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Discharge summary
|
report
|
Admission Date: [**2204-2-16**] Discharge Date: [**2204-2-22**]
Date of Birth: [**2153-9-21**] Sex: M
Service: SURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
[**2204-2-17**]: EGD/colonoscopy
[**2204-2-17**]: ex lap with right colectomy for retroperitoneal bowel
perforation
History of Present Illness:
50 year old male with cryptogenic cirrhosis s/p OLT [**2195**], ESRD
with nephrosclerosis and recent initiation of HD, metabolic
syndrome and h/o alcohol use who presents from liver clinic with
anemia.
He was admitted [**Date range (1) 17504**] and initiated on HD for his ESRD at
that time. During that admission he was noted to have anemia
and started on epo. Hgb was 7.6, Hct was 22.7 on discharge.
Over the last several weeks, he has been attending dialysis MWF
and has had issues with post-HD hypotension and dizziness.
Therefore, all of his antihypertensives have been stopped in the
last several weeks.
Yesterday he was seen for HD and labs were drawn and he was
found to have a Hgb of 7.2 per report. Today he was seen in the
liver clinic and found to have guaic positive stools and
tachycardia so he was directly admitted from clinic.
Currently, he reports mild fatigue but reports it is improved
since starting dialysis. He does endorse dizziness when
standing after his HD sessions but none in between those times.
His peripheral edema is improved since initiating HD. Denies
fevers or chills. Denies SOB, chest pain, palpitations, or
abdominal pain. No pain around tunneled HD line site. Denies
any blood in stool. No recent vomiting. No black stools. He
has never had an EGD/colonoscopy.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. Has had significant weight loss in the last year.
Past Medical History:
ESRD on HD
Cryptogenic cirrhosis (?alcohol induced) s/p OLT [**2195**],
complicated by biliary stricture requiring repeat surgery
Hypertension
Dyslipidemia/Hypertriglyceridemia
T2DM (last A1c 4.7 [**First Name8 (NamePattern2) **] [**Last Name (un) **] notes)
Metabolic syndrome
Hernia repair [**2163**]
Partial L nephrectomy [**2196**]
I & D leg abscess
[**Last Name (un) **] hepaticojejunostomy (side to side) with liver bx and
umbilical
hernia repair [**11-25**]
Recurrent umbilical hernia repair [**8-27**]
Hyperparathyroidism
Social History:
Lives with wife in [**Name (NI) 5110**]. Smokes 1/2-1ppd, x 25 yeras.
Drinks 1 drink/week, h/o alcohol use in the past and unclear if
prior contributing cause of his cirrhosis. No current drug use.
Works as a meat cutter, on disability for last several weeks.
Family History:
Denies family h/o liver or kidney disease. Father died of CHF.
Mother living.
Physical Exam:
Admission Physical Exam:
VS: 98.1 126/90 116 19 100%RA 83.9kg BS 136
GENERAL: Chronically-ill appearing male male. Comfortable,
appropriate and in good humor. Pale appearing.
HEENT: Sclera not icteric. PERRL, EOMI. Conjunctiva pale.
NECK: Supple with low JVP
CARDIAC: Tachycardia without murmurs, rubs or gallops.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-distended, non-tender to palpation. Multiple
well-healed surgical scars. No HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
[**Location (un) **] L>R
Pertinent Results:
Admission Labs:
[**2204-2-16**] 12:50PM WBC-6.2 RBC-2.28* HGB-7.4* HCT-25.8*
MCV-113*# MCH-32.6* MCHC-28.8*# RDW-14.1
[**2204-2-16**] 12:50PM NEUTS-77.9* LYMPHS-14.1* MONOS-6.8 EOS-0.4
BASOS-0.8
[**2204-2-16**] 12:50PM PLT COUNT-519*#
[**2204-2-16**] 12:50PM PT-11.5 PTT-35.6 INR(PT)-1.1
[**2204-2-16**] 12:50PM RET AUT-5.8*
[**2204-2-16**] 12:50PM TSH-1.9
[**2204-2-16**] 12:50PM calTIBC-252* VIT B12-1202* FOLATE-GREATER TH
FERRITIN-960* TRF-194*
[**2204-2-16**] 12:50PM ALBUMIN-3.2* CALCIUM-9.9 PHOSPHATE-2.3*
MAGNESIUM-2.0 IRON-34*
[**2204-2-16**] 12:50PM ALT(SGPT)-20 AST(SGOT)-39 LD(LDH)-198 ALK
PHOS-132* TOT BILI-0.8
[**2204-2-16**] 12:50PM GLUCOSE-91 UREA N-13 CREAT-3.9* SODIUM-137
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-29 ANION GAP-12
Studies:
ECG [**2204-2-16**]: Sinus rhythm. Right bundle-branch block. Compared
to the previous tracing of [**2204-2-1**] the rate has increased. The
QRS duration has diminished. Otherwise, no diagnostic interim
change
Bilateral UE U/s: Duplex was performed of bilateral upper
extremity veins and limited views of the brachial and radial
arteries were obtained. Phasic flow is seen in subclavian veins
bilaterally. A catheter is present on the right. The brachial
and radial arteries have triphasic waveforms bilaterally without
significant calcification. RIGHT: Cephalic vein diameters range
from 1.9 to 2.2 mm in the forearm and from 2.7 to 3.3 in the
upper arm. The basilic forearm diameters range from 1.2 to 1.6
in the upper arm from 1.8 to 2.2. The right brachial artery is
4.9 mm. The radial artery is 1.9 mm. LEFT: forearm cephalic
diameters range from 1.8 to 2.4, upper arm cephalic diameters
range from 2.1 to 3.3. The forearm basilic diameters range from
1.5 to 2.0 upper arm and basilic diameters range from 2.4 to
3.0. The left brachial artery is 4.8 mm and the left radial
artery is 2.3 mm. IMPRESSION: Patent cephalic and basilic veins
bilaterally with diameters as noted above.
EGD [**2204-2-17**]: Normal EGD to third part of the duodenum
Colonoscopy [**2204-2-17**]: Procedure: The procedure, indications,
preparation and potential complications were explained to the
patient, who indicated his understanding and signed the
corresponding consent forms. The efficiency of a colonoscopy in
detecting lesions was discussed with the patient and it was
pointed out that a small percentage of polyps and other lesions
can be missed with the test. A physical exam was performed. The
patient was administered moderate sedation. The physical exam
was performed prior to administering anesthesia. Supplemental
oxygen was used. The patient was placed in the left lateral
decubitus position.The digital exam was normal. The colonoscope
was introduced through the rectum and advanced under direct
visualization until the cecum was reached. The appendiceal
orifice and ileo-cecal valve were identified. Careful
visualization of the colon was performed as the colonoscope was
withdrawn. The colonoscope was retroflexed within the rectum.
The procedure was not difficult. The quality of the preparation
was good. The patient tolerated the procedure well. There were
no complications.
Findings: Mucosa: Otherwise normal mucosa throughout the colon
Flat Lesions:A few small localized angioectasias that were not
bleeding were seen in the cecum. An Argon-Plasma Coagulator was
applied for tissue destruction successfully.
Excavated Lesions:Multiple non-bleeding diverticula were seen in
the sigmoid colon. Diverticulosis appeared to be of moderate
severity.
Impression: Diverticulosis of the sigmoid colon, Angioectasias
in the cecum (thermal therapy), Normal mucosa in the colon,
Otherwise normal colonoscopy to cecum
[**Month/Day/Year **]: The angioectasias int he cecum are the likely
source of the anemia. A capsule endoscopy should be ordered as
an outpatient for evaluation of small bowel AVM. Repeat
colonoscopy in three months.
KUB [**2204-2-17**]: Pneumoperitoneum, status post endoscopy, consistent
with
perforated viscus.
Labs at Discharge:
[**2204-2-22**] 06:21AM BLOOD WBC-4.9 RBC-2.74* Hgb-8.5* Hct-28.5*
MCV-104* MCH-31.1 MCHC-29.8* RDW-15.8* Plt Ct-399
[**2204-2-22**] 06:21AM BLOOD Glucose-91 UreaN-13 Creat-5.5*# Na-140
K-3.4 Cl-101 HCO3-27 AnGap-15
[**2204-2-20**] 05:45AM BLOOD ALT-18 AST-21 AlkPhos-96 TotBili-1.0
[**2204-2-22**] 06:21AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8
Brief Hospital Course:
50 year old male with cryptogenic cirrhosis s/p OLT [**2195**], ESRD
on HD, metabolic syndrome and h/o alcohol use who presented with
anemia. Course complicated by perforated colon after
EGD/colonoscopy with subsequent exl-lap and right colectomy.
#. Perforated colon: He was initially admitted for anemia and
underwent EGD and colonoscopy on [**2204-2-17**] as workup for his
anemia. During his dialysis session after the procedures, he
began to complain of abdominal pain with some abdominal
guarding. KUB was ordered which showed free air in the
peritoneum. Surgery was consulted. Within the next 1-2 hours,
he developed rebound tenderness, fever to 102.7 and tachycardia.
He was initially given cipro/flagyl, then
vanc/zosyn/fluconazole and he was taken emergently to the OR for
ex-lap where he underwent right colectomy. POst-operatively, the
patient was advanced slowly on diet, and had return of bowel
function. Incision was clean/dry/intact
#. Anemia: He was initially admitted with anemia with Hgb 7.2
which was felt to be due to anemia of inflammatory block and
chronic kidney disease. He also had guaiac positive stools and
therefore underwent EGD/colonoscopy. EGD was unremarkable, and
colonoscopy revealed multiple angioectasias that could have been
the source of bleeding. He was transfused 2 units of blood
post-operatively.
#. Chronic kidney disease, stage V: Has had recent initiation of
HD earlier this month. He had upper extremity vein mapping with
plans for future fistula placement. His antihypertensives were
held given his issues with orthostasis and hypotension after HD
sessions. Last hemodialysis was [**2204-2-22**]
#. Cirrhosis s/p OLT [**2195**]: No evidence of decompensation. No
encephalopathy or ascites on exam. He was continued on his home
cyclosporine and MMF, as well as bactrim prophylaxis.
#. Type 2 DM: All recent HbA1c's have been 5.0 or less. He was
continued on a very gentle sliding scale.
#. Hyperlipidemia: Continued home statin
Medications on Admission:
Nephrocaps 1 cap po daily
Alendronate 35mg po qweek
Cyclosporine modified 125mg po bid
MMF 250mg po bid
Omega 3 fatty acids 2 caps po bid
Pravastatin 80mg po daily
Sulfamethoxazole-trimethoprime 400-80mg po daily
ASA 81mg po daily
Calcium carbonate-vitamin D3 600mg-400 unit po bid
Recently stopped:
Diltiazem ER 120mg po daily
Furosemide 40mg po daily
Metoprolol tartrate 100mgpo qam, 150mg po qpm
Discharge Medications:
1. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
4. cyclosporine modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours): Dispense same generic as he has been
getting please.
Disp:*180 Capsule(s)* Refills:*2*
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Other
Medications on hold : aspirin, metoprolol, lasix and alendronate
7. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet
Sig: One (1) Tablet PO twice a day.
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
9. pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
retroperitoneal right colonic perforation [**12-22**] argon-coagulation
during colonoscopy
A-V malformation cecum
s/p Right colectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you have fever,
chills, nausea, bloody vomit, vomiting, increasing abdominal
pain, diarrhea, bloody stool, diarrhea or incision redness,
bleeding or drainage.
Continue outpatient hemodialysis per routine schedule
Continue medications with some adjustments, food and fluid
restrictions per your kidney doctors [**Name5 (PTitle) 7219**]. Please
note that your cyclosporine dosage was changed while you were
hospitalized. [**Name5 (PTitle) 1326**] coordinator will follow up with
regarding dose. Also please hold for now your aspirin, lasix,
metoprolol and alendronate. These will be re-evaluated at your
clinic visit next week.
Please take your blood pressure daily and bring copy of record
with you to the clinic visit.
You should not shower with the tunneled dialysis access in your
chest. Monitor the exit site for redness, drainage or bleeding
and call the [**Name5 (PTitle) **] clinic at [**Telephone/Fax (1) 673**] if this occurs. A
culture was taken on [**2204-2-22**] from the exit site.
No driving if taking narcotic pain medication
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2204-2-27**] 8:45
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2204-3-14**] 1:20
Completed by:[**2204-2-22**]
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"403.91",
"588.81",
"571.5",
"562.10",
"V42.7",
"585.6",
"587"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"45.93",
"45.13",
"39.95",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
11488, 11494
|
8048, 10045
|
277, 395
|
11672, 11672
|
3656, 3656
|
12963, 13272
|
2891, 2971
|
10495, 11465
|
11515, 11651
|
10071, 10472
|
11823, 12940
|
3011, 3637
|
231, 239
|
7683, 8025
|
423, 2042
|
3672, 7663
|
11687, 11799
|
2064, 2595
|
2611, 2875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,740
| 186,780
|
5379
|
Discharge summary
|
report
|
Admission Date: [**2133-1-30**] Discharge Date: [**2133-2-7**]
Date of Birth: [**2069-2-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
1. Hepatocellular carcinoma.
2. Cholelithiasis.
3. Hepatitis C infection.
Major Surgical or Invasive Procedure:
[**2133-1-30**] Cholecystectomy and segment 6 resection
History of Present Illness:
63-year-
old female with a history of HCV genotype 1. An ultrasound
for surveillance on [**2132-12-29**], demonstrated a new 1.6
x 1.9 x 2.1 cm lesion in segment 6 of the right lobe of the
liver with ill-defined margins in the internal vascularity
concerning for hepatoma. She had unchanged cholelithiasis and
an unchanged renal angiomyolipoma. On [**2133-1-14**], an
MRI demonstrated a 2.6 cm arterial enhancing lesion in
segment 6 consistent with hepatocellular carcinoma. 63-year-
old female with a history of HCV genotype 1. An ultrasound
for surveillance on [**2132-12-29**], demonstrated a new 1.6
x 1.9 x 2.1 cm lesion in segment 6 of the right lobe of the
liver with ill-defined margins in the internal vascularity
concerning for hepatoma. She had unchanged cholelithiasis and
an unchanged renal angiomyolipoma. On [**2133-1-14**], an
MRI demonstrated a 2.6 cm arterial enhancing lesion in
segment 6 consistent with hepatocellular carcinoma. She
provided informed consent for a segment 6 mass resection and
cholecystectomy.
