.83",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10481, 10528
|
5370, 6986
|
349, 421
|
10682, 10682
|
2291, 5347
|
11155, 11693
|
1898, 2039
|
8335, 10458
|
10549, 10661
|
7012, 8312
|
10859, 11132
|
2138, 2272
|
284, 311
|
449, 1210
|
10696, 10835
|
1232, 1566
|
1582, 1882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,308
| 166,770
|
5540
|
Discharge summary
|
report
|
Admission Date: [**2186-3-8**] Discharge Date: [**2186-3-15**]
Date of Birth: [**2110-7-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
75 year old man with mild dementia, CAD, s/p CABG (LIMA to LAD,
SVG to OM1/OM2, SVG to PDA), and prior stent to OM2 graft, PVD,
s/p fem [**Doctor Last Name **] in [**2174**], HTN, Aortic stenosis, CRI (cr 1.9), DM
admitted on [**2186-3-4**] to [**Hospital3 **] with chest pain that was
not relieved with nitro. Per patient, he has chest pain although
not reliably with exertion that is usually relieved with one
nitro. On Friday night he had his usual chest pain but it was
not relieved with nitro. This pain was associated with SOB. It
did not radiate but felt like pressure.
He called the EMTs who told him to take an aspirin and brought
him to [**Hospital3 **]. He was given lasix, labetolol, and nitro
sl for SBP>200. BP came down to 150. The first troponin was
indeterminate (0.16) in the setting of CRI. EKG showed NSR with
rate 75bpm, 1st degree AVB with IVCD and 1mm ST depression in
lateral aspect with no change from prior EKGs. On admission he
also had SOB and CXR that was reportedly consistenet with CHF as
well as mildly elevated BNP (627). He was given 40mg IV lasix
and was admitted for ROMI and CHF exacerbation.
The next day the patient underwent a nuclear stress test that
showed diffuse ST depressions II, III, aVF, V4-V6. His troponins
then rose with peak troponin of 4.77 and CKMB 16.8. Patient was
started on heparin. He was not treated with plavix because of
concern for three vessel disease and potential cardiac surgery.
Trops then dropped back down to 2.99. The patient never reported
CP while hospitalized.
Last cath ([**2181**] at [**Hospital1 2177**]) showed patent grafts and 60% stenosis
in SVG to OM2 which was not intervened upon. In [**2180**] patient had
cath at [**Hospital1 18**] and had stent placed in SVG to OM2 graft.
He was evaluated with MR of the spine at the OSH for h/o severe
spinal stenosis and right-sided radiculopathy. There was
consideration for epidural injection, however, because of the
cardiac issues this was deferred.
It was decided to transfer patient to [**Hospital1 18**] for cardiac cath
and potential intervention on the OM2 lesion.
VS prior to transfer: 144/68, 59 SB, 20, 97.6, 95% on room
air.
Patient was transferred directly to the cath lab at [**Hospital1 18**].
There he underwent cardiac cath with attempted intervention on
OM2 lesion at end of previously placed stent, however, they were
unable to pass the wire and no intervention was done. The
patient's procedure was complicated by a groin hematoma.
Pressure was held for 1.5 hours. Patient remained
hemodynamically stable throughout.
Past Medical History:
Cardiac Risk Factors: Diabetes(+), Dyslipidemia(+),
Hypertension(+)
Cardiac History: CABG, in [**2175-2-2**] anatomy as follows:
LIMA-LAD, SVG-OM1, SVG-OM2, SVG-rPDA
Percutaneous coronary intervention ([**2180**]):
1. Selective coronary angiography demonstrated a right dominant
system with severe three vessel disease. The left main was
without stenoses. The LAD had a 100% mid vessel occlusion with
diffuse disease. The left circumflex had 100% proximal
occlusion. The RCA was 100% occluded in the mid-vessel.
2. Selective graft angiography demonstrated a patent SVG-OM1
and
SVG-rPDA. The SVG to OM2 had a 90% stenosis at the distal
anastamosis. The LIMA-LAD could not be selectively engaged
because of subclavian tortuosity. Nonselective injections
demonstrated a patent graft.
3. Left ventriculography was not performed.
4. Stenting of the OM2 was performed via the SVG with a 2.5 x
13 mm
Cypher.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG-OM1, SVG-rPDA, and LIMA-LAD.
3. SVG-OM2 with 90% stenosis in the distal anastamosis.
4. Stenting of the OM2. (reportedly), in [**2181**] anatomy as
follows: patent grafts, 60% distal stenosis in the SVG to Om2-
medical, mangement continued.
PCI [**2181**] at [**Hospital1 2177**]:
LAD 100% occluded proximally
LCX 100% occluded proximally
RCA 100% occluded mid
LMCA 70% diffuse stenosis
Grafts:
- LIMA to LAD patent
- SVG to OM1: patent with diffuse disease
- SVG to OM2: Patent with 60% distal stenosis
- SVG to PDA: Patent
Pacemaker/ICD: NONE
Other Past History:
Severe spinal stenosis with right leg radiculopathy
BPH
anxiety
depression
prior left hip fracture
right knee replacement
appy
DJD
mild dementia
CAD s/p CABG (LIMA to LAD, SVG to OM1/OM2, SVG to PDA), prior
DES to OM2 graft in [**2180**] (at [**Hospital1 18**])
PVD s/p fem [**Doctor Last Name **] in [**2174**]
HTN
Aortic stenosis
CRI (cr 2.2 at baseline)
DM
Social History:
He is retired and engaged. His fiance comes over all day but he
lives alone. Social history is significant for the 1ppd X
30years. Pt quit smoking in [**2146**]. There is history of alcohol
abuse but he quit drinking 35years ago.
Family History:
Patient has son with [**Name (NI) 11398**].
Physical Exam:
VS - T 97.3 HR 61bpm BP 168/67 RR 20 O2sat 96% RA
Gen: Elderly male in NAD lying flat
HEENT: NCAT. Sclera anicteric.
Neck: Supple with JVP to angle of jaw while lying flat.
CV: RR, normal S1, S2. [**2-17**] SM RUSB->axilla and carotids
Chest: CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Hematoma in right groin,
non-pulsatile, dressing C/D/I
Ext: No edema.
Neuro: Alert. Oriented X [**12-16**]. Confused at times (which is
baseline)
.
Pulses:
Right: Carotid 2+ Femoral doppler DP doppler PT doppler
Left: Carotid 2+ Femoral doppler DP doppler PT doppler
Pertinent Results:
Labs on admission:
.
[**2186-3-8**] 10:05PM POTASSIUM-4.5
[**2186-3-8**] 10:05PM CK(CPK)-116
[**2186-3-8**] 10:05PM CK-MB-4
[**2186-3-8**] 10:05PM HCT-31.2*
[**2186-3-8**] 10:05PM PLT COUNT-243
.
.
Cardiac Cath:
.
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed severe left main plus three vessel native coronary
artery
disease. The LMCA had a 90% stenosis. The LAD and LCX were
occluded
proximally, and the RCA occluded distally.
2. Selective venous conduit angiography revealed a patent
saphenous
vein grafts to OM1, OM2 and PDA. The SVG-OM1 had a occlusion in
the
native OM1 distal to a previously placed stent. The SVG-OM2 had
a 50%
stenosis in the proximal portion of the graft.
3. Nonselective angiography of the LIMA demonstrated a tubular
50-60%
stenosis in the mid LAD.
4. Unsuccessful PTCA attempt of the totally occluded OM vessel
(See
PTCA comments).
5. Failed attempt to close the right femoral arteriotomy site
with a
Perclose closure device - manual compression applied.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease with patent LIMA
and SVG
grafts.
2. Unsuccessful PTCA attempt of the occluded OM branch.
3. Unsuccessful closure attempt of the right femoral arteriotomy
site
with a Perclose closure device.
.
[**3-9**] Echo:
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal to mid inferior and inferolateral segments. 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. The ascending aorta is mildly dilated. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
IMPRESSION: Mild focal LV systolic dysfunction. Mild calcific
aortic valve stenosis. Mild mitral regurgitation. Dilated
thoracic aorta.
.
Compared with the report of the prior study (images unavailable
for review) of [**2181-2-2**], lateral wall hypokinesis is not seen
on the current study. Aortic stenosis is seen on the current
study.
.
[**3-9**] Groin hematoma:IMPRESSION: Large 5.1 x 3.5 x 4.2 cm
hematoma in the right groin with a small 1.7 x 0.8 x 2.4 cm
pseudoaneurysm demonstrating to- and- fro to the common femoral
aneurysm.
.
[**3-10**] CT head: No acute intracranial process. Moderate
age-appropriate diffuse cerebral atrophy.
.
[**3-14**] CXR-
.
Left-sided dual-chamber pacemaker ends in expected position.
Sternotomy wires
are intact. The aorta is tortuous and calcified. Lungs are
clear. There is
no pneumothorax and no pleural effusion. Hilar contours are
normal. Heart
size is top normal.
.
[**3-14**]:
R Groin U/S preliminary:
.
Interval thrombosis of the small, remaining patent section of a
prior
pseudoaneurysm. No residual flow. Persistent hematoma in the
right groin,
slightly smaller than previously.
.
Brief Hospital Course:
75 M with CAD s/p CABG (LIMA-LAD, SVG-OM1, SVG-OM2, SVG-PDA) and
DES to OM2 in [**2180**] admitted for NSTEMI and had subsequent
unsucessful PCI on the native OM2. Course marked by symtomatic
bradycardia and chest pain with hypertension.
.
#. CAD: Cath showed stenosis at end of stent in OM2 that was
unable to be intervened upon. Patient was initially loaded with
plavix in the cath lab. Plavix was then continued on the floor.
Patient was continued on asa, statin and imdur. Patient
continued to have episodes of chest pain associated with
elevated BPs and lateral ST depressions on EKG. This would
resolve with BP control and the EKG changes would come down to
baseline, his last episode of chest pain was on [**2186-3-11**]. His ACE
inhibitor was changed to long-acting and his beta blocker was
increased for better HR control to maximize his anti-anginal
regimen. Patient was also started on Ranolazine 500mg [**Hospital1 **],
continued on Plavix from OSH. However, with increase of beta
blocker, the patient had onset of bradycardia with some pauses
as long as 6 seconds so the beta blocker had to be discontinued.
He was transferred to the CCU for better monitoring given the
long pauses and chest pain associated with HTN. In the CCU
patient was monitored prior to receiving pacemaker on [**3-13**].
Carvedilol was added to his regimen on [**2186-3-14**]. Patient did not
have chest pain after [**3-11**], he reported no dyspnea on exertion.
His HR was in 60-70s at time of discharge and his Carvedilol was
increased to 6.25mg [**Hospital1 **]
.
#. Sick sinus syndrome: Patient was hypertensive necessitating
increase of his beta blocker. This resulted in bradycardia with
pauses on telemetry up to 6 seconds. A dual chamber pacemaker,
[**Company **], placed on [**2186-3-13**]. Patient was started on Carvedilol
as above. He will require follow up with device clinic and Dr.
[**Last Name (STitle) **].
.
#. CHF, chronic. Acute on chronic, likely systolic. LVEF 55%
reportedly on TTE at OSH but did have symptoms of CHF requiring
diuresis. Repeat ECHO on [**3-9**] showed 55-60% EF, mild regional
left systolic disfunction with hypokinesis of the bassal or mid
inferior inferolateral segments. After [**3-9**] he remained
euvolemic on exam and did not require further diuresis or
oxygen. His ACE inhibitor was changed to long-acting, his beta
blocker was changed as above, and he was continued on his imdur
at increased dose, statin, and a high-dose aspirin.
.
# Aortic stenosis. Patient had moderate-severe AS (valve area
0.9cm on prior TTE) which was not evaluated during
catheterization. It was thought that his chest pain may in part
be causing angina and SOB. Repeat TTE on [**3-9**] showed a moderate
AS (*1.3 cm2) so it was thought more likely that the chest pain
was from his CAD not the AS.
.
#. CRI: Patient with baseline creatinine 1.8-2.0, Stage II.
Initially his HCTZ was held given dye load at cath and concern
for contrast-induced nephropathy, however, creatinine remained
stable at 1.7. As patient was euvolemic and other BP medications
were titrated up it was decided not to re-start the HCTZ.
.
# HTN. Was fluctuating throughout hostpital stay with elevations
thought to lead to chest pain/demand ischemia. Patient was
uptightrated on antihypertensives and was discharged on
Carvedilol 6.25 [**Hospital1 **], Lisinopril 40mg QHS, Nifedipine 90mg CR QD.
With this regimen SBPs ranged 120s - 150 mmHg. He will reqiure
further follow up and uptightration of medication for goal BP of
< 130/80.
.
# Spinal Stenosis: Patient was evaluated at OSH for possibility
of epidural block.
managed with percocet and neurontin as he had been getting at
home and OSH while he was here. Pain was well controlled with
Acetaminophen 650 mg QID standing.
.
#. DM2: PO medications were discontinued while inpatient. He
was continued ISS and lantus as he had been getting at OSH. He
required uptightration of Lantus to 17 U QHS with resultant AM
BG of 169. He will require further uptightration of this scale
return to his oral regimen. Patient was continued on Neurontin
at home doses.
.
# Dementia. Appeared to be at baseline per OMR. He was alert
and oriented x3, his attention and immediate recall were intact.
Due to ? psychomotor slowing he underwent a CT head which was
consistent w/ dementia. Patient has had a hx of frequent falls,
however states that had none in the past month. He will require
rehabilitation management. He was continued on Aricept. He will
require outpatient follow up.
.
# Depression/anxiety: Appeared euthymic throughtout admission.
Patient was continued on Lexapro.
.
He was discharged in a hemodynamically stable condition, free of
chest pain. He will require optimization of antihypertensive
regimen, blood glucose control and follow up of his pain
control. He will require cardiology, electrophysiology, device
clinic and PCP follow up.
Medications on Admission:
OUTPATIENT MEDICATIONS:
Actos 15mg QD
Aricept 10mg QD
ASA 81mg QD
Avandia 2mg QD
Captopril 50mg TID
Flomax 0.4mg QD
Glucatrol XL 20mg QD
HCTZ 25mg QD
Labetolol 200mg [**Hospital1 **]
Lexapro 10mg QD
Lotrisone Cream [**Hospital1 **]
NTG PRN
Protonix 40mg QD
Trazodone Q6H
Xanax 1mg [**Hospital1 **] PRN
Zocor 80mg QD
MEDICATIONS ON TRANSFER:
Atropine 0.8mg IV PRN hypotension
Colace 100mg [**Hospital1 **]
MOM PRN HS
Maalox 30mL Q4-6H PRN
Tylenol Q4-6H
Nitrostat 0.4mg SL
Lantus 10units QHS
Neurontin 600mg QHS
Aspirin 81mg QD
glipizide 20mg QD
flomax 0.4mg QD
lexapro 10mg QD
Protonix 40mg QD
HCTZ 25mg QD
aricept 10mg QD
captopril 50mg TID
labetolol 200mg [**Hospital1 **]
xanax mg QHS
imdur 120mg daily
SS regular insulin
neurontin 300mg TID
SQ heparin (last given at 12pm)
percocet 1-2 tabs Q3H PRN
NOT ON PLAVIX.
**D5W at 100/hour
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Lotrisone 1-0.05 % Cream Sig: One (1) application Topical
twice a day.
7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
16. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO DAILY (Daily).
17. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
18. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 1 days.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17) U
Subcutaneous at bedtime.
22. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
23. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
24. Insulin Lispro 100 unit/mL Solution Sig: see attached scale
Subcutaneous once a day.
Discharge Disposition:
Extended Care
Facility:
Bostonian - [**Location (un) 86**]
Discharge Diagnosis:
Primary: NSTEMI, Moderate AS, Sick sinus syndrome, Hypertensive
emergency
Secondary: HTN, CAD, DM2, CKD, Depression, Dementia, Spinal
stenosis
Discharge Condition:
The patient was afebrile, hemodynamically stable, and chest pain
free prior to discharge.
Discharge Instructions:
You were admitted to the hospital with chest pain. You had a
cardiac catheterization that showed that you have a blockage.
Unfortunately, nothing could be done about the blockage.
You also have a valve in your heart that is not opening enough.
This could also contribute to your chest pain. Due to inability
to intervene with catheterization, your pain was treated
medically. Your medication regimen was changed significantly
(see below). You should only take the medications as prescribed
below.
Your hospital stay was complicated by significantly decreased
heart rate, which required placement of a pacemaker. You
tolerated this procedure well. Your hospitalization was also
complicated by formation of a pseudoaneurysm, this resolved on
its own.
Medication Changes: multiple medications changes, please see
attached list. You should only take the medications prescribed
to you at this time until you obtain follow up with your PCP or
Cardiologist.
With above treatment treatment, your chest pain improved and
eventially resolved by [**2186-3-11**].
Should you experience further chest pain, shortness of breath,
palpitations, faintness, severe weakness or any other symptom
concerning to you, please call the doctor at your rehabilitation
facility or go to the emergency room.
Followup Instructions:
Appointment #1
MD:Specialty: Device Clinic
Date and time: [**2186-3-21**] at 9am
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 62**]
Appointment #2
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18323**]
Specialty: pcp
Date and time: [**3-23**] at 11am
Location: [**Hospital1 **]
Phone number: [**Telephone/Fax (1) 18325**]
Appointment #3
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]
Specialty: Cardiology
Date and time: [**3-28**] at 3pm
Location: [**Hospital1 **]
Phone number: [**Telephone/Fax (1) 4475**]
Appointment #4
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Cardiac Electrophysiology
Date and Time: [**3-29**] at 3pm
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg [**Location (un) **]
Phone number: [**Telephone/Fax (1) 3342**]
Completed by:[**2186-3-17**]
|
[
"440.4",
"272.4",
"V43.65",
"294.8",
"311",
"715.96",
"997.2",
"300.00",
"414.2",
"V45.81",
"427.81",
"428.23",
"V45.82",
"403.00",
"428.0",
"410.71",
"250.00",
"997.1",
"414.01",
"V58.67",
"440.20",
"724.00",
"585.9",
"424.1",
"E879.0",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"88.56",
"88.57",
"37.22",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
17047, 17108
|
9118, 14020
|
325, 351
|
17296, 17388
|
5830, 5835
|
18726, 19704
|
5158, 5203
|
14907, 17024
|
17129, 17275
|
14046, 14046
|
6884, 8514
|
17412, 18168
|
5218, 5811
|
14070, 14363
|
18188, 18703
|
275, 287
|
380, 2952
|
8523, 9095
|
5849, 6867
|
14388, 14884
|
2974, 3887
|
4910, 5142
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,999
| 126,011
|
53686
|
Discharge summary
|
report
|
Admission Date: [**2179-4-3**] Discharge Date: [**2179-4-19**]
Date of Birth: [**2136-7-18**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
upper endoscopy
central line placement
arterial line placement
intubation
bronchoscopy
History of Present Illness:
This is a 42-year-old male with known alcoholism who presents
from [**Hospital1 **]-N with GI bleed. Per reports patient was taken into
protective custody for section 35 for involuntary detox. While
in the holding chamber, patient was noted to have a seizure and
fell to the ground. He was found to be post-ictal with head
laceration and was taken to [**Hospital1 **]-N for further evaluation of head
injuries. While at [**Hospital1 **]-N patient was found to have projectile
coffee ground emesis. Patient was intubated for airway
protection. Of note patient had a prolonged, traumatic
intubation requiring several attempts. Patient was started on
octreotide and protonix and given 6LNS along with 2 units of
pRBCS and FFPs. He was then sent to [**Hospital1 18**] for further
evaluation.
Per police recrods, patient on [**4-1**] told father that he was
"going to drink himself to death." [**Name (NI) **] father advised
patient to call police however when patient did not, he did
himself. Police then placed patient in protective custody. On
[**4-2**], patient was placed on section 35 for mandatory detox. On
SW note, patient was noted to be very tremulous and patient had
blood on shirt.
In the ED, initial VS were:
-Patient was continued Protonix and octreotide drip
-There is a cuff leak and the ET tube will likely need to be
replaced. Given that this was an extremely difficult intubation,
and that he has ventilating and oxygenating very well it is
safest to be done in the ICU with anesthesia.
-CTX was given for SBP prophylaxis
-ET tube was moved 4 cm
-NG tube hooked to wall suction and put out coffee-grounds
-Liver and GI were consulted
Patient was then admitted to ICU for further management. VS
prior to transfer were HR 100 O2 sat 100% BP 94/52.
.
On arrival to the MICU, patient was sedated and intubated.
Past Medical History:
- "liver disease" with "borderline ascites"
- alcoholism
- Told he had 5 "spots" on lungs
- Recurrent epistaxis x 1 year
- Dysphagia
Social History:
Most details are unknown and except that is an alcoholic. Per
police records, was homeless as of [**2179-3-30**]. Heavy drinking for
the last 7 days. Heavy tobacco use. Recently evicted from
apartment.
Family History:
unknown
Physical Exam:
admission exam
Vitals: afebrile 91/65 96 97% on CMV 100% PEEP 5 500x14
General: intubated and sedated
HEENT: pupils 1-2mm b/l OG in place, putting coffee grounds,
occipital laceration with 4 staples in place
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Back: scattered ecchymoses
Ext: warm, well perfused, 2+ pulses, trace to 1+ edema b/l,
scattered ecchymoses
Neuro: sedated
PHYSICAL EXAMINATION:
VS: 98.2 119/63 93 18 99%RA
GENERAL: Awake, alert, oriented x3
HEENT: Sclera icteric. PERRL, EOMI.
CARDIAC: RRR, S1 S2 no MRG
LUNGS: CTAB anteriorly, no crackles, wheezes or rhonchi.
ABDOMEN: NABS, soft, non-tender to palpation. No HSM or
tenderness.
EXTREMITIES: Warm and well perfused, no clubbing, cyanosis or
edema.
Neuro: alert, oriented x3, no longer dysarthric, not agitated.
Pertinent Results:
[**2179-4-3**] 01:04AM BLOOD WBC-4.4 RBC-3.12* Hgb-11.1* Hct-33.3*
MCV-107* MCH-35.5* MCHC-33.2 RDW-14.8 Plt Ct-33*
[**2179-4-3**] 05:37AM BLOOD WBC-3.9* RBC-2.60* Hgb-9.2* Hct-27.9*
MCV-107* MCH-33.2* MCHC-31.2 RDW-14.8 Plt Ct-82*#
[**2179-4-3**] 12:13PM BLOOD Hct-29.8*
[**2179-4-3**] 05:40PM BLOOD Hct-30.1* Plt Ct-36*#
[**2179-4-3**] 09:29PM BLOOD Hct-31.1* Plt Ct-50*
[**2179-4-4**] 01:04AM BLOOD WBC-4.2 RBC-2.69* Hgb-9.1* Hct-28.3*
MCV-105* MCH-33.9* MCHC-32.2 RDW-14.7 Plt Ct-56*
[**2179-4-4**] 05:15AM BLOOD Hct-29.1* Plt Ct-50*
[**2179-4-4**] 08:42AM BLOOD Hct-28.0* Plt Ct-60*
[**2179-4-4**] 01:25PM BLOOD Hct-25.7* Plt Ct-51*
[**2179-4-4**] 04:56PM BLOOD Hct-26.1*
[**2179-4-4**] 08:34PM BLOOD Hct-24.2* Plt Ct-53*
[**2179-4-5**] 12:20AM BLOOD Hct-27.2* Plt Ct-50*
[**2179-4-5**] 04:16AM BLOOD WBC-3.9* RBC-2.48* Hgb-8.5* Hct-26.5*
MCV-107* MCH-34.3* MCHC-32.2 RDW-15.3 Plt Ct-55*
[**2179-4-5**] 11:40AM BLOOD WBC-4.1 RBC-2.53* Hgb-8.9* Hct-27.0*
MCV-107* MCH-35.3* MCHC-33.1 RDW-15.3 Plt Ct-59*
[**2179-4-5**] 04:31PM BLOOD WBC-3.3* RBC-2.46* Hgb-8.5* Hct-26.4*
MCV-107* MCH-34.6* MCHC-32.3 RDW-15.7* Plt Ct-67*
[**2179-4-6**] 03:20AM BLOOD WBC-3.8* RBC-2.56* Hgb-8.8* Hct-27.4*
MCV-107* MCH-34.4* MCHC-32.1 RDW-15.3 Plt Ct-73*
[**2179-4-6**] 03:35PM BLOOD WBC-2.9* RBC-2.68* Hgb-9.2* Hct-28.9*
MCV-108* MCH-34.3* MCHC-31.8 RDW-15.5 Plt Ct-77*
[**2179-4-7**] 04:00AM BLOOD WBC-3.3* RBC-2.91* Hgb-9.8* Hct-31.2*
MCV-107* MCH-33.6* MCHC-31.3 RDW-15.0 Plt Ct-88*
[**2179-4-8**] 03:55AM BLOOD WBC-4.3 RBC-2.93* Hgb-10.0* Hct-30.8*
MCV-105* MCH-34.1* MCHC-32.5 RDW-14.9 Plt Ct-106*
[**2179-4-9**] 04:13AM BLOOD WBC-4.9 RBC-2.99* Hgb-10.1* Hct-31.8*
MCV-106* MCH-34.0* MCHC-31.9 RDW-15.1 Plt Ct-134*
[**2179-4-10**] 04:43AM BLOOD WBC-5.6 RBC-3.09* Hgb-10.7* Hct-33.4*
MCV-108* MCH-34.5* MCHC-31.9 RDW-15.3 Plt Ct-161
[**2179-4-10**] 12:53PM BLOOD WBC-6.7 RBC-3.18* Hgb-10.9* Hct-34.3*
MCV-108* MCH-34.3* MCHC-31.8 RDW-15.0 Plt Ct-204
[**2179-4-11**] 05:45AM BLOOD WBC-8.0 RBC-3.16* Hgb-10.9* Hct-34.3*
MCV-109* MCH-34.6* MCHC-31.8 RDW-15.4 Plt Ct-217
[**2179-4-12**] 05:55AM BLOOD WBC-8.5 RBC-3.08* Hgb-10.5* Hct-33.4*
MCV-108* MCH-34.0* MCHC-31.4 RDW-15.5 Plt Ct-226
[**2179-4-13**] 05:55AM BLOOD WBC-9.7 RBC-3.06* Hgb-10.4* Hct-33.3*
MCV-109* MCH-34.0* MCHC-31.3 RDW-15.5 Plt Ct-249
[**2179-4-14**] 09:40AM BLOOD WBC-9.8 RBC-3.11* Hgb-10.8* Hct-34.0*
MCV-109* MCH-34.6* MCHC-31.7 RDW-15.4 Plt Ct-251
[**2179-4-15**] 06:00AM BLOOD WBC-9.8 RBC-3.14* Hgb-10.6* Hct-34.5*
MCV-110* MCH-33.9* MCHC-30.8* RDW-15.1 Plt Ct-264
[**2179-4-16**] 06:28AM BLOOD WBC-8.9 RBC-2.79* Hgb-9.4* Hct-29.8*
MCV-107* MCH-33.8* MCHC-31.6 RDW-15.3 Plt Ct-241
[**2179-4-16**] 01:00PM BLOOD WBC-9.5 RBC-3.08* Hgb-10.4* Hct-33.1*
MCV-108* MCH-33.9* MCHC-31.5 RDW-15.5 Plt Ct-246
[**2179-4-17**] 05:45AM BLOOD WBC-7.9 RBC-2.80* Hgb-9.6* Hct-29.8*
MCV-107* MCH-34.4* MCHC-32.2 RDW-15.7* Plt Ct-216
[**2179-4-18**] 05:45AM BLOOD WBC-8.6 RBC-2.68* Hgb-9.3* Hct-28.6*
MCV-107* MCH-34.6* MCHC-32.5 RDW-15.8* Plt Ct-210
[**2179-4-19**] 05:35AM BLOOD WBC-7.8 RBC-2.74* Hgb-9.4* Hct-29.3*
MCV-107* MCH-34.2* MCHC-32.0 RDW-15.8* Plt Ct-206
[**2179-4-3**] 02:12AM BLOOD PT-14.6* PTT-32.6 INR(PT)-1.4*
[**2179-4-3**] 06:38PM BLOOD PT-15.0* INR(PT)-1.4*
[**2179-4-4**] 01:04AM BLOOD PT-16.2* PTT-34.6 INR(PT)-1.5*
[**2179-4-6**] 03:20AM BLOOD PT-15.5* PTT-33.7 INR(PT)-1.5*
[**2179-4-7**] 10:56AM BLOOD PT-16.1* PTT-34.0 INR(PT)-1.5*
[**2179-4-8**] 03:55AM BLOOD PT-17.1* PTT-35.5 INR(PT)-1.6*
[**2179-4-9**] 04:13AM BLOOD PT-17.5* PTT-34.0 INR(PT)-1.6*
[**2179-4-10**] 04:43AM BLOOD PT-16.3* PTT-33.7 INR(PT)-1.5*
[**2179-4-11**] 05:45AM BLOOD PT-16.0* PTT-36.0 INR(PT)-1.5*
[**2179-4-12**] 05:55AM BLOOD PT-15.0* PTT-39.3* INR(PT)-1.4*
[**2179-4-13**] 05:55AM BLOOD PT-15.4* PTT-35.6 INR(PT)-1.4*
[**2179-4-14**] 09:40AM BLOOD PT-15.8* PTT-38.7* INR(PT)-1.5*
[**2179-4-15**] 06:00AM BLOOD PT-15.7* PTT-41.2* INR(PT)-1.5*
[**2179-4-16**] 06:28AM BLOOD PT-15.9* PTT-40.4* INR(PT)-1.5*
[**2179-4-17**] 05:45AM BLOOD PT-16.3* PTT-48.0* INR(PT)-1.5*
[**2179-4-18**] 05:45AM BLOOD PT-16.7* INR(PT)-1.6*
[**2179-4-19**] 05:35AM BLOOD PT-15.5* PTT-37.7* INR(PT)-1.5*
[**2179-4-19**] 05:35AM BLOOD PT-15.5* PTT-37.7* INR(PT)-1.5*
[**2179-4-3**] 02:12AM BLOOD Glucose-104* UreaN-5* Creat-0.6 Na-140
K-3.2* Cl-103 HCO3-30 AnGap-10
[**2179-4-3**] 12:13PM BLOOD Glucose-78 UreaN-8 Creat-0.9 Na-140
K-3.1* Cl-104 HCO3-29 AnGap-10
[**2179-4-3**] 09:29PM BLOOD UreaN-10 Creat-0.8 Na-141 K-3.5 Cl-109*
HCO3-25 AnGap-11
[**2179-4-4**] 01:04AM BLOOD Glucose-79 UreaN-10 Creat-0.8 Na-142
K-4.0 Cl-110* HCO3-24 AnGap-12
[**2179-4-4**] 01:25PM BLOOD Glucose-62* UreaN-13 Creat-0.8 Na-142
K-3.5 Cl-112* HCO3-22 AnGap-12
[**2179-4-5**] 04:16AM BLOOD Glucose-72 UreaN-17 Creat-1.0 Na-138
K-3.7 Cl-108 HCO3-21* AnGap-13
[**2179-4-5**] 04:31PM BLOOD Glucose-96 UreaN-19 Creat-1.1 Na-140
K-3.5 Cl-108 HCO3-23 AnGap-13
[**2179-4-6**] 03:20AM BLOOD Glucose-101* UreaN-20 Creat-1.3* Na-144
K-3.8 Cl-109* HCO3-24 AnGap-15
[**2179-4-6**] 03:35PM BLOOD Glucose-125* UreaN-19 Creat-1.3* Na-145
K-3.6 Cl-110* HCO3-26 AnGap-13
[**2179-4-7**] 04:00AM BLOOD Glucose-135* UreaN-20 Creat-1.2 Na-145
K-3.6 Cl-106 HCO3-27 AnGap-16
[**2179-4-7**] 04:26PM BLOOD Glucose-120* UreaN-20 Creat-1.2 Na-145
K-3.6 Cl-105 HCO3-30 AnGap-14
[**2179-4-8**] 03:55AM BLOOD Glucose-114* UreaN-18 Creat-1.1 Na-145
K-3.2* Cl-102 HCO3-32 AnGap-14
[**2179-4-8**] 02:41PM BLOOD Glucose-123* UreaN-19 Creat-1.2 Na-146*
K-3.4 Cl-104 HCO3-31 AnGap-14
[**2179-4-9**] 04:13AM BLOOD Glucose-121* UreaN-18 Creat-1.1 Na-147*
K-3.6 Cl-106 HCO3-30 AnGap-15
[**2179-4-10**] 04:43AM BLOOD Glucose-112* UreaN-22* Creat-0.9 Na-146*
K-3.9 Cl-108 HCO3-26 AnGap-16
[**2179-4-11**] 05:45AM BLOOD Glucose-106* UreaN-30* Creat-1.3* Na-148*
K-3.7 Cl-108 HCO3-25 AnGap-19
[**2179-4-12**] 05:55AM BLOOD Glucose-100 UreaN-30* Creat-1.3* Na-148*
K-3.6 Cl-110* HCO3-25 AnGap-17
[**2179-4-13**] 05:55AM BLOOD Glucose-96 UreaN-24* Creat-1.1 Na-148*
K-3.4 Cl-110* HCO3-23 AnGap-18
[**2179-4-14**] 09:40AM BLOOD Glucose-143* UreaN-20 Creat-1.1 Na-144
K-3.4 Cl-108 HCO3-26 AnGap-13
[**2179-4-15**] 06:00AM BLOOD Glucose-104* UreaN-24* Creat-1.2 Na-145
K-3.9 Cl-108 HCO3-24 AnGap-17
[**2179-4-16**] 06:28AM BLOOD Glucose-101* UreaN-26* Creat-1.1 Na-140
K-3.6 Cl-105 HCO3-21* AnGap-18
[**2179-4-17**] 05:45AM BLOOD Glucose-101* UreaN-21* Creat-0.9 Na-137
K-3.6 Cl-104 HCO3-21* AnGap-16
[**2179-4-18**] 05:45AM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-137
K-3.7 Cl-104 HCO3-20* AnGap-17
[**2179-4-19**] 05:35AM BLOOD Glucose-96 UreaN-16 Creat-0.9 Na-133
K-3.7 Cl-102 HCO3-20* AnGap-15
[**2179-4-3**] 02:12AM BLOOD ALT-31 AST-191* AlkPhos-128 TotBili-4.2*
[**2179-4-3**] 06:38PM BLOOD LD(LDH)-282*
[**2179-4-4**] 01:04AM BLOOD ALT-26 AST-162* AlkPhos-104 TotBili-4.9*
[**2179-4-5**] 04:16AM BLOOD ALT-24 AST-129* LD(LDH)-228 AlkPhos-101
TotBili-6.4*
[**2179-4-6**] 03:20AM BLOOD ALT-23 AST-118* AlkPhos-100 TotBili-7.6*
[**2179-4-7**] 04:00AM BLOOD ALT-26 AST-116* LD(LDH)-250 AlkPhos-114
TotBili-8.1*
[**2179-4-8**] 03:55AM BLOOD ALT-27 AST-121* LD(LDH)-278* AlkPhos-117
TotBili-9.4*
[**2179-4-9**] 04:13AM BLOOD ALT-29 AST-124* AlkPhos-138*
TotBili-10.8*
[**2179-4-10**] 04:43AM BLOOD ALT-33 AST-131* AlkPhos-144* TotBili-9.6*
[**2179-4-11**] 05:45AM BLOOD ALT-32 AST-131* AlkPhos-136* TotBili-9.8*
[**2179-4-12**] 05:55AM BLOOD ALT-35 AST-135* AlkPhos-132* TotBili-9.6*
[**2179-4-13**] 05:55AM BLOOD ALT-37 AST-130* AlkPhos-117 TotBili-10.0*
[**2179-4-14**] 09:40AM BLOOD ALT-40 AST-146* AlkPhos-121 TotBili-11.0*
[**2179-4-15**] 06:00AM BLOOD ALT-40 AST-157* AlkPhos-142*
TotBili-10.7*
[**2179-4-16**] 06:28AM BLOOD ALT-36 AST-143* AlkPhos-129 TotBili-9.6*
[**2179-4-17**] 05:45AM BLOOD ALT-35 AST-142* AlkPhos-138* TotBili-9.5*
[**2179-4-18**] 05:45AM BLOOD ALT-35 AST-147* AlkPhos-132* TotBili-9.8*
[**2179-4-19**] 05:35AM BLOOD ALT-34 AST-141* AlkPhos-136* TotBili-9.2*
[**2179-4-19**] 05:35AM BLOOD Albumin-3.4*
[**2179-4-3**] 06:38PM BLOOD Hapto-10*
[**2179-4-3**] 06:38PM BLOOD D-Dimer-1761*
[**2179-4-15**] 06:00AM BLOOD VitB12-1257* Folate-7.1
[**2179-4-15**] 06:00AM BLOOD TSH-3.9
[**2179-4-3**] 02:12AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
[**2179-4-4**] 03:42PM BLOOD Smooth-NEGATIVE
[**2179-4-3**] 09:34AM BLOOD AMA-NEGATIVE
[**2179-4-3**] 09:34AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2179-4-4**] 03:42PM BLOOD IgG-1170 IgM-52
[**2179-4-5**] 12:20AM BLOOD Vanco-12.5
[**2179-4-4**] 05:14AM BLOOD Vanco-10.9
[**2179-4-3**] 02:12AM BLOOD HCV Ab-NEGATIVE
CERULOPLASMIN
Test Result Reference
Range/Units
CERULOPLASMIN 26 18-36 mg/dL
THIS TEST WAS PERFORMED AT:
[**Company **]-[**Hospital1 **]
[**State 106177**]
[**Hospital1 **], [**Numeric Identifier 19694**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 67457**], MD
Comment: CHEM # 62442E
ALPHA-1-ANTITRYPSIN
Test Result Reference
Range/Units
ALPHA-1-ANTITRYPSIN QN 159 83-199 mg/dL
THIS TEST WAS PERFORMED AT:
[**Company **]-[**Hospital1 **]
[**State 106177**]
[**Hospital1 **], [**Numeric Identifier 19694**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 67457**], MD
Comment: CHEM # 62442E
[**2179-4-3**] 04:45AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-6.0 Leuks-MOD
[**2179-4-9**] 08:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2179-4-12**] 09:16AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.0 Leuks-NEG
[**2179-4-3**] 04:45AM URINE RBC-26* WBC-32* Bacteri-FEW Yeast-NONE
Epi-1
[**2179-4-12**] 09:16AM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-0
NonsqEp-<1
[**2179-4-4**] 7:54 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2179-4-7**]**
GRAM STAIN (Final [**2179-4-4**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2179-4-7**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
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 +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
RUQ U/S [**4-3**]:
IMPRESSION:
1. Echogenic liver compatible with fatty infiltration, although
other forms
of cirrhosis/fibrosis are favored.
2. Non-distended gallbladder with wall edema likely reflecting
sequelae of
hepatic disease.
3. Patent hepatic vasculature, but reversal of left portal vein
flow,
suggesting a degree of portal hypertension.
4. Splenomegaly.
EGD [**4-3**]:
Findings: Esophagus:
Other A dark flat spot was noted in the lower esophagus,
extending 2 cm above the GE junction to the GE junction. There
was no apparent clot, ulceration, tear, or varix at this
location. As the lesion was not bleeding, no therapy was
applied. No esophageal varices.
Stomach:
Contents: Coffee ground heme was seen in the whole stomach.
Mucosa: Diffuse granularity and mosaic appearance of the mucosa
were noted in the stomach. These findings are compatible with
portal hypertensive gastropathy.
Flat Lesions Three red spots with adherent clots were noted in
the stomach cardia and fundus. These had the appearance of
visible vessels. The clots were removed by washing and
suctioning, for visualization of the underlying lesions. There
were no gastric varices or ulcerations seen. A gold probe was
successfully applied to each of these spots successfully for
hemostasis.
Other No gastric varices.
Duodenum:
Mucosa: Localized erythema and granularity of the mucosa with
no bleeding were noted in the duodenal bulb compatible with
bulbar duodenitis.
Impression: Coffee ground heme in the stomach.
Portal hypertensive gastropathy.
Three flat red spots in the stomach cardia and fundus, with
adherent clots, treated with cautery. (thermal therapy)
Bulbar duodenitis.
Single dark flat spot in the lower esophagus to the GE junction,
without clot, ulceration, tear, or varix.
No esophageal varices.
No gastric varices.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is a 42yo male with
known alcoholism on section 35 for involuntary detox presenting
s/p fall found to have coffee ground emesis transferred for
management of GI bleed and alcoholic liver disease.
# GI Bleed: patient presented with coffee ground emesis and
upper GI bleed suspected. He underwent EGD without evidence of
varices, but found to have 3 ulcers. He required 2 units of
PRBCs and 3 units of platelets during admission. He was
initially started on octreotide, PPI, and sucralfate. Octreotide
was discontinued given no varices. He completed 5 days of abx
for SBP prophylaxis. He was also found to be H. pylori positive
and was started on triple therapy.
# Airway Management/respiratory status: Patient intubated at OSH
for airway protection in the setting of altered mental status
and UGIB. He was extubated successfully on [**4-7**]. His fluid
overload was treated with lasix [**Hospital1 **].
# PNA: CXR concerning for bilateral lower lobe consolidations.
Repeat CXR on [**4-5**] showed increased retrocardiac opacity.
Patient was initially started on ceftriaxone for SBP prophylaxis
which was changed to vanc/cefepime/flagyl on [**4-3**]. This was
subsequently changed to vanc/zosyn and then vanc d/c on [**4-6**] and
Zosyn d/c on [**4-7**]. His sputum grew MSSA. Spiked no further
fevers throughout the hospitalization.
# Alcoholic Cirrhosis/ETOH abuse: Patient presented without
known history of liver disease, however imaging suggestive of
cirrhosis. Given ETOH history, AST>ALT with rising tbili likely
related to ETOH vs decompensation secondary to GI bleed.
Hepatitis serologies negative. [**Doctor First Name **], AMA, smooth negative, alpha
antitrypsin, ceruloplasmin negative. He was started on lactulose
and rifaxamin. He was not treated for alcoholic hepatitis with
steroids due to recent GI bleed but was started on
pentoxyphylline as his discriminant function score was 36. LFTs
plateaued and began to downtrend a few days prior to discharge.
His nutritional status was supported initially with tube feeds,
multivitamin, thiamine, folate.
# Head laceration/Head strike: Prior to presentation patient
fell and hit head with +LOC. He had CT head and neck which were
negative for acute process. He was placed in a C-collar which
was cleared after patient was extubated. Patient underwent
laceration repair with 4 staples in ED which were removed on
[**4-10**].
# Altered mental status: Patient arrived intubed and sedated. He
required large amounts of benzos for sedation and withdrawal
purposes. His midazolam was switched to precedex prior to
extubation and his CIWA scale was discontinued on day 5 to avoid
additional benzo administration. After extubated patient
continued to remain altered. This was likely multifactorial from
excessive benzo administration taking time to clear, hepatic
encephalopathy, and ICU delirium. Patient was continued on
lactulose and was started on standing olanzapine, which
ultimately was discontinued after psych consultation as it
caused him to be dysarthric.
# Section 35/Depression: patient was apparently saying he??????s
going to ??????drink himself to death??????. When mental status cleared,
he no longer expressed these symptoms. He was initiatially
under Section 35 (involuntary detox) per his father, however
since he was admitted to the hospital and underwent detox here,
the section 35 was suspended. The patient was discharged into
the care of his mother temporarily, however there was nothing
further to be done to prevent him from drinking as his father
would have to go back to court to have the section 35
reinstated.
Transitional Issues:
- needs PCP (provided # to [**Company 191**])
- needs hepatologist (provided # to liver here)
- needs enrollement in relapse prevention program
Medications on Admission:
none
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours).
Disp:*3600 ML(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO TID (3 times a day).
Disp:*63 Tablet Extended Release(s)* Refills:*0*
5. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
6. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 3 days.
Disp:*3 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) 1 injection
Intramuscular as needed: as needed for bee stings.
Disp:*1 pen* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal seizure
Upper gastrointestinal bleed
Aspiration pneumonia
H.pylori infection
Alcoholic hepatitis
Alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
You are able to walk but are not safe to be out on your own.
For this reason you are being discharged into the care of your
mother for the time being till you recover further.
Discharge Instructions:
You were admitted for seizure, gastrointestinal bleeding, severe
alcohol withdrawal, cirrhosis of the liver and alcoholic
hepatitis.
You were treated for 16 days with resolution of most of your
medical issues. Your alcoholic hepatitis (liver inflammation
from alcohol) has improved but is not 100% better. If you drink
again, you risk severe liver injury and death, including "sips"
of alcohol; there is no "safe" amount of alcohol for you to
drink from now on.
Please note that you are being discharged on new medications for
your liver disease. Please take them as prescribed.
Followup Instructions:
Please call [**Hospital 191**] clinic here to establish care with a new primary
care doctor at [**Telephone/Fax (1) 2010**].
With a hepatologist of your choice, call [**Telephone/Fax (1) 2422**] and make
an appointment to be seen in [**11-23**] weeks. You have advanced liver
disease and will need to be followed for this in the future.
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,101
| 161,140
|
44642
|
Discharge summary
|
report
|
Admission Date: [**2162-4-3**] Discharge Date: [**2162-4-9**]
Date of Birth: [**2099-10-19**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Shellfish / Penicillin G / Bactrim
Attending:[**First Name3 (LF) 18970**]
Chief Complaint:
Hypotension, Lethargy
Major Surgical or Invasive Procedure:
Femoral line placement, arterial line placement
EGD with duodenal biopsy [**4-7**]
History of Present Illness:
Mr. [**Name14 (STitle) 95546**] is a 62 year old male with a history of AIDS (CD4
count 29, viral load 319) complicated by [**Female First Name (un) **] esophagitis and
recent [**Doctor First Name **] [**Doctor First Name **] infection who presents from home after being
found lethargic in his bathroom by his partner. [**Name (NI) **] report he
was seen to be in his usual state of health the day prior to
presentation. His health has been declining recently but he had
recently been discharged from rehab and was doing well. He
reports compliance with his medications. He denies any recent
fevers, chills, nasal congestion, sore throat, dysphagia, chest
pain, dyspnea, nausea, vomiting, abdominal pain. He has had
loose stools over the past few weeks without melena or
hematochezia. No dysuria or hematuria. No leg pain or
swelling. No new rashes. No recent travel. No known sick
contacts.
.
In the ED his initial vitals were T: 98.8 BP: 107/74 HR: 124 RR:
16 O2: 97% on RA. He received 7 liters of normal saline and was
started on levophed for [**Name (NI) **] pressure support. He received
vancomycin, ceftriaxone and flagyl. He had an LP performed with
opening pressure 23. Attempts were made to obtain an
intrajugular central line but he became bradycardic with
trendelenberg position so he had a femoral line placed. He is
admitted to the MICU for further management.
On arrival to the MICU he continues on levophed for [**Name (NI) **]
pressure support. He is alert and oriented x 2 (not to time).
He has no complaints. He does not recall the events that brought
him to the hospital.
Past Medical History:
HIV serodiagnosed [**2142**] with history of noncompliance to ART
[**Female First Name (un) 564**] esophagitis
Pyelonephritis [**7-29**] E. coli
MRSA anterior chest wall abscess [**5-29**]
Overactive bladder
L foot numbness
Diverticulosis
Sinusitis
Anogenital HPV s/p OR excision [**9-25**], [**12-28**], [**10-29**]
Crystal meth use leading to nonadherence to HAART
Severe cryptosporidial diarrhea [**9-26**]
HTN
Dyslipidemia
Social History:
Home: Lives with his partner, [**Name (NI) 1158**].
Occupation: retired accountant
Tobacco: Denies
Drugs: Denies current drug use but previous history of sniffing
crystal meth
EtOH: Denies
Pets: 2 pet cats
Sick contacts: None
Travel: Denies any recent travel, although does report a history
of travel to [**Country 3399**]
Family History:
Mother - alive in her 90s w/ dementia
Father - died of copd
Brother - Diabetes [**Name (NI) **] and Hypertension
Physical Exam:
Vitals: T: 101.4 BP: 106/67 P: 78 R: 22 O2: 94% on RA
General: Alert to person, hospital, not date, lethargic, no
distress
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes appreciated
Neurologic: CN II-XII tested and intact, strength 5/5 in upper
and lower extremities, sensation intact to light touch, reflexes
2+ throughout
Pertinent Results:
Admission Laboratories:
Hematology:
[**2162-4-2**] 05:10PM WBC-3.9* RBC-4.17* HGB-12.4* HCT-35.8* MCV-86
MCH-29.7 MCHC-34.6 RDW-19.0*
[**2162-4-2**] 05:10PM NEUTS-70.0 LYMPHS-24.3 MONOS-4.7 EOS-0.5
BASOS-0.4
[**2162-4-2**] 05:10PM PLT COUNT-116*
[**2162-4-2**] 05:10PM PT-14.8* PTT-34.7 INR(PT)-1.3*
Chemistries:
[**2162-4-2**] 04:15PM GLUCOSE-108* UREA N-31* CREAT-1.4* SODIUM-134
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
[**2162-4-2**] 05:10PM ALBUMIN-3.6 CALCIUM-8.3*
[**2162-4-2**] 05:10PM ALT(SGPT)-36 AST(SGOT)-70* CK(CPK)-1066* ALK
PHOS-121* AMYLASE-87 TOT BILI-0.3
[**2162-4-2**] 05:24PM LACTATE-1.9
[**2162-4-3**] 04:46AM LD(LDH)-319* CK(CPK)-1597*
Urinalysis:
[**2162-4-2**] 11:15PM URINE [**Year/Month/Day 3143**]-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2162-4-2**] 11:15PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2162-4-2**] 11:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.040*
Cerebrospinal Fluid:
[**2162-4-3**] 01:31AM CEREBROSPINAL FLUID (CSF) PROTEIN-98*
GLUCOSE-49
[**2162-4-3**] 01:31AM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-2* POLYS-0
LYMPHS-92 MONOS-5 ATYPS-3
[**2162-4-3**] 01:31AM CEREBROSPINAL FLUID (CSF) WBC-7 RBC-27*
POLYS-0 LYMPHS-90 MONOS-5 ATYPS-4 MACROPHAG-1
CT Abdomen and Pelvis: 1. No radiological evidence of colitis.
No evidence of free fluid or free air in the abdomen or pelvis.
The appendix is not visualized. 2. Several enlarged
retroperitoneal and mesenteric lymph nodes are of concern for
lymphoma or metastatic disease in this immunocompromised
patient. Percutaneous sampling is recommended.
CXR: The cardiomediastinal silhouette is unremarkable. There is
no focal pulmonary consolidation.
CT Head: No acute intracranial abnormality. MR is more sensitive
in the detection of small masses.
Duodenal bx from EGD: no abnormal pathology
Brief Hospital Course:
62 year old male with a history of AIDS (CD4 count 29, viral
load 319) who presents from home after being found down from his
partner, now febrile to 101.4 and hypotensive requiring
pressors.
HOSPITAL COURSE BY PROBLEMS:
Septic Shock: On admission patient was febrile, tachycardic,
and hypotensive. He initially required 7 liters of normal
saline and levophed for [**Year/Month/Day **] pressure support. He had a
femoral line placed for rescusitation. On arrival to the ICU
his pressors were quickly weaned off. In terms of sources for
her sepsis the differential was broad. He was empirically
started on vancomycin, ceftriaxone and flagyl per the infectious
disease service. Cerebrospinal fluid, [**Year/Month/Day **], urine and stool
cultures were sent. Cryptococcal antigen was negative. At the
time of MICU transfer all cultures were negative to date. Pt
remained normotensive for the remaining stay on the floor.
Diarrhea: Pt continued to have watery diarreha while on the
floor. He had over 10 episodes of "vegetable soup" like diarreha
per day w/ about 5 overnight. The frequency continued to
improve. All infectious workup was negative. No bacterial
infection was seen. He did have crytosporidium diarreha in the
past but said the current diarreha was different in quality.
C.diff was negative. O&P negative. All other rarer causes
including cryptosporidium, giardia, microspora, cyclospora,
vibrio, yersinia were negative. Since studies were negative and
appeared small bowel-like in nature GI decided to do an EGD w/
duodenal bx which is also negative. Slowly diarreha resolved on
its own, with two episodes on day of discharge and appeared to
be resolving. Diarrehea may have been viral.
Enlarged RP lymph nodes - Enlarged retroperitoneal lymph nodes
may be related to [**Doctor First Name **] vs. new malignancy. If new malig lymphoma
may be contributing to diarreha. Initally with radiology read as
enlargement pt was sent for IR-guided, but the interventional
attending reviewed the films and thought there was no signficant
change. We called the radiologist to ask him to amend his read,
but said that they reviewed the film for a long time and
strongly felt that there was significant change. The problem was
that the comparison film was 5yr ago and rate of growth was
uncertain. Upon discussing with IR again they recommended PET/CT
to help direct which LN to bx. However, pt's requistion lost in
system and was would have had to stay over 3day weekend to get
done, and decided to schedule for outpatient. The PCP should
follow up with the results of the PET and decide if IR-guided
biopsy is needed.
Elevated CKs: Likely related to being down for prolonged period
of time (approximately 6-12 hours). He continued to make good
urine output and his CKS trended down. Resolved on the floor.
Altered Mental Status: On presentation he was alert and
oriented x 2. This quickly resolved only a few hours after
arrival to the MICU. It was felt to be related to his severe
infection although HIV encephalopathy was also a consideration.
On floor remained AOx3.
HIV: CD4 count 29 in [**2162-2-21**]. Recently became more compliant
with HAART. He was continued on his home HAART and prophylaxis
regimen.
Pancytopenia: WBC count baseline between [**1-26**], hematocrit
between 30 to 35 and platelets are typically within normal
limits. ID believed this was most likely secondary to his HIV
[**Doctor First Name **] infection: [**Doctor First Name **] culture positive in [**Month (only) 956**]. Repeat
mycolytic cultures were sent. He was continued on his
outpatient regimen of clarithromycin, ethambutol and rifabutin.
Medications on Admission:
Dapsone 100 mg daily
Etravirine 200 mg [**Hospital1 **]
Fluconazole 400 mg daily
Fluoxextine 20 mg daily
Lansoprazole 20 mg dily
Darunavir 600 mg [**Hospital1 **]
Raltegravir 400 mg PO BID
Ritonavir 100 mg [**Hospital1 **]
Azithromycin 1200 mg qweek
Clarithromycin 500 mg PO BID
Ethambutol 1000 mg daily
Rifabutin 150 mg every other day
Docusate 100 mg PO BID
Senna 8.6 mg PO BID
Zofran 4 mg PO Q8H
Heparin TID
Camphor-Menthol daily
Tylenol
Discharge Medications:
1. Dapsone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Etravirine 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
3. Fluconazole 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q24H (every
24 hours).
4. Fluoxetine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Darunavir 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
7. Raltegravir 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
8. Ritonavir 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times
a day).
9. Azithromycin 600 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO once a
week.
10. Clarithromycin 250 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).
11. Ethambutol 400 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO DAILY (Daily).
12. Metronidazole 1 % Gel [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for eosinophilic pustular folliculitis.
13. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day.
14. Rifabutin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO EVERY OTHER
DAY (Every Other Day).
15. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day as
needed for constipation.
16. Zofran 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO every eight (8)
hours.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
- diarrhea
- paraortic and mesentaric lymphadenopathy
Secondary diagnosis:
- HIV
Discharge Condition:
good, diarrhea improved, hemodynamically stable
Discharge Instructions:
You had diarrhea that was likely infectious possibly from a
virus, but no specific bacteria was found. The biopsy results
are still pending and when you follow up with Dr. [**Last Name (STitle) **] the
results should be ready at that time. The PET scan will be done
as outpatient and then Dr. [**Last Name (STitle) **] will decide if a lymph node
biopsy is needed at that point.
Medication changes:
- none
If your symptoms of severe diarrhea return or you have fevers >
101, or weakness and light-headedness please return to the ED.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2162-4-29**] 9:00
Completed by:[**2162-4-14**]
|
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"272.4",
"276.8",
"031.2",
"276.2",
"995.92",
"780.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.29",
"38.91",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
11425, 11482
|
5700, 8532
|
332, 417
|
11627, 11677
|
3767, 5531
|
12260, 12535
|
2862, 2976
|
9850, 11402
|
11503, 11503
|
9382, 9827
|
11701, 12081
|
2991, 3748
|
12101, 12237
|
271, 294
|
445, 2055
|
5540, 5677
|
11598, 11606
|
11522, 11577
|
8548, 9356
|
2077, 2505
|
2521, 2846
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,631
| 184,214
|
4680
|
Discharge summary
|
report
|
Admission Date: [**2138-10-20**] Discharge Date: [**2138-10-27**]
Date of Birth: [**2077-11-3**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Codeine / Lidocaine / Vicodin
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Dizziness and Low Blood Pressure
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
60 yo F with ESRD on HD, DM1, CAD s/p CABG [**2121**], CHF EF 30%(s/p
ICD) who was sent to ED from dialysis after experiencing
hypotension and dizziness. She had been treated with cefazolin
[**Date range (1) 19770**] and Vanc [**Date range (1) 19503**] at HD for positive Coag neg staph
bacteremia. On [**2138-10-16**], patient underwent exchange over a wire
of left femoral tunneled hemodialysis catheter because of
persisent bacteremia with coag negative staph.
.
In the ED, initial VS: 98.7 94 105/47 18 97% 2L on SBP 75-80.
FSBG low. Refusing central lines, refusing labs, got 22G in arm.
Given Got vanco in ED. CXR unchanged. VS: 98.6 82 100/33 12.
.
Currently, patient reported fatigue and some nausea at dialysis.
She reported that the antibiotics made her feels sick. She
reportst that normally her blood pressures run low SBP in
70-80s. She reports poor appetie and poor PO intake over the
weekend. Her boyfriend reports that she has had nausea,
vomiting, and diarrhea in the past 3 weeks after dialysis. Also
she reports a lesion on her finger.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- ESRD: Initially HD, transitioned to PD ([**6-5**])- now back on HD;
per renal fellow ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**]), patient has repeatedly been
clotting off catheters so was started on low dose coumadin. No
INR target was set - pt was just given 1mg per day. Her INR was
initially 2.5 but is now 1.8. Does make urine still; urinates
1x/day.
-PE (Occurred in setting of catheter placement and SVC
thrombosis in [**11-6**], but was asymptomatic at that
time)-maintained on coumadin
- DM Type I: Diagnosed 44 yr ago (Hgb A1C [**7-7**] - 5.3%)
- CAD s/p CABG ([**2121**]), MI x2
- CHF (EF 30%) s/p ICD
- h/o non-sustained v-tach s/p ICD
- Hyperlipidemia
- Chronic anemia
- Hypothyroidism
- Cholecystectomy
- Osteoporosis
- L knee nondisplaced patellar fracture [**2137**]
- gout
Social History:
Lives with boyfriend of 15 years - she suggested that her
boyfriend is sometimes verbally aggressive/blames her for
getting ill, but did not want o go further into this. She denied
physical abuse. No alcohol, drugs, tobacco use.
Family History:
Father with DM, CAD, MI. Mother with stroke and [**Name (NI) 2481**].
Physical Exam:
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 35.9 ??????C (96.7 ??????F)
Tcurrent: 35.9 ??????C (96.7 ??????F)
HR: 89 (78 - 89) bpm
BP: 95/39(54) {86/30(42) - 96/44(54)} mmHg
RR: 16 (15 - 21) insp/min
SpO2: 92%
Heart rhythm: SR (Sinus Rhythm)
Height: 63 Inch
Total In:
358 mL
PO:
TF:
IVF:
358 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
358 mL
Respiratory
O2 Delivery Device: None
SpO2: 92%
Physical Examination
General Appearance: Well nourished, No acute distress, Thin,
Anxious
Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale,
Sclera edema
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), S4
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , Diminished: bases)
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): , Movement: Purposeful, Tone: Not
assessed
Pertinent Results:
[**2138-10-20**] 06:39PM TYPE-[**Last Name (un) **] PO2-59* PCO2-40 PH-7.37 TOTAL CO2-24
BASE XS--1
[**2138-10-20**] 06:21PM GLUCOSE-98 UREA N-26* CREAT-4.0* SODIUM-136
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-22 ANION GAP-18
[**2138-10-20**] 06:21PM estGFR-Using this
[**2138-10-20**] 06:21PM ALT(SGPT)-7 AST(SGOT)-16 CK(CPK)-18* ALK
PHOS-271* TOT BILI-0.2
[**2138-10-20**] 06:21PM CK-MB-NotDone cTropnT-0.10*
[**2138-10-20**] 06:21PM CALCIUM-7.5* PHOSPHATE-5.9* MAGNESIUM-1.6
[**2138-10-20**] 06:21PM CORTISOL-16.0
[**2138-10-20**] 06:21PM WBC-20.4*# RBC-3.38* HGB-10.8* HCT-34.6*
MCV-103* MCH-32.1* MCHC-31.3 RDW-17.5*
[**2138-10-20**] 06:21PM NEUTS-93.5* LYMPHS-3.9* MONOS-1.9* EOS-0.2
BASOS-0.3
[**2138-10-20**] 06:21PM PLT COUNT-450*#
[**2138-10-20**] 11:15AM PT-18.4* INR(PT)-1.7*
.
CXR [**10-20**]
1. Femoral dialysis catheter tip advanced to the junction of the
SVC and right atrium. Please correlate for positional adequacy.
2. Cardiomegaly.
.
Echo [**10-21**]
The left atrium is moderately dilated. The right 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 is moderately 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). with moderate global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2137-9-27**], no
vegetations are seen.
CT Scan [**2138-10-22**]
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: In the visualized
thorax, there
is a small left pleural effusion and associated relaxation
atelectasis.
Atelectatic changes are also seen at the right lung base, though
some regions
suggest possibility of aspiration as well. The heart is top
normal in size.
There are dense coronary artery calcifications. There is no
pericardial
effusion.
There is a small amount of pneumoperitoneum with the bulk of
free air located
anterior to the liver. Locules of gas seen anteriorly throughout
the abdomen
and inferiorly to below the pelvis (series 2, image 57).
In the abdomen, evaluation of the solid organs is limited
without intravenous
contrast. Linear regions of low density adjacent to calcified
hepatic
arteries, particularly in the left [**Last Name (LF) 3630**], [**First Name3 (LF) **] be dilated bile
ducts. The
atrophic pancreas, spleen, and adrenals appear normal. Vessels
are densely
calcified suggesting diabetes. Both kidneys are again atrophic.
There is distention of small bowel loops to 2.7 cm (series 300B,
image 10).
There is effacement of fat about the small bowel and thickened
walls in the
upper loops of bowel. Small locules of air also seen in the
superior and
anterior central small bowel loops (series 2, image 39). No
definite
pneumatosis is seen.
There is effactment of fat about large bowel. Bowel wall
thickness is
difficult to establish without oral contrast but appears
abnormal the
descending colon. There is a locule of gas abutting a portion of
hepatic
flexure of the colon (series 2, image 39). Fluid is seen
adjacent to the
descending colon towards the sigmoid (series 2, image 51; series
300B, image
22).
There is no pathologic abdominal lymphadenopathy. The takeoffs
of the celiac
and superior mesenteric arteries are densely calcified as are
all the
intra-abdominal vessels. Given no intravenous contrast was
administered,
assessing patency is not possible with this study.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: A left femoral
venous central
line is seen with tip terminating in the right atrium. The
bladder
demonstrates air anteriorly, probably from instrumentation.
Multiple calcific
round densities within the bulky anteverted uterus suggest
dystrophic
calcification within fibroids. Fluid tracks down the paracolic
gutters more on
the left than right. Adnexa are unremarkable. There is no pelvic
lymphadenopathy.
MUSCULOSKELETAL: There is no suspicious osteolytic or
osteoblastic lesion.
Multilevel degenerative changes are seen in the spine. A small
umbilical fat-
containing hernia is seen.
IMPRESSION:
1. Pneumoperitoneum.
2. Abnormal small bowel loops, gas distended, probably will wall
thickening
and demonstrate fat pericolonic fat effacement. A larger locules
of gas is
seen abutting a segment of small bowel centrally suggestive of a
focus of
perforation.
3. Possible bowel wall thickening involving the colon and
pericolonic fat
effacement involving all large bowel. This may be seen in
colitis
(nonspecific). Fluid tracks down the paracolic gutters more on
the left than
right. A locule of air abutting a segment of hepatic flexure.
4. Densely calcified aorta and celiac and superior mesenteric
artery takeoffs
in this context is suspiscious for an ischemic component.
However, given that
no IV contrast was administered, cannot assess vessel patency.
5. Left pleural effusion and associated relaxation atelectasis.
6. Dense vascular calcifications.
7. Small fat-containing umbilical hernia.
8. Atrophic kidneys and pancreas.
Brief Hospital Course:
MICU Course:
The patient was admitted to the medical ICU for hypotension and
concern for recurrent bacteremia after dialysis. She did not
require vasopressor agents, and was treated with vancomycin, on
an HD protocol. She was empirically treated for C. diff though
results did not return while she was in the ICU. Echocardiogram
showed no masses or vegetations, though did show her EF was now
20%, similar to 25% from most recent other echocardiogram. Renal
recommended starting Florinef after she had an appropriate [**Last Name (un) 104**]
stim. Her metoprolol was held.
During an episode of dialysis, she became again hypotensive and
developed increased abdominal pain following completion. Serial
KUBs became positive for free air, and CT scan of the abdomen
confirmed viscous perforation. She was started on broad spectrum
antibiotics, and a surgical consultation was obtained.
Unfortunately, given the risk of surgery, it was felt that she
would likely not survive the operation. The surgical risk was
discussed with the patient, and a plan to pursue comfort
oriented goal of care was put into place. Palliative care
followed in consultation. She was continued on antibiotics, and
also on norepinephrine that had been started the evening of the
ct findings. Dialysis was stopped, and on [**2118-10-27**] she had a
cardiac arrest, and was declared dead at 1625 without
resuscitation efforts. Family was at the bedside.
Medications on Admission:
-ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth every other
day
-AMIODARONE - 200 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
-AMOXICILLIN - 500MG Capsule - TAKE 4 TABLETS ONE HOUR BEFORE
PROCEDURE
-NEPHROCAPS 1 mg by mouth once a day
-CALCIUM ACETATE [PHOSLO] 667 mg Capsule PO TID
-HUMALOG - 100 U/ML Solution - SS
-INSULIN GLARGINE [LANTUS]- 100 unit/mL Solution - 12-15 units
daily
-LEVOTHYROXINE [SYNTHROID] - 125 mcg Tablet - 1 Tablet(s) by
mouth once a day, alternating with 112mcg daily
-METOPROLOL SUCCINATE [TOPROL XL] - 25 mg by mouth daily on non
dialysis days
-NITROGLYCERIN - 0.4MG Tablet, Sublingual - TAKE AS DIRECTED
-OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C. by
mouth twice a day
-PRAVASTATIN - 40 mg Tablet - by mouth once a day in the evening
-WARFARIN - 2 mg Tablet - [**2-1**] Tablet(s) by mouth daily or as
directed by coumadin clinic
-ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) by
mouth once a day
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypotension
Bowel Perforation
Mesenteric Ischemia
Cardiac Arrest
End Stage Renal Disease
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"276.1",
"V45.02",
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"038.9",
"272.4",
"V66.7",
"414.00",
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"250.01",
"733.00",
"V45.11",
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"244.9",
"427.5",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12345, 12354
|
9902, 11330
|
344, 358
|
12486, 12625
|
4163, 9879
|
2801, 2872
|
12375, 12465
|
11356, 12322
|
2887, 4144
|
272, 306
|
386, 1677
|
1699, 2538
|
2554, 2785
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,384
| 142,794
|
9395
|
Discharge summary
|
report
|
Admission Date: [**2137-9-20**] Discharge Date: [**2137-9-24**]
Date of Birth: [**2099-9-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 37 year old female with schizoaffective d/o,
depression, seizure d/o, ESRD from IGA nephropathy, very poor
access with transhepatic HD catheter on coumadin admitted for
UGIB. Patient was recently discharged on [**2137-9-12**] for UGIB.
Patient required 15u PRBCs during that admission. GI performed
endoscopy which showed severe esophagitis with friability and
contact bleeding. There was also a visible vessel in esophagus
which was treated with epinephrine injection and 2 clips.
Patient was discharged and now returns with coffee ground emesis
x 2 days. Patient reports N/V yesterday x 2 and [**3-10**] more this
morning which prompted her to return to the ED. She denies any
hematemesis, melena, hematochezia, fevers, chills, dizziness or
lightheadedness. Patient does report some
epigastric/periumbilical pain with her vomiting, she denies any
current abd pain.
In the ED: Temp 98.5, HR 99, BP 113/65, RR 20, 99% on trach
mask.
Patient seen by GI in the ED who recommended IR treatment for
her GI bleed. Patient given Protonix 40mg IV x 1.
Of note, patient has HD catheter going to her hepatic vein which
is her only access placed [**3-15**]. She requires coumadin for
patency. The HD catheter has been exchanged several times
previously for clot and sepsis. Has required IR guided placement
of central lines as well, difficult peripheral access.
.
Past Medical History:
ESRD [**3-9**] IgA nephropathy,
Schizoaffective disorder,
Depression,
Chronic anemia,
GERD,
h/o Cardiomyopathy: ECHO [**2137-8-6**] EF >65%, hyperdynamic, LVH, no
valvular disease
Hypothyroidism,
h/o GI bleed,
RLE DVT,
Seizure disorder,
h/o tracheal stenosis s/p trach, on TM at 7L/min at rehab
h/o malignant hypothermia
PAST SURGICAL HISTORY:
s/p L upper and lower extremity AV fistulae(failed),
s/p R upper extremity AV fistula (basilic vein
transposition(failed),
s/p R forearm AV graft (failed),
s/p attempted insertion of a peritoneal dialysis catheter
(failed), central venous stenosis,
Innominate venous stenosis,
s/p R brachioarterial->axillary AV graft, nonfunctional,
status post multiple thrombectomies and angioplasties,
s/p tracheostomy,
s/p thrombectomy of AV graft x5,
s/p Transhepatic HD catheter placement
All: Penicillins, Tetracyclines, Succinylcholine, Clozaril
(Oral) (Clozapine), Calcium Channel Blocking
Agents-Benzothiazepines, Beta-Adrenergic Blocking Agents
Social History:
Currently living at [**Hospital **] rehab. No tobacco, EtOH, illicit
drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: Temp 99.2, HR 79, BP 111/53, RR 17, 100% 12Ltrach mask
General: NAD, lying comfortably in bed
HEENT: NC/AT, PERRLA, EOMI, MMM
Neck: Trach, no LAD
Lungs: CTAB, no wheezes, crackles or ronchi
CVS: +S1/S2, no M/R/G, RRR
ABD: Soft, NT/ND. + transhepatic HD line on right abdomen.
Extrem: Warm, no peripheral edema
Neuro: AAOx3, CN II-XII grossly intact, moves all extremities on
command
Pertinent Results:
[**2137-9-21**] 05:52PM BLOOD WBC-3.3* RBC-3.33* Hgb-10.1* Hct-32.1*
MCV-96 MCH-30.4 MCHC-31.6 RDW-15.1 Plt Ct-187
[**2137-9-22**] 05:35AM BLOOD WBC-3.8* RBC-3.22* Hgb-10.1* Hct-30.9*
MCV-96 MCH-31.3 MCHC-32.6 RDW-16.0* Plt Ct-229
[**2137-9-23**] 06:15AM BLOOD WBC-3.9* RBC-3.23* Hgb-9.6* Hct-30.6*
MCV-95 MCH-29.9 MCHC-31.5 RDW-15.6* Plt Ct-221
[**2137-9-20**] 05:35PM BLOOD Neuts-81.2* Lymphs-10.3* Monos-5.1
Eos-3.0 Baso-0.4
[**2137-9-22**] 05:35AM BLOOD Plt Ct-229
[**2137-9-23**] 06:15AM BLOOD PT-15.2* PTT-20.6* INR(PT)-1.3*
[**2137-9-22**] 05:35AM BLOOD Glucose-65* UreaN-48* Creat-6.5*# Na-139
K-5.7* Cl-103 HCO3-25 AnGap-17
[**2137-9-23**] 06:15AM BLOOD Glucose-74 UreaN-51* Creat-7.3* Na-133
K-5.5* Cl-99 HCO3-24 AnGap-16
[**2137-9-21**] 12:19AM BLOOD Calcium-9.3 Phos-2.1* Mg-1.9
[**2137-9-23**] 06:15AM BLOOD Calcium-9.9 Phos-3.8 Mg-2.1
[**2137-9-21**] 12:19AM BLOOD TSH-6.5*
Brief Hospital Course:
This is a 37 year old female with schizoaffective d/o,
depression, seizure d/o, ESRD from IGA nephropathy, very poor
access with transhepatic HD catheter on coumadin admitted with
coffee ground emesis.
# UGIB: Patient with recent hx of UGIB, found to have
esophagitis and visible vessel in esophagus which was clipped at
that time. Now presenting with coffee ground emesis. GI saw her
in the ED and recommended continued monitoring and consideration
of IR embolization if bleeding continued. She had one episode of
emesis with ? coffee grounds shortly following admission but
other than this, had no signs of bleeding. Her hematocrit
remained stable above 30 (which was above her baseline. She
remained hemodynamically stable throughout her course. IV PPI
was given with transition to PO. Sucralfate also continued,
note she should not be on this medication for very prolonged
courses given aluminum content (though small) in ESRD patient.
Diet advanced. She is on LOW DOSE PROPHYLACTIC coumadin for
catheter patency, and this was restarted without incident.
# ESRD. Pt with ESRD on HD via transhepatic catheter. She
received HD on friday and monday during her stay. Coumadin 1 mg
given for transhepatic line patency (1 mg daily only, should not
follow INR). Patient followed by renal during this admission.
Recent line infection, but per old notes she has completed
treatment (vancomycin not continued) (completed 6 weeks of
therapy on [**2137-9-15**]). Will have have ID followup as outpatient.
Should receive Epo with HD. Phos binders continued.
# Hypothyroidism. TSH noted to be elevated to 6.5, repeat 4.9,
with normal free T4. Follow-up in the out-patient setting.
During GIB she was given IV replacement and then transitioned
back to PO.
# Schizoaffective disorder/depression. Continued fluphenazine
without incident.
# Respiratory failure/s/p trach. Most recently with trach due
to upper airway inflammation during extubation attempt (about
one month ago). Suggest continued weaning with decreasing trach
size and eventual decannulation while at [**Hospital1 **]. She
continued comfortably on trach mask at 35-40%.
# Full code.
Medications on Admission:
Albuterol MDI 2 puffs QID
Calcium Acetate 667 mg TID with meals
Cinacalcet 90 mg daily
Fluphenazine 2.5 mg [**Hospital1 **], and 10 mg HS
Levothyroxine 100 mcg daily
Midodrine 5 mg TID for SBP <90
Pantoprazole 40 [**Hospital1 **]
Warfarin 1 mg daily
alteplase prn to HD cath
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Fluphenazine HCl 2.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Upper gastrointestinal bleeding secondary to severe esophagitis
End-stage renal disease secondary to IgA nephropathy on
hemodialysis
Schizoaffective disorder
Tracheomalacia status post tracheostomy in [**8-/2137**]
Discharge Condition:
Stable
Discharge Instructions:
You were treated at [**Hospital1 18**] for an upper GI bleed in conjunction
with nausea and vomiting. During your admission, there were no
signs of further bleeding and the nausea/vomiting ceased. Your
hematocrit was found to be consistent with the values which are
normal for you. You did not require any transfusions on this
admission. Please follow up with your infectious disease doctor
as noted below.
Followup Instructions:
Please followup with your doctors [**First Name (Titles) **] [**Last Name (Titles) **] upon your return.
We have rescheduled your appointment with Infectious disease
clinic for [**10-29**] at 10:30 am.