Past Medical History:
PMH: hepatitis C ?from blood transfusion, HTN
PSH: R carpal tunnel release [**7-27**]
Social History:
Divorced. She has one child age 35. She is currently disabled.
She has a master's degree in art.
Family History:
mother age 83 Alzheimer's. Her father died at 94 after colon
surgery. Her paternal grandfather died in his 70s of
unknown causes. Her paternal grandmother died in her 70s of
heart disease.
Physical Exam:
T98.3 HR 79 BP 121/79, RR16, O2 sat 97% Wght 67.6 kilos
Gen: She is a well-developed, well-nourished female in no acute
distress. Skin: Nospider angiomata or palmar erythema.
HEENT: No scleral icterus. Oropharynx clear.
Neck: No lymphadenopathy or thyromegaly.Carotids 2+/4+ without
bruits. Lungs: Clear to auscultation.
Cardiac: Normal S1-S2. No S3, S4, murmurs, or rubs.
Regular rate and rhythm.
Abdominal exam is benign. Normal bowel sounds. She has no
hepatosplenomegaly,
masses, or tenderness.
Extremities: No peripheral edema. Pulses are 2+/4+.
Neurologically grossly intact without asterixis
Pertinent Results:
CXR [**2-3**] In comparison with the study of [**2-2**], there is some
improved lung
volumes. Persistent haziness in the right hemithorax is
consistent with
pleural fluid with compressive basilar atelectasis. Less
prominent.
Atelectasis and effusion are seen on the left. The upper lung
zones are
clear.
Pathology:
Liver, segment 6 mass (A-F):Hepatocellular carcinoma, 2.1 cm,
See Synoptic Report.Uninvolved liver parenchyma with:
1. Moderate portal and periportal mononuclear inflammation
(Grade 2).
2. Mild to moderate macro and micro vesicular steatosis.
3. Trichrome stain shows increased fibrosis and septa formation
(Stage 3).
4 Iron stain shows no stainable iron.
Note: These findings are consistent with viral hepatitis
(HCV) Grade 2 inflammation, Stage 3.
Gallbladder (G):
Chronic cholecystitis.
Brief Hospital Course:
[**2133-1-30**] Patient admitted to the surgical service
postoperatively. Perioperative antibiotics. Patient had Foley
in place. Acute pain managed patient's perioperative narcotics
as intrathecal morphine was given preoperatively.
[**2133-1-31**] -[**2-1**] Overnight patient did well . She was advanced to
sips with maintenance fluids the following morning. Dilaudid PCA
was started for pain control.
[**2133-2-2**] In the am of [**2-2**] patient was noted to have rapid heart
rate. ECG performed showed atrial fibrillation with RVR to the
180s. Stat cardiac enzymes and chemistry panel was sent.
Patient was placed on telemetry and metoprolol 5 mg x3 given.
CXR was performed with mild fluid overload thus prompting
administration of 10 of IV Lasix. Diltiazem was given 2 times
with SBP decreased to high 70-80s. Patient was transferred to
the ICU. Amiodarone was loaded and a both a amiodarone and
diltiazem drip was started. Patient's heart rate became better
controlled and eventually concerted to sinus rhythm. She was
advanced to a regular diet.
[**2133-2-3**] Once amiodarone weaned of pt was bridged with 200 mg Po
amiodarone. Foley discontinued.
[**2133-2-4**] Pt consulted to work with patient and a bowel regimen of
MOM and Dulcolax was prescribed
[**2133-2-5**] Overnight patient had brief self terminating episode of
afib with rate to the 130 for 10 minutes. Metoprolol 5 mg was
given after termination for further beta blockade
[**2133-2-6**] Patient was monitored for an additional 24 hours for
further arrhythmia without further problems.
[**2133-2-7**]: [**Name2 (NI) **] tolerating a regular diet, pain well controlled
with po pain medications
Medications on Admission:
[**Last Name (un) 1724**]: HCTZ 25', lisinopril 10', omeprazole 20', sertraline 100',
trazodone 100 qHS, Tylenol p.r.n, calcium 500", chondroitin
sulfate, glucosamine 1500"
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
Disp:*20 Tablet(s)* Refills:*0*
8. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours: [**Month (only) 116**] use in combination with the oxycodone for pain
relief. Maximum 6 tablets daily.
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Chondroitin Sulfate 250 mg Capsule Sig: One (1) Capsule PO
twice a day.
12. Glucosamine 750 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatocellular carcinoma, Cholelithiasis, Hepatitis C infection.
Discharge Condition:
Good
A+Ox3
Ambulatory
Discharge Instructions:
Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarrhea, increased abdominal pain, incisional
redness, drainage or bleeding or inability to take or keep down
food/fluids or medications.
You have been started on a new medication called amiodarone for
the transient atrial fibrillation you had post surgery. If at
home you note that you are having palpitations, chest pain or
difficulty breathing you should proceed to the emergency room.
Call your primary care physician if these symptoms come and go
quickly. A cardiology follow up has been scheduled for you.
No heavy lifting.
No driving if taking narcotic pain medication.
You may resume all of your home medications.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2133-2-11**]
11:40
[**First Name9 (NamePattern2) 21861**] [**Location (un) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2133-4-23**] 11:40
[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time: [**2133-2-9**] 08:40
Call your ophthalmologist to schedule an eye exam.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2133-2-9**]
|
[
"571.5",
"574.10",
"155.0",
"070.54",
"368.8",
"401.9",
"E878.6",
"276.6",
"427.31",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.22"
] |
icd9pcs
|
[
[
[]
]
] |
6422, 6428
|
3430, 5104
|
386, 444
|
6537, 6561
|
2587, 3407
|
7343, 7954
|
1750, 1943
|
5328, 6399
|
6449, 6516
|
5130, 5305
|
6585, 7320
|
1958, 2568
|
273, 348
|
472, 1506
|
1528, 1617
|
1633, 1734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,521
| 166,817
|
4876
|
Discharge summary
|
report
|
Admission Date: [**2102-3-12**] Discharge Date: [**2102-3-20**]
Date of Birth: [**2025-11-26**] Sex: M
Service: [**Doctor Last Name 1181**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old
male with a past medical history significant for diabetes
mellitus, end-stage renal disease, on hemodialysis secondary
to diabetes, bilateral below knee amputations, and congestive
heart failure, who noted, on the morning of admission, pink
discoloration of his left fifth fingertip. In the area, he
had an old crusted eschar. The patient denied trauma and the
patient did not know how the finger got discolored. The
patient has peripheral neuropathy and did not feel anything
knew. The patient denied fever, chills, rashes, nausea,
vomiting, diarrhea. The patient has stable dyspnea on
exertion but no chest pain.
In the Emergency Department, the eschar was unroofed with
minimal purulence. The patient was given Ancef 1 gram IV
times one.
PAST MEDICAL HISTORY:
1. Diabetes mellitus times 50 years.
2. End-stage renal disease, on hemodialysis Tuesday,
Thursday, and Saturday.
3. GERD.
4. Peripheral vascular disease, status post bilateral BKA.
5. Atrial fibrillation.
6. History of CHF.
7. Depression.
8. Hypothyroidism.
9. Hepatitis B.
10. Peripheral neuropathy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Proamatine 5 three times per week.
2. Amiodarone 200 q.d.
3. Aspirin 81 mg q.d.
4. Coumadin 1 mg q.d.
5. Epogen 5,000 units three times a week.
6. Humulin [**11-25**].
7. Levoxyl 150 micrograms q.d.
8. Lopressor 100 mg b.i.d.
9. Metamucil.
10. Nephrocaps 400 mg q.d.
11. Peri-Colace 100 mg q.d.
12. Prilosec 20 b.i.d.
13. Zoloft 75 q.d.
14. Renagel 800 t.i.d.
15. PhosLo two tablets t.i.d.
16. B6 50 b.i.d.
17. B12 one q.d.
FAMILY HISTORY: Significant for diabetes mellitus. The
patient's mother died at 81, history of an ulcer. Father died
at 88 due to heart problems.
SOCIAL HISTORY: The patient lives with his sister and
nephew. [**Name (NI) 1139**]: Smoked 50 years, a pack and a half, quit
ten years ago. Alcohol: One to two beers per week.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.6, BP 152/60, pulse 72, respiratory rate 24. General:
The patient was a pleasant man, looking his stated age, in no
apparent distress. HEENT: The pupils were equal, round, and
reactive to light. The oropharynx was clear. The mucous
membranes were moist. Neck: Supple. No lymphadenopathy.
No JVD. Lungs: Clear to auscultation bilaterally. Heart:
Regular rate and rhythm. Normal S1, S2, III/VI systolic
ejection murmur at the right upper sternal border. Abdomen:
Soft, nontender, nondistended with active bowel sounds.
Extremities: Bilateral BKAs without edema. Left fifth
finger with redness and warmth at tips with open ulcer,
nonpurulent, nondraining, 2+ radial pulse.
LABORATORY/RADIOLOGIC DATA: White count 14.0, 81%
neutrophils, 11% lymphs, hematocrit 31.4, platelets 472,000.
PT 14.1, INR 1.3. Sodium 138, potassium 3.6, chloride 98,
bicarbonate 27, BUN 27, creatinine 4.5, glucose 281. Left
fifth finger swab Gram's stain negative for polys or
micro-organisms, culture pending.
Left fifth digit film: No osseous destruction suggesting
osteomyelitis.
TTE in [**2101-12-21**] showed an ejection fraction of greater
than 55%, trace AR and mild MR.
Dobutamine echocardiogram in [**2101-12-21**] without
inducible ischemia.
HOSPITAL COURSE: This is a 76-year-old man with
insulin-dependent diabetes mellitus, end-stage renal disease
on hemodialysis with a history of atrial fibrillation and
history of CHF who presents with left fifth fingertip ulcer
and cellulitis. There was no evidence of osteomyelitis and
no obvious evidence of acute infection, although the patient
was started on Zosyn 2.25 grams IV q. eight to cover for
Pseudomonas. Blood cultures were sent and the patient was
treated with wet-to-dry dressings q.d. All diabetes and
medications for his end-stage renal disease were continued.
The patient was noted to be subtherapeutic for his atrial
fibrillation and thus was given an additional dose of
Coumadin. Goal INR was [**1-23**].
Of note, during the hospital course, the patient was noted to
have elevated blood pressures and his metoprolol was
increased to 125 mg b.i.d. Otherwise, issues remained
stable.
The following day, the patient had an episode of nausea and
vomiting times one but no abdominal pain. A chest x-ray and
a KUB were ordered. The KUB did not demonstrate obstruction
or free air. The chest x-ray demonstrated a new left pleural
effusion with probable increase in heart size, pleural
plaques, and calcification. Since the pleural effusion did
not have any obvious etiology, it was determined that
eventual thoracentesis would be needed, but at this time
there was still concern that the finger ulceration could be
due to an emboli, thus an echocardiogram was ordered and the
patient was continued on Zosyn.
The plastic surgeons who specialize in hands were consulted.
In addition to concern for embolic phenomenon, Transplant
Surgery was consulted because of possible vascular steal
phenomenon in the setting of his AV fistula in that arm,
although it has been present for years. The patient also had
upper arterial Dopplers performed on [**2102-3-15**].
The patient continued to be asymptomatic at this time, and
antibiotics and local management were continued. A CT of the
chest was ordered to further evaluate the pleural effusion.
The CT suggested question of a left hilar mass as well as a
layering pleural effusion as well as known pleural plaques
that remained stable.
Transplant Surgery, after reviewing the duplex of the left
arm which showed a stenotic proximal AVF just distal to the
arterial anastomosis, determined that the patient would go to
the OR on [**2102-3-16**] for Perma-Cath placement as well as
ligation of the AV fistula because this was resulting in a
steal syndrome and arterial insufficiency.
The patient went to the OR on [**2102-3-16**] and was noted to have
a complicated course. Following the AV fistula ligation and
the Perma-Cath insertion under MAC anesthetic, the patient
had airway obstruction and hypoxia. Thus, he was converted
to general anesthesia. At this time, his rhythm changed from
sinus rhythm to atrial fibrillation with hypotension
requiring boluses of Neo-Synephrine. The patient was also
given Lopressor 50 mg and Esmolol 50 mg for rate control. At
the end of the case, the patient was breathing spontaneously,
but it was determined that the patient should be kept
intubated.
He was transferred to the PACU and was stable. At that
point, a Neo drip was started. Cardiology and the Medicine
Team were contact[**Name (NI) **] and it was decided to cardiovert the
patient at the bedside in the PACU since it was a controlled
situation. He was given one shock at 200 joules, and
promptly converted to sinus rhythm. A chest x-ray done in
the PACU demonstrated a large pleural effusion but there was
concern for hemothorax since [**08**],000 units of IV heparin was
given intraoperatively. A chest tube was placed by the
surgeons and 850 cc of slightly serosanguinous fluid was
drained.
The patient was then transferred to the SICU for monitoring
following his AV ligation, Perma-Cath placement, DC
cardioversion for atrial fibrillation as well as chest tube
placement. By [**2102-3-17**], the patient was off
Neo-Synephrine and the patient was extubated without
difficulty. At this point, Surgery recommended the
discontinuation of the Zosyn and he was transferred to the
floor. The chest tube was discontinued on [**2102-3-18**].
The patient eventually received a bed on [**2102-3-18**] on
the floor, continued to do well without complaints but was
noted to be back in atrial fibrillation on the EKG, but had
no symptoms and was maintaining his blood pressure.
At this point, the pleural effusion had been drained via the
chest tube by the surgeons, cytology results were still
pending. The patient continued hemodialysis and was being
continuously anticoagulated for his atrial fibrillation. The
patient did remain on Zosyn, although thought he could be
switched to p.o. antibiotics at this point. Otherwise, the
patient remained stable.
By [**2102-3-20**], the patient continued to feel fine and was
just anxious to go home. At this point, he remained on his
aspirin and beta blocker, as well as Coumadin for
anticoagulation with a goal INR of [**1-23**]. He was also
continued on his Amiodarone and remained in sinus. Cytology
from the pleural effusion remained pending, but the workup
was deferred to outpatient. The patient was continued on
dialysis Tuesday, Thursday, and Saturday, continued his
midodrine prior to dialysis as well as his other renal
medications. Regarding diabetes, he was continued on his
q.i.d. fingersticks with fixed and sliding scale insulin. He
was also continued on his levothyroxine.
Since the patient remained stable and all issues could be
deferred to outpatient, the patient was discharged home on
[**2102-3-20**].
DISCHARGE DIAGNOSIS:
1. AV fistula steal syndrome, status post AV fistula
ligation with Perma-Cath placement.
2. Left pleural effusion of unknown etiology.
3. Atrial fibrillation, status post DC cardioversion.
4. Diabetes mellitus with end-stage renal disease requiring
hemodialysis.
5. Congestive heart failure.
6. Left pinky ulceration.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with PCP,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in one to two weeks; had an appointment
on [**2102-3-27**] at 12:10 p.m. The patient was instructed to
continue dialysis as usual on Tuesdays, Thursdays, and
Saturdays.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg q.d.
2. Aspirin 81 mg q.d.
3. Insulin fixed and sliding scale.
4. Levothyroxine 150 micrograms q.d.
5. Multivitamin.
6. Disanthrol/Docusate b.i.d.
7. Sertraline 75 mg q.d.
8. Sevelamer 800 mg t.i.d.
9. Calcium acetate 667 mg t.i.d. with meals.
10. Midodrine 5 mg three times a week with dialysis.
11. Dulcolax two tablets q.d. as needed.
12. Metoprolol 75 mg b.i.d.
13. Warfarin 1 mg q.o.d.
14. Epogen 5,000 units three times a week.
15. Prilosec 20 mg b.i.d.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 8876**]
MEDQUIST36
D: [**2102-5-24**] 09:33
T: [**2102-5-28**] 10:47
JOB#: [**Job Number 20357**]
|
[
"996.73",
"250.61",
"511.9",
"403.91",
"512.1",
"427.31",
"681.00",
"428.0",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"39.43",
"38.95",
"99.61",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
1833, 1965
|
9853, 10598
|
9138, 9463
|
3477, 9117
|
9487, 9796
|
1379, 1816
|
2183, 3459
|
990, 1356
|
1982, 2168
|
9821, 9830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,256
| 170,652
|
49021
|
Discharge summary
|
report
|
Admission Date: [**2187-10-1**] Discharge Date: [**2187-10-2**]
Date of Birth: [**2137-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
cc: chest pain
transferred to micu for: respiratory distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
50 y/o M w/Alport syndrome, ESRD on HD, CHF, HTN, who presented
to the ED last pm c/o left sided chest pain. Per the notes, the
pt developed left sided chest pain at rest, constant, lasting 2
days, not pleuritic. On arrival to the ED, his pressure was
198/112, p 78, rr 16, 100% on RA. Throughout his time in the
ED, he become progressively more hypertensive, eventually
getting as high as 269/148 (has happened in past per notes.)
Along with this he became more agitated and was paranoid, trying
to pull his lines out. He then became hypoxic to 69% on RA and
was intubated. While in the ED, he received metoprolol 5mg iv
x4 and 25 mg po x1, hydroxyzine 25 po x1, ativan 1 mg po x1 and
2 mg iv x2, sublingual nitro, benadryl, nitropaste, haldol 10 mg
IM, D50, a nitro gtt, propofol, and fentanyl. He was then
transferred to the MICU for further care.
Past Medical History:
1. Alport's syndrome with ESRD, s/p 2 failed renal transplants
([**2152**] and [**2168**]), now on MWF HD.
2. CHF w/EF >55%
3. HTN
4. SVT s/p ablation [**3-22**]
5. Cataracts
6. Hx seizures (? metabolic per notes)
7. R hydrocele
Social History:
divorced w/2 children, ages 10 and 13. used to work with
computers. 3 pack yr hx. Occ EtOH. hx marijuana and cocaine,
none x 2 yrs. No IVDU.
Family History:
mother with alport's syndrome, father with CAD and CABG at age
60, brother died at 16 yrs old from ESRD
Physical Exam:
T: 96.5 BP: 137/85 P: 70
Vent: AC FiO2 60% 500x14 Peep 5 O2 sat 100%
Gen: intubated/sedated, intermittently agitated, not following
commands
HEENT: NC, AT. R pupil surgical, L pupil pinpoint. sclerae
anicteric.
Neck: JVD approx angle of jaw.
Lungs: scattered crackles anteriorly, no wheezes or rhonchi
CV: RRR, +S4, II/VI SEM at apex
Abd: mildly distended, nontender, hypoactive bowel sounds
Ext: warm/dry, 2+ dp bilaterally
Pertinent Results:
[**2187-9-30**] 10:10PM PLT COUNT-218
[**2187-9-30**] 10:10PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+
[**2187-9-30**] 10:10PM NEUTS-54 BANDS-0 LYMPHS-37 MONOS-5 EOS-3
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2187-9-30**] 10:10PM WBC-9.1 RBC-3.25* HGB-10.2* HCT-31.5* MCV-97
MCH-31.4 MCHC-32.3 RDW-20.6*
[**2187-9-30**] 10:10PM CALCIUM-10.8* PHOSPHATE-9.0* MAGNESIUM-2.2
[**2187-9-30**] 10:10PM CK-MB-6
[**2187-9-30**] 10:10PM cTropnT-0.15*
[**2187-9-30**] 10:10PM CK(CPK)-327*
[**2187-9-30**] 10:10PM GLUCOSE-102 UREA N-57* CREAT-13.3*#
SODIUM-140 POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-26 ANION GAP-23*
[**2187-10-1**] 04:50AM PT-13.5* PTT-23.9 INR(PT)-1.2
[**2187-10-1**] 04:50AM PLT COUNT-228
[**2187-10-1**] 04:50AM WBC-14.5*# RBC-3.48* HGB-10.9* HCT-36.7*
MCV-106*# MCH-31.4 MCHC-29.7* RDW-20.8*
[**2187-10-1**] 04:50AM CK-MB-7
[**2187-10-1**] 04:50AM cTropnT-0.14*
[**2187-10-1**] 04:50AM CK(CPK)-404*
[**2187-10-1**] 04:50AM GLUCOSE-70 UREA N-66* CREAT-14.5*# SODIUM-139
POTASSIUM-7.8* CHLORIDE-94* TOTAL CO2-19* ANION GAP-34*
[**2187-10-1**] 04:52AM LACTATE-8.3*
[**2187-10-1**] 06:05AM TYPE-ART RATES-/18 TIDAL VOL-500 PO2-416*
PCO2-50* PH-7.31* TOTAL CO2-26 BASE XS--1 -ASSIST/CON
ECG: rate 87, NRS, normal axis, slightly prolonged QT at 465,
LAE, LVH, ST depression approx 0.5 mm II/III/avF (old), J point
elevation V2-4 (old), TWI III (old). On earlier ECG this
evening had TWI in V6 that resolved this AM.
*
CXR: increased perihilar markings (vs RML infiltrate), ETT 6 cm
above carina, no effusions.
*
CT head:
COMPARISON: [**2187-9-19**].
FINDINGS: There is no intracranial hemorrhage, abnormal
extra-axial fluid collection, mass effect or midline shift. The
ventricles are normal, and the cisterns are patent. The
[**Doctor Last Name 352**]-white matter interface is preserved. The visualized
paranasal sinuses are clear. A loop of the orogastric tube is
present in the nasopharynx.
IMPRESSION: No intracranial hemorrhage or mass effect.
Brief Hospital Course:
50 y/o AAM w/PMHx significant for Alport's disease and ESRD on
HD, with numerous past admissions for hypertensive emergency and
altered mental status.
Patient was initially found to have hypertensive emergency, with
systolic blood pressures in the 260s with signs of end-organ
damage (flash pulmonary edema and altered mental status.) It is
unclear whether this is due to worsening renal fxn, increased
volume load with a two day delay since prior hemodialysis, or
drug use, with history of prior cocaine use. Patient was placed
on a nitroglycerin drip initially, and was hemodialyzed
urgently. He was then placed back on metoprolol and lisinopril
as well. His serum toxicology screens were sent and were
positive only for tylenol. His lethargy improved as well with
improvement in his blood pressure, and on discharge was alert
and oriented. His head CT was negative.
*
Patient was initially found to be in hypoxic respiratory
failure, and was intubated. This was thought due to flash
pulmonary edema in setting of hypertensive emergency. Patient
received hemodialysis, and was extubated after hemodialysis. On
discharge, he had a clear lung exam and good oxygen saturations
on room air.
*
Patient initially presented with complaints of chest pain, with
negative cardiac enzymes except for positive troponin in setting
of ESRD. EKG showed no ischemic changes. He was continued on
ASA, BB, and ACEI. His LDL in [**2185**] was 83, indicating no need
for initiation of a statin.
*
Patient initially had leukocytosis, likely in setting of stress.
Patient remained afebrile and was not started on antibiotics.
*
Patient was noted to have an anion gap metabolic acidosis, with
AG 26, likely due to renal failure and lactic acidosis, and
returned to baseline with dialysis. He was also noted to have
metabolic alkalosis, of unclear etiology.
*
Patient has ESRD secondary to Alport's, with history of 2 failed
transplants in past. He was continued on sevelamer, and
continued on hemodialysis. His pruritus was thought secondary to
uremia and he received a course of steroids. He also had
restless legs, for which he was discharged home on mirapex. His
ferritin level was checked and was elevated.
*
Patient remained full code throughout his hospital stay. He was
discharged to home in stable condition.
.
Medications on Admission:
1. Prednisone 5 mg po daily
2. Lisinopril 5 mg po daily
3. Pantoprazole 40 mg po daily
4. Diphenhydramine 25 mg po q6h prn
5. Sevelamer 1600 mg po tid
6. Toprol 50 mg po daily
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Mirapex 0.125 mg Tablet Sig: One (1) Tablet PO at bedtime:
Before bedtime & also two hours prior to hemodialysis. .
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Malignant hypertension
ESRD on hemodialysis
Restless legs syndrome
Anemia of chronic disease
Pruritus
Respiratory failure secondary to pulmonary edema
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L.
If you develop nausea, vomiting, shortness of breath, swelling
in your ankles, or chest pain, headache, or vision change,
please call your primary care doctor
Followup Instructions:
1. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2187-10-16**] 9:30
2. Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP Date/Time:[**2187-10-16**] 10:30
3. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2187-10-29**] 8:30
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,030
| 197,504
|
17824
|
Discharge summary
|
report
|
Admission Date: [**2191-5-15**] Discharge Date: [**2191-5-25**]
Date of Birth: [**2143-8-12**] Sex: M
Service: Medicine, [**Hospital1 **] Firm
ADMISSION DIAGNOSIS: Esophageal varices and massive upper
gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 2253**] presented to
[**Hospital6 49460**] on [**2191-5-14**] with
a massive upper gastrointestinal bleed, altered mental
status, acute renal failure, and coagulopathy.
The patient's hematocrit was noted to be 14 at the outside
hospital, creatinine was 3.6, and INR was 3.4. An octreotide
drip was started, and the patient was transfused a total of 6
units of packed red blood cells and 4 units of fresh frozen
plasma.
A head computed tomography was performed which was negative
for an intracranial hemorrhage but was for atrophy. An
esophagogastroduodenoscopy demonstrated grade 2 varices and
portal gastropathy. The patient was started on spontaneous
bacterial peritonitis prophylaxis secondary to a history of
ascites on a computed tomography scan from [**2189-9-19**].
Mr. [**Known lastname 2253**] was transferred to [**Hospital1 188**] for further management. Of note, the patient was
intubated for airway protection on presentation to
[**Location 49461**] [**Hospital 12018**] Hospital.