We also feel that you are approaching the time to have your
tracheostomy decannulated. Please talk to your doctors [**First Name (Titles) **] [**Name5 (PTitle) 32080**] about this.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2137-9-24**]
|
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"459.2",
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"345.90",
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"V58.61",
"244.9",
"285.9",
"V45.1",
"V12.51",
"530.81",
"583.9",
"403.91",
"530.82",
"530.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7560, 7639
|
4301, 6455
|
415, 422
|
7898, 7907
|
3388, 4278
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8362, 8903
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2943, 2961
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6781, 7537
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7660, 7877
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7931, 8339
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2186, 2829
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2976, 3369
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364, 377
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450, 1818
|
1841, 2163
|
2845, 2927
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,273
| 166,231
|
34295
|
Discharge summary
|
report
|
Admission Date: [**2198-7-17**] Discharge Date: [**2198-7-28**]
Date of Birth: [**2149-6-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Acute Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50M, alcoholic but with no other PMH developed sudden onset
of sharp, severe abdominal pain almost 48hrs ago a few hours
after dinner. It was [**2200-7-21**], radiated to his back and was felt
over his entire upper abdomen. +vomitting, febrile to 101.0 at
home. no diarrhea, constipation, HA/CP/SOB. Never had symtoms
like this before. Went to [**Hospital3 **] where he was reported
to have been tachycardic in the 130s with some labored
breathing.
He was resusitated with about 8L of IVF and had a CT scan that
was concsistent with pancreatitis. Was transferred to [**Hospital1 18**] for
further management.
Past Medical History:
appendectomy when young
Social History:
Pt. is married and has 3 children, (28, 26 and 21). Pt. works in
Heating and Air Conditioning installation.
previous 12-18 beers/day drinker, decreased about 2 years
ago to 6 drinks/day a few times a week. Denies ever ebing in
withdrawl. no IVDU or tobacco
Physical Exam:
100.4 117-125HR 148/97 15-22RR 93%4L NC
diaphoretic and mild abnormal breathing, but NAD, AOX3
no scleral icterus
RRR
CTAB , mild decrease at bases
very distended, soft, tympanitic, TTP over entire upper abdomen,
no rebound or guarding
+[**12-13**] LE edema
guiac negative, no masses
Pertinent Results:
[**2198-7-17**] 02:26PM BLOOD WBC-24.1* RBC-4.82 Hgb-14.5 Hct-42.7
MCV-89 MCH-30.1 MCHC-34.0 RDW-12.6 Plt Ct-235
[**2198-7-20**] 01:15AM BLOOD WBC-15.9* RBC-3.38* Hgb-10.4* Hct-30.7*
MCV-91 MCH-30.7 MCHC-33.8 RDW-12.7 Plt Ct-271
[**2198-7-25**] 05:45AM BLOOD WBC-24.6* RBC-4.12* Hgb-12.3* Hct-37.3*
MCV-91 MCH-29.9 MCHC-33.0 RDW-13.0 Plt Ct-587*
[**2198-7-27**] 05:15AM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-133
K-4.0 Cl-96 HCO3-21* AnGap-20
[**2198-7-17**] 02:26PM BLOOD ALT-24 AST-43* AlkPhos-47 Amylase-571*
TotBili-1.7*
[**2198-7-17**] 02:26PM BLOOD Lipase-609*
[**2198-7-21**] 02:33AM BLOOD ALT-22 AST-31 LD(LDH)-559* AlkPhos-51
Amylase-85 TotBili-0.7
[**2198-7-21**] 02:33AM BLOOD Lipase-111*
[**2198-7-27**] 05:15AM BLOOD ALT-36 AST-46* AlkPhos-76 Amylase-163*
TotBili-0.7
[**2198-7-27**] 05:15AM BLOOD Lipase-162*
[**2198-7-27**] 05:15AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.1 Mg-2.0
[**2198-7-17**] 02:26PM BLOOD Triglyc-343*
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-7-18**] 1:05
PM
IMPRESSION: Markedly low lung volumes with haziness at both
bases, likely due to a combination of atelectasis and effusion.
Cardiomegaly and haziness of pulmonary vasculature suggests
overhydration.
.
ECHO
Conclusions
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. There is no aortic valve stenosis. 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.
.
Radiology Report CT ABD W&W/O C Study Date of [**2198-7-26**] 2:45 PM
IMPRESSION:
1. Necrotizing pancreatitis, progressive in comparison to CT
[**2198-7-16**].
Approximately one-third of the pancreas does not enhance,
consistent with
necrosis.
2. Extensive peripancreatic fluid, with infiltration of the
stomach and
associated thickening of the splenic flexure.
3. Left pleural effusion.
4. No pseudoaneurysm or splenic vein thrombosis is identified.
.
Brief Hospital Course:
This is a 49 year old male with EtOH abuse and Acute
Pancreatitis who was transferred from [**Hospital3 3765**] here for
further management. Outside CT abd showed evidence of
pancreatitis, with concern for necrotizing pancreatitis.
He was admitted to the ICU for fluid resuscitation and for EtOH
withdrawl management, including respiratory monitoring. Full
labs were drawn and a foley catheter was placed to monitor
hydration status. He was made NPO, placed on a CIWA scale, and
ABX were held.
Over the following day, signs of ETOH withdrawal began to
manifest and there were definite concerns for DTs. He was placed
on standing ativan and given thiamine. Pt also began to run
fevers to 101. A CXR showed markedly low lung volumes with
haziness at both bases, likely due to a combination of
atelectasis and effusion. Cardiomegaly and haziness of pulmonary
vasculature suggesting overhydration.
A Labetolol drip was started for hypertension and tachycardia
over the ensuing days, and a TTE was done, showing normal EF and
no vegetations. Cardiac enzymes were negative. Blood cultures
([**1-13**]) were negative.
He was seen by speech and swallow in the ICU, and it was felt
suitable to to give him nectar thickened liquids, supervised,
which he seemed to tolerate except for one episode of vomiting.
Over the next few days, his DTs began to improve, and he was
sent to the floor on 1:1 sitter on telemetry. He continued to do
well, the sitter was d/c'd, and speech and swallow approved him
for regular diet, unsupervised. He tolerated this well.
On HD 10, he was doing remarkably better, tolerating regular
diet with nausea or vomiting and was alert and oriented. Minimal
pain. A repeat abd CT scan at this time showed: Necrotizing
pancreatitis, progressive in comparison to CT [**2198-7-16**].
Approximately one-third of the pancreas does not enhance,
consistent with necrosis. Also with extensive peripancreatic
fluid, with infiltration of the stomach and
associated thickening of the splenic flexure. However, given his
significant clinical improvement, the decision was made to
discharge him, although he was kept overnight for a one time
fever spike to 101. A UA showed moderate bacteria, and blood and
urine cx were sent. He was sent home on 3 days of Cipro, and
will plan for a repeat CT scan of the abdomen in 3 weeks, with
f/u in Dr.[**Name (NI) 2829**] clinic.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for agitation, withdrawl symptoms.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): Follow-up with your PCP about continuing this
medication beyond one month.
Disp:*60 Tablet(s)* Refills:*0*
5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pancreatitis
Abdominal Pain
EtOH Abuse
Discharge Condition:
Good
Discharge Instructions:
You were admitted with Acute Pancreatitis
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**12-13**] weeks. Call to schedule an
appointment.
Please follow-up with Dr. [**Last Name (STitle) **] on [**2198-8-17**] at 11:45. You will
need a CT scan prior to this appointment. Arrive at 9:30am to
the [**Hospital Ward Name 23**] Center for your CT scan.
Completed by:[**2198-7-28**]
|
[
"303.91",
"599.0",
"577.0",
"401.9",
"276.6",
"291.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7036, 7042
|
3966, 6342
|
332, 339
|
7131, 7138
|
1623, 3943
|
8537, 8892
|
6397, 7013
|
7063, 7110
|
6368, 6374
|
7162, 8514
|
1318, 1604
|
274, 294
|
367, 979
|
1002, 1028
|
1044, 1303
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,570
| 152,741
|
1461
|
Discharge summary
|
report
|
Admission Date: [**2128-6-16**] Discharge Date: [**2128-6-20**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This 81 year old Chinese speaking female came to the ER on [**6-15**]
following a single episode of bloody vomiting and one maroon
stool. She had been admitted at [**Hospital6 2561**] from the
17th to the 19th for hematemesis. There she was found to have a
single gastric ulcer in her lesser curvature, transfused
multiple times, given Protonix and famotidine; she was
discharged on Protonix in what appears to be good condition.
The patient was in her usual state of good health until about
3-4 weeks ago when she developed toothache. She started taking
ibuprofen for it at [**First Name8 (NamePattern2) **] [**Last Name (un) 5487**] dose. She had several episodes of
tarry stools during this period and then had a single episode of
bloody vomitus on the the 17th which necessitated her admission
at [**Hospital3 **]. Following her discharge, the patient appeared
to have done well until the early hours of this morning when she
had single maroon stool. This was followed by vomiting of about
1 cup's worth of bright red blood.
ER Course: Her blood pressure was 90/50 with a heart rate of 58.
Patient underwent gastric lavage with normal saline which
immediately returned positive. IV access was obtained. The
patient was found to be thrombocytopenic to 36 and platelets
were hung; 2 units of PRBCs were typed and held for the patient.
She was transferred to the ICU for further management.
MICU/ED course:. In [**Name (NI) **] pt was HD stable and Hct was 28. Pt was
given 1 L NS and had NG lavage with 1 lieter which failed to
clear. Plt count noted to be 36 so pt given 1 bag plt. Pt
transferred to MICU. In MICU, pt recieved 2 u PRBC as Hct was
28.2. Repeat Hcts were over 30 until this 10 am [**6-17**] Hct 28.6.
Repeat Hct ordered for 6 pm. EGD today showed red blood in
fundus and stomach body. Single cratered 9 mm ulcer in insicura
of stomach with suggestions of recent bleeding. Few superficial
non-bleeding 3 mm ulcers in pylorus
Over the last 24 hrs, Patient's hematocrit remained stable @ 29.
No melena; no hematemesis. Remained on clears. Patient remained
in ICU as no beds on floor.
She is to be transfused 1 upRBC today and have a repeat hct
check
Past Medical History:
Patient generally maintains good health; there is a remote (10
years ago) history of maroon stools; she has had some trouble
with fillings in her lower teeth.
Glaucome
Social History:
She moved here many years ago from [**Country 5142**]. She was originally
from [**Country 651**]. She lives with husband and is a former smoker (30
pack year history and stopped several years ago)
Family History:
sister with diabetes
Physical Exam:
T98.6 Tc 98.4 BP 130/60-70 p72-74 O2 96-99% RA
Gen: Comfortable, conversant in Chinese; able to communicate via
translation chart.
Skin: WWP
Chest: CTAB. Left subclavian in place-no erythema or induration
CVS: RRR, normal S1/S2, no MGR.
Abd: BS++, NT/ND.
Ext: Indurated tender area at site of previous IV on L arm.
Neuro: Alert, conversant; moving all extremities.
Pertinent Results:
[**2128-6-18**] 06:31PM BLOOD WBC-8.0 RBC-3.60* Hgb-11.3* Hct-31.1*
MCV-87 MCH-31.5 MCHC-36.4* RDW-14.0 Plt Ct-180
[**2128-6-18**] 10:02PM BLOOD Hct-30.3*
[**2128-6-17**] 04:10AM BLOOD Glucose-90 UreaN-19 Creat-0.5 Na-145
K-3.3 Cl-114* HCO3-22 AnGap-12
[**2128-6-17**] 04:10AM BLOOD Calcium-7.6* Phos-3.5# Mg-2.3
[**2128-6-17**] 04:10AM BLOOD WBC-7.9 RBC-3.42* Hgb-10.3* Hct-30.2*
MCV-88 MCH-30.1 MCHC-34.2 RDW-14.2 Plt Ct-187
[**2128-6-18**] 03:55AM BLOOD Glucose-76 UreaN-10 Creat-0.5 Na-141
K-3.6 Cl-109* HCO3-24 AnGap-12
[**2128-6-18**] 03:55AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.7
[**2128-6-18**] 03:55AM BLOOD WBC-7.5 RBC-3.22* Hgb-10.0* Hct-27.8*
MCV-87 MCH-31.1 MCHC-35.9* RDW-14.2 Plt Ct-171
[**2128-6-18**] 03:55AM BLOOD Plt Ct-171
Brief Hospital Course:
THe patient has had a unremarkable hospital course after
transfer to floor. She received 1 u on [**6-18**]. Her Hct bumped from
31 to 35. She has no complaints. Her BP is stable from SBP
120-130. Her HR stable at 70-80. Her stool quality has improved
from blackish to brownish. She is to discharged pending a repeat
Hct check on 5pm and [**6-20**] AM.
Medications on Admission:
On admission to hospital:
Protonix 40 mg po once daily; Unknown Chinese herbal medicine
("Po [**Last Name (un) **] pills") which she takes for "abdominal discomfort."
This was reviewed with our pharmacists, and was found to have
anti-platelet effects. SHE SHOULD NOT TAKE THIS MEDICATION IN
THE FUTURE. Alphagan eye drops; Xylatan eye drops.
On transfer from MICU to floor:
Tylenol
Brimonidine Tartrate 0.15% Ophth. 1 DROP OU [**Hospital1 **]
Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP OU [**Hospital1 **]
Latanoprost 0.005% Ophth. Soln. 1 DROP OU HS
Pantoprazole 40 mg PO Q12H
Zolpidem Tartrate 5 mg PO HS:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
gastrointestinal bleed
Discharge Condition:
stable and well
Discharge Instructions:
Please call 911 or go to nearest emergency room if you
experience worsening blood in stool, lightheadness, chest pain,
shortness of breath or worsening abdominal pain
Followup Instructions:
Please make appointment with Dr. [**First Name (STitle) 2643**] at the [**Hospital1 18**] in [**5-4**] weeks
for follow-up appointment for EGD to monitor healing of ulcer.
|
[
"E935.9",
"287.5",
"531.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"45.13",
"44.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5113, 5119
|
4095, 4448
|
279, 285
|
5186, 5203
|
3328, 4072
|
5418, 5593
|
2905, 2927
|
5140, 5165
|
4474, 5090
|
5227, 5395
|
2942, 3309
|
217, 241
|
313, 2484
|
2506, 2675
|
2691, 2889
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,425
| 126,931
|
42014
|
Discharge summary
|
report
|
Admission Date: [**2114-10-12**] Discharge Date: [**2114-10-21**]
Date of Birth: [**2060-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Mitral Valve Regurgitation
Major Surgical or Invasive Procedure:
mitral valve repair (32mmedwards Ring), ligation of left atrial
appendage [**2114-10-15**]
left and right heart catheterizations, coronary angiogram
[**2114-10-12**]
History of Present Illness:
This 54 year old woman with a history of mitral regurgitation
and asthmahas been experiencing cough and shortness of breath
with exertion over the last few weeks. She was seen by her PCP
earlier in the week and was prescribed Zithromax for possible
asthma exacerbation. She was also referred for an echo,since
she had not had one recently.
An echo was done on [**2114-10-9**] which demonstrated severe
prolapse/partial flail of the posterior mitral valve leaflet,
severe mitral regurgitation with an eccentric predominantly
posteriorly directed jet, mild tricuspid regurigation and
hyperdynamic systolic dysfunction. Left atrium linear dimension
was moderately enlarged.
As a result of the patient's symptoms and these echo findings,
the patient has been referred by Dr. [**Last Name (STitle) 1923**] (her cardiologist)
for urgent catheterization.
Past Medical History:
Mitral Regurgitation
Asthma
Scoliosis (previous surgery as child)
Vertigo
Social History:
Ms. [**Known lastname 91213**] is married and works as a banker in [**Location (un) 86**].
She lives with her husband in [**Name (NI) 1110**]. They have one child. She
denies smoking and drinks one alcoholic beverage per month. He
denies illicit drug use.
Family History:
Her mother died of a cerebral vascular accident in her 70's.
She has no family history of early myocardial infarction,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admit Exam:
VS: T=98.2 BP=120/63 HR=94 RR=17 O2 sat=97% RA
GENERAL: 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 at the clavicle.
CARDIAC: RRR, holosystolic murmur in all windows, loudest at the
mitral area with radiation to the carotids. No carotid bruits
auscultated.
LUNGS: No chest wall deformities, crackles at the bases,
otherwise clear.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. R femoral
Catheterization site dressing c/d/i, no evidence of hematoma, no
bruit auscultated.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2114-10-12**]: Cardiac Catheterization
1. Selective coronary angiography in this right dominant system
demonstrated no angiographically apparent disease. The LMCA,
LAD, LCx, and RCA were normal.
2. Limited resting hemodynamics revealed elevated left sided
filling
pressures with a mean PCWP of 25 mmHg. There were large V waves
on PCWP
tracing, consistent with significant mitral regurgitation. There
was moderate pulmonary artery hypertension with a PASP of 51
mmHg. The cardiac output was preserved at rest with a cardiac
index of 3.1
L/min/m2.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Mitral Regurgitation.
[**2114-10-13**] TEE:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are myxomatous. The mitral valve leaflets are
elongated. There is partial posterior mitral leaflet flail. An
eccentric, anteriorly directed jet of severe (4+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Myxomatous mitral valve with posterior leaflet
prolapse and partial flail resulting in severe, anteriorly
directed mitral regurgitation. At least moderate pulmonary
hypertension. Preserved regional and global biventricular
systolic function. Biatrial dilatation.
[**2114-10-21**] 06:20AM BLOOD WBC-4.9 RBC-2.85* Hgb-8.2* Hct-25.4*
MCV-89 MCH-28.8 MCHC-32.3 RDW-12.4 Plt Ct-511*
[**2114-10-21**] 06:20AM BLOOD PT-11.9 INR(PT)-1.0
[**2114-10-21**] 06:20AM BLOOD UreaN-14 Creat-0.6 Na-140 K-4.4 Cl-103
Brief Hospital Course:
Following admission catheterization was performed to reveal
normal coronary anatomy and modersately elevated right heart
pressures. On [**10-15**] she went to the operatin gRoom where mitral
repair and left atrial ligation were undertaken. She weaned
from bypass easily on Neoynephrine and Propofol in sinus rhythm.
She awoke intact, was weaned from the ventilator and extubated.
The pressor weaned off and beta blockade was begun. Diuresis
towards her preoperative weight was begun.
Physical Therapy worked with her and she was transferred to the
step down unit. Chest tubes and wires were removed per
protocol. Arrangements were made for follow up appointments and
medications were as noted. She was discharged to home on
post-operative day six.
Medications on Admission:
-Albuterol Sulfate 90 mcg/Actuation Inhalation HFA Aerosol
Inhaler 1-2 puffs 4 to 6 hrs as needed
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg (two tablets) daily for one week, then decrease to
200mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
Disp:*14 Tablet(s)* Refills:*2*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 14 days.
Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*2*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
mitral regurgitation
asthma
scoliosis
s/p mitral valve repair,ligation of left atrial appendage
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema:none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**11-27**] at 1:30pm
Cardiologist:Dr.[**Last Name (STitle) 1923**] ([**Telephone/Fax (1) 2258**]) on [**11-8**] at 9:10am in
[**Location 4288**] office
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 3100**] ([**Telephone/Fax (1) 644**]) in [**4-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2114-10-21**]
|
[
"428.33",
"285.1",
"493.90",
"737.30",
"276.52",
"427.89",
"788.5",
"429.5",
"424.0",
"416.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"35.12",
"37.23",
"38.93",
"37.36",
"37.49"
] |
icd9pcs
|
[
[
[]
]
] |
6863, 6922
|
4914, 5669
|
338, 506
|
7062, 7238
|
2892, 3445
|
8162, 8817
|
1779, 1982
|
5817, 6840
|
6943, 7041
|
5695, 5794
|
3462, 4891
|
7262, 8139
|
1997, 2873
|
272, 300
|
534, 1390
|
1412, 1487
|
1503, 1763
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,100
| 155,992
|
50241
|
Discharge summary
|
report
|
Admission Date: [**2142-7-11**] Discharge Date: [**2142-7-17**]
Date of Birth: [**2065-10-1**] Sex: F
Service: MEDICINE
Allergies:
Diltiazem / Vasotec / Cardizem / Dicloxacillin / Vioxx / Codeine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
admitted for left shoulder surgery
Major Surgical or Invasive Procedure:
shoulder arthroplasty
central line
History of Present Illness:
76 yo female with h/o CAD s/p MI, ischemic CM (EF=21%), OA, CRI,
and HTN who initially presented to [**Hospital1 18**] [**7-11**] for a L shoulder
arthroplasty. Post-op [**7-11**], the patient developed hypotension
with SBP in the 80s and was anuric. She was given IVF
(approximately 4 liters total) and transferred to the [**Hospital Ward Name 12837**] for further management. In the PACU, she was transiently
started on Neo, which was stopped on [**2142-7-12**] at 4AM. She was
then stable without complaints. During this interval, the
patient also developed A fib with RVR, which was felt to be new.
At that point, the patient was evaluated by the med-consult
team, and the decision was made to transfer the patient to
medicine.
.
After transfer to medicine, EP evaluated the patient and
recommended starting amiodarone and digoxin, with plans for
cardioversion in the future after INR [**1-18**] for 4 weeks. The
patient was started on amio, digoxin, as well as heparin gtt.
.
The following morning ([**7-13**]), the patient became hypotensive at
around 11am with BP 80/40 and was anuric. Hct had fallen from
28.5 to 22.8 overnight. She received at total of 1.5 liters NS,
as well as 2 units PRBCs. Subsequently, her BP stablized at
106/70, with increased urine output. She was sating in the high
90's throughout this event. The MICU team was called for
evaluation at this point. Approximately 45 minutes later, the
patient dropped her BP to 82/58. She received an additional 1L
NS which brought her SBP back up to the 100's. The patient was
in T-[**Doctor Last Name **] and began to cough, with gurgling breath sounds.
Patient still satting well at 95-100% on 2L NC. ABG was
7.31/40/72, lactate 1.0, Hct 26. The patient c/o mild SOB and
left shoulder pain. The primary medicine team commented that
her left shoulder appeared more edematous than it had the
evening before. She denied SOB, palpitations, nausea, vomiting,
BRBPR, dysuria.
Past Medical History:
Past Cardiac History:
1. Coronary artery disease, status post myocardial infarction
in
[**2136-8-15**] with an left anterior descending stent, status
post coronary artery bypass graft; SVG-OM2, SVG-D2, LIMA-LAD.
2. Cardiac cath [**2141-1-3**] showing patent grafts
3. Congestive heart failure: diastolic dysfunction, seen in
[**Hospital 1902**] clinic, recent TTE in [**9-18**] showed EF=40-45%, mild [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 55200**], nl LV size.
4. [**2-15**] P-MIBI-moderate severe fixed defect at apex, moderate
partially reversible defect in anterior wall, mild fixed defect
in septum, no significant change from prior study (EF= 36%).
OTHER PMH:
1. Hypertension.
2. Hyperlipidemia.
3. CVA in [**2136-9-14**] (post-op CABG). With residual right
arm deficits. MRI/MRA [**10-19**] showing old left parietal lobe
infarct, decreased flow basilar artery; all unchanged from prior
studies
4. History of gout.
5. OSA, on bipap
6. Colonoscopy [**1-18**]-polypectomy of distal sigmoid; path c/w
hyperplastic polyp
7. Bilateral TKR's [**2134**]
8. s/p Hysterectomy
9. s/p cholecystectomy
Social History:
She lives with her daughter. Denied alcohol or illicit drug use.
Quit tobacco use 35 years ago (used to smoke 1.5 ppd)
Formerly married
Retired, multiple jobs in past including factory worker, nurse's
aide, office assistant
Daughter assists with cooking/cleaning
Has VNA occasionally
Walks with cane at times
Family History:
CAD, HTN
Mother died breast cancer age 51
Physical Exam:
Physical Exam upon admission to MICU
VS - HR 103; BP 98/70; RR = 22; O2 100% 2L NC
GEN - obese AA female, appears uncomfortable, tachypneic,
gurgling breaht sounds, coughing
HEENT - NCAT, PERRL bilat, EOMI, OP clear
NECK: supple, no LAD, unable to assess JVP due to habitus
CV: irreg, irreg, distant HS, no M
PULM: +crackles bilaterally, course breath sounds, no wheezes
ABD: NABS, soft, NT, ND, obese
EXT: trace pedal edema bilat, L-shoulder markedly edematous,
tender to palpation, bandage c/d/i.
Neuro: CNII-XII intact, soft touch intact, strength symmetric
RECTAL: guaiac negative brown stool
Pertinent Results:
[**2142-7-11**] 08:14PM WBC-11.5*# RBC-3.80* HGB-10.5* HCT-33.3*
MCV-88 MCH-27.5 MCHC-31.5 RDW-15.0
[**2142-7-11**] 08:14PM NEUTS-83.4* LYMPHS-11.2* MONOS-2.8 EOS-2.6
BASOS-0.1
[**2142-7-11**] 08:14PM HYPOCHROM-1+
[**2142-7-11**] 08:14PM PLT COUNT-362
[**2142-7-11**] 08:14PM PT-12.9 PTT-27.5 INR(PT)-1.1
[**2142-7-11**] 12:05PM TYPE-ART PO2-170* PCO2-30* PH-7.38 TOTAL
CO2-18* BASE XS--5
[**2142-7-11**] 12:05PM GLUCOSE-94 LACTATE-1.2 NA+-139 K+-4.2 CL--111
[**2142-7-11**] 12:05PM HGB-10.7* calcHCT-32
[**2142-7-11**] 12:05PM freeCa-1.36*
[**2142-7-11**] 10:41AM TYPE-ART PO2-169* PCO2-40 PH-7.35 TOTAL
CO2-23 BASE XS--3 INTUBATED-INTUBATED
[**2142-7-11**] 10:41AM GLUCOSE-104 LACTATE-1.8 NA+-139 K+-4.3
CL--108
[**2142-7-11**] 10:41AM HGB-11.2* calcHCT-34
[**2142-7-11**] 10:41AM freeCa-1.10*
[**2142-7-11**]: OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Left shoulder severe osteoarthritis.
POSTOPERATIVE DIAGNOSIS: Left shoulder severe
osteoarthritis.
PROCEDURE: Left total shoulder arthroplasty.
ANESTHESIA: General combined with interscalene block.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 150 cc.
INDICATIONS FOR PROCEDURE: This 76-year-old female has been
complaining of 1 year of increasing left shoulder pain
despite conservative treatment. She is status post left
shoulder arthroscopic subacromial decompression by me a year
ago. At that time, she was noted to have severe degenerative
changes, grade 4, of the glenohumeral articulation. After
failure of conservative treatment, she elected to have left
total shoulder arthroplasty.
DESCRIPTION OF PROCEDURE: The patient was brought to the
operating room after left shoulder interscalene block was
introduced satisfactorily by the anesthesia service in the
preoperative area. She was placed supine on the operating
room table and underwent general endotracheal anesthesia
without complication. She received 600 mg of clindamycin IV
preoperatively. She was placed in modified beach chair
position. All bony prominences were well padded. The left
shoulder was prepped and draped in the standard sterile
fashion. An anterior deltopectoral approach was utilized
after infiltrating the skin with 10 cc of 2% Xylocaine with
epinephrine. The incision was carried sharply through the
skin and subcutaneous tissues just lateral to the coracoid
process.
The deltopectoral interval was developed. A deep retractor
was placed. The clavipectoral fascia incised just lateral to
the conjoined tendon. The [**Last Name (un) **] retractor was placed beneath
the conjoined tendon medially and the deltoid laterally. The
subscapularis bursa was excised. The anterior humeral
circumflex vessels were coagulated. A portion of the humeral
insertion of the pectoralis muscle was released to gain
better exposure. Arthrotomy was then performed of the
glenohumeral articulation by dissecting through the
subscapularis and capsule insertion approximately 1 cm medial
to the insertion of the lesser tuberosity using
electrocautery. The arm was placed in approximately 40
degrees of retroversion. Severe degenerative changes of the
glenohumeral articulation. The sagittal saw was then used to
remove the humeral head using the Osteonics guide as a
template. Osteophytes were removed with a rongeur.
The arm was then extended, and using the Osteonics straight
reamers, the intramedullary canal reamed up to a size 13 mm.
The arm was then placed back on the padded arm table, and
attention directed to the glenoid. The [**Last Name (un) 104772**] humeral head
retractor was placed beneath the posterior aspect of the
glenoid. The labrum was removed. The biceps tendon was noted
to be lacerated, therefore, it was dissected and excised. The
Osteonics reamer was then used to remove any remaining
articular cartilage on the glenoid. The [**Last Name (un) 30565**] drill was
then used to fashion a keyhole in the central portion of the
glenoid. An angled curet was used to remove cancellous bone
in the glenoid. The glenoid was copiously irrigated with
antibiotic solution, thoroughly dried. Polymethacrylate
cement was mixed and then packed into the keyhole slot for
the glenoid, and a #5 glenoid cement keeled Osteonics
component cemented into place. The cement hardened. The loose
and redundant cement was removed. The glenoid was noted to be
well fixed.
The arm was then extended again, and the real humeral
prosthesis, size 13, was press fit into place after
successive trial broaches had been used and the fins cut in
standard fashion. The prosthesis was placed in approximately
40 degrees of retroversion. Various humeral head trials were
used, and a size 45 x 15 gave the best soft tissue tension
with the ability of us to passively place the patient's arm
over her head with external rotation approaching 60 degrees
to 70 degrees.
The wound was then copiously irrigated. The humeral stem
dried thoroughly of liquid, and the real 45 x 15 Osteonics
humeral head impacted into place. Again, trial reduction was
noted to be satisfactory. The wound was copiously irrigated
with antibiotic solution. The deep retractors were removed.
The cephalic vein was noted to have a laceration, therefore,
it was tied off with 3-0 silk. The wound was closed in layers
using 0 Vicryl running for the deltopectoral fascia, 2-0
Vicryl for the dermis and running subcuticular 3-0 Prolene
for the skin. Steri-Strips were applied along with a dry
dressing, sling, and CryoCuff. Sponge and needle counts were
correct x2.
The patient was awakened from general anesthesia, extubated
without difficulty, and transferred to the recovery room in
satisfactory condition having tolerated the procedure without
complications.
OPERATIVE REPORT ([**2142-7-13**])
FIRST ASSISTANT: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15949**], RES
PREOPERATIVE DIAGNOSIS: Hematoma, left shoulder.
POSTOPERATIVE DIAGNOSIS: Hematoma, left shoulder.
PROCEDURE PERFORMED: Washout left shoulder wound.
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 75 cc.
INDICATIONS FOR OPERATION: This 76 year old female is status
post a left total shoulder arthroplasty by me 2 days ago.
Today she was noted to have a falling hematocrit and swelling
of the left shoulder. Concern was for an expanding hematoma.
After explaining to her and her family the treatment options,
I recommended that she had exploration of the left shoulder
wound with washout of hematoma.
DESCRIPTION OF OPERATION: The patient was brought to the
operating room and placed supine upon the table. She
underwent general endotracheal anesthesia without
complication. The left shoulder was prepped and draped in
standard sterile fashion. She was given 60 mg of clindamycin
IV preoperatively. The edges of the wound were opened. There
was noted to be an extensive amount of clotted blood
throughout the wound, including superficial and deep fascia.
The deltopectoral interval was also opened. There was noted
to be diffuse, mild oozing from multiple muscle points. This
was coagulated with electrocautery. No gross vascular
bleeders were encountered. Gelfoam with thrombin was used
help stop the bleeding along the inferior aspect of the
wound. The wound was copiously irrigated with antibiotic
solution and closed in layers using 0 Vicryl running for the
deltopectoral fascia, 2-0 Vicryl for the dermis, and staples
for the skin. The patient tolerated the procedure without
complication and was transferred back to the intensive care
unit in intubated fashion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 104773**], M.D. [**MD Number(1) 104774**]
CXR ([**2142-7-14**]): The patient is status post sternotomy, with
mild-to-moderate cardiomegaly. There is prominence of upper zone
vessels, with diffuse vascular blurring consistent with CHF.
There is blunting of both costophrenic angles consistent with
small pleural effusions. There is increased retrocardiac density
consistent with left lower lobe collapse and/or consolidation.
Compared with earlier the same day, the small pleural effusions
are new.
Echo ([**2142-7-16**]):
1. The left atrium is normal in size. The left atrium is
elongated.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
mildly
depressed. Resting regional wall motion abnormalities include
mid and distal
septal akinesis.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation
seen.
5. Mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation
is seen.
6.There is no pericardial effusion.
Brief Hospital Course:
The patient was admitted electively for L shoulder arthroplasty
and underwent this procedure on [**2142-7-11**]. Post-op, the patient
was noted to be in atrial fibrillation. She was started on a
heparin gtt and transfered to the medical service.
Electrophysiology evaluated the patient and recommended starting
amiodarone and digoxin, with plans for cardioversion in the
future after INR [**1-18**] for 4 weeks. The patient was started on
amio, digoxin, as well as heparin gtt.
.
The following morning ([**7-13**]), the patient became hypotensive at
around 11am with BP 80/40 and was anuric. Hct had fallen from
28.5 to 22.8 overnight. She received at total of 1.5 liters NS,
as well as 2 units PRBCs. Subsequently, her BP stablized at
106/70, with increased urine output. She was sating in the high
90's throughout this event. The MICU team was called for
evaluation at this point. Approximately 45 minutes later, the
patient dropped her BP to 82/58. She received an additional 1L
NS which brought her SBP back up to the 100's. The patient was
in T-[**Doctor Last Name **] and began to cough, with gurgling breath sounds.
Patient still satting well at 95-100% on 2L NC. ABG was
7.31/40/72, lactate 1.0, Hct 26. The patient c/o mild SOB and
left shoulder pain. The primary medicine team commented that her
left shoulder appeared more edematous than it had the evening
before. She denied SOB, palpitations, nausea, vomiting, BRBPR,
dysuria.
The patient's ICU course was significant for the following
issues:
1) HYPOTENSION: Given drop in Hct and increased swelling of left
shoulder after heparin gtt started, hypovolemia [**1-17**] to acute
blood loss into her shoulder was suspected. The patient was
taken back to the OR for revision of operative site (left
shoulder), which revealed some oozing but no clear vessel
responsible for major bleed. Pt was sent back to the unit
intubated and sedated. Calculated Hct from ABG was ~23, and
given the pt's poor IV access (1 peripheral IV), the a right
subclavian central line was placed while the pt was intubated
and sedated. 2U PRBC given, pt extubated the next am without
complication. GI bleed thought to be unlikely given guaiac
negative. Sepsis was also thought to be unlikely given no
apparent infectious source, afebrile, and normal WBC.
The patient was initially given boluses of IVF. She was
subsequently started on dopamine gtt for BP support and for
tailoring of her heart failure. Serial hct were checked and
noted to be stable. Over the course of her hospitalization, the
patient was transfused 6 units PRBCs. Her anticoagulation was
initially held. The patient's blood pressure improved with
diuresis and her dopamine was weaned off on [**2142-7-15**]. Her BP has
been stable since that time with SBPs in the 110 range and MAP >
60. She was re-started on her carvedilol and her other BP meds
should be re-started on her other home meds (diovan, aldactone)
as tolerated.
.
2) RESP DISTRESS: The patient was thought to be mildly volume
overloaded. She was intubated in the operating room but quickly
extubated. She was weaned off oxygen prior to discharge.
.
3) CHF: The patient was diuresed with iv lasix while on dopamine
for BP support. Her volume status improved and her creatinine
returned to baseline. Her heart failure regimen of carvedilol,
diovan, aldactone will need to be re-initiated as her BP
tolerates at rehab. An echocardiogram on [**2142-7-16**] revealed an EF
of 45% to 50%.
4) Atrial fibrillation/flutter: The patient had a history of
paroxysmal atrial fibrillation/flutter. Post-op, she was
started on amiodarone and digoxin for rate control and she was
started on a heparin gtt for anticoagulation. She was monitored
on telemetry. The plan had been for cardioversion in [**2-16**] weeks
after full anticoagulation. After discussion with the
orthopedic physicians and cardiology, the patient was re-started
on coumadin on the date of discharge ([**2142-7-17**]) and was not to be
bridged with lovenox given the risk of bleeding. Her goal INR
is [**1-18**]. Her coumadin will need to be titrated to reach this
goal. Her amiodarone was stopped in the setting of absent
anticoagulation. She should be re-started on amiodarone 200mg
qd once anticoagulated. She will need follow up with
electrophysiology and INR checks after discharge from rehab.
.
5) ACUTE ON CHRONIC RENAL FAILURE: The patient was thought to be
in acute renal failure from ATN form hypotension vs. heart
failure. Her creatinine improved with management of her
hypotension and heart failure. Medications were renally dosed.
SHe was at her baseline renal function (1.3) at the time of
discharge.
6) CAD: The patient was continue on lipitor, aspirin. She was
re-started on her BB and her diovan should be re-started as her
BP tolerates.
.
7) Gout: Her allopurinol was held in the setting of acute renal
failure, but was re-started prior to discharge (renal dosed).
.
8) GERD: The patient was continued on protonix.
9) CODE: The patient remained a full code throughout this
admission.
10 Follow up: The patient will need to follow up with her
primary care provider and with orthopedic doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
She will also need to be set up with INR checks and follow up
with her cardiologist upon discharge from rehab.
.
Completed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], ED1
Medications on Admission:
Aldactone 25 mg qd
Allopurinol 100 mg qd
Coreg 6.25 mg [**Hospital1 **]
Coumadin 5 mg qd, 7.5 mg q Friday
Lipitor 20 mg qd
Lasix 80 mg qd
Aspirin 81 mg qd
KCl 10 meq qd
Diovan 80 mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain/fever.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
titrate up to 80mg qd .
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): 5 mg qd except Friday 7.5 mg qd.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p shoulder arthroplasty
blood loss anemia
Atrial fibrillation
congestive heart failure
hypotension
acute/chronic renal failure
hypertension
Gout
Discharge Condition:
good, stable blood pressures off pressors x 48 hours
Discharge Instructions:
Take all your medications as directed. Follow up with your
primary care doctor and with the orthopedic doctor as below.
Followup Instructions:
You have a follow up appointment with Dr.[**Name8 (MD) 96749**] NP [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on Monday [**7-23**] at 9:30 AM in his clinic. If you need
to change your appointment call [**Telephone/Fax (1) 18002**]. Provider:
[**Name10 (NameIs) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ORTHOPEDIC PRACTICE Where: [**Doctor Last Name **] ORTHOPEDIC
PRACTICE Date/Time:[**2142-7-23**] 9:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2142-10-23**] 8:30
Follow up with NP[**First Name4 (NamePattern1) 6304**] [**Last Name (NamePattern1) **] on Thursday, [**7-19**] at 10:30 AM.
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 3670**]: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-7-19**]
10:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"438.9",
"274.9",
"458.29",
"272.0",
"584.9",
"427.31",
"414.01",
"285.1",
"715.31",
"412",
"428.32",
"593.9",
"998.12",
"401.9",
"V43.65",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.80",
"83.09"
] |
icd9pcs
|
[
[
[]
]
] |
20003, 20082
|
13305, 18361
|
360, 397
|
20273, 20327
|
4554, 13282
|
20496, 21663
|
3879, 3922
|
18958, 19980
|
20103, 20252
|
18749, 18935
|
20351, 20473
|
3937, 4535
|
18372, 18723
|
286, 322
|
425, 2385
|
2407, 3536
|
3552, 3863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,706
| 178,283
|
9966
|
Discharge summary
|
report
|
Admission Date: [**2165-2-27**] Discharge Date: [**2165-2-28**]
Date of Birth: [**2103-1-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP and sphincterotomy
History of Present Illness:
62 yo male with hx of CAD s/p CABG, ischemic CMPY, and gallstone
and pancreatic stone pancreatitis who presented to OSH with
abdominal pain transferred to [**Hospital1 18**] for ERCP now s/p
sphincteromy but aborted pancreatic duct stone removal. Prior to
recent presentation pt was treated with ERCP in [**7-17**] for
pancreatic stones which they were hesitant to attempt to remove
given his cardiomyopathy so he was manage expectantly. He
represented to OSH on [**2165-2-14**] with increasing adominal pain in
his epigastrum radiating to his chest. He had negative CE, but
amylase and lipase were elevated to 319 and 3209, respectively.
CT scan showed no acute abnormalities with coarse calcifications
in the pancreatic head with calcified gallstones. He slowly
improved with central line placement, TPN and NPO with
advancement to clears, and he was transferred to [**Hospital1 18**] for ERCP
vs laproscopic surgical therapy for definitive treatment. He was
initially reluctant to have a procedure due to his cardiac risk
but was seen by cardiology who felt his risk was not
unreasonable and the patient was agreeable. Of note during his
OSH stay he developed a cough with LLL infiltrate on CXR so was
started on CTX and azithromycin changed to vancomycin. Pt
tolerated his ERCP well on [**2164-2-28**] during which he received 3.1L
of crystaloid. The procedure was difficult and pancreatic stones
were unable to be removed although extensive sphincterotomy was
performed. He had severe nausea and abdominal pain post
procedure so given risk of ERCP induced pancreatitis in pt with
poor LV function he was tranferred to the ICU for close
post-procedure monitoring.
Past Medical History:
Pancreatitis
CAD s/p CABG [**2143**]
left orchiectomy for orchitis
CHF EF 25-35% s/p AICD
COPD
HTN
TIA/CVA [**2158**]
remote EtOH
recurrent pancreatitis
cholelithiasis
BPH
Social History:
Drank heavily until first pancreatitis flare in [**7-17**]. Cont to
smoke 1 ppd since age 12, no use of other illicit substances.
Lives with his wife.
Family History:
Brother died of unknown type of CA, father died at 37 of
rheumatic heart disease, no other hx of CAD, CVA, CA or
pancreatic disease
Physical Exam:
T 99.0 HR 90 BP 110/75 RR 16 O2Sat 99% on 6L
Gen-mild pain
HEENT-PERRL, JVP to 7cm, MM dry
Hrt-RRR, nS1 S2, [**3-19**] SM at RUSB, no R or G
Lungs-crackles 2/3 up bilat
Abd-distended and tympanitic, no fluid wave, mild diffuse
tenderness
Extrem-2+ radial and dp pulses
Neuro-CNII-XII intact, [**6-15**] UE strength, distal sensation intact
Pertinent Results:
WBC 9.2 Hct 30.7 Plt 332
.
Chem 7
138 104 12 140
3.7 25 0.7
.
AP 54 AST 42 ALT 53 amylase 183
.
Ca 8.0 Mg 1.7 Phos 2.9
.
[**2165-2-18**] ETT-EF 36%, WMA septal, anterior and lateral worse toward
the apex with coincident fixed perfusion defects
.
ECG- a sensed and V paced with intermittent AV sequestial
pacing, cannot assess for ischemia with pacing.
.
CXR-bibasilar atelectasis
.
[**2165-2-27**] ERCP:
1. Localized continuous congestion of the mucosa was noted in
the first part of the duodenum
2. Cannulation of the bile duct was performed with a
sphincterotome using a free-hand technique.
3. The common bile duct was normal.
4. There were gallstones seen in the gallbladder
5. A biliary sphincterotomy was performed in the 12 o'clock
position using a sphincterotome.
6. Cannulation of the pancreatic duct was performed with a 5-4-3
tapered catheter.
7. Large impacted stones could be seen in a highly irregular
pancreatic duct in the head of the pancreas.
8. We were unable to traverse the stones with a guidewire.
9. A pancreatic sphincterotomy was performed using a
sphincterotome.
10. Pancreatic fluid mixed with stone fragments were seen
following the pancreatic sphincterotomy.
Brief Hospital Course:
62 yo male with hx of CAD s/p CABG, ischemic CMPY, and gallstone
and pancreatic stone pancreatitis who presented to OSH for
abdominal pain transferred for ERCP now s/p sphincterotomy but
aborted pancreatic duct stone removal.
.
## Abdominal pain: Patient received uneventful sphincterotomy
after presenting to OSH with symptoms consistent with acute
pancreatitis. The procedure was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **].
Given instrumentation and dye injection into the pancreatic duct
during ERCP, the pt was at increased risk of ERCP-induced
pancreatitis. He was therefore transferred to the ICU for
further monitoring. The morning following the procedure, the
patient was completely asymptomatic without any complaints of
abdominal pain, nausea, or vomiting. It was therefore requested
that he be transferred back to his initial hospital for further
watchful waiting. It was also discussed, given his improved
cardiac function on a recent study, whether surgery would be an
option for treating this disease. However, this decision will
be deferred to his primary physicians.
.
## Cardiomyopathy: Recent imaging study suggested improving pump
function. He diuresed well on his own following the procedure
without need for any diuretics. His ace inhibitor and beta
blocker were restarted the morning following his procedure.
.
## Coronary artery disease: No evidence of ischemia over the
course of admission. Not on aspirin apparently since starting
warfarin at time of TIA in [**2158**]. Warfarin was held with the
possibility of further procedures in the near future.
.
## COPD: No documented PFTs in our system, although does have
significant smoking hx. Sounded more bronchospastic on exam
during admission. He was continued on albuterol, ipratropium as
needed.
.
## Pneumonia: Recently completed 10-day course of Zosyn. No
clinical evidence of pneumonia currently. He was not treated
with antibiotics following his procedure.
.
## TIA: On warfarin as an outpatient, although reason is not
entirely clear as there is no evidence that patient has atrial
fibrillation. Likely fewer bleeding events with aspirin with
similar secondary prevention benefit. He was not restarted on
aspirin or warfarin as described above, however, this should be
addressed with cardiolist/PCP at later time.
Medications on Admission:
Outpt meds:
Folate 1mg qd
Toprol XL 25mg qd
Lasix 40mg qd
Lipitor 20mg qd
Coumadin 2mg qd with 3mg on Wed
Imdur 60mg qd
Lisinopril 10mg qd
Prozac 20mg qd
Omeprazole 20mg qd
Creon
.
Meds on transfer:
Tylenol
Lipitor 20mg qd
Zosyn
Clonopin 0.5mg tid prn
Fluoxetine 20mg qam
Folate 1mg qd
Imdur 60mg qam
Lactulose 30ml qd
Lisinopril 10mg qam
Magaldrate 10mg qid prn
Reglan 10mg qachs
Toprol XL 25mg qd
MOM prn
Morphine 4mg q3h prn
ondansetron 4mg q8h prn
Protonix 40mg [**Hospital1 **]
Zolpidem 5mg qhs
Ipratropium and albuterol nebs
Discharge Medications:
1. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO ONCE (Once) as needed for nausea for 1 doses.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety, agitation.
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for indigestion.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheeze.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheeze.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
15. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed for nausea.
16. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: pancreatic stones, pancreatitis s/p ERCP
Secondary: CAD, CHF, COPD, HTN, BPH
Discharge Condition:
stable, pain-free, breathing comfortably on RA
Discharge Instructions:
You are being transferred back to [**Hospital3 3583**] for further
monitoring of your abdominal pain and pancreatic stones.
Followup Instructions:
Follow up with your PCP and gastroenterologist 1-2 weeks after
you are discharged from the hospital.
|
[
"V45.81",
"428.0",
"600.00",
"577.8",
"577.0",
"414.00",
"401.9",
"496",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
8833, 8848
|
4177, 6501
|
328, 353
|
8978, 9027
|
2948, 4154
|
9199, 9303
|
2432, 2566
|
7083, 8810
|
8869, 8957
|
6527, 6708
|
9051, 9176
|
2581, 2929
|
274, 290
|
381, 2051
|
2073, 2247
|
2263, 2416
|
6726, 7060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,744
| 111,029
|
12162
|
Discharge summary
|
report
|
Admission Date: [**2169-9-25**] Discharge Date: [**2169-10-9**]
Date of Birth: [**2106-2-15**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Gangrenous left third toe.
HISTORY OF PRESENT ILLNESS: History of present illness was
obtained from the husband and computer records since the
patient is aphasic. This is a 63 year-old white female with
a history of atrial fibrillation status post cerebrovascular
accident times four, peripheral vascular disease, status post
popliteal peroneal bypass graft with a left TMA resulting in
a left below the knee amputation in [**Month (only) 958**] of this year and a
right popliteal peroneal nonrevealing saphenous vein in
[**Month (only) 956**] of this year who developed right third toe
discoloration a few weeks prior to admission. She was seen
by her podiatrist initially and then on follow up noted to
have gangrenous changes. The patient was referred to Dr.
[**Last Name (STitle) **] who saw her in the office today. She is now
admitted for further evaluation and treatment of her
gangrene.
ALLERGIES: Vancomycin hives. Coumadin and aspirin cause
retinal bleed. Tape causes rash.
MEDICATIONS:
1. Insulin 75/25 30 units q.a.m. and 30 units at supper.
2. Lexapro 20 mg q day.
3. Aggrenox one b.i.d.
4. Fosamax 70 mg q Sunday.
5. Multivitamin tablet one q.d.
6. Vitamin E, C and B-6 one q.d.
7. __________ with fiber one can with breakfast.
8. Altace 2.5 mg q.a.m.
9. Co-enzyme Q.
10. Betacarotene.
PAST MEDICAL HISTORY:
1. Atrial fibrillation initially diagnosed in [**2168-6-13**].
2. Cerebrovascular accident in [**2167-1-15**] and [**2168-6-13**]
treated with Plavix with residual expressive aphasia.
3. Diabetes since the age of 50 with neuropathy and
retinopathy.
4. History of left deep venous thrombosis in [**2162**] treated
with Coumadin.
5. Thyroid nodule with subtotal thyroidectomy.
6. Osteoporosis on Fosamax.
7. Depression.
8. Mature cataracts OU.
9. VRE infection.
10. Left below the knee amputation stump in [**2169-5-14**].
11. Peripheral vascular disease.
PAST SURGICAL HISTORY;
1. Subtotal thyroidectomy.
2. Amputation of the right first toe.
3. Left popliteal peroneal nonreverse saphenous vein in [**2168-6-13**].
4. Left TMA in [**2168-6-13**].
5. Left below the knee amputation in [**2169-2-11**].
6. Right AK popliteal peroneal in [**2169-1-14**].
7. Revision of left below the knee amputation in [**2169-1-14**].
8. Vitrectomy left.
SOCIAL HISTORY: She is married and lives with her husband.
She uses left prosthesis part of the day and wheel chair the
rest of the day.
PHYSICAL EXAMINATION: Vital signs temperature 98.6. 142/76,
64, 18, O2 sat 96% on room air. General appearance, alert,
cooperative white female in no acute distress. HEENT
examination unremarkable. Tongue is midline. Carotids are
palpable without bruits. Pulse examination shows palpable
carotids, radials 2+, femoral on the right is 1+, popliteal
nonpalpable. Dorsalis pedis pulse and posterior tibial pulse
are nondopplerable. On the left the popliteal is nonpalpable
and she has a below the knee amputation. There are no
femoral bruits. Chest examination lungs are clear to
auscultation. Heart is irregular regular rhythm. Abdominal
examination was obese with bowel sounds, nontender, no masses
or organomegaly. Left below the knee amputation is a 1 cm
lateral incision opening with foul odor and surrounding
erythema. There is a 1 cm diameter traumatic lesion on the
dorsum of the right hand and right knee with surrounding
erythema, but no drainage. The right leg is moderate ankle
edema and erythema of the distal two thirds of the leg. The
leg is cool to touch. There is small dry eschar on the right
first toe amputation and the second toe with gangrenous right
third toe changes with minimal drainage from the lateral
aspect. Right heel is without fissures or pressure ulcers.
Neurologically she has expressive aphasia and emotionally is
very labile.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. She is placed on VRE precautions. Routine
laboratories were obtained, white blood cell count 11.1,
hematocrit 35.2, platelets 450 K, BUN 22, creatinine 1.0, K
4.6, PT/INR 12.7 and 1.1. Chest x-ray showed no active
cardiopulmonary disease. Electrocardiogram showed atrial
fibrillation. Wound cultures were obtained. Initial swab
grew beta streptococcus group B, moderate growth and
Corynebacterium. Blood cultures were obtained on [**2169-9-26**],
which were no growth and finalized on [**2169-10-2**]. Blood
cultures were no growth and finalized. Stool cultures were
obtained, because of loose stools. C-diff was negative. The
patient's swab cultures grew beta streptococcus group B and
Corynebacterium. The patient was continued on antibiotics.
She was intravenously hydrated and underwent arteriogram on
[**2169-9-26**]. Arteriogram demonstrated abdominal aorta widely
patent with infrarenal aorta with bilateral renal arteries
and brisk filling nephrograms. There is a widely patent
common iliac and external iliac arteries, hypogastric
bilaterally are patent. The run off to the right lower
extremity, patent common femoral profunda and superficial
femoral artery. The superficial femoral artery occludes at
the [**Doctor Last Name **] canal. There is a blind segment of popliteal and
reconstitutes and then occludes. A TB constitutes just
distal to its origin. The PT and peroneal are occluded at
its origins. The AT fills the distal peroneal artery the
collaterals above the ankle. The peroneal artery then fills
retrograde and is patent in the upper calf. The PT
reconstitutes at the level of the ankle. The dorsalis pedis
is poorly visualized. These findings were discussed with Dr.
[**Last Name (STitle) **].
Post angio creatinine was 1.0, remained stable. Vein mapping
of the upper extremity and lower extremity including
saphenous was obtained to determine vein conduit. The
patient underwent on [**2169-9-30**] a right distal superficial
femoral artery proximal anterior tibial nonreverse saphenous
vein graft bypass using two segments of the greater saphenous
from the right and left thighs, angioscopy with valve lysis.
The patient tolerated the procedure well. JPs were placed in
the right thigh. The patient was transferred to the PACU in
stable condition. Immediately postoperatively she was
hemodynamically stable. Postoperative hematocrit was 32.6,
BUN 11, creatinine 0.8, K 4.0. The patient continued to do
well and showed a dopplerable dorsalis pedis and posterior
tibial and popliteal pulses on the operative side. The JP
drainage was serosanguinous output. The patient was in
atrial fibrillation and she required beta blockade for rate
control. She continued to do well and was transferred to the
VICU for continued monitoring and care. The patient required
neo-synephrine postoperative and fluid boluses for systolic
hypotension. Her temperature max was 100.4 to 100.3. She
remained in atrial fibrillation with a V rate of 77, systolic
was 132, diastolic 49, CVP 2. The patient's hematocrit
drifted to 28.5, BUN and creatinine remained stable.
Blood cultures were obtained, which were finalized at no
growth. C-diff was obtained, which was negative.
Neo-synephrine wean was begun. Diet was advanced as
tolerated. The patient was transfused 1 unit of packed red
blood cells. Her calcium was repleted. Intravenous
antibiotics were continued. She was placed on subcutaneous
heparin for deep venous thrombosis prophylaxis and remained
in the VICU. Postoperative day two the patient required 2
units of packed red blood cells. Post transfusion hematocrit
was 28.5 to 27. The following morning hematocrit was 27.7
with a white blood cell count of 13.3. BUN and creatinine 15
and 1.0, K 4.3. Physical examination was unremarkable. She
had dopplerable dorsalis pedis pulses and posterior tibial
pulses and palpable popliteal. Wounds were clean, dry and
intact. Morphine for analgesic control was converted to
Oxycodone. Neo-synephrine was weaned off and she continued
on her Lopressor systolic blood pressure is 114/40. She
required additional unit of blood with Lasix. She was
delined and transferred to the regular nursing floor,
ambulation to chair was begun. Postoperative day three the
patient defervesced to 99.2. She was continued on Linezolid,
Zosyn and Flagyl. Hematocrit post transfusion was 29.5, BUN
12, creatinine 0.7. Zosyn was discontinued. Levofloxacin
was started for enterococcus coverage. The Foley was
discontinued. CVL was converted to a peripheral line.
Case management was requested to begin rehab screening. The
patient underwent toe amputation on [**2169-10-6**] of toes two,
three, four and five without incident. The initial dressing
was removed on postoperative day one. The wound was clean,
dry and intact. Physical therapy felt that she would require
rehab to bring her to baseline. Her white blood cell count
remained stable at 15.2 her hematocrit was 33. Oxycodone and
morphine were utilized for pain. The remaining hospital
course was unremarkable. The patient was discharged to rehab
on [**2169-10-9**]. Her wounds were clean, dry and intact. Skin
clips were intact. The distal left saphenous vein harvest
site showed skin dehiscence, normal saline wet to dry
dressings were begun. The amputation sites were clean, dry
and intact without erythema, ecchymosis or ischemic skin
changes. The first metatarsal head showed some ulceration,
superficial normal saline wet to dry dressings were begun on
this. The patient will be allowed to ambulate full weight
bearing with healing sandle on the right foot. Skin clips
sutures remain in place for a total of seven more days and
then could be discontinued on [**2169-10-17**]. The toe amputation
site sutures remain in place for a total of four weeks until
seen in follow up. The patient will continue on antibiotics
for a total of seven days post discharge.
DISCHARGE MEDICATIONS:
1. Aspirin/Persantine 25/200 mg tables one b.i.d.
2. Fosamax 70 mg one q Sunday.
3. Citalopram oxalate 10 mg tablets two for a total dose of
20 q.a.m.
4. Senna tabs two q.d. prn.
5. Dulcolax suppository q.d. prn.
6. Multivitamin capsules one q.d.
7. Oxycodone 5 mg tablets one q 4 to 6 hours prn for pain.
8. Acetaminophen 325 mg tablets one to two q 4 to 6 hours
prn for pain.
9. Linezolid 600 mg q 12 hours for a total of fourteen days.
10. Ramipril 1.25 capsules two q.a.m.
11. Lopressor 25 mg b.i.d.
12. Flagyl 500 mg t.i.d. times fourteen days.
13. Levofloxacin 500 mg q.d. times fourteen days.
14. Zyloprim 5 mg at h.s. prn.
15. Miconazole powder to affected areas t.i.d. prn.
DISCHARGE DIAGNOSES:
1. Right third toe gangrene and leg cellulitis.
2. Failed right AK popliteal peroneal bypass graft.
3. Status post right femoral anterior tibial bypass with
composite bilateral saphenous vein.
4. Right toe amputations two through four.
5. Blood loss anemia corrected.
6. Systolic hypotension corrected.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2169-10-9**] 08:37
T: [**2169-10-9**] 09:54
JOB#: [**Job Number 38097**]
|
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22,851
| 128,768
|
43081
|
Discharge summary
|
report
|
Admission Date: [**2112-6-12**] Discharge Date: [**2112-6-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82F with hx of CAD s/p MI in [**2103**], PVD s/p AKA, DM, HTN, high
cholesterol, CHF (10%) who presents with acute onset sob. Per
family, pt has been fatigue with decreased appetite since her
discharge from the hospital last week. (Of note, pt was recently
admitted to [**Hospital1 18**] from [**Date range (1) 62162**] with gross hematuria with clots
in the setting of a supratherapeutic INR of 3.3; urology was
consulted and recommended CBI and treating UTI; hematuria
cleared by hospital day #3 and pt was discharged.) She was also
complaining of pain on urination and back pain. Her family
states that they were told to increase her fluid intake to try
to flush out the hematuria so the patient has been drinking
three 20oz mugs of water per day (~1.8-2.0 liters). Yesterday,
pt was not very hungry and only wanted soup so she had a
"cup-o-soup" and some crackers. She started feeling slightly
short of breath last night but was able to sleep. This morning,
pt's daughter found the pt sitting upright, with labored
breathing, cold and clammy. The pt was also complaining of chest
tightness and she took SL NTG x 2 without relief. She therefore
presented to the ER.
.
On arrival to ER, pt's BP was 160s/80s with a HR in the 100s.
She was given metoprolol 5mg IV x 1 and started on a NTG gtt.
She was also given 20mg of lasix and 1mg of morphine. A foley
was placed and gross hematuria returned. Cardiology was
consulted for ST depressions noted on EKG. Heparin and plavix
were held due to hematuria and supratherapeutic INR. Urology was
consulted for the hematuria and they recommended continuous
bladder irrigation.
.
On arrival to the floor, pt was very short of breath,
diaphoretic and complaining of chest pain and back pain. She was
given 60mg IV lasix and placed on CPAP 5/5, 40% FiO2.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or rigors
and 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, ankle edema.
Past Medical History:
1. CAD s/p MI in '[**03**]
2. CHF with EF of 20-25%, severe global HK
3. DMII, on insulin
4. HTN
5. Hypercholesterolemia
6. PVD s/p right axillary bifem bypass in [**2108**]
7. Atrial fib/flutter post op in [**2108**]
8. Anemia (Fe deficiency)
9. h/o CVA
[**15**]. h/o cataracts
11. h/o fatty liver
12. Nephrolithiasis
.
PAST SURGICAL HISTORY:
1. Cholecystectomy, remote.
2. Right ureteral stenting for large stones, [**2102**]
3. Appendectomy, remote.
4. Bilateral cataract surgeries, remote.
5. Right axillary bifemoral bypass on [**2108-3-27**].
6. Left AKA [**4-/2111**]
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Temp 95.5. Blood pressure was 130/68 mm Hg while seated. Pulse
was 100 beats/min and regular, respiratory rate was
36breaths/min on 100% NRB. Generally the patient was well
developed, well nourished and well groomed. The patient was
oriented to person, place and time.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The were no chest wall
deformities, scoliosis or kyphosis. The respirations were
labored with use of accessory muscles. Lung sounds were very
decreased with crackles about [**2-2**] way up.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. No murmurs
.
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. Extremities were cool and clammy.
.
Pulses:
Right: Carotid 2+ Femoral 1+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 1+
.
Pertinent Results:
[**2112-6-12**] 10:15AM WBC-21.6* RBC-2.78*# HGB-8.6*# HCT-26.0*#
MCV-93 MCH-30.8 MCHC-32.9 RDW-15.9*
[**2112-6-12**] 10:15AM CK-MB-NotDone
[**2112-6-12**] 10:15AM cTropnT-0.07*
[**2112-6-12**] 10:15AM CK(CPK)-75
[**2112-6-12**] 05:00PM CK-MB-53* MB INDX-10.0 cTropnT-1.11*
[**2112-6-12**] 05:00PM CK(CPK)-531*
.
EKG demonstrated sinus tach at 106, nl axis, ST elevation in
V1-V3 and aVR with ST depressions in V5-V6; compared to EKG from
[**2112-6-2**], ST elevations are slightly worse and ST depressions
are new
.
2D-ECHOCARDIOGRAM performed on [**2111-4-20**] demonstrated: EF 20-25%
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is severe regional left
ventricular systolic dysfunction with near akinesis of the
distal 2/3rds of the ventricle. Basal segments are hypokinetic.
No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2108-4-2**],
systolic function appears similar and c/w multivessel CAD (was
regional dysfunction previously) and the severity of mitral
regurgitation is reduced (previously mild-moderate).
.
CARDIAC CATH performed on [**2107-10-25**] demonstrated:
1. Resting hemodynamics revealed significantly elevated
filling pressures (PCWP 22, LVEDP 27), relatively preserved CI
(2.6) and severe hypertension (SBP 190).
2. Left ventriculography revealed severe systolic dysfunction
with an EF of 24%.
3. Coronary angiography revealed a right dominant system. The
LMCA did not have any significant obstructive disease. The LAD
had a 100%mid occlusion. The LCX had a 70% mid stenotic lesion.
The RCA had a 70% origin stenosis and a 50% mid stenosis.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systolic and diastolic ventricular dysfunction.
.
CXR:
1. Increased interstitial marking and upper zone vascular
redistribution and increased opacity at right lower lobe
suggesting presence of pulmonary edema.
2. Linear markings at the left lower lobe suggesting the
presence of atelectasis. Small amount of left-sided pleural
effusion is also present.
3. Unchanged appearance of small calcified granuloma of the left
upper lobe.
.
CT abd/pelvis:
1. Limited study due to nonadministration of intravenous
contrast. Severely calcified aorta and major branches.
2. Unchanged calcified aneurysm at the cardiac apex.
3. Status post axillofemoral and transfemoral vascular bypass
graft.
4. Diverticulosis, without evidence of acute diverticulitis.
.
CTA chest:
1. Small bilateral pleural effusions, right greater than left,
and
interlobular septal thickening consistent with pulmonary
edema/CHF.
2. Heavy atherosclerotic calcification of the coronary arteries.
Left ventricular calcified aneurysm at the cardiac apex,
unchanged.
3. Enlarged right hilar lymph node measuring 2.2 cm x 1.7 cm,
while this may be seen in the setting of fluid overload, close
interval followup is recommended with repeat CT of the chest in
three months. Alternatively, this lymph node would be amenable
to transbronchial biopsy. In addition, if prior CTs of the chest
are available for comparison, an addendum can be made to this
report.
4. No evidence of thoracic aortic aneurysm or dissection.
5. Patent right axillary-distal bypass graft.
6. Filling defect within the proximal SMA which may be secondary
to chronic occlusion, correlation with patient's symptoms is
recommended. If clinically warranted, CTA of the mesenteric
vasculature may be performed.
Brief Hospital Course:
82F with hx of 3-vessel CAD s/p MI in [**2103**], PVD s/p AKA, DM,
HTN, high cholesterol, CHF (EF 20%) who presents with acute
onset of SOB due to exacerbated CHF, also found to have
hematuria requiring 2U pRBC transfusions and continuous bladder
irrigation.
.
1. CHF: EF last year [**25**]-25%. Acute exacerbation likely
precipitated by increased water intake combined with increased
salt intake one day PTA. Pt's family denies any medications
changes and pt did not receive large amount of fluid (i.e. PRBC
transfusion) during last admission. Patient was admitted to CCU.
Aggressive diuresis and blood pressure control lead to fast
improvement of respiratory status. She did not require CPAP
anymore soon after having been in the CCU. Diuresis was
continued with [**Year (2 digits) **] of negative 1.5-2.0L. She was continued on
toprol, ACE-I, digoxin. Coumadin was discontinued given that the
risk of development of clot (in setting of LV hypokinesis) was
highest within first 6 months of MI (her MI was in [**2103**]).
.
2. Ischemia: EKG with ST depressions, however, likely strain
pattern in setting of HTN and resp distress. Not the likely
precipitant for this CHF exacerbation. Enzymes peaked at a CK of
56, MB of 9.0 and Trop of 2.85. Likely all due to demand
ischemia. Pt without intervenable disease, not a cath candidate.
Patient was started on ASA 325, then reduced to 81 qd because of
hematuria. Heparin gtt and plavix were not given b/o hematuria.
BP was controlled as above. Statin was continued.
.
3. Rhythm: hx of afib/flutter post op in [**2108**]; EF of <35% and
occasional runs of NSVT on tele, ? possibly candidate for ICD
which should be considered in the future.
.
4. Hematuria: Recent admission for gross hematuria without
definitive cause identified. Also longstanding history of less
severe microscopic hematuria concerning for malignancy. During
this admission, again found to have substantial hematuria.
Extraglomuerular given the presence of clots. Per family, right
ureteral stent is in place from [**2102**]; however, after discussion
with radiology, imaging did not show any presence of stent. Also
per urology, stent must have been taken out long time ago. INR
was supratherapeutic on coumadin, likely contributing to
hematuria. Coumadin was discontinued during this admission (no
need anymore for anticoagulation as mentioned above). Also, her
daily aspirin was decreased from 325mg daily to 81mg daily. A
3-way foley for CBI was placed. CBI was performed until urine
cleared. 2U pRBC were initially required to stabilized Hct. Ucx,
UA and cytologies were sent. Cultures were negative. Urology was
consulted and recommends outpatient cystoscopy and CT urogram.
An appointment has been scheduled.
.
5. DM: Pt missed am doses of insulin, thus on admission with
markedly elevated glucose and positive ketones in urine. Patient
was kept intially on an insulin drip but was switched to RISS
after BG control. Her home regimen of NPH was restarted.
.
6. Back Pain: Located in between shoulder blades, not
reproducible. No dissection seen on chest CTA. Tylenol prn.
Soon resolved after admission.
.
7. Anemia: Hct 26 down from 39 eight days ago. Possible sources
of blood loss include abdomen (neg abd CT), urine (unclear
whether gross hematuria can lead to Hct drop of 13 points in one
week), GI tract (guaiac all stools). Patient required 2U PRBC
initially to stabilize Hct. Hct remained stable around 28 since
then.
.
8. Leukocytosis: On admission, afebrile though leukocytosis
elevated to 21,000 with left shift. During last admission, pt
treated with 7 days of cipro for pos UA though urine cx was
negative. Ddx includes stress reaction (though higher than
typically seen with stress rxn), c diff (given recent abx use),
new UTI, pneumonia (none seen on CXR), malignancy (esp given
hilar LN and microscopic hematuria). Also with elevated lactate.
Lactate came down, Ucx was negative, Bcx were pending upon
discharge. WBC trended down but should be followed up as
outpatient.
.
9. Supratherapeutic INR: symptomatic with gross hematuria; no
other signs of active bleeding. Coumadin was discontinued as
mentioned above.
.
10. Hilar LN: 2.2 x 1.7cm hilar lymph node seen on CTA. Will
need followup in 3 months with another chest CT. Ddx includes
volume overload, malignancy, infection.
.
11. SMA occlusion: seen on abd CT; appears chronic per
radiology; if abd pain would develop, mesenteric ischemia should
be considered. Guaiac'd stools and monitored with abdominal
exams.
.
12. FEN: Initially NPO until resp status had stablized; 1.5L
fluid restriction, [**Doctor First Name **], cardiac diet thereafter.
.
13. Access: right IJ, 20g PIV
.
14. Ppx: supratherapeutic INR, PPI (on at home)
.
15. Code: full, confirmed with patient
.
16. Comm: daughter [**Name (NI) **]
.
Medications on Admission:
1. Metoprolol Tartrate 25 mg tid
2. Acetaminophen 325 mg prn
3. Isosorbide Dinitrate 10 mg tid
4. Captopril 12.5 mg tid
5. Pantoprazole 40 mg qd
6. Furosemide 40 mg qd
7. Aspirin 325 mg qd
8. Digoxin 125 mcg qd
9. Rosuvastatin 10mg qhs
10. NPH 36U qam, 16U qpm
11. Regular 14U qam, 16U qpm
12. Coumadin 1.5mg qd (none since Friday)
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Insulin Regular Human 100 unit/mL Cartridge Sig: Ten (10) U
Injection qAM.
6. Insulin Regular Human 100 unit/mL Cartridge Sig: Five (5) U
Injection qPM.
7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty
(30) U Subcutaneous qAM.
8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twelve
(12) U Subcutaneous qPM.
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Isosorbide Mononitrate 30 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*
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. Acute congestive heart failure exacerbation
2. Coronary artery disease, 3-vessel disease, s/p MI in [**2103**]
4. Hematuria, requiring 2U pRBC transfusion
5. Hypertension
.
Secondary Diagnosis:
1. Hyperlipidemia
2. Peripheral vascular disease of the extremities, s/p
amputation
3. h/o stroke
4. Chronic Anemia, requiring 2U pRBC
5. Diabetes
6. Atrial fibrillation, post op
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Urinating clear yellow urine
Discharge Instructions:
You have been treated for acute worsening of your chronic heart
failure and for bleeding in your urine. You have received
medications to increase your urine output and decrease your
blood pressure. You have also received blood products because of
blood in your urine
.
You should avoid any salty foods and too much fluid intake.
Limit your salt intake to less than 2grams of sodium per day.
Limit your fluid intake to less than 1.5 liters. You should
weigh yourself daily. If your weight increases by more than 2
pounds please inform your primary care physician
.
You need to follow up with urology for further workup of your
bladder bleeding. You will have a cat scan before your urology
appointment
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed.
- Discuss with Dr. [**Last Name (STitle) **] whether you should start a medication
named Aldactone for your heart failure.
- We have stopped your coumadin. You should not start this
again because it likely contributed to the bleeding in your
urine.
- your aspirin has been decreased to 81mg once a day
.
On your CT scan there was a enlarged hilar lymph node. You will
need to have another CT scan of your chest in 3 months to
re-evaluate this lymph node. Please inform Dr. [**Last Name (STitle) **] of this
finding.
Followup Instructions:
Please follow up with your primary care doctor ([**Last Name (LF) 5533**],[**First Name3 (LF) **]
M. [**Telephone/Fax (1) 3581**]) in [**2-2**] weeks from now.
.
You will have a cat scan of your bladder and kidneys on Thurs,
[**6-23**] at 1:30. Radiology is located in the [**Hospital Ward Name **] building,
[**Location (un) **]. You must not eat anything for 3 hours prior to the
cat scan
.
Please follow up with urology (Dr. [**Last Name (STitle) 3748**], phone ([**Telephone/Fax (1) 8791**],
[**Location (un) 470**], [**Hospital Ward Name 23**] Building) on [**7-14**] at 8AM.
.
***You were found to have an enlarged lymph node in your chest.
This may have been due to the congestive heart failure but this
needs to be followed. You will need to have a repeat chest CT
in 3 months. Dr. [**Last Name (STitle) **] can schedule this for you. ***
Completed by:[**2112-6-16**]
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17046, 17928
|
3289, 3371
|
13617, 14940
|
15041, 15041
|
13260, 13594
|
6615, 8398
|
15575, 17023
|
2915, 3148
|
3386, 4501
|
222, 227
|
299, 2549
|
15257, 15438
|
15060, 15236
|
2571, 2892
|
3164, 3273
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,655
| 148,418
|
7782
|
Discharge summary
|
report
|
Admission Date: [**2161-8-5**] Discharge Date: [**2161-8-12**]
Date of Birth: [**2108-11-18**] Sex: F
Service: TRANS [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
black female with end-stage renal disease secondary to
polycystic kidney disease on hemodialysis since [**2157-3-3**] on
Mondays, Wednesdays, and Fridays. Patient was listed on the
kidney transplant list since [**2157-9-2**]. Patient denies
any recent infections, fevers, chills, nausea, vomiting, or
diarrhea. Her polycystic kidney disease was diagnosed when
patient was 36 years old. Disease is bilateral in nature.
It was first symptomatic with hypertension. Patient is being
admitted for cadaveric renal transplant.
PAST MEDICAL HISTORY:
1. Polycystic kidney disease.
2. Diabetes type 2.
3. History of fibroids.
4. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Total abdominal hysterectomy in [**2147-9-3**].
2. Tubal ligation.
3. Left AV fistula.
4. Sinus surgery for polyps.
ALLERGIES:
1. Zestril.
2. Pet dander.
3. Dust.
HOME MEDICATIONS:
1. Lipitor 10 mg q. day.
2. [**Doctor First Name **] 180 mg q. day.
3. Starlix 120 mg t.i.d. before meals.
4. Aciphex 20 mg q. day.
5. Nephrocaps one capsule per day.
6. PhosLo 657 mg before meals.
7. Neurontin 300 mg q.h.s.
8. Folic acid one q. day.
9. Vitamin C 500 q. day.
10. Flonase two sprays per nostril per day.
11. Lactulose 20 cc t.i.d.
12. Fish oil supplements with meals.
SOCIAL HISTORY: Patient has no tobacco history and is a
recreational drinker.
FAMILY HISTORY: Patient has an extensive family history of
polycystic kidney disease. Mother, brother, eight aunts, and
her daughter are all afflicted with the disease. Her father
had diabetes.
PHYSICAL EXAMINATION: On physical exam the patient is
afebrile. Vitals are stable. Temperature 98.9, pulse 68,
blood pressure 120/70, respirations 18. Patient is in no
apparent distress, alert and oriented times three.
Normocephalic. Extraocular muscles intact. Pupils equal,
round, reactive to light. No scleral icterus noted. Neck is
supple. No lymphadenopathy, no jugular venous distention.
Heart is regular rate and rhythm. No murmurs. Lungs are
clear to auscultation bilaterally. Abdomen is soft,
nontender, nondistended, positive bowel sounds. Extremities:
No edema noted. Rectal and pelvic exams deferred.
Patient was admitted to the Transplant Surgery service, Dr.
[**Last Name (STitle) **] attending.
LABORATORY DATA: Labs sent off were CMP, EBV panels, CBC,
Chem-10, cholesterol, triglycerides, and coags. Patient was
also ordered for a chest x-ray and EKG per preoperative
protocol. In addition, the following immunosuppressive drugs
were ordered on call to the Operating Room: Thyroglobulin
125 mg, Solu-Medrol 500 mg, CellCept [**Pager number **] mg, and Kefzol 1000
mg. Hibiclens scrub was administered to the abdomen prior to
going to the Operating Room. Patient was also typed and
crossed for two units of packed red blood cell.
Patient's EKG was normal sinus rhythm, marked left axis
deviation, old inferior infarct, lateral ST-T changes,
nonspecific, and there was no previous tracing for
comparison. Chest x-ray was found to have no significant
cardiopulmonary abnormalities.
HOSPITAL COURSE: Patient was taken to the Operating Room on
[**2161-8-5**] for cadaveric renal transplant. For detailed
account, please see operative report. Postoperatively,
patient went from the Postanesthetic Care Unit to the
Surgical Intensive Care Unit secondary to patient's systolic
blood pressure unable to be sustained above 120 without
Neo-Synephrine drip.