Mr. [**Known lastname 2253**] presented to [**Hospital1 69**]
via transfer on [**2191-5-15**]. An abdominal ultrasound
demonstrated no portal venous flow and positive hepatofugal
flow in the portal vein.
An esophagogastroduodenoscopy was performed on [**2191-5-16**]
which demonstrated grade 3 varices in the lower one third of
the esophagus and middle one third of the esophagus. These
varices were injected with morrhuate. Also, there was [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear seen in the cardia and portal gastropathy
was also commented upon.
The patient was continued on levofloxacin and Flagyl for a
question of an aspiration pneumonia and spontaneous bacterial
peritonitis prophylaxis. While in the Intensive Care Unit,
the patient remained on a proton pump inhibitor q.12h., an
octreotide drip, and received a further 6 units of packed red
blood cells and 6 units of fresh frozen plasma.
Since [**5-17**], the patient's hematocrit had been with q.8h.
hematocrit checks, averaging between 34 and 35. Also of
note, the patient was started on nadolol.
The patient was intubated on arrival and subsequently
extubated on [**5-18**] in the morning and remained on 4 liters
nasal cannula with an oxygen saturation of greater than 93%.
Also notable was blood cultures on [**5-15**] which were
positive in [**1-22**] bottles for coagulase-negative
Staphylococcus; 1/2 bottles on [**5-16**] were positive for
coagulase-negative Staphylococcus; and negative blood
cultures from [**5-17**] and [**5-18**].
Secondary to these blood cultures and fevers, the patient's
right femoral central venous line was changed to a right
internal jugular central venous line on [**5-17**]. As the
patient had presented to the outside hospital in acute renal
failure, with volume resuscitation the patient's creatinine
decreased to 0.8 on the day of transfer to the medical floor.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Pancreatitis.
3. Alcoholic cirrhosis with encephalopathy and ascites.
4. Chronic anemia.
5. Hypertension.
6. History of prior alcohol withdrawal seizures.
ALLERGIES: ERYTHROMYCIN (causes a rash).
MEDICATIONS ON ADMISSION: Atenolol, Lasix, Prilosec,
spironolactone, and diazepam.
MEDICATIONS ON TRANSFER TO THE MEDICAL FLOOR:
1. Octreotide 50 mcg per hour.
2. Lactulose 30 mL p.o. three times per day.
3. Regular insulin sliding-scale.
4. Protonix 40 mg p.o. twice per day.
5. Folic acid 1 mg p.o. once per day.
6. Thiamine 100 mg p.o. once per day.
7. Levofloxacin 500 mg p.o. once per day (started on [**5-17**]).
8. Flagyl 500 mg p.o. three times per day (started on [**5-17**]).
9. Nadolol 20 mg p.o. once per day.
FAMILY HISTORY: Family history is significant for alcohol
and coronary artery disease.
SOCIAL HISTORY: The patient lives alone in an apartment.
The patient is on disability. He smokes one pack per day and
has attended Alcohol Anonymous meetings since [**2191-4-19**]. The patient did note binge drinking about one week
prior to his presentation to the outside hospital.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on transfer revealed vital signs with a temperature of 100.2
degrees Fahrenheit, heart rate was 86, blood pressure was
115/78, respiratory rate was 25, and oxygen saturation was
95% on room air. In general, chronically ill-appearing, in
no acute distress. Alert and oriented times two. Head,
eyes, ears, nose, and throat examination revealed sclerae
were anicteric. Mucous membranes were moist. The oropharynx
was clear. Pupils were equally round and reactive to light.
Extraocular movements were intact. The neck was supple.
Right internal jugular in place and intact, without erythema
or tenderness. The chest examination revealed symmetric
excursion. Decreased breath sounds at the right base;
otherwise, no wheezes, rhonchi, or rales. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. No third heart sound
or fourth heart sound. No murmurs or rubs. No right
ventricular heave appreciated. Point of maximal impulse was
not displaced. The abdomen was mildly distended. Soft and
nontender. Normal active bowel sounds. The liver edge was
not palpable. There were no spider angiomata or
telangiectasia on the abdomen. Several telangiectasias were
noted, however, on the face. Extremity examination revealed
1+ pedal and hand edema. Dorsalis pedis pulses were 2+.
Neurologic examination revealed distal sensation was intact.
Quadriceps were 2 to 3+ bilaterally. Biceps were 2+
bilaterally. No asterixis noted.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
transfer revealed white blood cell count was 12.4, hematocrit
was 35.1, and platelets were 61. Sodium was 142, potassium
was 3.6, chloride was 110, bicarbonate was 23, blood urea
nitrogen was 16, creatinine was 0.6, and blood glucose was
118. Calcium was 7.6, magnesium was 1.7, and phosphate was
3.4. Prothrombin time was 19.2, INR was 2.4, and partial
thromboplastin time was 34.6.
PERTINENT LABORATORY VALUES ON DISCHARGE: Laboratories on
discharge revealed white blood cell count was 10.5,
hematocrit was 34, and platelets were 130. Prothrombin time
was 18.4, partial thromboplastin time was 32.8, and INR was
2. Potassium was 4.4. Blood urea nitrogen was 9.
Creatinine was 0.8. Liver function tests were significant
for a total bilirubin of 1.7 and a LD of 290; otherwise,
liver function tests were within normal limits.
PERTINENT RADIOLOGY/IMAGING: An abdominal ultrasound on
[**2191-5-15**] demonstrated retrograde flow in the right
portal vein. Anterograde flow in the left portal vein with
recannulized periumbilical vein noted. Flow in the splenic
vein was antegrade. There was no definite flow within the
main portal vein; however, this may have been noted for
technical reasons. There was splenomegaly and findings
consistent with cirrhosis. The spleen was noted to be 14 cm.
A chest x-ray on [**2191-4-20**] demonstrated a diminished
patchy density at the right apex. Perihilar opacities were
persistent. A right pleural effusion was noted. There were
multiple left-sided rib fractures noted.
Left elbow and left ankle plain films were significant for an
irregularity in the later epicondyle; raising the question of
chronic tendinitis in the left elbow. Otherwise, there was
no evidence of fracture. The ankle films demonstrated
swelling of the soft tissue laterally. There were no
apparent fractures.
A right lower extremity ultrasound was significant for patent
vasculature. No deep venous thrombosis was identified.
An esophagogastroduodenoscopy performed on [**2191-5-16**]
demonstrated grade 3 varices seen in the lower third of the
esophagus and middle third of the esophagus. The varices
were noted to oozing. Five 2-cc sodium morrhuate injections
were applied for hemostasis with partial success. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear with a stigmata of recent bleeding was
demonstrated in the cardia. The stomach was significant for
diffuse discontinuous erythema, congestion, petechiae, and
erosion of the mucosa with no bleeding noted in the fundus
and in the stomach body. These findings were compatible with
portal gastropathy. The duodenum was noted to be normal.
MICROBIOLOGY RESULTS: Blood cultures from [**2191-5-15**]
were positive in [**1-22**] bottles for coagulase-negative
Staphylococcus resistant to penicillin; and sensitive to
oxacillin, levofloxacin, gentamicin, erythromycin, and
clindamycin. 1/2 bottles on [**2191-5-16**] was positive for
coagulase-negative Staphylococcus resistant to gentamicin,
levofloxacin, oxacillin, and penicillin.
Blood cultures from [**5-17**], [**5-18**], and [**5-19**] were
negative for growth at the time of this dictation.
A catheter tip from the right femoral central venous line was
cultured and was negative for growth on [**2191-5-17**].
IMPRESSION: Mr. [**Known lastname 2253**] is a 47-year-old gentleman with
presentation to an outside hospital with a massive upper
gastrointestinal bleed secondary to esophageal varices.
The patient was transferred for further management to [**Hospital1 1444**].
The patient was stabilized with an octreotide infusion,
multiple transfusions of packed red blood cells and fresh
frozen plasma. An esophagogastroduodenoscopy performed
demonstrated grade 3 varices which were partially treated
with sclera therapy. Status post sclera therapy, the
patient's hematocrit levels remained stable with no
significant decrements after [**2191-5-17**].
The patient's encephalopathy continued to improve throughout
his hospitalization.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. UPPER GASTROINTESTINAL BLEED ISSUES: Mr. [**Known lastname 2253**] was
transferred for further evaluation and management of a
massive upper gastrointestinal bleed with a hematocrit of 14
on presentation.
The patient's blood volume was supported with transfusions of
packed red blood cells. The patient received a total 6 units
of packed red blood cells while in the Medical Intensive Care
Unit at [**Hospital1 69**]. The patient's
coagulopathy was also reversed with fresh frozen plasma while
he was experiencing the acute hemorrhage.
A esophagogastroduodenoscopy was performed which was
significant for findings as described above.
The patient remained on octreotide for five days after the
bleeding was controlled. After the patient's last blood
transfusion on [**2191-5-17**], q.8h. hematocrit checks
remained stable and above 30. The patient's octreotide was
discontinued on [**2191-5-21**].
While hospitalized, the patient remained on Protonix
initially intravenously q.12h. He was subsequently switched
to an oral regimen as the patient could tolerate.
Mr. [**Known lastname 2253**] was started on nadolol prior to discharge from the
Medical Intensive Care Unit, and his heart rates decreased
and remained in the 80s with this medication. The patient
remained hemodynamically stable throughout his admission on
the medical floor.
Mr. [**Known lastname 2253**] will require a repeat esophagogastroduodenoscopy
as an outpatient. I contact[**Name (NI) **] the patient's
gastroenterologist that had seen Mr. [**Known lastname 2253**] while at
[**Location 49461**] [**Hospital 12018**] Hospital Emergency Department
(Dr. [**Last Name (STitle) **]. The patient will schedule an appointment to see
Dr. [**Last Name (STitle) **] within two weeks following discharge.
2. ALCOHOLIC CIRRHOSIS WITH ENCEPHALOPATHY ISSUES: Mr.
[**Known lastname 2253**] was originally intubated for airway protection
secondary to the massive upper gastrointestinal bleeding. He
was transferred to [**Hospital1 69**] while
intubated. There was concern with his prior history of
alcohol withdrawal seizures and recent binge drinking prior
to presentation. However, the patient had no episodes of
withdrawal seizures while admitted in the Medical Intensive
Care Unit or on the medical floor.
Upon extubation on [**5-18**] and subsequent weaning of
sedation, the patient's mental status continued to improve.
Mr. [**Known lastname 2253**] was maintained on a lactulose regimen to achieve
two to three bowel movements per day. This regimen was
lactulose 30 mL p.o. twice per day.
Upon discharge, the patient was alert and oriented to person,
place, and time. He was noted to have no asterixis on
examination prior to discharge.
As Mr. [**Known lastname 2253**] was noted to have ascites on computed
tomography scan in [**2189-9-19**], he was placed on
spontaneous bacterial peritonitis prophylaxis with
levofloxacin at [**Location 49461**] [**Hospital 12018**] Hospital. This
medication was continued for spontaneous bacterial
peritonitis prophylaxis while at [**Hospital1 190**] as well as treatment for an aspiration
pneumonia in conjunction with Flagyl. The patient remained
afebrile throughout his hospitalization on the medical floor.
3. COAGULOPATHY ISSUES: Mr. [**Known lastname 49462**] coagulopathy was
initially treated with a transfusion of fresh frozen plasma
while he was acutely bleeding. Upon stabilization of his
upper gastrointestinal bleed, Mr. [**Known lastname 2253**] was administered
oral vitamin K without reversal of his INR.
The patient's INR trended up to 3 on [**2191-5-21**]. He was
switched to vitamin K subcutaneously with a slow decrease in
his INR to 2.2 on the day prior to discharge.
4. ACUTE RENAL FAILURE ISSUES: Mr. [**Known lastname 2253**] was noted to be
in acute renal failure on presentation to the outside
hospital with a creatinine of 3.6.
Upon volume resuscitation, the patient's creatinine quickly
diminished from 2.9 on [**5-15**] to 0.8 on the day prior to
discharge.
As the patient was being treated with diuretics for his known
ascites, careful addition of spironolactone and Lasix
resulted in no further increase in the patient's creatinine.
5. RIGHT LOWER EXTREMITY EDEMA ISSUES: Several days prior
to discharge, the patient was noted to have increasing right
lower extremity edema.
Mr. [**Known lastname 2253**] had been somewhat noncompliant with keeping his
lower extremities elevated. However, a right lower extremity
ultrasound was performed to evaluate for deep venous
thrombosis. No deep venous thrombosis was demonstrated on
this study performed on [**2191-5-24**]. [**Male First Name (un) **] stockings were
applied and are recommended to continue to treat this edema.
6. INFECTIOUS DISEASE ISSUES: As noted above, the patient
was maintained on spontaneous bacterial peritonitis
prophylaxis. Secondary to the concern of aspiration
pneumonia, the patient was to be treated with a 14-day course
with levofloxacin and Flagyl. The last dose was to be
administered on [**2191-5-30**].
A question of an aspiration pneumonia was raised secondary to
the patient's fevers, leukocytosis, and a right-sided
infiltrate noted on [**5-15**].
7. NUTRITIONAL ISSUES: Mr. [**Known lastname 49462**] diet was continually
advanced. He tolerated and increasing amount of protein very
well without evidence for worsening encephalopathy.
At the time of discharge, the patient was receiving a diet
restricted to 2 g of sodium and 1 g/kg of protein per day.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Esophageal varices.
3. [**Doctor First Name **]-[**Doctor Last Name **] tear.
4. Acute blood loss anemia.
5. Thrombocytopenia.
6. Hepatic encephalopathy.
7. Ascites.
8. Aspiration pneumonia.
9. Coagulopathy.
10. Edema.
11. Hypokalemia
12. Portal vein thrombosis; no anticoagulation per
Gastroenterology recommendations.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. once per day (last dose to be
administered on [**2191-5-30**]).
2. Flagyl 500 mg p.o. three times per day (last dose to be
administered on [**2191-5-30**]).
3. Thiamine 100 mg p.o. once per day.
4. Folic acid 1 mg p.o. once per day.
5. Protonix 40 mg p.o. twice per day.
6. Nadolol 20 mg p.o. once per day.
7. Lasix 20 mg p.o. once per day.
8. Spironolactone 50 mg p.o. four times per day.
9. Lactulose 30 mL p.o. twice per day (goal bowel movements
of two to three per day).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. Mr. [**Known lastname 2253**] was to follow up with Dr. [**Last Name (STitle) **] in two weeks
after discharge. Attempting to schedule an appointment with
Dr. [**Last Name (STitle) **] at the time of this dictation. The patient was to
call telephone number [**Telephone/Fax (1) 49463**] to schedule an
appointment. The address is [**Location (un) 5871**] Gastroenterology, [**Street Address(2) 49464**], [**Location (un) 5871**], [**Numeric Identifier 49465**].
2. Mr. [**Known lastname 2253**] was to follow up with the Liver Service at the
[**Hospital1 69**] as directed by his
gastroenterologist in [**Location (un) 5871**].
3. While at [**Hospital1 69**], the
patient was seen by Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
DISCHARGE STATUS: The patient was to be discharged to a
[**Hospital 3058**] rehabilitation facility; [**Hospital1 49466**] in [**Location (un) 5871**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. [**MD Number(1) 33177**]
Dictated By:[**Name8 (MD) 44562**]
MEDQUIST36
D: [**2191-5-24**] 16:17
T: [**2191-5-24**] 16:52
JOB#: [**Job Number 49467**]
cc:[**Telephone/Fax (1) 49468**]
|
[
"285.1",
"789.5",
"571.2",
"584.9",
"507.0",
"572.2",
"456.20",
"452",
"530.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.15",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4045, 4117
|
15648, 16025
|
16051, 16565
|
3521, 4028
|
16598, 17561
|
10098, 15626
|
186, 248
|
17576, 17915
|
6456, 10064
|
277, 3227
|
3249, 3493
|
4134, 6441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
287
| 174,293
|
16060
|
Discharge summary
|
report
|
Admission Date: [**2167-5-22**] Discharge Date: [**2167-5-27**]
Date of Birth: [**2096-12-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 70-year-old male
with recurrent nasal-ethmoid adenocarcinoma, who underwent a
craniofacial resection for ethmoid cancer with lateral
rhinotomy. Past medical history of this cancer also had
surgery x2 for this problem twice in the past.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: On physical exam, blood pressure was
147/66, pulse 110. In general, elderly man in no acute
distress, walks with a cane. HEENT: Positive clear
rhinorrhea bilateral nares. Pupils are equal, round, and
reactive to light. EOMs full. No lymphadenopathy, no
thyromegaly. Chest was clear to auscultation. Cardiac:
Regular, rate, and rhythm, no murmurs, rubs, or gallops.
Abdomen is soft, nontender, nondistended, negative masses,
negative hepatosplenomegaly. Extremities: No clubbing,
cyanosis, or edema. His strength is [**4-27**] in all muscle
groups.
MEDICATIONS PREOPERATIVE:
1. Ranitidine.
2. Vioxx.
3. Folic acid.
He was admitted status post a subfrontal craniotomy with
resection of the nasal-ethmoid carcinoma. Surgeons were
[**Doctor Last Name 1906**], Caradonnar, and [**Doctor Last Name **]. He had no complications from
the surgery. He was monitored in the Intensive Care Unit
overnight. His vital signs remained stable. He was
afebrile. He remained intubated and sedated. He awoken to
painful stimuli. His pupils were pin point and brisk. He
had cough and gag intact, withdraw extremities to nailbed
pressure. His vital signs were stable. His lungs were
clear.
On postoperative day #1, he still continued to be intubated.
Was awake, following commands bilaterally. His IP strength
was [**4-27**]. He had antigravity strength in both his upper and
lower extremities. His dressing was clean, dry, and intact.
He had no evidence of CSF leak and his vital signs were
stable.
Patient was extubated on [**2167-5-24**]. His vital signs were
stable. He was afebrile. He opened his eyes spontaneously.
He is moving all extremities with good strength. His
dressing was clean, dry, and intact. EOMs were full. He was
transferred to the floor on postoperative day #2. His vital
signs were stable. He is afebrile. Pupils are 2.5 down to 2
and brisk. His grasp was strong, he was following commands.
He had no evidence of CSF leak. His dressing was clean, dry,
and intact. He did have some periods of agitation, and was
receiving Haldol for that and he had a sitter while he was in
the Intensive Care Unit.
His sitter was discontinued before he went to the floor. He
had a swallow evaluation which showed that he was
............. and had aspirating on thin liquids. He was
made NPO.
On [**2167-5-26**], he was awake, alert, and oriented times three
with bilateral drift. Grasps were 4+/5. IPs are [**4-27**]. His
eyes were swollen shut. His smile was symmetric. He was
seen by Physical Therapy and Occupational Therapy and found
to require rehab.
On [**2167-5-27**], he had a repeat swallow evaluation which he
passed. He was started on a soft solid diet with some nectar
thick liquids, and was ready for discharge to rehab. His
vital signs remained stable. His incision was clean, dry,
and intact.
DISCHARGE MEDICATIONS:
1. Heparin 5,000 units subQ q12h.
2. Famotidine 20 mg po bid.
3. Metoprolol 25 po bid, hold for systolic blood pressure
less than 110, heart rate less than 55.
4. Folic acid 1 mg po q day.
5. Acetaminophen 650 po q4h prn.
6. Hydromorphone 1-2 mg po q4h prn.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: He should have his staples removed
on postoperative day #10, and follow up with Dr. [**Last Name (STitle) 1906**] at
[**Hospital 4415**] in six weeks.
[**First Name8 (NamePattern2) 900**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 1908**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2167-5-27**] 11:40
T: [**2167-5-27**] 12:20
JOB#: [**Job Number 45953**]
|
[
"160.3",
"198.4",
"197.3",
"714.0",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"22.63",
"01.51",
"01.6",
"22.42",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3339, 3598
|
3657, 4082
|
468, 3316
|
161, 445
|
3623, 3632
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,453
| 135,657
|
32351
|
Discharge summary
|
report
|
Admission Date: [**2134-9-22**] Discharge Date: [**2134-9-29**]
Date of Birth: [**2089-3-19**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Ciprofloxacin
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD with variceal banding on [**9-22**]
History of Present Illness:
Mr, [**Known lastname 53917**] is a 45 y/o M with h/o Etoh cirrhosis c/b esophageal
varices s/p banding and ascites complains of epigastric and
right upper quadrant pain. This began yesterday. Also had [**3-25**]
episodes of coffee-ground emesis and continues to feel nauseous.
Has had black, tarry, dark stool x 1 only. Has not had further
bowel movements. Also had one episode of emesis with red blood.
Denies fevers, chills, chest pain, shortness of breath,
dizziness, lightheadedness.
Reports that his belly pain is epigastric, throbbing in quality,
worse when he lays down flat.
In the ED, he received protonix 80 mg IV and then 8 mg/hr gtt,
octreotide gtt started, and ceftriaxone x 1 for SBP prophylaxis.
Past Medical History:
EtoH cirrhosis
Esophageal Varices
- Grade II and s/p banding procedures
- s/p multiple variceal bleeds, 6 episodes from [**2128**] to [**11-27**]
s/p multiple bandings
- [**11-30**] EGD: 1 cord of grade 2 varices, 2 cords of grade 1
varices were seen in the lower third of the esophagus; changes
consistent with Barrett's
Chronic pancreatitis
EtOH abuse
Bipolar disorder
S/p CCY in [**5-29**]
S/p Right ACL replacement and meniscectomy in [**2126**]
Social History:
Drinks 1-1.5 pints of whiskey per day, last drink 6 pm day
before admission. Denies ever smoking, denies ilicits. Lives
in an apt in [**Location (un) 86**] with roommates, does not have a close
relationship with his family
Family History:
h/o alcoholism and kidney cancer
Physical Exam:
ADMISSION EXAM:
VS: 98.2, 110/74, 87, 7, 95% RA
GENERAL: AOx3, NAD
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: CTAB no crackles or wheezes, non labored
ABDOMEN: soft, tender to palpation in epigastrium, nondistended.
no guarding or rebound, neg HSM. neg [**Doctor Last Name 515**] sign.
EXT: wwp, no edema. DPs, PTs 2+.
SKIN: dry, no rash, no evidence of chronic liver disease
NEURO/PSYCH: CNs II-XII intact. Pupils 3cm bilaterally and
PERRLA. strength and sensation in U/L extremities grossly
intact. gait not assessed.
DISCHARGE PHYSICAL EXAM
Physical exam:
Vitals: T 98.8 BP 92/46 HR 84 RR 20 O2 Sat 97% on RA
I&Os: [**Telephone/Fax (1) 75582**], while ordered to be NPO.
General: Lying in bed in NAD, sleeping but easily arousable.
Ext: Warm. No pitting edema.
Pertinent Results:
ADMISSION LABS:
[**2134-9-22**] 04:00AM BLOOD WBC-3.5* RBC-2.86*# Hgb-8.3*# Hct-24.5*#
MCV-86 MCH-29.0 MCHC-33.9 RDW-16.3* Plt Ct-128*#
[**2134-9-22**] 04:00AM BLOOD Neuts-63.2 Lymphs-29.4 Monos-3.0 Eos-4.2*
Baso-0.2
[**2134-9-22**] 04:00AM BLOOD Glucose-125* UreaN-8 Creat-0.6 Na-138
K-5.2* Cl-104 HCO3-21* AnGap-18
[**2134-9-22**] 04:00AM BLOOD ALT-22 AST-105* AlkPhos-276* TotBili-0.5
[**2134-9-22**] 01:26PM BLOOD Calcium-7.8*
[**2134-9-22**] 04:15AM BLOOD Lactate-2.0
DISCHARGE LABS:
CXR [**2134-9-22**]: Tip of the new endotracheal tube is at the thoracic
inlet, no less than 4 cm from the carina. Enteric tube passes
into the stomach and out of view. Lungs are low in volume but
clear. Normal cardiomediastinal and hilar silhouettes and
pleural surfaces.
EGD [**2134-9-22**]:
Esophageal varices (ligation)
Esophagitis
Mucosa suggestive of Barrett's esophagus
Gastric erosions
Mild portal gastropathy was noted. No gastric varices were seen.
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue octreotide gtt
Continue ceftriaxone 1 g Q24 hours
Start carafate [**Hospital1 **] once extubated and tolerating POs
Check H pylori serology
[**Hospital1 **] PPI
Serial Hgb with goal >8
Discuss alcohol abstinence; will need CIWA scale inhouse
Should follow up with his outpatient gastroenterologist for f/u
of liver disease and Barrett's esophagus
Brief Hospital Course:
Mr. [**Known lastname 53917**] is a 45 year old male with PMH of EtOH cirrhosis
complicated by esophageal varices and ascites who presented with
hematemesis x 3 and melena, initially admitted to the MICU for
EGD, called out to the floor on [**2134-9-22**]. His EGD showed
variceal disease with one varix that had stigmata of bleeding
and was banded transferred to the medicine floor for further
management.
# Hematemesis: His story was concerning for an upper GI bleed
and so the liver team performed an EGD on morning of admission
which showed an esophageal varix with red-dot stigmata of
bleeding. He is now status post banding of this lesion and they
did not see other evidence of bleed. He does continue to have
evidence of his chronic reflux changes of [**Doctor Last Name 15532**]??????s esophagus as
well. He was maintained on an octreotide ggt x 72 hours,
ceftriaxone for infectious prophylaxis in setting of his upper
GI bleed, and carafate. He was initially put on Pantoprazole
drip and this was transitioned to [**Hospital1 **] PPI after EGD then to PO
pantoprazole [**Hospital1 **]. His diet was advanced successfully, and his
Hct remained stable at 23-24 throughout admission. He did not
require blood transfusions. H. pylori found to be negative. When
the octreotide was discontinued, his home nadolol was restarted;
however for episodes of asymptomatic hypotension with systolics
as low as mid-80s, the home nadolol was decreased to 10mg daily.
The patient was also discharged with single-strength Bactrim to
complete a 5 day course for SBP prophylaxis. The patient has
repeat endoscopy scheduled with Dr. [**Last Name (STitle) **] for [**2134-10-28**].
# Respiratory status: He was intubated for the EGD, and
successfully extubated shortly after without complications.
Patient remained on room air through his medicin floor course.
# Abdominal pain: Likely multifactorial with contributions from
chronic pancreatitis, ascites pressure, component of
functional/chronic pain medication. Patient was made NPO and
diet was advanced as tolerated. On day of discharge, patient was
tolerating an oral diet. Pain was controlled with Dilaudid 2-4mg
every 6 hours PRN.