Ultrasound of transplanted kidney on postoperative day number
one to investigate anuric patient had the following findings.
No paranephric fluid collection and no hydronephrosis, normal
venous flow, abnormal arterial flow demonstrating only
systolic flow and no diastolic flow corresponding to a
resisted index of one.
A renal nuclear scan was also obtained on postoperative day
number one with the following findings. Blood flow images
show normal renal perfusion. Renalgram images show delayed
excretion. Above-described finding consistent with acute
tubular necrosis.
On postoperative day number two patient remained in the ICU,
blood pressure being 101/98 on one microgram of
Neo-Synephrine. On postoperative day number two patient
remained anuric and labs were significant for a protein of
6.4. Patient was taken to hemodialysis at that time. In
addition, Thymocyte treatment was continued.
On postoperative day number three patient was on CellCept,
Solu-Medrol 120 mg, and a fourth dose of Thymo. Blood
pressure was in the 120s on 0.7 mcg of Neo. Urine output was
still minimal at this time. Patient was transferred to the
floor.
On postoperative day number four [**Hospital 228**] hospital course
was unremarkable.
On postoperative day number five patient was on another dose
of ATG 125, Prednisone 40, and CellCept [**Pager number **] p.o. Patient
again received hemodialysis on that day. Urine output
continued to be minimal.
On postoperative day number six patient's urine output
continued to be minimal. Prograf was started that night, 1
mg, and folate was discontinued.
On postoperative day #7 patient received hemodialysis and
after hemodialysis was deemed well enough to go home.
Patient was also seen by Gastrointestinal for recurrent
reflux. GI scheduled outpatient follow up for her.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Status post cadaveric renal transplant.
2. Delayed graft function.
3. Acute tubular necrosis.
4. Polycystic kidney disease.
5. Diabetes.
6. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS:
1. Bactrim Single Strength p.o. q. day.
2. Colace 100 mg p.o. b.i.d.
3. Nystatin 5 cc, swish and swallow, q.i.d.
4. Valcyte 450 mg p.o. q.o.d.
5. CellCept [**Pager number **] mg b.i.d.
6. Calcium carbonate 1500 mg t.i.d.
7. Advair Diskus 150, one disk, b.i.d.
8. Aciphex 20 mg p.o. q. day.
9. Nystatin powder, apply to groin area b.i.d.
10. Percocet, one to two, q. four to six hours p.r.n. pain.
11. Lactulose 30 cc p.o. q. eight hours p.r.n. for
constipation.
12. Tacrolimus 5 mg p.o. b.i.d.
13. Prednisone 20 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. Follow up with Dr. [**Last Name (STitle) **] [**2161-8-20**], 10:40 a.m.
2. Follow up with Dr. [**Last Name (STitle) **] on [**2161-9-1**] at 12 noon in
the Transplant Center.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2161-8-12**] 15:30
T: [**2161-8-13**] 14:35
JOB#: [**Job Number 28180**]
|
[
"996.81",
"530.81",
"585",
"458.2",
"584.5",
"250.60",
"284.8",
"276.7",
"753.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
5494, 5532
|
1579, 1760
|
5553, 5736
|
5759, 6297
|
3298, 5472
|
6321, 6738
|
895, 1070
|
1088, 1482
|
1783, 3280
|
191, 746
|
768, 872
|
1499, 1562
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,482
| 148,269
|
35104
|
Discharge summary
|
report
|
Admission Date: [**2123-12-3**] Discharge Date: [**2123-12-7**]
Date of Birth: [**2072-6-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Penicillins / Augmentin / Bactroban
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for R crani for MCA Aneurysm Clipping
Major Surgical or Invasive Procedure:
Rt Crani for MCA Aneurysm Clipping
History of Present Illness:
Elective admission for R crani for MCA Aneurysm Clipping
Past Medical History:
PMHx:
HTN
ischemic colitis ([**2121**], no sx)
Social History:
NC
Family History:
nc
Physical Exam:
On Discharge: Pt is A&Ox3, PEERL, follows commands, is [**3-27**]
strength throughout due to deconditioning. No neurologic
deficits
Pertinent Results:
[**2123-12-3**] 10:35PM GLUCOSE-136* UREA N-10 CREAT-0.6 SODIUM-142
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15
[**2123-12-3**] 10:35PM WBC-10.5 RBC-3.93* HGB-11.0* HCT-32.7* MCV-83
MCH-27.9 MCHC-33.6 RDW-14.9
[**2123-12-7**] 05:55AM BLOOD WBC-6.0 RBC-3.79* Hgb-10.6* Hct-31.9*
MCV-84 MCH-28.0 MCHC-33.3 RDW-14.6 Plt Ct-349
[**2123-12-7**] 05:55AM BLOOD PT-11.0 PTT-25.2 INR(PT)-0.9
[**2123-12-7**] 05:55AM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-140
K-3.8 Cl-103 HCO3-29 AnGap-12
[**2123-12-7**] 05:55AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.7
Head CT [**12-3**] IMPRESSION: Post-operative changes as described.
New right frontal high attenuation extra- axial collection
likely post-operative in nature. Follow up recommended.
Head CT [**12-4**] IMPRESSION:
1. No significant interval change from one day prior with stable
small right extra-axial, likely postoperative hematoma. No CT
findings to suggest acute stroke.
2. Slight interval increase in air-fluid level within the right
sphenoid
sinus, likely related to intubated status, although acute
sinusitis is not
excluded.
Brief Hospital Course:
Pt was transferred to ICU post-op where she was closely
monitored and was transfused 2 units PRBCs for low Hct,
responded well and now stable. She was then transferred to the
floor where she tolerated a regular diet, pain medication was
titrated to effect, and PT/OT cleared her for home.
Medications on Admission:
Keppra 1500mg"
Lisinopril 10mg'
Vicodin prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for headache: Please do not drink or drive while
taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
3. Keppra 500 mg Tablet Sig: Three (3) Tablet PO twice a day.
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-23**]
Tablets PO Q4H (every 4 hours) as needed for Headache.
Disp:*80 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
R MCA Aneurysm
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you haven been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in 5 days ([**12-13**]) for removal of
your staples/sutures and/or a wound check. This appointment can
be made with the Nurse Practitioner. Please make this
appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a
distance from our office, please make arrangements for the same,
with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2123-12-7**]
|
[
"E878.8",
"338.18",
"401.9",
"998.12",
"305.1",
"437.3",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
2895, 2901
|
1877, 2167
|
364, 401
|
2960, 2984
|
764, 1854
|
4581, 5187
|
593, 597
|
2262, 2872
|
2922, 2939
|
2193, 2239
|
3008, 4558
|
612, 612
|
626, 745
|
268, 326
|
429, 487
|
509, 557
|
573, 577
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,089
| 114,974
|
42703
|
Discharge summary
|
report
|
Admission Date: [**2120-2-21**] Discharge Date: [**2120-3-21**]
Date of Birth: [**2066-6-25**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
s/p Motor cycle crash
Major Surgical or Invasive Procedure:
Placement of left chest tube [**2-24**], chest tube removed on [**2-27**]
PICC placment [**2120-2-26**]. PICC line removed [**2120-3-4**]
History of Present Illness:
52 M +EtOH, s/p motorcycle crash intubated on scene w/ left
clavicle fracture, left [**4-8**] rib fracture, pulmonary and splenic
contusions. He reportedly was not moving left side of body when
found by road. He was intubated for GCS of 8 at scene and was
initally taken to OSH but transferred to [**Hospital1 18**] for further care
given multiple injuries.
Past Medical History:
CAD s/p stent (? last five years), ETOH use. unknown other pmh
Social History:
Lives with mother
Owner of "several businesses"
Family History:
Unknown
Physical Exam:
Admission Physical Exam -
T 99.0 P: 82 R: 14 BP:141/61 SaO2: 95% on NC
General: asleep, responds to verbal stimuli but falls back
alseep readily, on re-examination patient was more easily
aroused
HEENT: wearing stiff c-collar, abrasions and erythema of left
side of face/head, with echymosis posterior to left ear
Neck: c-collar in place
Pulmonary: significant upper airway congestion with son[**Name (NI) 7884**]
breathing while asleep, no wheezes/rales appreciable; no chest
wall crepitus
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;
Skin: no rashes noted; significant echymosis over left
mid-clavicular area, echymosis behind left ear as noted above
Mental Status: Somnolent, responsive to verbal stimuli and light
touch, able to follow some limited midline and appendicular
commands. Regarded interviewer and able to localize pain. Upon
re-examination patient was able to nod yes to some questions but
not consistently.
Cranial Nerves:
II: PERRL 2 to 1mm bilaterally
III, IV, VI: unable to evaluate fully, adduction/abduction
intact bilaterally
V: difficult to assess but facial sensation appeared intact to
pinprick
VII: no facial droop at rest, difficulty opening eyes
bilaterally, decreased left sided activation with smile,
noticeable deficit on left side with smiling on re-examination
VIII: responds to some verbal stimuli/commands, unable to assess
further
IX, X: +cough/gag reflex
[**Doctor First Name 81**]: limited by c-collar and injuries, trapezius intact
bilaterally
XII: Tongue protrudes in midline
Motor:
- Difficulty following individual strength testing , no pronator
drift on RUE, extended RUE above head, no RUE asterixis,
-normal bulk, normal tone throughout though variable increase in
RUE tone over course of exam. No pronator drift on right.
-LUE flaccid other than flicker of third and fourth digits
Reflexes:
-RUE biceps and brachioradialis 2+, triceps difficult to
ellicit,
-LUE biceps 1 (decreased), ticeps absent, brachioradialis 2
(normal),
-lower extremity reflexes 2+ throughout
Sensory: intact to light touch on RUE, LLE, RLE, localized to
pain on RUE. Appeared to have sensation to pinprick bilaterally
on face though difficult to assess
Exam upon discharge:
VS: 98.2 90 124/88 18 room air sats 98%
Neuro: Awake, alert and oriented x2-3
Cor: RRR
Lungs: CTA bilaterally
Abd: soft, non tender
Extr: Ambulates independently
Pertinent Results:
[**2120-3-14**] 09:06AM BLOOD WBC-7.1 RBC-3.87* Hgb-12.2* Hct-36.5*
MCV-94 MCH-31.6 MCHC-33.5 RDW-12.5 Plt Ct-457*
[**2120-3-14**] 09:06AM BLOOD Plt Ct-457*
[**2120-3-14**] 09:06AM BLOOD Glucose-108* UreaN-18 Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-24 AnGap-16
[**2120-3-14**] 09:06AM BLOOD Calcium-9.8 Phos-3.8 Mg-1.8
[**2120-2-28**] 02:10AM BLOOD WBC-10.0# RBC-3.00* Hgb-9.8* Hct-27.5*
MCV-92 MCH-32.7* MCHC-35.6* RDW-12.2 Plt Ct-230
[**2120-2-27**] 01:41AM BLOOD WBC-5.5 RBC-2.78* Hgb-9.1* Hct-26.1*
MCV-94 MCH-32.6* MCHC-34.7 RDW-12.1 Plt Ct-193
[**2120-2-21**] 10:15PM BLOOD WBC-11.7* RBC-3.81* Hgb-12.6* Hct-36.2*
MCV-95 MCH-33.1* MCHC-34.8 RDW-12.2 Plt Ct-202
[**2120-2-28**] 02:10AM BLOOD Neuts-71* Bands-0 Lymphs-18 Monos-8 Eos-2
Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1*
[**2120-2-28**] 02:10AM BLOOD Plt Smr-NORMAL Plt Ct-230
[**2120-2-27**] 01:41AM BLOOD Plt Ct-193
[**2120-2-22**] 05:30PM BLOOD Fibrino-250#
[**2120-2-22**] 12:52AM BLOOD Fibrino-151*
[**2120-2-28**] 02:10AM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-142
K-3.4 Cl-107 HCO3-25 AnGap-13
[**2120-2-27**] 01:41AM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-143
K-3.4 Cl-109* HCO3-28 AnGap-9
[**2120-2-22**] 05:30PM BLOOD ALT-45* AST-73* LD(LDH)-341* AlkPhos-56
TotBili-1.0
[**2120-2-22**]: chest x-ray:
Cardiomediastinal contours are normal. There are low lung
volumes. Bibasilar opacity, larger on the left side are better
seen in prior CT. There is no evident pneumothorax. Multiple
left rib fractures and left clavicle comminuted fracture are
again noted. ET tube is in standard position. NG tube tip is out
of view below the diaphragm. Left perihilar opacity is
unchanged.
[**2120-2-22**]: CTA neck:
IMPRESSION:
1. New focus of subarachnoid hemorrhage in the left sylvian
fissure with
stable subtle and questionable trace of blood products in the
right
perimesencephalic cistern.
2. No evidence of contusions or extra-axial hemorrhage.
3. Stable area of hyoattenuation in the left temporal lobe,
likely
representing encephalomalacia from prior trauma.
4. Normal CTA of the head and neck.
[**2120-2-22**]: skull films:
IMPRESSION:
1. No radiopaque foreign body detected.
2. Left rib and clavicle fractures and pleural/parenchymal
changes in the left lung
[**2120-2-23**]: MRI of brachial plexus:
1. Limited study as the procedure had to be abandoned for
patient's safety
due to agitation. Limited images of the brachial plexus
demonstrate no overt compressive mass. The hematoma surrounding
the left clavicular fracture appears to be separate from the
brachial plexus. Assessment of nerve root edema cannot be made
on these T1-weighted images.
2. Small left pleural effusion.
[**2120-2-23**]: MRI of cervical spine:
IMPRESSION: No evidence of ligamentous trauma or evidence of
significant bony trauma in the cervical region. No vertebral
malalignment. Soft tissue
changes in the left supraclavicular region and left side of the
neck could be secondary to patient's history of left-sided
clavicular and rib fractures and correlation with brachial
plexus MRI recommended. No evidence of intraspinal hematoma or
cord compression. Degenerative changes predominantly at C5-6 and
C6-7 levels.
[**2120-2-23**]: MR of the head:
IMPRESSION: 1. Blood in the left sylvian fissure, representing
subarachnoid hemorrhage seen on the previous CT.
2.Small areas of slow diffusion in the subinsular brain likely
representing small acute associated infarcts.
3. Slow diffusio and increased signal right lateral aspect of
mid brain due to infarct or contusion.
4. No mass effect or hydrocephalus seen.
5. Prominent subarachnoid spaces are seen in the frontal region,
likely
representing a small subdural hygromas.
[**2120-2-23**]: chest x-ray:
Left lung base consolidation, most likely atelectasis with
associated likely small left pleural effusion.
[**2120-2-24**]: chest x-ray:
left chest tube is present. It overlies the lower left lung.
There is
pleural fluid tracking along the left chest, with multiple
left-sided rib
fractures. The pleural effusion appears smaller compared with
the film
obtained earlier the same day ([**2120-2-24**] at 5:28 a.m.) No
pneumothorax is
detected. If clinically indicated, a lateral view may help to
better define the position of the left-sided chest tube.
The cardiomediastinal silhouette is prominent as are the upper
zone vessels,
though these are likely accentuated by low inspiratory volumes.
Probable
atelectasis in the right cardiophrenic angle, but no definite
right-sided
effusion. Comminuted fracture of the left mid clavicle again
noted.
[**2120-2-26**]: chest x-ray:
IMPRESSION:
1. Right-sided PICC terminating at the mid SVC.
2. Unchanged position of a left thoracostomy tube. No
pneumothorax.
[**2120-2-27**]: ECHO:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). There is no
pericardial effusion.
No cardiac source of embolus identified (cannot definitively
exclude).
Agitated saline study at rest revealed evidence of an
intracardiac shunt (atrial septal defect or stretched patent
foramen ovale).
[**2120-2-27**]: chest x-ray:
FINDINGS: In comparison with the study of [**2-26**], the tip of the
right
subclavian catheter has been advanced to beyond the cavoatrial
junction. Left chest tube remains in place and there is no
pneumothorax. Continued low lung volumes. Maild engorgement of
indistinct pulmonary vessels is consistent with mild elevation
of pulmonary venous pressure. Areas of more coalescent
opacification at the left base and mid zone could reflect
developing consolidation in the appropriate clinical setting.
[**2120-2-27**]: chest x-ray:
IMPRESSION: No pneumothorax following chest tube removal.
[**2120-2-28**]: chest x-ray:
Increased density of left hemithorax may represent large
layering effusion but is concerning for reaccumulation of known
hemothorax.
[**2120-2-28**]: LENI's lower ext:
IMPRESSION: No DVT
[**2120-3-2**] 8:06 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2120-3-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2120-3-3**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
52 year old gentleman, s/p motor-cycle crash received as a
trauma transfer, already intubated. he was admitted to the Acute
Care Surgery team and transferred to the trauma ICU. Upon
admission, he demonstrated a completely unresponsive left upper
extremity and review of OSH films demonstrated a left pulmonary
contusion, left sided rib fractures ([**4-8**]), left clavicle
fracture, and a splenic contusion. Head cat scan showed a small
subarachnoid hemorrhage.
His course in the ICU is summarized below by system:
Neuro: Upon admission he was initially agitated while intubated.
Sedation was weaned and he was extubated that day without
difficulty. Given his inability to move his LUE and mechanism of
injury, suspicion of a brachial plexus injury was high and
neurology was consulted. Bilateral upper extremity ABIs were
performed to assess for arterial injury. The ABI's were equal,
making arterial injury very unlikely. CTA of the head and neck
demonstrated a small LEFT sided subarachnoid hemorrhage.
Neurosurgery was consulted and they recommended a 7 day course
of dilantin. An MRI showed small, likely acute, infarcts in the
sub insular brain, as well as slow diffusion of the right
lateral midbrain. His mental status slowly improved while in the
intensive care unit from initially being aphasic and agitated to
eventually being easily directable and stating coherent phrases.
He was given several doses of Ativan daily, and we were able to
wean Ativan usage after beginning scheduled Zyprexa on HD 6. On
transfer to the floor, he was on Zyprexa 10mg TID requiring no
Ativan.
CV: He was hemodynamically stable throughout his stay. It is
believed he has a drug-eluding stent, placed 3 years ago. He was
reportedly on Plavix prior to the accident. He was started on
aspirin [**Hospital **] hospital day 2 then on [**Hospital **] hospital day 8 once
tolerating PO and was cleared by Neurology. He was finally left
on Plavix with no aspirin as per recommendations of Neurology.
PUL: There was no difficulty with ventilation while intubated
and he protected his airway post-extubation despite having
limited mental status. He had a very small pneumothorax on
admission scan. Serial chest x-ray showed a delayed left
effusion (found to be hemothorax) and a chest tube was placed HD
3. The tube initially drained 600cc blood, with 500cc
sero-sanguinous fluid over the next 48 hours. The chest tube was
removed HD 7 and post-pull film confirmed no residual
pneumothorax.
GI: He had no significant gastrointestinal injuries or issues.
He had a splenic contusion that was managed conservatively.
GU/FEN: His Foley catheter was removed hospital day # 3. He was
kept NPO with no nutrition until HD# 6, when TPN was begun.
Given his functional gut, we would have preferred to use
[**Last Name (un) **]-gastric or gastrostomy feedings, but he was felt to be too
high risk for pulling at or removing a feeding tube. By HD# 8,
his mental status had improved to the point that a trial of PO
intake was begun.
MSK: For his left clavicle fracture, the orthopaedic consult
service recommended a sling and physical therapy. His rib
fractures were managed conservatively.
Venous access: A Right upper extremity PICC line was placed
[**2120-2-26**] and removed on [**2120-3-4**].
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
His floor course after transfer out of the ICU as follows:
He was transferred to the surgical floor on HD #8. Because small
infarcts were seen on CT scan and MRI implicating a possible
stroke, recommendations were made for a echocardiogram. The
agitated saline study at rest revealed evidence of an
intracardiac shunt (atrial septal defect or stretched patent
foramen ovale). He was seen by Neurology stroke who recommended
cardiac monitoring to rule out any cardiac arrhythmia as a
source of his stoke. He continued on his Plavix. He had been
started on clear liquids on HD #8, but demonstrated difficulty
swallowing and a speech a swallow study was ordered. This study
showed that he was able to swallow liquids and was advanced to a
regular diet with supervision during meals. His TPN was
discontinued on HD #10. His neurological status continued to
wax and wane with periods of agitation alternating with periods
of lucidity on scheduled doses of Zyprexa and intermittent
Haldol. With adjustments in his medication, his mental
gradually improved with decreased frequency of restlessness.
Several family/team meetings were held during his stay to
provide support and also address his discharge needs.
He was intermittently agitated throughout his stay requiring
anti-psychotics which were adjusted several times. Psychiatry
was consulted and his medications were changed so that at time
of discharge he is receiving Depakote 1000 mg q HS and
Olanzapine 10 mg po BID.
His vital signs have remained stable and without fevers since
his transfer out of the ICU. He is tolerating a regular diet.
He was evaluated by physical and occupational therapy and made
significant progress in terms of his strength and balance. His
left upper arm paresis related to a brachial plexus injury, as
well as a right cerebral peduncle infarct has shown marked
improvement.
He is being discharged to a residential program specializing in
neuro-cognitive issues.
Medications on Admission:
Unknown
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): hold for diarrhea.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. olanzapine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. divalproex 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO HS (at bedtime).
9. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: please take with food.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Manor
Discharge Diagnosis:
s/p Motor vehicle crash
Injuires:
Left clavicle fracture
Left rib fracture [**4-8**] with small pneumothorax
Left pulmonary contusion
Splenic contusion
Small left subarachnoid hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - unsteady on feet, uses walker
Discharge Instructions:
You were admitted to the hospital after you were involved in a
motor cycle crash. As a result of the crash, you sustained a
small bleedinf injury in your head, rib fractures with a small
collapse of your lung, a fracture of your left clavicle, and a
small bruise to your spleen and lung. You were monitored in the
intensive care unit upon admission where you had a chest tube
placed for the collapsed lung. Because of your injuries, you
were seen by Orthopedics and Neurology. You did not require any
surgery for your injuries. Once your vital signs stabilized, you
were transferred to the surgical floor. You are slowly
recovering from your injuries.
It is being recommended that you be discharged to a program that
specializes in trauamtic brain injury - arrangments have been
made for you for this after hospital discharge.
Followup Instructions:
Your insurance records are incomplete- please call our
registration department at ([**Telephone/Fax (1) 22161**] before your first
appointment.
An appointment has been made for you with new Primary [**Name8 (MD) **] MD:
[**2120-4-18**] 02:20p [**Last Name (LF) **],[**First Name3 (LF) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Hospital 191**] MEDICAL UNIT
(SB)[**Telephone/Fax (1) 2010**]
Department: NEUROLOGY
When: WEDNESDAY [**2120-5-15**] at 1 PM
With: DRS. [**Name5 (PTitle) **] & [**Last Name (un) **] [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2120-3-21**]
|
[
"810.02",
"861.21",
"851.82",
"865.09",
"745.5",
"342.92",
"434.91",
"E816.2",
"414.01",
"V45.82",
"953.4",
"310.2",
"807.06",
"860.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"34.04",
"38.97",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16559, 16614
|
10345, 15686
|
327, 468
|
16845, 16845
|
3551, 10322
|
17874, 18621
|
1022, 1031
|
15746, 16536
|
16635, 16824
|
15712, 15721
|
17016, 17851
|
1046, 1814
|
265, 289
|
496, 855
|
2103, 3343
|
16860, 16991
|
877, 941
|
957, 1006
|
3364, 3532
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,673
| 180,117
|
9530
|
Discharge summary
|
report
|
Admission Date: [**2156-2-1**] Discharge Date: [**2156-2-4**]
Date of Birth: [**2074-6-26**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 year old woman with UC followed by Dr. [**Last Name (STitle) 1940**] and HTN as
well as PE s/p IVC filter, CAD s/p MI [**2134**], DM, diverticulitis
and CHF EF 35-40% admitted to OSH with abdominal pain, N/V/D on
[**1-19**] now being transferred for surgical evaluation of
pancolitis. She was noted to have pancolitis on CT scan and was
being treated with solumedrol 125mg IV q8hours. She continued to
have diarrhea and liquid stools. On the floor, she had episode
of AF with RVR with flash pulmonary edema and was transferred to
ICU. She was reportedly never hypotensive and was treated with
IV lopressor as well as amiodarone for an episode of VT. No
documentation of lost pulse. She was being diuresed aggressively
with lasix 40mg IV BID up until 1 day ago when she became
hypotensive to 80s/50s. She previously had PICC which was
self-discontinued and midline was placed for access. In the 24
hours prior to trasnfer, she received 500cc boluses x 2 for low
UOP(230cc last 24 hours). She remained in NSR after being
started on amio 200mg PO BID for VT and AF. TTE revealed EF
35-45%. Recal tube draining brown, foul smelling guaiac neg
stool. She was seen by surgery who felt she needed a colectomy.
She also underwent colonoscopy which revealed friable colon.
.
On arrival to ICU, patient reports abdominal discomfort and
appears pale, somnolent during exam but arousable. Denies SOB,
CP, palpitations, N/V.
Past Medical History:
Ulcerative Colitis
IMI [**2137**]
h/o PE [**2138**] s/p IVC filter
Macular degeneration
DM
Hyperlipidemia
HTN
PVD
Social History:
Has 2 sons who are HCPs. She is a widow. Does not smoke
cigarettes or drink alcohol.
Family History:
unable to obtain
Physical Exam:
GEN: Somnolent but arousable, awakens to voice
HEENT: Pupils reactive, patient legally blind, EOMI, anicteric,
MMM, op without lesions, no supraclavicular or cervical
lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or
thyroid nodules
RESP: Exp wheezes throughout. No crackles.
CV: tachy. irreg irreg. S1 and S2 wnl, no m/r/g
ABD: mildy distended, diffusely tender without rebound or
guarding. increased TTP epigastrum. +b/s, no masses or
hepatosplenomegaly. rectal tube draining brown/maroon stool.
EXT: no c/c. Anasarca.
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOriented to place (hospitl, self and family members
names).
Pertinent Results:
[**2156-2-1**] 03:31AM BLOOD WBC-7.0 RBC-3.70* Hgb-11.5* Hct-33.7*
MCV-91 MCH-31.2 MCHC-34.3 RDW-14.8 Plt Ct-95*#
[**2156-2-2**] 01:06PM BLOOD WBC-13.3*# RBC-2.82* Hgb-9.0* Hct-25.4*
MCV-90 MCH-32.0 MCHC-35.4* RDW-15.3 Plt Ct-98*
[**2156-2-4**] 12:47AM BLOOD WBC-17.6* RBC-2.79* Hgb-8.9* Hct-26.5*
MCV-95 MCH-31.9 MCHC-33.6 RDW-15.8* Plt Ct-103*
[**2156-2-1**] 03:31AM BLOOD PT-11.3 PTT-38.3* INR(PT)-0.9
[**2156-2-2**] 08:16PM BLOOD PT-14.0* PTT-28.1 INR(PT)-1.2*
[**2156-2-4**] 12:47AM BLOOD PT-16.3* PTT-29.2 INR(PT)-1.4*
[**2156-2-1**] 03:31AM BLOOD Glucose-41* UreaN-28* Creat-0.8 Na-141
K-3.8 Cl-109* HCO3-20* AnGap-16
[**2156-2-2**] 01:06PM BLOOD Glucose-98 UreaN-29* Creat-0.8 Na-138
K-2.8* Cl-106 HCO3-22 AnGap-13
[**2156-2-4**] 12:47AM BLOOD Glucose-191* UreaN-39* Creat-1.2* Na-142
K-4.6 Cl-112* HCO3-19* AnGap-16
[**2156-2-1**] 03:31AM BLOOD ALT-21 AST-25 LD(LDH)-300* CK(CPK)-47
AlkPhos-71 TotBili-0.2
[**2156-2-1**] 02:47PM BLOOD CK-MB-5 cTropnT-0.02*
[**2156-2-1**] 02:47PM BLOOD CRP-82.6*
Imaging:
[**2-1**] CXR:
FINDINGS: There are no old films available for comparison. The
heart is
upper limits normal in size. The aorta is mildly calcified.
There are
bilateral lower lobe infiltrates, left greater than right and a
small left
effusion. There is a left-sided PICC line with tip close to
midline, not yet crossing to the superior vena cava. There is no
pneumothorax.
.
[**2-1**] Abd XRay:
IMPRESSION: Abnormal appearance to midabdominal loops with
relatively a
featureless appearance. No evidence of obstruction.
Brief Hospital Course:
81F with UC, HTN, CAD presenting with hypotension and abdominal
pain/diarrhea/pancolitis, consistent with sepsis from abdominal
source. See below for discussion of each issue.
1. Hypotension: was related to sepsis. Improved with fluid
boluses initially. She was started on broad spectrum abx for
presumed intraabdominal sepsis. She then changed her code
status to CMO and refused antibiotics for about 12 hours. The
next day, she changed her mind and antibiotics were restarted,
but she still did not want any aggressive or invasive care. A
CT was planned to evaluate her abdomen, but refused by the
patient. After about 36 hours since restarting her antibiotics,
she again developed hypotension. After talking with the family,
pressors were not started and she expired.
.
2. Abdominal pain/Pancolitis: Pt with pancolitis on CT scan and
malnutrition, failure to thrive. Surgery was consulted and she
was not a candidate. GI was consulted and they recommended
decreasing her steroids. She remained on steroids until she
became CMO.
.
3. AF: Not anticoagulated. Was on amio drip initially but
pressures did not tolerate. She was switched to PRN metoprolol
boluses.
.
4. Wheezing/resp distress: Likely related to volume challenge
since was not wheezing prior to fluid boluses and has know low
EF. Was on supplemental O2 and had no futher shortness of
breath.
.
5. Goals of care: she was initially DNR/DNI and then refused
aggressive and interventional measures. Her sepsis eventually
led to shock and she passed away very comfortably with a few
doses of morphine for her abdominal pain.
Medications on Admission:
Lisinopril 40mg PO BID
Metoprolol 50mg PO BID
Metformin 1000mg PO BID
Sulfasalazine 1000mg PO BID
Felodipine 10mg PO daily
Cosopt drops
Folic acid 1mg Po daily
Simvastatin 20mg Po daily
Xalatan
Meclizine 25mg PO TID as needed
HCTZ 12.5mg Po daily
.
Meds on transfer: Solumedrol 125IV q8, Amiodarone 250mg PO BID
Discharge Medications:
n/a, expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Ulcerative Colitis
Septic Shock
Infection of unknown origin
Discharge Condition:
n/a expired
Discharge Instructions:
You came into the hospital with pancolitis and low blood
pressures. It was likely due to an infection in your abdomen.
You chose not to do aggressive care and unfortunately the
infection progressed and was terminal.
Followup Instructions:
n/a expired
Completed by:[**2156-2-4**]
|
[
"287.5",
"272.4",
"427.31",
"362.50",
"038.9",
"556.6",
"275.2",
"273.8",
"V12.51",
"427.1",
"369.4",
"412",
"V49.86",
"443.9",
"995.92",
"785.52",
"276.8",
"401.9",
"263.9",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6281, 6290
|
4280, 5881
|
317, 324
|
6413, 6427
|
2723, 4257
|
6692, 6734
|
2025, 2043
|
6244, 6258
|
6311, 6311
|
5907, 6156
|
6451, 6669
|
2059, 2704
|
263, 279
|
352, 1769
|
6330, 6392
|
1791, 1907
|
1923, 2009
|
6174, 6221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,975
| 156,516
|
31885
|
Discharge summary
|
report
|
Admission Date: [**2130-9-23**] Discharge Date: [**2130-10-7**]
Date of Birth: [**2112-4-16**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Sulfa (Sulfonamides) / Ceclor
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
Left neck swelling
Major Surgical or Invasive Procedure:
- Incision and drainage left neck and LN excision
- Incision and drainage of left neck wound
History of Present Illness:
18F with 2 week history of L neck swelling. She presented to
the ER with "meningeal symptoms" on [**9-13**] and was diagnosed with
URI and UTI for which she took 3 days of cipro. A LP was done
at that visit and was negative. She has noted L neck tenderness
and a progressive increase in swelling that has become more
acute (larger) this past Tuesday. She has had a low-grade
temp at home and feels extremely fatigued. She is tolerating a
regular diet with minimal discomfort with swallowing. She has
had no respiratory distress, dysphagia, frank odynophagia,
otalgia, cough, increased rhinorrhea over her baseline with her
allergies or weight loss. She has not had to use her inhaler.
No known sick contacts. She is here with her parents.
Past Medical History:
PMH: Seasonal allergies, excercise induced asthma
PSH: none
Social History:
No tobacco. Social ETOH. NoIVDA. Lives in [**Location **] and is a
freshman at [**Male First Name (un) **] college. Studying business and hopes to
open an italian restaurant.
Family History:
nc
Physical Exam:
PE: per ORL initial note
100.4 112 121/82 18 99% RA
NAD, normal voice and resp effort without stridor or stertor
L-sided swelling without overlying erythema at the angle of the
L
mandible and infra-auricular extending down along SCM.
PERRLA, EOMI
EARS: AU: Auricle, EAC and TM wnl
Nose: Nl ant mucosa, septum and inferior turbinates b/l.
Inferior
septal spur along R anterior septum.
OC/OP: minimal limitation of mouth opening, tongue mobile, no
masses or lesions, airway patent, parotid and submandibular
ducts
without discharge, FOM soft, tonsils [**11-22**]+ without exudates or
erythema, uvula midline and wnl, dentition and gingiva wnl
NECK: Diffuse swelling and tenderness to palpation of L neck
along SCM, mostly at angle of mandible and infra-auricular. No
other discrete LAD or masses, trachea midline.
FOE: The scope was easily passed through the L nares. NP and
Eustachian tubes wnl. Prominent adenoids. Pharyngeal walls wnl,
Sharp epiglottis,Airway widely patent, no pooling in piriforms
b/l, TVC mobile b/l, [**Male First Name (un) **] edema or erythema of post-cricoid
region.
Pertinent Results:
CT Neck [**9-23**]
Inflamed and enlarged level II lymph nodes in the left neck with
suppurative changes in the dominant node. Findings are
concerning for adenitis though primary source of infection is
unclear.
CT Neck [**9-25**]
Enlarged level II left neck lymph nodes with unchanged
appearance of an abscess versus suppurative lymph node.
Pathology - Florid follicular hyperplasia with paracortical
expansion and focal folliculolysis; see note.
CT Neck [**9-28**]
Slight reduction in the size of the abscess with interval
placement of a draining catheter. The tip of a draining catheter
is not visualized within the cavity of the abscess and appears
to be below the inferior margin of the abscess. Significant
adjacent soft tissue expansion which could be due inflammatory
edema or post surgical hematoma causing impingement as well as
deviation of the airway.
MRA Neck [**9-30**]
Findings indicative of thrombosis or slow flow within the left
internal jugular vein which appears to be new since the previous
CT of [**2130-9-28**]. Given the area of low signal in the place of
previously noted jugular vein, this most likely represents
thrombosis. A followup study as clinically appropriate is
advised with a CT venography of the neck for better assessment
and visualization of the thrombus.
[**2130-9-23**] 05:48PM URINE HOURS-RANDOM
[**2130-9-23**] 05:48PM URINE GR HOLD-HOLD
[**2130-9-23**] 05:48PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2130-9-23**] 05:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2130-9-23**] 03:20PM GLUCOSE-112* UREA N-6 CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
[**2130-9-23**] 03:20PM estGFR-Using this
[**2130-9-23**] 03:20PM WBC-15.2* RBC-4.05* HGB-13.4 HCT-37.7 MCV-93
MCH-33.1* MCHC-35.5* RDW-12.2
[**2130-9-23**] 03:20PM NEUTS-84.3* LYMPHS-12.0* MONOS-2.6 EOS-0.9
BASOS-0.2
[**2130-9-23**] 03:20PM PLT COUNT-388
Brief Hospital Course:
Pt is an 18yF who presented with left neck swelling and was
admitted to ORL for management of the swelling. After three
days of antibiotics (Clinda and Unasyn) and an interval CT scan
showing no improvement, the decision was made to I&D the
swelling. The patient tolerated the procedure well and was
transfered to the floor with a penrose in place. After initial
improvement, the swelling increased POD#2 and a repeat scan
showed increased edema and airway deviation. Fiberoptic
examination showed some supgraglottic edema, and the patient was
having increased difficulty handling her secretions, so we
decided to transfer her to an ICU. Infectious disease was
consulted and recommended switching the Clindamycin with
Vancomycin and Meropenim and a series of labs and cultures. We
later that night proceded to take her to the operating room for
a fiberoptic nasal intubation and wound re-exploration and
cleanout. The patient tolerated the procedure well with no
complications. For further detail of the procedure please refer
to the operative note. Post operatively, the patient was
transfered back into the ICU. Her Vancomycin was stoppped per
ID on [**10-2**]. On [**2130-10-2**] the patient was successfully
extubated. On [**2130-10-3**] she was transferred to the floor form the
ICU. On [**10-4**] her blood was sent for EBV, HIV, [**Doctor First Name **], CMV, and
RPR. EBV was isolated from her blood culture. She was told
that she had the EBV and told to refrain from contact sports and
to follow up with her primary care doctor. Her wound was packed
daily and left to heal by secondary intention. She continued
her IV Meropenim while inhouse. She was discharged on PO
Levofloxacin and PO Flagyl for two weeks with a follow up
appointment with ID to follow up all her cultures.
Upon discharge, the patient is afebrile with all vitals stable,
tolerating po feeds, ambulating well, urinating without
difficulty, and with pain controlled on po pain medication. She
will follow up with Dr [**First Name (STitle) **] in [**11-22**] weeks.
Medications on Admission:
albuterol, BCP, [**Doctor First Name 130**]
Discharge Medications:
1. Ortho Tri-Cyclen (28) Oral
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for Pain for 2 weeks: Do Not
drive on this medication.
Disp:*40 Tablet(s)* Refills:*0*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 4 weeks: Stop taking [**2130-10-27**].
Disp:*28 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 4 weeks: Stop Taking [**2130-10-27**].
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Left cervical lymphadenopathy
Left Internal jugular thrombosis
Discharge Condition:
Stable
Discharge Instructions:
Seek immediate medical attention for fever >101.5, chills,
marked increase in left neck swelling, redness, pain, or
anything else that is troubling you. Do not drive or drink
alcohol while taking narcotic pain medications. Resume all home
medications. Call your surgeon to make follow up appointment.
Followup Instructions:
Call Dr.[**Name (NI) 18353**] office to schedule a follow up appointment in
[**11-22**] weeks.
|
[
"997.3",
"997.2",
"682.1",
"478.6",
"478.22",
"453.8",
"785.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"28.0",
"40.11",
"83.09"
] |
icd9pcs
|
[
[
[]
]
] |
7530, 7591
|
4641, 6704
|
315, 410
|
7698, 7707
|
2622, 4618
|
8056, 8154
|
1482, 1486
|
6799, 7507
|
7612, 7677
|
6730, 6776
|
7731, 8033
|
1501, 2603
|
257, 277
|
438, 1187
|
1209, 1271
|
1287, 1466
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,078
| 153,670
|
43361
|
Discharge summary
|
report
|
Admission Date: [**2102-6-5**] Discharge Date: [**2102-6-15**]
Date of Birth: [**2036-7-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Haldol / Prolixin / Sulfasalazine / Thorazine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain/Transfer for cardiac catheterization
Major Surgical or Invasive Procedure:
[**2102-6-5**] - Cardiac catherization (no intervention)
[**2102-6-9**] - CABGx2 (LIMA->LAD, SVG->OM), MV Repair (27mm Duran
ancore band)
History of Present Illness:
This is a 64 man with mental retardation, schizophrenia, CAD p/w
atypical chest pain x1-2 weeks to [**Hospital1 **] [**Location (un) 620**]. Now with increased
pain with exertion and DOE with stairs and long distances. CE
were negative. +MIBI. Rec'd heparin IV over weekend and stopped
this am to cath showing 3VD.
.
OSH ED, 97.8 77 136/69 16 99RA. Rec'd ASA, NTG SL,
protonix 40mg PO, Plavix 300mg. CE negative x3. Stress +MIBI.
Patient transferred to BIMDC [**6-5**] for cath and further eval.
Cath [**6-5**] showed heavily calcified and function 3VD and
mod-severe LV systolic ht failure. Consulting cardiothoracics
for possible CABG.
.
ROS: no f/c/n/v/SOB/radiation/pain with palpation of chest or
positional change/recent URI. +occas unsteady gait.
Past Medical History:
1. Mental retardation
2. Coronary artery disease
- TTE [**7-22**]: LVEF 30-35% mod global HK, 2+ MR
3. Diabetes mellitus
4. Paranoid schizophrenia
5. Chronic diarrhea
6. Anemia
7. h/o subdural hematomas [**7-22**] (asa/plavix were held)
8. h/o MSSA bacteremia
9. Chronic renal insufficiency CrCl 54
Cardiac risk factors: DM2, age, MI, elev lipids
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66070**] (DMA)
Social History:
Lives at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] House (group home). According case manage
[**Doctor Last Name 1356**] (cell) [**Telephone/Fax (1) 93355**], patient makes own medical decisions
and does not have a legal guardian or health care proxy. [**Name (NI) 4084**]
tobacco/ETOH.
Family History:
noncontributory
Physical Exam:
97.1 121/66 66 18 100%RA
GEN: NAD, pleasant
HEENT: mmm, OP clear, anicteric, PERRL, EOMI
CV: nl S1 S2, rrr, no m/r/g
Pulm: CTAB at bases, no wheeze
ABD: soft, NTND, +BS
Ext: nonedematous, DPP 2+, warm
Neuro: AO to self, "hospital" and year
Pertinent Results:
[**2102-6-5**] 10:45AM PT-13.5* PTT-34.4 INR(PT)-1.2*
[**2102-6-5**] 10:45AM WBC-4.3# RBC-2.85* HGB-10.0* HCT-28.0* MCV-98
MCH-35.1*# MCHC-35.6* RDW-13.2
[**2102-6-5**] 10:45AM ALT(SGPT)-13 AST(SGOT)-26 ALK PHOS-85 TOT
BILI-0.2
[**2102-6-5**] 10:45AM GLUCOSE-135* UREA N-45* CREAT-1.5* SODIUM-138
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2102-6-5**] 05:39PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2102-6-15**] 06:40AM BLOOD WBC-9.0 RBC-2.62* Hgb-8.5* Hct-25.5*
MCV-97 MCH-32.4* MCHC-33.3 RDW-15.6* Plt Ct-165#
[**2102-6-15**] 06:40AM BLOOD Glucose-168* UreaN-72* Creat-2.3* Na-139
K-5.0 Cl-100 HCO3-27 AnGap-17
[**2102-6-5**] Cardiac Catheterization
1. Selective coronary angiography of this left dominant system
demonstrated two vessel CAD. The LMCA was heavily calcified with
a
distal 50% stenosis. The LAD is heavily calcified with diffuse
disease
up to 70% in the mid and proximal vessel. The LCX was moderately
calcified with proximal tapering through two retroflexed turns
to an
eccetric tubular 70% stenosis. The very high OM1 demonstrated
ostial 80%
ISR of the old stent. The OM2 was a modest vessel with proximal
70%
disease. The RCA was small and non-dominant.
2. Left ventriculography was defered due to high filling
pressures and
renal insufficiency.
3. Limited resting hemodynamics demonstrated elevated left sided
filling
pressures with LVEDP=20 mmHg.
[**2102-6-9**] ECHO
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate to
severe global left ventricular hypokinesis. Overall left
ventricular systolic function is severely depressed. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve
prolapse or flail segments. Mitral annulus in endosystole is
34mm. There is a central regurgitant jet across the mitral valve
with blunting of pulmonary venous inflow and a vena contract of
5-6mm c/w. Moderate to severe (3+) mitral regurgitation.
[**2102-6-15**] 06:40AM BLOOD WBC-9.0 RBC-2.62* Hgb-8.5* Hct-25.5*
MCV-97 MCH-32.4* MCHC-33.3 RDW-15.6* Plt Ct-165#
[**2102-6-14**] 06:40AM BLOOD Hct-25.1*
[**2102-6-13**] 06:30AM BLOOD WBC-8.4 RBC-2.56* Hgb-8.4* Hct-24.6*
MCV-96 MCH-32.8* MCHC-34.2 RDW-15.8* Plt Ct-103*
[**2102-6-15**] 06:40AM BLOOD Plt Ct-165#
[**2102-6-15**] 06:40AM BLOOD Glucose-168* UreaN-72* Creat-2.3* Na-139
K-5.0 Cl-100 HCO3-27 AnGap-17
[**2102-6-14**] 06:40AM BLOOD UreaN-69* Creat-2.3* K-4.8
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2102-6-5**] via
transfer from the [**Location (un) 620**] [**Hospital1 18**] for a cardiac catheterization
and further management of his chest pain. He underwent a cardiac
catheterization which revealed severe three vessel disease and
plavix was given and heparin was started. Given the severity of
his disease, the cardiac surgical service was consulted and Mr.
[**Known lastname **] was worked-up in the usual preoperative manner. He
was noted to be anemic and was transfused with packed-red blood
cells. Dental clearance was obtained by contacting his dentist
prior to his operative date. On [**2102-6-9**], Mr. [**Known lastname **] was
taken to the operating room where he underwent coronary artery
bypass grafting to two vessels as well as a mitral valve repair
using a 27mm duran ancore band. He tolerated the procedure well
and for further details, please refer to operative note.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. By postoperative day one, Mr.
[**Known lastname **] was awake, neurologically intact and extubated. His
drains were removed per protocol. He was slowly weaned from
pressors. He was transfused for postoperative anemia. On
postoperative day three, Mr. [**Known lastname **] 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. He had some atrial
fibrillation/flutter which was treated successfully with an
increase in his beta blockade. Mr. [**Known lastname **] developed a mild
postoperative renal failure with his creatinine elevating to 2.3
however stabilized with less aggressive diuresis. Mr.
[**Known lastname **] continued to make steady progress and was discharged
on POD # 6.
Medications on Admission:
1. Protonix 20mg QD
2. Lasix 40mg QD
3. Aspirin 325mg QD
4. Ferrous gluconate 324mg QD
5. Neurontin 800mg [**Hospital1 **]
6. Zoloft 200mg QHS
7. Risperdal 1mg QHS
8. Avandia 8mg QD
9. Glyburide 5mg [**Hospital1 **]
10. MVI QD
11. Lipitor 10mg QD
12. Tylenol PRN
13. Loperamide PRN
14. Lubriderm lotion PRN
15. Amoxicillin PRN dental
16. Colace 100mg [**Hospital1 **]
17. Gemfibrozil 600mg [**Hospital1 **]
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
13. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
16. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
CAD
DM
schizophrenia
anemia
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no lifting > 10# for 10 weeks
no creams, lotions or powders to any incisions
Followup Instructions:
with Dr.[**Last Name (STitle) 7842**] in [**1-20**] weeks
with Dr. [**Last Name (STitle) 1016**] in [**1-20**] weeks
with Dr. [**Last Name (STitle) **] in [**2-18**] weeks
Completed by:[**2102-6-15**]
|
[
"428.0",
"412",
"413.9",
"427.31",
"428.20",
"414.01",
"424.0",
"V45.82",
"997.1",
"272.4",
"319",
"997.5",
"593.9",
"250.00",
"295.90",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"89.60",
"39.61",
"35.33",
"37.22",
"99.04",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9469, 9553
|
5418, 7336
|
359, 498
|
9625, 9632
|
2385, 5395
|
9804, 10007
|
2081, 2098
|
7794, 9446
|
9574, 9604
|
7362, 7771
|
9656, 9781
|
2113, 2366
|
272, 321
|
526, 1290
|
1312, 1736
|
1752, 2065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,605
| 190,755
|
38083
|
Discharge summary
|
report
|
Admission Date: [**2179-11-9**] Discharge Date: [**2179-11-23**]
Date of Birth: [**2094-9-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Amoxicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Cerebral vascular accident
Major Surgical or Invasive Procedure:
Redosternotomy Mitaral valve replacement #25 tissue valve
History of Present Illness:
Mrs. [**Known lastname **] is an 85 yo female s/p MV repair on [**2177-8-27**] who has
had multiple TIAs this year with 6 just since [**Month (only) 216**]. She had a
stroke in [**Month (only) **] that lasted for 12 hrs. Most recent was Fri the
12th with L sided weakness/numbness that last 45 minutes.
Also in [**Month (only) 956**] she had PE and IVC filter. She has been on
coumadin for the pe and has had a stroke when her INR was
suprathrapeutic. She has undergone considerable work-up,
including echo. Echo revealed small mass (thrombus vs
vegetation). Blood cultures were negative. Dr. [**Last Name (STitle) **] saw the
patient in [**Month (only) **] and determined that surgical risk
outweighed
benefit given her age and redo status.
She has subsequently been admitted to an outside hospital. Echo
reveals an increase in size and complexity of the mass. She
remains afebrile with negative blood cultures and no stigmata of
endocarditis. She is transferred for surgical evaluation.
Past Medical History:
Mitral Regurgitation
h/o Acute diastolic heart failure
chronic Atrial fibrillation
h/o Deep vein thrombosis
Osteoarthritis of left knee with dislocated joint
Spinal stenosis
Hypertension
Left hip bursitis
Renal calculi
s/p Tonsillectomy
s/p repair left wrist fracture
s/p Total abdominal hysterectomy
s/p Bilateral cataract surgery
Social History:
Race: caucasian
Last Dental Exam:[**5-4**]
Lives with:husband
Occupation:retired school nurse
Tobacco: denies
ETOH: denies
Family History:
father ?MI, grandfather deceased from MI at 65
Physical Exam:
Pre-op Physical Exam
Pulse: 65 SR Resp: 15 O2 sat: 100%
B/P Right: 120/60 Left:
Height: Weight: 71.6 kg
General: NAD, conversant
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] + BS [x]
Extremities: Warm [x], well-perfused [x] Edema [x] __1+
No splinter hemorrhages, [**Doctor First Name **]-way lesions.
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: x Left:x
Discharge exam:
VS T97.2 HR 71 Afib BP 127/76 RR 18 O2sat 99% RA
Wt 77.8kg
Gen: NAD
Neuro: A&Ox3, MAE. nonfocal exam
Pulm: diminished left base
CV: irreg irreg, sternum stable, incision-CDI
Abdm: soft, NT/NABS
Ext: warm, well perfused. 1+ bilat LE edema
Pertinent Results:
Admission labs:
[**2179-11-9**] 09:00PM PT-23.0* PTT-37.5* INR(PT)-2.1*
[**2179-11-9**] 09:00PM PLT COUNT-342
[**2179-11-9**] 09:00PM WBC-6.5 RBC-4.50# HGB-13.7# HCT-40.0# MCV-89
MCH-30.5 MCHC-34.3 RDW-12.7
[**2179-11-9**] 09:00PM ALBUMIN-4.0 CALCIUM-8.7 PHOSPHATE-2.5*
MAGNESIUM-1.9
[**2179-11-9**] 09:00PM LIPASE-57
[**2179-11-9**] 09:00PM ALT(SGPT)-18 AST(SGOT)-23 LD(LDH)-251* ALK
PHOS-117* AMYLASE-139* TOT BILI-0.4
[**2179-11-9**] 09:00PM GLUCOSE-113* UREA N-13 CREAT-0.6 SODIUM-136
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11
Discharge Labs:
[**2179-11-22**] 05:15AM BLOOD WBC-8.2 RBC-3.41* Hgb-10.5* Hct-31.5*
MCV-92 MCH-30.7 MCHC-33.2 RDW-14.8 Plt Ct-236#
[**2179-11-23**] 06:50AM BLOOD PT-27.7* INR(PT)-2.5*
[**2179-11-22**] 05:15AM BLOOD Plt Ct-236#
[**2179-11-22**] 05:15AM BLOOD PT-15.7* INR(PT)-1.4*
[**2179-11-23**] 06:50AM BLOOD UreaN-15 Creat-0.7 Na-131* K-4.1 Cl-100
[**2179-11-22**] 05:15AM BLOOD Glucose-96 UreaN-14 Creat-0.6 Na-135
K-4.4 Cl-100 HCO3-27 AnGap-12
[**2179-11-23**] 06:50AM BLOOD Mg-2.0
[**2179-11-16**]
TEE
Pre-CPB: 1 The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the body of the left atrium. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
thrombus is seen in the left atrial appendage.
2. Left ventricular wall thicknesses and cavity size are normal.
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**1-25**]+) aortic regurgitation is seen.
6. A mitral valve annuloplasty ring is present. At least 2
vegetations seen on the anterior and posterior leaflets. There
is severe valvular mitral stenosis (area <1.0cm2). Due to
co-existing aortic regurgitation, the pressure half-time
estimate of mitral valve area may be an OVERestimation of true
mitral valve area. Mitral valve area was calculated at 0.8-0.9
cm2. There is moderate functional mitral stenosis (mean gradient
5 mmHg) due to mitral annular calcification. Mild (1+) mitral
regurgitation is seen.
7. There is no pericardial effusion.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 7772**] were notified in person of the
results.
Post-CPB: On infusion of phenylephrine. AV pacing for prolonged
PR interval. Well seated bioprothetic valve in the mitral
postion. Small inferiolateral perivalvular leak. Small central
leak. Peak gradient 5 mmHg, mean gradient 4 mmHg at cardiac
output of 2.5. Preserved biventricular systolic function. AI and
TR remain [**1-25**]+. Aortic contour normal post-decannulation.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2179-11-23**] 9:48
AM
Final Report: Since the prior exam, the bilateral chest tubes
have been removed. There are very small bilateral apical
pneumothoraces, slightly larger on the right than left. The
right pneumothorax measures approximately 12 mm and the left
approximately 7 mm. There is no evidence of tension. Bibasilar
atelectasis is unchanged. There is no definite pleural
effusion. There is no pulmonary edema. Severe cardiomegaly is
stable. The mediastinal contours are unchanged. Sternal wires
are intact. Mediastinal clips are noted.
IMPRESSION:
1. Small biapical pneumothoraces after chest tube removal.
2. Stable bibasilar atelectasis.
3. Stable severe cardiomegaly.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Chest CT from [**11-23**]- per verbal report: no official reead at
this time.
Right upper lobe opacity measuring 16x2cm likely hematoma but
cannot be sure.
Substernal fluid collection measuring 6x2cm likely normal
post-op changes
Recommend: followup CT in 6 weeks
Brief Hospital Course:
The patient was transferred from outside hospital after several
TIA's. She had known mitral valve mass vs vegetation and was
preop for redo mitral valve replacement. She brought to the
operating room on [**11-16**] and underwent mitral valve replacement,
please see operative report for details in summary she had: Redo
sternotomy and redo mitral valve surgery with mitral valve
replacement with a [**Street Address(2) 17009**]. [**Hospital 923**] Medical Bicor Epic tissue
heart valve. Her bypass time was 80 minutes with a crossclamp
time of 61 minutes. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU intubated
on levophed and propofol. She initally had moderate amount of
bleeding and required products, she began to manifest tampanade
physiology, an echo was performed which confirmed tamponade. She
returned to the operating room for exploration and removal of
clot and correction of coagulopathy. See operative notes for
details. Once returning from the OR she was hemodynamically
stable and levophed infusion was weaned. She continue to have
moderate chest tube drainage and was given additional red blood
cells and platelets on POD#1. Her bleeding resolved and she was
extubated on POD#1 without difficulty.
Once extubated he was alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Low dose Beta blocker was initiated at first due to bradycardia
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery on POD2. Chest tubes and pacing wires were
discontinued per cardiac surgery protocol without complication.
The remainder of her hospital course was uneventful, she was
worked with nursing and physical therapy services for assistance
with strength and mobility. By the time of discharge on POD7
the patient was ambulating with assistance the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged to [**Hospital3 7665**] in [**Location (un) 12017**] in good condition
with appropriate follow up instructions. She is to follow up
with Dr [**Last Name (STitle) **] in 1 month.
Medications on Admission:
Atorvastatin 20mg daily
Cardizem CD 120mg daily
Furosemide 40mg daily
Toprol XL 50mg daily
Pantoprazole 40mg daily
KCl 40mEq daily
Warfarin 2mg daily
Aspirin 81mg daily
Calcium Carbonate 500mg daily
Vit D3 1,000 Units daily
Magnesium Chloride (slow mag) 64mg [**Hospital1 **]
MVI daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Vitamin D 1000 UNIT PO DAILY
7. Warfarin MD to order daily dose PO DAILY
target INR 2-3.0
8. Acetaminophen 650 mg PO Q4H:PRN pain
9. Amiodarone 400 mg PO DAILY
400mg Daily x 1 week then 200mg daily
10. Bisacodyl 10 mg PR DAILY:PRN constipation
11. Docusate Sodium 100 mg PO BID
12. Furosemide 40 mg PO DAILY
13. Metoprolol Tartrate 25 mg PO TID
14. Milk of Magnesia 30 ml PO DAILY
15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
16. Slow-Mag *NF* (magnesium chloride) 64 Oral [**Hospital1 **]
17. Potassium Chloride 20 mEq PO Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p redo sternotomy/mitral valve replacement/excision of mitral
valve mass
PMH:
Acute diastolic heart failure admission [**5-4**], Mitral
regurgitation, atrial fibrillation cardioverted [**5-4**], deep vein
thrombosis, Osteoarthritis left knee with dislocated joint,
spinal stenosis, hypertension, Left hip bursitis, Renal calculi,
Mitral Valve repair [**2177-8-24**], tonsillectomy, ORIF left wrist
fracture, total abdominal hysterectomy, bilateral cataracts
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, with assistance
Sternal pain managed with Ultram and tylenol
Incision: Sternum-healing well no erythema or drainage
Edema: 1+ bilateral LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] [**2179-12-22**] at 1:15p
Cardiologist Dr. [**Last Name (STitle) 26033**] [**2179-12-13**] at 12:45p [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 85017**] in [**1-25**] weeks
**Will need follow-up CT chest in 6 weeks to assess opacity in
right upper lobe*
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2179-11-23**]
|
[
"434.11",
"428.0",
"V58.61",
"423.3",
"E878.1",
"715.36",
"453.9",
"401.9",
"V12.54",
"998.11",
"V12.51",
"427.31",
"E878.4",
"424.0",
"428.22",
"790.92",
"V12.55",
"996.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"88.56",
"88.72",
"37.22",
"39.61",
"38.93",
"34.03"
] |
icd9pcs
|
[
[
[]
]
] |
10317, 10364
|
7002, 9264
|
340, 400
|
10868, 11052
|
2997, 2997
|
11660, 12236
|
1937, 1985
|
9601, 10294
|
10385, 10847
|
9290, 9578
|
11076, 11637
|
3569, 6979
|
2000, 2719
|
2735, 2978
|
274, 302
|
428, 1425
|
3013, 3553
|
1447, 1780
|
1796, 1921
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,029
| 194,661
|
47735
|
Discharge summary
|
report
|
Admission Date: [**2116-11-27**] Discharge Date: [**2116-11-28**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
cardiac arrest (asystolic)
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 M h/o laryngeal ca (XRT), s/p laryngectomy, DM, HTN,
hyperlipidemia, CVA (R parietal), s/p R CEA, prostate ca s/p XRT
c/b proctitis, recently d/c'd from [**Hospital1 **] for increased sputum
production, was in his USOH until ~12:15AM [**2116-11-27**]. Pt was
sitting in a chair, then noted by his sister to slump over and
become unresponsive. No preceding evidence of chest pain, SOB,
n/v, palpitations or seizure activity.
.
Pt was pulseless for ~15minutes until EMS arrivated, and was
found to be in asystole by AED. He was intubated through
existing stoma, (right mainstem intubation), received 3 rounds
of epi, 1 round of atropine, with return of pulse after ~36
minutes.
.
Upon arrival @ [**Hospital1 18**] ED, 96.4 SBP 110/70, HR 130. R FEMORAL TLC
placed sterily as BPs dropped to 70s, and pt started on [**Last Name (un) **]
gtt. EKG= sinus tach, RBBB, STD laterally, CXR revealed R
mainstem intubation, RT placed trach, and tube withdrawn. CTA
was negative for PE. CT HEAD negative for acute bleeding or
herniation. Pupils noted to be unequal (R 2.5, L 5mm), though
?[**12-26**] atropine. Bedside USN of heart w/o obvious effusion per ED.
FAST u/s negative for intraabdominal bleed.
.
.
EKG shows retrograde p-waves, ?junctional tachy, diff STD, 1,
avl, v3-6, baseline rbbb, lafb (?),
Past Medical History:
1. HTN
2. DM type II - HgbA1c of 6.5 in [**4-30**]
3. CHF - diastolic, EF >55%
4. s/p R CEA
5. L ICA stenosis - 80-99%
6. prostate cancer s/p resection, complicated by XRT proctitis
7. thyroid resection w/ subsequent hypothyroidism
8. laryngeal cancer s/p laryngectomy and radiotherapy, stoma x
15 yrs
9. CAD
10. hypercholesterolemia
11. anemia w/ baseline Hct 30-32
12. CRI
13. h/o strokes in R parietal lobe, posterior limb
14. angioectasias of rectum and distal sigmoid colono [**12-26**] XRT
proctitis, last colonoscopy [**3-29**]
15. AS
16. MRSA tracheitis
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Lives at home with his sister. Ambulates at
baseline with a walker and wheelchair.
Physical Exam:
VS: T 93.1, BP109/60 , HR 85 , RR 20, O2 % on AC 500x16 50% 5
Gen: elderly male, intubated, sedated.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. right pupil, fixed, XXmm, left
pupil, fixed, XXmm, both non-reactive to light.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c No femoral bruits.
Skin: susbtantial erythema, chronic venous changes B LE, healed
ulcers B LE.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
[**2116-11-27**] 01:55AM BLOOD WBC-12.6* RBC-3.07* Hgb-9.4* Hct-30.6*
MCV-100* MCH-30.6 MCHC-30.7* RDW-15.7* Plt Ct-294
[**2116-11-27**] 08:00AM BLOOD WBC-11.8* RBC-2.81* Hgb-8.6* Hct-26.9*
MCV-96 MCH-30.5 MCHC-31.8 RDW-15.9* Plt Ct-270
[**2116-11-27**] 08:00AM BLOOD PT-18.3* PTT-150* INR(PT)-1.7*
[**2116-11-27**] 08:00AM BLOOD Glucose-127* UreaN-22* Creat-1.9* Na-138
K-4.6 Cl-105 HCO3-23 AnGap-15
[**2116-11-27**] 01:55AM BLOOD UreaN-21* Creat-1.8* Na-135 K-4.4 Cl-102
HCO3-19* AnGap-18
[**2116-11-27**] 01:55AM BLOOD ALT-19 AST-28 CK(CPK)-176* AlkPhos-96
Amylase-88 TotBili-0.3
[**2116-11-27**] 08:00AM BLOOD ALT-20 AST-40 LD(LDH)-278* CK(CPK)-510*
AlkPhos-91 TotBili-0.4
[**2116-11-27**] 01:55AM BLOOD CK-MB-11* MB Indx-6.3* cTropnT-0.03*
[**2116-11-27**] 08:00AM BLOOD CK-MB-42* MB Indx-8.2 cTropnT-0.45*
[**2116-11-27**] 01:55AM BLOOD Albumin-3.0* Calcium-6.9* Phos-6.6*
Mg-2.0
[**2116-11-27**] 08:00AM BLOOD Calcium-6.8* Phos-4.1# Mg-1.9 Cholest-84
[**2116-11-27**] 08:00AM BLOOD Triglyc-36 HDL-35 CHOL/HD-2.4 LDLcalc-42
[**2116-11-27**] 08:00AM BLOOD %HbA1c-5.8
[**2116-11-27**] 01:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.7
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2116-11-27**] 07:24AM BLOOD Type-ART pO2-165* pCO2-34* pH-7.41
calTCO2-22 Base XS--1 Intubat-INTUBATED
[**2116-11-27**] 02:08AM BLOOD Glucose-199* Lactate-6.3* Na-135 K-4.4
Cl-104 calHCO3-19*
[**2116-11-27**] 02:08AM BLOOD freeCa-0.91*
STUDIES:
[**2116-11-27**] TTE:
The left atrium is mildly dilated. There is symmetric left
ventricular hypertrophy (at least moderate). The left
ventricular cavity is small. Overall left ventricular systolic
function is low normal (LVEF 50%) secondary to hypokinesis of
the apex. The right ventricular cavity is mildly dilated. Right
ventricular systolic function appears depressed (possibly
severe). The aortic valve leaflets are moderately thickened.
Significant aortic stenosis is present (not quantified). Mild to
moderate ([**11-25**]+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. The mitral valve leaflets are structurally
normal. There is severe mitral annular calcification. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2114-2-13**], apical hypokinesis of the left
ventricle and global hypokinesis of the right ventricle are now
present.
.
.
[**2116-11-27**] CT HEAD:
1. No acute intracranial pathology including no evidence of
hemorrhage.
2. Old infarct of the right parietal lobe with associated
encephalomalacic
changes as described.
3. The junction of C1-C2 shows severe degenerative disease.
.
.
[**2116-11-27**] CTA CHEST:
1. No pulmonary embolism.
2. Moderate bilateral pleural effusion, right greater than left
with reactive atelectasis. Diffuse ground-glass opacities at
lung bases, increased interstitial markings and reflux of
intravenous contrast into the IVC suggest cardiac dysfunction.
3. Trachestomy tube extends into the right mainstem bronchus.
4. Focal areas of consolidative changes in the lung apices and
right lower lobe are suggestive of aspiration or pnuemonia.
5. Anterior dislocation of the left shoulder and left clavicular
fracture.
.
.
[**2116-11-27**] CT CSPINE:
1. No fracture is noted. Mild grade 1 anterolisthesis of C4 over
C5 is
visualized with mild thecal sac compression.
2.Diffuse degenerative disease of the cervical spine.
Brief Hospital Course:
88 M no known h/o CAD, dCHF (EF>55%), DM, HTN, hyperlipid, R
CVA, h/o laryngeal ca s/p laryngectomy, prostate ca presenting
after witnessed asystole carduac arrest x 15min, with ROC after
36min.
.
The patient was transferred to the CCU with stable BP in normal
sinus rythym on EKG.
.
In the setting of prolonged asystolic cardiac arrest with
minimal neurologic function upon neurologic exam at time of CCU
evaluation, discussion between the CCU team the patient's
family, and ultimately palliative care, resulted in agreement
that the goals of care for the patient comfort measures only.
.
Prior to final decision, neurology consult obtained, and as
pupils were fixed and non-responsive, there was loss of most
brain stem reflexes, loss of response to painful stimuli, and
myoclonic jerking which indicate severe anoxic brain injury with
an extremely poor prognosis for meaningful recovery, it was felt
that there was no role for further imaging, EEG, labs,
hyperventilation or steroids at that time.
.
Pt was treated with fentanyl and midazolam gtt. He remained
intubated until [**2113-11-29**] as per family request until additional
family members could arrive at the hospital. On [**2116-11-28**] he was
extubated and expired.
Medications on Admission:
synthroid 125 mcg po qdaily
plavix 75mg po qdaily
aspirin 81mg po qdaily
atorvastatin 10mg po qdaily
metoprolol succinate 25mg po qdaily
pantoprazole 40mg po qdaily
ferrous sulfate 325mg po qdaily
epo 10,000 UNTS QMOWEFR
Discharge Medications:
pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired.
Discharge Condition:
pt expired.
Discharge Instructions:
pt expired.
Followup Instructions:
pt expired.
|
[
"333.2",
"414.01",
"V10.46",
"V10.21",
"403.90",
"276.2",
"272.0",
"585.9",
"428.0",
"V66.7",
"427.5",
"428.30",
"250.00",
"348.1",
"244.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8616, 8625
|
7075, 8309
|
292, 298
|
8680, 8693
|
3402, 6043
|
8753, 8767
|
2353, 2518
|
8580, 8593
|
8646, 8659
|
8335, 8557
|
8717, 8730
|
2533, 3383
|
226, 254
|
326, 1625
|
6052, 7052
|
1648, 2212
|
2228, 2337
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
246
| 197,430
|
424
|
Discharge summary
|
report
|
Admission Date: [**2130-6-1**] Discharge Date: [**2130-6-7**]
Date of Birth: [**2061-8-26**] Sex: M
Service: SURGERY
Allergies:
Codeine / Meperidine / Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Autoimmune hepatitis
HCC
Major Surgical or Invasive Procedure:
Left hepatic lobectomy, caudate lobe resection, cholecystectomy,
intraoperative ultrasound.
History of Present Illness:
The patient is a 68-year-old male with a history of auto-immune
hepatitis and cirrhosis who developed right upper quadrant
abdominal pain. An ultrasound demonstrated a large mass in the
right lobe of the liver that on biopsy was consistent with
hepatocellular carcinoma. His AFP was 336. A CT scan of the
chest and abdomen demonstrated no evidence of pulmonary
metastases. The patient had a large mass lesion measuring 12.7 x
9.2 x 11.2 cm arising primarily in the medial segment of the
left lobe. The middle hepatic vein was not visualized but the
right hepatic vein and the left lateral segment hepatic veins
were identified. The mass lesion superiorly appears to abut not
invade the right lobe of the liver. The patient does not have
evidence of portal hypertension. The patient after informed
consent is now brought to the operating room for left hepatic
lobectomy, possible left trisegmentectomy, caudate lobe
resection and cholecystectomy.
Past Medical History:
hyperchol, HTN, CAD s/p CABG (echo --> EF 50%), NIDDM
Social History:
He has no history of alcohol use, smoking, IV drug use, tattoos,
or marijuana use. BS degree. Retired in [**2127**]. He was an
accountant for over 48 years with [**Company 2676**]. He has seven
children and 20 grandchildren.
Family History:
diabetes, hypertension, prostate cancer, colon cancer. His
mother is alive
at age 88. His father died at age 88 of prostate cancer.
Physical Exam:
DISCHARGE PE:
Vitals: 98.9 82 133/74 20 96% room air
NAD
RRR
CTAB
soft, ND, appropriately tender
Incision: c/d/i
no c/c/e
Pertinent Results:
ADMISSION LABS:
[**2130-6-1**] 06:27PM BLOOD WBC-8.5# RBC-3.37* Hgb-10.7* Hct-32.4*
MCV-96 MCH-31.7 MCHC-33.0 RDW-15.2 Plt Ct-334
[**2130-6-1**] 06:27PM BLOOD Glucose-173* UreaN-21* Creat-1.2 Na-136
K-5.2* Cl-103 HCO3-22 AnGap-16
[**2130-6-1**] 06:27PM BLOOD ALT-486* AST-788* AlkPhos-208*
TotBili-2.4*
[**2130-6-1**] 06:27PM BLOOD Calcium-9.3 Phos-5.6* Mg-1.5*
.
DISCHARGE LABS:
[**2130-6-7**] 05:07AM BLOOD WBC-4.7 RBC-3.16* Hgb-10.1* Hct-30.7*
MCV-97 MCH-32.1* MCHC-33.0 RDW-14.9 Plt Ct-282
[**2130-6-5**] 04:55AM BLOOD PT-11.8 PTT-23.2 INR(PT)-1.0
[**2130-6-7**] 05:07AM BLOOD Glucose-140* UreaN-18 Creat-1.3* Na-136
K-4.7 Cl-100 HCO3-35* AnGap-6*
[**2130-6-7**] 05:07AM BLOOD ALT-171* AST-56* AlkPhos-194* Amylase-66
TotBili-0.8
[**2130-6-7**] 05:07AM BLOOD Lipase-123*
[**2130-6-7**] 05:07AM BLOOD Albumin-2.6* Calcium-8.7 Phos-3.4 Mg-1.9
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 1369**] Hepatobiliary Surgery
Service at the [**Hospital1 69**] on [**2130-6-1**].
He underwent a left hepatic lobectomy, caudate lobe resection,
cholecystectomy, intraoperative ultrasound. For details of the
operation, please refer to the operative report. His
postoperative course was uncomplicated. Immediately
post-operatively, he was transferred to the SICU. He remained
stable in the SICU on POD 1. His pain control was increased and
was deemed stable for transfer to the floor. On POD 2, he
remained afebrile and had good urine output. His foley catheter
was discontinued without difficulty voiding and he was advanced
to a clear liquid diet, which he tolerated well. On POD 3,
[**Last Name (un) **] was consulted for his uncontrolled diabetes. His central
line was discontinued. He remained afebrile and toelrating a
clear liquid diet. He reported no flatus or bowel movements.
On POD 4, he continued to remain afebrile. He continued to not
have signs of return of bowel fuction and he was given a
dulcolax suppository without a bowel movement. His [**Doctor Last Name **] drain
continued to have minimal output and it was discontinued. On
POD 5, he remained afebrile and tolerating a diabetic diet. He
had a fleets enema with a resultant bowel movement and he was
started on milk of magnesia. His pain continued to be
well-controlled. He was deemed stable for discharge on POD 6,
afebrile, tolerating a diabetic diet, ambulating well with good
pain control. He will follow-up with Dr. [**Last Name (STitle) **] and [**Last Name (un) **].
Medications on Admission:
metoprolol 25mg [**Hospital1 **]
lisinopril 5mg daily
HCTZ 12.5mg daily
pravachol 40mg daily
prilosec 20mg daiy
ISS
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
3. HOME MEDICATIONS
Please resume all your previous home medications EXCEPT for a
change in your insulin dosages. You are on glargine 30 units at
bedtime. Please resume your previous humalog sliding scale.
4. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
(0.3mL) Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Autoimmune hepatitis
HCC
Discharge Condition:
Stable
Discharge Instructions:
Please call your physician or go to the emergency room for the
following:
- chest pain
- shortness-of-breath
- increased redness or drainage from your wounds
- temperature > 101.5
- inability to tolerate food
- or other concerns
.
Please take your pain medication and stool softener as
prescribed.
.
No heavy activity or lifting (anything that makes you strain)
for 4-6 weeks. Continue to ambulate. You may shower, but no
baths for 4-6 weeks.
.
Please keep a journal of your blood sugars to bring to your
follow-up appointment with Dr. [**Last Name (STitle) 3617**].
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 3618**] to schedule a follow-up
appointment.
.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week from
your date of discharge.
.
Please call Dr. [**Last Name (STitle) 3617**] ([**Last Name (un) **]) at [**Telephone/Fax (1) 2378**] for a follow-up
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"568.0",
"414.00",
"571.49",
"155.0",
"278.00",
"272.0",
"571.5",
"401.9",
"V58.67",
"327.23",
"250.02",
"V13.01",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"40.11",
"51.22",
"50.3",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
5306, 5312
|
2912, 4522
|
340, 434
|
5381, 5390
|
2043, 2043
|
6007, 6502
|
1747, 1882
|
4688, 5283
|
5333, 5360
|
4548, 4665
|
5414, 5984
|
2423, 2889
|
1897, 1897
|
1911, 2024
|
276, 302
|
462, 1410
|
2059, 2407
|
1432, 1487
|
1503, 1731
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,272
| 164,272
|
35971
|
Discharge summary
|
report
|
Admission Date: [**2190-4-30**] Discharge Date: [**2190-5-3**]
Date of Birth: [**2123-5-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2190-4-30**] cardiac catheterization with placement of 3 drug eluding
stents to right coronary artery
History of Present Illness:
66 year old female with history of HTN, hyperlipidemia,
bilateral hip osteoarthritis s/p right THR presents with chest
pressure this morning, now admitted to the CCU for continued
management following PCI for inferolateral [**Month/Day/Year **].
Patient was in her usual state of health two days ago when she
experience the onset upper back pain and throat burning at rest,
as though someone was "sitting on her chest". These symptoms
were [**5-9**] in intensity, lasted about 30 minutes, and resolved
without intervention. There were no other associated symptoms.
Over the past two days, the patient reports feeling more sweaty
than usual, which she attributed to the weather.
This morning, she reports the sudden onset of similar symptoms
while lying in bed- throat burning, upper back pain, and chest
pressure, [**9-8**]. The symptoms persisted, and she presented to
[**Hospital3 4107**]. Initial vital signs were 97.7 177/98 HR 78
RR 16 O2 sat 97%, ECG at [**Hospital1 **] showed ST elevation in III and
aVF with reciprocal changes. Troponin I was noted to 0.56.