# EtOH abuse: Maintained on CIWA protocol but did not require
prn benzodiazepines for withdrawal symptoms. Social work consult
was obtained for EtOH programs and living situation. His
outpatient PCP reported that he was previsouly homeless, put
into housing with lots of support/team case worker. Social work
saw the patient while on the medicine floor to possibly persue a
Section 35. On the medicine floor, the patient stated a plan to
attend a Men's Health Group near [**Hospital1 2177**], which he is attended in
the past. He also stated a plan to talk regularly with two
therapists that he said he had close relationships with. Patient
was encouraged to keep this plan. Because he consistently stated
his plan to multiple providers on his health care team, the
decision was made not to persue Section 35. However, should the
patient re-present for alcohol related illness or intoxicated,
then a Section 35 may be persued.
# Pancytopenia: His WBC dropped to 1.6 at nadir with platelets
80. He has a history of this in the past and it is likely
related to liver disease and alcohol abuse. Rebounded on its
own, should be followed as an outpatient. Attributed
pancytopenia to marrow suppression in the setting of patient's
alcohol abuse.
# Bipolar disorder: Currently not on therapy. Patient denied
SI/HI. Would like outpatient psychiatric follow-up to be
arranged at [**Hospital1 18**]. Upon discharge, patient was provided with
telephone number to call and make an appointment with psychiatry
at [**Hospital1 18**].
Medications on Admission:
1. Nadolol 20 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) 2-4 mg PO Q6H:PRN pain (has a few of
these left)
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
RX *zolpidem 10 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
2. traZODONE 100 mg PO HS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth Four times daily Disp
#*56 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
7. Nadolol 10 mg PO DAILY
HOLD for SBP < 100, HR < 60
RX *nadolol 20 mg Half tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
8. HYDROmorphone (Dilaudid) 2-4 mg PO Q6H:PRN pain
hold for sedation, rr<12
RX *hydromorphone 2 mg [**12-21**] tablet(s) by mouth every 6 hours Disp
#*56 Tablet Refills:*0
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth for two more days Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed due to varix
Alcoholic cirrohsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].
You were initially admitted to the Intensive Care Unit because
of coffee-gound emesis. You underwent a scope of your upper GI
tract, which found the potential source of bleeding. Your blood
level was monitored during this admission and was stable after
the procedure, which is good news. You will need to follow-up
with Dr. [**Last Name (STitle) **] on [**2134-10-28**] for repeat endoscopy, to
ensure that everything is stable.
STOP drinking alcohol. Your most recent admission and previous
admissions at [**Hospital1 18**] have been related to the consquences of
drinking excessive amounts of alcohol. You stated a plan to
attend Men's Health and Recovery and talk to private counselors
who you have worked with in the past. If you feel that you need
more support in the future to abstain from alcohol, please let
your health care providers know.
You have a follow-up appointment at [**Hospital6 733**], the
primary care clinic at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. In
regards to Psychiatric care, please call Dr. [**Last Name (STitle) 30940**] to perform
an intake with him and to schedule a new patient appointment.
Take all medications as instructed.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2134-10-6**] at 11:50 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your new primary care doctor in
follow up.
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2134-11-8**] at 1:45 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Psychiatry
Phone: [**Telephone/Fax (1) 1387**]
[**Hospital Ward Name 452**] 2/[**Hospital1 **] 1
[**Location (un) 86**], [**Numeric Identifier 718**]
Please contact Dr. [**Last Name (STitle) 30940**] ([**Telephone/Fax (1) 75583**] to perform an intake
with him, and then you will be able to schedule a new patient
appointment.
Department: ENDO SUITES
When: THURSDAY [**2134-10-28**] at 11:00 AM
Department: ENDOSCOPY SUITE
When: THURSDAY [**2134-10-28**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
|
[
"572.3",
"285.9",
"577.1",
"571.2",
"E939.4",
"458.29",
"284.19",
"E935.2",
"E941.3",
"530.85",
"303.91",
"456.20",
"789.59",
"530.10",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9252, 9258
|
4127, 7845
|
308, 349
|
9350, 9350
|
2723, 2723
|
11034, 12699
|
1830, 1865
|
8084, 9229
|
9279, 9329
|
7871, 8061
|
9501, 11011
|
3214, 4104
|
2497, 2704
|
257, 270
|
377, 1098
|
2739, 3197
|
9365, 9477
|
1120, 1571
|
1587, 1814
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,757
| 190,195
|
28287
|
Discharge summary
|
report
|
Admission Date: [**2167-7-28**] Discharge Date: [**2167-9-8**]
Date of Birth: [**2109-1-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
ambien overdose, acute renal failure, compartment syndrome
Major Surgical or Invasive Procedure:
b/l fasciotomy
History of Present Illness:
This is a 58 y/o F with history of depression who presents to ER
from OSH, after intentional ambien overdose 2 days prior to
admission in a suicide attempt. She ingested 20 ambien and
washed this down with alcohol. She subsequently lost
consciousness and awoke on her couch on [**7-27**] with severe
bilateral leg pain. Called 911 and presented to OSH. At OSH, CK
120,000. New ARF with creatinine of 3. Found to have bilateral
LE DVT's and bilateral compartment syndrome. Transferred to
[**Hospital1 18**] ER.
.
In ER, seen by ortho trauma. Found to have elevated compartment
pressures requiring bilateral fasciotomy.
.
Past Medical History:
h/o depression
h/o ccy
Social History:
lives at home; h/o ETOH abuse, last ETOH 2 days ago. History of
withdrawal symptoms. Denies h/o seizures
Family History:
mother with h/o depression
Physical Exam:
vitals- T 96.0, HR 119, BP 152/79, RR 19, 96%
gen- sleepy but arousable, mentating appropriately, no acute
distress
heent- EOMI. pupils 2mm, reactive b/l. no scleral icterus. OP
clear
pulm- CTA b/l. no r/r/w
cv- tachy, regular, no m/r/g
abd- soft, NT/ND. no organomegaly. Well healed mid-abdominal
surgical scar
ext- b/l wound vac s/p fasciotomy. distal extremities warm, 1+
pulses
neuro- alert and oriented x 3. [**3-20**] UE motor, LE- able to wiggle
toes b/l. decreased sensation to LT over dorsum of L foot >R. UE
sensation intact.
Pertinent Results:
OSH labs:
========
[**2167-7-27**]- CK 120,906; MB 202.99; TropI 0.1 (<0.1); Salicylate <4;
TSH 4.9, T4 6.9, T3 29.6; Tylenol <10
Urine Tox neg; WBC 17.1, HCT 46.8, PLT 358;
Na 133, K 4.6, XL 100, CO2 34, BUN 34, Cr 2.8, Glu 132
Alb 3.8, CA 7.8, AST 909, ALT 368
.
EKG - NSR. nl intervals, axis; TWI V1-V2; upsloping ST segment
in III
Admission Labs:
===============
[**2167-7-28**] 12:55AM WBC-12.5* RBC-4.20 HGB-13.9 HCT-39.1 MCV-93
MCH-33.1
[**2167-7-28**] 12:55AM NEUTS-76* BANDS-5 LYMPHS-11* MONOS-8 EOS-0
BASOS-0
[**2167-7-28**] CALCIUM-6.7* PHOSPHATE-5.9* MAGNESIUM-2.1
[**2167-7-28**] CK-MB-159* MB INDX-0.2
[**2167-7-28**] LIPASE-28
[**2167-7-28**] ALT(SGPT)-365* AST(SGOT)-777* CK(CPK)-[**Numeric Identifier 68683**]* ALK
PHOS-95 AMYLASE-42 TOT BILI-0.7
[**2167-7-28**] 12:55AM GLUCOSE-152* UREA N-43* CREAT-3.2* SODIUM-138
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-20
[**2167-7-28**] ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
.
CK TREND:
==========
[**2167-7-28**] CK(CPK)-[**Numeric Identifier 68684**]*
[**2167-7-28**] CK(CPK)-[**Numeric Identifier 68685**]*
[**2167-7-28**] CK(CPK)-[**Numeric Identifier 68686**]*
[**2167-7-29**] CK(CPK)-[**Numeric Identifier 68687**]*
[**2167-7-29**] CK(CPK)-[**Numeric Identifier 68688**]*
[**2167-7-30**] CK(CPK)-8491*
[**2167-7-31**] 04:30AM BLOOD CK(CPK)-7709*
[**2167-8-1**] 08:02AM BLOOD CK(CPK)-4412*
[**2167-8-1**] 04:32PM BLOOD CK(CPK)-3852*
[**2167-8-2**] 04:14AM BLOOD CK(CPK)-3220*
[**2167-8-3**] 08:11AM BLOOD CK(CPK)-1665*
.
Radiology:
===========
Head CT [**2167-7-28**]: no acute pathology
Brief Hospital Course:
Brief Hospital Course: 58 y/o female with recent ambien
overdose, down for 2 days, complicated by rhabdo, ARF, b/l
compartment syndrome
# Acute Renal Failure - Secondary to rhabdomyolysis. Given
aggressive IVF hydration with normal saline to maintain urine
output greater than 100cc/hr. CK's trended down over her
hospital course (peak CK at OSH of 120,000) however creatinine
continued to rise from 3.2 on admission to 5.5 over first 24
hours. Bicarbonate fluids were attempted transiently to maintain
hydration and promote urine alkanalization, however this was
subsequently discontinued. Creatinine increased to a peak of 7.7
on [**8-4**], however of note, she remained non-oliguric throughout
and did not require dialysis. Fluid resucitation subsequently
stopped secondary to the development of pulmonary edema. She
responded well to IV diuresis with lasix and did not require
ventilatory support. She continued to make good urine output off
standing IV fluids. At time of discharge her creatinine had
recovered to 0.7.
# Compartment syndrome- Secondary to rhabdomyolysis requiring
bilateral fasciotomy on [**7-28**]. Wound vacs placed for drainage at
continuous pressure. Underwent closure of lateral fasciotomies
bilaterally on [**7-30**]. Medial wound not able to be closed
secondary to massive edema. Plastic surgery evaluated with plan
for closure on [**8-7**]. Of note, bloody drainage and oozing with
hematocrit down to 19-20. Blood transfusions given to maintain
hematocrit greater than 21. Leg pain controlled with morphine
PCA, then with prn morphine. She was discharged to follow-up in
Plastic Surgery clinic in ~2 weeks.
# Ambien overdose- In setting of suicide attempt. Now denies
suicidal or homicidal ideations. Serum/Urine tox negative on
admission. Psychiatry and social work consulted. Monitored with
sitter. Plan to transfer to psychiatry service after stable from
medicine standpoint for monitoring.
# ETOH abuse- Monitored for signs/symptoms of withdrawl.
Required small amounts of ativan per CIWA scale. No DT's or w/d
seizure activity.
# Bilateral DVTs- Diagnosed on outside hospital LENIs.
Ultimately, she continued to ooze so anticoagulation had to be
discontinued. An IR-guided temporary IVC filter was placed.
The patient will need to follow up with IR for removal of IVC
filter for 3 weeks from insertion ([**2167-8-27**]). She will
ultimately need a 6 month course of coumadin. Upon re-starting
the coumadin she will need close monitoring of her hemtocrit to
monitor for re-bleeding.
.
# Code - Full
.
# Dispo - The patient was transferred to the [**Hospital3 **]
inpatient psychiatry service. The follow-up appointments for
the plastic surgery department and the radiology department will
be sent to the psychiatry unit. Also, she was given an
appointment with a new primary care physician.
Medications on Admission:
None regularly
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) for 10 days.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5016**] [**Doctor Last Name 1495**] Raphaels TCU - [**Location (un) 7661**]
Discharge Diagnosis:
Primary:
Drug overdose
Suicide attempt
Rhabdomyolysis
.
Secondary:
Lower extremity compartment syndrome
Deep vein thrombosis
Acute renal failure
Alcohol abuse
Discharge Condition:
stable. transferring bed to chair, tolerating oral nutrition and
medications.
Discharge Instructions:
You have been evaluated and treated for muscle breakdown, renal
failure following your ingestion of sleeping medicine.
Following your recovery from this experience, you were evaluated
by the psychiatry service who recommended that you be
transferred to an inpatient psychiatry hospital.
.
Please take your medications as prescribed.
.
Attend the follow-up appointments that will be scheduled for
you.
Followup Instructions:
You will be transferred to the [**Hospital3 **] inpatient psychiatry
service.
You will need 3 important appointments in follow-up:
1) Plastic Surgery in 2 weeks
2) Interventional Radiology in [**8-29**] days: to have the IVC
filter removed at which time you will resume coumadin.
3) New Primary Care physician.