Creatinine 1.2, BUN 39. Patient received nitro SL, ASA 325,
clopidogrel 600 mg, atorvastatin 80 mg, morphine, metoprolol,
heparin, and Integrilin. Blood pressure was 138/83 prior to
transfer to [**Hospital1 18**] [**Location (un) 86**] for PCI.
In the cath lab at [**Hospital1 18**], initial vital signs were 123/72, HR
65. Heparin was converted to bivalrudin, and Integrilin was
continued. Diltiazem 500 mcg x 1 was given, along with NTG
boluses. Arterial access was gained through right radial
artery. After wire was across RCA lesion and balloon inflated,
blood pressure dropped to 84/53, and HR was 53. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 3 were
placed, dopamine was started, and atropine was given. A right
heart cath was then performed, and RA pressures were 8/9/6, PA
pressures 36/13/21, PA sat 79%, PCWP 13, with CI 4.22. Patient
was then transferred to the CCU for continued management.
Upon arrival to the CCU, patient reported feeling tired. She
denied and chest pressure, throat symptoms, or back pain. She
had no other complaints.
REVIEW OF SYSTEMS
She 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. 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 mild dyspnea on
exertion over the past few months (climbing stairs). Denies
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. She does note some
unintential weight gain due to inactivity and diet (high
cholesterol/fat)
Past Medical History:
hypertension
hyperlipidemia
right hip osteoarthritis s/p THR
left hip osteoarthritis
macular degeneration
Social History:
-Tobacco history: 30 pack year history, quit 20 years ago
-ETOH: denies
-Illicit drugs: denies
Patient lives alone in [**Hospital1 392**]. She worked in the sheriff's
office in [**Location (un) 86**].
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Brother has CAD s/p CABG. Another
brother died of a [**Last Name **] problem, not related to heart attacks
per patient.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 80/43 -> 101/55, HR 88, RR 16, 92% on RA, 100% on 2
liters.
GENERAL: Pleasant female, no distress. 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 [**7-8**] cm when supine.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI late peaking systolic murmur best
heard at LUSB. 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 anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Sheath in right
femoral vein.
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+
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.2 Tc 97.0 HR 77-82 RR 18 BP 105-141/56-77.
GENERAL: Pleasant female, AAOx3.
HEENT: MMM, OP clear.
NECK: No appreciable JVD.
CARDIAC: RR. normal S1, S2. II/VI late peaking systolic murmur
best heard at LUSB.
LUNGS: Nonlabored. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: No edema
Pertinent Results:
ADMISSION LABS:
[**2190-4-30**] 11:45AM BLOOD WBC-6.6 RBC-3.92* Hgb-11.2* Hct-34.1*
MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 Plt Ct-217
[**2190-4-30**] 11:45AM BLOOD Neuts-71.2* Lymphs-25.9 Monos-2.0 Eos-0.3
Baso-0.6
[**2190-4-30**] 11:45AM BLOOD PT-16.0* PTT-83.7* INR(PT)-1.5*
[**2190-4-30**] 11:45AM BLOOD Glucose-163* UreaN-34* Creat-1.0 Na-137
K-4.0 Cl-107 HCO3-18* AnGap-16
[**2190-4-30**] 11:45AM BLOOD CK(CPK)-467*
[**2190-4-30**] 11:45AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9
CARDIAC ENZYMES:
[**2190-4-30**] 11:45AM BLOOD CK-MB-46* MB Indx-9.9* cTropnT-0.69*
[**2190-4-30**] 09:27PM BLOOD CK-MB-44*
[**2190-5-1**] 04:01AM BLOOD CK-MB-21* cTropnT-0.95*
LIPIDS:
[**2190-5-2**] 07:49AM BLOOD Triglyc-137 HDL-70 CHOL/HD-2.2 LDLcalc-60
DISCHARGE LABS:
[**2190-5-3**] 07:23AM BLOOD WBC-7.1 RBC-3.59* Hgb-10.2* Hct-31.4*
MCV-88 MCH-28.5 MCHC-32.6 RDW-13.4 Plt Ct-212
[**2190-5-3**] 07:23AM BLOOD PT-10.5 PTT-28.2 INR(PT)-1.0
[**2190-5-3**] 07:23AM BLOOD Glucose-89 UreaN-28* Creat-1.0 Na-140
K-4.1 Cl-107 HCO3-23 AnGap-14
[**2190-5-3**] 07:23AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1
MICRO: NONE
IMAGING:
[**2190-4-30**] ECHO:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient. No VSD.
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.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
MS. Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Physiologic TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2190-4-30**] CARDIAC CATH
PRELIMINARY
LAD 30% mid
LCx 80% ostial OM1, 80% mid circumflex
RCA 90% mid, 70% distal, 70% distal
HEMODYNAMICS:
RA mean 6
PA 36/13
PCWP 10
Aorta 112/48
HR around 90 BPM
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
Ms. [**Known lastname 23203**] is a 66 year old female with hypertension (HTN),
hyperlipidemia (HLD), osteoarthritis who presented with chest
pressure found to be due to inferolateral ST elevation
myocardial infarction ([**Known lastname **]), with persistent hypotension after
balloon inflation requiring dopamine. She was weaned off the
dopamine during the first 24 hours post-cath and remained stable
hemodynamically and chest pain free.
ACTIVE PROBLEMS
# [**Name2 (NI) **]- ST elevation in III greater than II, with ST depression
in I, aVL suggested that right coronary artery was the culprit
lesion. The patient had 3 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] placed in the RCA but still
had LCx 80% ostial OM1, 80% mid circumflex which was not treated
given her hypotension (see below). In the cath lab, she was
started on intregrillin which was continued for 12 hours and
then discontinued. Her post-intervention echo showed preserved
LV ejection fraction (60%) and no focal wall motion
abnormalities.
-New Medications:
-Aspirin 81mg qday
-Plavix 75mg po qday
-Atorvastatin 80mg po qday
-F/u the patient continues to have stenosis of the LCx and need
for intervention on this can be addressed at follow-up with Dr.
[**Last Name (STitle) **]
#Blood pressure control: While in the cath lab, the patient had
hypotension after inflating the balloon in RCA. Her right heart
cath had normal pressures so a temporary vagal response was the
most likely etiology of her hypotension. She was started on
dopamine drip in the cath lab. PCWP was 10, so slight
hypovolemia may have contributed- patient received a total of
1200 cc normal saline and was able to wean off dopamine drip
within the first 24 hours. She had no evidence of infection to
suggest sepsis as an etiology of hypotension. Her blood
pressure was stable on her home regimen: lisinopril 10 mg daily
and metoprolol succinate 50 mg daily.
# Hyperlipidemia-Changed rosuvastatin to atorvastatin 80 mg
daily for better risk factor modification. Admission CK was
253, AST/ALT 36/20, lipid panel LDL 60, HDL 70, TG 137.
# Osteoarthritis- Used acetaminophen for pain control; held
Celebrex due to possible interaction with coronary artery
disease.
# Right knee [**Hospital Ward Name 4675**] cyst: She continued to have pain behind
right knee and exam was consistent with [**Hospital Ward Name 4675**] cyst.
Ultrasound confirmed this. Advised her to use tylenol for pain
control.
TRANSITIONAL ISSUES:
- Will likely need intervention to left circumflex
- monitor for side effects of medications including muscle aches
from atorvastatin and bleeding
- monitor symptoms of osteoarthritis and consider changing pain
regimen as an outpatient
Medications on Admission:
Celebrex 200 mg daily
lisinopril 10 mg daily
rosuvastatin 20 mg daily
Zyrtec 10 mg daily
multivitamin daily
ocuvite daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
5. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for allergy symptoms.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ocuvite Oral
8. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
ST elevation myocardial infarction
.
Secondary diagonosis:
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 23203**],
You were admitted to the hospital because you were having chest
pain. Your EKG and lab work showed that you had a heart attack,
called myocardial infarction. You had 3 stents placed in the
right artery of your heart to open this up and restore blood
flow to your heart. You were started on new medications to help
modify your risk for further heart disease. It is especially
important for you to take aspirin and plavix daily for one year
and possibly longer. Do not stop taking aspirin and plavix or
miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or the stent may clot off and cause another heart
attack.
You initially went to the ICU but you remained stable after the
stents were placed and now you are ready to be discharged.
You should follow-up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 8757**] below. It
is important to bring all your medications to each appointment
so your doctors [**Name5 (PTitle) **] update their records and adjust the [**Name5 (PTitle) 4319**] as
needed.
The following changes were made to your medications:
START TAKING THE FOLLOWING MEDS:
- Aspirin 81 mg daily to keep the stent open and prevent another
heart attack.
- Plavix (clopidogrel) 75 mg daily to keep the stent open and
prevent another heart attack.
- Metoprolol succinate 50 mg daily to lower your heart rate
- Increase rosuvastatin (Crestor) to 40 mg daily to lower your
cholesterol
.
STOP TAKING THE FOLLOWING MEDS:
-Celebrex- this medication is not good to take right after
having a heart attack. If you need to take something for pain we
recommend you take tylenol instead (maximum of 4g in one day)
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Dr. [**Last Name (STitle) 18323**].
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] PA
When: Tuesday [**5-11**] at 1:45pm
Address: [**Street Address(2) 4472**],[**Apartment Address(1) 24519**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 18325**]
Department: CARDIAC SERVICES
When: FRIDAY [**2190-5-28**] at 9:00 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
|
[
"272.4",
"414.01",
"410.21",
"715.95",
"401.9",
"458.29",
"V15.82",
"727.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"99.20",
"00.40",
"88.55",
"37.23",
"00.47",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
11953, 11959
|
8272, 10772
|
281, 388
|
12108, 12108
|
5192, 5192
|
14023, 14623
|
3593, 3802
|
11202, 11930
|
11980, 12087
|
11056, 11179
|
12259, 14000
|
5943, 8249
|
3842, 4839
|
10793, 11030
|
5686, 5927
|
231, 243
|
416, 3226
|
5208, 5669
|
12123, 12235
|
3248, 3355
|
3371, 3577
|
4864, 5173
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,739
| 175,431
|
13054
|
Discharge summary
|
report
|
Admission Date: [**2201-4-17**] Discharge Date: [**2201-4-24**]
Date of Birth: [**2125-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
esophageal ca
Major Surgical or Invasive Procedure:
s/p laporascopic esophagectomy [**4-17**] for esophogeal Cancer.
Jejunostomy-tube replaced [**4-19**].
Past Medical History:
Hypertension, Hyperlipidemia, Colon CAncer, Arthritis, Coronary
artery disease
Social History:
lives alone in [**Location (un) 620**]
Family History:
n/a
Physical Exam:
NAD
RRR
CTA b/l
incision clean/dry/intact
Pertinent Results:
[**2201-4-17**] 04:33PM BLOOD WBC-8.5# RBC-3.33* Hgb-10.8* Hct-31.0*
MCV-93 MCH-32.4* MCHC-34.7 RDW-15.9* Plt Ct-158
[**2201-4-17**] 04:33PM BLOOD PT-12.5 PTT-24.7 INR(PT)-1.1
[**2201-4-17**] 04:33PM BLOOD Glucose-132* UreaN-24* Creat-1.7* Na-137
K-5.0 Cl-107 HCO3-21* AnGap-14
[**2201-4-17**] 08:46AM BLOOD Type-ART pO2-175* pCO2-49* pH-7.34*
calHCO3-28 Base XS-0 Intubat-INTUBATED
[**2201-4-17**] 08:46AM BLOOD Glucose-150* Lactate-1.0 Na-136 K-4.2
Cl-104
[**2201-4-17**] 08:46AM BLOOD Hgb-10.7* calcHCT-32
[**2201-4-17**] 08:46AM BLOOD freeCa-1.14
[**2201-4-21**] 11:30PM BLOOD WBC-5.0 RBC-2.71* Hgb-8.8* Hct-24.5*
MCV-90 MCH-32.5* MCHC-35.9* RDW-15.5 Plt Ct-141*
[**2201-4-21**] 11:30PM BLOOD Plt Ct-141*
[**2201-4-21**] 11:30PM BLOOD Glucose-101 UreaN-29* Creat-1.0 Na-140
K-3.7 Cl-105 HCO3-24 AnGap-15
[**2201-4-21**] 05:38AM BLOOD CK(CPK)-169
[**2201-4-21**] 11:30PM BLOOD Calcium-7.6* Phos-2.7 Mg-1.6
Brief Hospital Course:
Patient was admitted [**2201-4-17**] for elective minimally invasive
thoracoscopic and laparoscopic total esophagogastrectomy. He
tolerated procedure well please see operative note for detail.
After recovery in PACU he was transferred to [**Wardname 836**] for further
care. Initial postoperative CXR showed minimal Right apical ptx
and right subcutaneous emphysema.
On POD2 his chest tubes were placed to water seal and follwup
CXR showed tiny right apical pneumothorax and bibasilar linear
atelectasis and small amount of residual pneumoperitoneum.
On POD 3 he had asymtomatic bout of atrial fibrillation up to
160's which responded to medical managment with IV lopressor.
On POD6 his right chest tube was removed and followup CXR was
unremarkable compared to prior. He also received an radiologic
evaluation of his esophagus anastomosis and emptying which
revealed no evidence of anastomotic leak status post
esophagectomy and slightly slow transit into the small bowel.
On POD7 the remaining left side chest tube was removed along
with nasogastric tube. subsequent CXR revealed stable sml apical
ptx seen in prior studies otherwise unremarkable.
His hospital course was otherwise unremarkable and was cleared
for discharge home [**2201-4-24**] with appropiate followup with Dr.
[**Last Name (STitle) **].
Discharge Medications:
1. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*240 ML(s)* Refills:*0*
4. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: Fifteen (15) cc PO
BID (2 times a day).
5. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO ONCE
(Once) for 1 doses.
Disp:*120 ML(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. tubefeeding
ProBalance 75/hr for 24 hours continuous
See instruction sheet for rate for variable hour duration
7.5 cans ProBalance/day
9. tube feeding pump
Kangaroo Pump
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Homecare
Discharge Diagnosis:
s/p lap esophagectomy [**4-17**] for esophogeal CAncer.
Jejunostomy-tube replaced [**4-19**].
PMHx: Hypertension, Hyperlipidemia, Colon CAncer, Arthritis,
Coronary arterty disease
PSHx: Right hemicolectomy, Coronary artery bypass graft, Left
port and Jejunostomy tube placement [**1-8**]
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name **]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] for:
fevers, shortness of breath, chest pain, nausea, vomitting,
difficult swallowing, or constipation longer than 4 days.
Take medications as listed on discharge instructions.
Tubefeeding of ProBalance goal 75cc/hr for 24 hours. And as
scheduled provided in instructions for 20 hours, 16 hours, 12
hours duration.
Tube feeding support w/ [**Hospital 5065**] Healthcare-[**Telephone/Fax (1) 39931**].
VNA with Physician's HomeCare-[**Telephone/Fax (1) 39932**].VNA will assist you
w/ wound assessment and management, tubefeedings together w/
[**Hospital1 5065**].
YOu may shower when you get home. No tub baths or swimming for
3-4 weeks.
YOu may take clear-full liquids until follow appointment with
Dr. [**Last Name (STitle) 952**] in [**9-26**] days.
Followup Instructions:
Call Dr.[**Doctor Last Name **]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] for an
appointment in [**9-26**] days.
Completed by:[**2201-4-29**]
|
[
"512.1",
"492.8",
"568.0",
"150.5",
"997.1",
"427.31",
"272.4",
"V10.05",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.02",
"42.23",
"96.6",
"43.99",
"99.04",
"54.51"
] |
icd9pcs
|
[
[
[]
]
] |
4156, 4211
|
1639, 2951
|
344, 449
|
4543, 4550
|
706, 1616
|
5438, 5593
|
624, 629
|
2974, 4133
|
4232, 4522
|
4574, 5415
|
644, 687
|
291, 306
|
471, 551
|
567, 608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,555
| 137,509
|
2368
|
Discharge summary
|
report
|
Admission Date: [**2163-7-16**] Discharge Date: [**2163-7-21**]
Date of Birth: [**2108-8-29**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillin G Potassium / Penicillins
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Renal colic
Major Surgical or Invasive Procedure:
Right ureteral stent placement, right ureteroscopy with laser
lithotripsy
History of Present Illness:
54 y morbidly obese male with right lower quadrant pain for the
past 5 days. He states the pain occasionally is bad enough to
cause him nausea. He has had no fevers, chills or vomiting. HE
first went to an outside hospital where plain films were taken
noting no problems, then a CT urogram noted a 5mm right mid
ureteral stone. Contrast was given showing the expected delay in
the right side. Today his Cr. has elevated to 2.2 from a
baseline of 1.3. Currently his pain is well controlled and he
is
tolerating clear liquids.
Past Medical History:
PMH:
1. History of pseudomonas cellulitis and bacteremia at [**Hospital 12302**] in [**2158-6-8**].
2. History of recurrent cellulitis.
3. Proteus bacteremia.
4. Coronary artery disease, s/p MI in [**2153**].
5. CHF
6. Hyperlipidemia.
7. HTN
8. Chronic renal insufficiency, baseline creatinine 1.3.
9. Asthma.
10. Morbid obesity.
11. Onychomycosis.
12. Severe lymphedema secondary to obesity.
13. Status post left hip replacement in [**2154**].
14. Polyps, adenoma in [**2158-11-8**].
15. Depression.
16. Gout
17. Erectile dysfunction
Physical Exam:
afebrile
comfortable
obese abdomen, soft non tender
no CVA tenderness
Pertinent Results:
[**2163-7-16**] 02:50AM BLOOD WBC-10.2 RBC-4.52* Hgb-13.4* Hct-39.9*
MCV-88 MCH-29.6 MCHC-33.6 RDW-13.2 Plt Ct-210
[**2163-7-17**] 08:17AM BLOOD Glucose-115* UreaN-20 Creat-2.2* Na-139
K-4.1 Cl-103 HCO3-28 AnGap-12
[**2163-7-16**] 02:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2
Brief Hospital Course:
Urology summary:
Mr. [**Known lastname 12303**] was admitted for acute on chronic renal failure and
obstructing right mid-ureteral stone. He underwent right laser
lithotripsy of ureteral stone and ureteral stent placement
[**2163-7-18**]. Post-operative course complicated by pulmonary edema and
he was observed in the intensive care unit and diuresed. Foley
removed POD1. At discharge patient's pain well controlled with
oral pain medications, tolerating regular diet, voiding without
difficulty, and oxygenating well on room air. He will follow-up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] as an outpatient for stent removal and
his PCP [**Name Initial (PRE) 176**] 2 weeks for creatinine check and medication
reconcilation (captopril and [**Name Initial (PRE) **] held).
[**Hospital Unit Name 153**] summary:
Mr. [**Known lastname 12303**] was admitted for monitoring after a desaturation while
in the PACU after lithotripsy. This most likely represents
obesity-hypoventilation complicated by derecruitment of alveoli
with peri-procedural sedation. The patient almost certainly has
sleep apnea by history (snoring and apneic spells) and exam
(thick neck). He was also diuresed >3L given IVF administered
prior to procedure and holding of diuretics on admission with
pre-procedure renal failure. At the time of transfer he did have
a 4L oxygen requirement to keep SaO2>90%. He was evaluated by
sleep medicine who recommended auto-BiPap prior to discharge and
outpatient sleep study and sleep medicine follow-up.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain for 2 weeks.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 1 months.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
8. home O2
patient will need 4L home oxygen at rest and with exertion
9. [**Known lastname 11573**] 20 mg Tablet Sig: 1-3 Tablets PO once a day as needed
for shortness of breath or wheezing: Continue regular home
titration.
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right ureteral stone, obstructing
Acute on chronic kidney failure
Discharge Condition:
Stable
Discharge Instructions:
Specific insturctions:
You may shower and bathe normally. Do not drive or drink
alcohol if taking narcotic pain medication. Hold [**Hospital **] and
captopril until you see your primary care doctor within [**2-9**]
weeks. Otherwise, resume all of your home medications. Call Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office for follow-up appointment
([**Telephone/Fax (1) 5727**]) AND if you have any urological questions. If you
have fevers > 101.5 F, vomiting, severe abdominal pain, or
inability to urinate, call your doctor or go to the nearest
emergency room.
Definitions
Ureter: the duct that transports urine from the kidney to the
bladder:
Stent: a plastic hollow tube that is placed into the ureter,
from the kidney to the bladder to prevent the ureter from
swelling shut.
General Instructions
Despite the fact that no skin incisions were used, the area
around the ureter and bladder is irritated. The stent is
required in order keep the ureter open and urine flowing from
the kidney to the bladder. Because one end of the ureter is in
the bladder, it can cause irritation to the bladder. Therefore,
it is normal to feel that you need the urge to urinate
frequently when the stent is in place. Although the stent can be
uncomfortable, it is important to have the stent to avoid
damaging the kidney and ureter after your procedure. You may see
some blood in your urine while the stent is in place and a few
days afterward. Drink lots of fluid ?????? this will help clear up
your urine.
Diet
You may return to your normal diet immediately. Because of the
raw surface of your bladder, alcohol, spicy foods, acidy foods
and drinks with caffeine may cause irritation or frequency and
should be used in moderation. To keep your urine flowing freely
and to avoid constipation, drink plenty of fluids during the day
(8 - 10 glasses).
Activity
Your physical activity doesn't need to be restricted. However,
if you are very active, you may see some blood in the urine. We
would suggest to cut down your activity under these
circumstances until the bleeding has stopped.
Bowels
It is important to keep your bowels regular during the
postoperative period. Straining with bowel movements can cause
bleeding. A bowel movement every other day is reasonable. Use a
mild laxative if needed, such as Milk of Magnesia [**3-13**]
Tablespoons, or 2 Dulcolax tablets. Call if you continue to have
problems. If you had been taking narcotics for pain, before,
during or after your surgery, you may be constipated. Take a
laxative if necessary.
Medication
You should resume your pre-surgery medications unless told not
to. In addition you will often be given an antibiotic to prevent
infection. These should be taken as prescribed until the bottles
are finished unless you are having an unusual reaction to one of
the drugs.
Problems [**Name (NI) **] Should Report to Us
a. Fevers over 100.5 Fahrenheit.
b. Heavy bleeding, or clots (See notes above about blood in
urine).
c. Inability to urinate.
d. Drug reactions (Hives, rash, nausea, vomiting, diarrhea).
e. Severe burning or pain with urination that is not improving.
Follow-up
You have and internal stent and it is important to have a
follow-up appointment to remove your stent. Call your doctor for
this appointment when you get home.
Followup Instructions:
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office for follow-up appointment
([**Telephone/Fax (1) 5727**]) AND if you have any urological questions.
See your primary care doctor. [**First Name (Titles) **] [**Last Name (Titles) **] and captopril until you
see your primary care doctor within 1-2 weeks. Your creatinine
should be checked at time as well.
|
[
"428.0",
"V85.4",
"459.81",
"514",
"591",
"585.9",
"592.1",
"V43.64",
"412",
"414.01",
"V14.0",
"600.00",
"274.9",
"493.90",
"427.89",
"428.30",
"584.9",
"327.23",
"278.01",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"56.0",
"59.8",
"56.31"
] |
icd9pcs
|
[
[
[]
]
] |
4935, 4993
|
2051, 3603
|
329, 405
|
5103, 5112
|
1636, 2028
|
8474, 8864
|
3626, 4912
|
5014, 5082
|
5136, 8451
|
1546, 1617
|
278, 291
|
433, 964
|
986, 1531
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,638
| 172,531
|
15379
|
Discharge summary
|
report
|
Admission Date: [**2175-3-20**] Discharge Date: [**2175-3-24**]
Date of Birth: [**2108-5-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
diarrhea x4-5 days, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 yo female with ischemic cardiomyopathy (EF 10-25%), h/o
DVT/PE on coumadin, HTN, and AFib s/p BiV ICD who presented with
diarrhea x3 days (large volumes, 5 watery stools per day),
chills, abd bloating, and general malaise. She had an episode of
syncope on the day of admission. Denies head trauma. She
reported no recent travel. She notes that her family had similar
symptoms one week prior. She denied N/V/BRBPR/CP/SOB. In the ED
she was found to be hypotensive, hyperkalemic, in ARF (baseline
Cr 1.2-1.3), and with an elevated INR. She responded to
agressive fluid hydration in the ED with MAPs in the 60's. INR
initially 20.0 down to 5.4 after multiple doses of Vit K,
coumadin being held. She was initially admitted to the MICU for
fluid boluses and close monitoring. All her BP meds and
diurectics were initially held.
Past Medical History:
1. ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD
2. Coronary artery disease status post PTCA and stenting of the
LAD in [**2164**].
3. h/o PE secondary to DVT s/p IVC filter
4. Atrial fibrillation status post cardioversion and
biventricular pacemaker implantation.
5. HTN
6. Obesity
7. PVD
8. small VSD
9. hypothyroidism
Social History:
Pt lives alone. She is not married. She reports a 20 pack year
history, however she quit 30 yrs ago. Denies EtOH or illicit
drug use.
Family History:
Mother had MI at age 50. Father in good health. Maternal uncle
died of MI in his 50's.
Physical Exam:
T 98.1, 117/71, 73, 20, 97% RA, LOS + 1.1 L
Gen: well appearing overweight female in NAD
HEENT: MMM, anicteric
Neck: No JVD, No LAD
CV: RRR, Nl S1S2, + S3, no M
Lungs: CTAB
Abd: obese, distended, NT, hyperactive BS, No HSM appreciated
Ext: no edema, strong DP pulses, tenderness to palpation lateral
aspect of right ankle
Neuro: A&Ox3, [**4-20**] muscle strength UE/LE
Pertinent Results:
Studies:
CXR [**2175-3-21**]:
The triple lead AICD/pacemaker remains in place. There is
persistent cardiomegaly, without evidence of failure. The lungs
are clear. Soft tissues and osseous structures are unchanged.
ECHO ([**11/2173**]) - EF 20-25%, 1+ AR, 1+ MR, [**12-18**]+ TR, moderate
pulmonary HTN
CATH ([**9-/2172**]) - patent mid-LAD stent. clean LCX. Recannulized
RCA lesion. no LV gram.
TTE ([**2175-3-15**]) = EF 20% (unchanged from prior study)
Labs:
[**2175-3-20**] 05:57PM GLUCOSE-124* UREA N-64* CREAT-3.3* SODIUM-139
POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
[**2175-3-20**] 05:57PM CALCIUM-9.6 MAGNESIUM-2.2
[**2175-3-20**] 05:56PM GLUCOSE-134* UREA N-64* CREAT-3.4* SODIUM-137
POTASSIUM-8.0* CHLORIDE-102 TOTAL CO2-26 ANION GAP-17
[**2175-3-20**] 05:56PM CK(CPK)-115
[**2175-3-20**] 05:56PM CK-MB-3 cTropnT-0.01
[**2175-3-20**] 05:56PM CALCIUM-9.5 MAGNESIUM-2.3
[**2175-3-20**] 05:56PM URINE HOURS-RANDOM UREA N-558 CREAT-122
SODIUM-63
[**2175-3-20**] 05:56PM URINE OSMOLAL-473
[**2175-3-20**] 05:56PM PT-53.0* PTT-46.1* INR(PT)-17.7
[**2175-3-20**] 02:14PM GLUCOSE-129* NA+-140 K+-6.5* CL--99* TCO2-23
[**2175-3-20**] 12:45PM GLUCOSE-162* UREA N-69* CREAT-4.0*#
SODIUM-134 POTASSIUM-7.1* CHLORIDE-98 TOTAL CO2-25 ANION GAP-18
[**2175-3-20**] 12:45PM ALT(SGPT)-26 AST(SGOT)-31 LD(LDH)-404* ALK
PHOS-95 AMYLASE-103* TOT BILI-0.8
[**2175-3-20**] 12:45PM CK(CPK)-109
[**2175-3-20**] 12:45PM LIPASE-105*
[**2175-3-20**] 12:45PM cTropnT-0.03*
[**2175-3-20**] 12:45PM CK-MB-3
[**2175-3-20**] 12:45PM ALBUMIN-4.9*
[**2175-3-20**] 12:45PM CALCIUM-10.3* PHOSPHATE-4.3 MAGNESIUM-2.5
[**2175-3-20**] 12:45PM TSH-1.8
[**2175-3-20**] 12:45PM DIGOXIN-1.4
[**2175-3-20**] 12:45PM WBC-8.2# RBC-4.99# HGB-16.0# HCT-47.0# MCV-94
MCH-32.1* MCHC-34.1 RDW-13.3
[**2175-3-20**] 12:45PM NEUTS-88.8* LYMPHS-8.2* MONOS-2.4 EOS-0.4
BASOS-0.2
[**2175-3-20**] 12:45PM PLT COUNT-119*
[**2175-3-20**] 12:45PM PT-50.9* PTT-46.4* INR(PT)-16.3
Brief Hospital Course:
66 yo female with ischemic cardiomyopathy (EF 10-25%), HTN, h/o
PE/DVT on Coumadin, and AFib s/p BiV ICD who presented with
diarrhea x3 days, syncope, and hypotension.
1. Hypotension resolved with aggressive fluid hydration.
Etiology thought to be secondary to hypovolemia from diarrhea,
Lasix, and poor PO intake. Baseline SBP in the 80's as per Dr
[**Last Name (STitle) **]. Initally all Diuretics and anti-hypertensive were held.
- Carvedilol was increased to 12.5 mg [**Hospital1 **] prior to discharge.
Will need to be titrated back to 25 [**Hospital1 **] as an outpt. She will
follow up closely with the CHF service ([**Name8 (MD) 698**] NP 2-7768).
- Digoxin restarted.
- Captopril was slowly added and she was discharged on
Lisinopril 20 mg daily.
- She was discharged on lasix 40 mg daily
- She was tolerating adequate po intake on day of discharge.
2. Diarrhea now resolved. Etiology appears to be gastroenteritis
given sick contacts, fevers, and rapid resolution of symptoms.
Her diarrhea was likely the cause of her hyperkalemia.
- Her diet was advanced as tolerated.
3. ARF now resolved (baseline Cr 1.2-1.3). Etiology thought to
be pre-renal azotemia.
- Her lasix and ACEI were slowly added back to her medical
regimen w/o difficulty.
4. Hyperkalemia resolved with insulin and Kayexalate in ED.
Etiology thought to be secondary to ARF and massive
diarrhea/metabolic acidosis. Pt also taking KCl as outpt. Her
KCL was held.
5. Elevated INR improving s/p Vit K. Coumadin was held held
throughout admission (treated with Coumadin for h/o PE/DVT,
AFib, low EF). No evidence of bleeding during her stay. Her INR
was 3.3 on day of discharge. She will continue to hold
Coumadin. She will follow-up with her PCP for INR checks and
will restart Coumadin when indicated.
6. Ischemic Cardiomyopathy (EF 20%). Followed by Dr. [**Last Name (STitle) **].
- B-B restarted slowly, will continue to titrate up as an
outpatient.
- Her ACEI and Dig were restarted.
- Her Lasix was restarted at discharge.
- Her anticoagulation was held at discharge given elevated INR.
- She was continued on ASA 81 and Lipitor
7. Right lateral malleolar pain. An orthopeadic consultation was
obtained. They felt the plain film findings represent OA from a
previous ankle injury and that there was no evidence of acute
trauma. Pt also with asymmetric calf size, LENI's without
evidence of DVT.
Medications on Admission:
1. Lasix 40 mg daily
2. Coreg 25 mg [**Hospital1 **]
3. Digoxin 0.125 mg QOD
4. Lisinopril 20 mg daily
5. Lipitor 20 mg daily
6. ASA 81 mg daily
7. Coumadin 7.5 mg x1 day and then 5 mg x2 days
8. Prevacid 30 mg [**Hospital1 **]
9. Synthroid 112 mcg daily
10. TNG prn
11. Amiodarone 200 mg daily
12. KCl 10 mEq daily
Discharge Medications:
1. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*15 Tablet(s)* Refills:*2*
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diarrhea
Hypotension secondary to hypovolemia
Discharge Condition:
Good
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you expereince lightheadedness, shortness of breath,
chest pain, or have any other concerns.
You are taking half your regular dose of Coreg. Please do not
take Potassium until you see your primary care physician.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 44658**] next week. [**Telephone/Fax (1) 44659**]
Please call the Congestive Heart Failure Clinic on Monday to
discuss your medications. ([**Name8 (MD) 698**] [**Telephone/Fax (1) 44660**]). Please
weigh yourself daily and take all your medications as
perscribed.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"787.91",
"780.2",
"425.4",
"276.7",
"428.0",
"427.31",
"785.59",
"V58.61",
"584.9",
"276.5",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8002, 8008
|
4221, 6603
|
342, 348
|
8098, 8104
|
2210, 4198
|
8435, 8872
|
1718, 1806
|
6969, 7979
|
8029, 8077
|
6629, 6946
|
8128, 8412
|
1821, 2191
|
275, 304
|
376, 1205
|
1227, 1551
|
1567, 1702
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,013
| 182,359
|
38695
|
Discharge summary
|
report
|
Admission Date: [**2172-4-4**] Discharge Date: [**2172-4-7**]
Date of Birth: [**2106-6-28**] Sex: M
Service: SURGERY
Allergies:
Cefuroxime / Metronidazole
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
abdominal pain, shortness of breath, hypotension
Major Surgical or Invasive Procedure:
central line placement x2, dialysis catheter placement,
endotracheal intubation, foley placement
History of Present Illness:
65yo male with polycystic kidney/liver disease admitted to the
ED with worsening abdominal pain, increasing abdominal girth,
shortness of breath, and hypotension (as low as SBP 40s). In ED
patient received 2L saline, placed on dopamine for BP with
improved blood pressure. Patient admitted to ICU. After
paracentesis, was found to have spontaneous bacterial
peritonitis and placed on antibiotics.
Past Medical History:
1. Polycystic liver and kidney disease
2. Anticoagulated given risk of clot (sedentary and IVC
compression)
3. Coronary artery disease status post stenting x5 in [**2165-6-18**]
4. Umbilical hernia s/p repair with mesh
5. Degenerative bone disease
6. Amputation of 2 fingers due to a snowblower accident
7. Tonsillectomy and adenoidectomy
8. Right foot and leg cellulitis in [**2170-5-18**]
Social History:
1. Occupation: Patient was a city bus driver x 36 years and
recently retired. Currently receiving disability.
2. EtOH: Patient does not drink alcohol.
3. Smoking: Patient has never been a smoker.
4. Drugs: Patient has never used any other substances.
Family History:
Father and twin brother who both had polycystic liver and kidney
disease. His father died at age 63 from arterial sclerosis and
his twin brother died at age 58 of colon cancer. The patient
also has an uncle who was diagnosed with polycystic liver and
kidney disease however he also died at age 68 of heart disease.
The patient's mother died at age 87 from Alzheimer's and
emphysema. He does have one other brother who does not have
polycystic liver and polycystic kidney disease but suffers from
diabetes mellitus type 2 and has had a quadruple bypass
Brief Hospital Course:
Mr. [**Name14 (STitle) 85970**] was admitted to the Transplant Surgery Service on
[**2172-4-4**] for increasing abdominal girth and pain, shortness of
breath and hypotension. On the day of admission, a paracentesis
was performed yielding a high PMN count c/w spontaneous
bacterial peritonitis. He was hemodynamically unstable and
placed on pressors. He eventually developed respiratory failure
and unable to properly oxygenate/ventilate due to his abdominal
girth/resuscitation efforts and was intubated on [**2172-4-5**]. His
course has been significant for worsening cardiac function due
to low intravascular volume and body positioning requiring
multiple pressors, respiratory failure ultimately leading to
ARDS, kidney failure requiring CVVHD, anemia and coagulopathy
requiring transfusion of blood products, and a broadening of his
antibiotics to cover possible sources of infection.
On [**2172-4-7**], the patient's wife and daughter ([**Name (NI) **]) met with
the SICU, Transplant, and Social Work teams and expressed that
the patient would have wished to forego any of the afore
mentioned efforts. They also mentioned that the patient--and
the family--wishes the patient to pass comfortably and with
dignity. The patient was therefore made "comfort measure only."
The [**Location (un) 511**] Organ Bank was contact[**Name (NI) **] ([**Name (NI) **] at
1-[**Telephone/Fax (1) 85971**], at 12:29, [**2172-4-7**]) and declined. The patient
finally succumber and passed away on [**2172-4-7**] at 13:50 d/t
cardiopulmonary collapse. family present at the bedside.
Medications on Admission:
allopurinol 100', calcitriol 0.5', enalapril 20", hydrocodone
7.5/500 prn, furosemide 40' (recently stopped), clotrimazole 10
PRN, terazosin 10 QHS, nadolol 40', nifedipine 60 ER', MVI,
spironolactone 50', Coumadin 6 EOD, Coumadin 7 EOD, miralax prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary collapse
Discharge Condition:
Expired
|
[
"751.62",
"785.52",
"286.9",
"585.3",
"518.81",
"038.9",
"276.2",
"753.12",
"584.9",
"995.92",
"567.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"54.91",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4016, 4025
|
2136, 3715
|
333, 431
|
4093, 4103
|
1556, 2113
|
4046, 4072
|
3741, 3993
|
245, 295
|
459, 857
|
879, 1271
|
1287, 1540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,077
| 100,284
|
34586+57930
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-10-5**] Discharge Date: [**2152-10-15**]
Date of Birth: [**2096-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2152-10-10**] Mitral Valve Repair (Quadrangular Resection w/28mm ring)
& Coronary Artery Bypass Graft x 4 (LIMA-LAD, SVG-Dg, SVG-Ramus,
SVG-OM2)
History of Present Illness:
Mr. [**Known lastname 4643**] presented to OSH c/o shortness of breath that
developed approximately 1 month ago and progressively worsened
over several days before presenting to ED.
Past Medical History:
Diabetes Mellitus, Hyperlipidemia, Astham/Chronic obstructive
pulmonary disease, h/o Pancreatitis
Social History:
Quit smoking 20 yrs ago after 60pky. Denies alcohol for past 10
yrs.
Family History:
Mother w/ 2 MI's. Brother died from a MI in late 60's. Another
brother died from a MI at 64.
Physical Exam:
VS: 105 16 132/79 5'5" 180#
Gen: Well-appearing male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL
Neck: Supple, FROM, -JVD, -Carotid bruit
Chest: CTAB
Heart: RRR 3/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**10-10**] Echo: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with added focalities inn inferior and septal walls with mildly
preserved function in the anterior and lateral walls. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. There is no pericardial effusion. Dr.[**Last Name (STitle) **] was notified
in person of the results on [**2152-10-10**] at 8:30AM. POST-BYPASS: For
the post-bypass study, the patient was receiving vasoactive
infusions including epinephrine at 0.03mcg/kg/min and
phenylephrine at 0.7 mcg/kg/min. Normal Right ventricular
function. LVEF 20%. There is a prosthesis (ring)in the mitral
position. It is stable and functioning well. There is no
stenosis or regurgitation across the mitral valve. Intact
thoracic aorta.
[**2152-10-6**] 12:43AM BLOOD WBC-8.6 RBC-4.62 Hgb-13.9* Hct-40.5
MCV-88 MCH-30.2 MCHC-34.5 RDW-13.1 Plt Ct-256
[**2152-10-12**] 05:30AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.7* Hct-28.1*
MCV-90 MCH-30.9 MCHC-34.4 RDW-13.2 Plt Ct-139*
[**2152-10-6**] 12:43AM BLOOD PT-14.0* PTT-23.5 INR(PT)-1.2*
[**2152-10-10**] 12:35PM BLOOD PT-15.2* PTT-35.1* INR(PT)-1.3*
[**2152-10-6**] 12:43AM BLOOD Glucose-122* UreaN-26* Creat-1.0 Na-142
K-4.5 Cl-106 HCO3-28 AnGap-13
[**2152-10-12**] 05:30AM BLOOD Glucose-115* UreaN-17 Creat-1.2 Na-136
K-4.9 Cl-106 HCO3-27 AnGap-8
Brief Hospital Course:
Mr. [**Known lastname 4643**] was transferred from OSH after cardiac cath revealed
left main and multi-vessel disease. As well as echo showing 3+
mitral regurgitation. Upon admission he was appropriately
medically managed and worked-up for surgery. On [**10-10**] he was
brought to the operating room where he underwent a coronary
artery bypass graft x 4 and mitral valve repair. Please see
operative report for surgical detail. Following surgery he was
transferred to the CVICU for invasive management in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one his
chest tubes were removed. All drips were weaned off on post-op
day one and on post-op day two he was transferred to the
telemetry floor for further care. Beta blockers and diuretics
were initiated and he was gently diuresed towards his pre-op
weight. On post-op day three his epicardial pacing wires were
removed. The remainder of his postoperative course was
essentially uneventful. He was transfused a total of 2 units
PRBCs postoperatively for anemia. He continued to progress and
on POD#5 was discharged to home with VNA. He was instructed on
all necessary follow up appointments.
Medications on Admission:
Tricor 145mg qd, Glucophage 500mg QID, Lantus 20U qAM, Lipitor
40mg qd, Byetta, Niacin 1000mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*1*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*1*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Tab Sust.Rel.
Particle/Crystal PO once a day .
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once daily.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Mitral Regurgitation s/p Mitral Valve Repair
PMH: Diabetes Mellitus, Hyperlipidemia, Astham/Chronic
obstructive pulmonary disease, h/o Pancreatitis
Discharge Condition:
good
Discharge Instructions:
1)Shower daily. Wash incisions with soap and water. Pat dry
only. Please do not apply lotions or creams to surgical
incisions.
2)No driving for at least one month.
3)No lifting more than 10lbs for at least 10 weeks.
4)Call cardiac surgeon if there is any concern for sternal wound
infection.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 10740**] in [**2-16**] weeks
Cardiologist in [**3-19**] weeks
Completed by:[**2152-10-17**] Name: [**Known lastname **],[**Known firstname **] R. Unit No: [**Numeric Identifier 12759**]
Admission Date: [**2152-10-5**] Discharge Date: [**2152-10-15**]
Date of Birth: [**2096-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Clarification of the term heart failure in the discharge summary
dated [**2152-10-15**] refers to systolic heart failure.Evidenced on
echo [**2152-10-10**]: There is severe regional left ventricular
systolic dysfunction
with added focalities in inferior and septal walls with mildly
preserved function in the anterior and lateral walls. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2152-10-31**]
|
[
"428.20",
"577.1",
"414.01",
"411.1",
"424.0",
"493.20",
"250.00",
"V12.54",
"V58.67",
"285.9",
"V15.82",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61",
"36.15",
"36.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7631, 7809
|
3358, 4580
|
342, 491
|
6294, 6300
|
1323, 3335
|
6640, 7608
|
925, 1019
|
4727, 5964
|
6063, 6273
|
4606, 4704
|
6324, 6617
|
1034, 1304
|
283, 304
|
519, 702
|
724, 823
|
839, 909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,451
| 114,840
|
5230+55652
|
Discharge summary
|
report+addendum
|
Admission Date: [**2127-12-4**] Discharge Date: [**2127-12-13**]
Date of Birth: [**2056-4-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Positive stress test
Major Surgical or Invasive Procedure:
[**2127-12-5**] - Urgent off-pump coronary artery bypass graft x3: Left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal and posterior descending
arteries.
[**2127-12-4**] - Cardiac catheterization
History of Present Illness:
This is a 71 year old male with polycystic kidney disease,
dialysis dependent who was in the process of kidney transplant
evaluation. The patient had CT chest on [**2127-10-1**] revealing a 2.2
x 2.1 x 2.4 cm right upper lobe lung nodule, which was treated
with antibiotics. He then had a repeat CT chest [**2127-11-6**]
revealing increased size to 2.9 x 2.5 x 2.6 cm. Patient was
being worked up for a right upper lobe nodule removal and was
found to have a positive stress test. Upon telephone interview
with patient he states he gets fatigue very easily, he denies
chest discomfort. Patient complains of shortness of breath on
exertion for the past six months.
Past Medical History:
Hypertension
COPD
Polycystic Kidney Disease on HD since [**1-5**] 3x week M-W-F
Left leg claudication
Ventral Hernia
Hypercholesterolemia
Cardiac Arrest [**2124**]
GERD
Arthritis
Past Surgical History
Cerebral artery aneurysm clipping [**2114**]
Abdominal Aortic aneurysm repair [**2124**] at [**Hospital1 112**]
Social History:
Lives with:Married with a son and daughter [**Name (NI) 2270**] who is his
health care proxy, his wife has [**Name (NI) 2481**].
Occupation:retired
Tobacco:denies (quit 3 years ago), smoked 1ppd for 50 yrs
ETOH:denies (quit 3 yrs ago)
Family History:
Family History:adopted, family history unknown
Physical Exam:
Pulse: 67 Resp: 14 O2 sat: 99% RA
B/P Right: 184/78 on nitro
Height:6'1" Weight:214lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x](distant)
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]large abdominal incision, midline
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 1+ Left:1+
Carotid Bruit Right: - Left:-
LEFT ARM FISTULA
Pertinent Results:
[**2127-12-4**] Cardiac Catheterization
1. Coronary angiography in this right dominant system
demonstrated a
distal lesion in the LMCA extening in the proximal LAD of 60-70%
stenosis. The LAd had a 60-70% mid ulcerated lesion with a 90%
distal
lesion into the diag bifurcation. The Lcx was normal. The RCA
had a 60%
mid and 70% distal lesion.
2. Limited hemodynamics revealed severe centralized
hypertenison to
193mm Hg that was treated with a nitroglycerine drip during the
procere.
3. In the post procedure holding are the patient developed a
mild-moderate size hematoma in the right groin that was easily
controlled and regressed with manual pressure
[**2127-12-5**] ECHO
Intraoeprative findings:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. There are
simple atheroma in the ascending aorta. The aortic arch is
mildly dilated. There are complex (>4mm) atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen.
Mild to moderate ([**12-28**]+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 7772**] was notified in person of the results.
[**2127-12-5**] Carotid ultrasound
Mild heterogeneous plaque bilaterally with bilateral 1-39% ICA
stenosis. Vertebral abnormalities as described above without any
significant evidence of inflow disease on the left.
[**2127-12-5**] Femoral ultrasound
Normal study, without pseudoaneurysm, AV fistula, or hematoma.
[**2127-12-10**] 07:01AM BLOOD WBC-7.4 RBC-2.67* Hgb-8.8* Hct-26.3*
MCV-99* MCH-32.9* MCHC-33.3 RDW-15.1 Plt Ct-174#
[**2127-12-5**] 05:07PM BLOOD PT-14.9* PTT-28.4 INR(PT)-1.3*
[**2127-12-10**] 07:01AM BLOOD Glucose-125* UreaN-65* Creat-8.1*# Na-137
K-4.7 Cl-95* HCO3-26 AnGap-21*
[**Known lastname 21376**],[**Known firstname 21377**] [**Medical Record Number 21378**] M 71 [**2056-4-26**]
Radiology Report CHEST (PA & LAT) Study Date of [**2127-12-9**] 9:04 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2127-12-9**] 9:04 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 21379**]
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
71 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
r/o inf, eff
Final Report
CLINICAL HISTORY: Status post CABG, evaluate for pleural
effusion.
COMPARISON: Multiple radiographs dating back to [**2127-12-5**], most
recently
[**2127-12-6**]; outside CT [**2127-11-6**] and PET [**2127-11-15**].
FINDINGS: Compared to [**2127-12-6**], lung volumes are improved.
There is mild
bibasilar atelectasis with improvement in retrocardiac
atelectasis. A tiny
left pleural effusion is seen. There is no pneumothorax or
pulmonary vascular
congestion. A calcified granuloma is at the right lung base. A
right medial
apical mass corresonds to mass seen on outside CT and PET. The
heart is stably
enlarged. The mediastinal width is decreased since [**2127-12-6**] in
this patient
status post CABG. A right internal jugular catheter terminates
in the mid
SVC.
IMPRESSION:
1. Tiny left pleural effusion.
2. Improved retrocardiac atelectasis with mild persistent
bibasilar
atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: TUE [**2127-12-9**] 1:41 PM
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2127-12-4**] for a cardiac
catheterization following a positive stress test. He underwent
stress testing due to an enlarging right upper lobe lung nodule
which is being followed by thoracic surgery with planned future
surgical intervention. His catheterization revealed severe left
main and three vessel disease. Given the severity of his
disease, the cardiac surgical service was consulted. Mr. [**Known lastname **]
was worked-up in the usual preoperative manner including a
carotid duplex ultrasound which showed mild bilateral internal
carotid artery disease. On [**2127-12-5**], Mr. [**Known lastname **] was taken to the
operating room where he underwent off-pump coronary artery
bypass grafting to three vessels. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next 24 hours, he awoke neurologically
intact and was extubated. Beta blockade, aspirin and a statin
were resumed. Plavix was started and is to be continued for 3
months given his off-pump surgery. He resumed his hemodialysis
as per preoperatively. The renal service followed him closely
while recovering from his cardiac surgery. On postoperative day
one, he was transferred to the step down unit for further
recovery. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Lasix
was resumed at 40mg daily per the renal service and per
preoperatively. He continued to not make a significant amount of
urine. He had a short episode of atrial fibrillation which
quickly converted back to normal sinus rhythm with amiodarone.
He continued to make steady progress and was discharged home on
postoperative day 6. He will follow-up with Dr. [**First Name (STitle) **], Dr.
[**Last Name (STitle) 7047**] and Dr. [**Last Name (STitle) 17918**] as an outpatient. He will also resume
his normal hemodialysis schedule as an outpatient. He will
follow-up with Dr. [**First Name (STitle) **] of thoracic surgery on [**1-6**] @ 9AM
regarding management of his lung nodule. He will get home PT
with VNA services.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - [**12-28**] every four (4) hours as needed for
shortness of breath or wheezing
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by
Other Provider) - 1 mg Capsule - one Capsule(s) by mouth daily
CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg
Capsule - two Capsule(s) by mouth three times daily
EPOETIN ALFA [EPOGEN] - (Prescribed by Other Provider) - 2,000
unit/mL Solution - 2400 units 3x/week
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
LABETALOL - (Prescribed by Other Provider) - 300 mg Tablet - 1
Tablet(s) by mouth twice a day
PARICALCITOL [ZEMPLAR] - (Prescribed by Other Provider) - 2
mcg/mL Solution - 3mcg three times a week with dialysis
REMVELA - (Prescribed by Other Provider) - - two tablets
three
times daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
VERAPAMIL - (Prescribed by Other Provider) - 180 mg Cap,24 hr
Sust Release Pellets - 0.5 (One half) Cap(s) by mouth four times
a week, S,T,T, S
Medications - OTC
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
iron) Tablet - one Tablet(s) by mouth daily
FIBER - (Prescribed by Other Provider) - 0.52 gram Capsule - 2
(Two) Capsule(s) by mouth twice daily
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 3
months.
Disp:*90 Tablet(s)* Refills:*0*
3. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*0*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO Daily in the
evening.
Disp:*30 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. 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*
7. 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*
8. paricalcitol 5 mcg/mL Solution Sig: 3mcg Intravenous 3X/WEEK
(TU,TH) as needed for w/ HD.
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks: Then switch to 1 tablet, 200mg daily thereafter.
Disp:*37 Tablet(s)* Refills:*0*
10. labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day:
hold until after HD on dialysis days .
Disp:*60 Tablet(s)* Refills:*0*
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Epogen 2,000 unit/mL Solution Sig: 2400 (2400) Units
Injection Three times per week with hemodialysis.
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
Coronary artery disease s/p off pump CABG
Atrial Fibrillation
Hypertension
Chronic obstructive pulmonary disease
Polycystic Kidney Disease on HD
Left leg claudication
Ventral Hernia
Hypercholesterolemia
Cardiac Arrest [**2124**]
Gastroesophageal reflux disease
Arthritis
Calcified aorta
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocer
Incisions:
Sternal - healing well, no erythema or drainage
Leg: Left - healing well, no erythema or drainage.
Edema +1 bilateral
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then again in the
evening. Please also take your temperature, these should be
written down on the chart provided.
4) No driving for approximately one month and while taking
narcotics. This will be discussed at follow up appointment with
surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Continue hemodialysis per your schedule and as instructed by
your nephrologist [**Doctor First Name **] [**Doctor Last Name **].
7) Take amiodarone 400mg (Two tablets) daily for 1 week and then
decrease to 200mg (1 tablet) daily until otherwise instructed by
your cardiologist and/or PCP.
8) Take plavix 75mg daily for 3 months then stop. This is for
your off-pump surgery.
9) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2128-1-5**] 1:00
Thoracic Surgery: Dr [**First Name (STitle) **] [**0-0-**] Date/Time:[**2128-1-6**] 9:00
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17918**] in [**3-31**] weeks [**Telephone/Fax (1) 17919**]
Cardiologist: Dr. [**Last Name (STitle) 7047**] in 4 weeks.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2127-12-11**] Name: [**Known lastname 3547**],[**Known firstname 3458**] Unit No: [**Numeric Identifier 3548**]
Admission Date: [**2127-12-4**] Discharge Date: [**2127-12-13**]
Date of Birth: [**2056-4-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
pt was discharged from the hospital as walking out he had a
syncopal episode in the setting of hypotension. He was
re-admitted cardiology was consulted and saw the patient. The
syncopal episode was in the setting of orthostatic hypotension
with no arrhythmia noted on telemetry they felt this was likely
a vasovagal event. CT angio revealed no PE, Lower extremity
ultrasound was negative for DVT and echo was negative for
pericardial effusion. They recommended stopping amiodarone and
monitor him overnight. He had no further episodes was has
discharge on [**2127-12-13**].
Major Surgical or Invasive Procedure:
[**2127-12-5**] - Urgent off-pump coronary artery bypass graft x3: Left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal and posterior descending
arteries.
[**2127-12-4**] - Cardiac catheterization
Physical Exam:
T: 97.8 HR: 60-70 no ectopy, BP 140's/80 Sats: 98% RA Wt: 94.3
General: 71 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR, normal S1,S2 no murmur
Resp: decreased breath sounds
GI: benign
Extr warm tr edema
Neuro: awake, alert and oriented
Pertinent Results:
[**2127-12-12**] 02:22PM BLOOD WBC-8.1 RBC-2.58* Hgb-8.3* Hct-25.4*
MCV-99* MCH-32.4* MCHC-32.8 RDW-15.4 Plt Ct-176
[**2127-12-12**] 02:22PM BLOOD Glucose-142* UreaN-69* Creat-8.7*# Na-136
K-4.9 Cl-94* HCO3-28 AnGap-19
[**2127-12-11**] No evidence of acute deep venous thrombosis in both
lower
extremities. Limited evaluation of the left peroneal vein of the
left calf.
[**2127-12-11**]: CTA IMPRESSION:
1. No central or lobar pulmonary embolism. Evaluation for
segmental and
subsegmental pulmonary emboli is limited by contrast bolus.
2. Interval median sternotomy with CABG. Ill-defined fluid
posterior to the
sternum could be explained by the recent surgery, although,
infection cannot
be excluded, and correlation clinically is recommended.
3. Possible filling defect in the left atrial appendage could be
thrombus and
can be further evaluated with echocardiography.
4. 3.5 cm right upper lobe lung mass, concerning for malignancy.
5. Small bilateral layering pleural effusions.
6. Secretions in the proximal trachea.
7. Centrilobular emphysema.
8. 1 cm pericardiac lymph node.
[**2127-12-11**]:
Echo: The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%). The right ventricular cavity is mildly dilated with
depressed free wall contractility. The aortic root is mildly
dilated at the sinus level. 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. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion. Diastolic intramyocardial flow
is seen in the interventricular septum most likely representing
intramyocardial coronary artery flow.
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 3
months.
Disp:*90 Tablet(s)* Refills:*0*
3. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*0*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO Daily in the
evening.
Disp:*30 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. 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*
7. 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*
8. paricalcitol 5 mcg/mL Solution Sig: 3mcg Intravenous 3X/WEEK
(TU,TH) as needed for w/ HD.
9. labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day:
hold until after HD on dialysis days .
Disp:*60 Tablet(s)* Refills:*0*
10. Epogen 2,000 unit/mL Solution Sig: 2400 (2400) Units
Injection Three times per week with hemodialysis.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then again in the
evening. Please also take your temperature, these should be
written down on the chart provided.
4) No driving for approximately one month and while taking
narcotics. This will be discussed at follow up appointment with
surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Continue hemodialysis per your schedule and as instructed by
your nephrologist [**Doctor First Name **] [**Doctor Last Name **].
7) Take plavix 75mg daily for 3 months then stop. This is for
your off-pump surgery.
8) Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2127-12-14**]
|
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53,878
| 115,519
|
50384
|
Discharge summary
|
report
|
Admission Date: [**2164-6-23**] Discharge Date: [**2164-7-5**]
Date of Birth: [**2113-11-22**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Dilaudid
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
feeling unwell, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo bedbound morbidly obese female with history of IDDM2, HTN,
HL, OHS on 4L at home, and prior PE who presents with chills and
weakness x 1 day. She reports feeling hot and sweaty at home,
with burning noted in bilateral legs. She has new LLE swelling
and redness. She denies overt fevers at home. She reports a
cough with occaisional yellow sputum. She reports one episode
of coughing a small clot of blood. She denies SOB or CP
currently. She reports dizziness and lightheadedness. She
denies abdominal pain, dysuria, N/V/D. She notes neck and upper
back pain since the top of an ambulance stretcher lowered
quickly while she was on it last week. She has been taking
valium and percocet that was prescribed at a recent epi visit.
In the ED, initial vitals were pain 10 100.3 105 96/40 18 96%
2L.
- hypotensive with sBP in 80's
- meets SIRS criteria
- CBC - WBC 22.1, Chem 7, lactate 1.3, blood cultures
- 3.5L of IVF
- pt cannot fit inside CT scanner so CTA not done
- CXR - central pulm vasc mildly prominent - suggestive of mild
pulmonary vasc congestion, no definite pleural effusion or
pneumo, pleural thickening lateral L lung apex - not
signficantly changed.
- b/l LE ultrasounds ordered but inconclusive
- Tx for presumed cellulitis of LLE - IV vanc and clinda
- c/s surgery - concern for LLE nec fasc - exam consistent with
cellulitis, cont abx, leg elevation. ACS will continue to
follow.
- BP around lower forearm, readings unreliable
- febrile to 101, 1gram of tylenol
- 1500mg of UOP reported in ED
Most recent vitals prior to transfer: afeb 109 30 98/61 99% on
4L.
On arrival to the MICU, she is reporting burning in her left
lower leg.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency.
Past Medical History:
# Morbid obesity -- over 600 lbs, bedbound
# Diabetes mellitus type II
# Hypertension
# Hyperlipidemia
# Hypothyroidism
# Obesity hypoventilation syndrome, on home O2 3-4 L
# Likely OSA -- refused sleep study
# Asthma
# Pulmonary Embolism ([**2163-4-27**]): suspected and treated but
unable to image
# Tracheostomy ([**2163-4-19**]) -- later removed at rehab
# VRE UTI -- during admission ([**Date range (3) 105005**])
# Chronic Lymphedema
# Developmental / Behavioral Issues
# Depression
# Chronic Low Back Pain
# GERD
Social History:
Lives alone, with 24 hour home health aide. She endorses only
rare social alcohol intake and she smokes [**12-19**] cigarettes daily.
She was previously wheelchair bound, but is now bed bound. Her
mother bought her a new [**Name (NI) 2598**] lift but her aides have not been
taught how to use this yet. Home health aide helps her with
cooking, cleaning, and bathing. Patient has a long psychiatric
history including counseling since childhood, learning
disabilities, she has left the hospital AMA on multiple
occasions, she has had Code Purples called for aggressive
behavior, she has been accused of calling EMS inappropriately
(several times per month at one point) for factitious
complaints, and she has reported history of sexual assault.
There have been SW involved to try to have this patient live in
rehab or another situation to better care for herself but these
attempts have all failed.
Family History:
Father with "belly" cancer. Mother alive & healthy, 2
grandparents w/DM. Brother died of illicit drug related causes.
Physical Exam:
Admission physical exam:
Vitals: 101 107 79/22 20 96% on 4L
General: Alert, oriented, difficulty with moving in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops heart
sounds muffled
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: +BS, obese, soft, non-tender, non-distended
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, LLE with warm erythematous confluent rash and small
nontender nonfluctuant bullae
Skin: bilateral erythematous patches under nipples
Neuro: CNII-XII intact, moving all 4 extremities
Discharge physical exam:
Vitals: T98.5, BP 108/64, HR 92, RR 20, 99% on 2L
General: Alert, oriented, difficulty with moving in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
heart sounds muffled
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: +BS, obese, soft, non-tender, non-distended
GU: Foley removed
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, LLE with dramatically improved erythema, with continued
1cm bullae
Skin: bilateral erythematous patches under nipples
Neuro: CNII-XII intact, moving all 4 extremities
Pertinent Results:
Admission labs:
[**2164-6-23**] 02:48PM BLOOD WBC-22.1*# RBC-3.12* Hgb-9.2* Hct-28.9*
MCV-93 MCH-29.4 MCHC-31.8 RDW-14.6 Plt Ct-244
[**2164-6-23**] 02:48PM BLOOD Neuts-93.8* Lymphs-3.7* Monos-2.2 Eos-0.2
Baso-0.1
[**2164-6-23**] 09:23PM BLOOD PT-14.3* PTT-31.5 INR(PT)-1.3*
[**2164-6-23**] 02:48PM BLOOD Glucose-142* UreaN-61* Creat-1.5* Na-140
K-4.6 Cl-92* HCO3-37* AnGap-16
[**2164-6-23**] 09:23PM BLOOD Calcium-8.6 Phos-3.7# Mg-2.2
[**2164-6-23**] 02:47PM BLOOD Lactate-1.3
RELEVENT LABS (LINEZOLID MONITORING):
[**2164-7-5**] 06:00AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.0* Hct-30.4*
MCV-93 MCH-27.6 MCHC-29.7* RDW-15.0 Plt Ct-509*
[**2164-7-3**] 06:00AM BLOOD Neuts-72.3* Lymphs-19.6 Monos-3.8 Eos-3.7
Baso-0.7
[**2164-7-3**] 06:00AM BLOOD ALT-19 AST-18 CK(CPK)-23* AlkPhos-87
TotBili-0.4
[**2164-7-3**] 07:05AM BLOOD Lactate-1.0
Discharge labs:
[**2164-7-5**] 06:00AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.0* Hct-30.4*
MCV-93 MCH-27.6 MCHC-29.7* RDW-15.0 Plt Ct-509*
[**2164-7-5**] 06:00AM BLOOD Glucose-109* UreaN-31* Creat-0.9 Na-139
K-4.8 Cl-93* HCO3-36* AnGap-15
[**2164-7-5**] 06:00AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.6
Microbiology:
[**2164-6-29**] SEROLOGY/BLOOD ASO Screen-FINAL NEGATIVE
[**2164-6-29**] BLOOD CULTURE Blood Culture, Routine-PENDING, no
growth at discharge
[**2164-6-28**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH FINAL
[**2164-6-26**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH FINAL
[**2164-6-25**] BLOOD CULTURE Blood Culture, Routine- NO GROWTH FINAL
[**2164-6-23**] BLOOD CULTURE Blood Culture, Routine- NO GROWTH FINAL
[**2164-6-23**] 2:40 pm BLOOD CULTURE
**FINAL REPORT [**2164-6-29**]**
Blood Culture, Routine (Final [**2164-6-29**]):
VIRIDANS STREPTOCOCCI.
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final [**2164-6-24**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 720PM
[**2164-6-24**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2164-6-23**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}
PERTINENT IMAGING:
pCXR [**2164-6-29**] FINDINGS: Unchanged mild fluid overload.
Unchanged moderate cardiomegaly. No larger pleural effusions.
No focal parenchymal opacity suggesting pneumonia. Retrocardiac
atelectasis is unchanged.
[**2164-6-23**] LENIs
FINDINGS:
The study is suboptimal due to patient's body habitus. Color
flow is seen within the left common femoral vein with
appropriate waveforms. Flow can also be detectted within the
left popliteal vein. The remaining left lower extremity veins
could not be imaged with ultrasound due to patient's body
habitus.
IMPRESSION:
Non-diagnostic study due to patient's body habitus.
Brief Hospital Course:
50 yo bedbound morbidly obese female with history of DM2, HTN,
HL, OHS on 4L at home, and prior PE who presented with weakness
and chills as well as left leg pain found to be hypotensive with
cellulitis of the left lower extremity. Hospital course
complicated by difficult to control blood glucose.
# Hypotension: Most likely related to infection with sepsis.
[**Month (only) 116**] also be related to recent valium/percocet use or medication
administration problems ie overdosing of diuretics. Prior
history of PE with patient reported noncompliance with
anticoagulation. No reason to suspect AI, patient reports
adequate PO intake at home, and no symptoms concerning for ACS.
Valium and percocet were held. The patient's BP was fluid
responsive, though there was difficulty measuring blood pressure
accurately in light of the patient's morbid obesity and
difficulty with proper blood pressure cuff measurement. Upon
transfer to the regular medical floor patient's BP was stable,
with hypotension to SBP of 80s-90s upon restarting home dose
lasix and antihypertensives.
-Blood pressure should be checked at next [**Month (only) 3390**] appointment and
dosage of lasix and antihypertensive adjusted accordingly
# Sepsis due to LLE cellulitis: Presented with low grade fever,
tachycardia, hypotension, and leukocytosis in the setting of new
evidence of rash and erythema on LLE concerning for LE
celluitlis. Patient was started on vancomcyin and cefepime as
well as clindamycin in light of presence of bullae. Blood
cultures returned with 1 bottle growing GPCs, which speciated as
Strep viridans, felt to be a contaminant by ID consult service.
She was continued on vancomycin, cefepime, and clindamycin with
clinical improvement in her lower extremity. On her last day in
the ICU, the patient was transitioned to PO linezolid and PO
metronidazole and PO ciprofloxacin. On the medical floor,
metronidazole was stopped after discussion with ID, but it was
restarted several days later after WBC increased off
metronidazole. Patient completed 10 day course of
cipro/linezolid/flagyl. LLE had minimal erythema at time of
discharge.
#Obesity hypoventilation syndrome: Patient was stable on home
3-4L O2 by nasal cannula but had an episode of tachypnea above
baseline, with wheezing on exam and volume overload on portable
chest xray. Wheezing improved with albuterol nebs, and tachypnea
improved following 80mg IV furosemide. Given difficulty of
ruling out pulmonary embolism with imaging in this patient and
recent refusals of subcutaneus heparin ppx, heparin drip was
started overnight, but discontinued the following morning, given
clinical improvement with diuresis and bronchodilators. BNP
during the episode came back at >1200, and PO furosemide was
restarted (had been held for hypotension as above) at half the
pre-admission dose, and tachypnea improved.
-Follow up with [**Month (only) 3390**] regarding outpatient furosemide dosing
# [**Last Name (un) **]: Likely prerenal in the setting of febrile illness. Serum
creatinine improved with labs after 3.5L of fluid in the ED, and
remained stable in MICU ranging from 1.3-1.5 and further
recovered to 0.7 while on the medicine floor.
-Patient has been advised in not to use NSAIDS, but she insists
that naproxen is the only [**Doctor Last Name 360**] that alleviates her headaches
#uncontrolled DM II: she had an episode of relative hypoglycemia
the day after she was transferred from the MICU, attributed to
decreased po intake. [**Last Name (un) **] was consulted and adjusted her U500
insulin dosing.
CHRONIC ISSUES:
# Possible history of pulmonary embolism: Patient has been
treated empirically in the past for PE, but diagnostic work up
for this morbidly obese patient is challenging. During this
hospital stay patient was briefly anticoagulated overnight as
discussed above, but heparin was stopped when volume overload
and/or mucus plugging was felt to be more likely explanation for
respiratory status. Patient intermittently refused subcutaneous
heparin ppx throughout this hopspitalization.
# Asthma: Patient was stable on home 4L oxygen. Continued
albuterol, advair, fluticasone
#Hypothyroid: continued levothyroxine
#GERD:continued pantoprazole
#Hyperlipidemia: continued rosuvastatin, aspirin
#Hypertension: lisinopril-hydrochlorothiazide were held [**1-19**]
hypotension in the ICU, restarted prior to discharge
#Chronic lower back pain: held naproxen, treated with
acetaminophen while admitted
Transitional issues for this patient:
-Recovery of mobility: mother is very concerned patient has not
been up to chair in a year
-Readdressing doses of antihypertensives and furosemide
-Follow up with [**Last Name (un) **] regarding dosing of U500 insulin
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
2. Diazepam 5 mg PO Q12H:PRN pain, spasm
3. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
5. Furosemide 80 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. lisinopril-hydrochlorothiazide *NF* 20-12.5 mg Oral [**Hospital1 **]
8. Nystatin Powder *NF* 100,000 unit/gram Mucous Membrane prn
irritation
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Prochlorperazine 5-10 mg PO Q6H:PRN nausea, vomiting
12. Rosuvastatin Calcium 40 mg PO HS
13. Aspirin 81 mg PO DAILY
14. Docusate Sodium 200 mg PO BID
15. Naproxen 250 mg PO Q8H:PRN pain
16. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb by mouth every
six (6) hours Disp #*1 Unit Refills:*2
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
RX *Flovent HFA 110 mcg/actuation 1 puff inhalation twice a day
Disp #*1 Inhaler Refills:*0
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
RX *Advair Diskus 250 mcg-50 mcg/Dose 1 puff inhalation twice a
day Disp #*1 Inhaler Refills:*0
6. Levothyroxine Sodium 150 mcg PO DAILY
RX *levothyroxine 150 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*0
9. Rosuvastatin Calcium 40 mg PO HS
RX *Crestor 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg t tablet by mouth twice a day Disp #*60 Tablet
Refills:*0
11. Diazepam 5 mg PO Q12H:PRN pain, spasm
RX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*30 Tablet
Refills:*0
12. lisinopril-hydrochlorothiazide *NF* 20-12.5 mg ORAL [**Hospital1 **]
RX *lisinopril-hydrochlorothiazide 20 mg-12.5 mg 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
13. Prochlorperazine 5-10 mg PO Q6H:PRN nausea, vomiting
RX *prochlorperazine maleate 5 mg [**12-19**] tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
14. Nystatin Powder *NF* 100,000 unit/gram Mucous Membrane prn
irritation
RX *nystatin 100,000 unit/gram 1 application twice a day Disp
#*60 Gram Refills:*0
15. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
16. Sarna Lotion 1 Appl TP QID:PRN itch
RX *Sarna Anti-Itch 0.5 %-0.5 % 1 application to affected areas
four times a day Disp #*1 Tube Refills:*0
17. U500 25 Units Breakfast
U500 12 Units Lunch
U500 25 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *One Touch Ultra Test As directed 5-8 times daily Disp #*1
Box Refills:*2
RX *Humalog 100 unit/mL Up to 25 Units per sliding scale four
times a day Disp #*4 Vial Refills:*2
RX *One Touch Delica Lancets 1 injection 5-8 times daily Disp
#*1 Box Refills:*2
RX *Easy Touch Insulin Syringe 31 gauge X [**5-2**]" As directed [**4-24**]
times daily Disp #*1 Box Refills:*2
RX *Humulin R U-500 "Concentrated" 500 unit/mL (Concentrated) 1
injection as directed. 25 Units before BKFT; 12 Units before
LNCH; 25 Units before DINR; Disp #*7 Vial Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
# Sepsis attributed to cellulitis of the left lower extremity
Secondary diagnoses:
# Type 2 DM - uncontrolled
# Supermorbid obesity
# hypothyroidism
# Hypertension
# Depression/anxiety
# Probable OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 105003**],
It was a pleasure participating in your care during your
hospitalization for a skin infection on your left leg. When you
first came to the hospital you had low blood pressures and were
admitted to the intensive care unit. With antibiotics, your
blood pressure and infection improved on the regular medical
floor. You have cleared your infection and do not need
additional antibiotics.
While you were here, we had difficulty managing your blood
sugars, but the doctors from the [**Name5 (PTitle) **] were consulted to assist
us. Your new insulin regimen is as outlined below. Please
continue to use this sliding scale until you follow up with the
[**Last Name (un) **].
You are on scheduled doses of U500 insulin. One unit of U500
insulin is equal to five units of regular insulin. An outline
of your insulin dosing is attached. It is listed in units of
U500 insulin. Below is a brief summary, but should not be used
to replace the attached insulin outline.
-Breakfast: 25 units of U500 insulin (equal to 125 units of
regular
insulin).
-Lunch: 12 units of U500 insulin (equal to 60 units of regular
insulin).
-Dinner: 25 units of U500 insulin (equal to 125 units of regular
insulin).
-PRIOR to each meal, and at night, you should be monitoring your
blood sugars and giving yourself short acting insulin (Humalog)
based on its level just before eating. The sliding scale doses
are also included in the attached insulin outline.
-You previously were taking 30 units of U500 insulin at home
(equal to 150 units of regular insulin). The doctors at the
[**Name5 (PTitle) **] feel that you will likely require this dose of insulin as
you continue to recover. If you find that your blood sugars are
persistently elevated, please contact the [**Name (NI) **] doctors [**Name5 (PTitle) **] your
[**Name5 (PTitle) 3390**] to speak about adjusting your insulin dosing levels.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2164-7-13**] at 1:45 PM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern1) 105006**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call your doctor at the [**Last Name (un) **] to schedule an appointment
to help manage your diabetes.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2164-7-5**]
|
[
"724.2",
"V85.45",
"401.9",
"300.00",
"305.1",
"276.69",
"311",
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"493.90",
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"315.9",
"995.92",
"272.4",
"327.23",
"564.00",
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"457.1",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16726, 16783
|
8192, 11759
|
353, 360
|
17047, 17047
|
5399, 5399
|
19118, 19731
|
3882, 4001
|
13871, 16703
|
16804, 16804
|
12954, 13848
|
17182, 19095
|
6247, 8169
|
4041, 4694
|
16907, 17026
|
2076, 2404
|
286, 315
|
388, 2057
|
5415, 6231
|
16823, 16886
|
17062, 17158
|
11775, 12928
|
2426, 2948
|
2964, 3865
|
4719, 5380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,633
| 165,463
|
22628
|
Discharge summary
|
report
|
Admission Date: [**2191-2-25**] Discharge Date: [**2191-2-26**]
Date of Birth: [**2119-7-13**] Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is a 71 year old
male with mild dementia who was a pedestrian hit by a truck
at 40 miles an hour, thrown 20 feet away with loss of
consciousness and laceration of the head. He was combative at
the scene with worsening mental status. Upon arrival of EMS,
he was intubated. His blood pressure remained in the 70s. He
was found to have a flail chest on both sides and he was
transported to [**Hospital1 18**] for further management. In flight, the
patient's chest was needle decompressed on both sides. Upon
arrival into the Trauma Bay, the patient was intubated and
nonresponsive (the patient received a small amount of
fentanyl and one dose of paralytic in flight).
PHYSICAL EXAMINATION: He was intubated, moving bilateral
upper and lower extremities minimally. The pupils were 2 mm
and nonreactive. There was significant laceration on the
patient's forehead and head down to the skull; however, no
evidence of skull fracture on visual inspection. TMs are
clear bilaterally. Mucous membranes seemed intact. He had a
flail chest and crepitus on the right side. Abdomen seems
mildly distended. Pelvis is visibly unstable. There is blood
at the meatus. Rectal exam - decreased tone and guaiac
negative. There is visibly inverted and shortened right leg
with unstable hip, unstable left knee, bruising over the left
hand. The pulses are 2 plus bilaterally throughout. Upon
arrival, the patient had a heart rate of 110 with blood
pressure of 70 systolic, sating around 90 percent.
PERTINENT LABS: Upon arrival, the patient's white blood cell
count was 12.5, hematocrit 30.2, PT 16.4, PTT 53.8, INR 1.7,
fibrinogen 1.8. His ToxScreen was negative. Sodium was 143,
potassium 3.9, chloride 110, bicarb 22, glucose 264, BUN 13,
creatinine 1.3, amylase 92, lactate of 7.5, calcium 8.8. His
first gas was 7.13, 47, 115, 17, -13.
PAST MEDICAL HISTORY:
1. Mild mental retardation.
2. Hypertension.
ALLERGIES: No known drug allergies.
PAST SURGICAL HISTORY: None.
OUTPATIENT MEDICATIONS: Unknown.