[**Name10 (NameIs) **] appointments will be made for you and the schedule will be
sent to the [**Hospital3 **] facilit tomorrow.
|
[
"453.42",
"584.5",
"285.1",
"305.1",
"728.88",
"303.90",
"305.80",
"428.0",
"967.8",
"291.81",
"E950.2",
"707.13",
"729.72",
"296.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"86.59",
"38.7",
"83.09",
"83.65",
"86.69",
"86.74",
"93.59",
"83.45"
] |
icd9pcs
|
[
[
[]
]
] |
7243, 7358
|
3484, 6298
|
373, 390
|
7561, 7641
|
1824, 2160
|
8090, 8533
|
1225, 1253
|
6363, 7220
|
7379, 7540
|
6324, 6340
|
7665, 8067
|
1268, 1805
|
275, 335
|
418, 1040
|
2176, 3438
|
1062, 1087
|
1103, 1209
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,891
| 149,385
|
27215
|
Discharge summary
|
report
|
Admission Date: [**2155-3-12**] Discharge Date: [**2155-3-14**]
Date of Birth: [**2107-9-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
V tach
Major Surgical or Invasive Procedure:
VT ablation
History of Present Illness:
47 year old man with non-ischemic cardiomyopathy (EF 30%), non
flow limiting CAD, HTN, hyperchol p/w SOB. Pt was having
exertional abdominal tightness and SOB for the past 8 weeks. His
outpt cardiologist Dr [**Last Name (STitle) **] thought that this might be a
manifestation of angina. Hence pt was getting a stress MIBI test
to assess for coronary ischemia. Dr [**Last Name (STitle) **] also increased his
dose of metoprolol and added furosemide 20 qd. Pt says he felt
better with the furosemide for about a week after seeing Dr
[**Last Name (STitle) **] but again started to have similar symptoms. Today at the
stress test the pt was feeling SOB and was found to have a WCT
even before he started the stress test. He was also diaphoretic.
He received IV metoprolol 5 x 2 but did not slow down. Hence he
was sent to the ER.
In ED, initial vitals were 98.4 141 139/102 18 100%/RA. ECG
showed VT. Later he was hypotensive to 90s. He received amio 150
Iv x 1 and then went into sinus rhythm. He was thought to have
pulm edema and recd IV lasix x 1. After about 45 mins he again
went into VT with SBP down to 80s. He recd another bolus of IV
amio 150 x 1 and was started on amio drip at that time. He was
in VT at a HR of around 130 for a couple of hours and then went
back into sinus rhythm. He also recd metoprolol 5 Iv x 1 and
morphine 4 IV x1 for back pain.
On floor, patient was feeling fine. Denied SOB, CP, dizziness,
palpitations.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. He endorsed dyspnea on
exertion. Has been using 2 pillows when sleeping at night.
Past Medical History:
Cardiomyopathy--non-ischemic. alcohol and substance abuse is
mostly likely the cause
Coronary artery disease--non flow limiting lesions
hypertension
depression
anxiety
history of herniated disc L5-S1 with two back surgeries, one in
[**2144**] and one in [**2146**]
status post right ankle surgery in [**2148**]
CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
Social History:
The patient lives with his wife and 11-year-old
daughter. [**Name (NI) **] has four kids. He is originally from
[**State 350**]. He works in building maintenance for the [**Location (un) **]
Group in the [**Hospital1 778**]. He quit using alcohol and using cocaine
four years ago and he now endorses smoking three-quarters of a
pack of cigarettes per day. He denies any history of
intravenous
drug use. He is monogamous with one sexual partner, his wife.
Family History:
The patient's father died of MI when he was in
his 40s. No other family history.
Physical Exam:
VS: 98 120/89 15 103 98/RA
GENERAL: WDWN male in NAD. Lying in bed with head elevated.
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 JVD midneck.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles. Had
b/l mild wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2155-3-12**] 09:35PM POTASSIUM-4.9
[**2155-3-12**] 05:46PM GLUCOSE-126* UREA N-22* CREAT-1.2 SODIUM-138
POTASSIUM-6.2* CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2155-3-12**] 05:46PM cTropnT-0.13*
[**2155-3-12**] 05:46PM CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-1.9
[**2155-3-12**] 05:46PM PT-17.3* PTT-30.6 INR(PT)-1.6*
[**2155-3-12**] 10:15AM GLUCOSE-181* LACTATE-2.8* NA+-141 K+-5.0
CL--98* TCO2-21
[**2155-3-12**] 10:10AM GLUCOSE-207* UREA N-19 CREAT-1.0 SODIUM-139
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
[**2155-3-12**] 10:10AM CK(CPK)-116
[**2155-3-12**] 10:10AM CK-MB-6
[**2155-3-12**] 10:10AM CK-MB-6
[**2155-3-12**] 10:10AM CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2155-3-12**] 10:10AM WBC-10.4 RBC-5.97 HGB-18.3* HCT-56.3* MCV-94
MCH-30.6 MCHC-32.5 RDW-14.0
[**2155-3-12**] 10:10AM NEUTS-68.1 LYMPHS-26.0 MONOS-4.6 EOS-0.7
BASOS-0.6
[**2155-3-12**] 10:10AM PLT COUNT-183
[**2155-3-12**] 10:10AM PT-15.9* PTT-30.9 INR(PT)-1.4*
ECG: Wide complex tach, likely V tach of fascicular origin at
150 bpm.
TTE: The left atrial volume is markedly increased (>32ml/m2).
The right atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with akinesis of the inferior and
inferolateral segments and hypokinesis of all other segments.
The anterior septum and anterior wall have relatively preserved
function.. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. An eccentric, posteriorly
directed jet of mild to moderate ([**12-6**]+) mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2152-3-23**],
the left ventricle is more dilated and overall ejection fraction
is significantly lower. The inferior and inferolateral segments
were moderately hypokinetic and are now akinetic, the other
segments were mild hypokinetic and now are more severely
hypokinetic. The degree of mitral regurgitation has increased.
Brief Hospital Course:
# Wide complex tachycardia: Pt with first documented episode of
V tach. Has h/o non-ischemic cardiomyopathy and was having SOB
since past 2 months. Likely was having pulm edema causing SOB as
he did feel better after starting furosemide by his outpt
cardiologist. Patient required lidocaine boluses and lidocain
drip for night prior to VT ablation in order to keep him in
sinus rhythm. He underwent VT ablation [**2155-3-13**] after which he
remained in NSR aside from 10beat run of NSVT on telemetry
overnight. This run of NSVT was at a faster rate than his prior
episodes and was thought to be from a different focus. This
could be a result of his cardiomyopathy.
# Cardiomyopathy: On TTE this admission he had worsened EF and
WMA as compared to prior in [**2151**]. This may have been [**1-6**]
tachycardia from VT for several weeks, however, it may also be
from CAD. He will have a CMR as an outpatient to assess for
scar. He may also benefit from a viability study to ascertain
whether a cardiac cath and reperfusion could increase his pump
function. If his EF does not improve in the next few months
while he remains in NSR and is maximally medically managed if
his EF doesnt improve, he may need AICD in the future. Will
continue ACE, statin, aspirin, and beta blocker as outpatient.
# Hypertension: Continued home enalapril
# Hyperlipidemia: Continued home atorvastatin
# Chronic back pain: Continued home percocet
# CODE: full
Medications on Admission:
ATORVASTATIN - 10 mg qd
ENALAPRIL MALEATE - 20 mg qd
FUROSEMIDE - 20 mg qd
IBUPROFEN - 800 mg tid prn
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd
MUPIROCIN - 2 % Ointment
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1- 2
Tablet(s) q8 prn
ZOLPIDEM - 10 mg Tablet qhs prn
ASPIRIN - 325 mg Tablet,qd
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg qd
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 7 weeks.
Disp:*30 Patch 24 hr(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for back pain.
9. Motrin 800 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for pain.
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for anxiety.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
VT
Non-ischemic cardiomyopathy
Chronic systolic heart failure
Viral syndrome
Tobacco Use
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital with an abnormal heart rate.
You had a procedure to fix this heart rate. Your heart has been
in a normal rhythm since that procedure. You will need to be
seen by your primary cardiologist Dr. [**Last Name (STitle) **] to discuss the
possibility of a follow up echocardiogram and/or cardiac MRI.
You may be called to schedule the cardiac MRI prior to your
appointment with Dr. [**Last Name (STitle) **].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Medication Changes:
START: Nicotine patch 21mg daily for 7 weeks then cut down to
14mg patch
START: Spironolactone 25mg daily
Please continue to take your other home medications, including
toprol XL, lasix, atorvastatin, enalapril, and aspirin as
prescribed.
Please come back to the hospital or call your doctor if you have
chest pain, palpitations, extreme fatigue, shortness of breath,
fainting or near-fainting, dizziness, light-headedness,
abdominal pain, nausea, leg swelling, weight gain more than 3lbs
in one day or any other concerning symptoms.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**2155-4-1**] at 4pm.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**2155-4-21**] 9:20 to discuss whether you will need an echocardiogram
and to schedule a cardiac MRI.
Completed by:[**2155-3-14**]
|
[
"427.1",
"401.9",
"414.01",
"425.4",
"305.1",
"428.22",
"079.99",
"272.4",
"724.2",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
9857, 9863
|
6850, 8293
|
322, 336
|
10015, 10089
|
4367, 6827
|
11233, 11616
|
3372, 3456
|
8701, 9834
|
9884, 9994
|
8319, 8678
|
10113, 10653
|
3471, 4348
|
10673, 11210
|
276, 284
|
364, 2398
|
2420, 2877
|
2893, 3356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,183
| 134,091
|
37665
|
Discharge summary
|
report
|
Admission Date: [**2175-8-17**] Discharge Date: [**2175-8-29**]
Date of Birth: [**2101-10-9**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
epigastric pain and left ankle pain
Major Surgical or Invasive Procedure:
hepatic arteriogram
right chest tube thoracostomy
History of Present Illness:
Mrs. [**Known lastname 84454**] was transferred from [**Hospital1 **] [**Location (un) 620**] after evaluation
in their Emergency Room due to her falling down 6 stairs while
walking in the dark. She complained of left ankle pain and
epigastric pain. She had a torso CT which showed a liver
laceration, and possible right parietal bleed. Her C spine
showed no fractures. She was then stabilized and transferred to
[**Location (un) 86**] for further evaluation and managemnent.
Past Medical History:
none
Social History:
No tobacco
No ETOH
No tobacco
No ETOH
Family History:
non contributory
Physical Exam:
temp 98 HR 105 BP 159/87 RR26 O2Sat 100%
HEENT small laceration right temple, PERRLA
Neck supple, non tender
Chest Clear, no deformities
COR RRR
Abd diffuse tenderness RUQ, mildly distended
Ext left ankle tender over lat malleolus
Pertinent Results:
[**2175-8-17**] 11:20PM WBC-22.1* RBC-3.59* HGB-10.4* HCT-31.7*
MCV-88 MCH-28.9 MCHC-32.6 RDW-13.8
[**2175-8-17**] 11:20PM PLT COUNT-329
[**2175-8-17**] 11:20PM PT-12.9 PTT-23.0 INR(PT)-1.1
[**2175-8-17**] 11:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-8-17**] 11:36PM GLUCOSE-144* LACTATE-2.8* NA+-141 K+-3.4*
CL--103 TCO2-25
[**2175-8-17**] 11:20PM UREA N-20 CREAT-0.7
[**2175-8-18**] Hepatic angiography : Celiac axis and hepatic
arteriograms demonstrating patency of the hepatic vasculature
with no areas of active extravasation or pseudoaneurysm
formation. Scalloped appearance of the liver compatible with
subcapsular hematoma. No intervention was deemed necessary given
hepatic arteriogram
results.
[**2175-8-20**] left ankle : Mild soft tissue swelling is present
adjacent to the lateral malleolus. A small well-corticated
osseous density is present, and likely reflects a sequela of old
injury. No definite acute fracture is identified. Plantar spur
is incidentally noted on the lateral view as well as increased
ossification at the Achilles tendon ligament insertion.
[**2175-8-20**] Head CT : 1. Decreased conspicuity of the known right
parietotemporal subarachnoid hemorrhage, without evidence of new
acute hemorrhage or major vascular territory infarct.
2. Right frontal lobe encephalomalacia likely due to chronic
infarct. Agree with prior recommendation an MRI may be obtained
on a non-urgent basis to further characterize.
[**2175-8-21**] Chest CTA :
)No aortic dissection or pulmonary embolism.
2) Large right pleural effusion, actively increasing,
responsible for lower lobe collapse.
3)Moderate cardiomegaly with a small pericardial effusion.
4)Large intrahepatic hematoma.
Brief Hospital Course:
Mrs. [**Known lastname 84454**] was admitted to the Trauma ICU for close blood
pressure monitoring, serial hematocrits and possible
embolization of the liver laceration. She was taken for
angiography on [**2175-8-18**] and of note there was no active bleeding
nor abnormality other than mass effect from a subcapsular
hematoma. She was transferred to the Trauma floor for further
management but required readmission to the ICU secondary to
severe agitation and hypoxia.
CTA of the chest ruled out PE however she had a large right
pleural effusion which required chest tube placement. The
drainage was straw colored and initially drained 1 liter. She
had a very tiny apical space post chest tube placement which was
unchanged over multiple days and again stable after chest tube
removal on [**2175-8-28**].
She was seen by the Physical therapy service after confirming
that she did not have a left ankle fracture and she was full
weight bearing on both lower extremities but very deconditioned
and they recommended short term rehab prior to returning home.
At the time of discharge she was tolerating a regular diet, up
and ambulating with assistance and had no neurologic deficits.
She was discharged on [**2175-8-29**].