HOSPITAL COURSE: Upon arrival, the ET tube positioning was
confirmed with CO2 indicator and bilateral chest tubes were
placed for prophylaxis. The patient started receiving blood
products, initially untyped blood followed by FFP, platelets
and cryoprecipitate which improved his blood pressure to 120s-
140s and heart rate decreased down to 80s. Because there was
blood in the meatus, the Urology service was consulted over
the phone who recommended one pass at the Foley. The Foley
was placed easily; however, only a minimal amount of urine
was obtained, so the Foley was left in place. However,
balloon was not inflated. The patient's pelvis was fixed with
a sheath. Orthopedic Service was consulted immediately and
recommended external fixation of both pelvis and bilateral
lower extremities. As we were finishing these procedures, the
patient became again hypotensive down to 70s-80s and
tachycardic. More blood products were given. Given a very
high possibility of bleeding into the pelvis from a pelvic
fracture, Interventional Radiology consult was immediately
obtained. At the same time, given distended abdomen, a DPL
was performed which was essentially negative. At that time,
the patient again improved his blood pressure to 120s-140s
with normal heart rate. Given seemingly hemodynamic
stability, the Interventional Radiology attending wished to
attempt a CT scan before proceeding to angio. The patient was
brought into the CT Suite. A quick scan of the chest and
abdomen was performed that revealed still a pneumothorax on
the left side. At that point, the patient started dropping
his saturations down to 80s. Another chest tube with a 6-
French was placed in the CT Suite. At the same time, the
right chest tube which was still functional and was in place
by way of CT scan, started putting out more bloody discharge
which had then totalled about 1 liter in 6 hours. The CT scan
revealed, as above, persistent pneumothorax on the left which
was fixed with another chest tube, hemothorax on the right
with significant bilateral contusions. There were multiple
rib fractures on the right, some mesenteric stranding,
partial rupture of the right kidney and the Foley looked like
it was in the bladder. No other abnormalities were noted. The
bony abnormalities included, as above, rib fractures,
bilateral acetabular fractures, pelvic fracture. At that
point, the patient was brought into the Angio Suite where
angio was performed (I forgot to mention that a left
subclavian Cordis as well as a left femoral Cordis were
placed emergently from the initial workup). The patient had
an angio which revealed slight bleeding from the right lower
pole of the kidney which was embolized. It also revealed a
small aneurysm in the spleen which was unclear whether it was
a new or old finding and it was embolized as well. No other
significant abnormalities were found. Throughout that, the
patient remained intermittently hemodynamically unstable,
requiring continuous amounts of blood products, fluids as
well as pressor support with epinephrine. The patient was
brought into Intensive Care Unit where his temperature was
found to be 88. His groin arterial and venous line were
changed and AV rewarming was initiated. A new set of labs was
sent which showed continuous coagulopathy and anemia with a
hematocrit of 20. The patient continued to receive red blood
cells, platelets, FFP and fibrinogen. Temperature was coming
up with AV rewarming, although it was getting continuously
more difficult to ventilate the patient. He had desaturations
in the mid 80s. In the meantime, the patient's abdomen was
becoming bigger and more tense. The measured bladder pressure
was 48. A chest x-ray done emergently revealed no significant
pneumothorax, but significant bilateral contusions, edema as
well as the fluid overload. Throughout this process,
continuous discussions with the family were undertaken and
through these discussions as we were updating the family,
they requested less and less of invasive support until
finally, given the fatality of the situation, they decided to
change the patient to CMO status until finally the patient
expired at 3:24.
CONDITION ON DISCHARGE: The patient expired. The coroner was
contact[**Name (NI) **] and accepted the case.
DISCHARGE DIAGNOSES:
1. Motor vehicle accident.
2. Rib fractures.
3. Bilateral pulmonary contusions.
4. Bilateral pneumothoraces.
5. Pelvic fracture.
6. Right femur fracture.
7. Bilateral acetabular fractures.
8. Left knee fracture.
9. Skull laceration.
10. History of hypertension.
11. History of mental retardation.
12. Anemia due to bleeding into ? pelvis and right
thigh.
13. Hypomagnesemia.
14. Hypocalcemia.
15. Respiratory failure.
16. Abdominal compartment syndrome.
17. Acute lung injury.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Doctor Last Name 5186**]
MEDQUIST36
D: [**2191-2-26**] 06:57:57
T: [**2191-2-26**] 07:46:03
Job#: [**Job Number 58662**]
|
[
"806.60",
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"401.9",
"285.1",
"958.4",
"861.21",
"518.5",
"868.04",
"902.87",
"860.4",
"958.8",
"808.9",
"998.11",
"821.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"99.05",
"54.25",
"38.91",
"99.04",
"99.07",
"39.79",
"38.93",
"34.04",
"96.71",
"78.17",
"88.42",
"86.59",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
6459, 7244
|
2190, 6328
|
2130, 2137
|
2162, 2172
|
866, 1655
|
165, 843
|
1672, 1999
|
2021, 2106
|
6353, 6438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,485
| 140,147
|
46777
|
Discharge summary
|
report
|
Admission Date: [**2184-11-24**] Discharge Date: [**2184-11-25**]
Date of Birth: [**2142-1-27**] Sex: F
Service: MEDICINE
Allergies:
Augmentin / Zomig / Reglan
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42 yo F w/ DMI w/ DKA/HHS. pt presents with hyperglycemia, per
home glucometer fs >600 since noon. 42 yo F w/ DMI currently
being treated for cdiff. Was not able to get PO vanc and was
only taking flagyl. EKG no changes. Started w/ 10U/hr regular
insulin, has gotten 3L IVF NS. Cr 1.9 elevated from baseline.
Abd pain currently she says is c/w her colitis. She is also
having leg spasms has got 5mg valium X2 and 1mg dilaudid. Took
her flagyl. Since her recent d/c from [**Hospital1 18**] she was d/c'd from
MRWH w/ flagyl for c.diff. MRWF microlab confirmed cdiff +. Pt.
states that her husband did not want her to come home from the
hospital at that point and she is upset because her son is
leaving for the navy.
.
In the ICU she says that her sugars had been fairly well
controlled at home 130s-200 until yesterday afternoon when it
climbed to 348. She administered her SSI and her glucose climbed
to >600. She became frustrated and stopped checking her FSBS as
frequently. Her husband found out that her glucose was very
elevated and became angry. They argued, she called him fat and
he crushed his wedding ring with some pliers. She denies any
violence.
.
She has been having around 8 BMs/day non bloody. She had some
chest discomfort last night which resolved spontaneously. She
also complains of leg cramps which she has occasionally, her PCP
has tried valium for these but only dilaudid works.
.
In the ED, initial VS: 97.7, 91, 123/70, 14, 100% RA
Past Medical History:
1. Diabetes mellitus type 1 diagnosed age 15, followed by
[**Last Name (un) **]. Has had 4-5 episodes of DKA. Has had one seizure in the
context of hypoglycemia years ago. Checks her sugars at
least 6x/day.
2. Gastroparesis with frequent hospital admissions; had G tube
and J tube in past (2 yrs ago)
3. Peripheral neuropathy
4. Diabetic foot ulcers, s/p bilateral great toe amputation, s/p
debridement
5. Thalassemia - per pt, has had 5 [**Last Name (un) **] tx in past, usually
around HCT of 23. Gets EPO q week.
6. Migraine headache
7. GERD
8. S/p hysterectomy for heavy menses
9. S/p eye surgery
[**84**]. S/p oopherectomy
11. Restless leg syndrome
12. S/p portacath placement [**5-31**] due to poor access
13. Depression
14. Anxiety
15. C. diff infection
Social History:
Married. Quit smoking 16yrs ago, smoked 1-1.5 PPD x 13yrs
previously; uses occasional alcohol, but no IV drug use
Family History:
Grandfather died of MI, oldest son has Afib, brother with type 2
diabetes mellitus, aunt with type 1 diabetes mellitus
Physical Exam:
PE on admission:
Vitals - T 97.7, 91, 123/70, 14, 100% RA
GENERAL: A/Ox3, sobbing, NAD
HEENT: No icterus
CARDIAC: RRR, No MRG
LUNG: CTAB
ABDOMEN: Soft, moderately tender in LLQ, BS hyperactive
EXT: No edema, barely palpable DP/PT pulses
NEURO: Absent knee reflexes
PE on transfer to the floor:
Vitals - T 97.8 124/71 (BP range 88-137/62-82) 14 100% RA
GENERAL: NAD
HEENT: Normocephalic, atraumatic. No scleral icterus. PERRL.
MMM. OP clear. Neck Supple, No LAD.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. Portacath without surrounding erythema.
LUNGS: CTAB bilaterally.
ABDOMEN: +BS. Tender in left quadrant. no rebound. Non
distended.
EXTREMITIES: No edema or calf pain. DP pulses +1 bilat. Missing
great toe on each foot.
SKIN: Bruises on shin.
NEURO: Alert and answering all questions appropriately. CN 2-12
grossly intact.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
[**2184-11-24**] 01:30AM [**Month/Day/Year 3143**] WBC-4.2 RBC-4.44 Hgb-8.5* Hct-32.3*
MCV-73* MCH-19.2* MCHC-26.4* RDW-17.2* Plt Ct-245
[**2184-11-24**] 01:30AM [**Month/Day/Year 3143**] Neuts-62.5 Lymphs-31.3 Monos-3.7 Eos-1.8
Baso-0.7
[**2184-11-24**] 01:30AM [**Month/Day/Year 3143**] Plt Ct-245
[**2184-11-24**] 01:30AM [**Month/Day/Year 3143**] Glucose-1025* UreaN-36* Creat-1.9*
Na-119* K-6.5* Cl-85* HCO3-19* AnGap-22*
[**2184-11-24**] 01:30AM [**Month/Day/Year 3143**] Calcium-9.5 Phos-3.8 Mg-1.9
[**2184-11-24**] 05:40AM [**Month/Day/Year 3143**] Osmolal-305
[**2184-11-24**] 04:57AM [**Month/Day/Year 3143**] pO2-60* pCO2-42 pH-7.35 calTCO2-24 Base
XS--2 Comment-GREEN TOP
-------------------
DISCHARGE LABS:
[**2184-11-25**] 06:40AM [**Month/Day/Year 3143**] WBC-3.8* RBC-4.39 Hgb-8.6* Hct-29.2*
MCV-66*# MCH-19.6* MCHC-29.5*# RDW-17.2* Plt Ct-255
[**2184-11-25**] 06:40AM [**Month/Day/Year 3143**] Glucose-47* UreaN-19 Creat-1.1 Na-144
K-4.5 Cl-112* HCO3-23 AnGap-14
[**2184-11-24**] 09:24AM [**Month/Day/Year 3143**] CK(CPK)-179*
[**2184-11-24**] 03:09PM [**Month/Day/Year 3143**] CK(CPK)-253*
[**2184-11-25**] 12:20AM [**Month/Day/Year 3143**] CK(CPK)-213*
[**2184-11-24**] 09:24AM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-<0.01
[**2184-11-24**] 03:09PM [**Month/Day/Year 3143**] CK-MB-6 cTropnT-<0.01
[**2184-11-25**] 12:20AM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-<0.01
[**2184-11-25**] 06:40AM [**Month/Day/Year 3143**] Calcium-9.4 Phos-3.5 Mg-2.0
Brief Hospital Course:
# DKA/HHS: Patient presented with glucose of 1025 and DKA
symptoms. DKA likely caused by not taking insulin vs. cdiff
causing dehydration. Patient was started on insulin gtt in the
ED, and admitted to MICU for management of DKA. Gap closed on
the next day. Insulin gtt was discontinued, and patient was
transferred to the floor with her outpatient insulin regimen.
Patient's [**Month/Day/Year **] glucose was well-controlled on discharge.
Because she got into a big fight with her husband on the day of
presentation, patient was also seen by social work who provided
support. Patient will follow up at the [**Hospital **] clinic the day
after discharge. An appointment was made for her.
.
# C.diff colitis: Patient was diagnosed with c. diff colitis on
[**11-16**], and she is in the middle of a 2 week course of PO flagyl.
Patient continues to complain of abdominal tednerness,
especially in the left side, no rebound, no elevated WBC.
Patient states she initially had seen [**Month/Year (2) **] in her stool, which
has resolved. Her abdominal pain and diarrhea are improving.
Patient's abdominal pain was controlled with tylenol.
.
# ARF: Patient's baseline Cr 1.1-1.2, she presented with
creatinine of 1.9. Likely [**1-26**] volume depletion. After getting IV
fluids, creatinine was back down to 1.1 on discharge.
.
# Chest pain: Patient developed one episode of chest pain while
in the MICU, which resolved spontaneously. EKG was essentially
unchanged from priors. Cardiac enzymes were normal.
.
# Peripheral neuropathy: Home dose gabapentin was continued.
.
# Leg cramps: Patient tends to get leg cramps when she is in
DKA. Symptoms resolved on lorazepam.
.
# Restless leg syndrome: Patient has h/o iron deficiency, which
likely is the etiology of restless leg syndrome. Fe
supplementation was continued.
.
# hyperlipidemia: Home dose atorvastatin was continued.
.
# Hypertension: Patient takes hydralazine and lisinopril for
hypertension, and midodrine for hypotension at home.
.
# GERD: Home dose pantoprazole was continued.
.
# Chronic pain: ICU team contact[**Name (NI) **] patient's PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) **]
MD ([**Telephone/Fax (1) 99277**], and found that patient was on outpatient
narcotics for her neuropathy and was stopped after overdose and
falls. PCP recommended that we limit narcotics as patient has
addiction history. Home lidocaine patch and gabapentin were
continued.
.
#. Migraines: Patient had no migraine symptoms during this
hospital stay. Home sumatriptan and butalbital-acet-caff PRN
were ordered, but patient did not require any migraine
medications.
.
# FEN: Patient was continued on home calcium and vit D. Her
electrolytes were monitored and repleted prn. She was put on
diabetic diet, and she tolerated POs well.
.
# PPX: home PPI, heparin SQ
.
# ACCESS: Port
.
# CODE: Full (confirmed)
.
# CONTACT: [**Name (NI) 4906**] is emergency contact [**Name (NI) **] [**Telephone/Fax (1) 99278**]
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qhs ().
5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headaches.
8. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-26**]
Tablets PO Q8H (every 8 hours) as needed for migraine HA.
[**Month/Day (2) **]:*60 Tablet(s)* Refills:*0*
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. Sumatriptan Succinate 6 mg/0.5 mL Solution Sig: One (1)
Subcutaneous X1 (ONE TIME) as needed for migraine HA.
15. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous qam.
[**Month/Day (2) **]:*1 units* Refills:*2*
16. Novolog 100 unit/mL Solution Sig: Nine (9) units
Subcutaneous four times a day as needed for [**Month/Day (2) **] glucose >120:
at breakfast, lunch or dinner time, if [**Month/Day (2) **] glucose is 120-159,
then take 9U; if 160-199, then take 10U; if 200-239, then take
11U; if 240-279, then take 12U;
if 280-319, then take 13U; if 320-361, then take 14U; if >361,
[**Name8 (MD) 138**] MD.
[**Name8 (MD) **]:*1 * Refills:*2
17. Flagyl 800 mg po q8hrs
18. Lisinopril 5mg daily
19. Epogen injection
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety, leg cramps.
4. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for headache.
11. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for migraine.
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 BID (2 times a day).
14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
16. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) Unit
Subcutaneous qam.
17. Novolog 100 unit/mL Solution Sig: sliding scale
Subcutaneous QACHS.
18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
19. Sumatriptan Succinate 6 mg/0.5 mL Solution Sig: One (1)
Subcutaneous once a day as needed for migraine.
20. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
21. Epogen Injection
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes Mellitus Type I
C. diff colitis
Discharge Condition:
Stable, afebrile. Glucose well-controlled. Back to home insulin
regimen.
Discharge Instructions:
It was a pleasure to be involved in your care, Ms. [**Known lastname **]. You
were admitted to [**Hospital1 69**] because of
DKA in the setting of recent c. diff infection. You were
treated with insulin drip in the intensive care unit initially,
before you were transferred to the regular medicine floor. You
glucose was well-controlled on transfer, and you were back on
your home insulin regimen on discharge.
Your medications were not changed. Please continue your
outpatient insulin regimen, and follow up at the [**Hospital **] clinic
tomorrow. You have an appointment. Please also continue flagyl
for c. diff infection.
Followup Instructions:
Please follow up at [**Hospital **] clinic tomorrow, Friday, [**11-26**], [**2183**] at 9:30am.
|
[
"300.4",
"357.2",
"276.51",
"250.63",
"707.15",
"346.90",
"250.13",
"V49.71",
"536.3",
"584.9",
"530.81",
"280.9",
"282.49",
"333.94"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12202, 12208
|
5336, 8308
|
293, 300
|
12293, 12369
|
3825, 3825
|
13049, 13148
|
2720, 2840
|
10350, 12179
|
12229, 12272
|
8334, 10327
|
12393, 13026
|
4561, 5313
|
2855, 2858
|
250, 255
|
328, 1788
|
3841, 4545
|
2872, 3806
|
1810, 2571
|
2587, 2704
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,530
| 173,168
|
44089
|
Discharge summary
|
report
|
Admission Date: [**2129-4-26**] Discharge Date: [**2129-4-29**]
Service: Acove
CHIEF COMPLAINT: Mental status change.
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
Russian speaking female with CAD, dementia, hypertension,
atrial fibrillation and history of hip fracture and open
reduction and internal fixation who presented with change in
mental status. The night prior to admission the patient had
increasing shortness of breath with exertion resulting in
difficulty ambulating. When visited by the VNA on the day of
admission, the patient was short of breath, sleepy and
unarousable. She was transferred to the Emergency Room where
on arrival she received Narcan with little improvement and
was found to be in atrial fibrillation. Neurology consult
was obtained and the exam was non focal but limited by
decreased consciousness. MRI/MRA of the head was obtained
which showed moderate small vessel disease but no acute
infarct. LP was attempted multiple times without success and
patient was admitted to MICU for close observation. In the
MICU the patient's mental status had returned to baseline by
the time of transfer. She received Aricept and Zyprexa and
was minimally responsive after that. The morning after she
was found to be in congestive heart failure and diuresed.
Aricept and Zyprexa were held and the patient returned to
[**Location 213**] mental status.
PHYSICAL EXAMINATION: On examination the patient had a
normal mental status exam, alert and oriented times three,
appropriate behavior and mental status was thought to be at
baseline per her son. She denied any complaints and stated
that her breathing was better since the Lasix.
PAST MEDICAL HISTORY: Coronary artery disease status post
CABG in [**2124**], hypertension, hip fracture status post open
reduction and internal fixation, dementia on Aricept, atrial
fibrillation, paroxysmal.
MEDICATIONS: Zoloft 100 mg po q day, Aricept 10 mg po q day,
enteric coated Aspirin 325 mg po q day, Multivitamin one po q
day, Diltiazem 240 mg po q day, Pravachol 10 mg po q day,
Zyprexa, Ambien, Ativan.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
She lives with her husband.
PHYSICAL EXAMINATION: The patient had a temperature of 96.7,
blood pressure 112/35, pulse 84, respiratory rate 16 and
oxygen saturation of 95% on one liter. On general
examination the patient is alert and cooperative, in no
apparent distress. HEENT: Pupils equally round and reactive
to light, extraocular movements intact and oropharynx was
clear. Neck exam was significant for JVD to the earlobe.
Lung exam revealed bibasilar crackles. Heart exam revealed
regular irregular rhythm with 2-3/6 systolic murmur at the
left upper sternal border. Abdominal exam was soft,
nontender, non distended with normal bowel sounds.
Extremities revealed no edema. Neurological exam revealed
the patient to be alert and oriented times three per son.
The patient was moving all four extremities with sensation
grossly intact.
LABORATORY DATA: The patient had a white blood cell count of
7.4, hematocrit 39.8, platelet count 205,000, INR was 1.5.
Urinalysis was negative. The patient had a bicarb of 33 with
BUN of 21, creatinine 0.6. The patient had a B12 of 513, TSH
1.4, negative tox screen.
HOSPITAL COURSE: The patient is an 85-year-old female with
history of CAD, hypertension, dementia and atrial
fibrillation admitted with change in mental status and
shortness of breath.
1. Neurologic: The patient presented with decreased
awareness and presence of somnolence on admission. This was
thought to be multifactorial secondary to polypharmacy with
the patient taking Zyprexa, Aricept, Ativan and Ambien as
well as in the setting of CHF causing hypoxia. The patient
had a toxic metabolic work-up that included normal TSH,
normal B12, normal RPR. The patient was diuresed and Zyprexa
was held in an effort to improve the patient's mental status.
Throughout the time on the general medicine floor, the
patient's mental status was at baseline. Her medications
were discussed with her outpatient psychiatrist, Dr. [**Last Name (STitle) 94651**]
who felt that the patient might benefit from a brief time in
the [**Hospital 1634**] [**Hospital **] Rehab. The patient's family refused this.
The decision was made to restart the patient's Aricept and
try an alternative neuroleptic such as Risperdal. The
patient will follow-up with her outpatient psychiatrist.
Evaluation by physical therapy felt that the patient was
stable for discharge to home. The patient refused any rehab
placement.
2. Congestive heart failure: The patient presented with
increasing shortness of breath likely leading to hypoxia and
change in mental status. With diuresis of 1 to 1.5 liters
per day, the patient had marked improvement in oxygenation
and was able to have a saturation of 93% on room air and
return to her baseline mental status. She likely will need
to be discharged on Lasix. An echocardiogram was performed
which showed normal LV function, left atrial abnormality,
trace AR and mild MR. She will be followed by her primary
care physician who is also in cardiology.
3. Atrial fibrillation: The patient presented to the
hospital in atrial fibrillation after being in sinus. The
patient's case was discussed with her outpatient
cardiologist, Dr. [**Last Name (STitle) 3357**] who felt that anticoagulation would
be risky in a patient with high likelihood of fall. She was
continued on Aspirin.
4. Renal: The patient presented with contraction alkalosis
and this increased with diuresis. She was given potassium
chloride with some improvement in her alkalosis. Her
creatinine remained stable throughout the admission.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged with follow-up
with Dr. [**Last Name (STitle) 3357**] in one week. She will also follow-up with
Dr. [**Last Name (STitle) 94651**] in [**1-12**] weeks. The patient was advised to
discontinue Zyprexa, Ambien and Ativan.
DISCHARGE MEDICATIONS: Included Pravachol 20 mg po q day,
Zoloft 100 mg po q day, Aricept 10 mg po q day, Aspirin 325
mg po q day, Multivitamin one orally daily, Diltiazem 240 mg
po q day, Lasix 20 mg po bid, Tylenol 650 mg po q 4-6 hours
prn pain, Dulcolax one po q day for constipation prn,
Risperdal 0.5 mg po bid as needed for agitation.
The patient will have a creatinine and potassium checked in
follow-up with Dr. [**Last Name (STitle) 3357**].
DISCHARGE DIAGNOSIS:
1. Congestive heart failure.
2. Atrial fibrillation.
3. Polypharmacy.
4. Contraction alkalosis.
5. Hypertension.
6. History of hip fracture status post open reduction and
internal fixation.
7. Coronary artery disease status post CABG in [**2124**].
8. Dementia.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2129-4-29**] 14:42
T: [**2129-4-29**] 15:13
JOB#: [**Job Number 94652**]
cc:[**Last Name (STitle) 94653**]
|
[
"428.0",
"780.09",
"311",
"V45.81",
"276.3",
"401.9",
"E947.8",
"E939.3",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6087, 6518
|
6539, 7090
|
3346, 5763
|
2259, 3328
|
109, 132
|
161, 1407
|
1713, 2147
|
2164, 2236
|
5788, 6063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,655
| 120,113
|
54319
|
Discharge summary
|
report
|
Admission Date: [**2134-9-6**] Discharge Date: [**2134-9-14**]
Date of Birth: [**2064-10-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillin G / Sulfur / Bactrim Ds / Sulfa (Sulfonamide
Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Positive stress test
Major Surgical or Invasive Procedure:
[**2134-9-7**] cardiac catherization
History of Present Illness:
Mrs. [**Known lastname 69520**] is a 69 year old female with known severe aortic
stenosis, which has largely been thought asymptomatic for years.
Despite this, she underwent stress testing recently, which
demonstrated a markedly blunted blood pressure response to
exercise of <20 mmHg, with a poor exercise tolerance, indicating
likelihood of developing severe symptoms in the next year or so.
About a year ago, and again in the spring of [**2133**], she sustained
two small strokes, fortunately without significant residual
neurologic deficits. The thought was that these events were
quite likely a result of calcium embolization from the valve (or
microthrombosis on the valve leaflets). At this time she is
managed with Warfarin for this, however it is the impression of
her neurologist Dr. [**Last Name (STitle) **] that following valve replacement
warfarin may no longer be indicated in her for stroke
prevention. Given her recent stress test and prior strokes, she
was referred for consideration of aortic valve replacement with
a tissue valve. Now admitted for cardiac catherization with
prehydration for preoperative evaluation.
Past Medical History:
Aortic Stenosis
Dyslipidemia
Hypertension
Diabetes Mellitus
Stroke [**3-7**] and [**3-8**]
Gastroesophageal reflux disease
Osteoarthritis
Breast Cancer s/p mastectomy with no radiation
s/p Exploratory laparotomy
Social History:
Occupation: office work currently not working
Lives with daughter
[**Name (NI) 1139**] denies
Etoh: occassional
Family History:
father [**Name (NI) 111268**] at 82 history of myocardial infarction
Mother deceased at age 82 s/p CABG
Grandchild with bicuspid AV
Physical Exam:
Physical Exam
Pulse: 73 Resp: 16
B/P Right: 188/91 Left: 149/80 (mastectomy side)
Height: 4' 11" Weight: 141
General:no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X], visual field deficit right
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X] Well healed left mastectomy
incision
Heart: RRR [X] 3/6 SEM, Nl S1-S2
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] well healed laparotomy incision
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Bilateral L>R Below knee. Multiple spider
varicosities
Neuro: Alert and oriented x3 nonfocal left arm weaker than right
but minimal Left handed
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Transmitted murmur bilaterally
Pertinent Results:
[**2134-9-6**] 12:40PM PT-14.8* PTT-24.7 INR(PT)-1.3*
[**2134-9-6**] 12:40PM PLT COUNT-300
[**2134-9-6**] 12:40PM WBC-9.4 RBC-4.62 HGB-11.7* HCT-37.5 MCV-81*#
MCH-25.3* MCHC-31.1 RDW-16.9*
[**2134-9-6**] 12:40PM TSH-3.1
[**2134-9-6**] 12:40PM %HbA1c-6.5*
[**2134-9-6**] 12:40PM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-4.0
MAGNESIUM-1.8
[**2134-9-6**] 12:40PM LIPASE-41
[**2134-9-6**] 12:40PM ALT(SGPT)-9 AST(SGOT)-20 LD(LDH)-236 ALK
PHOS-117 AMYLASE-88 TOT BILI-0.6
[**2134-9-6**] 12:40PM GLUCOSE-110* UREA N-35* CREAT-1.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
[**2134-9-6**] 01:49PM URINE RBC-0-2 WBC-[**6-9**]* BACTERIA-MOD
YEAST-NONE EPI-[**3-4**]
[**2134-9-6**] 01:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2134-9-13**] 05:50AM BLOOD WBC-9.6 RBC-3.50* Hgb-9.2* Hct-28.8*
MCV-82 MCH-26.4* MCHC-32.0 RDW-16.9* Plt Ct-125*
[**2134-9-13**] 05:50AM BLOOD Plt Ct-125*
[**2134-9-13**] 05:50AM BLOOD PT-13.1 INR(PT)-1.1
[**2134-9-13**] 05:50AM BLOOD Glucose-122* UreaN-24* Creat-1.5* Na-141
K-3.9 Cl-101 HCO3-30 AnGap-14
[**2134-9-7**] Cardiac cath: 1. Selective coronary angiography in this
left dominant system demonstrated one vessel disease. The LMCA
had no angiographically apparent disease. The LAD had a 60%
stenosis in the origin of a small diagonal vessel. The Cx had no
angiographically apparent disease. The RCA was a small
non-dominant vessel with no angiographically apparent disease.
2. Limited resting hemodynamics showed normal filling pressures
with a PCWP of 10mmHg. The pulmonary artery pressures were
normal with a PASP of 25 mmHg. The central aortic pressure was
121/56 mmHg. The cardiac index was preserved at 2.1 L/min/m2. 3.
There was severe aortic stenosis with a peak to peak gradient of
42 mmHg and a calculated [**Location (un) 109**] of 0.6 cm2.
[**2134-9-8**] Carotid U/S: Less than 40% stenosis of the bilateral
internal carotid arteries.
[**2134-9-10**] Echo: PREBYPASS: No atrial septal defect is seen by 2D
or color Doppler. There is mild 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.
The ascending aorta is moderately dilated. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. POSTBYPASS: There is a well seated well functioning
bioprosthesis in the aortic position. No aortic insufficiency is
visualized. Biventricular systolic function remians preserved.
The study is otherwise unchanged from the prebypass period.
Radiology Report CHEST (PA & LAT) Study Date of [**2134-9-13**] 12:02
PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 111269**]
69 year old woman s/p AVR
eval for pleural effusions
Final Report
INDICATION: Status post aortic valve repair. Evaluate for
pleural effusions.
FRONTAL AND LATERAL CHEST: Patient is status post median
sternotomy and
aortic valve repair. A small left pleural effusion persists. A
small amount of pneumopericardium is also unchanged. Pulmonary
vascularity is stable. No new focal lung consolidation or
pneumothorax is identified.
IMPRESSION: Tiny left pleural effusion and a small residual
pneumopericardium status post aortic valve repair.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Brief Hospital Course:
Admitted for intravenous hydration for cardiac catheterization
and heparin drip for bridge from Coumadin. She underwent cardiac
catheterization and preoperative workup for aortic valve
surgery. She was found to have urinary tract infection which was
treated with appropriate antibiotics. She was brought to the
operating room on [**9-10**] and underwent a aortic valve replacement
with #23 [**Company 1543**] Porcine valve. Please see OR results for
details. She tolerated the operation well and was transferred
from the operating room to the cardiac surgery ICU. She remained
hemodynamically stable in the immediate post-operative period.
Her sedation was weaned within 24 hours, she awoke
neurologically intact and was extubated. On post-op day one she
was transferred to the stepdown floor for continued
post-operative care. All chest tubes and epicardial pacing wires
were removed per cardiac surgery protocol. Her activity was
advanced with the assistance of the nursing and physical therapy
staff. The patient's neurologist and cardiologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**]
were contact[**Name (NI) **] regarding the continuation of coumadin and both
agreed that it was safe to discontinue the coumadin at this time
(pt was previously on coumadin for hx of CVAx2). The remainder
of here post-operative course was uneventful and on post-op day
4 she was discharged to home.
Medications on Admission:
Warfarin 1 mg daily
Simvastatin 20 mg daily
Pantoprazole 40 mg daily
Metoprolol 25 mg [**Hospital1 **]
Vitamin B-12 1000mg daily
Celebrex daily
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) 40mg Tablet PO once a
day for 7 days: discontinue after 7 days.
Disp:*7 * Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 7 days: discontinue after 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temp/pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*75 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Dyslipidemia, Hypertension, Diabetes Mellitus, Stroke [**3-7**]
and [**3-8**], Gastroesophageal reflux disease, Osteoarthritis,
Breast Cancer s/p mastectomy with no radiation, s/p Exploratory
laparotomy
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) You should wash incision daily with soap and water. No
lotions creams or powders to incision until it has healed. No
bathing or swimming for 6 weeks.
5) No lifting more then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month from date of surgery.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks- appt to be scheduled prior to discharge
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17025**] in [**1-1**] weeks ([**Telephone/Fax (1) 6699**])
Dr [**First Name (STitle) **] [**Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1504**])
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in [**2-2**] weeks
Patient to call to schedule all appointments
Completed by:[**2134-9-14**]
|
[
"424.1",
"414.01",
"599.0",
"782.1",
"530.81",
"438.19",
"041.02",
"715.96",
"V10.3",
"V15.82",
"401.9",
"272.4",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"37.23",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9649, 9704
|
6701, 8119
|
356, 394
|
10000, 10006
|
2990, 6678
|
10668, 11129
|
1942, 2075
|
8313, 9626
|
9725, 9979
|
8145, 8290
|
10030, 10645
|
2090, 2971
|
296, 318
|
422, 1562
|
1584, 1797
|
1813, 1926
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,523
| 164,156
|
50492
|
Discharge summary
|
report
|
Admission Date: [**2158-6-8**] Discharge Date: [**2158-6-30**]
Date of Birth: [**2074-6-4**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Chest Pain/SOB
Major Surgical or Invasive Procedure:
[**2158-6-18**] Right video-assisted thoracoscopy converted to right
thoracotomy, decortication of lung and evacuation of retained
hemothorax/empyema.
[**2158-6-22**] Percutaneous tracheostomy placement and
gastroesophagoscopy with percutaneous gastrostomy tube
placement.
History of Present Illness:
84M s/p fall approximately 2 days prior to admission presents as
a transfer from OSH with chest pain and shortness of breath. Pt
was found to have an INR of 11 (coumadin for h/o DVT) and
multiple rib fractures on exam prior to admission. Pt states
that his fall was mechanical.
Past Medical History:
DVT, right leg in 11/[**2156**]. Hypertension,
seasonal allergies, COPD, elevated cholesterol, osteoarthritis
of
the hip, BPH.
Social History:
No drug abuse
Family History:
NC
Physical Exam:
Vitals: T 99.7 75 119/61 20 99%
Exam:
Pertinent Results:
[**2158-6-8**] 08:25PM WBC-12.0* RBC-3.09* HGB-9.7* HCT-28.6* MCV-93
MCH-31.5 MCHC-34.0 RDW-14.6
Brief Hospital Course:
Patient was transferred from an OSH with known diagnosis of
hemothorax and multiple rib fractures and was seen and
stabilized in the trauma bay. After receiving FFP to correct his
elevated INR, a chest tube was placed with ~1600cc output on
placement. He was admitted to the ICU for management and his
chest tube output was followed. He required 5 units of pRBCs to
maintain adequate hematocrit, and this was followed and
transfused as needed throughout the remainder of his stay.
On HD 2, the patient was c/o significant pain and this was
affecting his respiratory status/pulmonary toilet so the Acute
Pain Service was consulted regarding epidural placement. They
determined the patient would be best served by placement of a
paravertebral block and this was performed at the bed side.
Following this, the patient was transferred to the floor for
further management.
On the floor his respiratory status was adequate, but he
continued to complain of significant pain, so he was started on
a Dilaudid PCA. Additionally because of his c/o shoulder pain he
was evaluated by the orthopedics service, who indicated that no
acute intervention was needed, and the patient could follow up
with them as an outpatient.
On [**6-13**] the patient was triggered for mental status changes which
were determined to be from his narcotics. Additionally, he had
some difficulty maintaining his sats and his O2 requirements
were increasing. Because of this he was transferred to the ICU
with a plan to have an epidural placed by the acute pain
service, which was performed without difficulty. The patient
stayed in the ICU overnight for monitoring of his blood
pressures [**1-10**] concern for hypotension given his volume status
and new epidural placement. After he was stable and his epidural
was functioning he was transferred back to the floor for further
management.
His epidural was eventually removed and he was placed on an oral
regimen. His chest tube was also removed; he is on his home
pulmonary meds and prn nebulizers. He was evaluated by Physical
therapy and is being recommended for rehab after his acute
hospital stay.
On [**6-17**] the patient went into rapid atrial fibrillation and
respiratory distress with a fever of 102 F, and altered mental
status. He required a total of 15 mg IV lopressor pushed and
he returned to [**Location 213**] sinus rhythm. CXR and stat labs/cultures
were sent and he was found to have a leukocytosis. Given his
acute respiratory distress he required intubation.
On [**2158-6-18**], Patient brought to OR with Thoracic surgery for
right video-assisted thoracoscopy which was converted to right
thoracotomy. Three chest tubes were placed in the chest. The
most anterior tube was a right-angle tube. The middle tube was
and anterior apical tube and the more posterior tube at the skin
was a posterior apical tube.
The patient was started on tube feeds. His blood cultures 7/10
grew MSSA. [**6-17**] Ucx grew PROBABLE ENTEROCOCCUS ~5000/ML. [**6-18**]
Pleural clot cultures demonstrated MRSA.
[**6-22**]: [**Name (NI) **] wife was consented for trach and PEG, this was
performed without complication after tube feeds were held for
the appropriate amount of time preop. Pain control still an
issue. Started Roxicet via G tube.
[**6-23**] Tube feeds started via PEG tube, patient tolerating this
well. + BM's
7/17 L PICC line placed. Lasix gtt for diuresis. Started on
diamox for increasing respiratoy acidosis with lasix. Chest CT
performed.
[**6-25**] 1 chest tube removed and 2 chest tubes remaining placed to
pneumostat by Thoracic surgery team. Tube feeds advanced to
goal of 50cc/hr
[**2158-6-26**] Chest tube x2 placed to pneumostat. Continued on
Vancomycin and Zosyn. Tube feeds at goal. Dispo planning.
[**6-26**]: No acute events. Secretions noted to be thicker, sputum gs
and cx sent.
[**6-27**]: Started on seroquel for anxiety/agitation and discontinued
zyprexa. Patient had high residuals from tube feeds (~500ml),
tube feeds were held and PEG was clamped. Sputum culture
growing heavy pseudomonas
[**6-28**]: TF residuals ~400cc/24hr, decreased rate and thickness.
Erythromycin 250mg PO Q6h. Anterior chest tube d/c'd
[**6-29**]: Patients chest tube was discontinued and the patient was
discharged to a long term acute care facility
Medications on Admission:
Coumadin, HCTZ, Lipitor, Betaxolol, Spiriva, Flomax
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
over right side of chest wall.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for wheeze, SOB.
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
16. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
18. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p Fall
Right rib fractures [**3-16**]
Right hemothorax
Right gluteal hematoma
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:
*
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-17**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Follow up in 2 weeks in [**Hospital 2536**] clinic, call [**Telephone/Fax (1) 600**] for an
appointment.
|
[
"041.04",
"477.8",
"041.12",
"272.0",
"715.35",
"288.60",
"276.2",
"V12.51",
"427.31",
"510.9",
"807.05",
"292.81",
"518.81",
"V58.61",
"E935.2",
"486",
"038.11",
"401.9",
"496",
"276.52",
"860.2",
"599.0",
"995.92",
"V43.65",
"E885.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.72",
"03.90",
"31.1",
"34.04",
"38.93",
"33.23",
"43.11",
"96.04",
"05.31",
"34.51",
"96.6",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7483, 7555
|
1265, 5565
|
280, 555
|
7678, 7678
|
1141, 1241
|
9845, 9953
|
1061, 1065
|
5667, 7460
|
7576, 7657
|
5591, 5644
|
7853, 9313
|
9329, 9822
|
1080, 1122
|
226, 242
|
583, 862
|
7693, 7829
|
884, 1014
|
1030, 1045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,283
| 145,503
|
6294
|
Discharge summary
|
report
|
Admission Date: [**2188-2-8**] Discharge Date: [**2188-2-11**]
Service: PURPLE SURGERY
CHIEF COMPLAINT: Port-A-Cath insertion into left subclavian
arteries status post removal and arterial stent.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 24421**] is an 85 year-old
woman who presents with severe depression and requiring
intravenous access. She presents now for Port-A-Cath
placement.
PAST MEDICAL HISTORY:
1. Breast cancer.
2. Mitral regurgitation.
3. Status post left TKR.
4. Status post hip fracture.
5. Depression.
6. Urinary incontinence.
7. Glaucoma.
8. Anxiety.
MEDICATIONS: Amlodipine 2.5 mg po q day, calcium carbonate
650 mg po t.i.d., Famotidine 20 mg po b.i.d., Ritalin 2.5 mg
po b.i.d., Risperdal 0.5 mg po q day, Detrol 2 mg po q day,
Dulcolax and Colace prn.
ALLERGIES: Morphine, shellfish, sulfa.
SOCIAL HISTORY: The patient lives at [**Hospital 100**] Rehab.
PHYSICAL EXAMINATION: Vital signs pulse 75. Blood pressure
120/64. Respirations 15. O2 sat 99% on room air. Heart is
regular rate and rhythm. Lungs are clear to auscultation
bilaterally. Abdomen soft, nontender, nondistended.
Extremities are without clubbing, cyanosis or edema.
HOSPITAL COURSE: Ms. [**Known lastname 24421**] was taken to the Operating Room
on [**2188-2-8**] for attempted Port-A-Cath placement. The
procedure was complicated by arterial placement of the
dilator. The patient was subsequently transferred to the
catheterization laboratory where the dilator was removed
and stent placed. She was administered thrombin, Protamine
and aspirin following the procedure. She did well. She was
monitored in the Intensive Care Unit overnight without any
evidence of bleeding. Ms. [**Name14 (STitle) 24422**] did have some episodes of
bradycardia and was monitored closely. She was
evaluated by cardiology and Gerontology who felt this was a
sinus rhythm and recommended follow up as an outpatient. By
[**2188-2-11**] the patient continued to do well. Her hematocrit
remained stable. She was felt stable at this time for
discharge back to her rehabilitation facility.
PHYSICAL EXAMINATION ON DISCHARGE: Vital signs temperature
98.9. Pulse 68. Blood pressure 128/76. Respirations 18.
O2 sat 95% on room air. Heart is regular rate and rhythm.
Lungs are clear to auscultation bilaterally. Left chest
wound is dressed and dry. Abdomen is soft, nontender,
nondistended, with normoactive bowel sounds. Extremities are
without clubbing, cyanosis or edema.
DISCHARGE MEDICATIONS: Plavix 75 mg po q day, Protonix 40 mg
po q day, Detrol 2 mg po b.i.d., Risperdal 0.5 mg po q day,
Ritalin 2.5 mg po b.i.d., aspirin 325 mg po q day, calcium
carbonate 650 mg po t.i.d., Dulcolax and Colace prn,
Amlodipine 2.5 mg po q day.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Ms. [**Known lastname 24421**] is to be discharged to [**Hospital 100**]
Rehab.
DISCHARGE DIAGNOSES:
1. Status post attempted left Port-A-Cath placement with
subsequent subclavian arterial placement dilator.
2. Status post stent placement subclavian artery.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Doctor First Name 24423**]
MEDQUIST36
D: [**2188-2-11**] 11:04
T: [**2188-2-11**] 11:10
JOB#: [**Job Number 24424**]
|
[
"998.2",
"V10.3",
"424.0",
"300.4",
"427.89",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
2787, 2896
|
2917, 3356
|
2526, 2765
|
1221, 2133
|
939, 1203
|
2148, 2502
|
117, 210
|
239, 410
|
432, 851
|
868, 916
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,616
| 175,657
|
7232
|
Discharge summary
|
report
|
Admission Date: [**2113-11-18**] Discharge Date: [**2113-11-28**]
Date of Birth: [**2030-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Pacemaker implant
History of Present Illness:
This is an 83 yo male with a history of CAD, CHF, CKD, and a.fib
who presents with sympomatic bradycardia. The symptoms
apparently began this morning when his caregivers noted that he
was "not himself". He noted that he felt dizzy standing up in
the morning to shave and had multiple presyncopal episodes
throughout the day. He does note some mild DOE starting today
but denies any chest discomfort. Prior to today he was in his
USOH, fully functional. Later that day, his grandaughter found
him at home, diaphoretic, nauseous, and with decreased
responsiveness. He was sitting in a chair and was thought to
maybe pass out at one point, when his eyes rolled back in his
head. 911 was then called.
EMS responded to the scene and found his heart rate to be in the
20s with a BP of 80s/P. He was given bicarb and atropine by EMS
with no effect. They tried to externally pace him but could not
capture.
On arrival to the ED, initial vitals were 97.5, 36, 112/43,
satting 99% on 4L. His FS was noted to be greater than assay. At
this time he was much more responsive and with stable BP. He
received 10units IV insulin and 2L NS.
Past Medical History:
-CABG: [**2104**]- LIMA to the diagonal branch, solitary saphenous
graft to LPDA. Followed by Dr. [**Last Name (STitle) **] at NEBH.
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2109-9-2**] at NEBH after + thallium stress with ischemia at low
workload
RCA- 100% occluded at mid portion, high grade ostial disease
Saphenous graft to PDA- patent
LIMA to diagonal [**Last Name (un) **]- widely patent but anastomosed into
disease diagonal branch with backflow to LAD
LCx- 100% occluded
-CHF- echo in [**2109**]- EF 45%
-Paroxysmal A.fib
-PVD
-Chronic renal insufficiency (Cr 1.7-1.9 in [**2113**])
-Anemia NOS (Baseline 30-31)
-DM
-HTN
-HL
-Legally blind/diabetic retinopathy
-History of tachy-brady syndrome. He has had runs of
Mobitz II block, which have been felt to be asymptomatic. There
has been no evidence of prolonged block on multiple monitoring.
Social History:
Mr. [**Known lastname **] continues to live with his wife and has four hours of
shared personal care assistance in thehome, which is typically
devoted to his wife's personal care.
-Tobacco history:Quit smoking > 40 years ago.
-ETOH: None
-Illicit drugs: None
Family History:
CAD in several brothers
Physical Exam:
On Admission:
VS: T=98.3 BP=139/63 HR=36 RR=16 O2 sat=100% 2L
GENERAL: WDWN in NAD. Oriented x2.5. 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. Brady, 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/e. No femoral bruits. 1+ LE edema
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:
[**2113-11-28**] 07:10AM BLOOD WBC-4.1 RBC-2.95* Hgb-9.9* Hct-27.9*
MCV-95 MCH-33.4* MCHC-35.3* RDW-16.1* Plt Ct-171
[**2113-11-23**] 07:04AM BLOOD WBC-5.0 RBC-2.57* Hgb-8.6* Hct-24.2*
MCV-94 MCH-33.6* MCHC-35.6* RDW-14.5 Plt Ct-120*
[**2113-11-20**] 03:32AM BLOOD Neuts-81.9* Lymphs-10.7* Monos-6.4
Eos-0.7 Baso-0.3
[**2113-11-28**] 07:10AM BLOOD PT-15.0* PTT-30.8 INR(PT)-1.3*
[**2113-11-23**] 01:25PM BLOOD PT-28.0* PTT-36.3* INR(PT)-2.8*
[**2113-11-28**] 07:10AM BLOOD Glucose-103 UreaN-15 Creat-1.3* Na-141
K-3.9 Cl-109* HCO3-23 AnGap-13
[**2113-11-19**] 04:03AM BLOOD LD(LDH)-221 CK(CPK)-94 TotBili-0.4
DirBili-0.2 IndBili-0.2
[**2113-11-20**] 03:32AM BLOOD CK-MB-6 cTropnT-0.16*
[**2113-11-28**] 07:10AM BLOOD Mg-2.0
[**2113-11-19**] 04:03AM BLOOD Hapto-104
[**2113-11-19**] 04:05PM BLOOD TSH-2.0
[**2113-11-18**] 07:24PM BLOOD Lactate-2.3* K-5.3
ECHO [**11-20**]
Suboptimal image quality. Normal left ventricular cavity size
with regional systolic dysfunction most c/w multivessel CAD.
Mild mitral regurgitation.
Brief Hospital Course:
This is an 83 year old male with extensive CAD, CHF, CKD, and
a.fib presents with new onset bradycardia and hyperglycemia.
.
# Bradycardia: Unclear precipitant but his baseline EKG showed
RBBB and LAFB so any further conduction system degeneration
would likely result in complete heart block, likely infranodal,
which is more likely given his lack of response to atropine. No
signs of acute ischemia and cardiac enzymes were cycled to
confirm. According to his family, SOB is pt's anginal
equivalent.
Pt initially had temporary pacer wire placed after INR reversed
with FFP. Permanent pacemaker was placed the next morning, which
pt tolerated well and had no furthur arrhythmias. There was no
indication for ICD and warfarin was restarted prior to DC.
# GI bleed: On [**11-23**] pt passed some guaiac positive dark stool
with question of flecks of blood, in the setting of dropped
hematocrit to 24.2 Pt remained hemodynamically stable and was
transfused one unit of pRBCs. He was held over the weekend for
lowering of INR and prep for EGD and colonoscopy given unstable
hematocrit and anticoagulation. Monday with INR of 1.7, pt was
taken for EGD which showed gastritis and duodenitis with
biopsies taken, and also a colonoscopy with multiple polyps but
polypectomy not done and pt recommended to have repeat scope
with lower INR and better prep. Pt's hematocrit remained stable
and he did not have any more guaiac positive stools. On
discharge hematocrit was 27.9.
#Hyperglycemia: Cause was unclear as there was no signs of
infection on U/A or CXR and no localizing signs. [**Month (only) 116**] be a sign
of coronary ischemia. Patient denied missing medications and has
been well controlled on them prior. Pt was initially on insulin
drip for several hours and then was well controlled on insulin
sliding scale.
# Dementia and mental status changes: Pt showed signs of
delirium, with visual and auditory hallucinations in the ICU.
History of dementia with ongoing workup exacerbated by blindness
and ICU delirium. Recent MRI ([**9-11**]) showed microvascular
ischemia. No evidence of infection by fever or WBC, and neuro
exam was unchanged throughout. Pt responded well to Haldol 2mg
as needed at night. Delirium resolved once pt was transferred to
the floor.
# Acute on chronic renal failure: On presentation, Cr was
elevated to 2.5 from basline 1.7-1.9, thought to be secondary to
poor forward flow in setting of bradycardia. Renal function was
monitored and improved with pacing of heart rate. ACEi was
initially held and restarted prior to discharge.
# Hyponatremia: Pt with sodium 131 on admission likely due to
hyperglycemia, and resolved with control of BS.
# HTN: Initially home PO regimen was held due to
hypotension/bradycardia and restarted. Pt discharged on
beta-blocker, ACEi and lasix.
# CAD: On presentation troponins were slightly elevated, thought
to be secondary to renal failure. Pt was medically managed with
ASA, statin, ACEi, beta blocker once appropriate with blood
pressure and renal function.
# CHF: Restarted on home doses of ACEi, lasix and BB once
tolerated by blood pressure and renal function.
# PVD: Stable. Pt continued on Cilostazol
# Hyperlipidemia: Continued on statin
# Atrial fibrillation: Initially did not require rate control
due to presumed AV disease and heart block. Pt's coumadin was
held briefly for PPM placement, bridged with heparin and
coumadin restarted.
# Iron Def. Anemia: Stable at baseline, continue iron.
Medications on Admission:
ATORVASTATIN 10 mg daily
CILOSTAZOL 100 mg twice a day
FUROSEMIDE 80 mg daily
LISINOPRIL - 5 mg daily
METOPROLOL SUCCINATE 100mg PO daily
WARFARIN 5 mg daily
ASPIRIN - 81 mg daily
FERROUS SULFATE - 325 mg daily
Glipizide ER 10mg qAM 5mg qPM
MVI
Discharge Medications:
1. Outpatient Lab Work
Please check Chem 7, INR, hct on [**2113-12-1**] and call results to
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 719**].
2. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Glucotrol XL 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*60 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
8. Glucotrol XL 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO at bedtime.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
9. Metoprolol Succinate 25 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*
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 5 days.
Disp:*1 bottle* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Bradycardia
Dementia with transient Delerium
Acute on Chronic Renal Failure
Hypertension
Acute on Chronic Congestive Heart Failure
Peripheral Vascular Disease
Acute Blood Loss Anemia
Discharge Condition:
stable
Discharge Instructions:
You had a slow heart rate and a pacemaker was placed to keep
your heart rate in a normal range. Your kidney function worsened
but is now improving. Please get your labs drawn on Friday
[**12-1**] and have the results called to Dr. [**Last Name (STitle) **].
You had a colonoscopy that showed multiple benign looking
polyps. The colonoscopy will need to be repeated with a better
bowel prep and a INR of < 1.4 to remove these polyps. the
endoscopy of your stomach showed gastritis and you have been
started on pantoprazole to take twice daily to treat this.
New Medicines:
1. Glucatrol for your diabetes which is a long acting form of
Glipizide
2. Miconazole for the rash
3. Metoprolol was decreased
4. Furosemide and Lisinopril was unchanged
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7960**] Date/Time:
[**12-11**] at 11:30am.
[**Hospital **] clinic:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2113-11-30**]
11:00
.
Primary Care:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 13171**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2113-12-5**] 9:30
.
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2114-1-22**] 2:00
Completed by:[**2113-12-1**]
|
[
"211.3",
"403.90",
"362.01",
"584.9",
"427.89",
"285.1",
"585.9",
"250.50",
"276.1",
"427.31",
"414.01",
"578.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.82",
"45.23",
"38.93",
"37.71",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
10082, 10139
|
4678, 8157
|
329, 348
|
10366, 10375
|
3631, 4655
|
11284, 11875
|
2688, 2713
|
8453, 10059
|
10160, 10345
|
8183, 8430
|
10399, 11261
|
2728, 2728
|
278, 291
|
376, 1504
|
2743, 3612
|
1526, 2396
|
2412, 2672
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,720
| 133,853
|
49933
|
Discharge summary
|
report
|
Admission Date: [**2173-1-11**] Discharge Date: [**2173-1-25**]
Date of Birth: [**2127-3-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Tetracyclines
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
abdominal pain, hematemesis
Major Surgical or Invasive Procedure:
Subclavian TLC placement
History of Present Illness:
45 y/o male w/ a past medical history significant for HIV and
AIDS defining illnesses including PCP in the past (last CD4
count reported to be 195, vl 338,000 in [**2172-11-28**]), HCV, and
EtOH abuse presented to the ED on [**1-11**] complaining of abdominal
pain, nausea and vomiting for five days and one day of coffee
ground emesis. He reported heavy drinking (1 gallon of vodka
per day) starting 3.5 months ago. He was seen in the ED the day
prior to admission ([**1-10**]) for abdominal pain and found to have
elevated amylase and lipase, but the patient left AMA. The
morning of admission, [**1-11**] the patient reports prolonged
retching after which he had coffee ground emesis (several
episodes).
ROS: denies hematemesis, BRBPR, melena, fever, chills, cough,
sob, chest pain.
In ED, the patient was given protonix IV, underwent aggressive
repletion of his electrolytes, and was started on IV
levo/flagyl. His lipase was measured at 2047, down from >5300 on
[**1-10**] measured prior to the patient leaving AMA. The patient was
initially moved to the MICU for aggressive fluid resuscitation
and electrolyte repletion. An NGT was placed for decompression,
and a TLC was placed in the left subclavian. The patient was
made NPO. An abdominal CT was performed and showed inflammation
of the head of the pancreas c/w pancreatits but no evidence of
necrosis or pseudocyst. The patient remained in the ICU for
three days and was called out to the floor on [**1-14**]. At that
point his HCT had remained stable for several days and he had
had no episodes of further coffee ground emesis and remained
guiac negative.
Past Medical History:
- HIV, last CD-4 count 195, vl 338,000 in [**1-2**]. AIDS defining
infections including: PCP, [**Name Initial (NameIs) 11395**]. followed by dr. [**Last Name (STitle) **] at
[**Hospital1 778**] Comm Health
- Hepatitis C. grade [**11-29**] liver fibrosis.
- Alcohol abuse. h/o withdrawl seizures, shakes, ?DTs. Last
drink the day of admission.
- Polysubstance abuse.
- History of Tylenol overdose.
- Peripheral neuropathy. Neurogenic bladder formerly requiring
self catheterization in the past
- CAD s/p stent LCx [**2165**]
Social History:
lives in apartment in community in [**Hospital1 778**] for HIV positive
patients. Gets methadone dosing at BayCove.
Family History:
Non-contributory
Physical Exam:
Admission
T 99.9 HR 91 BP 135/94 RR 31 O2Sat 99%RA
Gen: lying in bed, diaphoretic
HEENT: NCAT, dry mm, no chovstek's sign
Neck: no jvd
CV: regular no mrg
Lungs: decreased BS and rales at bases bilaterally
Abd: soft, mildly distended, moderate lower abdominal tenderness
without rebound or involuntary guarding, no caput, no fluid wave
Ext: no cce, no trousseau's, no palmar erythema
On discharge
PE: Tmax/Tcurr 99.8 HR 80 BP 132/80 RR 20 sats 98% RA
I/O 1200IVF/1800PO/1100urine, BMx2 guiac neg (24h)
GEN: drowsy, NAD, walking in room
HEENT: NCAT, PERRL, EOMI, anicteric sclera, dry MM, oral pharynx
clear
NECK: no JVD
PULM: CTA bl, no wheeze, good air movement in upper lung fields
CV: tachycardic, regular, no m/r/g
ABD: +BS, soft NT, distended, midline abdominal scar, no
rebound, no guarding
EXT: no edema
NEURO: CN intact, no focal motor or sensory deficits
Pertinent Results:
admission chemistries
[**2173-1-10**] 02:45PM BLOOD Glucose-188* UreaN-21* Creat-2.1* Na-129*
K-3.0* Cl-93* HCO3-19* AnGap-20
[**2173-1-11**] 02:00PM BLOOD Albumin-3.4 Calcium-5.4* Phos-3.0 Mg-0.7*
discharge chemistries
[**2173-1-25**] 07:00AM BLOOD Glucose-99 UreaN-16 Creat-1.3* Na-136
K-4.5 Cl-108 HCO3-23 AnGap-10
[**2173-1-25**] 07:00AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.4*
admission CBC
[**2173-1-10**] 02:45PM BLOOD WBC-28.6*# RBC-5.25# Hgb-16.6# Hct-46.6#
MCV-89 MCH-31.7 MCHC-35.7* RDW-14.1 Plt Ct-114*
[**2173-1-10**] 02:45PM BLOOD Neuts-78* Bands-10* Lymphs-9* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
discharge CBC
[**2173-1-25**] 07:00AM BLOOD WBC-4.5 RBC-2.80* Hgb-8.3* Hct-25.8*
MCV-92 MCH-29.8 MCHC-32.3 RDW-14.1 Plt Ct-383
[**2173-1-25**] 11:20AM BLOOD Hct-26.6*
CD4 counts
[**2173-1-22**] 06:50AM BLOOD CD3%-87 Abs CD3-2133* CD4%-17 Abs
CD4-404 CD8%-66 Abs CD8-1612* CD4/CD8-0.3*
Coags on admission
[**2173-1-10**] 02:45PM BLOOD PT-14.9* PTT-29.0 INR(PT)-1.4
Coags at discharge
[**2173-1-24**] 06:30AM BLOOD PT-12.0 PTT-27.1 INR(PT)-0.9
U/A
[**2173-1-11**] 09:56PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2173-1-11**] 09:56PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2173-1-11**] 09:56PM URINE RBC-[**1-30**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2173-1-11**] 09:56PM URINE Hours-RANDOM Creat-63 Na-71
[**2173-1-11**] 09:56PM URINE Osmolal-435
LFTs on admission
[**2173-1-10**] 02:45PM BLOOD ALT-54* AST-118* AlkPhos-155*
Amylase-1282* TotBili-0.9
[**2173-1-11**] 02:00PM BLOOD ALT-58* AST-117* LD(LDH)-1682*
AlkPhos-156* Amylase-731* TotBili-0.9
[**2173-1-10**] 02:45PM BLOOD Lipase-5310*
LFTs on discharge
[**2173-1-24**] 06:30AM BLOOD ALT-30 AST-60* LD(LDH)-345* AlkPhos-95
TotBili-0.4
[**2173-1-24**] 06:30AM BLOOD Lipase-105*
[**2173-1-12**] CXR
Allowing for apical lordotic projection and low lung volumes,
the heart size and mediastinal contours are within normal
limits. A nasogastric tube is present, but the distal tip is
difficult to identify due to underpenetrated technique. There is
a probable small right pleural effusion extending into the major
fissure. There is no evidence of pneumothorax.
[**2173-1-12**] Repeat CXR
Compared with earlier the same day, a left subclavian central
line has been placed -- the tip overlies the proximal SVC. No
pneumothorax is identified. An NG tube is present, tip overlying
fundus. There is p atchy atelectasis at left base, in the
setting of low lung volumes.
[**2173-1-12**] CT Abd
IMPRESSION: Acute pancreatitis, possibly with very slight
worsening of inflammatory changes in the anterior pararenal
space compared to the examination performed earlier today. A
portion of the pancreatic head demonstrates decreased
enhancement on the contrast enhanced images, which may represent
early changes of necrosis.
CT Abd pelvis [**2173-1-19**]
IMPRESSION: Stable appearance of acute pancreatitis, without
evidence of new gas or fluid collections, or new areas of
necrosis.
2. Small left pleural effusion and atelectasis with resolution
of the right pleural effusion.
CXR [**2173-1-20**] IMPRESSION: Chest clear. No infiltrates. No evidence
of pneumonia
CT of Sinuses [**2173-1-21**]
FINDINGS: There is no evidence of sinusitis or mucosal
thickening involving the maxillary, sphenoid, ethmoid, or
frontal sinuses. The optic struts are bilaterally aerated. The
right cribriform plate is 1 mm superior to the left. There is
mild right-sided nasal septal deviation.
IMPRESSION: No evidence of sinusitis.
ECHO [**2173-1-22**] Conclusions:
The left atrium is normal in size. Right ventricular chamber
size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally
normal with good leaflet excursion and no aortic regurgitation.
No masses or vegetations are seen on the aortic valve. There is
no aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The
estimated pulmonary artery systolic pressure is normal. There is
no
pericardial effusion.
IMPRESSION: Normal study. No echocardiographic evidence of
endocarditis
[**2173-1-24**] RENAL ULTRASOUND: The right kidney measures 9.2 cm, and
the left kidney measures 10.5 cm. There is no hydronephrosis,
renal masses, or renal calculi identified. No perinephric fluid
collections are seen.
IMPRESSION: No evidence of hydronephrosis.
[**2173-1-24**] CT ABD/PELVIS IMPRESSION
1. No evidence of hemorrhage within the abdomen or pelvis.
2. Stable appearance of peripancreatic stranding and fluid
without evidence of drainable focal fluid collections. These
findings are consistent with acute pancreatitis.
3. Interval resolution of left pleural effusion and improvement
in aeration of the left lower lobe.
Brief Hospital Course:
45 y/o male with HIV/AIDS, HCV, who presented to the hospital
with acute pancreatitis likely related to EtOH ingestion and
question of a possible UGIB given reported history of coffee
ground emesis. The [**Hospital 228**] hospital course will be reviewed by
problem list.
#Pancreatitis: On admission the patient had a markedly elevated
lipase consistant with pancreatitis, the etiology of which was
thought to be most likely ETOH induced. The patient's abdominal
CT on admission did not show any evidence of pseudocyst
formation and subsequent repeat Abdominal CT's during the
[**Hospital 228**] hospital course also were negative for pseudocyst
formation. On initial presentation, both GI and Surgery were
consulted. The patient was initially managed in the MICU were he
received agressive IVF hydration and was maintained NPO and
given TPN. The patient's abdominal pain was slow to resolve and
therefore his diet was advanced very slowly. At the time of
discharge the patient was tolerating PO without difficulty
taking both his meds and food.
.
#GI Bleed : Per patient report on admission he had had several
episodes of coffee ground emesis. In the hospital however, no
further episodes were noted. This emesis was most likely ETOH
gastritis or [**Doctor First Name 329**] [**Doctor Last Name **] tear. GI decided to not do an EGD
during this admission. The patient's HCT remained stable
throughout his hospital stay and he was transitioned from IV
protonix to PO at discharge.
#ETOH withdrawal: The patient was maintained on a CIWA scale to
monitor for signs of withdrawal while in house. Initially he was
maintained on standing valium IV, which was subsequently
discontinued.
#HTN: The patient's HTN may be related to his EtOH use history.
He was treated with metoprolol and hydralazine IV while NPO, but
when he was able to take PO meds he was transitioned to PO
atenolol with good effect.
#HIV: The patient's HAART was held at the advice of his ID
physician since several of these medications may cause
pancreatitis. He will be restarted on therapy as an outpatient
when his acute illness has improved.
#CAD: The patient is s/p cath with PCI stent. In the setting of
his GI bleed, ASA was held and his statin was also held because
of his acute pancreatitis. These will be addressed during the
patient's outpatient follow up appointment.
#FEN: The patient was initially maintained on TPN while NPO. An
NGT was never placed because it was thought the patient's bowel
function would return quickly because of his good response to
IVF hydration. He initially received massive electrolyte
repleation during the acute phase of his pancreatitis and while
on the floor continued to have daily electrolyte monitoring and
repletion. At the time of discharge he was tolerating PO without
difficulty.
#ID: Shortly after transfer to the hospital floor from the MICU
the patient developed a fever. A CXR revealed a pneumonia, which
was treated with levaquin. The patient continued to spike high
fevers, however, and was therefore empirically started on both
vancomycin and flagyl in addition to the levaquin. His central
line was d/c'd and cultures were negative. UA was negative,
blood cultures were negative. ECHO did not show any evidence of
endocarditis and since CT was negative for sinusitis. The
patient was then taken off all antibiotics and his fever
disappeared. As a result it was thought the source was most
likely drug related, likely [**12-30**] vancomycin. The patient had been
afebrile for >72 with a normal WBC count at the time of
discharge.
#MS: After transfer from the MICU the patient began to complain
of increasing abdominal pain. On admission it was reported and
the patient verified he had a long history of chronic pain
problems. [**Name (NI) **] also stated he was taking methadone daily ~80mg in
addition to neurontin and a fentanyl patch. In the MICU the
patient had been receiving dilaudid IV for pain control. He was
transitioned to his medications that he per report had been
taking. The patient was noted to be very somnolent by the
nursing staff and house staff. Near the end of the [**Hospital 228**]
hospital stay he was found with RR of 12/min and unable to be
aroused. He was given Narcan IV and his mental status improved.
The patient was also quite constipated [**12-30**] all the pain
medication he had been receiving. After this episode his pain
medications were drastically altered and he also received
kayexelate which lowered his K and caused him to have multiple
bowel movements. The patient was discharged on methadone, but at
a much lower dose and was maintained on his fentanyl patch. His
PMD will adjust his pain medications as appropriate.
Medications on Admission:
atenolol, fentanyl patch, methadone, lisinopril
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
5. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every [**3-3**]
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pacreatitis
Secondary diagnoses
HIV/AIDS
CAD
GI bleed
Gastritis
HTN
Discharge Condition:
good
Discharge Instructions:
Take the medications prescribed for you as directed. Do not
drink alcohol. You were given a letter to take to [**Hospital **] clinic
for authorization of methadone distribution. Dr. [**Last Name (STitle) 5543**] will
increase your dose from this baseline level if needed.
You have a follow up appointment scheduled for Thursday at
[**Hospital6 **] to see Dr. [**Last Name (STitle) 5543**]. Your bloodwork
will need to be tested during this visit.
Return to the ED for evaluation if you develop chest pain,
shortness of breath, abdominal pain, nausea, vomiting, black or
bloody stools, lightheadedness or any other concerning symptoms.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5543**] on Thursday [**2173-1-28**] at
Call [**Telephone/Fax (1) 2393**] if you need to reschedule or have any
questions.
During this visit you will need to have a CBC, CHEM10 drawn as
well as any other blood work Dr. [**Last Name (STitle) 5543**] thinks is necessary.
|
[
"042",
"291.81",
"560.1",
"535.31",
"577.0",
"584.9",
"789.5",
"401.9",
"303.91",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13980, 13986
|
8506, 13199
|
329, 356
|
14099, 14105
|
3632, 8483
|
14791, 15105
|
2709, 2727
|
13297, 13957
|
14007, 14078
|
13225, 13274
|
14129, 14768
|
2742, 3613
|
262, 291
|
384, 2007
|
2029, 2560
|
2576, 2693
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,819
| 145,411
|
3425
|
Discharge summary
|
report
|
Admission Date: [**2186-9-28**] Discharge Date: [**2186-10-7**]
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
gentleman admitted for sinus bradycardia.
The patient went to see his primary care physician (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]) on the day of admission with a complaint of ankle
swelling for the past one to two months. There, he was noted
to have sinus bradycardia on an electrocardiogram with a rate
in the 30s to 40s. He was urgently sent for cardiac
evaluation by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**].
He was seen in Dr.[**Name (NI) 12467**] office with an interpreter.
Apparently, he is able to walk five to ten blocks. He
complains of pain and cramping in the left calf which wakes
him from sleep times the past several months. It does not
involve his toes. It occurs less in the right leg. Not
clearly provoked by exertion. Clearly worse at night.
Therefore, Dr. [**Last Name (STitle) 73**] had the patient admitted directly to
the floor for management. He requested the patient have a
cardiac catheterization for consideration of a pacemaker
placement.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Type 2 diabetes mellitus.
3. Hypertension.
4. History of radiation to the larynx in the Soviet [**Hospital1 1281**] in
the [**2153**] for presumed laryngeal cancer. No further details
available.
5. History of aspiration pneumonia.
6. History of gastrojejunostomy tube; status post aspiration
pneumonia (now removed).
7. History of syncopal episode last Fall and Holter monitor
in [**2185-11-11**] showing sinus bradycardia, but not
severe.
8. History of abnormal stress test in [**2185-1-11**]. The
patient had chest pain and a positive stress test showing a
moderate sized inferior wall reversible defect and was
referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who advised cardiac
catheterization at that time.
MEDICATIONS ON ADMISSION: (Medications prior to admission
included)
1. Avandia 4 mg by mouth once per day.
2. Coumadin 5 mg by mouth once per day.
3. Cozaar 50 mg by mouth once per day.
4. Glyburide 3 mg by mouth twice per day.
5. Protonix 40 mg by mouth once per day.
6. Lipitor 10 mg by mouth once per day.
ALLERGIES: The patient reports no known drug allergies.
SOCIAL HISTORY: The patient does not smoke or drink alcohol.
He is Russian-speaking only and lives in [**Location 583**].
PHYSICAL EXAMINATION ON PRESENTATION: General physical
examination upon admission revealed the patient was a
well-developed and well-developed Russian-speaking white
gentleman. The patient was alert and in no acute distress.
Head, eyes, ears, nose, and throat examination revealed
normocephalic and atraumatic. Pupils were equal, round, and
reactive to light. The oropharynx was clear. The mucous
membranes were moist. Neck examination revealed no
lymphadenopathy. Normal thyroid. Bilateral carotid bruits
were auscultated. The lungs were clear to auscultation
bilaterally. No wheezes, rhonchi, or rales. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds auscultated. No
murmurs, rubs, or gallops. The abdomen was soft, nontender,
and nondistended. No hepatosplenomegaly. Lower extremity
examination revealed 1+ edema bilaterally. Groin examination
revealed no bruits. Skin examination revealed no rashes.
Neurologic examination was grossly intact.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CORONARY ARTERY DISEASE: The patient was admitted to the
telemetry floor. He was monitored overnight without any
evidence of symptomatic bradycardia.
He underwent a cardiac catheterization on [**2186-9-29**]
with stent placement in the right coronary artery and left
anterior descending artery. The catheterization also showed
diffuse left circumflex disease.
Status post catheterization, the patient had a vagal episode
resulting in his heart rate decreasing to 39 and a systolic
blood pressure in the 60s. He responded to 1 mg of atropine.
There were no electrocardiogram changes noted at this time.
He was continued on aspirin, Plavix, Lipitor, and Losartan.
No beta blocker was given in light of the patient's sinus
bradycardia.
Status post cardiac catheterization, the patient was also
noted to have an elevation in his creatine kinase levels to
values of 1034; however, the MB fraction was low. It was
felt that this was secondary to difficult hemostasis status
post sheath removal after his cardiac catheterization. It
was not felt to be related to continued coronary ischemia.
In light of this elevation of creatine kinase levels, the
patient underwent an ultrasound of his right groin in order
to rule out pseudoaneurysm formation. This was negative.
2. CAROTID ARTERY DISEASE ISSUES: The patient underwent
bilateral carotid Doppler ultrasound on [**2186-9-29**].
This showed right internal carotid stenosis of 80% to 99%,
left internal carotid artery stenosis of 80% to 99%, and left
internal carotid artery stenosis of 70% to 79%.
It was felt that the patient's carotid stenosis could be
contributing to his bradycardia. A magnetic resonance
imaging/magnetic resonance angiography of the patient's head
and neck was planned to further evaluate his carotid disease,
but this was unable to be obtained secondary to the patient's
recent coronary artery stent placement.
The patient was seen by the Vascular Surgery Service
regarding his asymptomatic carotid stenosis and was felt not
to be a surgical candidate in light of his need to continue
Plavix for three months status post carotid artery stent
placement. Therefore, the patient underwent carotid stent
placement via a subclavian angiography on [**2186-10-4**].
He underwent a baseline computed tomography scan of the head
which was negative prior to this intervention.
He was also seen in consultation by the Neurology Stroke
Service. They performed serial examinations before and after
his carotid artery stent placement.
Status post carotid artery stent placement, the patient was
monitored in the Coronary Care Unit overnight; specifically,
to maintain blood pressure values in the 120 to 150 range in
case he needed pressor support.
Overall, the patient tolerated the right internal carotid
artery stent placement well with no neurologic events. He
was transferred to the floor on [**2186-10-5**]. On the
floor, he underwent neurologic check every four hours. His
Losartan dose was decreased to 25 mg by mouth once per day in
order to maintain a systolic blood pressure in the 120 to 150
range. He was continued on aspirin and was to continue
Plavix therapy for life.
3. SINUS BRADYCARDIA ISSUES: Initially, the patient was
admitted for evaluation and likely pacemaker placement.
However, the pacemaker evaluation was postponed pending
evaluation of the patient's coronary arteries and carotid
arteries.
As reported above, the patient underwent stenting to the mid
left anterior descending artery and distal right coronary
artery. The patient also underwent stenting to the right
internal coronary artery. This resulted in a subsequent
increase in his heart rate. At that point, it was felt that
the patient no longer warranted emergent pacemaker placement.
He was discharged to home on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor in
order to further evaluate his heart rate for any evidence of
symptomatic bradycardia. He was to follow up in three weeks
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] for further evaluation.
4. TYPE 2 DIABETES MELLITUS ISSUES: Throughout his hospital
stay, the patient was maintained on a regular insulin
sliding-scale. His outpatient oral hypoglycemic regimen was
initiated prior to discharge, and he tolerated this well.
5. RIGHT LUNG NODULE ISSUES: The patient had evidence of a
right upper lung nodule of 9 mm in diameter. This was seen
on a baseline computed tomography of the chest that was
evaluated during this admission. Per Radiology, it was
recommended that the patient undergo a follow-up computed
tomography scan in three months in order to assess for
interval change. If an interval change does occur, the
patient should undergo an outpatient evaluation of the mass
including a possible oncologic workup.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE STATUS: The patient's discharge status was to
home.
DISCHARGE DIAGNOSES:
1. Bradycardia.
2. Coronary artery disease.
3. Carotid artery stenosis.
4. Hypertension.
5. Type 2 diabetes mellitus.
6. Lung nodule.
7. Chronic renal insufficiency.
8. Anemia secondary to acute blood loss.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg by mouth once per day.
2. Pantoprazole 40 mg by mouth once per day.
3. Lipitor 10 mg by mouth once per day.
4. Aspirin 325 mg by mouth once per day.
5. Avandia 4 mg by mouth once per day.
6. Losartan 20 mg by mouth once per day.
7. Glyburide 3 mg by mouth twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to make an appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] (telephone number [**Telephone/Fax (1) 902**]) for three
weeks after discharge.
2. The patient was also instructed to make an appointment
with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] for three months after discharge.
3. The patient already had a follow-up appointment scheduled
with his primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) in the
[**Doctor Last Name 780**] Building on [**2186-11-7**] at 10:20 a.m.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Dictator Info 15838**]
MEDQUIST36
D: [**2186-10-23**] 16:11
T: [**2186-10-24**] 09:02
JOB#: [**Job Number 15839**]
cc:[**Last Name (NamePattern4) 15840**]
|
[
"427.89",
"250.00",
"401.9",
"433.10",
"998.12",
"530.81",
"414.01",
"E878.8",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"99.20",
"37.22",
"88.52",
"36.05",
"88.41",
"88.55",
"36.07",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
8568, 8784
|
8810, 9105
|
2029, 2377
|
9138, 10052
|
3585, 8434
|
8449, 8547
|
118, 1192
|
1214, 2002
|
2394, 3551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,175
| 107,641
|
12013+12014
|
Discharge summary
|
report+report
|
Admission Date: [**2184-2-10**] Discharge Date: [**2184-3-12**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 37724**] is a 76 year old
man who was brought to the Trauma Bay as a trauma plus after
he had been hit by a car as a pedestrian. He had loss of
consciousness at the scene and was found to be combative at
the scene with a frontal laceration. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma
scale of 13 on arrival and was extremely combative and had no
recall of the event. He was also hypertensive to systolic of
180s on arrival.
PAST MEDICAL HISTORY: Macular degeneration.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Examination on arrival revealed
temperature of 96.8, pulse 120, pressure 174/palpable.
Oxygen saturation was 100% nonrebreather. Pupils are equal
and reactive. Extraocular movements intact. Face is
midline. Tympanic membranes are clear and trachea is
midline. There is a laceration above the right eye
approximately 2 cm and left orbital bruising. His heart is
regular but tachycardiac. Lungs are clear. Abdomen is soft,
flat and nontender. Pelvis is stable. Rectal is normal with
a normal tone, heme is guaiac negative. There were no
stepoffs in the back. Neurological examination is
significant for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 13. There are
abrasions in the right knee with no deformities of the
extremities in the Trauma Bay.
Physical examination at discharge revealed a temperature of
97.3, pulse 72, pressure 132/80, respirations 20s and oxygen
95% on face mask. This is an elderly man in no acute
distress who when given glasses smiles and tries to converse.
His heart is regular, his lungs are clear. His abdomen is
soft and nontender. The percutaneous endoscopic jejunostomy
tube site is clean. His extremities are frail and have boots
to protect from pressure ulcers.
LABORATORY DATA: Laboratory data on discharge revealed a
white count of 13.6, hematocrit of 30, platelet count 643,
sodium 140, potassium 3.9, chloride 102, bicarbonate 29, BUN
19, creatinine 0.5, glucose 114, magnesium 1.9. Radiological
studies, trauma series on arrival on [**2-10**] shows normal
heart size without mediastinal widening. Lungs are
hyperinflated. There is no evidence of pneumothorax or
pleural effusion. The AP view of the pelvis shows fracture
of the right pubic bone.
Computerized tomography scan of the head on arrival shows
question of small subarachnoid hemorrhage in the frontal
area. Computerized tomography scan also shows multiple
fractures including fracture of the right zygomatic arch,
bilateral fracture superior, posterior and lateral portions
of the maxillary sinuses, bilateral fracture through the
anterior walls of the maxillary sinuses, air fluid levels in
the maxillary sinuses. There is a small pneumocephalus.
Facial computerized tomography scan shows the fractures as
described above in the head computerized tomography scan.
The mandible is intact. There are bilateral frontal
contusions. Repeat head computerized tomography scan within
a day of arrival shows hemorrhages in the frontal, right
parietal and left occipital lobes and small hemorrhage of
blood in the subarachnoid space. Also a small amount of gas
anterior to the left temporal lobe associated with sphenoid
[**Doctor First Name 362**] fracture. Computerized tomography scan of the abdomen
on arrival shows fracture of the left inferior pubic ramus,
extensive pancreatic calcification consistent with chronic
pancreatitis, ectatic infrarenal abdominal aorta measuring
2.4 cm.
Magnetic resonance imaging scan of the cervical spine shows
no evidence of ligamentous injury. There is moderate
degenerative change. There are no apparent fractures on the
cervical spine studies.
Left hand films show fractures at the base of the first and
second metacarpals. Thoracolumbar spine films show diffuse
osteopenia, however, no evidence of thoracic or lumbar spine.
There is lumbar spine scoliosis with degenerative changes.
HOSPITAL COURSE: Mr. [**Name14 (STitle) 37725**] was admitted to the Intensive
Care Unit after suffering extensive head and facial trauma
when he was hit by a car on [**2184-2-10**]. He received
an orthopedic, neurosurgery, plastics and ophthalmology
consultation for a full evaluation. Relevant details of his
hospital course are described by systems below:
Neurological - Mr. [**Name14 (STitle) 37725**] suffered multiple intracranial
hemorrhages and subarachnoid bleed as evident on computerized
tomography scans which were repeated serially through his
hospital course. His hemorrhages evolved over the first day
and then were stable throughout the course. Neurosurgery was
consulted and no operative management was indicated. For
this reason, Mr. [**Name14 (STitle) 37725**] was observed off his Dilantin
regimen in the hospital. His mental status is not at
baseline due to his cranial injuries. Currently he is awake,
is able to communicate slightly, however, in a
noncomprehensive fashion. He shows no signs of agitation and
seems to understand what he is being told. Once his
hemorrhages were found to be stable he was started on
subcutaneous heparin and was cleared by Neurosurgery for
rehabilitation. His cervical spine was cleared with an
magnetic resonance imaging scan after which the collar was
taken off. His thoracolumbar spine was cleared by thoracic
films obtained during his visit. At discharge, he is
cooperative, pleasant, somewhat communicative, unable to
perform activities of daily living and is only on Tylenol prn
for pain medications. His Dilantin was discontinued during
his hospital course without problems.
Cardiac - Mr. [**Name14 (STitle) 37725**] has remained stable throughout his
hospital course from a cardiovascular perspective. Initially
his blood pressure was controlled as per guidelines
established by Neurosurgery. Through his hospital course it
became evident that he has some component of high blood
pressure which is now being treated by Lopressor which is
currently at 50 mg b.i.d. He has been on this dose for
several weeks and has a stable blood pressure and heartrate
without any signs of arrhythmia.
Respiratory - Mr. [**Name14 (STitle) 37725**] did not suffer any direct injury
to the lung, however, approximately on [**2-29**], he was found
to have an aspiration event. For this, he had to be
transferred to the Intensive Care Unit and was intubated. He
received a full course of treatment of Vancomycin,
Levofloxacin and Flagyl for any aspiration pneumonia. He was
extubated around [**3-8**] and since then has been stable on
the floor. He is off all antibiotics. He requires
suctioning and chest physical therapy to prevent further
episodes of pneumonia.
Gastrointestinal - Mr. [**Name14 (STitle) 37725**] on hospital day #10 after
tolerating nasogastric feeds received a percutaneous
endoscopic gastrostomy tube placement. He has tolerated
these tube feeds at goal for most of his hospital course.
Due to an aspiration event, around [**2-29**], his tube feeds
were stopped and his percutaneous endoscopic gastrostomy tube
was converted to a percutaneous endoscopic jejunostomy tube.
Now he is tolerating tube feeds again at goal. He is having
bowel movements and has a soft, nondistended abdomen.
During his hospital course Mr. [**Name14 (STitle) 37725**] also had an episode
of lower gastrointestinal bleed. He received multiple units
of transfusions for his lower gastrointestinal bleed which
when assessed by angiogram was rectal bleed, reachable in the
operating room. He was taken to the Operating Room on [**2-28**] and his rectal ulcer that was bleeding was oversewn using
three stitches. Since then he has remained stable and shows
no signs of gastrointestinal bleed. His hematocrit is stable
at 30 on discharge.
Also on discharge, Mr. [**Name14 (STitle) 37725**] is on Zantac and Colace and
Reglan for prophylaxis.
Infectious disease - Mr. [**Name14 (STitle) 37725**] was treated for a full
course of Vancomycin, Levofloxacin and Flagyl for aspiration
pneumonia from which he recovered. One of the cultures
through an arterial line during his course had an
enterococcus resistant to Vancomycin which was treated with
linezolid. Infectious disease consult was obtained for which
linezolid was given for seven days. On discharge he has
finished his course of linezolid and there are no signs of
any more enterococcus infection. His white count at
discharge is coming down and is at 13. During his aspiration
pneumonia course his white count maxed at about approximately
25.
Hematology - Mr. [**Name14 (STitle) 37725**] lost a significant amount of blood
during his lower gastrointestinal bleed in the middle of his
hospitalization. This gastrointestinal bleed was stopped in
the Operating Room by placing three stitches in his rectum.
He was placed on Epogen for a short term to recover his
hematocrit. On discharge he has a stable hematocrit of 30.
He is no longer on Epogen.
Renal - Mr. [**Name14 (STitle) 37725**] has made adequate urine throughout his
hospital course and has a normal creatinine. He has a condom
catheter in place to monitor his urine output.
Prophylaxis - Once cleared by Neurosurgery, Mr. [**Name14 (STitle) 37725**] was
placed on heparin subcutaneous prophylaxis. He also received
Zantac for prophylaxis. He has multiporous boots on his feet
to prevent pressure ulcers to his heels.
Ophthalmology - Mr. [**Name14 (STitle) 37725**] was seen by Ophthalmology early
in his hospital course after his trauma and was cleared to
have no entrapment. He is recommended to have a follow up
for routine examination after his discharge.
Plastics - Mr. [**Name14 (STitle) 37725**] received a plastic surgeon for
multiple facial fractures as described in the head
computerized tomography scan. He was found to have
nonoperative fractures and did not receive any plastic
surgery operations.
Orthopedics - Mr. [**Name14 (STitle) 37725**] was taken to the Operating Room on
[**2-20**], for repair of fracture in his left first metacarpal.
This fracture was repaired and is currently splinted in a
cast. He is to follow up with Plastic Surgery as an
outpatient for this.
In summary Mr. [**Name14 (STitle) 37725**] is an unfortunate 76 year old man who
was brought to the Trauma Bay on [**2184-2-10**] after he
was struck by a car at which time he suffered multiple facial
fractures and intracranial hemorrhages. He also had a
fracture of his left first metacarpal and the left pubic
rami. His hospital course was complicated by a slow recovery
from his cranial bleeds which have left him below his
baseline for his neurological function. He also received
repair of his left metacarpal and percutaneous endoscopic
gastrostomy tube placement which was later converted to a
percutaneous endoscopic jejunostomy tube. His hospital
course was also complicated by an episode of lower
gastrointestinal bleed which was repaired by placing stitches
in the rectum at the site of the bleed and a course of
aspiration pneumonia which he recovered from with a course of
antibiotics.
On discharge Mr. [**Name14 (STitle) 37725**] is stable, is able to communicate
slightly but noncomprehensively and has a tube feed through
which he is tolerating tube feeds at goal, he is having bowel
movements and is voiding through his condom catheter. His
functional status is out of bed with assist. He does not
have any family in contact, however, does have a legal
guardian and friends.
MEDICATIONS ON DISCHARGE:
1. Zantac 150 mg per jejunostomy tube b.i.d.
2. Reglan 10 mg per jejunostomy tube t.i.d.
3. Lopressor 50 mg per jejunostomy tube b.i.d.
4. Colace 100 mg per jejunostomy tube b.i.d.
5. Heparin 5000 units subcutaneously b.i.d.
6. Tube feeds, ProMod with fiber at 60 cc/hr
7. Free water 100 cc per jejunostomy tube t.i.d.
ADDENDUM: Mr. [**Name14 (STitle) 37725**] will be followed by [**Hospital **]
Rehabilitation at [**Hospital6 256**] which
also serve [**Hospital3 7**].
FOLLOW UP: Trauma Clinic in two weeks. Follow up in
plastics with Dr. [**Last Name (STitle) 24130**] at [**Hospital6 2018**] in two weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To Rehabilitation.
DISCHARGE DIAGNOSIS:
1. Pedestrian struck by car.
2. Multiple intracranial hemorrhages.
3. Left first metacarpal fracture.
4. Left pubic rami fracture, nonoperable.
5. Hypertension.
6. Recovery from lower gastrointestinal bleed in the rectum.
7. Recovery from aspiration pneumonia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2184-3-12**] 15:06
T: [**2184-3-12**] 16:07
JOB#: [**Job Number 37726**]
Admission Date: [**2184-2-10**] Discharge Date: [**2184-3-12**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Name14 (STitle) 37725**] is a 76 year old
man who was brought to the Trauma Bay as a trauma plus after
he had been hit by a car as a pedestrian. He had loss of
consciousness at the scene and was found to be combative at
the scene with a frontal laceration. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma
scale of 13 on arrival and was extremely combative and had no
recall of the event. He was also hypertensive to systolic of
180s on arrival.
PAST MEDICAL HISTORY: Macular degeneration.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Examination on arrival revealed
temperature of 96.8, pulse 120, pressure 174/palpable.
Oxygen saturation was 100% nonrebreather. Pupils are equal
and reactive. Extraocular movements intact. Face is
midline. Tympanic membranes are clear and trachea is
midline. There is a laceration above the right eye
approximately 2 cm and left orbital bruising. His heart is
regular but tachycardiac. Lungs are clear. Abdomen is soft,
flat and nontender. Pelvis is stable. Rectal is normal with
a normal tone, heme is guaiac negative. There were no
stepoffs in the back. Neurological examination is
significant for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 13. There are
abrasions in the right knee with no deformities of the
extremities in the Trauma Bay.
Physical examination at discharge revealed a temperature of
97.3, pulse 72, pressure 132/80, respirations 20s and oxygen
95% on face mask. This is an elderly man in no acute
distress who when given glasses smiles and tries to converse.
His heart is regular, his lungs are clear. His abdomen is
soft and nontender. The percutaneous endoscopic jejunostomy
tube site is clean. His extremities are frail and have boots
to protect from pressure ulcers.
LABORATORY DATA: Laboratory data on discharge revealed a
white count of 13.6, hematocrit of 30, platelet count 643,
sodium 140, potassium 3.9, chloride 102, bicarbonate 29, BUN
19, creatinine 0.5, glucose 114, magnesium 1.9. Radiological
studies, trauma series on arrival on [**2-10**] shows normal
heart size without mediastinal widening. Lungs are
hyperinflated. There is no evidence of pneumothorax or
pleural effusion. The AP view of the pelvis shows fracture
of the right pubic bone.
Computerized tomography scan of the head on arrival shows
question of small subarachnoid hemorrhage in the frontal
area. Computerized tomography scan also shows multiple
fractures including fracture of the right zygomatic arch,
bilateral fracture superior, posterior and lateral portions
of the maxillary sinuses, bilateral fracture through the
anterior walls of the maxillary sinuses, air fluid levels in
the maxillary sinuses. There is a small pneumocephalus.
Facial computerized tomography scan shows the fractures as
described above in the head computerized tomography scan.
The mandible is intact. There are bilateral frontal
contusions. Repeat head computerized tomography scan within
a day of arrival shows hemorrhages in the frontal, right
parietal and left occipital lobes and small hemorrhage of
blood in the subarachnoid space. Also a small amount of gas
anterior to the left temporal lobe associated with sphenoid
[**Doctor First Name 362**] fracture. Computerized tomography scan of the abdomen
on arrival shows fracture of the left inferior pubic ramus,
extensive pancreatic calcification consistent with chronic
pancreatitis, ectatic infrarenal abdominal aorta measuring
2.4 cm.
Magnetic resonance imaging scan of the cervical spine shows
no evidence of ligamentous injury. There is moderate
degenerative change. There are no apparent fractures on the
cervical spine studies.
Left hand films show fractures at the base of the first and
second metacarpals. Thoracolumbar spine films show diffuse
osteopenia, however, no evidence of thoracic or lumbar spine.
There is lumbar spine scoliosis with degenerative changes.
HOSPITAL COURSE: Mr. [**Name14 (STitle) 37725**] was admitted to the Intensive
Care Unit after suffering extensive head and facial trauma
when he was hit by a car on [**2184-2-10**]. He received
an orthopedic, neurosurgery, plastics and ophthalmology
consultation for a full evaluation. Relevant details of his
hospital course are described by systems below:
Neurological - Mr. [**Name14 (STitle) 37725**] suffered multiple intracranial
hemorrhages and subarachnoid bleed as evident on computerized
tomography scans which were repeated serially through his
hospital course. His hemorrhages evolved over the first day
and then were stable throughout the course. Neurosurgery was
consulted and no operative management was indicated. For
this reason, Mr. [**Name14 (STitle) 37725**] was observed off his Dilantin
regimen in the hospital. His mental status is not at
baseline due to his cranial injuries. Currently he is awake,
is able to communicate slightly, however, in a
noncomprehensive fashion. He shows no signs of agitation and
seems to understand what he is being told. Once his
hemorrhages were found to be stable he was started on
subcutaneous heparin and was cleared by Neurosurgery for
rehabilitation. His cervical spine was cleared with an
magnetic resonance imaging scan after which the collar was
taken off. His thoracolumbar spine was cleared by thoracic
films obtained during his visit. At discharge, he is
cooperative, pleasant, somewhat communicative, unable to
perform activities of daily living and is only on Tylenol prn
for pain medications. His Dilantin was discontinued during
his hospital course without problems.
Cardiac - Mr. [**Name14 (STitle) 37725**] has remained stable throughout his
hospital course from a cardiovascular perspective. Initially
his blood pressure was controlled as per guidelines
established by Neurosurgery. Through his hospital course it
became evident that he has some component of high blood
pressure which is now being treated by Lopressor which is
currently at 50 mg b.i.d. He has been on this dose for
several weeks and has a stable blood pressure and heartrate
without any signs of arrhythmia.
Respiratory - Mr. [**Name14 (STitle) 37725**] did not suffer any direct injury
to the lung, however, approximately on [**2-29**], he was found
to have an aspiration event. For this, he had to be
transferred to the Intensive Care Unit and was intubated. He
received a full course of treatment of Vancomycin,
Levofloxacin and Flagyl for any aspiration pneumonia. He was
extubated around [**3-8**] and since then has been stable on
the floor. He is off all antibiotics. He requires
suctioning and chest physical therapy to prevent further
episodes of pneumonia.
Gastrointestinal - Mr. [**Name14 (STitle) 37725**] on hospital day #10 after
tolerating nasogastric feeds received a percutaneous
endoscopic gastrostomy tube placement. He has tolerated
these tube feeds at goal for most of his hospital course.
Due to an aspiration event, around [**2-29**], his tube feeds
were stopped and his percutaneous endoscopic gastrostomy tube
was converted to a percutaneous endoscopic jejunostomy tube.
Now he is tolerating tube feeds again at goal. He is having
bowel movements and has a soft, nondistended abdomen.
During his hospital course Mr. [**Name14 (STitle) 37725**] also had an episode
of lower gastrointestinal bleed. He received multiple units
of transfusions for his lower gastrointestinal bleed which
when assessed by angiogram was rectal bleed, reachable in the
operating room. He was taken to the Operating Room on [**2-28**] and his rectal ulcer that was bleeding was oversewn using
three stitches. Since then he has remained stable and shows
no signs of gastrointestinal bleed. His hematocrit is stable
at 30 on discharge.
Also on discharge, Mr. [**Name14 (STitle) 37725**] is on Zantac and Colace and
Reglan for prophylaxis.
Infectious disease - Mr. [**Name14 (STitle) 37725**] was treated for a full
course of Vancomycin, Levofloxacin and Flagyl for aspiration
pneumonia from which he recovered. One of the cultures
through an arterial line during his course had an
enterococcus resistant to Vancomycin which was treated with
linezolid. Infectious disease consult was obtained for which
linezolid was given for seven days. On discharge he has
finished his course of linezolid and there are no signs of
any more enterococcus infection. His white count at
discharge is coming down and is at 13. During his aspiration
pneumonia course his white count maxed at about approximately
25.
Hematology - Mr. [**Name14 (STitle) 37725**] lost a significant amount of blood
during his lower gastrointestinal bleed in the middle of his
hospitalization. This gastrointestinal bleed was stopped in
the Operating Room by placing three stitches in his rectum.
He was placed on Epogen for a short term to recover his
hematocrit. On discharge he has a stable hematocrit of 30.
He is no longer on Epogen.
Renal - Mr. [**Name14 (STitle) 37725**] has made adequate urine throughout his
hospital course and has a normal creatinine. He has a condom
catheter in place to monitor his urine output.
Prophylaxis - Once cleared by Neurosurgery, Mr. [**Name14 (STitle) 37725**] was
placed on heparin subcutaneous prophylaxis. He also received
Zantac for prophylaxis. He has multiporous boots on his feet
to prevent pressure ulcers to his heels.
Ophthalmology - Mr. [**Name14 (STitle) 37725**] was seen by Ophthalmology early
in his hospital course after his trauma and was cleared to
have no entrapment. He is recommended to have a follow up
for routine examination after his discharge.
Plastics - Mr. [**Name14 (STitle) 37725**] received a plastic surgeon for
multiple facial fractures as described in the head
computerized tomography scan. He was found to have
nonoperative fractures and did not receive any plastic
surgery operations.
Orthopedics - Mr. [**Name14 (STitle) 37725**] was taken to the Operating Room on
[**2-20**], for repair of fracture in his left first metacarpal.
This fracture was repaired and is currently splinted in a
cast. He is to follow up with Plastic Surgery as an
outpatient for this.
In summary Mr. [**Name14 (STitle) 37725**] is an unfortunate 76 year old man who
was brought to the Trauma Bay on [**2184-2-10**] after he
was struck by a car at which time he suffered multiple facial
fractures and intracranial hemorrhages. He also had a
fracture of his left first metacarpal and the left pubic
rami. His hospital course was complicated by a slow recovery
from his cranial bleeds which have left him below his
baseline for his neurological function. He also received
repair of his left metacarpal and percutaneous endoscopic
gastrostomy tube placement which was later converted to a
percutaneous endoscopic jejunostomy tube. His hospital
course was also complicated by an episode of lower
gastrointestinal bleed which was repaired by placing stitches
in the rectum at the site of the bleed and a course of
aspiration pneumonia which he recovered from with a course of
antibiotics.
On discharge Mr. [**Name14 (STitle) 37725**] is stable, is able to communicate
slightly but noncomprehensively and has a tube feed through
which he is tolerating tube feeds at goal, he is having bowel
movements and is voiding through his condom catheter. His
functional status is out of bed with assist. He does not
have any family in contact, however, does have a legal
guardian and friends.
MEDICATIONS ON DISCHARGE:
1. Zantac 150 mg per jejunostomy tube b.i.d.
2. Reglan 10 mg per jejunostomy tube t.i.d.
3. Lopressor 50 mg per jejunostomy tube b.i.d.
4. Colace 100 mg per jejunostomy tube b.i.d.
5. Heparin 5000 units subcutaneously b.i.d.
6. Tube feeds, ProMod with fiber at 60 cc/hr
7. Free water 100 cc per jejunostomy tube t.i.d.
ADDENDUM: Mr. [**Name14 (STitle) 37725**] will be followed by [**Hospital **]
Rehabilitation at [**Hospital6 256**] which
also serve [**Hospital3 7**].
FOLLOW UP: Trauma Clinic in two weeks. Follow up in
plastics with Dr. [**Last Name (STitle) 24130**] at [**Hospital6 2018**] in two weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To Rehabilitation.
DISCHARGE DIAGNOSIS:
1. Pedestrian struck by car.
2. Multiple intracranial hemorrhages.
3. Left first metacarpal fracture.
4. Left pubic rami fracture, nonoperable.
5. Hypertension.
6. Recovery from lower gastrointestinal bleed in the rectum.
7. Recovery from aspiration pneumonia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2184-3-12**] 15:06
T: [**2184-3-12**] 16:07
JOB#: [**Job Number 37726**]
|
[
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"285.1",
"577.1",
"507.0",
"707.0",
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"E818.7",
"808.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
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25281, 25301
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24600, 25081
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17100, 24574
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|
13080, 13567
|
13589, 13671
|
25248, 25257
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,629
| 172,111
|
18572
|
Discharge summary
|
report
|
Admission Date: [**2207-4-24**] Discharge Date: [**2207-5-8**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Dyspnea and hemoptysis
Major Surgical or Invasive Procedure:
intubation - [**4-27**]
arterial line placement - [**4-27**]
cardiac catheterization - [**4-28**]
History of Present Illness:
Mr. [**Known lastname 30380**] is an 87 year old man with COPD, CAD, CHF and Afib who
presented to BIDN complaining of dyspnea and hemoptysis. Patient
reports productive cough with yellow sputum for the past 3 weeks
that was treated with azithromycin by his primary care doctor
one week ago. Patient also c/o hemoptysis for the past 4-5 days,
which he described as "big globs" of blood. Patient also
endorses fever and chills at home.
At BIDN, initial VS were 98.1 140 132/67 24 76% RA that
improved to 95% on NRB. Labs revelaed WBC 13.1 91.6%N and INR
8.0. CXR revealed RUL consolidation c/f PNA, and he received CTX
1g IV, Vitamin K and was transfered to [**Hospital1 18**] for further care.
At [**Hospital1 18**] initail VS were 99.0 120 111/70 24 94% 15L NRB. Labs
revealed lactate 2.9, WBC 13 92.5%N, HCT 40.7, Cr 2.2, proBNP
4254, TropT 0.28. ABG 7.43, 28, 81. Patient received 2 units
FFP, 40mg IV lasix, 10mg IV diltiazem, 30mg PO diltiazem, 500mg
IV azithromycin and 1g IV vancomycin. The patient was then
admitted to the MICU.
On arrival to the MICU, the patient happeard was dyspnic with
oxygen saturation of 90% on NRB and was placed on non-invasive
ventillation with improvement to 100% oxygen saturation.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Atrial fibrillation and systolic CHF. EF of 35% to 40%
- CAD s/p CABG (2 vessel, LIMA to LAD, rSVG to OM) in [**2198**]
- Rheumatic heart disease s/p bioprosthetic AVR in [**2198**]
- Mitral valve prolapse
- Bioprosthetic AVR [**2198**] (bovine)
- AAA 3.9 cm in [**10/2206**] follow at [**Hospital 18**] [**Hospital **] Clinic
- Hypertension
- High cholesterol
- Restrictive lung disease
- Asthma
- Polymyalgia rheumatica, on 10mg prednisone daily
- History of cholecystectomy
- Hemorrhoids
- Chronic renal insufficiency, baseline creatinine 1.6 to 1.9
- Cataract surgery, left
- Anemia
- Seasonal allergy
- Chronic anal fissure
Social History:
Patient lives with his wife and acts as her caretaker as she has
mild dementia. He was trained as a merchant [**Hospital1 **] but worked
in construction. He previously smoked [**1-30**] ppd x30 years, quit
in [**2164**]. He has 3 alcoholic drinks a year. No recreational
drug use.
Family History:
Pt is adopted, so unknown.
Physical Exam:
Admission Physical Exam:
General: Tachypnic, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to 16cm H2O, no LAD
CV: tachycardic irrgeular rhythm, no rubs, gallops
Lungs: Rales in RUL and BL bases, no wheezes,
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, MAEW
Pertinent Results:
Admission Labs:
[**2207-4-24**] 10:50AM BLOOD WBC-13.0*# RBC-4.32* Hgb-12.6* Hct-40.7
MCV-94 MCH-29.2 MCHC-31.0 RDW-14.0 Plt Ct-271#
[**2207-4-24**] 10:50AM BLOOD Neuts-92.5* Lymphs-4.0* Monos-3.0 Eos-0.4
Baso-0.2
[**2207-4-24**] 10:50AM BLOOD PT-36.6* PTT-33.8 INR(PT)-3.6*
[**2207-4-24**] 10:50AM BLOOD Glucose-157* UreaN-69* Creat-2.2* Na-135
K-4.9 Cl-99 HCO3-21* AnGap-20
[**2207-4-24**] 10:50AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.6
[**2207-4-24**] 11:05AM BLOOD Lactate-2.9*
Cardiac Labs:
[**2207-4-24**] 10:50AM BLOOD CK-MB-8 cTropnT-0.29* proBNP-4254*
[**2207-4-24**] 10:50AM BLOOD cTropnT-0.28*
[**2207-4-24**] 10:50AM BLOOD CK(CPK)-283
[**2207-4-24**] 10:13PM BLOOD CK-MB-4 cTropnT-0.37*
[**2207-4-24**] 10:13PM BLOOD CK(CPK)-215
[**2207-4-25**] 05:35AM BLOOD CK-MB-4 cTropnT-0.24*
[**2207-4-25**] 05:35AM BLOOD CK(CPK)-169
[**2207-4-25**] 01:24PM BLOOD CK-MB-5 cTropnT-0.18*
[**2207-4-25**] 01:24PM BLOOD CK(CPK)-138
[**Hospital3 **]:
[**2207-4-25**] 05:35AM BLOOD Cortsol-30.1*
Microbiology:
[**2207-5-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2207-5-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2207-5-1**] URINE URINE CULTURE-FINAL
[**2207-4-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}
[**2207-4-24**] MRSA SCREEN MRSA SCREEN-FINAL
[**2207-4-24**] URINE Legionella Urinary Antigen -FINAL
[**2207-4-24**] URINE URINE CULTURE-FINAL
[**2207-4-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2207-4-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
.
Imaging:
CXR [**4-24**]
Possible asymmetric right greater than left, pulmonary edema;
superimposed
infectious process not excluded. Given history of hemoptysis,
underlying
pulmonary hemorrhage is not excluded. Small right pleural
effusion.
CXR [**4-25**]
Status post median sternotomy for CABG with overall stable
cardiac and
mediastinal contours. Prosthetic aortic valve. There is interval
worsening
of bilateral airspace and interstitial process which may reflect
pulmonary
edema, worsening pneumonia, or a progressing hypersensitivity
reaction.
Pulmonary hemorrhage could also have this appearance. Clinical
correlation is advised. No pneumothorax. No acute pulmonary
abnormality appreciated.
TTE [**4-25**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is borderline low (LVEF 50%). A bioprosthetic aortic
valve prosthesis is well seated, with normal leaflet/disc motion
and transvalvular gradients. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-29**]+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
borderline low left ventricular systolic function. Well-seated
bioprosthetic aortic valve with normal transvalvular gradients.
Mild to moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2204-5-30**], the
left ventricular function appears less vigorous. The gradients
across the bioprosthetic aortic valve are normal.
CXR [**4-26**]
FINDINGS: As compared to the previous radiograph, there are
unchanged
bilateral airspace opacities and a small right pleural effusion.
The
opacities and the effusion have not changed in the interval.
Moderate
cardiomegaly, status post CABG with subsequent position of the
surgical
material. No other relevant findings.
CXR [**4-27**]
IMPRESSION: Slight improvement in diffuse pulmonary opacities,
suggesting
decrease in edema, with probable superimposed pneumonia.
CT Chest [**4-28**]
FINDINGS: There is mild, apical-predominant centrilobular and
paraseptal
emphysema. Diffuse ground-glass opacities are present throughout
both lungs, involving all lobes and extending to the pleural
surfaces. Early fibrosis with mild honeycombing at the lung
bases. Mild diffuse peribronchial wall thickening, but no
interstitial thickening. No pleural effusions. Heart is normal
in size, without pericardial effusion. Changes of coronary
artery bypass grafting, with mediastinal clips. Note is made of
a prosthetic aortic valve and discarded right atrial/ventricular
pacemaker leads. Diffuse calcific atherosclerosis is present in
the thoracic aorta. Prominent mediastinal nodes measure up to
12 mm in short axis in the superior right paratracheal region,
10 mm in the inferior right paratracheal region, and 13 mm in
the subcarinal region. Changes of median sternotomy, with
multiple chronically fractured and malpositioned sternal wires.
No sternal fluid collections or osseous abnormalities.
Examination is not tailored for subdiaphragmatic evaluation, but
reveals a
nasogastric tube in appropriate position. Gastric diverticulum
arises from
the greater curvature. Cholecystectomy changes. Accesorry
splenule is
present. Multiple colonic diverticula, without acute
inflammation.
IMPRESSION: Diffuse ground-glass pulmonary opacities and early
fibrosis.
Given patient history, this may represent acute-on-chronic
organizing
pneumonia, acute interstitial pneumonitis, less likely fibrosis
with
superimposed infection.
.
Right Heart Cardiac Catheterization [**2207-4-28**]
Cardiac Output Results
Phase Fick C.O. (l/min) Fick C.I.(l/min/m2)
4.39 2.25
Hemodynamic Measurements (mmHg)
Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
RA 10 9 13 80
RV 35 7 90
PCW 12 12 14 89
PA 35 17 24 84
Radiology Summary
Total Cine Runs
Fluoro Time (minutes) 0.90
Effective Equivalent Dose Index (mGy) 12.43
Findings
ESTIMATED blood loss: <10 cc
Hemodynamics (see above):
Assessment & Recommendations
1. Mild pulmonary hypertension
2. Mildly elevated filling pressures.
3. Preserved Cardiac Output.
4. No indication for selective pulmonary vasodilators.
.
[**2207-4-30**] CXR
REPORT: Status post sternotomy. NG tube courses throughout the
mediastinum to its expected location in the stomach. The ET tube
is in good position, lying about 4 cm above the carina.
There is a right-sided internal jugular line in unchanged
position. There is symmetrical blunting of both costophrenic
sulci. Generalized increased lung markings consistent most with
fluid overload are grossly unchanged.
More confluent abnormalities in the left lung base in particular
are also
unchanged. I note also CT from [**2207-4-28**] suggesting this and
in fact very little fluid overload, so presumptively the changes
represent the ongoing alveolitis-type changes identified on that
radiograph.
.
[**2207-5-1**] CXR
FINDINGS: Bilateral diffuse lung opacities are presisting. On
concurrent
review with prior chest CT dated [**2207-4-28**], these opacities
represent a
combination of ground-glass opacities and consolidation and
bibasilar
fibrosis, unchanged since [**2207-4-28**], but improved since [**4-24**], [**2206**]. All these changes are more on the right side and may
represent continuing
alveolitis. As appreciated on recent chest CT, there was no
component of
pulmonary edema then nor in today's radiograph. Mild widening of
the
mediastinum is from increased mediastinal fat in conjunction
with multiple
lymph nodes as appreciated on the chest CT. There is evidence of
prior median sternotomy and sternal sutures are intact.
Effusions, if any, are small bilaterally and unchanged. There is
no pneumothorax. Heart size is normal.
Hilar contours are unremarkable. Aorta has a mild tortuous
course and
demonstrates mild-to-moderate and severe atherosclerotic
calcification.
Brief Hospital Course:
87M with COPD, CAD, CHF and Afib presenting with cough, dyspnea
and hemoptysis admitted with PNA and pulmonary edema.
# Dyspnea and Sepsis: Patient likely had bacterial pneumonia
that followed a viral URI several weeks ago. On admission, felt
to have pulmonary edema and pneumonia, treated for both with
ceftriaxone/azithromycin and diuresis. After 7L diuresis,
patient had no improvement. On [**4-27**] he was noted to have
increasing respiratory distress and was electively intubated.
Following intubation he became hypotensive and required pressor
support during [**4-27**] and [**4-28**]. Cardiac Catheterization showed
wedge of 14 with V wave of 80. CT Chest revealed ground-glass
opacities consistent with acute-on-chronic organizing pneumonia
or acute interstitial pneumonitis. Was treated with high dose
steroids with apparent initial improvement and was extubated.
His mental status was very altered after extubation requiring
olanazpine with mild effect. He had a respiratory
decompensation after several days of extubation requiring
reintubation. Abx were broadened to vanco/zosyn and he was
started on solumedrol 1gm IV for 3 days for concern for
undertreated COP, as his infectious work-up to date had not been
revealing and his extensive work-up for cardiac causes of his
dyspnea and respiratory failure was negative. As such, given the
lack of an alternative diagnosis and the suspicion that COP may
be the cause of his respiratory failure, aggressive
glucocorticoid treatment was pursued in an effort to give him
every chance to survive his acute illness. After three days of
treatment with pulse-dose Solumedrol, however, there was no
meaningful improvement in his respiratory status and his overall
clinical status was progressively worsening with progressive
acute renal failure, falling platelets, and worsening mental
status (decreasing responsiveness despite holding sedative.) To
objectively assess his pulmonary response to steroids, we
obtained a repeat CT scan after completing three days of pulse
dose steroids which did not show improvement. Given this, and
given overall status of resp failure, renal failure, altered
mental status - several meetings were held with the patient's
son [**Name (NI) **] (the patient's HCP) and decision was made to move to
CMO. Terminally extubated and passed away on [**5-8**] with son at
bedside.
.
# AMS - ICU delirium compounded by high steroid dose. Managed
with olanzapine with mild effect. His mental status deteriorated
to the point that he was essentially non-responsive, including
several absent brinstem reflexed (no corneal reflex, no cough,
no gag, minimal pupillary response) prior to his being
transitioned to CMO care.
.
# Anuric renal failure - Patient was noted to have increasing
Creatinine after reintubation that was concerning for ATN due to
an episode of hypotension and hypoperfusion. His creatinine
continued to rise and he developed anuric renal failure over the
last day of his ICU stay.
.
# Afib w/ RVR: Patient had a HR in the 140s at BIDN and received
10mg IV and 30mg PO diltiazem at [**Hospital1 18**] ED. His HR was controlled
to 100-120 by arrival to the ICU. His home metoprolol was
initially resumed, stopped [**4-27**] given hypotension. Digoxin was
started [**4-27**] for rhythm control.
Medications on Admission:
Aspirin 81 mg daily
Omeprazole 20 mg daily
Saline Nasal spray daily
Warfarin 2.5 mg daily
Lasix 20 mg daily
Metoprolol Succinate 50 mg daily
Pravastatin 80 mg daily
Ropinirole 0.5 mg [**Hospital1 **]
Fluticasone 110 mcg/Actuation 2 Puff [**Hospital1 **]
Fluticsone 50 mcg nasal spray
Prednisone 10 mg daily
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxic respiratory failure
Anuric renal failure
Atrial fibrillation with RVR
Delirium
Discharge Condition:
Patient expired after having been transitioned to CMO after
progressive multiorgan system failure prompted discussion with
his family and HCP.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
Completed by:[**2207-5-10**]
|
[
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"276.0",
"493.20",
"403.90",
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"287.5",
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"515",
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"516.36",
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"V45.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"37.23",
"88.56",
"33.24",
"96.71",
"93.90",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15029, 15038
|
11332, 14631
|
272, 371
|
15168, 15312
|
3627, 3627
|
15377, 15424
|
3042, 3070
|
14989, 15006
|
15059, 15147
|
14657, 14966
|
15336, 15354
|
3110, 3608
|
1647, 2069
|
210, 234
|
399, 1628
|
3643, 11309
|
2091, 2724
|
2740, 3026
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,528
| 187,203
|
22759
|
Discharge summary
|
report
|
Admission Date: [**2137-3-27**] Discharge Date: [**2137-4-22**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Sternal wound infection
Major Surgical or Invasive Procedure:
1. Sternal debridement [**2137-3-28**]
2. Muscle flap closure [**2137-4-2**]
History of Present Illness:
83 yo male well known to the cardiac surgery service, recently
s/p CABG x3 on [**2137-2-26**], who returns with purulent drainage from
his sternal wound. Was treated for COPD exacerbation with
steroids in the post-op period. During routine post-op check
was noted to have frank purulent drainage from the lower pole of
the incision and an open area. Upon further questioning of the
rehab facility where he was staying, it became evident that the
drainage began on [**2137-3-19**] and was treated with PO cipro and
topical neosporin and dressing changes. Admitted for
debridement and closure, and IV antibiotics.
Past Medical History:
Type 2 DM
CHF
s/p hemicolectomy
hypercholesterolemia
PVD (chronic leg ulcers)
glaucoma
newly diagnosed lung cancer
Social History:
Widowed.
Former smoker.
Family History:
non-contributory
Physical Exam:
Afebrile, VSS
Neck: soft, supple
Chest: RRR, bilateral expiratory wheezes; 3 cm open area at
upper pole, purulent drainage from lower pole, unstable sternum
c movement at lower half c respiration
Abd: soft, NT, ND
Ext: venous stasis changes/ulcers
Pertinent Results:
[**2137-4-19**] 05:57AM BLOOD WBC-9.9 RBC-3.49* Hgb-9.8* Hct-29.8*
MCV-85 MCH-28.0 MCHC-32.7 RDW-15.6* Plt Ct-361
[**2137-4-19**] 05:57AM BLOOD Plt Ct-361
[**2137-4-19**] 05:57AM BLOOD Glucose-50* UreaN-21* Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-30* AnGap-9
[**2137-4-19**] 05:57AM BLOOD ALT-10 AST-13 AlkPhos-99 Amylase-105*
TotBili-0.3
[**2137-4-19**] 05:57AM BLOOD Albumin-2.6* Mg-1.7
[**2137-4-18**] 11:32AM BLOOD Vanco-10.1*
Brief Hospital Course:
83 yo male well known to the cardiac surgery service, s/p CABG
x3 on [**2137-2-26**], who returns with purulent drainage from his
sternal wound. Was treated for COPD exacerbation with steroids
in the post-op period. During routine post-op check was noted
to have frank purulent drainage from the lower pole of the
incision and an open area. Upon further questioning of the
rehab facility where he was staying, it became evident that the
drainage began on [**2137-3-19**] and was treated with PO cipro and
topical neosporin and dressing changes. Admitted for
debridement and closure, and IV antibiotics on [**2137-3-27**].
On admission he was placed on IV levo and vancomycin. OR on
[**2137-3-28**] for sternal debridement. For more detailed account,
please see operative note. Post-op he was transferred to the
CSRU where Plastic Surgery evaluated him and placed a VAC
dressing in the open wound. After cultures were finalized, he
was put on oxacillin. He was also found to be CDiff positive on
POD 2 and was place on PO flagyl. OR on [**2137-4-2**] for flap
closure by Plastics. For more detailed account, please see
operative note. Post-op he was transferred to the CSRU. On POD
1, he was noted to have some asymmetric swelling on the left
side of his chest. U/S showed soft tissue swelling and no
hematoma or fluid collection. He was transferred to the
telemetry floor on PODs [**8-21**]. A PICC was placed for onging
vancomycin administration. On PODs [**9-21**], the ceftaz was
discontinued with ongoing abx coverage with vanco only.
He remained an inpatient with his JP drains still in place and
being monitored closely by plastics.
On [**4-8**] (PODs [**11-25**]) he was complaining of penile burning with a
diagnosis of paraphimosis. A urology consult was obtained with
reduction of paraphimosis and complete resolution of pain within
twelve hours.
On [**4-10**], a JP drain was removed with only one remaining.
He remained in patient through [**4-20**] for monitoring of drain by
plastic surgery team. Last JP drain was removed [**4-20**]. Rehab bed
unavailable until [**4-22**] -- plan to discharge to rehab with ongoing
abx.
Medications on Admission:
Lasix
Actos
Glyburide
ASA
Coreg
Lopressor
Lipitor
Lisinopril
Spiriva
Combivent
Advair
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): for 2 weeks after other antibiotics are stopped.
Disp:*90 Tablet(s)* Refills:*2*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Pioglitazone HCl 15 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Vancomycin HCl 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q24H (every 24 hours) for 4 weeks.
Disp:*42 Recon Soln(s)* Refills:*0*
15. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-20**]
Puffs Inhalation Q6H (every 6 hours) as needed.
16. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
17. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
18. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
19. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
20. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
Discharge Disposition:
Extended Care
Facility:
Mount [**Location (un) 33316**]
Discharge Diagnosis:
1. Mediastinitis
2. Diabetes mellitus, type 2
3. Hypertension
4. Hypercholesterolemia
5. Glaucoma
6. COPD
Discharge Condition:
Good
Discharge Instructions:
1. IV antibiotics per PICC line as directed.
2. Resume other medications as directed.
3. Call office or go to ER if fever/chills, drainage from
sternal incision, chest pain.
4. Shower and wash incisions daily. Do not apply any creams,
lotions, powders, or ointments to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **], 2-4 weeks, please call for appointment.
Dr. [**First Name (STitle) **], [**Hospital 3595**] Clinic, 1-2 weeks, please call for
appointment.
PCP/Cardiologist, 1-2 weeks, please call for appointment.
Completed by:[**2137-4-22**]
|
[
"459.81",
"162.5",
"998.59",
"428.0",
"008.45",
"605",
"276.2",
"730.08",
"250.00",
"998.31",
"V45.81",
"519.2",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"86.22",
"77.61",
"99.95",
"99.04",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
6493, 6551
|
1962, 4119
|
292, 371
|
6701, 6707
|
1512, 1939
|
7036, 7298
|
1211, 1229
|
4255, 6470
|
6572, 6680
|
4145, 4232
|
6731, 7013
|
1244, 1493
|
229, 254
|
399, 1016
|
1038, 1154
|
1170, 1195
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,136
| 145,667
|
46887
|
Discharge summary
|
report
|
Admission Date: [**2106-3-10**] Discharge Date: [**2106-3-16**]
Date of Birth: [**2022-10-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2106-3-11**] - Coronary Artery Bypass Grafting to one vessel (Left
internal mammary artery to left anterior descending
artery)/Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] Epic Porcine)
History of Present Illness:
83 year old male with a history of aortic stenosis, now with a
peak gradient of 90 mmHg, a mean of 57 mm Hg, and [**Location (un) 109**] of 0.7cm2
by recent echo. He has been fairly asymptomatic with regards to
his aortic stenosis. His wife recently noted some exertional
dyspnea and bilateral lower extremity. He was referred for a
cardiac catheterization and was found to have LAD disease and
severe aortic stenosis. He is admitted today for heparin bridge,
plan for CABG/AVR in AM.
Past Medical History:
Hypertension
Hyperlipidemia
Aortic Stenosis
Atrial Fibrillation
Chronic Renal Insufficiency (baseline
Diastolic Heart Failure
GERD
Complete heart block s/p pacemaker implant
Cholelithiasis
Colon Polyps s/p resection
Mild COPD s/p recent URI improved with short course of
steriods/advair (2 months ago)
PNA
Hyperkalemia
Anemia
Gout
Osteoarthritis in bilateral knees
HOH does not wear hearing aides
Social History:
Lives with wife; quit smoking >30 years ago, 30pack-yr hx,
occasional EtOH use, used to work in the meat business for Stop
and Shop
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse:60 Resp:18 O2 sat:98/RA
B/P Right:133/52 Left:134/59
Height:5'7" Weight:168 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2106-3-11**] ECHO
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is moderate symmetric left ventricular
hypertrophy. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). The right ventricular cavity is moderately dilated with
mild global free wall hypokinesis. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. There are
simple 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. There is moderate thickening of the mitral
valve chordae. Mild (1+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is no pericardial
effusion.
POST CPB: 1. Preserved [**Hospital1 **]-ventricular systolci function with
background inotropic support. 2. Bioprosthetic valve in aortic
position, Well seated and stable with good leaflet excursion. No
AI and minimal grqadient across the prosthesis. 3. Trace MR [**First Name (Titles) **] [**Last Name (Titles) 69961**]d tricuspid regurgitation
.
[**2106-3-10**] CT Scan: Severe calcification of the aortic valve.
Moderate hiatal hernia. Evidence of prior granulomatous
infection. Renal cyst. Mild emphysema.
[**2106-3-15**] CXR:
FRONTAL AND LATERAL CHEST RADIOGRAPHS: A left-sided pacemaker
generator pack
projects leads into the right atrium and ventricle. The patient
is status
post median sternotomy. Again seen is severe left lower lobe
atelectasis,
slightly worse since [**2106-3-13**]. An adjacent small left
pleural
effusion is also increased in size. The remaining lungs appear
well aerated.
There has been interval removal of a right IJ central venous
catheter. There
is no pneumothorax.
IMPRESSION: Slightly worsened left lower lobe collapse. Slightly
increased
small left pleural effusion.
202/22/12 03:45PM BLOOD WBC-7.5 RBC-3.75* Hgb-12.3* Hct-36.5*
MCV-97 MCH-32.8* MCHC-33.7 RDW-15.8* Plt Ct-171
[**2106-3-15**] 09:10AM BLOOD WBC-6.3 RBC-2.72* Hgb-8.7* Hct-25.7*
MCV-94 MCH-32.1* MCHC-34.0 RDW-16.2* Plt Ct-72*
[**2106-3-10**] 03:45PM BLOOD PT-11.1 PTT-19.5* INR(PT)-1.0
[**2106-3-15**] 09:10AM BLOOD PT-15.6* INR(PT)-1.5*
[**2106-3-10**] 03:45PM BLOOD Glucose-79 UreaN-32* Creat-1.1 Na-140
K-4.9 Cl-103 HCO3-30 AnGap-12
[**2106-3-15**] 04:15AM BLOOD Glucose-92 UreaN-26* Creat-1.4* Na-140
K-3.8 Cl-98 HCO3-33* AnGap-13
[**2106-3-10**] 03:45PM BLOOD ALT-19 AST-24 LD(LDH)-250 AlkPhos-58
Amylase-91 TotBili-0.8
[**2106-3-12**] 02:04AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.7*
[**2106-3-15**] 04:15AM BLOOD Mg-2.5
[**2106-3-15**] 09:10AM BLOOD WBC-6.3 RBC-2.72* Hgb-8.7* Hct-25.7*
MCV-94 MCH-32.1* MCHC-34.0 RDW-16.2* Plt Ct-72*
[**2106-3-15**] 09:10AM BLOOD Plt Ct-72*
[**2106-3-15**] 04:15AM BLOOD Glucose-92 UreaN-26* Creat-1.4* Na-140
K-3.8 Cl-98 HCO3-33* AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 7173**] was admitted to the [**Hospital1 18**] on [**2106-3-10**] for surgical
management of his aortic valve and coronary artery disease.
Heparin was started as he had been off his Coumadin for five
days in anticipation of surgery. A CT scan was performed which
showed severe calcification of the aortic valve a moderate
hiatal hernia, evidence of prior granulomatous infection, a
renal cyst and mild emphysema. On [**2106-3-11**], Mr. [**Known lastname 7173**] was taken
to the operating room where he underwent coronary artery bypass
grafting LIMA to LAD and an aortic valve replacement using a
23mm St. [**Male First Name (un) 923**] Epic Porcine valve. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next several hours, he awoke
neurologically intact and was extubated. EP service consulted on
patient for PPM interrogation. On post-op day one he was started
on beta-blockers and diuretics and was diuresed towards his
pre-op weight. Later on this day he was transferred to the floor
for further care. Chest tubes and epicardial pacing wires were
removed per protocol. Coumadin was started for his atrial
fibrillation and titrated for goal INR of [**2-18**].5. Renal function
bumped slightly to 1.4 and lasix was changed to pre-op dose of
po lasix from IV with good results. Electrolytes repleted as
needed. His CXR showed LLL collapse and he required CPT and
pulmonary toileting with good effect. He continued to make good
progress while working with physical therapy for strength and
mobility. On post-op day #5 he was discharged to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**]
Health Care with the appropriate medications and follow-up
appointments.
Medications on Admission:
ALLOPURINOL 100 mg [**Hospital1 **]
FUROSEMIDE 40 mg alternating with 1/2 tabs, daily - No
Substitution
HYDRALAZINE 25 mg TID
LOPRESSOR 100 mg [**Hospital1 **]
WARFARIN 5 mg Tablet- 1 Tablet by mouth once a day
ZOCOR 10MG Daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation [**Hospital1 **] (2 times a day).
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate for goal INR of [**2-18**].5.
Disp:*30 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis s/p aortic valve replacement
Coronary artery disease s/p coronary artery bypass graft
Past history:
Hypertension
Hyperlipidemia
Atrial Fibrillation
Chronic Renal Insufficiency (baseline
Diastolic Heart Failure
GERD
Complete heart block s/p pacemaker implant
Cholelithiasis
Colon Polyps s/p resection
Mild COPD s/p recent URI improved with short course of
steriods/advair (2 months ago)
PNA
Hyperkalemia
Anemia
Gout
Osteoarthritis in bilateral knees
HOH does not wear hearing aides
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema Right 2+ edema, left leg 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**4-14**] @1:15
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] on [**2106-4-5**] @1:30pm
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw: [**2106-3-16**]
Results to phone fax: PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 4469**] (F) [**Telephone/Fax (1) 99468**]
Completed by:[**2106-3-16**]
|
[
"585.9",
"272.4",
"715.36",
"V58.61",
"530.81",
"424.1",
"518.0",
"427.31",
"428.32",
"496",
"403.90",
"428.0",
"414.01",
"V15.82",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9026, 9056
|
5683, 7462
|
332, 543
|
9596, 9779
|
2427, 3577
|
10667, 11352
|
1642, 1724
|
7740, 9003
|
9077, 9575
|
7488, 7717
|
9803, 10644
|
1739, 2408
|
273, 294
|
571, 1057
|
1079, 1477
|
1493, 1626
|
3587, 5660
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,200
| 148,671
|
48632
|
Discharge summary
|
report
|
Admission Date: [**2113-9-14**] Discharge Date: [**2113-9-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y.o. female with diastolic CHF, COPD, restrictive lung
disease ([**3-2**] to scoliosis), OSA on home O2 at night (1-1.5L)
presented to the ED with four days of dyspnea on exertion over a
few days prior to admission with accompanying ankle swelling. Pt
attributes this acute change to consuming a large amount of
salty foods while spending time with family visiting from out of
town. She denies any weight change, fever/chills, cough, wheeze,
sputum, or hemoptysis, no recent colds or URI symotoms. In the
ED, her initial ABG was 7.33/75/61. She was briefly tried on
BiPAP but eventually refused it. She got Furosemide 40mg IV,
Methylprednisolone, Ceftriaxone, and Azithromycin. Given the
abnormal ABG, she was admitted to the ICU for treatment of CHF
and obstructive lung disease.
While in the ICU, she was diuresed overnight and the following
day with a total of 700/930 from midnight of the day of
admission until approximately 3:30 when she was assessed by the
general medicine team. During this time, she received a total of
100 mg IV of Lasix, 15 mg of Zaroxolyn and 2mg of Bumetanide.
She was transferred to the floor on 4L NC at 87-90% O2
saturation which is her baseline.
Past Medical History:
1. Restrictive lung dz [**3-2**] scoliosis
2. Chronic hypercapnea pCO2 in 50s-100s
3. COPD
4. Diastolic dysfunction EF>55%
5. PAF
6. OSA: intolerant of BiPAP in past, uses nocturnal O2 2L NC
7. HTN
8. spinal stenosis
9. Grave's disease: s/p ablation, now on Synthroid
10. TAH [**3-2**] fibroids
11. PFO
12. Hx of lacunar infarct
13. L eye CVA: residual visual field defect, [**2101**], on coumadin
14. L cataract surgery
[**22**]. Right breast CA s/p radiation on [**2084**]
Social History:
Widow, 2 kids, lives w/ daughter, +tob 100 pk yr
Family History:
+ca, cva, 3 siblings.
Physical Exam:
Vitals: T: 98.4, BP: 112/42, P: 66, R: 16-30, O2: 87-90% on 4L,
I/O 700/930 since MN
HEENT: NC/AT, PERRLA, EOMI, nares clear, OP nonerythematous
Neck: Supple, no lymphadenopathy
CV: S1, S2 nl, II/VI systolic murmur at RUSB
Lungs: crackles b/l, mid-way up lungs and expiratory wheezing,
no WOB
Abd: Soft, NT, ND, + BS
Ext: no clubbing, cyanosis, 1+ pitting edema b/l
Neuro: grossly intact
Pertinent Results:
[**2113-9-14**] 03:23PM PT-44.0* PTT-37.8* INR(PT)-5.0*
[**2113-9-14**] 03:23PM PLT COUNT-162
[**2113-9-14**] 03:23PM NEUTS-72.4* LYMPHS-23.6 MONOS-3.6 EOS-0.2
BASOS-0.2
[**2113-9-14**] 03:23PM WBC-8.0 RBC-4.32 HGB-11.7* HCT-37.2 MCV-86
MCH-27.1 MCHC-31.5 RDW-15.7*
[**2113-9-14**] 03:23PM TSH-1.1
[**2113-9-14**] 03:23PM CALCIUM-9.0 PHOSPHATE-2.8 MAGNESIUM-2.2
[**2113-9-14**] 03:23PM CK-MB-2 cTropnT-0.01
[**2113-9-14**] 03:23PM GLUCOSE-113* UREA N-39* CREAT-1.2* SODIUM-143
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-36* ANION GAP-12
[**2113-9-14**] 03:25PM TYPE-ART O2 FLOW-2 PO2-61* PCO2-75* PH-7.33*
TOTAL CO2-41* BASE XS-9
[**2113-9-14**] 03:51PM freeCa-1.17
[**2113-9-14**] 03:51PM GLUCOSE-107* LACTATE-1.6 NA+-144 K+-4.5
CL--99* TCO2-37*
[**2113-9-14**] 03:51PM TYPE-ART PH-7.30*
[**2113-9-14**] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2113-9-14**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
Brief Hospital Course:
[**Age over 90 **] y.o. female with HTN, Diastolic CHF, PAF, COPD, OSA and
restrictive lung disease here with increasing dyspnea on
exertion and peripheral edema x 4 days, transferred from the
MICU on [**9-15**] for continued treatment of CHF exacerbation. The
following issues were investigated during her hospitalization:
.
#Dyspnea on exertion/CHF: Likely due to a CHF decompensation on
top of baseline poor pulmonary function. Pt has a history of
diastolic dysfunction with reported dietary non-compliance
shortly before hospitalization, increasing peripheral edema and
rales, and evidence of pulm edema on CXR. No obvious ischemia on
EKG. She was aggressively diuresed with Zaroxolyn and Lasix. Her
outpatient regimen of Bumex was also used. A repeat CXR showed
resolution of the pleural effusion and no worsening of CHF.
However, she developed azotemia as a result of the aggressive
diuresis and for the remainder of her hospital stay, the goal
was even volume balance maintained with frequent, gentle fluid
boluses and prn diuresis. She was gradually started back on her
outpatient dose of Bumex by discharge.
# C. difficile: Pt. was found to be C. diff. positive on [**9-21**] at
which time she was started on Flagyl and placed on precautions.
Plan for 14 day course.
.
#Obstructive Lung Disease - The cause of the patient's
presenting symptoms was not felt to be a COPD exacerbation. She
was maintained on albuterol and spiriva inhalers and O2, with an
O2 saturation titrated to <92% given her history of C)2
retention and hypercarbic respiratory failure.
.
#Renal insufficiency - Initially the renal insufficiency was
thought to be due to the CHF exacerbation and with inital
diuresis, the patient's creatinine improved. However, with
additional diuresis, both BUN and creatinine rapidly increased.
Once patient's O2 requirement decreased and her pulmonary exam
improved with diuresis, her diuretics were held and frequent,
small boluses of NS were given to improve kidney function.
Kidney function was improved and stable on discharged.
.
#HTN - Patient was maintained on outpatient regimen of
Nifedipine and Diltiazem.
.
#Anticoagulation - Pt. has a history of PAF and retinal artery
thrombosis for which she was anticoagulated with Coumadin. Upon
admission, she was supratherapeutic with an INR of 5.3. Her
Coumadin was held and restarted once she'd become therapeutic.
.
# Anemia - Pt. had a 5 point Hct drop on transfer from ICU,
which was then found to return to baseline. With the multiple
fluid shifts during this hospitalization, her Hct fluctuated.
She was guiaic negative with no other sources of bleeding.
.
#Hypothyroidism - Pt's TSH was 1.1. She was maintained on her
outpatient regimen of Levoythyroxine
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
4. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day) as needed.
Disp:*qs * Refills:*0*
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: One (1) Spray
Nasal [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
10. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
Disp:*qs * Refills:*2*
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Congestive Heart Failure Exacerbation
Discharge Condition:
Stable
Discharge Instructions:
1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
2. Please take all of your medications as directed.
3. Please keep all of your follow-up appointments
4. Call your doctor or go to the ER for any of the following:
shortness of breath, leg swelling, chest pain, fevers, chills or
any other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2113-11-27**] 10:30
Please call to schedule an appointment with Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 10012**] next week.
|
[
"585.9",
"327.23",
"428.33",
"427.31",
"401.9",
"244.1",
"428.0",
"V10.3",
"491.21",
"008.45",
"737.30"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7828, 7907
|
3601, 6332
|
281, 288
|
7989, 7998
|
2547, 3578
|
8411, 8676
|
2100, 2123
|
6355, 7805
|
7928, 7968
|
8022, 8388
|
2138, 2528
|
222, 243
|
316, 1518
|
1540, 2017
|
2033, 2084
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,630
| 135,169
|
22962
|
Discharge summary
|
report
|
Admission Date: [**2129-2-18**] Discharge Date: [**2129-2-20**]
Date of Birth: [**2066-11-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
BRPBR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62yo Russian cardiologist who presented with bright red blood
per rectum since 7pm the day prior to admission. She is admitted
to the ICU for monitoring and preparation for colonoscopy. She
has 4 more episodes BRBPR. She describes clots with bright red
blood. Patient claims that she estimated blood loss of 2 L. She
was hemodynamically stable in the ED and had been given 1U of
PRBC and 2L NS She denies melena/hemetemesis/CP/SOB/dizziness.
She had colonoscopy [**2-10**] with removal of 2 polyps and had not
been bleeding until the day before.
Of note, she was recently discovered to have elevated
transminases on routine exam. Further workup revelas negative
Hep B&C + AMA, - [**Doctor First Name **] +RF. She had an MRI which showed
hemangioma. Liver biopsy confirms primary biliary cirrhosis. She
is foollowed by Dr.[**Last Name (STitle) 59294**].
Past Medical History:
1. appendectomy
2. primary biliary cirrhosis
3. atypical liver hmangioma
4. s/p rectal polypectomy at 32yo
5. rheumatoid arthritis
Social History:
She currently is single. She does not smoke. She does not
drink alcohol. She has no drug allergies.
Family History:
colon cancer
Physical Exam:
Gen-NAD, pleasant
HEENT-anicteric, oral mucosa moist, neck supple
CV-RRR, no r/m/g
resp-CTAB
[**Last Name (un) 103**]-+BS, soft, NT/ND, no HSM
neuro-A+O x3, PERL, EOMI, moves all 4 limbs, CNII-XII intact
skin-no rash
extremities-DP 2+ bilaterally, no pitting edema
Pertinent Results:
[**2129-2-18**] 05:55AM WBC-8.7 RBC-3.65* HGB-11.1* HCT-33.3* MCV-91
MCH-30.3 MCHC-33.2 RDW-13.1
[**2129-2-18**] 05:55AM PLT COUNT-180
[**2129-2-18**] 04:29AM HGB-9.8* calcHCT-29
[**2129-2-18**] 12:57AM PT-12.8 PTT-27.4 INR(PT)-1.0
[**2129-2-17**] 11:05PM GLUCOSE-93 UREA N-16 CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-30* ANION GAP-10
[**2129-2-17**] 11:05PM ALT(SGPT)-122* AST(SGOT)-89* LD(LDH)-184 ALK
PHOS-543* AMYLASE-96 TOT BILI-0.5
[**2129-2-17**] 11:05PM LIPASE-36
[**2129-2-17**] 11:05PM WBC-11.3*# RBC-4.22 HGB-12.8 HCT-37.6 MCV-89
MCH-30.4 MCHC-34.1 RDW-13.2
[**2129-2-17**] 11:05PM NEUTS-54.0 LYMPHS-40.8 MONOS-2.9 EOS-1.8
BASOS-0.5
[**2129-2-17**] 11:05PM PLT COUNT-218
U/S [**2-14**]:hemangioma
polypectomy [**2-14**]: adenoma
liver bx [**2-15**]:
Liver, core biopsy:
1. Moderate portal mixed cell inflammation, predominantly
composed of lymphocytes with scattered plasma cells and
neutrophils, with extension into lobules (interface hepatitis).
2. Focal bile duct damage and mononuclear cell infiltrate.
3. Occasional necrotic hepatocytes.
4. No granulomas seen.
5. Trichrome stain: Mild increase in portal fibrosis with
focal bridging.
6. Iron stain: Focal iron deposition in Kupffer cells.Note:
Possible etiologies include primary biliary cirrhosis, and
drug-induced liver injury. Clinical correlation is suggested.
Discharge labs:
[**2129-2-20**] 06:15AM BLOOD WBC-6.9 RBC-3.70* Hgb-11.1* Hct-31.9*
MCV-86 MCH-29.9 MCHC-34.7 RDW-13.2 Plt Ct-190
[**2129-2-20**] 06:15AM BLOOD Plt Ct-190
[**2129-2-20**] 06:15AM BLOOD Glucose-105 UreaN-12 Creat-0.7 Na-140
K-4.0 Cl-107 HCO3-25 AnGap-12
[**2129-2-20**] 06:15AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
Brief Hospital Course:
1. BRBPR - 62 year old previously healthy female with recent
diagnosis of primary biliary cirrhosis presented with BRBPR s/p
polypectomy. Her bleeding was felt to be due to the polypectomy
8 days ago, she was hemodynamically stable, platelets and coag
were normal. On admission two large bore IVs were placed. She
was transferred to the ICU for observation. She was transfused
with a total of 1 unit PRBCs and fluid. Serial HCTs showed
appropriate correction with no further bleeding. Her gastric
lavage was negative, she was prepped for colonoscopy however her
HCT was stable so the colonoscopy was never performed. On
hospital day #2 she was stable and transferred to the floor.
She tolerated regular diet. On hospital day 3 she had no
further bleeding for over 60 hours and was discharged home. She
was advised to avoid aspirin and NSAIDS for two weeks.
2. liver - On admission the patient was not aware of diagnosis
of PBC. She will need to follow up with GI as scheduled to
initiate treatment of PBC. She also had an atypical liver
hemangioma, which will require follow up U/S in 6 months.
Medications on Admission:
no home meds
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed post polypectomy
Secondary diagnosis
PBC
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with any lightheadedness, bleeding, or
other concerning symptoms.
Do not take any aspirin or NSAIDS for two more weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2129-2-21**] 4:30
|
[
"578.9",
"998.11",
"285.1",
"E878.8",
"276.8",
"714.0",
"571.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4748, 4754
|
3547, 4656
|
322, 328
|
4854, 4860
|
1814, 3196
|
5051, 5247
|
1500, 1514
|
4719, 4725
|
4775, 4833
|
4682, 4696
|
4884, 5028
|
3212, 3524
|
1529, 1795
|
277, 284
|
356, 1211
|
1233, 1366
|
1382, 1484
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,480
| 179,751
|
26826+57513
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-2-10**] Discharge Date: [**2192-2-28**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
status post fall
Major Surgical or Invasive Procedure:
IVC venogram, selective venography of bilateral renal veins, IVC
filter placement.
Percutaneous endoscopic gastrostomy tube placement.
History of Present Illness:
This is an 84 year old male transfer for outside hospital after
fall down [**9-27**] stairs at home (arround 4pm) and complaining of
"can not move my arms". He was transfer to the [**Hospital1 18**] and
evaluated by the Trauma Team. Steroids started in
outside hospital. [**Name (NI) 8817**] [**Known lastname **] (wife): [**Telephone/Fax (1) 66028**].
Past Medical History:
HTN
DVT
Physical Exam:
HR 83, BP 143/61, RR 16, Sat Os 98%.
GEN: Awake, alert, oriented x2. GCS 15.
HEENT: PERRLA, EOMI. Cervical collar in place.
Midline c-spine tenderness on palpation.
Proximal upper extremety motor function: biceps [**4-20**], distal [**1-22**]
(dificult evaluation, bilateral hand trauma). Lower extremety
motor function intact, no sign of deficit. Good rectal tone per
Trauma team notes.
Pertinent Results:
[**2192-2-10**] 07:57PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2192-2-10**] 07:57PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.045*
[**2192-2-10**] 07:57PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2192-2-10**] 07:57PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2192-2-10**] 07:30PM UREA N-52* CREAT-1.4*
[**2192-2-10**] 07:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-2-10**] 07:30PM PLT COUNT-168
[**2192-2-10**] 07:30PM PT-31.5* PTT-28.7 INR(PT)-3.4*
[**2192-2-10**] 07:30PM FIBRINOGE-344
C-SPINE CT [**2192-2-10**]:
1. Traumatic grade II anterolisthesis of C6 on C7 with right
inferior C6 facet fracture and locking of the C6-7 facets. The
left C6-7 facets are perched. There is likely moderate-to-severe
cord compression and associated epidural hematoma.
2. Prominent posterior soft tissue stranding and numerous
osseous fragments are observed posterior to the spinous
processes. These findings are worrisome for associated
ligamentous injury.
HEAD CT: There is residual IV contrast(given in OSH) in the
dural venous sinuses. A hazy area of increased attenuation is
observed in the medial right frontal lobe. There is no
hydrocephalus, shift of normally midline structures or major
vascular territorial infarction. [**Doctor Last Name **]-white differentiation is
preserved. Osseous structures are unremarkable. A small
subgaleal hematoma is noted over the posterior vertex.
MRI of C-SPINE:[**2192-2-11**]
Subluxation of C6 over C7 with appearances suggestive of a
flexion injury and disruption of the posterior longitudinal,
interspinous and anterior longitudinal ligaments and anterior
subluxation of C6 over C7. Moderate spinal canal stenosis and
indentation on the spinal cord at this level with a small
posterior epidural hematoma measuring approximately 1 cm. The
right facet joint is dislocated and locked and the left facet
joint is perched as described on the CT. No increased signal
seen within the spinal cord. Degenerative changes at other
levels.
BILAT LOWER EXTREMITY DOPPLER STUDY;[**2192-2-13**]
Evidence of chronic prior DVT on right leg. No acute DVT.
ECHO; [**2192-2-13**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
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. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
MR CERVICAL SPINE; MR THORACIC SPINE;LUMBAR SPINE [**2192-2-18**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with s/p cervical fusion, decreased lower
extremity movement
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the cervical and thoracic spine were acquired.
Comparison was made with the previous MRI examination of
[**2192-2-11**].
FINDINGS: Since the previous study, the patient has undergone
spinal fixation for correction of previously seen fracture
subluxation at C6-7 level. Laminectomy is seen from C3-4 to C6-7
level with pedicle screws from C5 to T1 level. There is
increased signal seen within the disc at C6-7 level indicating
previous trauma at this level. There is no intraspinal fluid
collection identified. There is no subdural hematoma or spinal
cord compression seen in the cervical region.
From skull base to C6 level, no increased signal seen within the
spinal cord. However, at C6-7 and inferiorly to T2 level, there
is increased signal seen within the central portion of the
spinal cord which could be secondary to cord edema or ischemic
changes within the cord.
In the thoracic region, multilevel degenerative changes are
seen. No evidence of abnormal signal seen within the thoracic
cord below T2 level. There is no evidence of intraspinal
hematoma seen.
IMPRESSION: Since the previous MRI study, the patient has
undergone fusion for previously noted subluxation at C6-7 level.
Increased signal is seen within the spinal cord from C6-7 to T2
level indicative of cord edema or ischemia within the cord.
Followup examination is suggested. Degenerative changes are seen
at multiple levels in the cervical and thoracic region. No
evidence of intraspinal fluid collection or extrinsic spinal
cord compression is seen. Multilevel degenerative changes.
Mild-to-moderate spinal stenosis at L4-5 level secondary to disc
bulging, central protrusion and facet degenerative changes.
Fluid within the facet joint at L4-5 level indicating increased
mobility.
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2192-2-10**] after sustaining a
fall down [**9-27**] stairs at home. At that time, chest and pelvis
X-rays were negative fro fractures, although he did have a tiny
right upper lobe nodule that should be followed up in one year.
Hand X-rays were negative for fracture. A CT of his C-spine
revealed a traumatic grade II anterolisthesis of C6 on C7 with a
right inferior C6 facet fracture and locking of the C6-7 facets.
The left C6-7 facets are perched. In addition, there was
evidence of moderate-to-severe cord compression and associated
epidural hematoma. There were also prominent posterior soft
tissue stranding and numerous osseous fragments posterior to the
spinous processes, which worrisome for associated ligamentous
injury. A CT of his head demonstrated a hazy area of increased
attenuation along the medial right frontal lobe, which was
unclear whether it was secondary to previously administered IV
contrast or a small amount of subarachnoid blood. An left
radial arterial line and a left subclavian central line were
placed and he was transferred from the ED to the ICU. He was
given Solumederol and Dilantin and kept NPO for surgery. Since
he had been on coumadin for a previous DVT (INR 1.6), he had to
be corrected with 2 units of FFP and vitamin K. On HD 2, a
repeat head CT showed a small focus of hyperdensity along the
medial border of the right frontal lobe concerning for an
intraparenchymal hemorrhage, as well as a small (4mm width)
subdural fluid collection concerning for a small subdural
effusion. An MRI of his spine showed a subluxation of C6 over C7
with appearances suggestive of a flexion injury and disruption
of the posterior longitudinal, interspinous and anterior
longitudinal ligaments and anterior subluxation of C6 over C7.
There was also evidence of moderate spinal canal stenosis and
indentation on the spinal cord at this level with a small
posterior epidural hematoma measuring approximately 1 cm. In
addition, the right facet joint is dislocated and locked and the
left facet joint is perched as described on the pervious CT. On
exam, he had [**3-21**] biceps strength, [**2-19**] quadriceps, [**12-22**] grip and
[**1-22**] DF/PF. He was taken to the OR where he had a posterior
cervical laminectomy with fusion of C4-C7 and evacuation of an
epidural hematoma by Dr. [**Last Name (STitle) 14354**] [**Name (STitle) **]. The operation went
well with no complications (please see operative note for
details), however he did require an emergent tracheostomy for a
difficult intubation by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**]. He did lose about 1
liter of blood during the operatuion and required 2500 ml of
crystalloid, 4 units of FFP, 5 units of RBCs, 1 unit of
platelets and 2 units of cryoprecipitate. Intraoperative X-rays
demonstrated posterior spinal rods and pedicle screws within the
C5, C6, and C7 vertebral bodies.
A postoperative chest X-ray demonstrated findings consistent
with CHF and fluid overload. He was maintained on lung
protective ventillation (high PEEP, high frequency, low tital
volume). His post op Hct was 33 and his INR was 1.3. His
pupils were minimally reactive. He had no gag or corneal
reflex. Due to his poor exam, he was given 25 g of mannitol.
He was transferred back to the ICU intubated and sedated. He
recieved perioperative empiric gentamycin vancomycin. He was
also on dilantin for seizure prophylaxis. He was to be in a
hard C-collar at all times. He required a levophed drip for
blood pressure control (goal SBP 130-140). He was acidotic to a
pH of 7.25, which improved throughout the [**Known lastname **] to 7.34. His
lactate was 8.9 initially, then peaked at 13.8 and then dropped
to 9.6. He also had an elevated troponin to 0.29, then 0.37,
which was though to be due to renal failure (createnine 1.9 from
1.4), although his EKG was significant for ST depressions in
V3-V6, II and AVF. On POD 1, he was started on mannitol 25 g Q
6 hours for 48 hours. A CT of his abdomen and pelvis was done
because of his acidosis and showed extensive consolidation of
both lower lung zones, with airspace opacities in the right
middle lobe, suggestive of aspiration or aspiration pneumonia,
small bilateral pleural effusions, diverticulosis without
diverticulitis, and small atrophic kidneys. A CT of his C-spine
showed a nondisplaced fracture, probably from hyperextension, of
anterior inferior portion of T2 vertebral body; this may involve
a tiny portion of the middle column, and therefore may be an
unstable fracture. It also showed slight retrolisthesis of C6
on C7 and slight anterolisthesis of C7 on T1, much improved
since last exam (both now grade 1). A CT of his head showed no
significant change. Cardiology was consulted due to his elevated
troponins and they recommended aspirin (when stable), B-blockers
to keep the HR at 60, and an echocardiogram. On POD 2, his
lactate was donw to 3.6. Levophed was weaned off. Tube feeds
were started via an NG tube (impact with fiber, goal 85 cc/h).
PT and PT saw and evaluated him. A repeat head CT showed
interval enlargement of bilateral frontal subdural hygromas,
which were not present on the initial CT of [**2192-2-10**]. It also
showed a persistent filiform hyperdensity at the medial aspect
of the right frontal lobe, unchanged since the prior study
(diagnostic possibilities include subarachnoid hemorrhage versus
vascular calcification). Lower extremity ultrasounds revealed
no evidence of acute DVT. An echocardiogram (EF > 55%) was
unremarkable. On POD 3, he was no longer acidotic (pH 7.42).
His INR 1.3, his createnine was 1.8, and his lactate was 1.3.
He had good biceps and shoulder shrug, but no triceps or grip
strength. An IVC filter was placed by Dr. [**Last Name (STitle) **] (due to
his past DVT and current contraindications to anticoagulation).
A chest X-ray demonstrated worsening CHF. On POD 4, his
createnine was down to 1.6. His WBC climbed from 12.4 to 15.9
and he had a temperature of 100, so he was started on Vancomycin
and Levaquin for pneumonia. He was able to tolerate a trach mask
and was weaned off of the ventillator. On POD 5, his createnine
was down to 1.3. His WBC was down to 12.7. His INR was down to
1.1. A swallow evaluation was done, which he failed due to
discoordinated swallow. On POD 6, his createnine was 1.1 and
his WBC was 10. A PEG tube was placed by Dr. [**Last Name (STitle) **] (please
see operative note for details). The operation went well with
no complications. On POD 7, he was still weak in both his upper
and lower extremities. A repeat spinal MRI was done- there was
no evidence of intraspinal fluid collection or extrinsic spinal
cord compression, with mild-to-moderate spinal stenosis at L4-5
level secondary to disc bulging and increased signal within the
spinal cord from C6-7 to T2 level indicative of cord edema or
ischemia within the cord. Tube feeds were restarted but held
overnight due to increased residuals. On POD 8, a SOMI brace
was ordered because we assumed that his T2 fracture seen on MRI
was unstablesince he was having some lower extremity weakness.
A medicine consult was called due to his generalized edema and
dyspnea. They recommended diuresis with lasix to a goal of 500
to 1000 ml negative for the [**Known lastname **] and we were able to accomplish
this. Caution was given not to over-diurese since he has a
propensity to go into atrial fibrillation. Free water was added
to his tube feeds due to hypernatremia. Troponins were re-drawn
and found to be 0.23. On POD 9, vancomycin was discontinued. We
doubted that he had a new cardiac event since his previous
elevations. On POD 10, dilantin was discontinued. Staples were
removed. His SOMI brace was determined to stay for 3 months. A
Passy-muir valve was unable to be placed due to the brace. He
required some suctioning for thick yellow secretions. Sputum
cultures were sent. On POD 11, nystatin swisha dn swallow was
started for oral thrush. On POD 12, levaquin was discontinued
as he completed his course for pneumonia. His sputum grew MRSA,
but medicine recommended witholding treatment unless there were
signs of infection. Lasix was held since he was euvolemic. On
POD 12, his chest X-ray showed decreased CHF.
On [**2192-2-24**] his somi brace changed over the [**Location (un) **] brace to
allow to use passimuir valve which works well. Trache cuff MUST
BE DEFLATED while using passimuir valve.
On [**2192-2-26**] patient had a emesis about 1000ml, hemaoccult was
positive, however occult blood in stool was negative on rectral
exam. Gastroentorology recommendation are to keep him NPO, check
serial Hct, repeat LFT's. His hct; has been hanging around 27.1
to 26.7(last one [**2-28**]). His tube feeds restarted slowly
(@10ml/hr to goal of 85 ml/hr)on [**2-28**], no more emesis noted
since the event, and LFT's has been slowly trending down.
Speech therapy reseen him on [**2-28**], he was able to keep passimuir
valve about an hour and did well, however ST thinks that he not
ready to eat yet.
Physical therapy and occupational therapy felt that he would
need acute rehab placement, see attached note for the
recommendation for rehab.
Patient discharged with follow up and discharge instructions.
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-19**]
Puffs Inhalation Q6H (every 6 hours) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a [**Known lastname **]).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a [**Known lastname **]).
5. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
[**Known lastname **]).
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a [**Known lastname **]) as needed for thrush.
13. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO TID (3 times a [**Known lastname **]) for 3 [**Known lastname **].
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a [**Known lastname **]).
15. Morphine 2 mg/mL Syringe Sig: [**12-19**] Injection Q4H (every 4
hours) as needed for breakthrough pain.
16. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q8H (every
8 hours) as needed.
17. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
18. Cefazolin 1 g Piggyback Sig: One (1) Intravenous every
eight (8) hours for 7 [**Known lastname **]: Last dose [**2192-3-2**].
19. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a [**Known lastname **]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
C6 on C7 atherolithesis, C6 facet fracture, locking of C6 and C7
facets, spinal cord epidural hematoma, unstable T2 fracture,
frontal intraparenchymal hemorrhage, small left subdural
hemorrhage, intraoperative blood loss anemia, decompensated
diastolic heart failure, non-ST-elevation MI, paroxysmal atrial
fibrillation, hypernatremia, ventillator associated pneumonia,
DVT s/p IVC filter, acute on chronic renal failure
Discharge Condition:
fair
Discharge Instructions:
Please continue current medications as directed. Please call or
come to the ED with any severe shortness of breath, headached,
chest pain, nausea, vomiting, or weakness in his arma or legs.
Please suction his trach as needed for his secretions.
Please contiune his tube feeds at goal.
Please give pain medication for shoulder and neck pains.
CAN BE OFF [**Location (un) **] BRACE WHILE IN BED. HE MUST WEAR HIS BRACE
WHEN OUT OF BED.
Keep IN THE C-COLLOR WHILE IN BED
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2731**]) in 6 weeks with
C-spine CT prior to follow up.
Your [**Location (un) **] brace will need to be removed in 3 months in Dr [**Name (NI) 14232**] office call for an appointment.
Completed by:[**2192-2-28**] Name: [**Known lastname **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Unit No: [**Numeric Identifier 11551**]
Admission Date: [**2192-2-10**] Discharge Date: [**2192-2-28**]
Date of Birth: [**2107-5-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 599**]
Addendum:
Please discard the information on the discharge summary stating
unstable T2 fracture; it is misread, it should be Nondisplaced
T2 fracture anterior inferior portion of the T2, likely stable.
To allow adequate healing he should stay bed or OOB with [**Location (un) 11552**]
brace.
Regarding Head CT read bilateral subdural hygroma is stable as
long as he is asymptomatic. If he becomes symptomatic(mental
status changes, increased headache, weakness, visual changes or
any other neurologica changes). Repeat head CT prior to follow
up with Dr [**Last Name (STitle) **] as sceheduled, if becomes asyptomatic would
get CT earlier.
Thanks
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11553**] [**Doctor Last Name 11554**], MS, ACNP
[**Numeric Identifier 11555**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] - [**Location (un) 95**] - [**Location (un) 4534**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2192-3-5**]
|
[
"482.41",
"707.8",
"112.0",
"518.5",
"427.31",
"428.31",
"410.71",
"V12.51",
"806.22",
"285.1",
"853.01",
"578.0",
"806.07",
"E880.9",
"276.2",
"507.0",
"V58.61",
"401.9",
"276.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.53",
"81.62",
"00.17",
"88.65",
"38.7",
"31.1",
"88.51",
"99.07",
"43.11",
"96.6",
"81.03",
"96.72",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
20184, 20419
|
6223, 15557
|
284, 422
|
18140, 18147
|
1260, 2412
|
18664, 20161
|
15580, 17552
|
4287, 6200
|
17696, 18119
|
18171, 18641
|
851, 1241
|
227, 246
|
450, 805
|
2421, 4250
|
827, 836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,947
| 110,386
|
16130
|
Discharge summary
|
report
|
Admission Date: [**2169-8-25**] Discharge Date: [**2169-9-6**]
Date of Birth: [**2095-1-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
left hip fracture noted at [**Hospital1 **] s/p mechanical fall
Major Surgical or Invasive Procedure:
Left Hemiarthroplasty
History of Present Illness:
74 yo female with who presented to [**Hospital1 **] s/p fall, found to
have left subcapital fracture by CT of hip, transferred to [**Hospital1 18**]
for further management.
She initally was in an MVA last year when it was noted that she
had a AAA on CXR. She then had an elective Thoracoabdominal
aortic aneurysm resection/repair with hospital course c/b
post-op respiratory failure, recurrent Afib, multiple
bronchs, L sided lung collapse, trach on [**2169-1-26**] after failed
extubation of [**2169-1-23**]. Trach was removed at Rehab, however she
was readmitted in [**2-11**] with slight hyperfunction of false vocal
cords, bilateral vocal cord immobility with ~1mm glottic gap
requiring trach placement on [**2169-3-7**].
Pt was walking with her walker when she tripped on the carpet
and fell onto her left L hip hitting her head at home. Denies
LOC, HA, neck pain, CP, SOB, weakness, LH. Assisted to bed, able
to bear wt for 2 steps. Pain localized to medial thigh with
movement of LLE. Was brought to [**Hospital1 **], initially XRay
unrevealing, CT though showed fx of L hip. Ortho evaluated in
ED, plan to perform ORIF during this admit after risk
stratified; NWB on L, no traction indicated, anticoagulate.
Given extensive comorbidities, she was admitted to Medicine for
periop management.
Past Medical History:
1. Thoracic and abdominal aortic aneurysm, repair [**1-14**], c/b resp
failure and trach.
2. Bilateral vocal cord paralysis, s/p repeat trach [**3-14**].
3. Clostridium difficile positivity.
4. VRE positivity.
5. Postoperative atrial fibrillation requiring cardioversion.
6. Hypertension.
7. Type 2 diabetes.
8. Osteoarthritis.
9. Lower back pain.
10. Hypercholesterolemia.
11. Left Breast Cancer - s/p lumpectomy
12. Atrial fibrillation - this was first noted post op from the
AAA repair. She was started on a BB and amio at that time then
DCCV. She has not been on coumadin.
.
PAST SURGICAL HISTORY:
-Thoracic/abdominal aortic aneurysm repair, [**2169-1-10**].
Social History:
Retired RN, she was living at home at the time of the hip
fracture. Her husband and daughter involved in her care. No
tob, etoh, other drugs. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] Globe reporter has been
following her [**Last Name (un) 26796**] in [**Hospital1 18**] s/p her hip fracture
Family History:
DM, ? type - in mother
Physical Exam:
Vitals: T 98.4 HR 64 BP 130/61 RR 24 Sat 92% on mist O2
Gen: elderly caucasian woman with trach mask in place, breathing
comfortably, A+Ox3, NAD
HEENT: NCAT, no bruising or ecchymosis, PERRL, EOMI, MMM, OP
clear
Neck: supple, trach in place, no LAD
CV: RRR nl s1 s2 no m/g/r
Lungs: CTA b/l
Abd: soft, nt, nd, +bs
Ext: L medial thigh pain with external rotation
Neuro: no sensory deficit in affected limb
EKG: sinus, nl rate, nl axis, nl intervals, LAE, Q III, aVF;
flat T's throughout limb leads and V4-V6, TWI in V1-V3, no sig
change since prior EKG [**2169-3-7**]
Pertinent Results:
Admission labs:
GLUCOSE-132* UREA N-14 CREAT-0.9 SODIUM-139 POTASSIUM-3.6
CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
WBC-9.9 RBC-4.31 HGB-12.1 HCT-36.6 MCV-85 MCH-28.0 MCHC-32.9
RDW-16.5*
NEUTS-84.0* LYMPHS-11.9* MONOS-3.5 EOS-0.2 BASOS-0.4
ANISOCYT-1+ MICROCYT-1+
PLT COUNT-179
PT-14.7* PTT-25.5 INR(PT)-1.5
CXR [**8-25**]:
Cardiomegaly unchanged. The aorta is very tortuous and dilated
as seen previously. There are postoperative changes in the left
hemithorax with rib fractures/ressections, which is unchanged
when compared to prior study. There is again noted a left
retrocardiac opacity silhouetting the left hemidiaphragm, which
is improved when compared to the prior study likely representing
atelectasis or scarring. The right lung is grossly clear. The
patient is status post tracheostomy. Tracheostomy tube appears
to be in appropriate position. In the left upper quadrant, there
are metallic wires and surgical clips. There is mild S-shaped
scoliosis of the thoracolumbar spine with some mild dextroconvex
thoracic component and levoconvex lumbar component. No evidence
of pneumothorax. There is mild upper zone redistribution of the
pulmonary vascularity, which could represent mild CHF. There are
degenerative changes of the sternoclavicular joints bilaterally.
HIP UNILAT MIN 2 VIEWS LEFT [**8-25**]:
Unusual small lucency involving the medial cortex of the left
proximal femur without clear fracture line identified.
Knee film [**8-27**]:
The alignment appears normal. There are some mild degenerative
changes. No fracture is identified.
Echo [**8-28**]:
Normal regional with low normal left ventricular systolic
function. Dilated ascending aorta. Mild-moderate pulmonary
artery systolic hypertension. Compared with the prior study
(tape reviewed) of [**2169-1-12**], the ascending aorta is minimally more
dilated. Global left ventricular systolic function is similar.
Micro: [**8-31**] sputum grew PSEUDOMONAS AERUGINOSA and ESCHERICHIA
COLI, both pan-sensitive.
VRE and MRSA screens were negative here. Has had a h/o of this
in the past.
Discharge labs:
[**2169-9-5**] 05:32AM BLOOD WBC-9.3 RBC-3.82* Hgb-10.5* Hct-33.2*
MCV-87 MCH-27.5 MCHC-31.7 RDW-15.4 Plt Ct-260
[**2169-9-4**] 05:52AM BLOOD PT-14.6* PTT-26.3 INR(PT)-1.4
[**2169-9-5**] 05:32AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-137
K-4.0 Cl-102 HCO3-27 AnGap-12
[**2169-8-25**] 07:00PM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
74 yo F s/p fall, found to have left subcapital hip fracture by
CT, admitted to medical service for risk stratification prior to
ORIF. She then had resp failure following ORIF requiring MICU
stay for diuresis and suctioning. She was transferred to the
floor and has been recovering well.
#) Left Hip Fx. She was kept non weight bearing until Left
hemiarthroplasty on [**8-29**]. She has multiple cardiac risk factors
making her intermediate risk and could achieve at least 4 mets
prior to recent surgery. She had a normal perfusion on a
Persantine MIBI preop in [**1-14**] at [**Hospital 620**] Hosp. A pre-op echo was
preformed on [**8-28**] revealing normal regional wall motion with low
normal left ventricular systolic function and mild-moderate
pulmonary artery systolic hypertension. When compared with the
prior study of [**2169-1-12**], the ascending aorta is minimally more
dilated with similar global left ventricular systolic function.
She received aggressive pulmonary toilet (chest PT, incentive
spirometry, encourage coughing) prior to surgery to maximize her
lung function. Her pain was well controlled with acetaminophen
1000mg q6h and oxycodone 5mg Q4H PRN prior to surgery. The
cemented left unipolar hip hemiarthroplasty was done on [**8-29**]
without complications. She was transfused 2 units of blood for
post-op anemia. She received Lovenox SC BID for prophylaxis.
She should remain on this until she has adequate activity. On
discharge her wound was without evidence of infection and had
some serous drainage.
#) Post-op Hypoxemia - After the hip surgery, she was
persistently and progressively hypoxemic and was requiring
increasing suctioning. She was transferred to the MICU on [**8-30**].
Her MICU course was significant for low grade temps and
increased sputum production. She was started on empiric Zosyn
and Vanco for hospital-acquired PNA. Her O2 sats gradually
improved and she made less secretions. In rehab, she will
continue to need suctioning and incentive spirometry as well as
to continue Zosyn/Vanc for a total of 7 days, ending on [**9-9**].
Her sputum culture grew pseudomonas (pansensitive), e.coli
(pansensitive), and staph aureus (MRSA).
.
#) Pain management: She hallucinations with the IV Dilaudid
given to her for her post-op pain. Therefore, her post op pain
was controlled with Tylenol 1 gm q6 hrs and oxycodone 5 mg po
prn. She also has chronic abdominal pain from her AAA surgery
since [**Month (only) 956**]. The pain service was consulted who recommended
starting neurontin 600 mg qhs. This should be titrated as
tolerated. Neurontin is for chronic pain from thoracoabdominal
aneurysm repair. At discharge, the Neurontin was controlling her
pain somewhat.
.
#) CAD (no known CAD though multiple cardiac risk factors
including age, DM, HTN). She had a normal stress test at [**Location (un) 620**]
prior to aneurysm repair.
She was continued on ASA 81mg qd, Simvastatin 10mg daily, and
Metoprolol.
.
#) Mild dystolic disfunction. She was on lasix QOD prior to
admission. This was not restarted at present, but if she
continues to require large amounts of TM O2, then consider
restarting.
.
#) AFIB: h/o postoperative atrial fibrillation requiring
cardioversion in [**1-14**]. She was in NSR and well rate controlled
with Amiodarone 400 daily and Metoprolol. She will f/u with Dr.
[**Last Name (STitle) **] as an outpatient about this. She will likely need
coumadin once she is no longer on Lovenox.
.
#) Trach care: She takes Guaifenesin prn, Atrovent neb prn, and
needs aggressive pulm toilet. Scheduled outpt pulm f/u. She also
needs ENT f/u (?h/o laryngeal dysfunction)
.
#) Type 2 diabetes: She was on Avandia 4mg daily prior to the
surgery. However, she has bot been requiring insulin here on a
RISS. She also has not been eating much. She may need to start
the Avandia again in the future as she eats more.
#) GERD: She is on Protonix 40 daily.
#) Insomnia: We continued her on outpatient dose of Ativan 0.5mg
qhs:prn
#) Depression: Celexa 40mg qd. Her mood was hopeful on
discharge.
Medications on Admission:
-APAP prn
-Protonix 40 daily
-Avandia 4mg daily
-Amiodarone 400 daily
-Aspirin 81 daily
-Simva 10 daily
-Bisoprolol 5mg daily
-Senna prn
-Colace qd
-Celexa 40mg qd
-Citracal 2 tabs [**Hospital1 **]
-KCl 20 mEq qd
-Gaifenesin prn
-Vicodin prn
-Lasix 20mg qod
-Ativan 0.5mg qhs:prn
-Atrovent neb prn
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous every twelve (12) hours for 7 days: Last dose is on
[**9-9**].
2. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 7 days: Last dose is
[**9-9**].
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours).
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
7. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): Continue this until that patient is ambulatory or
at least one month. Check weekly Cr and adjust the dose if
necessary.
8. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for sbp < 110, hr < 55 .
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): Max 4gm per day.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Give before washing or PT.
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for sbp < 110 .
16. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR
Injection ASDIR (AS DIRECTED).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
21. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
23. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day:
Hold if NPO.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Left Hip Fracture
Hypoxic respiratory failure
pneumonia
Secondary Diagnoses:
S/P Thoracoabdominal aortic aneurysm repair
Diabetes
Hypertension
Tracheostomy
Discharge Condition:
Good, O2 sat is 99% on 35% trach mask. All other vitals are
normal.
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience chest pain, shortness of breath,
worsening pain, or have any other concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] (PCP), [**Telephone/Fax (1) 8477**] in [**3-15**]
weeks.
Please follow-up the [**Hospital **] Clinic regarding your history of vocal
cord paralysis. ([**Telephone/Fax (1) 6213**]
Please follow-up in the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic. ([**Telephone/Fax (1) 46112**] in
[**3-15**] weeks.
You have the following appointments scheduled:
1. Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] (pulmonary) Where: [**Hospital 273**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-9-25**]
3:45
2. You have an appointment with Dr. [**Last Name (STitle) **] (cardiologist) on
[**10-11**] at 11:00AM at the [**Location (un) 620**] office. Call [**Telephone/Fax (1) 4105**] if you
are unable to make this.
3. You have an appointment with Dr. [**Last Name (STitle) **] (orthopedics) on [**10-12**]
at 2:20PM on the [**Location (un) **] of the [**Hospital Ward Name 23**] Center at [**Hospital1 771**]. Call [**Telephone/Fax (1) 9118**] if you are unable to
make this.
|
[
"285.1",
"428.33",
"733.00",
"997.3",
"530.81",
"V44.0",
"250.00",
"482.1",
"V10.3",
"E888.9",
"518.0",
"401.9",
"272.0",
"428.0",
"518.81",
"427.31",
"820.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12605, 12676
|
5836, 9889
|
377, 401
|
12896, 12966
|
3403, 3403
|
13175, 14314
|
2768, 2792
|
10237, 12582
|
12697, 12697
|
9915, 10214
|
12990, 13152
|
5481, 5813
|
2357, 2419
|
2807, 3384
|
12794, 12875
|
274, 339
|
429, 1733
|
3420, 5465
|
12716, 12773
|
1755, 2334
|
2435, 2752
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,866
| 175,398
|
48699
|
Discharge summary
|
report
|
Admission Date: [**2135-4-2**] Discharge Date: [**2135-4-7**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 50M with ESRD secondary to amyloidosis, on HD as well
as multiple other medical problems presenting with CP and
hypotension. He began having chest pain this evening while at
rest: SSCP, nonradiating, +SOB, +nausea, lasted 30-60 minutes,
resolved spontaneously. No history of similar pain in the past.
He also has had a nonproductive cough recently, but denies F/C.
.
EMS was called by his rehab facility because of this chest pain.
EMS reported that K was 7.9 today, initially though to be
post-HD (now seems more likely to have been pre-HD). He was
reportedly hypotensive in transit. On arrival, BP 80/55 -->
53/44. Multiple attempts were made to place a central line.
Although RIJ and L femoral arteries were easily cannulated, they
were unable to advance the wire. In the meantime, BP increased
to 90s SBP.
.
Labs revealed K 3.4 and elevated WBC. A PIV was eventually
placed for access. A 250cc bolus of NS was given. He was also
given aspirin, morphine, and a dose of cefepime and levofloxacin
(given the cough and elevated WBC, and ?infiltrate on CXR).
.
In addition, he was noted while in the ED to have tachycardia,
at times sinus tach and at times afib with RVR, rates as high as
160s. Given the hypotension, intermittent tachycardia, and
difficulty with access, he was admitted to the MICU.
.
On arrival to the MICU, he is CP free and VS are stable. He
complains of a frontal HA and of being thirsty. Otherwise ROS is
negative.
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-5**] now on HD- R
groin line
IVC stent
Sarcoidosis
Pulmonary aspergillosis
DM (diet controlled)
Chronic HCV
Hypertension
Sinusitis,
Paroxysmal atrial fibrillation,
C. difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity DVT ([**2132**])
Pancreatitis
Bilateral BKA
Right index and fifth finger amputations
Social History:
Smoked 1 ppd X 30 years but quit one year ago. No alcohol.
Previous drug use (IVDU). Girlfriend is involved in his care.
Family History:
Mother, brother with diabetes.
Physical Exam:
PE: On transfer to floor
VS: 97.4, HR: 80s-90s, 100s-120s/60s-70s, 18, 96% on RA.
Gen: Tired-appearing, NAD. Answering all questions
appropriately.
HEENT: PERRL, aniceric, MM slightly dry.
Neck: Supple, no LAD.
Lungs: Few bibasilar crackles R>L. No wheezes.
Heart: RRR, II/VI systolic murmur throughout, loudest at LLSB.
Abd: +BS. Soft, NT/ND.
Extrem: s/p b/l BKA. No edema. R femoral HD catheter, C/D/I, no
drainage, redness, or fluctuance.
Pertinent Results:
[**2135-4-2**] 09:10AM GLUCOSE-57* UREA N-36* CREAT-5.9* SODIUM-142
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-25 ANION GAP-22*
[**2135-4-2**] 09:10AM ALT(SGPT)-17 AST(SGOT)-24 LD(LDH)-229
CK(CPK)-28* ALK PHOS-152* TOT BILI-0.3
[**2135-4-2**] 09:10AM CK-MB-NotDone cTropnT-0.27*
[**2135-4-2**] 09:10AM ALBUMIN-3.7 CALCIUM-11.2* PHOSPHATE-7.6*
MAGNESIUM-2.1
[**2135-4-2**] 09:10AM WBC-12.8* RBC-3.38* HGB-9.8* HCT-31.6* MCV-94
MCH-29.1 MCHC-31.2 RDW-14.8
[**2135-4-2**] 09:10AM PLT COUNT-289
[**2135-4-2**] 06:36AM GLUCOSE-105 UREA N-34* CREAT-5.8* SODIUM-142
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-23*
[**2135-4-2**] 06:36AM CK(CPK)-33*
[**2135-4-2**] 06:36AM CK-MB-NotDone cTropnT-0.25*
[**2135-4-2**] 06:36AM CALCIUM-11.2* PHOSPHATE-7.7*# MAGNESIUM-2.2
[**2135-4-1**] 08:34PM GLUCOSE-343* LACTATE-2.2* NA+-139 K+-3.4*
CL--93* TCO2-28
[**2135-4-1**] 08:30PM UREA N-25* CREAT-4.8*
[**2135-4-1**] 08:30PM estGFR-Using this
[**2135-4-1**] 08:30PM CK(CPK)-17*
[**2135-4-1**] 08:30PM CK-MB-NotDone cTropnT-0.18*
[**2135-4-1**] 08:30PM WBC-12.9* RBC-3.34* HGB-9.9* HCT-31.7* MCV-95
MCH-29.6 MCHC-31.2 RDW-14.9
[**2135-4-1**] 08:30PM NEUTS-77.2* LYMPHS-14.7* MONOS-6.8 EOS-1.2
BASOS-0.2
[**2135-4-1**] 08:30PM PT-14.7* INR(PT)-1.3*
[**2135-4-1**] 08:30PM PLT COUNT-307
.
CXR:HISTORY: 50-year-old man with history of endocarditis,
osteomyelitis, diabetes mellitus, hypertension, end-stage liver
disease and pulmonary aspergillosis with mycetoma by CT. New
having hemoptysis. Please evaluate for interval change.
FINDINGS: The lungs are low in volume. In the lung apices, there
is pleural thickening chronic in nature. On today's examination,
there is a lucency in the right upper lung with a very thin
borders. There is no pleural effusion, however, there is
extensive linear pleural calcification. The heart is not
enlarged. In the hilar and mediastinal areas, are multiple
calcified lymph nodes.
There is a central line approach through the IVC terminating in
the SVC.
The visualized portions of the abdomen demonstrates heavily
calcified kidneys.
IMPRESSION:
1) Over a period of two days, there is abnormal lucency that is
seen only on the frontal radiograph in the right upper lobe with
a thin wall. This could either be an overlying superimposed
shadows vs. a true cavity in keeping with the patient's history
of mycetomas.
2) Pleural calcification likely secondary to asbestos-related
disease.
3) End-stage renal disease characterized by heavy calcification.
Multiple calcified lymph nodes that in general could be
sarcoidosis, occupational lung disease or a sequelae of
granulomatous disease.
.
CT CHEST W/O CONTRAST [**2135-4-3**] 7:40 PM
CT CHEST W/O CONTRAST
Reason: ? PNA
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with increasing WBC, concern for infiltrate on
CXR in context of multiple pulmonary problems (fungal infection,
sarcoid, pleural plaques).
REASON FOR THIS EXAMINATION:
? PNA
CONTRAINDICATIONS for IV CONTRAST: None.
CHEST CT, [**4-3**]
HISTORY: Increasing white count. Rule out pneumonia. Fungal
infections, sarcoid and pleural plaques in the history.
TECHNIQUE: Multidetector helical scanning of the chest was
performed without intravenous contrast [**Doctor Last Name 360**] reconstructed as
contiguous 5 and 1.25 mm thick axial and 5 mm thick coronal
images, compared to chest CT scanning, [**2134-10-12**] and
[**2135-1-14**].
FINDINGS:
Extremely heavy calcification in large mediastinal and hilar
nodes, and thickened pleura and pericardium, is all unchanged
since at least [**Month (only) **]. There is no appreciable pleural or
pericardial effusion and no indication of cardiac tamponade. In
the absence of intravenous contrast [**Doctor Last Name 360**] one can also
appreciate extensive mural calcification in the central
pulmonary arteries feature suggesting renal failure and possible
elevation of pulmonary artery pressure.
A large region of consolidation that has been present in the
left lung apex since [**10-13**] continues to decrease in
overall volume, probably clearing pneumonia in a region of
scarring and chronic atelectasis, but at the upper margin of it
there is now the suggestion of a 17 x 8 mm elliptical opacity in
cavity either a mycetoma or an inflammatory phlegmon in the
region of invasive aspergillosis. Right apical atelectasis or
conglomerate fibrosis is more severe. Previous peribronchial
infiltration in the right upper lobe, involving primarily the
axillary subsegments has improved. There are no new areas of
likely pulmonary infection.
IMPRESSION:
1. Interval development of mycetoma in a shrinking area of left
upper lobe consolidation, suggesting either mycetoma or
maturation of invasive aspergillosis.
2. Renal failure, probably explains particularly heavy
dystrophic calcification and granulomatous mediastinal lymph
nodes, pericardium, and bilateral pleural surfaces. No pleural
effusion and no evidence of cardiac tamponade.
3. Previous right upper lobe pneumonia or aspiration, largely
cleared.
Brief Hospital Course:
# Hypotension: Patient had hypotension per report upon
presentation but appeared to improve after small volume
hydration. [**Month (only) 116**] have been artifact secondary to difficulty of
obtaining blood pressure on patient versus hypotension secondary
to excessive volume removal at hemodialysis.
.
# Chest Pain: The patient had chest pain and cough. He was
ruled out for a myocardial infarction with negative enzymes x 3.
There were no changes on his EKG. He had cough and elevated
white count and was treated briefly with ceftriaxone that was
stopped once his CT came back as negative for infiltrate. His
chest pain resolved.
.
# Epistaxis: The patient had an episode of spontaneous
epistaxis that resolved. His hematocrit, platelets, and INR
were normal during the episode.
# Hemoptysis: The patient had hemoptysis x 3 of 5-10cc of dark
red sputum over the course of 48 hours. This occurred after his
epistaxis and may be related to inhaled blood versus his known
aspergillosis. He was evaluated by pulmonary who recommends
outpatient bronchoscopy. A CT showed essentially stable
aspergillosis.
.
# Atrial fibrillation with RVR: The patient has known atrial
fibrillation and had rapid ventricular response. This responded
well to beta blocker therapy.
.
# End-Stage Renal Disease on Hemodialysis: Patient continued
T/H/S hemodialysis while in house.
.
# Hyperkalemia: Patient had hyperkalemia upon admission that
responded to Kayexalate and hemodialysis therapy.
.
# DM: Patient was kept on a regular insulin sliding scale while
in house with appropriate glucose control
.
# Pulmonary aspergillosis: Patient is maintained on
voriconazole.
.
# MRSA/endocarditis/osteomyelitis: The patient was transistioned
from his vancomycin therapy to Bactrim therapy after discussion
with his primary care and ID physicians.
.
# Adrenal insufficiency: Patient continued on home low-dose
steroids.
Medications on Admission:
Megestrol 40 mg/mL Suspension 20 ml PO DAILY
Prednisone 5 mg QAM
Prednisone 2.5 mg QPM
Cinacalcet 60 mg DAILY
Sevelamer HCl 800 mg TID W/MEALS
Ascorbic Acid 500 mg DAILY
Folic Acid 1 mg DAILY
Voriconazole 100 mg Q12H
Sodium Chloride Nasal Spray QID
Metoprolol Tartrate 12.5 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **] as needed.
RISS
Vancomycin 1,000 mg at dialysis.
Vitamin B Complex once a day.
Trimethoprim-Sulfamethoxazole 160-800 mg 1 Tablet PO QHD as
needed for suppress MRSA infection: Give after HD T/Th/Sat each
week.
Pantoprazole 40 mg Q24H
Imodium prn
flagyl 250 tid (schedule to finish on [**2135-03-31**])
kayexelate 15g Sun, Mon, Wed, Fri
tylenol prn
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. B Complex Vitamins Capsule Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
9. Megestrol 40 mg/mL Suspension Sig: One (1) 10ml PO twice a
day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four
(4) Tablet PO QHD (each hemodialysis).
16. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED).
17. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Primary:
Hypotension attributed to hypovolemia
Epistaxis
Hemoptysis
Atrial fibrillation with rapid ventricular response
.
Secondary:
End stage renal disease on hemodialysis
Pulmonary aspergillosis
MRSA endocarditis
adrenal insufficiency
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with low blood pressure, high
potassium, and a fast heart rate from your atrial fibrillation.
All of these symptoms resolved during your stay.
Please continue to take your medications as prescribed. You
have follow-up appointments scheduled with a pulmonologist (lung
doctor) and your infectious disease Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**].
If you develop fevers, start coughing up blood, have a nosebleed
that does not stop or any other concerning symptoms please
contact a physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2135-4-25**] 7:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2135-4-25**] 8:00
[**2135-5-2**] 11:00a ID,[**Doctor Last Name **],[**Doctor Last Name **] LM [**Hospital Unit Name **], BASEMENT ID
WEST (SB)
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2135-4-7**]
|
[
"V49.62",
"041.11",
"135",
"070.54",
"427.31",
"V15.82",
"784.7",
"458.21",
"786.3",
"403.91",
"V49.75",
"786.50",
"250.00",
"277.39",
"276.7",
"117.3",
"585.6",
"255.41",
"E879.1",
"424.90",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11967, 12043
|
7918, 9821
|
289, 295
|
12324, 12333
|
2860, 5589
|
12972, 13550
|
2350, 2382
|
10543, 11944
|
5626, 5781
|
12064, 12303
|
9847, 10520
|
12357, 12949
|
2397, 2841
|
238, 251
|
5810, 7895
|
323, 1773
|
1795, 2195
|
2211, 2334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,425
| 137,253
|
25059
|
Discharge summary
|
report
|
Admission Date: [**2145-4-9**] Discharge Date: [**2145-4-29**]
Date of Birth: [**2083-3-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest/Neck Pain, Hypokalemia, Ventricular Tachycardia
Major Surgical or Invasive Procedure:
Cardiac catheterization
Substrate ablation for VT
Endotracheal Intubation
History of Present Illness:
Mr. [**Known lastname 62883**] is a 62 yo man with h/o CAD, DM, Bipolar d/o, COPD,
ETOH cirrhosis, transferred from [**Hospital3 **] today for
further management of ventricular tachycardia. Last night, he
developed left-sided chest and neck pain which is was his
anginal equivalent when he had IMI in [**2138**]. He denies SOB,
exertional dyspnea, PND. He has had increased abdominal
swelling since stopping his lasix > 1 month ago but reports no
LE edema.
.
He called 911 and was brought to [**Hospital3 7569**] where he was
found to be in VT with SBPs initially in 80s. He was shocked x
2 and his rhythm transitioned to afib with RVR with SBPs in 70s,
after which he was shocked again, returning to NSR with no acute
ST changes on EKG. Only when given etomidate and sedation prior
to shocks did he lose consciousness. He was initiated on
amiodarone, nitro, and heparin drips. He later reverted to
another extended run of ventricular tachycardia which appears to
have resolved spontaneously. Of note, his potassium at [**Location (un) **]
was initially 2.6, which was treated prior to arrival in ED
here.
In ED, here, repeat K 4.0, glucose 482. SBPs stable and pt.
noted to be in NSR on EKG and transferred to CCU for possible
cath.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools (though he has h/o portal gastropathy and
GI bleed per previous OSH notes). He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain.
.
He does report polyuria, polydipsia X 3-6 months, constipation,
increased stress and anxiety in the last few weeks with
increased nicotine and caffeine intake. No nausea, diarrhea,
emesis.
.
Cardiac review of systems is notable for chest pain as above,
absence of dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
CAD, s/p STE IMI with RCA stenting [**3-13**] and BMS x 3 to PDA in
[**3-/2143**]
Hyperlipidemia
Hypertension
Diabetes
Asthma
Bipolar disorder
History of alcohol abuse, none since [**2142-12-13**]
Cirrhosis with hepatoma, sclerosed in [**2144**]. + portal
gastropathy
COPD
GERD
Hx of subdural hematoma after being mugged (approximately 10
years ago)
? Iron deficiency anemia
? Prior GIB history per records from CCC (patient denies)
s/p double hernia repair
.
Cardiac Risk Factors: + Diabetes, + Hypertension, +
hyperlipidemia, + smoking
.
Cardiac History:
Percutaneous coronary intervention, in [**2138**] and [**2143**] anatomy as
follows:
posterior LV branch stent at [**Hospital1 2025**] in [**2138**]. Consequently, the
inferoposterior wall of his heart is severely hypokinetic and
his ejection fraction remains at 40%. He was evaluated with
cardiac catherization [**2143-4-9**] which demonstarted 90% R-PDA
lesion that was stented with a bare metal stent. The 80% lesion
in the posterior LV branch could not be treated as balloons
would not deliver into that vessel.
Social History:
Patient is divorced and lives alone. He worked as a concession
manager in the carnival business but due to medical issues has
not worked since last Spring. Patient has smoked up to 2-3 packs
a day for approximately 35-40 years. He is currently smoking one
pack a day.
His parents are deceased. He has a biological son who is
currently in prision in PA. He did not have this son with his
ex-wife.
Family History:
unknown
Physical Exam:
VS: T 98.0, BP 127/79, HR 74, RR 16 , O2 96% on RA
Gen: disheveled, middle-aged male in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. anxious.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVD
CV: Distant HS, RRR, nl s1s2, no MRGs. S3.
Chest: No chest wall deformities, scoliosis or kyphosis. No
crackles, coarse with wheezes bilaterally throughout, increased
E/I ratio. No dullness to percussion
Abd: soft, moderately distended. non tender [**Last Name (un) **] no fluid wave.
Liver tip to 2 cm. below costal margin, spleen tip also palpable
No abdominial bruits. + BS throughout
Ext: No c/c/e. No femoral bruits.
Skin: e/o of previous stasis dermatitis, no edema
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
Initial rhythm strip in EMS shows monomorphic wide-complex VT at
219, L BBB pattern. Seems to originate from low anteroseptal
area.
It appears, that he develops monomorphic VT in RBBB after
initial shock on rhythm strip. Shocked again, and appears to
irregular narrow complex tachycardia, likely afib with RVR.
Eventually, transitions back to monomorphic VT. 12-lead from
that shows RBBB pattern c/w origin from inferolateral focus.
.
EKG here shows NSR at 76 with IVCD (old), nl QT, Qs in inferior
leads c/w old inferior MI, also old
EKG demonstrated *** with no significant change compared with
prior dated ***.
.
Echo [**3-20**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe hypo/akinesis of the inferior and inferolateral walls.
The apical segments are not well seen (?LVEF = 40 %). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated at the sinus level. The aortic
valve leaflets 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. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2143-10-9**],
the findings are similar.
.
.
Cardiac Cath 3/[**2145**]. COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed two vessel coronary artery disease. The LMCA had no
angiographically apparent coronary artery disease. The LAD had
a 30%
mid vessel lesion and a 30% D2 lesion. The LCX had no
angiographically
apparent flow-limiting disease. The RCA had patent stents with
a 80%
distal lesion prior to the posterolateral branch and a 30% PDA
lesion.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 20 mm Hg and LVEDP of 34 mm Hg. There
was
moderate to severe pulmonary arterial hypertension of 49/21 mm
Hg.
There was normal systemic arterial hypertension of 124/57 mm Hg.
There
was no transvalvular gradient upon pullback of the catheter from
LV to
aorta. Cardiac index was preserved at 3.9 l/min/m2.
3. Left ventriculography revealed inferior akinesis with
moderate to
severe anterior hypokinesis and an LVEF of 30%. There was trace
mitral
regurgitation.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe left ventricular systolic and diastolic dysfunction.
3. Moderate to severe pulmonary arterial hypertension.
.
Echo [**2145-4-12**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe hypo/akinesis of the inferior and inferolateral walls.
The apical segments are not well seen (?LVEF = 40 %). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated at the sinus level. The aortic
valve leaflets 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. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2143-10-9**],
the findings are similar
.
CT PELVIS W/CONTRAST [**2145-4-12**] 3:31 AM
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST
Reason: ? PE
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with acute cardiopulmonary collapse, acidosis, ?
PE
REASON FOR THIS EXAMINATION:
? PE
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: 62-year-old man with acute cardiopulmonary
collapse, acidosis. Evaluate for pulmonary embolus.
COMPARISON: [**2144-11-13**].
TECHNIQUE: Non-contrast MDCT acquired axial images of the chest
followed by contrast-enhanced axial images of the chest, abdomen
and pelvis from the thoracic inlet to the pubic symphysis.
Multiplanar reformatted images were obtained.
CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The lungs
show no consolidation, mass or suspicious nodules. Note is made
of small bilateral pleural effusions and mild dependent
atelectasis. The heart is enlarged and shows heavy coronary
artery calcification as well as some calcification of the aortic
root. There is probably a stent within the right coronary
artery.
No filling defect is identified within the pulmonary arteries.
The thoracic aorta maintains a normal caliber and contour. Small
lymph nodes are seen within the mediastinum largest of which
measures 11 mm in the AP window.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Liver demonstrates
a shrunken, nodular architecture consistent with cirrhosis.
Again seen is post-RF ablation changes within segment VII,
unchanged. Focal area of low attenuation adjacent to the fissure
for the ligamentum teres (series 3B image 129) is unchanged.
The gallbladder, spleen, and adrenal glands are within normal
limits. The kidneys enhance and excrete contrast symmetrically.
Small hypodensities are seen within both kidneys, incompletely
characterized. The pancreas demonstrates atrophy and
calcification suggestive of chronic pancreatitis.
The intra-abdominal loops of large and small bowel maintain a
normal caliber. Two small rounded foci are seen within the
second and third portion of the duodenum measuring fat
attenuation which may represent lipoma.
The aorta branch vessels demonstrate heavy calcification. The
origin of the celiac is narrowed with possible retrograde
filling distally. Again note is made of mild focal aneurysmal
dilatation of the infrarenal aorta, unchanged. The SMA and [**Female First Name (un) 899**]
are patent. Multiple splenic varices with possible splenorenal
shunt are again identified. No free fluid, free air or
lymphadenopathy is appreciated. Note is made of subcutaneous
stranding involving the right lower anterior abdominal wall
(series 3B, image 170).
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid
colon are within normal limits. The bladder contains air, which
is likely related to the Foley catheter. The prostate is
enlarged and measures 5.5 x 4.1 cm. No lymphadenopathy is
appreciated.
The appendix is mildly dilated, measuring up to 7mm, with
adjacent fluid and stranding, which in the correct clinical
setting may represent appendicitis. Tip of right femoral
intravenous catheter terminates within the right iliac vein.
BONE WINDOWS: Multiple old healed rib fractures are identified.
No suspicious lytic or sclerotic lesion is identified. Prominent
Schmorl's node is identified within the superior endplate of the
L3 vertebral body.
IMPRESSION:
1. No pulmonary embolus. Small bilateral pleural effusions and
adjacent atelectasis.
2. Cardiomegaly, diffuse coronary artery and aortic
calcification. Stable mild aneurysmal dilatation of the
infrarenal aorta. Narrowing at the origin of the celiac artery
with possible retrograde filling distally. The SMA and [**Female First Name (un) 899**] are
patent.
3. Cirrhosis. Stable post-RF ablation changes seen within
segment VII of the liver. Splenic varices.
4. Non-specific, mildly dilated fluid-filled appendix with
surrounding inflammatory stranding within the right lower
quadrant. Follow-up CT can be performed if clinically warranted.
.
CT HEAD W/O CONTRAST [**2145-4-23**] 8:54 AM
CT HEAD W/O CONTRAST
Reason: bleed?
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with new right sided weakness for past 3-4 days
s/p VTach and intubation.
REASON FOR THIS EXAMINATION:
bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: New right-sided weakness.
TECHNIQUE: Routine non-contrast head CT.
FINDINGS: There is no evidence of hemorrhage, mass effect, shift
of normally midline structures, hydrocephalus, or infarction.
The density values of the brain parenchyma are within normal
limits and the [**Doctor Last Name 352**]-white matter differentiation is preserved.
The surrounding osseous and soft tissue structures are
unremarkable. The imaged paranasal sinuses show a right
maxillary mucous retention cyst.
IMPRESSION: No evidence of hemorrhage, mass effect, or evidence
of infarction.
.
MR CERVICAL SPINE W/O CONTRAST [**2145-4-25**] 11:36 AM
MR CERVICAL SPINE W/O CONTRAST
Reason: Please evaluate for cervical spine disc disease
[**Hospital 93**] MEDICAL CONDITION:
62 year old man a/w VT, coag negative bacteremia
REASON FOR THIS EXAMINATION:
Please evaluate for cervical spine disc disease
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: MRI OF THE CERVICAL SPINE.
CLINICAL INDICATION: 62-year-old man, please evaluate for
cervical spine disc disease.
COMPARISON: None.
TECHNIQUE: Sagittal T1, T2 and STIR images were obtained, axial
T1- and gradient-echo sequences were also performed.
FINDINGS: The visualized aspect of the craniocervical spine
demonstrates a prominent cisterna magna.
The signal intensity in the bone marrow of the cervical
vertebral bodies is slightly heterogeneous, likely consistent
with bone marrow replacement for fat and multilevel degenerative
disc disease.
At C2/C3, there is evidence of bilateral uncinate process
hypertrophy, producing bilateral neural foraminal narrowing, no
frank evidence of nerve root compression is observed.
At C3/C4, there is evidence of left uncinate process hypertrophy
as well as prominence of the articular joint facet, producing
left side neural foraminal narrowing and possible nerve root
compression, please correlate clinically.
At C4/C5, there is evidence of the posterior complex osteophytic
disc protrusion, producing anterior thecal sac deformity and
moderate-to-severe spinal canal stenosis, at this level, the
anterior-posterior diameter of the spinal canal is approximately
6 mm. Bilateral neural foraminal narrowing is detected at this
level with possible nerve root compression.
At C5/C6, there is also evidence of posterior osteophytic disc
bulge complex producing anterior thecal sac deformity and
moderate spinal canal stenosis, bilateral neural foraminal
narrowing is also detected at this level and mild hypertrophy of
the articular joint facets. This is a limited examination
secondary to motion artifact, however, there is no evidence of
abnormal signal within the spinal cord. The visualized aspects
of the vascular and paravertebral structures appear grossly
normal.
IMPRESSION: Multilevel degenerative disc disease of the cervical
spine as described in detail above, more evident at C4/C5 and
C5/C6. This is a limited examination secondary to motion
artifacts.
.
Cytology Report PLEURAL FLUID Procedure Date of [**2145-4-22**]
REPORT APPROVED DATE: [**2145-4-27**]
SPECIMEN RECEIVED: [**2145-4-23**] 08-[**Numeric Identifier **] PLEURAL FLUID
SPECIMEN DESCRIPTION: 50 ml. bloody fluid, 2 slides.
CLINICAL DATA: 62 yo m with alcoholic cirrhosis. large pleural
effusion
-- frankly bloody.
PREVIOUS BIOPSIES:
[**2143-5-16**] 06-[**Numeric Identifier 18526**] LIVER
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS.
.
Micro:
Pleural fluid gram stain and culture negative.
.
BCx [**4-11**]: coag negative staph
other BCx negative x 8
.
Sputum Cx negative x 4
.
UCx [**2145-4-11**]: pan-sensitive enterobacter AEROGENES, subsequent
UCx on [**2145-4-18**] negative
.
Catheter tip culture negative [**2145-4-13**]
.
Labs:
[**2145-4-9**] 10:30AM PT-11.2 PTT-33.4 INR(PT)-0.9
[**2145-4-9**] 10:30AM WBC-5.6 RBC-4.11* HGB-13.7* HCT-39.3* MCV-96
MCH-33.5* MCHC-35.0 RDW-13.3
[**2145-4-9**] 10:30AM NEUTS-77.9* LYMPHS-16.4* MONOS-4.3 EOS-1.1
BASOS-0.3
[**2145-4-9**] 10:30AM GLUCOSE-482* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
[**2145-4-9**] 10:30AM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2145-4-9**] 10:30AM CK(CPK)-68
[**2145-4-9**] 10:30AM cTropnT-<0.01
[**2145-4-9**] 10:30AM CK-MB-NotDone
[**2145-4-9**] 04:50PM CK-MB-NotDone cTropnT-0.02*
[**2145-4-9**] 06:07PM CK-MB-NotDone cTropnT-0.02*
[**2145-4-9**] 04:50PM ALT(SGPT)-19 AST(SGOT)-20 CK(CPK)-63 ALK
PHOS-65 TOT BILI-0.6
[**2145-4-9**] 04:50PM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-4.6*
MAGNESIUM-1.9
[**2145-4-9**] 04:50PM GLUCOSE-340* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2145-4-9**] 06:07PM TRIGLYCER-88 HDL CHOL-30 CHOL/HDL-4.7
LDL(CALC)-93
[**2145-4-9**] 06:07PM ALT(SGPT)-19 AST(SGOT)-19 CK(CPK)-62 ALK
PHOS-68 TOT BILI-0.6
[**2145-4-9**] 06:07PM GLUCOSE-162* UREA N-12 CREAT-0.8 SODIUM-143
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-27 ANION GAP-11
[**2145-4-9**] 08:35PM URINE HOURS-RANDOM POTASSIUM-81
[**2145-4-9**] 08:35PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.026
[**2145-4-9**] 08:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
[**2145-4-9**] 08:35PM URINE RBC->50 WBC-[**6-22**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2145-4-9**] 11:40PM POTASSIUM-3.8
[**2145-4-9**] 11:40PM MAGNESIUM-2.4
Brief Hospital Course:
# VT: Etiology of VT felt to be from old ischemia. He had a
cardiac catheterization which showed stable CAD. Hypokalemia
was felt to be a predisposing factor. Hypokalemia may have been
precipitated by polyuria due to hyperglycemia. Potassium was
repleted and he was started on a lidocaine drip. He was
switched to procainamide and transferred to the cardiac floor
initially without events but then returned to the CCU in the
setting of VT which was felt to be unstable based on his
clinical appearance (blood pressure during VT not documented).
The day after unstable VT he was taken to the EP lab where he
had inducible VT, but his clinical VT was not inducible. He
therefore underwent substrate-based ablation. Post-procedure he
had persistant rare PVCs with periods of bigeminy and bursts of
VT for several seconds with some drop in blood pressure. Plan
at this time is to continue to hold antiarrhythmics and titrate
up beta-blockade. Lidocaine, procainamide, and amiodarone are
relatively contraindicated given patient's liver disease. He was
started on Metoprolol 50 TID, which was limited by worsening
COPD. He was then changed to Toprol Xl 150mg. He had no further
episodes of VT. He had an ICD placed on [**4-28**]. He received
perioperative prophylactic abx -Vancomycin for one dose on [**4-29**]
and was discharged on two days Levofloxacin. He has cardiology
follow-up with Dr. [**Last Name (STitle) **].
.
# CAD/Ischemia: Unlikely this VT is [**2-13**] new ischemia given
negative enzymes. ASA continued, nadolol switched to
metoprolol. Continued ezetimibe. Counseled smoking cessation.
.
# Pump: Ischemic cardiomyopathy with EF 40% last year and repeat
echo this admission was unchanged. Patient is on a beta-blocker
but not an ACE-inhibitor as an outpatient. He was started on an
ACE-i when became hypertensive.
.
# Blood pressure: Patient was hypotensive in setting of likely
sepsis in days following intubation and required high doses of
phenylephrine and vasopressin transiently. He had a sinus
bradycardia in the 40s while on pressors and large amounts of
sedation. This resolved with weaning of pressors and sedation.
Cardiac output at time of catheterization showed high cardiac
output and low SVR so it was not felt that patient had
cardiogenic shock but more likely sepsis.
In setting of hypotension, seroquel and lithium were held.
Lithium should continue to be held because it may induce
arrhythmias.
.
#Sepsis
Likely due to enterobacter in urine which is being treated with
Ceftriaxone. CT of abdomen raised question of appendicitis
however this was felt to be low probability. He was given
several days of an empiric course of flagyl in addition to
ceftriaxone as it was difficult to assess exam while patient was
sedated and intubated. After extubation and when his mental
status improved, it became clear that the patient's abd exam was
benign; flagyl and ceftriaxone were discontinued. 1/2 bottles
from femoral line placed during code grew coag negative staph
which was felt to be a contaminant. The femoral line was
removed. Patient received three days of vancomycin while
awaiting culture results. After extubation, the patient
developed new fever, productive cough and left pleural effusion
with possible LLL PNA. He was started on abx for VAP (as
described below). He received an 8 day course of VAP abx. His
antibiotics were discontinued on [**4-27**].
.
# COPD/Respiratory failure:
Patient had wheezing on admission but did not appear in
respiratory distress. He was oxygenating well but was intubated
at the time of VT event. He maintained good oxygenation and
ventilation although he did have increase sputum production.
Extubation was limited mostly by patient's aggitation and
difficulty following commands. He was started on prednisone for
COPD flare prior to extubation given sginificant wheezing on
exam. He received 5 days of prednisone and then was switched to
dexamethasone, rapidly tapered and started on Advair. He
received nebs throughout his hospital course. Two days after
extubation he began spiking fevers, developed a cough as well as
LLL infiltrate and effusion. He was presumed to have a VAP and
was started on Vancomycin and Zosyn, completed an 8 day course.
He also received a thoracetensis: 2L serosanginous, exudative
fluid was removed, but it was not a parapneumonic effusion. He
also received gentle diuresis. His hypoxia and SOB significantly
improved with throracentesis, COPD tx and abx. His wheezing
became minimal and he was weaned off of oxygen.
.
# Upper Ext weakness: For the first several days after
extubation, the patient was delerius and agitated. As his
encephalopathy improved, he began complaining of upper ext
weakness particularly on the right side. Specifically, it was
noted that the patient did not bring his hand to his head to eat
and drink but brought his head down to the table. He was found
to have UE weakness specifically in shoulder girdle, R>L without
much weakness in his hands. A head CT was negative for acute
stroke. Neurology was consulted. They determined that the
patient's symptoms were more c/w with a peripheral process and
most likely a cervical or brachial plexus process. An MRI was
performed which showed cervical stenosis without change in the
spinal cord signal, along with narrowing of the neuronal
foramina. Neurology was consulted and they believed his
weakness was due to a plexopathy. He was given instructions and
contact information for neurology follow-up.
.
# Anemia: unclear etiology of anemia, possibly related to
underlying liver disease. B12/folate and iron studies are nl.
Acute drop after procedure from [**Date range (1) 4479**], improved in the
afternoon of discharge. This should be followed up with his PCP
at his appointment below.
.
# DM: Pt. states he will not do insulin injections as outpt.
Thiazolidinediones and metformin relatively contraindicated
given liver dz. Acarbose and sitagliptin are also possibilities
for him. While in house, he was started on glargine and ISS, the
glargine continued upon discharge. His blood glucose continued
to be poorly controlled despite aggressive SSI (requiring up to
80 units humalog) and glargine, though this was in the setting
of receiving oral steroids, which were discontinued on the day
of discharge. He was sent out on his home glyburide 5mg [**Hospital1 **],
and no further changes were made out of concern for hypoglycemia
while unmonitored at home as well as questions about patient
compliance. His blood glucose should be monitored and
medication regimen titrated per PCP.
.
# Cirrhosis: Appears well-compensated for now, no coagulopathy.
Somewhat old EGD showed only portal gastropathy without varices.
Seroquel was held and he was discharged on zyprexa
alternatively. Nadolol was changed to metoprolol, but could be
changed back prior for control of portal hypertension. This
decision was left to his primary hepatologist, Dr. [**Last Name (STitle) 497**], though
he is apparently transitioning to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] at [**Hospital1 3343**].
.
# Pleural effusion: Chest CT showed no evidence of malignancy.
Received a thoracetensis: 2L serosanginous, exudative fluid was
removed, but it was not a parapneumonic effusion. Imaging
showed no change afterward. Gram stain and culture were
negative. Cytology of the pleural fluid was negative for
malignancy. Etiology of exudative effusion is unclear. Could
be trauma related from procedures. He will likely need repeat
imaging and possibly a pulmonary follow-up.
.
# Psych:
Seroquel and lithium held in setting of hypotension for possible
contribution to bradycardia. Seroquel restarted once
bradycardia resolved for increasing aggitation, then held again
given his cirrhosis. Lithium continues to be held. Patient was
seen by psychiatry prior to intubation as patient attempted to
leave hospital. He was not felt to be competent though was
never actually section 12'd. He had altered mental status for
longer than anticipated after extubation, but this was
attributed to difficulty clearing medication in the setting of
cirrhosis. For 5-7 days after extubation, he continued to have
significant agitation, requiring constant supervison with a
sitter and was switched to Zyprexa. It was also though that
Prednisone could be causing agitation and hypomania, and
predinsone was rapidly tapered once his pulmonary status
improved. His agitation improved over time.
.
# Thrombocytopenia: chronic, at BL, likely [**2-13**] liver dz.
.
.
# This discharge summary was faxed to Dr. [**Last Name (STitle) 17029**] (PCP, [**Name Initial (NameIs) **]:
[**Telephone/Fax (1) 17030**]) at [**Telephone/Fax (1) 62884**] and Dr. [**First Name (STitle) 1726**] (switching to him
for hepatology, phone: [**Telephone/Fax (1) 62885**]) at [**Telephone/Fax (1) 62886**].
Medications on Admission:
- Furosemide 20 mg daily (not taking x 1 month [**2-13**] feeling
fatigue)
- Citalopram 20 mg daily
- Lithium 600mg qhs
- Quetiapine 200 mg qhs (also taking 100mg in afternoon prior to
naps quite regularly)
- Nadolol 20 mg qdaily (ran out months ago)
- Albuterol 2 puffs [**Hospital1 **]
- Pantoprazole 40 mg qdaily
- ezetimibe 10mg qdaily
- aspirin 325 mg
- Glyburide 5 mg [**Hospital1 **]
- ?metformin prescribed by PCP recently but not started
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 inhalation* Refills:*2*
7. Olanzapine 5 mg Tablet Sig: 1-2 Tablets PO twice a day: take
1 tablet each morning, take two tablets each evening.
Disp:*90 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-13**] inhalation
Inhalation twice a day.
Disp:*60 inhalations* Refills:*2*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
inhalation Inhalation four times a day.
Disp:*240 inhalations* Refills:*2*
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
12. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*1*
13. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: start on [**2145-4-30**].
Disp:*2 Tablet(s)* Refills:*0*
15. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
16. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 10 days: Do not take more than 2grams of Tylenol in 24
hours or you could risk further liver damage and death.
Disp:*40 Tablet(s)* Refills:*0*
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Astelin 137 mcg Aerosol, Spray Sig: [**1-13**] sprays each nostril
Nasal once a day as needed for allergy symptoms.
Disp:*1 sprayer* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary:
ventricular tachycardia
Chronic systolic and diastolic congestive heart failure
Pneumonia
COPD
Delirium
Cervical spondylosis
.
Secondary
Diabetes mellitis
Liver Cirrhosis
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for treatment of an unstable
rhythm named ventricular tachycardia. You were resuscitated and
intubated. After extubation, you developed a pneumonia for which
you were treated with antibiotics.
.
You received an ICD to prevent future episodes of unstable
ventricular tachycardia from occurring. You will need to
antibiotics for two days to prevent infection at the ICD. You
must keep your left arm still for the next two weeks to prevent
the ICD from being disrupted. Do not raise your left arm up. No
lifting, no excercise, no driving. Keep your arm in a sling at
night for two weeks. if you have pain, you may take Tylenol
325mg and Ibuprofen 600mg every 6 hours; you can take these
medications together. Do not take more Tylenol, or you risk
damaging your liver and causing a lethal injury. You have
follow-up in the device clinic next Wednesday. It is very
important for you to go to that follow-up, as it is for all of
the below follow-up appointments.
.
Please take your medications as described.
Your Lithium was discontinued because it may cause cardiac
irritability.
Your seroquel was discontinued because of risk for precipitating
arrythmias, and replaced with zyprexa.
You are being sent out with Advair as well. Please take all
your medications as prescribed.
.
For your right shoulder weakness, you are being given contact
information for a neurologist. Please follow up as below.
.
Please follow up with your appointments listed below. They are
very important for the maintenance of your health.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, fever, or any other
worrying symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2145-5-5**]
1:00pm
.
Please follow up with your PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2515**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 17030**]. Appointment set for you [**2145-5-12**] at
1:30pm.
.
Please call Dr. [**First Name (STitle) 437**] from Neurology at [**Telephone/Fax (1) 2928**] to schedule
an appointment within one month.
.
Please follow up with your cardiologist Dr. [**Last Name (STitle) **].
Appointment set for you on [**5-19**] at 3:40pm. Telephone ([**Telephone/Fax (1) 16930**].
.
Please call your psychiatrist [**Doctor First Name **] [**Doctor Last Name 2405**] ([**Telephone/Fax (1) 47576**] to
schedule an appointment within two weeks.
.
Please make an appointment with Dr. [**Last Name (STitle) 497**] ([**Telephone/Fax (1) 2422**]) or Dr.
[**First Name (STitle) 1726**] ([**Telephone/Fax (1) 62885**]) for liver follow-up in the next month.
|
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icd9cm
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[
[
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275, 330
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13956, 18594
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|
3588, 3988
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,191
| 181,302
|
53412+53413
|
Discharge summary
|
report+report
|
Admission Date: [**2152-5-4**] Discharge Date: [**2152-5-9**]
Date of Birth: [**2095-1-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Dilantin Kapseal / Phenobarbital / Penicillins / Mevacor /
Lipitor / Iodine-Iodine Containing / Tegretol / Klonopin /
Valium / Diamox Sequels / Paraldehyde / Zarontin / Valproic Acid
And Derivatives / Fiorinal / Cyproheptadine / Tranxene-SD /
Robaxin / Mebaral / Sudafed / Epinephrine / Ativan / Questran
Light / Lopid / Multivitamin / Iron / Depakote / Neurontin /
Primidone / Iodine / Barium Iodide / Zetia / Zyban / Depakene /
Lyrica
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-RI, SVG-OM, SVG-PDA)
[**2152-5-5**]
History of Present Illness:
57 year old female with a history of
hypertension, Dyslipidemia, atypical chest pain, seizure
disorder, s/p right temporal lobectomy, fibromyalgia, with one
month of intermittent chest pain, who presents with an abnormal
stress test, and is now referred for cardiac catheterization.
She
has a one month history of sharp, stabbing, substernal chest
pain with radiation to the ride side of her chest. She also
report some mild numbness down her left arm and up to the left
side of her face which would happen on occasion but not with
each
episode of chest pain. The pain occurs at random, with no set
pattern, and no precipitating factors. The pain lasts only
minutes and resolves on its own. She also reports some mild
wheezing which is not in relation to activity and is
intermittent. She also reports some dizziness and
lightheadedness
which she believes is related to migraine headaches. On cardiac
catheterization today she was found to have 3 vessel disease
including left main. She is now being referred to cardiac
surgery
for revascularization.
Past Medical History:
coronary artery disease
PMH:
? TIA [**2131**]
Seizures [**2124**] and [**2126**]
Encephalitis
Bronchitis
Seasonal allergies
Anemia (prior transfusions)
GERD
Precancerous skin lesions
Chronic pain/fibromyalgia
Hiatal Hernia
Past Surgical History:
S/P right temporal lobectomy [**2126**] (no further seizure since)
S/p Breast reduction
s/p Rhinoplasty
Social History:
The pt lives alone. She is currently on disability.
She has smoked one pack of cigarettes per day for the past 30
years. She denied use of alcohol or illicit drugs.
Family History:
No other family members with epilepsy. Multiple family members
have suffered intracranial hemorrhages and myocardial
infarctions.
Physical Exam:
Pulse:72 Resp:16 O2 sat:98/RA
B/P Right:144/75 Left:142/74
Height:5'2" Weight:140 lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
Intraop TEE [**2152-5-5**]
PRE-CPB:1. The left atrium is normal in size. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No thrombus
is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen.
7. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. Preserved biventricular
systolic function. Aortic contour is normal post decannulation.
[**2152-5-9**] 04:35AM BLOOD WBC-6.0 RBC-2.92* Hgb-8.8* Hct-25.0*
MCV-86 MCH-30.2 MCHC-35.3* RDW-14.9 Plt Ct-221
[**2152-5-8**] 06:00AM BLOOD WBC-7.1 RBC-2.94* Hgb-9.1* Hct-25.0*
MCV-85 MCH-30.9 MCHC-36.4* RDW-14.5 Plt Ct-157
[**2152-5-9**] 04:35AM BLOOD Glucose-110* UreaN-18 Creat-0.9 Na-136
K-3.9 Cl-95* HCO3-33* AnGap-12
[**2152-5-8**] 06:00AM BLOOD UreaN-17 Creat-0.8 Na-134 K-3.2* Cl-91*
[**2152-5-9**] 04:35AM BLOOD Mg-2.0
[**2152-5-8**] 06:00AM BLOOD Mg-1.7
Brief Hospital Course:
The patient was brought to the operating room on [**2152-5-5**] where
the patient underwent CABG x 4 with Dr. [**First Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically at
baseline and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility.
By the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to [**Hospital 38**] Rehab in
good condition with appropriate follow up instructions.
Medications on Admission:
BACLOFEN - 10 mg Tablet - Take 7 - 8 Tablet(s) by mouth daily as
directed Must be IVAX/ZENITH brand - No Substitution
CALAN SR - 240MG Tablet Extended Release - ONE BY MOUTH EVERY
DAY
- No Substitution
DARVOCET-N 100 - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 553**]
[**Last Name (NamePattern1) **]) - 100 mg-650 mg Tablet - 1 Tablet(s) by mouth as needed
for migraines Brand name only
FLUVASTATIN [LESCOL XL] - (Prescribed by Other Provider) - 80
mg
Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once
a
day
MOM[**Name (NI) **] [NASONEX] - 50 mcg Spray, Non-Aerosol - 2 sprays each
nostril once a day
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth three
times a day
PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth twice a day
take
pm on [**5-3**] and am on [**5-4**] for dye allergy
PRIMIDONE [MYSOLINE] - 50 mg Tablet - Take 4 Tablet(s) by mouth
daily Manufacturer must be: Valeant. NO SUBSTITUTION. - No
Substitution
PROPRANOLOL [INDERAL LA] - 60 mg Capsule,Extended Release 24 hr
-Take one Capsule(s) by mouth daily - No Substitution
RANITIDINE HCL - (Prescribed by Other Provider) - 300 mg Tablet
- 1 Tablet(s) by mouth at bedtime will take [**1-30**] tablet on
morning
of cath for dye allergy
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg Capsule
- Take 2 Capsule(s) by mouth daily - No Substitution
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day will start [**5-4**] am pre cath
DIPHENHYDRAMINE HCL [[**Hospital1 **] ALLERGY] - (Prescribed by Other
Provider; OTC) - 12.5 mg/5 mL Liquid - 10 ml by mouth once pm
[**5-3**]
for dye allergy pre cardiac cath/pt states can not take 50mg to
strong for her
DOCUSATE SODIUM [COLACE] - (OTC) - 50 mg Capsule - 1 Capsule(s)
by mouth as needed for constipation
IBUPROFEN - (OTC) - 200 mg Capsule - 1 Capsule(s) by mouth two
times a day
NAPROXEN SODIUM [ALEVE] - (OTC) - 220 mg Tablet - 1 Tablet(s)
by
mouth as needed for headache and severe muscle aches
SIMETHICONE [PHAZYME] - (OTC) - 180 mg Capsule - 1 Capsule(s)
by
mouth as needed for gas
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/HA/fever.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. fluvastatin 20 mg Capsule Sig: Four (4) Capsule PO Daily ().
7. mom[**Name (NI) 6474**] 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
Nasal daily ().
8. primidone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
9. baclofen 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for spasms .
10. baclofen 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
11. baclofen 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO TID (3 times a day).
15. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
18. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
coronary artery disease
PMH:
? TIA [**2131**]
Seizures [**2124**] and [**2126**]
Encephalitis
Bronchitis
Seasonal allergies
Anemia (prior transfusions)
GERD
Precancerous skin lesions
Chronic pain/fibromyalgia
Hiatal Hernia
Past Surgical History:
S/P right temporal lobectomy [**2126**] (no further seizure since)
S/p Breast reduction
s/p Rhinoplasty
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Trace LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (5) 88802**] Date/Time:[**2152-6-5**]
1:30
Cardiologist Dr. [**Last Name (STitle) **],[**Doctor First Name **] E. [**Telephone/Fax (1) 62**], [**7-7**] at 10:00AM at
[**Hospital1 **] [**Location (un) 620**]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 20009**],[**First Name3 (LF) 5557**] D. [**Telephone/Fax (1) 9347**] in [**5-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2152-5-9**] Admission Date: [**2152-5-9**] Discharge Date: [**2152-5-11**]
Date of Birth: [**2095-1-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Dilantin Kapseal / Phenobarbital / Penicillins / Mevacor /
Lipitor / Iodine-Iodine Containing / Tegretol / Klonopin /
Valium / Diamox Sequels / Paraldehyde / Zarontin / Valproic Acid
And Derivatives / Fiorinal / Cyproheptadine / Tranxene-SD /
Robaxin / Mebaral / Sudafed / Epinephrine / Ativan / Questran
Light / Lopid / Multivitamin / Iron / Depakote / Neurontin /
Primidone / Iodine / Barium Iodide / Zetia / Zyban / Depakene /
Lyrica
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Refused to enter rehab facility
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 109854**] is a 57 year old female s/p coronary artery bypass
grafting surgery on [**2152-5-5**]. Her hospital course was
uneventful and she was discharged to [**Hospital 38**] Rehab on [**5-9**] in good condition. On the day of discharge, she presented
back to [**Hospital1 18**] several hours later after refusal at rehab. On
presentation to emergency room on room air saturation 89%
however had been on [**3-2**] liters NC in hospital and discharged on
oxygen. Placed on 4 l NC oxygen saturation 94%. CXR obtained in
ED with left effusion no significant change from [**2152-5-8**] and
lungs with expiratory wheezes which she has been on nebulizers.
She denies shortness of breath and able to complete full
sentences. Also noted for fever 102 in ED , WBC this am 6 and
afebrile. U/A negative from this am, ED obtaining blood
cultures and giving vancomycin and cipro. Incisions without
erythema or drainage, no infiltrate on chest xray.
Past Medical History:
Coronary artery disease
? TIA [**2131**]
Seizures [**2124**] and [**2126**]
Encephalitis
Bronchitis
Seasonal allergies
Anemia (prior transfusions)
GERD
Precancerous skin lesions
Chronic pain/fibromyalgia
Hiatal Hernia
Past Surgical History:
S/P right temporal lobectomy [**2126**] (no further seizure since)
S/p Breast reduction
s/p Rhinoplasty
Social History:
The pt lives alone. She is currently on disability.
She has smoked one pack of cigarettes per day for the past 30
years. She denied use of alcohol or illicit drugs.
Family History:
No other family members with epilepsy. Multiple family members
have suffered intracranial hemorrhages and myocardial
infarctions.
Physical Exam:
ADMISSION
Pulse: 80 Sinus rhythm Resp:22
O2 sat: 89 on RA on arrival up to 94% on 4 L NC
BP 130/80
General: Sitting up on stretcher interactive, denies pain
Skin: Sternal incision healing no erythema or drainage
Left EVH with ecchymosis no erythema or drainage
HEENT: PERRLA [x] EOMI [x] wearing sunglasses
Chest: Expiratory wheezes throughout and decreased left base
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema trace bilateral
Lower extremities
Neuro: alert and oriented x3 nonfocal
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2152-5-9**] Portable Chest x-ray: Little interval change from prior
with continued left basilar atelectasis, small left pleural
effusion, and elevation of the left hemidiaphragm. Minimal
atelectasis in the right lung base is also similar.
[**2152-5-9**] 07:50PM BLOOD WBC-7.7 RBC-3.06* Hgb-9.6* Hct-26.3*
MCV-86 MCH-31.4 MCHC-36.5* RDW-14.8 Plt Ct-265
[**2152-5-10**] 04:45AM BLOOD WBC-6.5 RBC-2.71* Hgb-8.4* Hct-23.5*
MCV-87 MCH-31.0 MCHC-35.8* RDW-15.1 Plt Ct-228
[**2152-5-9**] 07:50PM BLOOD Glucose-133* UreaN-17 Creat-1.0 Na-135
K-4.2 Cl-90* HCO3-34* AnGap-15
[**2152-5-10**] 04:45AM BLOOD Glucose-130* UreaN-18 Creat-1.0 Na-135
K-3.5 Cl-89* HCO3-39* AnGap-11
[**2152-5-10**] 04:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.8
[**2152-5-9**] 07:50PM BLOOD Lactate-1.2
Brief Hospital Course:
Ms. [**Known lastname 109854**] was readmitted back to the cardiac surgical service
for observation. Lasix was continued for gentle diuresis.
Nebulizers and supplemental oxygen were titrated accordingly.
She was discharged back to rehab on [**2152-5-11**].
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/HA/fever.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. fluvastatin 20 mg Capsule Sig: Four (4) Capsule PO Daily ().
7. mom[**Name (NI) 6474**] 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
Nasal daily ().
8. primidone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
9. baclofen 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for spasms .
10. baclofen 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
11. baclofen 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO TID (3 times a day).
15. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
18. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 1 weeks.
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: 0.25 Tablet PO TID (3
times a day).
2. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
6. baclofen 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. baclofen 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
8. baclofen 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for spasm .
9. primidone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
10. Lescol 40 mg Capsule Sig: Two (2) Capsule PO daily ().
11. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain .
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. ibuprofen 200 mg Tablet Sig: One (1) Tablet PO q6hrprn () as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
History of Questionable TIA [**2131**]
History of Seizures, s/p right temporal lobectomy [**2126**]
Multiple Drug Allergies
Chronic pain, Fibromyalgia
Chronic Anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Trace LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2152-6-5**] @ 1:30 PM
Cardiologist: Dr. [**Last Name (STitle) **],[**Doctor First Name **] E. [**Telephone/Fax (1) 62**], [**7-7**] at 10:00AM
at
[**Hospital1 **] [**Location (un) 620**]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 20009**],[**First Name3 (LF) 5557**] D. [**Telephone/Fax (1) 9347**] in [**5-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2152-5-11**]
|
[
"276.3",
"729.1",
"414.01",
"272.4",
"V45.81",
"780.60",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"88.56",
"37.22",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
19415, 19512
|
16138, 16399
|
12856, 12863
|
19756, 19929
|
15346, 16115
|
20853, 21573
|
14425, 14558
|
18119, 19392
|
19533, 19735
|
16425, 18096
|
19953, 20830
|
14119, 14225
|
14573, 15327
|
12785, 12818
|
12891, 13856
|
13878, 14096
|
14241, 14409
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,805
| 136,765
|
20001
|
Discharge summary
|
report
|
Admission Date: [**2145-7-30**] Discharge Date: [**2145-8-15**]
Date of Birth: [**2063-7-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Morphine And Related
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Fever, decreased mental status
Major Surgical or Invasive Procedure:
OR for removal of infected VP shunt on [**7-31**]
PICC line placed on [**2145-8-1**] at 6:15pm
History of Present Illness:
Ms. [**Known lastname 17492**] is an 82 year old woman with dementia and presumed
NPH who was initially admitted to the neurosurgery service on
[**2145-7-30**] with a concern for an infected VP shunt. She initially
presented to [**Hospital1 **] [**Location (un) 620**] on [**2145-7-26**] with several days of nausea,
vomiting, and abdominal pain/distension. A CT there
demonstrated evidence of a partial small bowel obstruction as
well as a fluid collection at the abdominal tip of her VP shunt.
The bulb of her VP shunt was tapped on [**7-27**] and [**7-28**] growing
MSSA; LP on [**7-28**] demonstrated no WBCs and was culture negative.
She was put on vancomycin and cefazolin on [**7-28**] (later narrowed
to just cefazolin) and was transferred to [**Hospital1 18**] for presumed
shunt infection on [**7-30**]. On the morning of [**7-31**], she went to
the OR for removal of the VP shunt; intraoperatively, pus was
noted to be surrounding the ventricular catheter. A
post-operative CT scan of her head demonstrated a 1.9 cm left
frontal abscess at the prior site of the VP shunt.
Post-operatively, she began spiking temperatures and her
antibiotics were changed first to nafcillin/ceftriaxone, and
just broadened to vancomycin/ceftazidime this morning per ID
recommendations.
Over the past 24 hours, her mental status has been noted to
deteriorate markedly; at baseline, she is quite conversant
though has severely impaired short term memory. This morning,
the ID consultant noted her to be responsive only to sternal
rub. She was also spiking fevers over 104 and was noted to be
normotensive (in spite of her history of hypertension). She
also developed hypoxia with reported O2Sats in low 90s on room
air, up to 100% on NRB mask (ABG on NRB 7.45/35/409). Out of
concern for evolving sepsis, she is now transferred to the MICU.
Past Medical History:
- Hydrocephalus (presumed NPH) diagnosed ~3 yrs ago with VP
shunt placement at [**Hospital3 1196**] at that time; shunt
has undergone multiple revisions at NWH for recurrent blockages
(last one about a month ago)
- Alzheimer??????s dementia
- Hyperlipidemia
- Hypertension
Social History:
Drugs: denies
Tobacco: denies
Alcohol: denies
Other: lives with 24 hour caretaker
Family History:
noncontributory
Physical Exam:
Tmax: 40.3 ??????C (104.6 ??????F)
Tcurrent: 40.3 ??????C (104.6 ??????F)
HR: 92 (92 - 92) bpm
RR: 22 (22 - 22) insp/min
SpO2: 97%
General Appearance: Well nourished,
Head, Ears, Nose, Throat: Normocephalic, dry mucous membranes
Chest: diffusely ronchorous breath sounds
Cardiovascular: regular rate/rhythm, normal s1s2, no murmurs
Abdomen: soft, nondistended, normal bowel sounds, no grimacing
to palpation, no HSM
Extremities: warm, no edema, 1+ PT pulses
Neurologic: opens eyes to verbal command and follows some
commands; [**4-19**] grip strength; PERRL, EOMI, normal tone
Skin: Warm, dry, no rashes/jaundice
Brief Hospital Course:
MICU course:
1) Staph aureus cerebral abscess and VP shunt infection:
On the evening of [**8-1**] Ms. [**Known lastname 17492**] [**Last Name (Titles) 28316**] a fever to 104.6. Her
blood and urine were cultured and she was treated with tylenol
and a cooling blanket; she was begun on vancomycin and
ceftazidime. Her fever came down, but throughout [**8-2**] her mental
status waxed and waned with periods of near unresponsiveness. On
[**8-2**] sensitivities showed that the staph aureus infection was
sensitive to all assayed antibiotics except penicillin. However,
because of concern for polymicrobial infection, the broad
coverage with vanco and ceftaz was continued. Because of concern
for intraabdominal infection, a CT of the abdomen and pelvis
with contrast was pursued once her creatinine was back to
baseline (0.9). Ms. [**Known lastname 17492**] was too somnolent to drink contrast
safely thus an NG tube was placed. Contrast was given, and the
CT was negative for intraabdominal processes secondary to the
infected VP shunt. She improved dramatically by the morning of
[**2145-8-3**] and was transfered off the MICU to the general medicine
floor.
2) Acute renal failure:
Creatinine bumped from baseline of 0.9 to 1.2 in the setting of
her fever and decreased PO intake. This was thought to be most
consistent with a pre-renal azotemia however urine electrolytes
showed a FeNa of 1.7, consistent with a mixed picture. On [**8-2**],
with administration of bolus and maintenance fluids, her
creatinine had returned to 0.9.
3) Hypoxia:
Pt was transferred to the unit on 100% O2 by NRB mask. ABG at
that time was 7.45/35/409. However her respiratory status
stabilized and she was successfully switched to 2L by nasal
cannulae, with high (often 100%) O2 sats. Her CXR on [**8-2**] showed
clear lungs.
Hospital Course:
1. VP Shunt infection: S/p removal [**2145-7-31**], was initially
started on vancomycin and ceftazidime for broad coverage. Final
culture data showed MSSA per ID switched to nafcillin 2gm IV
Q4H. Patient was continuing fever spikes following removal of
the shunt (101.3 [**2057-8-2**], 102 [**2058-8-3**], 100.9 [**8-5**]) were
concerning for continuing infectious process. CT scan of head
on [**2145-8-5**] showed persistent fluid collection, was repeated on
[**2145-8-8**] showed ring enhancement of the same area. Neurosurgery
on board, ID recommended draining possible abscess as IV
antibiotics not effecting fever curve and mental status.
Patient scheduled to go to OR on [**2145-8-9**].
2. DVT UE BL: Secondary to PICC line, now present on the
opposite side, s/p removal of PICC and replacement. Arms were
elevated with no interventions recommended by IR on either side.
Right sided PICC removed [**8-4**]. Started patient on heparin drip
for anticoagulation, then discontinued the day of surgery. Will
hold off on changing PICC for now and will repeat US next week.
3. Acute renal failure: Resolved, see above MICU course.
4. AMS: likely delirium secondary to VP shunt infection on top
of baseline dementia from Alzheimer's Disease and NPH, however
may be secondary to natural progression of dementia. Held
namenda and Zyprexa as possible causes of sedation.
6. HTN: Continued metoprolol 25mg [**Hospital1 **], monitored BP.
7. FEN: Nutrition consulted, speech and swallow recommended po
diet but pureed solids and thin liquids with supplements via
NGT, then patient nearly aspirated with supervised feeds,
switched to NPO and all nutrition by tube feeds.
8. PPx: Heparin SC, heparin IV drip (on hold for surgery), Pt
kept in mitten restraints while inpatient as likely to pull out
tubing.
DNR/DNI
Patient was transferred back to the neurosurgery service from
the MICU. She was continued on her course of IV vancomycin. The
patient's mental status improved slightly. On [**8-11**] she was
moving all extremities and was able to speak in short phrases
and sentences. PT and OT worked with her and recommended rehab
for her. Speech therapy also was consulted but they were unable
to get her to eat on [**8-11**]. Palliative care was consulted and on
[**2145-8-15**] patient's daughter [**Name (NI) **] [**Name (NI) 9449**] decided she would
make patient comfort measures only. Patient received hospice
bed and was transferred CMO.
Medications on Admission:
Namenda 10mg qd
Atenolol 50mg qd
Detrol 2mg qd
Zyprexa 10mg qd
lipitor 20mg qd
Inpatient:
*cefazolin 1g IV q8h
Namenda 10mg qd
Atenolol 50mg qd
Detrol 2mg qd
Zyprexa 10mg qd
lipitor 20mg qd
famotidine
meperidine prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed: prn constipation.
Disp:*30 Tablet(s)* Refills:*2*
3. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 7 days.
Disp:*1 1 tube* Refills:*0*
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO or SL
PO Q2 hr prn: dyspnea or pain.
Disp:*1 30 ml* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 13054**] Hospice
Discharge Diagnosis:
dementia
Discharge Condition:
poor
cmo
Discharge Instructions:
Comfort measures only per proxy daughter [**Name (NI) **] [**Name (NI) 9449**]
[**Telephone/Fax (1) 53898**]
Followup Instructions:
not applicable
|
[
"584.9",
"272.4",
"324.0",
"293.0",
"401.9",
"041.11",
"996.63",
"331.0",
"294.10",
"560.9",
"331.3",
"453.8",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.43",
"01.39",
"38.93",
"96.6",
"02.05"
] |
icd9pcs
|
[
[
[]
]
] |
8509, 8564
|
3388, 5198
|
314, 411
|
8617, 8628
|
8785, 8803
|
2704, 2722
|
7947, 8486
|
8585, 8596
|
7706, 7924
|
5215, 7680
|
8652, 8762
|
2737, 3365
|
244, 276
|
439, 2285
|
2307, 2585
|
2601, 2688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,956
| 199,014
|
31533
|
Discharge summary
|
report
|
Admission Date: [**2156-9-21**] Discharge Date: [**2156-9-30**]
Date of Birth: [**2102-1-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal cancer
Major Surgical or Invasive Procedure:
Transhiatal esophagectomy w/ j-tube ([**9-21**]), reduction of hiatal
hernia, pyloroplasty.
History of Present Illness:
54 yo male w/ esophageal cancer admitted for resection via
esophagectomy
Past Medical History:
Esophageal ca, COPD, OSA (CPAP), GERD, lipids, recent PNA, s/p
back fusion, h/o diverticuli, pain, diabetes
Social History:
lives w/ wife and children
40 pk yaer smoker- quit 6 mos ago.
No ETOH
Family History:
non contributory
Physical Exam:
general: obese male in NAD
HEENT: unremarkable
COR: RRR S1, S2
RESP: CTA bilat
ABD: obese, round, NT, ND, +BS
extrem: No C/C/E
Neuro: A+OX3, multiple back surgeries -ambulates with crutches
x2.
Pertinent Results:
[**2156-9-21**] Pathology Tissue: THORACIC ESOPHAGUS AND [**2156-9-21**]
[**Last Name (LF) **],[**First Name3 (LF) 2389**] M. Not finalized
CT scan [**9-26**]: IMPRESSION:
1. Postoperative anterior subcutaneous fat inflammation along
with subcutaneous emphysema and minimal simple fluid collection
adjacent to the surgical drain site with a few pockets of air.
These findings are all likely postoperative, however,
superinfection of this small fluid cannot be excluded by CT
exam.
2. Bilateral simple pleural effusions (left greater than right)
with adjacent compression atelectasis of the lower lobes.
3. No intraabdominal/intrapelvic fluid collections. Likely
postoperative inflammation involving the mesentery and anterior
abdominal wall. Minimal amount of residual pneumoperitoneum is
noted.
4. Diverticulosis without evidence of acute diverticulitis.
Unchanged fatty infiltration of the liver.
[**9-28**]:
WBC 6.0 ; HCT 35.9*
glu 225* bun 8; creat 0.4*; NA 144; K 4.1
Brief Hospital Course:
pt was admitted on [**2156-9-20**] for and taken to the OR on [**9-21**] for
transhiatal esophagectomy, pyloroplasty, reduction of hiatal
hernia and feeding J-tube. OR course uneventful. Pt had NGT,
chest tube, JP anastomotic drain, j-tube, PICC line in place.
Admitted to ICU intubated for obdervation. An epidural was
placed for pain control.
PT was extubated on POD#1 and transferred from the ICU on POD
#1. Pt required insulin drip in the ICU for glucose management.
Pain control was a major issue during his hospital course d/t
chronic pain issues and new acute post op pain issues. The acute
pain service followed [**Last Name (un) **] closely. His epidural was d/c'd POD#4
and pain management was via PCA and at the time of discharge pt
was rec'ing roxicet via J-tube and PRN ativan for anxiety
(longstanding issue)
Pt progressed w/ post op course. Trophic tube feeds were started
on POD#3 and when bowel function returned, tube feeds were
increased to goal and he was [**Last Name (un) 1815**] well at the time of
discharge.
On POD#5 pt had temp spike and cervical neck incisional
erythema, neck wound was draining bilious drainage and wound was
opened. CT scan as reported in results section. Anastomotic
drain was d/c'd and pt was started on vanco, cipro, flagyl.
erythema decreased and wound bed is clean and granulating. IVAB
were d/c'd and pt has remained afeb and erythemia is resloving.
QID wet to dry dressing changes continue.
[**Last Name (un) **] was consulted for glucose management since pt is unable
to take oral hypoglycemia agents at this time and we do not put
meds via j-tube to avoid clogging (except lopressor). He will
need SQ insulin until he is able to take po meds.
He was followed by PT and rehab was recommended.
Medications on Admission:
metforamin 500", oxycontin 40", vicodin, celebrex 200', valium
10", doxepin 300', prilosec 20", zoloft 100", zocor 80',
albuterol
Discharge Medications:
1. tube feed
replete w/ fiber at 70cc/hr
flush w/ 50cc water every eight hours and before and after start
and stop tube feeds and medications
2. tube feed
replete with fiber 7 cans /day x 11 mos
3. tube feed
pump and supllies
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): crush into fine powder and dissolve completely in
water and give via J-tube.
5. Lorazepam 2 mg/mL Syringe Sig: .5 mg Injection NOON (At
Noon).
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
via j-tube Q4H (every 4 hours) as needed.
7. Hydromorphone 2 mg/mL Syringe Sig: 0.2-0.4 mg Injection Q3HR
() as needed for prn pain breathrough.
8. humalog
humalog 75/25 8 units at breakfast and dinner
then humalog sliding scale per fingerstick q 6hrs while on tube
feeds
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
transhiatal esophagectomy w/ j-tube ([**9-21**]).
Esophageal ca, COPD, OSA (CPAP), GERD, lipids, recent PNA, s/p
back fusion, h/o diverticuli, pain, diabetes
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience chest
pain, shortness of breath, fever, chills, nausea, vomiting,
diarrhea, abd pain, or any change in drainage from your neck
wound or foul smelling drainage.
NOTHING BY MOUTH.
Change your neck dressing every 4 hours during the day while you
are awake. moist-dry dressing.
If your feeding tube sutures become loose or break, please tape
tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding
tube falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner
because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form. You may put your lopressor medication in the
J-tube. It MUST be crushed into a fine powder then COMPLETELY
dissolved in water before putting into tube. Flush with 50cc
after each medication.
Flush your feeding tube with 50cc every 8 hours if not in use
and before and after every feeding.
Followup Instructions:
You have a barium swallow on [**2156-10-7**] at 10am in the [**Hospital Ward Name **]
clinical center [**Location (un) **] radiology. You also have a CXR after
the barium swallow in radiology. You have a follow up
appointment with Dr. [**Last Name (STitle) **] on [**2156-10-7**] at 2pm in the [**Hospital Ward Name 23**]
clinical center [**Location (un) **] .
Completed by:[**2156-9-30**]
|
[
"997.3",
"250.00",
"530.81",
"327.23",
"518.0",
"530.85",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"44.29",
"42.41",
"34.09",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
4761, 4833
|
2021, 3774
|
339, 433
|
5035, 5050
|
1017, 1998
|
6156, 6548
|
770, 788
|
3954, 4738
|
4854, 5014
|
3800, 3931
|
5074, 6133
|
803, 998
|
282, 301
|
461, 535
|
558, 667
|
683, 754
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,822
| 151,303
|
25242
|
Discharge summary
|
report
|
Admission Date: [**2146-8-17**] Discharge Date: [**2146-8-25**]
Date of Birth: [**2127-5-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Multiple stab wounds
Major Surgical or Invasive Procedure:
Complex repair of 16-cm facial laceration
Repair of leg lacerations x2 and neck lacerations x1
Central venous line placement
Partial closure of right chest wounds.
Flexible bronchoscopy
Tube thoracostomy x3
Endotracheal intubation
Right facial nerve repair
Physical Exam:
BP 80s/palp P110s R 24
Gen: Shock; awake, able to speak and answer questions on
arrival, then intubated
HEENT: Large lac to right face. EOEMI. PERRL 3-2bilat.
Neck: Trachea midline; suprasternal lac.
Chest: Bilateral mid-axillary chest wounds
CV: Tachy S1S2
Abd: Soft, NT ND, no obvious injuries.
Rectal: No tone (post-paralysis), guiac neg
Ext: Lac x 2 on right posterior calf. 1+DP bilat
Pertinent Results:
[**2146-8-17**] 07:49PM HCT-25.4*
[**2146-8-17**] 07:49PM PT-14.5* PTT-27.8 INR(PT)-1.4
[**2146-8-17**] 05:14PM GLUCOSE-116* LACTATE-1.5 K+-3.6
[**2146-8-17**] 03:47PM WBC-17.8* RBC-3.15* HGB-9.5* HCT-26.7* MCV-85
MCH-30.2 MCHC-35.6* RDW-14.8
[**2146-8-17**] 03:47PM PLT COUNT-126*
[**2146-8-17**] 03:47PM PT-14.2* PTT-27.9 INR(PT)-1.4
[**2146-8-17**] 02:35PM LACTATE-1.1
Brief Hospital Course:
The patient was hypotensive and tachycardic on arrival. He was
intubated and venous access was gained. Bilateral chest tubes
were placed with return of 1L of blood from the right chest. He
was taken immediately to the OR for resuscitation and repair of
lacerations; see operative note for details.
Post-operatively he was observed in the Trauma ICU and did well,
with no signs of further bleeding or instability. He was
extubated on HD2 and transferred to the floor.
He continued to have an air leak and a third chest tube was
placed. On HD2 he underwent a flexible bronchoscopy that showed
no signs of injury; see the op note for details. The chest tubes
were removed once the CXR showed decreased and stable
pneumothoraces on water seal; there was no return of hemothorax.
He was seen by Plastic Surgery and there was concern he had an
injury to his facial nerve, with weakness in the facial muscles
on the right side of his face. He underwent repair of his right
facila nerve on [**2146-8-24**].
Patient was seen and evaluated by Pain Service for right ankle
neuropathic pain; recommendations for Elavil 25mg po qd; this
was initiated on [**2146-8-25**].
Medications on Admission:
none
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*120 Capsule(s)* Refills:*0*
8. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Bilateral chest lacerations with right hemothorax.
Face laceration
Neck laceration
Leg laceration
s/p stabbing
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Plastic Surgery and Trauma Clinic next Tuesday.
Followup Instructions:
Call the Trauma Surgery clinic at [**Telephone/Fax (1) 6439**] for an
appointment next Tuesday for removal of your leg sutures.
Call the Plastic Surgery clinic at [**Telephone/Fax (1) 5343**] for an
appointment next Tuesday. Please let them know that you will
also be seen in the Trauma Clinic that same day.
Completed by:[**2146-8-30**]
|
[
"E966",
"891.0",
"389.03",
"956.9",
"873.0",
"305.00",
"860.5",
"951.4",
"874.8",
"872.02",
"518.81",
"285.1",
"873.41",
"958.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"99.05",
"96.05",
"83.65",
"04.3",
"96.04",
"96.71",
"38.93",
"34.04",
"99.04",
"99.07",
"96.52"
] |
icd9pcs
|
[
[
[]
]
] |
3541, 3590
|
1434, 2598
|
339, 598
|
3745, 3754
|
1024, 1411
|
3865, 4206
|
2653, 3518
|
3611, 3724
|
2624, 2630
|
3778, 3842
|
613, 1005
|
275, 301
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,114
| 101,731
|
854
|
Discharge summary
|
report
|
Admission Date: [**2117-3-30**] Discharge Date: [**2117-4-3**]
Date of Birth: [**2037-5-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5510**]
Chief Complaint:
Lower GIB
Major Surgical or Invasive Procedure:
4 units of packed red blood cells
History of Present Illness:
79 year old female with a past history of hypertension, type 2
diabetes, CAD s/p CABG x 4 and history of lower gastrointestinal
bleeding of unclear source who presents to the emergency room
with 4 days of "vaginal bleeding." Patient reports that she
first noted that she was bleeding on Saturday. It was primarily
bright red blood in the toilet bowel with stool with associated
fecal urgency. She denies abdominal pain. This is similar to her
episode of gastrointestal bleeding in [**2116-5-24**] but not as
profuse. The bleeding has continued over the past three days. It
is associated with mild left sided chest pressure which is not
worse with exertion, dyspnea on exertion, lightheadedness and
dizziness. She has not had any nausea, vomiting or hematemasis.
She denies melena. She has been eating well until the day of
presentation. Her urine output has been normal. Otherwise she
has been in her regular state of health.
.
In the emergency room her initial vitals were T: 98.1 BP: 169/67
HR: 87 RR: 16 O2: 98% on RA. She received one liter of normal
saline. She had a CXR which showed no acute process. She had a
normal EKG. She had two 20 g IVs placed and one liter of PRBCs
was hung. Vaginal exam was within normal limits. Rectal exam
showed no external hemorroids and gross blood at the anus. She
was hemodynamically stable throughout her time in the ER. She
was admitted to the MICU for further management.
.
Upon arrival to the MICU she denied any complaints. Her
lightheadedness, dizziness, chest pain and dyspnea have
resolved. Her last bowel movement was morning of admission. She
denies nausea, vomiting or abdominal pain. No dysuria or
hematuria or decreased urine output. No leg pain or swelling.
All other review of systems negative in detail.
Past Medical History:
Past Medical History:
- Coronary Artery s/p CABG [**2107**]
- Peripheral Vascular Disease
- Stage III chronic kidney disease (baseline creatine 1.3)
- Hypertension
- Type II Diabetes complicated by retinopathy, nephropathy
- Diverticulosis seen on colonoscopy [**5-31**]
- s/p toe amputation
Social History:
She is a retired administrator at [**Street Address(1) 5904**] Inn. She works
out at a senior gym three times a week. She does not smoke
cigarettes, drink alcohol, or use any recreational drugs. She
lives by herself but has family in the area.
Family History:
Diabetes mellitus-- mother, brother, and sister
[**Name (NI) 5905**] mother, father.
There is no history of kidney disease.
No family history of gastrointestinal bleeding.
Physical Exam:
On admissions -
Vitals: T: 98.4 BP: 136/72 HR: 73 RR: 14 O2: 99% on RA
Orthostatics: 122/59 (73); 119/67 (78); 112/55 (69)
General: Well appearing elderly female, no acute distress
[**Name (NI) 4459**]: Sclera anicteric, moist mucous mebranes, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Heart: RRR, s1 + s2, no murmurs, rubs, gallops
Abd: soft, non-tender, non-distended, +BS
Ext: Warm and well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact
Skin: no rashes or jaundice
Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2117-3-30**]:
IMPRESSION: No acute pulmonary process.
HEMATOLOGY:
[**2117-3-30**] 12:55PM BLOOD WBC-9.2 RBC-2.43*# Hgb-7.2*# Hct-21.3*#
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.1 Plt Ct-283
[**2117-3-30**] 07:34PM BLOOD Hct-26.6*
[**2117-3-31**] 04:10AM BLOOD WBC-8.9 RBC-3.77*# Hgb-11.1*# Hct-31.6*
MCV-84 MCH-29.5 MCHC-35.2* RDW-16.2* Plt Ct-207
[**2117-3-31**] 06:44PM BLOOD Hct-30.2*
COAGS:
[**2117-3-30**] 12:55PM BLOOD PT-13.6* PTT-29.0 INR(PT)-1.2*
[**2117-3-31**] 04:10AM BLOOD PT-13.2 PTT-29.3 INR(PT)-1.1
CHEMISTRY:
[**2117-3-30**] 12:55PM BLOOD Glucose-298* UreaN-43* Creat-1.4* Na-138
K-4.8 Cl-107 HCO3-23 AnGap-13
[**2117-3-31**] 04:10AM BLOOD Glucose-157* UreaN-33* Creat-1.1 Na-141
K-4.1 Cl-111* HCO3-22 AnGap-12
CARDIAC ENZYMES:
[**2117-3-30**] 12:55PM BLOOD CK(CPK)-224*
[**2117-3-30**] 12:55PM BLOOD CK-MB-7
[**2117-3-30**] 12:55PM BLOOD cTropnT-0.02*
[**2117-3-30**] 07:34PM BLOOD CK(CPK)-208*
[**2117-3-30**] 07:34PM BLOOD CK-MB-6 cTropnT-0.01
[**2117-3-31**] 04:10AM BLOOD CK(CPK)-172*
[**2117-3-31**] 04:10AM BLOOD CK-MB-5 cTropnT-0.02*
Brief Hospital Course:
MICU COURSE:
Patient presented with a hematocrit of 21 down from her baseline
of ~35. Gastroenterology was consulted and reported that this
was a likely diverticular bleed given her history of
diverticulosis on colonoscopies in the past. She was to be
treated conservatively with transfusions and monitoring. She
received a total of 4 units of packed red blood cells following
admission and had an appropriate HCT bump to 31.6. Serial HCTs
on [**2117-3-31**] revealed stabilized of her HCT at ~30 prior to
transfer to the floor. Her initial episode of chest pain in the
ED was not repeated following resuscitation with PRBCs. She had
a rule out for MI with three serial sets of cardiac enzymes with
downtrending CKs and normal troponins throughout. Concerning her
chronic kidney disease, at presentation she was at her baseline
Cr of approximately 1.3 and this fell to 1.1 on morning prior to
transfer out of MICU. Given her unknown volume status, her home
antihypertensives were initially held and after assurance of
stable hemodynamics, she was restarted on lisinopril. Concerning
her diabetes, she was managed with a lower dose of lantus given
that she was NPO when presenting to the unit. After
stabilization of her HCT, she began a diet of clears that was to
be advanced as tolerated. In the MICU the patient had no bowel
movements and was hemodynamically stable throughout her stay in
the MICU. She was feeling well when transferred out of the MICU.
.
MEDICINE FLOOR COURSE:
Patient had several red, guaiac positive BMs on the floor but
remained Hd stable and did not receive any further transfusions.
On the day of discharge, patient had guaiac postive stools that
was brown. Her lisinopril and metoprolol were continued but HCTZ
was held. Patient also had her ASA held given GIB with plan to
restart when she follows up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] next week. She
was restarted on her home dose of Lantus on the floor and was
managed on an insulin sliding scale.
Medications on Admission:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
daily
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
daily
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
8. CALCIUM 500+D 500 (1,250)-200 mg-unit daily
9. Lantus 100 unit/mL Solution Sig: Forty Five (45) units SC at
HS.
10. Insulin Sliding Scale
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
Units Subcutaneous at bedtime.
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
9. Insulin Aspart Subcutaneous
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: GI bleed requiring blood transfusion
Secondary: Diabates, Chronic kidney disease, Coronary artery
disease
Discharge Condition:
stable, afebrile
Discharge Instructions:
You presented to the hospital with a gastroentestinal bleed.
This was felt to be secondary to diverticula (or outpouchings)
in your colon. You were initially admitted to the ICU for
monitoring and received 4 units of blood. Your blood counts
stablaized prior to discharge and you were tolerating a regular
diet.
.
All of your medications were continued except aspirin and
hydrochlorothiazide which you should continue to hold until you
see Dr. [**Last Name (STitle) 131**] next week. Please keep your appointment with Dr.
[**Last Name (STitle) 131**] this [**Last Name (STitle) 2974**].
.
Please seek immediate medical attention if you note blood in the
stool, dizziness, shortness of breath, chest pain, abdominal
pain, vomitting, fevers, chills or any change from your baseline
health status.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 131**] at your previously scheduled
appointment on [**2117-4-9**]. Call [**Telephone/Fax (1) 133**] if you need to
reschedule.
Completed by:[**2117-4-4**]
|
[
"403.90",
"V18.0",
"250.50",
"362.01",
"V45.81",
"585.3",
"285.1",
"562.12",
"250.70",
"V17.49",
"414.01",
"250.40",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7966, 8023
|
4603, 6623
|
323, 358
|
8182, 8201
|
3487, 4248
|
9044, 9249
|
2740, 2913
|
7269, 7943
|
8044, 8161
|
6649, 7246
|
8225, 9021
|
2928, 3468
|
4265, 4580
|
274, 285
|
386, 2148
|
2192, 2463
|
2479, 2724
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,344
| 195,325
|
54104
|
Discharge summary
|
report
|
Admission Date: [**2172-6-3**] [**Year/Month/Day **] Date: [**2172-6-20**]
Date of Birth: [**2096-8-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fluid retention
Hypotension
Major Surgical or Invasive Procedure:
Intubation
PICC placement
Cardiac Cath
History of Present Illness:
75 yo M with Mantle cell lymphoma (on bendamustine and Rituxan),
atrial flutter, tachy-CM (last EF 45-50%), recent UTI and
episode of urinary retention, prostate cancer s/p XRT [**2158**],
HTN/HL/DM who was recently admitted to [**Hospital1 18**] for LE edema, is
presenting from [**Hospital1 1501**] for an evaluation of LE edema.
Of note, he was recently admitted to [**Hospital1 18**] [**Date range (1) 35870**] for LE edema
with was felt to be due to decreased lasix dose and
hypoalbuminemia (LENIs neg, no pelvic vein compression on CT
abd/pelv., TTE w/ mild worsening inferior hypokinesis). Notably
his SBP ranged in 80s-100s without symptoms, felt to be due to
hypovolemia, excessive doses of ACEi and BB. While on 80mg IV
lasix, BPs maintained in 80s. He was treated for a positive UCx
with ciprofloxacin and notably was found to have urinary
retnetion, felt to be due to prostate ca s/p XRT. He was seen
for chemo treatment on [**5-21**], when his BP was 95/43.
Since [**Month/Year (2) **], patient has remained relatively hypotensive
while at rehabilitation, BPs as low as 80s systolic. Over the
past week, noted urinary retention and dysuria. On day of
transfer, c/o of increasing malaise and weakness, leg swelling
and heaviness, requiring the use of a wheelchair. Of note, has
been diagnosed with a UTI on [**5-31**] (pseudomonas a.) and was
supposed to start treatment, however never initiated. On day of
transfer, VS were 95/52 101 18 98, wa noted to have Wt of 186,
3lbs up from day prior, he received an increased dose of lasix,
80mg PO.
In the ED, initial VS were: 98.5 62 100/40 18 92 on ? NC.
Patient's labs were notable for WBC of 5.6K with 10% bands, HCT
of 28, Plt of 180K, lactate of 2.3, positive UA, troponin of
0.03. ECG showed NSR with RBBB and old inferior MI; no evidence
of acute ischemia or electrical alternans. CXR showed
increasing L effusion and atelectasis. Patient was given 500mg
IV of ciprofloxacin, however was noted to have decrease in his
BPs to 80s systolic, w/o response to 500cc NS bolus and 6mg IV
of Zofran. He was then started on dopamine with improvement in
BPs to 130s systolic and tachycardia to 120s. CVL was placed at
RIJ and patient was changed to levophed. He underwent Bedside
US which showed moderate pericardial effusion, pulsus was not
checked.
On arrival to the MICU, patient's VS 135 106/68 18 96% RA.
Past Medical History:
- mantle cell lymphoma (s/p chemotherapy, 6 cycles Bendamustine
and Rituxan - last session [**2171-10-28**], last cycle of rituximab Day
1: [**2172-2-24**] Cycle end: [**2172-3-22**])
- rheumatic heart disease with acute rheumatic fever (subsequent
mitral regurgitation - posteriorly directed jet of mild to
moderate ([**2-3**]+) mitral regurgitation on [**2171-5-17**])
- s/p left scapular fracture
- s/p right first toe fracture
- s/p right lower extremity osteomyelitis (age 30 years old)
- gout
- s/p volar plate injury of 5th digit
- Divertiulitis with abdominal sepsis ([**2149**])
- hypertension
- hyperlipidemia
- allergic rhinitis
- cervical & lumbar disc disease (with right sciatica)
- prostate adenocarcinoma ([**Doctor Last Name **] 6, s/p XRT [**2158**])
- DM2 - noninsulin dependent
- vitamin D deficiency
- s/p ORIF left ankle fracture
- c. difficile infection
Social History:
Lives with his wife and two children. Retired. Former
maintanance, machinist and shipyard worker with asbestos
exposure. Quit smoking 25 years ago (10 years x 1 pack per
week). Occassional EtOH. No illicits.
Family History:
Negative for any type of cancer, leukemia, or lymphoma; however,
his sister has anemia and significant weight loss.
Physical Exam:
ADMISSION EXAM:
Vitals: Pulsus 10mmHg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear
Neck: supple, JVP 8cm, no LAD
CV: RR, normal S1 + S2
Lungs: decr breath sounds on LLL, no egophony
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
GU: no foley
Ext: 3+ pitting edema to knees, 2+ DP
Neuro: a/ox3, MOYb intact, normal language.
EOMI, face symmetric, palate symmetric, tongue midline.
LEs: R IP and Q [**4-6**], H4+/5, TA 4-/5, G [**6-6**]; IP/Q/H 4+/5, TA/G
[**6-6**], toes down, 2+ DTRs at [**Name2 (NI) **] and 3+ patellar b/l. normal
sphincter tone.
Dischage Exam: Patient deceased
Pertinent Results:
ADMISSION LABS:
[**2172-6-3**] 07:15PM BLOOD WBC-5.6# RBC-2.94* Hgb-8.8* Hct-27.7*
MCV-94 MCH-30.1 MCHC-32.0 RDW-17.4* Plt Ct-180
[**2172-6-3**] 07:15PM BLOOD Neuts-59 Bands-10* Lymphs-15* Monos-10
Eos-0 Baso-0 Atyps-3* Metas-3* Myelos-0
[**2172-6-3**] 07:15PM BLOOD Glucose-97 UreaN-19 Creat-0.7 Na-135
K-4.0 Cl-100 HCO3-27 AnGap-12
[**2172-6-3**] 07:15PM BLOOD Calcium-8.5 Phos-1.6* Mg-1.5*
[**2172-6-3**] 07:28PM BLOOD Lactate-2.3*
.
CXR [**2172-6-3**] 5:42 PM
FINDINGS: PA and lateral views of the chest were obtained. Since
the prior
exam, there is interval increase in the left pleural effusion. A
small right
pleural effusion is redemonstrated. Bibasilar consolidations are
likely
attributable to compressive atelectasis. Overall, heart and
mediastinal
contours appear stable. Degenerative changes at the right
shoulder are
redemonstrated. Degenerative changes in the T-spine also again
seen.
IMPRESSION: Increasing left effusion. Persistent smaller right
effusion.
Compressive lower lobe atelectasis.
.
CXR [**2172-6-4**] 12:11 AM
FINDINGS: As compared to the previous radiograph, patient has
received a
right internal jugular vein catheter. Catheter is in normal
position and
course, the tip projects over the mid SVC.
In unchanged manner, there is moderate cardiomegaly with a
relatively
extensive left pleural effusion and a left atelectasis.
A newly appeared minimal right pleural effusion cannot be
excluded. No
evidence of pneumonia.
.
ECHO
Due to [**2172-6-4**] 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. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Very small pericardial effusion, without any
evidence of hemodynamic significance. Grossly preserved
biventricular systolic function.
Compared with the prior study (images reviewed) of [**2172-4-13**],
the findings arppear similar, although inferior/inferolateral
hypokinesis is not appreciated on today's focused study.
Brief Hospital Course:
75 yo M with Mantle cell lymphoma (on bendamustine and Rituxan),
atrial flutter, tachy-CM (last EF 45-50%), recent UTI and
episode of urinary retention, prostate cancer s/p XRT [**2158**] who
was recently admitted to [**Hospital1 18**] for LE edema, who presented from
[**Hospital1 1501**] for an evaluation of LE edema, urinary retention and
hypotension.
# Mantle cell lymphoma. Reportedly improving with current chemo
prior to this. However, as hospitalization went on, became clear
that pleural effusions and pericardial effusions were malignant
in nature. [**Hospital1 3242**] service was following throughout. CT torso on
[**6-14**] showed worsening lymphoma. As a result, oncology started
Dexamethasone 20mg daily to arrest the lymphoma. MRI showed no
CNS disease. Persistent pressor requirement and unable to get
off vent (had been intubated for pericardiocentesis - see below)
with negative infectious work-up raised concern that all
problems stemming from overwhelming lymphoma. On [**6-18**] after 4
days of steroids with no response oncology met with family who
had expressed desires to not have prolonged intubation or life
support. Decision was made to pursue comfort-based goals of care
and withdraw other medical care. Patient expired on morning of
[**2172-6-20**].
# Sepsis. Patient admitted initially to [**Hospital Ward Name 332**] ICU on [**2172-6-3**]
with hypotension, tachycardia, low CVP and elevated SVO2.
Source of sepsis is most likely Pseudomonal UTI. Recurrent UTI
likely due to stricture from past prostate radiation. No
evidence of prostatitis on rectal exam. Of note, he has been
hypotensive, even at time of d/c during last admission to 80s.
Started on Meropenem for abx and initially on pressors, given
fluid boluses. Improved and was able to transfer to oncology
floor on [**2172-6-5**]. Finished course of meropenem for UTI but later
in hospitalization when in MICU7 (see below) more issues with
hypotension requiring pressors so placed back on vanco and
continued on meropenem empirically for HCAP.
# Worsening lung effusions: Initially was left-sided but right
sided developed as well. Warfarin stopped to allow proceedures
and on [**6-8**] the pt had diagnostic/therapeutic L thoracentesis by
IP revealing exudative effusions (pleural LDH 354, serum 445)
with +cytology. Due to concerns that this and LE edema due to
volume overload, cardiology was consulted and recommended
transfer to [**Hospital Ward Name **] on the cardiology floor for a lasix
drip. (Re swelling, on [**6-10**] LUE u/s demonstrated nearly occlusive
clot of L basilic). Ultimately IP placed pigtails on L and a few
days later on R. Effusions were successfully drained and stayed
resolved with pitails in place.
# Respiratory distress:
No significant breathing issues initially. However, after
transfer to the cardiology floor, pt increasingly tachypneic, RR
26-30, HR 120s on tele, sats to 70s on 2.5Lnc, started on NRB
wtih increased to 90-92%. The pt was given lasix 80mg IV x1,
started on nitro gtt. EKG showed increased rate but no acute ST
changes. Pt was transferred to the MICU7 for respiratory
distress. In MICU7 the pt was started on Bipap, continued on
lasix gtt with bolus 80mg without significant urine output. TTE
showed new moderate pericardial effusion, EF decreased to
45-50%. IP placed pigtail on left on [**2172-6-12**] to drain pleural
effusions and hopefully improve respiratory status. Pleural
fluid again with high LDH suggestive of malignancy. Was
electively intubated for pericadiocentesis on [**2172-6-15**] but unable
to get off vent after as get intermittently desating to 80s
despite passing many of SBTs. Decision ultimately made to
withdraw care and vent was titrated off.
# Hypotension: Had initially been hypotensive presumed to be due
to urosepsis (see above). This improved with Abx/IVF/brief
pressors. Was fine on the floor for 5 days but after transfer to
the MICU (see above) BP decreased to the 70s and he was started
on levophed. As above, TTE with new pericardial effusion.
Initially cardiology did not think pericardial drainage needed
has no evidence that hypotension due to poor cardiac output and
SVO2s were high (distributive shock). AM cortisol normal at 30.
Continued to require pressors and later cath (see below) didn't
indicate that shock due to tamponade.
# Pericardial Effusion: very small initially without any
hemodynamic effects. Etiology thought [**3-5**] to lymphoma. Grew
rapidly in size and cardiology ultimately took to cath lab for
pericardiocentesis. However, cath showed no abnormal pressure
elevations in RV arguing against any tamponade. This combined
with fact that growing mass was obstructing pericardium led to
aborting of attempt at pericardiocentesis.
# Atrial flutter: In sinus rhythm and Aflutter intermittently
throughout hospitalization. Beta blocker was held due to
hypotension and warfarin due to need for proceedures.
# Code Status: Initially full code although family expressing
that patient would not want prolonged ventilation or life
support. When became apparent that most of sickness due to
overwhelming lymphoma, decision made to withdraw medical care
except that focused on comfort. Patient passed away on morning
of [**2172-6-20**], time of death 07:30. Family notified. Autopsy
declined.
Medications on Admission:
-- Metoprolol 12.5mg [**Hospital1 **]
-- Neupogen 480mg SC daily
-- Lisinopril 2.5mg daily
-- FUROSEMIDE 80mg daily
-- OMEPRAZOLE 40 mg once a day
-- POLYETHYLENE GLYCOL
-- TAMSULOSIN 0.4 mg HS
-- WARFARIN 3mg daily, last INR 1.7 on [**6-2**]
-- Oxycodone 10mg Q6H prn
- ACETAMINOPHEN prn
-- ASPIRIN 81 mg Daily
-- CHOLECALCIFEROL 400 daily
-- DOCUSATE SODIUM 100 mg [**Hospital1 **]
-- LACTOBACILLUS ACIDOPH & BULGAR [LACTINEX] TID
-- MAGNESIUM OXIDE 400 mg [**Hospital1 **]
-- SENNOSIDES 8.6 mg 2 TabletS hs
-- SIMETHICONE 80 mg DAILY PRN
-- MVI
-- LIdoderm patch
-- Zofran
[**Hospital1 **] Medications:
Patient expired
[**Hospital1 **] Disposition:
Expired
[**Hospital1 **] Diagnosis:
Mantel Cell Lymphoma - Patient expired
[**Hospital1 **] Condition:
Patient Expired
[**Hospital1 **] Instructions:
Patient Expired
Followup Instructions:
Patient Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"394.1",
"909.2",
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"564.09",
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] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"37.21",
"96.72",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
6988, 12286
|
318, 359
|
4714, 4714
|
13160, 13314
|
3911, 4028
|
12312, 12890
|
4043, 4695
|
251, 280
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12967, 12976
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12920, 12937
|
387, 2770
|
4730, 6965
|
13004, 13089
|
2792, 3670
|
3686, 3895
|
13120, 13137
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,447
| 159,812
|
9661
|
Discharge summary
|
report
|
Admission Date: [**2139-2-8**] Discharge Date: [**2139-2-16**]
Date of Birth: [**2067-10-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Arrest and quadriplegia
Major Surgical or Invasive Procedure:
Cervical laminectomy inferior C2, C3,C4, C5.
History of Present Illness:
71-year-old male who was admitted to [**Hospital **] [**Hospital **] Medical
Center ER today after a fall. The patient became acutely
tetraplegic in the field and
was brought to the emergency room. He was worked up and found to
have severe cervical spinal stenosis from a calcified OPLL with
resultant narrowing of the spinal canal. The patient had a
whiplash injury with several broken areas of
calcifications. There was no clear cervical fracture identified.
The patient was emergently taken to the operating room for
decompression, assuming that he had suffered a cervical cord
contusion with subsequent swelling in the
setting of spinal stenosis.
Past Medical History:
-HTN
-DM2: Dx 15yrs ago, with nephropathy and mild neuropathy
-CAD: No MI, had mild sx and elective 3v-cabg [**2134**]
-R groin vessel injury: Had ?shunt related to pre-cabg cath,
lead to CHF sx, s/p repair
.
PSH:
-CABG [**2134**]
-R groin vessel repair [**2134**]
Social History:
SocHx: Lives with wife at home, independent. Smoked 1ppd x
20-30yrs, quit 20 yrs ago. Soc etoh.
Family History:
FHx: Father with ? [**Name2 (NI) 1364**] CA, died 57 y/o, mother with dm,
?abdominal tumor in 80's
Physical Exam:
T:96.7 BP:116/97 HR:68 RR:20 O2Sats:92% NC,
the 100% on the ventilator
Gen: Patient is awake, alert, oriented. He is on a back board
and
is wearing a hard cervical collar.
HEENT: Pupils:PERRL EOMs-intact
Neck: in cervical collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor: unable to move any extremity and does not withdraw to
painful stimuli
Sensation: Has no sensation in any of the 4 extremities. He does
have sensation on his face that is symmetric. He has a sensory
level of about C4 per neurology. I was unable to test this as
the
patient was being intubated during my exam.
Reflexes: none
Toes mute bilaterally
Rectal exam - no rectal tone
Pertinent Results:
[**2139-2-16**] 01:57AM BLOOD WBC-10.8 RBC-3.54* Hgb-10.0* Hct-28.8*
MCV-81* MCH-28.2 MCHC-34.6 RDW-16.1* Plt Ct-251
[**2139-2-15**] 02:10AM BLOOD WBC-11.1* RBC-3.68* Hgb-10.3* Hct-29.7*
MCV-81* MCH-28.0 MCHC-34.7 RDW-16.1* Plt Ct-251
[**2139-2-13**] 01:38AM BLOOD WBC-9.5 RBC-3.99* Hgb-11.1* Hct-32.9*
MCV-83 MCH-27.7 MCHC-33.6 RDW-16.2* Plt Ct-250
[**2139-2-14**] 03:11AM BLOOD Plt Ct-264
[**2139-2-11**] 02:03AM BLOOD PT-11.4 PTT-28.0 INR(PT)-1.0
[**2139-2-10**] 02:02AM BLOOD Plt Ct-312
[**2139-2-14**] 03:11AM BLOOD Glucose-264* UreaN-67* Creat-1.2 Na-144
K-4.0 Cl-111* HCO3-24 AnGap-13
[**2139-2-13**] 01:38AM BLOOD Glucose-259* UreaN-58* Creat-1.2 Na-146*
K-4.2 Cl-115* HCO3-22 AnGap-13
[**2139-2-12**] 02:02AM BLOOD Glucose-172* UreaN-50* Creat-1.3* Na-146*
K-4.3 Cl-116* HCO3-20* AnGap-14
[**2139-2-16**] 01:57AM BLOOD Calcium-8.0* Phos-3.9 Mg-3.5*
[**2139-2-15**] 02:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-3.2*
[**2139-2-14**] 03:11AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.6
[**2139-2-12**] 02:02AM BLOOD Phos-1.4*# Mg-2.5
Brief Hospital Course:
Mr [**Known lastname **] is a 71 year old man with an acute spinal cord
injury. He has ossification of the posterior longitudinal
ligament from C2-C5 with most likely underlying spondylotic
myelopathy. He either had a vagal episode or cardiac arrest at
the time and was quickly resuscitated. Emergently he was brought
to the [**Hospital1 18**] and taken to the OR for emergent decompression.
Post operatively he was found to remains flaccid and
quadriplegic. He had questionable withdrawal to pain in his feet
and hands, but there is only slight
spontaneous movement of his left hand. He does have a left
triceps reflex. The rest are absent with upgoing toes and a
triple flexion response. He is able to maintain his own
respiration and they are using CPAP. He was maintained in a
C-Collar, started on Decadron to hopefully reduce swelling, he
had a wound drain in place.
His SBP goal was greater than 100 requiring pressors. He also
required an insulin drip due to his diabetes. On post op day 1
an MRI was completed that showed ossification of the posterior
longitudinal ligament extending from the C2
through C4 vertebral body levels, compressing the spinal cord
anteriorly. At
C3/4, there is evidence of cord contusion. No cerebrospinal
fluid is seen
posterior to the cord at the level of compression and C3/4 and
C4/5 anterior ligamentous tears.
On Post OP day 2 he became more awake on a daily basis, shaking
head yes/no appropriately. He would withdraw vs triple flex his
lower extremities he did have some obvious sensation in his
lowers as he would withdraw his legs. However has time
progressed he had less movement of his lower extremities. He was
started on tube feeds for nutritional support. His wound drains
were dc'd on this day also.
Social work was involved with the family from admission, as the
family was made aware of the grave diagnosis and potential for
long term quadraplegia. The ICU team tried to wean the patient
ventilator with variable success alternating between periods of
CPAP and assist control.
The patient made clear attempts to self extubate this ET tube
with his tongue requiring reintubation.
After a family consensus that the patient clearly would never
want to live requiring 24 hour care they decided to make him
CMO, he was extubated and passed away within 2 hours and his
family was at his side.
Medications on Admission:
AVAPRO 300 mg--one tablet by mouth once a day
EPLERENONE 25MG--Take one by mouth every day
FUROSEMIDE 40 mg--one tablet by mouth once a day
IMDUR 30 mg--1 tablet by mouth daily
LIPITOR 20 mg--one tablet by mouth once a day
METOPROLOL TARTRATE 100MG--Take one by mouth twice a day
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Quadraplegia
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2139-2-17**]
|
[
"414.00",
"E885.9",
"401.9",
"V45.81",
"E849.5",
"357.2",
"V45.82",
"721.7",
"952.00",
"344.00",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.6",
"38.7",
"96.04",
"03.09",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6218, 6227
|
3508, 5858
|
337, 384
|
6283, 6292
|
2458, 3485
|
6348, 6386
|
1484, 1584
|
6189, 6195
|
6248, 6262
|
5884, 6166
|
6316, 6325
|
1599, 1931
|
274, 299
|
412, 1064
|
1946, 2439
|
1086, 1352
|
1368, 1468
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,561
| 104,125
|
18187
|
Discharge summary
|
report
|
Admission Date: [**2130-9-11**] Discharge Date: [**2130-9-25**]
Service:HEPATOBILIARY SURGERY SERVICE
DISCHARGE DIAGNOSIS
1. Adenocarcinoma of the gallbladder.
2. Hypertension.
3. Aortic stenosis.
4. Cataracts.
CHIEF COMPLAINT: Painless jaundice.
HISTORY OF PRESENT ILLNESS: This 79-year-old female presents
on [**2130-9-11**] with painless jaundice for ten days. The patient
had felt weak with a decrease in appetite for the past three
to four weeks and had a five pound weight loss. The patient
denied any abdominal pain, no nausea, vomiting, history of
ulcer disease. The patient had an endoscopic retrograde
cholangiopancreatography on [**2130-9-6**]. Study showed
obstruction in portions above the cystic duct. The patient
also had entry of the cystic duct that was irregular
consistent with tumor brush biopsies and a 17 French stent
was placed. The patient had no diarrhea since barium for CT
scan. Denied feeling febrile or having chills. No nausea or
vomiting, some constipation, no chest pain, short of breath,
dysuria, normal bowel habits.
PAST MEDICAL HISTORY: Significant for hypertension, heart
murmur, bilateral cataracts, early menopause, right wrist
fracture in [**2096**] and aortic stenosis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Potassium chloride 20 mEq q day.
2. Hydrochlorothiazide 25 mg q day.
3. Lipitor 10 mg q day.
4. Toprol 50 mg q day.
5. Aspirin 81 mg q day.
SOCIAL HISTORY: The patient had a history of smoking 20 pack
years, quit 29 years ago, one drink per day.
FAMILY HISTORY: No history of cancer. Mother had a stroke.
Father had a heart attack.
LABORATORY: At [**Hospital3 **] Hospital showed a total bilirubin of
40, sodium 129, potassium 2.4, chloride 95, bicarbonate 20,
the albumin was 3.6, white count 9.8, CA-199 was 26,000. The
patient had an ultrasound done also at [**Hospital3 **] Hospital
which showed positive gallstone obstruction, intrahepatic
ducts without dilated or distended common bile duct or
dilated pancreatic duct. The patient had CT which showed
calcified gallstones in the gallbladder, dilated
intra-hepatic bile ducts, no gross masses.
Chest x-ray showed chronic interstitial and chronic
obstructive pulmonary disease, bibasilar linear densities
consistent with fibrosis. An echocardiogram showed ejection
fraction of 65% Mild aortic regurg, Doppler evidence of left
ventricular diastolic dysfunction. Moderate severe calcified
aortic stenosis.
PHYSICAL EXAMINATION: The patient was afebrile with normal
vital signs. The patient was alert and oriented. Had
icteric sclera and was very jaundice. Regular rate and
rhythm with a 3/6 systolic ejection murmur. Lungs were clear
to auscultation bilaterally. Her abdomen was soft,
nontender, nondistended. There was no edema. Her
neurological exam showed cranial nerves 2 through 12 were
grossly intact and normal. She had grossly intact sensory
and motor function.
The patient was admitted as a 79-year-old female with a
questionable mass, was scheduled for percutaneous
transhepatic tubes to be placed in the morning, was made NPO,
put on intravenous fluid maintenance at 100, started on
Ampicillin and Gentamicin for on-call for the percutaneous
transluminal coronary angioplasty. The patient was scheduled
to be seen by Cardiology for cardiac workup. Cardiology
consult on the patient and recommended close hemodynamic
monitoring if surgery was needed with a Swann, no further
workup needed and to continue beta-blockade during admission.
On hospital day two, the patient was afebrile, vital signs
were stable, the patient was brought for PTC performed with
bilateral PTC drains placed. However PTC wad cancelled on
hospital day two because prior to patient being called she
spiked a temperature to 101.7. On hospital day three the
patient was brought and PTC stents were placed. The patient
tolerated the procedure well and was transferred back to the
floor, however, the patient had a T-max of 101.2, was
afebrile immediately following the procedure. The patient
was subsequently transferred to the Intensive Care Unit for a
low blood pressure and elevated temperature, the patient's
white count was 21.0 and required a Neo drip to maintain
adequate blood pressures. The patient had a significant
fluid requirement in addition however, the patient did well.
Arterial line and left subclavian line were placed to better
monitor the patient's hemodynamic status and better
facilitate resuscitation. The patient continued to be weaned
from a Neo drip in the Intensive Care Unit, blood pressures
responding well, continued to receive intravenous fluids.
White count trended down on hospital day five, post procedure
day two, the patient is on intravenous Vancomycin and Zosyn.
Her white count at this time was 7.6.
On hospital day seven the patient was transferred from
Intensive Care Unit to the floor. The patient had been
weaned from her drips and was continued to do well. The
patient continued to have a low white count, was afebrile,
continued to be jaundiced and have hypokalemia and an
elevated bilirubin but was overall hemodynamically stable.
The patient was transfused with one unit of packed red blood
cells on hospital day eight for anemia. The Vancomycin was
removed. The patient was continued on Zosyn.
On hospital day eight, Anesthesia was consulted for the
possibility of an operative candidacy for removal of possible
mass. The patient was seen by Anesthesia and was deemed to
be moderate to severe risk. The patient was continued on
intravenous antibiotics. On hospital day nine, in addition
to having hyperkalemia was found to have low albumin and TPN
was started for nutritional supplement. The patient was
started on a soft diet. The patient's bilirubin continued to
be elevated at 14.4.
On hospital day ten the patient went for cholangiogram.
Cholangiogram showed stenosis in both biliary trees. The
patient had a transient jump in temperature to 100.4 after
cholangiogram and a slight jump in her white count from 7 to
11.2. The patient however continued to remain stable.
Bilirubin also jumped from 14 to 16.7. The patient was
continued on TPN, regular diet and transitioned to oral pain
medicines.
The patient was begun on calorie counts, it was found that
the patient was receiving approximately 773 calories, it was
felt that she can continue with her TPN and calorie counting.
At this time pathology brushings were returned and it was
found that the patient had adenocarcinoma. This was
discussed with the patient and the patient's family and a
family meeting was arranged. Palliative care was also
available. The patient was met with husband and children and
discussed goals of care. The patient had understood at this
time that she had a surgically unresectable tumor and her
prognosis was three the four months. She was agreeable to
continuing with Hospice care and VNA outside the hospital.
On hospital day two, the patient was continued on TPN and
pain management as needed. The patient was begun planning
for hospice care on hospital day 15. The patient continued
to be afebrile, vital signs were stable. The patient's
laboratory showed an elevated bilirubin to 13, however, white
count was stable. The patient was comfortable in no acute
distress. The patient had explored hospice options and plan
was to discharge patient with home hospice care. The patient
will be discharged on her medicines, Atorvastatin 10 mg p.o.
q day, Percocet 1 to 2 tablets p.o. every 4 to 6 hours as
needed for pain, Actigall 300 mg tablets, one tablet by mouth
three times a day, Metoprolol 50 mg tablets half tablet by
mouth twice a day, Hydrochlorothiazide 25 mg one tablet by
mouth per day, Protonix 40 mg one tablet by mouth per day and
Ciprofloxacin 500 mg tablets, one tablet by mouth twice a day
for 14 days.
The patient will follow-up with her primary care physician
and will [**Name9 (PRE) 702**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one to two
weeks. The patient will have VNA to keep drain tubes kept
and to keep dressings around drains dry and intact. The
patient will keep a regular diet, will not have any TPN but
may supplement her diet with nutritional shakes. The
patient's post discharge services will be with Hospice care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2130-9-25**] 13:43
T: [**2130-9-25**] 15:33
JOB#: [**Job Number 50276**]
|
[
"273.8",
"424.1",
"276.6",
"401.9",
"515",
"156.8",
"458.29",
"038.49",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"99.07",
"97.05",
"99.04",
"51.12",
"38.93",
"51.98",
"99.15",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
1562, 2469
|
2492, 8582
|
244, 264
|
292, 1076
|
1099, 1438
|
1454, 1545
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,251
| 113,393
|
45441
|
Discharge summary
|
report
|
Admission Date: [**2153-4-19**] Discharge Date: [**2153-4-24**]
Service: NEUROLOGY
Allergies:
Penicillins / Codeine / Sulfonamides / Aspirin / Valium /
Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril
/ Egg / Oxycontin
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right sided weakness, speech difficulties-CODE STROKE
Major Surgical or Invasive Procedure:
tPA [**2153-4-19**]
History of Present Illness:
92W h/o afib not on AC presents as CODE STROKE after acute onset
of garbled speech, right sided weakness and left gaze
preference.
Last seen well @ 1:20pm by driver. Onset of symptoms @ 1:20pm
noted by driver that patient began to have garbled speech.
Driver subsequently called for an ambulance which brought pt to
[**Hospital1 18**] ED.
NIHSS
1a. alert 0
1b. LOC questions 2
1c. LOC commands 2
2. Gaze 1
3. Visual 0 (chronically blind)
4. Facial palsy 2
5. Motor L arm 0
5. Motor R arm 2
6. Motor L leg 0
6. Motor R leg 3
7. Limb ataxia 0
8. Sensory 0
9. Best language 2
10. Dysarthria 1
11. Extinction 2
NIHSS Total 17
Head and neck CTA showed ?LMCA distal division occlusion. Labs
INR 1.1, Cr 1.1 and FS 114.
Past Medical History:
-- CAD: s/p MI x2; s/p Cypher stent to RCA in [**2148**]; [**12-11**] P-MIBI:
Normal pharmacologic stress myocardial perfusion with normal
left
ventricular cavity size and wall motion.
-- Chronic diastolic CHF: Echo [**2151-3-4**] EF >55%, 1+MR, 1+ TR,
mild PA systolic
pressure
-- Hypertension
-- Diabetes mellitus
-- Atrial fibrillation - per history but currently in sinus. Not
on coumadin
-- Sjogren's syndrome / scleroderma.
-- squamous cell carcinoma
-- Interstitial lung disease
-- osteoporosis, with vertebral compression fractures.
-- GERD / esophageal dysmotility / peptic ulcer disease.
-- Macular degeneration
-- h/o DVT
-- s/p colectomy
-- s/p strokes x4
-- s/p TAH/RSO
-- s/p post appendectomy
-- h/o femoral hernia repair
-- Pancreatic lesion that needs follow up
-- influenza [**2-/2153**]
Reportedly no h/o seizures.
Social History:
Patient was a [**Hospital1 18**] employee x 36 years, widowed. She has 2
children, one in [**State **] and [**State 4565**]. Patient walks with a
cane. Patient lives in [**Location **] Place [**Hospital3 **]. Patient
reports she walks with cane assist only although she is legally
blind.
Tobacco: 15 pk-yr, quit 65 yrs ago
ETOH: None
Illicts: None
Son [**Name (NI) **] [**Name (NI) **] (HCP) [**Telephone/Fax (1) 96979**] in [**State **] but will be
coming
into town this weekend.
Family History:
One child died at age 60 of CAD/cancer
Father died at 52 of MI
Physical Exam:
T- 99.4 BP- 143/77 HR- 102 RR- 38 100 O2Sat NC FS 104
Gen: Lying in bed, tremulous and mild distress
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
CV: sinus tachycardia, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally but tachypneic
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert but not coherent. Rambling
speech
with incoherent content. Does not answer questions or follow
commands.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Left gaze preference but intact extraocular
movements with OCMs. R UMN facial droop. Palate elevation
symmetrical. Tongue midline, movements intact
Motor/Sensory:
Decr'd bulk throughout and tone decr'd on the right. Does not
cooperate with formal resistance testing but moves left arm
purposefully and leg spontaneously. Much fewer spontaneous
movement from the right side but will withdraw to noxious stim
bilaterally, again less on the right.
Reflexes: +2 symm throughout. Right toe upgoing and left toe
downgoing.
Coordination/Gait/Romberg: Unable.
Pertinent Results:
Trop-T: <0.01
138 102 19 114 AGap=18
-----------------
4.3 22 1.1
estGFR: 46/56 (click for details)
CK: 30 MB: Notdone
Ca: 9.6 Mg: 1.9 P: 2.6
ALT: 14 AP: 77 Tbili: 0.8 Alb:
AST: 23 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 42
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
MCV 93
7.6 D > 12.2 < 261 D
37.3
N:46.1 L:41.0 M:8.5 E:3.1 Bas:1.3
PT: 12.5 PTT: 25.6 INR: 1.1
UA neg
CT ABDOMEN/PELVIS [**4-19**]
CT OF THE ABDOMEN: Chronic interstitial lung changes at the
bases of the lungs bilaterally are again identified, similar in
appearance. Mild cardiomegaly is again identified. Coronary
artery calcifications are again identified. Extensive
calcification of the aorta and its branches is also noted. The
patency of these vessels cannot be evaluated due to lack of
contrast. However, within the limitations of a non- contrast
scan, the small bowel loops are unremarkable. There is no wall
thickening or bowel dilatation. The spleen is unremarkable.
Within the liver, multiple low- attenuation lesions (2, 24 and
2, 29) are identified and not completely evaluated on this
single phase study. Within the pancreas, there are two hypodense
lesions (2, 27 and 2, 29). These are incompletely characterized
on this non- contrast study. Multiple bilateral renal cysts are
again identified, most of which have increased in size when
compared to the prior exam. Contrast from prior CAT scan is seen
within the collecting system of the right kidney, however,
minimal contrast appears to fill the right ureter. There has
been interval development of right- sided hydronephrosis due to
a right- sided [**Month/Year (2) 96980**] obstruction. The left kidney demonstrates
normal excretion of contrast. Scattered mesenteric and
retroperitoneal lymph nodes are again identified, none of which
meet CT criteria for pathological enlargement. Patient is status
post right hemicolectomy. There is no free fluid or free air.
CT OF THE PELVIS: The rectum and sigmoid colon are unremarkable.
There is diverticulosis without evidence of diverticulitis.
There is a Foley catheter within the bladder. Contrast is seen
within the bladder lumen. There is no pelvic or inguinal
lymphadenopathy. Extensive diverticulosis without evidence of
diverticulitis is noted. Numerous phleboliths are seen within
the pelvis.
BONE WINDOWS: Multiple old right-sided rib fractures are
identified, with delayed/non-[**Hospital1 **] of right tenth rib. No
suspicious lytic or sclerotic lesions are noted.
IMPRESSION: Please note there is a change from the initial wet
read; the presence of right sided hydronephrosis is now added..
1. There has been interval development of right-sided
hydronephrosis and right- sided [**Hospital1 96980**] obstruction.
2. Interval increase in size of numerous bilateral renal cysts.
3. Multiple hepatic cysts.
4. Pancreatic hypodense lesions, incompletely characterized.
4. Extensive calcifications of the aorta and its branches.
5. Diverticulosis without evidence of diverticulitis.
6. Right-sided rib fractures with possible delayed/nonunion of
the right tenth rib (300B, 7).
ECHO:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. 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. Mild to moderate ([**12-6**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with mild systolic
dysfunction. Preserved left ventricular systolic function.
Mild-moderate mitral regurgitation. Moderate-to-severe tricuspid
regurgitation. Moderate pulmonary hypertension.
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,
edema, or major vascular territorial infarction evident on this
non-contrast head CT. No change since [**2153-2-3**]. Again seen
is prominence of the ventricles and sulci consistent with
age-related involutional changes. [**Doctor Last Name **]-white matter
differentiation is preserved. Again seen is chronic wall
thickening and atelectasis of the left maxillary sinus. The eyes
deviated leftward.
CTA OF THE HEAD AND NECK: The vertebral and carotid arteries are
seen from the origin, intracervical courses, with no significant
stenosis. The cavernous carotids are mildly calcified and
tortuous, nearly kissing at the center. The major vessels of the
circle of [**Location (un) 431**] and its major branches are patent, with no
flow-limiting stenosis or aneurysm detected. The vertebrobasilar
system is also patent, with no stenosis.
CT PERFUSION: There is an area of abnormal perfusion with
increased mean transit time and decreased cerebral blood flow
and blood volume, which is mild to moderate in extent, in the
left posterior cerebral artery circulation distribution,
concerning for an area of ischemia or infarction.
EKG: Sinus rhythm. Frequent atrial premature beats. Left axis
deviation. Probable old anteroseptal myocardial infarction.
Non-specific inferolateral ST-T wave changes. Compared to the
previous tracing of [**2153-4-19**] frequent atrial premature beats are
new. Left bundle-branch block has resolved. Clinical correlation
is suggested.
Brief Hospital Course:
A/P 92W h/o afib not on AC presents as CODE STROKE after onset
of garbled speech, right sided weakness and left gaze preference
and arrived to ED within 3 hours of time of onset and was given
TPA for NIHSS 17 and concern for left MCA occlusion on CTA head
nonreformatted. Rec'd TPA at 3:35pm and then admitted to
neuroICU. On Vanc, Aztreonam, Flagyl for fever 102 emp pulm
coverage d/t tachypnea on presentation.
NEURO:
Admitted to the ICU for close observation and post-tPA care.
Neurologically she fared well throughout the entire
hospitalization, with gradual near-full recovery. An EEG showed
only some mild diffuse intermittent theta-range slowing (formal
report pending at time of discharge). Since she's has such
remarkable recovery and the initial imaging studies, including
CT/CTA/perfusion did not reveal a LMCA stroke, and MRI was done
to assess for older strokes or signs of this recent stroke. It
revealed no DWI abnormalities, mild white matter
microangiopathic changes, and intact vessels intracranially
(formal read pending) . She was started on Plavix in lieu of
Aspirin [**1-6**] allergy. Given the previous admission where she had
altered mental status and speech resolved with resolution of the
fever, it is a possibility that she had the same issue now.
CARDIO
Recurrent episodes of CP reported upon Tx out of unit to floor.
Serial EKGs (3) and serial enzymes ruled out MI. Bloodpressure
was allowed to autoregulate. No further issues during
hospitalization. She was restarted on her home-meds gradually.
RESP
CXR as outlined under results, no PNA. No respiratory issues
during admission.
GI/ABD/UG
An abdominal scan was done for a high lactate and fever,
revealing no soource of infection but a it did reveal
right-sided hydronephrosis and right- sided [**Month/Day (2) 96980**] obstruction.
There also was extensive diverticulosis without evidence of
diverticulitis, multiple hepatic cysts, bilateral renal cysts
that had increased in number and hypodensities in the pancreas
that were anticipated. Urology was [**Month/Day (2) 653**] for the
hydronephrosis and [**Name (NI) 96980**] stenosis, and after reviewing the images
they said it was OK to follow it over time as long as she was
asymptomatic .
ID
High grade fever on admission, empirically treated with broad
spectrum ABx. D/C'd on day 3. No growth all cultures (urine,
blood), CXR negative).
ENT
She complained of a fullness of her L ear on day 3, on the
floor, and of earpain bilaterally on day 4, both self-resolved
with negative bedside otoscopy.
HEME/ONC The PCP was [**Name (NI) 653**] regarding the issues above, and
in his notes it is outlined that no further workup for her
pancreatic lesion was to be done. He is aware of the
hydrouretero-nephrosis. Also, Coumadin should be considered
given her atrial fibrillation.
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaled every 12 hours as
needed for shortness of breath
ATORVASTATIN - 10 mg Tablet - 1 once a day
CLONAZEPAM - 0.5 mg Tablet - [**12-6**] Tablet(s) by mouth twice a day
ESCITALOPRAM [LEXAPRO] - 10 mg Tablet - 1 Tablet(s) by mouth
once
a day
ISOSORBIDE MONONITRATE - 120 mg Tablet Sustained Release 24 hr -
1 Tablet(s) by mouth 1
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth four times a
day
as needed
METOPROLOL TARTRATE [LOPRESSOR] - 50 mg Tablet - [**12-8**] Tablet(s)
by
mouth twice a day
NITROGLYCERIN - 0.3MG Tablet, Sublingual - USE AS DIRECTED
RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 Tablet(s) by mouth a
week
Medications - OTC
ASPIRIN [ASPIRIN EC] - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet, Delayed Release (E.C.)(s) by mouth once a day
CALCIUM - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth three times a day
OMEPRAZOLE - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s)
by mouth once a day
ALL: Penicillins / Codeine / Sulfonamides / Aspirin / Valium /
Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril
/ Egg / Oxycontin
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every twelve (12) hours as needed for shortness of
breath or wheezing.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonazepam 0.5 mg Tablet Sig: half Tablet PO twice a day as
needed for anxiety.
5. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Nitroglycerin Oral
8. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Clopidogrel 75 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:
Possible stroke
Discharge Condition:
Improved. No pronator drift, perhaps only mild 'cupping' of the
R hand but no paresis. Neurological exam has returned to
pre-admission baseline, no focal findings.
Discharge Instructions:
You have been admitted with an altered mental status and fever,
and there were signficant concerns for stroke. You have received
iv tPA, a strong medication that resolves clot. You have
recovered well with antibiotics as well.
You have also been started on Plavix. Please take all your
medications excactly as directed and please attend all your
follow-up appointments.
Please report to the nearest ER or call 911 or your PCP
immediately when you experience recurrence of weakness,
numbness, tingling, problems with speech, language, walking,
thinking, headache, or difficulties arousing, or any other signs
or symptoms of concern.
Followup Instructions:
1 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. Phone:[**Telephone/Fax (1) 96976**]
Date/Time:[**2153-5-2**] 10:30
2 Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Date/Time:[**2153-5-15**] 10:20
3 NEUROLOGY - Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2153-6-11**] 1:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2153-4-24**]
|
[
"V15.82",
"388.70",
"V10.83",
"428.32",
"401.9",
"434.91",
"250.00",
"428.0",
"515",
"369.4",
"V12.51",
"591"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14536, 14594
|
9540, 12358
|
404, 425
|
14654, 14820
|
3791, 7999
|
15502, 16051
|
2546, 2610
|
13538, 14513
|
14615, 14633
|
12384, 13515
|
14844, 15479
|
2625, 2963
|
310, 366
|
453, 1173
|
3142, 3772
|
8008, 9517
|
3002, 3126
|
2987, 2987
|
1195, 2030
|
2046, 2530
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,130
| 108,013
|
30909+57728
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-7-17**] Discharge Date: [**2200-7-29**]
Date of Birth: [**2132-6-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2200-7-18**] Cardiac Catheterization
[**2200-7-21**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to diagonal, vein grafts to left
anterior descending and obtuse marginal). Mitral Valve Repair
utilizing a 28mm CE Annuloplasty Ring.
[**2200-7-21**] Re-Exploration for Bleeding
History of Present Illness:
[**Known firstname 25368**] [**Known lastname 73102**] is a 68-year-old man with a past medical history of
coronary artery disease, congestive heart failure, hypertension
and hypercholesterolemia who was admitted for prehydration prior
to cardiac catheterization.
His main complaint is of dyspnea. He gets moderate dyspnea with
exertion that is readily relieved with rest. This occurs nearly
every day. It got somewhat better after starting Lasix. He
also has thigh pain with exertion that is relieved with sitting
down. This also occurs nearly every day. He denies orthopnea,
PND, leg edema, lightheadedness, syncope, and palpitations. He
otherwise feels well. All other systems were reviewed and
negative.
He brought with him his medical records from [**State 4565**]. He had
an anterior myocardial infarction on [**2199-1-13**] that was
complicated by cardiogenic
shock and managed expectantly. His expectant management was
apparently due to esophageal bleeding (possibly variceal, but no
evident liver disease) that occurred two days prior to this. He
underwent angiography a month later. There was no report, but
some images are included in his papers. There is LAD and LCx
disease evident, but the clinical notes only refer to the LCx
disease. Echocardiograms variously showed LVEFs from 15% to
30%, generally around 20%. He also underwent a cardiac MR. The
report is not included in his paperwork, but the clinic notes
describe it as showing an LVEF of 10% with anterior scar. No
mention is made of viability in the other territories. He was
considered for an ICD but was apparently turned down. He was
told that it wasn't worth it for him.
Past Medical History:
Ischemic Cardiomyopathy, Systolic Congestive Heart Failure,
Coronary Artery Disease, Mitral Regurgitation, Prior MI [**2198**]
complicated by cardiac arrest, Chronic Renal Insufficiency,
COPD, History of Upper GI Bleed secondary to esophogeal varices
- s/p cauterization, History of ETOH abuse
Social History:
Former smoker, 50 pack year history of tobacco. Former heavy
alcohol abuse, none since [**2198**]. He is a former carpenter and
Marine Corp Veteran. Lives in [**State 4565**] and is here visiting
for the summer. Currently living with his daughter.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: T 96.6, BP 112/58, HR 66, RR 20, SAT 97% on room air
General: Well developed man, no distress
Eyes: PERRL, pink conjunctivae, no xanthelasma
ENT: MMM without pallor or cyanosis
Neck: Normal carotid upstrokes, no carotid bruits, no jugular
venous distention, no goiter
Lungs: Clear, normal effort
Heart: RRR, normal S1 and S2, no m/r/g, lateral PMI, precordium
quiet
Abd: Soft, NTND, NABS, no organomegaly, normal aorta without
bruit
Msk: Normal muscle strength and tone, normal gait and station,
no
scoliosis or kyphosis
Ext: No c/c/e, normal femoral and absent pedal pulses
Skin: No ulcers, xanthomas or skin changes due to arterial or
venous insufficiency
Neuro: A and O to self, place and time, appropriate mood and
affect
Pertinent Results:
[**2200-7-18**] 06:05AM BLOOD WBC-4.9 RBC-3.23* Hgb-10.4* Hct-31.6*
MCV-98 MCH-32.2* MCHC-32.8 RDW-18.2* Plt Ct-142*
[**2200-7-18**] 06:05AM BLOOD PT-13.7* PTT-37.4* INR(PT)-1.2*
[**2200-7-18**] 06:05AM BLOOD Glucose-79 UreaN-34* Creat-2.0* Na-135
K-4.3 Cl-104 HCO3-24 AnGap-11
[**2200-7-18**] 10:00AM BLOOD ALT-7 AST-12 AlkPhos-87 Amylase-62
TotBili-0.7
[**2200-7-18**] 10:00AM BLOOD %HbA1c-5.9
[**2200-7-18**] 06:05AM BLOOD Triglyc-37 HDL-57 CHOL/HD-2.1 LDLcalc-53
[**2200-7-18**] Cardiac Cath: 1. Selective coronary angiography of this
right dominant system revealed 3 vessel coronary artery disease.
The LMCA had no angiographically apparent flow limiting lesions.
The LAD had a proximal 70% stenosis and a 60% ostial D1. The
vessel was heavily calcified. The LCX was a heavily calcified
vessel with a 90% ostal lesion and mid vessel stenosis of 70%
into the OM. The RCA was a dominant vessel adn was occluded
proximally and filled via bridging and left to right
collaterals. 2. Resting hemodynamics revealed markedly elevated
left and right sided filling pressures, severe pulmonary
hypertension and a preserved cardiac index. 3. Left
ventriculography was deferred.
[**2200-7-19**] Echocardiogram: The left atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 11-15mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. No masses or thrombi are seen in
the left ventricle. Overall left ventricular systolic function
is severely depressed with global hypokinesis, inferior akinesis
and distal septal, distal anterior and apical akineisi to
dyskinesis. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated. There is moderate global
right ventricular free wall hypokinesis. 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 (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 73102**] was admitted under cardiology and underwent cardiac
catheterization which revealed severe three vessel coronary
artery disease(see result section), along with severe pulmonary
hypertension(PA pressure 75/22 with a mean of 41mmHg). Based
upon the above results, cardiac surgery was consulted and
further evaluation was performed. Echocardiogram was notable for
severely depressed left ventricular function(LVEF of 20%) and
moderate mitral regurgitation. There was only trace aortic
insufficiency with 1-2+ tricuspid regurgitation. Workup
confirmed history of chronic renal insufficiency. His admission
creatinine was 2.0, with mild improvement to 1.6 prior to
surgical intervention. He otherwise remained stable on medical
therapy and was cleared for surgery.
On [**7-21**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting along with mitral valve repair. For surgical details,
please see separate dictated operative note. Postoperative
course was complicated by persistent mitral regurgitation and
bleeding which required re-exploration. Following surgical
intervention, he was transferred to the CSRU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated. He slowly weaned from inotropic support and was
eventually transferred to the SDU on postoperative day three. He
He developed hypotension (after receiving a dose of carvedilol)
with atrial fibrillation and was transferred back to the
intensive care unit on [**2200-7-25**] for pressure support. He was
stabilized and had no further episodes of hypotension and was
subsequently transferred back to the step down unit on [**2200-7-26**].He
was started on Toprol XL (which he has tolerated well), and was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. He has remained stable and
is ready for discharge.
Medications on Admission:
Albuterol MDI, Alprazolam prn, Aspirin 81 qd, Ambien prn,
Atrovent MDI, Coreg 3.125 [**Hospital1 **], Digitek 125 mcg qd, Diovan 40 qd,
KCL, Lasix 40 qd, Lovastatin 40 qd, Paxil 20 qd, Nitro prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Ischemic Cardiomyopathy, Systolic Congestive Heart Failure,
Coronary Artery Disease, Mitral Regurgitation - s/p CABG, MV
Repair
Postoperative Bleeding - s/p Re-Exploration
PMH: Prior MI [**2198**] complicated by cardiac arrest, Chronic Renal
Insufficiency, COPD, History of Upper GI Bleed secondary to
esophogeal varices - s/p cauterization, History of ETOH abuse
Discharge Condition:
Stable
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-24**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-22**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**2-22**] weeks.
Completed by:[**2200-7-29**] Name: [**Known lastname 12180**],[**Known firstname 7090**] R Unit No: [**Numeric Identifier 12181**]
Admission Date: [**2200-7-17**] Discharge Date: [**2200-7-29**]
Date of Birth: [**2132-6-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4551**]
Addendum:
please see revised medication schedule
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*01*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 1612**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2200-7-29**]
|
[
"414.01",
"427.31",
"416.0",
"412",
"593.9",
"V11.3",
"424.0",
"496",
"401.9",
"998.11",
"272.0",
"428.0",
"V15.82",
"428.20",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.03",
"99.07",
"89.60",
"36.15",
"36.12",
"88.56",
"37.23",
"99.05",
"35.33",
"99.06",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12012, 12233
|
5968, 7925
|
328, 638
|
9821, 9830
|
3748, 5945
|
10212, 10912
|
2935, 2978
|
10935, 11989
|
9434, 9800
|
7951, 8147
|
9854, 10189
|
2993, 3729
|
281, 290
|
666, 2335
|
2357, 2653
|
2669, 2919
|
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