Medications on Admission:
ASA 81 mg PO daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
S/P fall with subcapular hematoma
SAH
Right pleural effusion
Discharge Condition:
stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2359**] for a follow up appointment in 2
weeks
call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 8506**] for a follow up appointment in 2
weeks
Completed by:[**2175-8-29**]
|
[
"434.90",
"276.1",
"275.2",
"E880.9",
"041.85",
"511.9",
"864.02",
"293.0",
"599.0",
"860.2",
"285.1",
"873.42",
"518.82",
"845.00",
"851.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"34.04",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
4755, 4900
|
3084, 4314
|
350, 402
|
5033, 5042
|
1298, 3061
|
6012, 6256
|
1012, 1030
|
4383, 4732
|
4921, 5012
|
4340, 4360
|
5066, 5989
|
1045, 1279
|
275, 312
|
430, 911
|
933, 939
|
955, 996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,252
| 112,446
|
28386
|
Discharge summary
|
report
|
Admission Date: [**2197-9-16**] Discharge Date: [**2197-12-27**]
Date of Birth: [**2197-9-16**] Sex: M
Service: Neonatology
HISTORY: Baby boy [**Known lastname 68869**], twin No. 1, was born weighing 718
grams, the product of a 24 and 6/7 weeks gestation pregnancy.
He was born to a 34-year-old G2, P0, now 2 mother. Maternal
history was notable for short cervix with cerclage placement
prenatally.
Prenatal screens - blood type O positive, antibody negative,
HbSAg negative, RPR nonreactive, rubella immune, GBS unknown.
This infant was born by cesarean section after unstoppable
preterm labor. The infant emerged with a weak cry, was brought
to the warmer, given some positive pressure ventilation and
intubated in the delivery room.
PHYSICAL EXAMINATION: Anterior fontanel open and flat.
Coarse breath sounds bilaterally with good breaths
bilaterally. Positive red reflexes bilaterally. No
murmur. normal S1S2. Normal pulses. Soft, nondistended, no
masses. Moved all extremities equally. Pink and well
perfused. Three-vessel cord, patent anus.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The infant had respiratory distress syndrome on
admission to the NICU and was intubated and received surfactant
therapy x2. He remained ventilated with conventional ventilation
until [**2197-10-11**], which is day of life 25 when he required
high frequency ventilation at that time for sepsis issues.
Within 24 hours he returned to conventional ventilation. In the
setting of his chronic lung disease, he was started on Lasix on
DOL #42 ([**10-28**]), receiving Lasix every Monday, Wednesday and
Friday. He extubated to CPAP on [**2197-11-7**], day of life 52,
successfully weaned to nasal cannula on [**2197-11-27**],
which is day of life 73. He weaned to room air on [**2197-12-17**], and has remained stable on room air since that
time. He has had no apnea or bradycardia issues for well over
a week. He was given caffeine citrate from [**2197-11-19**],
through till [**2197-10-17**], at which time caffeine was
discontinued due to increased heart rate. Caffeine was never
restarted thereafter.
Currently, he is receiving Lasix every Monday, Wednesday and
Friday. He had been receiving KCl as well but this was
discontinued on [**12-20**] and his most recent Cl on [**12-26**] was 106
with a K of 5.5. The infant will be followed for chronic
lung disease by Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 37305**] at [**Hospital3 1810**] and has
a follow- up appointment on [**1-5**].
CARDIOVASCULAR: The infant presented with symptoms of PDA on
[**2197-9-17**], at which time indomethacin was given. A
post-indomethacin echocardiogram on [**2197-9-19**] showed
that that the ductus was closed. Followup echocardiogram was done
on [**2197-10-3**], due to re-presentation, which showed a small
1 mm PDA. No indomethacin was given at that time. Two further
echocardiograms have been done, both in [**Month (only) 359**] (23 and 26th)
due to persistent murmurs. Both of those showed a very tiny PDA,
neither of which was treated with Indocin. The infant has
been hemodynamically stable and at this time does not have a
murmur and has normal heart rate and blood pressure. No
further issues. He does not have a murmur at the time of
discharge.
The infant did present with a brief period of supraventricular
tachycardia on [**2197-10-17**], at which time caffeine citrate
was discontinued and no urther episodes have been observed.
FLUIDS, ELECTROLYTES AND NUTRITION: IV fluids were initiated
on admission to the NICU and changed to total parental nutrition
over the next few days. An umbilical arterial catheter was placed
and a double lumen umbilical venous line was also placed on
admission. The infant was started on enteral feedings on
[**2197-9-21**], with a slow feeding advance and achieved full
enteral feedings. A PICC line was placed on [**2197-9-23**].
The double lumen UVC was discontinued at that time. Enteral
feedings were advanced and the infant achieved full enteral
feedings by [**2197-9-30**]. Enteral feedings were then
further concentrated to caloric density of breast milk 30 calorie
per ounce with Beneprotein.
The infant had an episode of abdominal distention with an
abnormal KUB and was treated for 14 days for medical necrotizing
enterocolitis which was started on [**2197-10-10**]. The KUB
subsequently normalized and the infant was restarted on enteral
feedings on [**2197-10-27**]. Feedings advanced without an
incident.
Currently, he is feeding PO ad lib of 26 calorie breast milk
mixed as breast milk with 4 calories of Similac powder per ounce
and 2 calories of corn oil per ounce. The infant's most recent
weight is 2810 grams. He is gaining well. He is taking
approximately 3 ounces every 4 hours enterally. Most recent set
of electrolytes were done on [**2197-12-26**], and the results
are Na=138, K=5.5, Cl=106, HCO3=23. His most recent head
circumference is 34 cm, most recent length is 48 cm, both done on
[**2197-12-26**]; at present he is 10 to 25th percentile for
weight, 50 to 75th percentile for head circumference, and 25th to
50th percentile for length. He is on daily multivitamins, 1 ml
per day.
Renal: On [**2197-12-26**], renal ultrasound was performed
which showed bilateral calcifications in both kidneys, consistent
with chronic lasix use.
GASTROINTESTINAL: The infant did have a period of medical
necrotizing enterocolitis that was discussed under fluid,
electrolytes and nutrition as above, treatment from [**2197-10-10**], through [**2197-10-27**]. The infant did have
hyperbilirubinemia with a peak bilirubin level of 3.8/ 0.3
and did receive a total of 8 days of phototherapy.
HEMATOLOGY: The patient's blood type is A positive, DAT
negative. The infant has received numerous blood product
transfusions, and in total has received 5 transfusions of
packed red blood cells with the most recent transfusion being
on [**2197-10-28**]. The infant is on elemental iron, ferrous
sulfate at 0.5 ml PO daily. Most recent hematocrit was 36 on
[**2197-12-12**], with a reticulocyte count of 8.1%.
INFECTIOUS DISEASE: CBC and blood culture were screened on
admission to the NICU. The infant had a white blood cell
count of 5.1 with 29 polys, yielding an ANC of 1479. There
was no left shift. The infant received 48 hours of ampicillin
and gentamycin initially which were subsequently discontinued
when the blood culture remained negative at that time. The
infant had a sepsis evaluation done on [**2197-9-29**], at
13 days of life due to clinical instability. CBC at that time
was normal but the blood culture grew staph epidermidis
bacteremia. The infant was started on vancomycin and
gentamycin and given a 7-day course of antibiotics at that
time. At the end of that course of antibiotics, the infant
presented with medical necrotizing enterocolitis and that was
on [**2197-10-10**]. The antibiotic therapy was switched to
Zosyn to treat for medical necrotizing enterocolitis at that
time. The infant received 12 days of Zosyn therapy which was
changed on [**2197-10-21**], to vancomycin, gentamycin and
clindamycin when a blood culture grew positive at that time
for gram positive cocci. CBC at that time was not shifted on
[**2197-10-10**]. The infant received an additional 7 days of
antibiotics which were subsequently discontinued on [**2197-10-27**]. The infant had a yeast diaper rash and was treated
with miconazole powder from [**2197-10-21**], through till
[**2197-10-29**]. There have been no further infectious
disease issues.
NEUROLOGY: The infant has had numerous cranial ultrasounds
done on [**2197-9-18**], [**2197-9-25**], [**2197-10-16**], [**2197-12-21**], all within normal limits.
SENSORY: Hearing screen was performed and the infant passed
in both ears.
OPHTHALMOLOGY: The infant has had numerous ophthalmological
examinations. The initial examination was done on [**2197-10-30**], and the most recent ophthalmologic examination was
[**2197-10-26**]. The infant did have mild ROP but has
progressed to mature eyes on [**2197-10-26**], and the plan
is for follow up with ophthalmology in 9 months after
discharge.
PSYCHOSOCIAL: [**Hospital1 18**] social worker has been involved with the
family. If there are any concerns, she can be reached at [**Telephone/Fax (1) 56048**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
[**Location (un) **].
CARE RECOMMENDATIONS:
1. Ad lib PO feedings of breast milk 26 calorie per ounce
made as breast milk with 4 calorie per ounce of Similac
powder and 2 calories per ounce of corn oil.
2. Medications: Elemental iron 0.5 ml per day. Daily
multivitamin drops 1 ml per day, Lasix 5.5 mg which
equals 0.6 ml once daily on Mondays, Wednesdays and
Fridays.
3. Car seat positioning. The infant was tested in the infant
car seat and did not pass in an upright position. It was
recommended that the infant be discharged in an infant
car bed in a supine position.
4. State newborn screens: Numerous state newborn screens
have been sent and the most recent screen is normal.
5. Immunizations received: The infant received Pediarix
vaccine on [**2197-11-19**], pneumococcal vaccine on
[**2197-11-20**], Synagis on [**2197-12-25**].
6. Immunizations Recommended:
Synagis RSV prophylaxis should be continued monthly through
[**Month (only) 958**].
Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointment is recommended with the pediatrician
on [**2187-12-29**]. Also followup appointment on [**1-5**] at 1 p.m.
with Dr. [**Last Name (STitle) 37305**], from pediatric pulmonology at [**Hospital3 18242**]. VNA referral after discharge. Early intervention follow
up and Infant [**Hospital **] Clinic at [**Hospital3 1810**].
DISCHARGE DIAGNOSES:
1. Prematurity born at 24 and 6/7 weeks gestation.
2. Twin No. 1, respiratory distress syndrome, resolved
3. Rule out sepsis.
4. Patent ductus arteriosus, resolved
5. Necrotizing enterocolitis, resolved
6. Staph epidermidis bacteremia, resolved
7. Chronic lung disease.
8. Hyperbilirubinemia, resolved
9. Anemia of prematurity.
10. Retinopathy of prematurity, resolved.
11. Left hydrocele.
12. Bilateral renal calcifications Lasix-induced
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Name8 (MD) 68870**]
MEDQUIST36
D: [**2197-12-26**] 22:22:26
T: [**2197-12-27**] 02:27:30
Job#: [**Job Number 68871**]
|
[
"747.0",
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"427.89",
"770.81",
"769",
"709.8",
"776.6",
"778.6",
"V31.01",
"779.81",
"765.03",
"779.89",
"779.3",
"777.5",
"771.81",
"593.89",
"362.21",
"770.7",
"550.90",
"765.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"99.15",
"38.92",
"99.04",
"96.6",
"96.72",
"96.04",
"93.90",
"03.31",
"99.83"
] |
icd9pcs
|
[
[
[]
]
] |
8373, 8526
|
10170, 10876
|
8548, 9393
|
1117, 8317
|
783, 1088
|
9424, 10149
|
8342, 8349
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,950
| 167,106
|
8638
|
Discharge summary
|
report
|
Admission Date: [**2184-6-8**] Discharge Date: [**2184-6-16**]
Date of Birth: [**2139-3-29**] Sex: M
Service: SURGERY
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Multiple colon polyps likely related to [**Location (un) **]
Syndrome/Familial polyposis.
Major Surgical or Invasive Procedure:
s/p TAC and ileorectal anastomosis
History of Present Illness:
This patient presented with multiple polyps in
his colon. No sign of malignancy, however. His preoperative
discussion included the options of total colectomy with
ileostomy, ileoanal pouch surgery and because he had apparent
rectal sparing, an ileorectal anastomosis. This was discussed
with GI as well and they concurred that this option in this
man with a defibrillator and a pacemaker and cardiomyopathy
was probably a sensible option.
Past Medical History:
Hypertrophic cardiomyopathy as above
Chest wall fibromas-getting worked up for
Fibromal removal '[**68**]
Nasal cyst removal
Sinus surgery x 2
s/p tonsillectomy
Social History:
Lives with partner. [**Name (NI) **] is a project manager. No smoking.
Occasional EtOH.
Family History:
F: died of sudden cardiac death at 38. 1 sister with
asymptomatic hypertrophic cardiomyopathy, s/p ICD placement.
Physical Exam:
At Disharge:
Vitals:
Gen: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB
ABD: +BS, soft, ND, appropriately tender
Incision: Midline incision OTA with staples. Some staples
removed distally with serosanguinous discharge. Packed with W-D
gauze and DSD on top. Decreased erythema.
Pertinent Results:
[**2184-6-14**] 06:00AM BLOOD WBC-8.2 RBC-5.02 Hgb-15.1 Hct-42.0 MCV-84
MCH-30.0 MCHC-35.9* RDW-12.7 Plt Ct-232
[**2184-6-9**] 04:18AM BLOOD WBC-10.8 RBC-4.57* Hgb-13.7*# Hct-37.6*
MCV-82 MCH-29.9 MCHC-36.4* RDW-12.8 Plt Ct-160
[**2184-6-12**] 05:57PM BLOOD Neuts-72.6* Lymphs-15.6* Monos-6.2
Eos-5.2* Baso-0.3
[**2184-6-14**] 06:00AM BLOOD Plt Ct-232
[**2184-6-10**] 04:38AM BLOOD PT-15.1* PTT-29.2 INR(PT)-1.3*
[**2184-6-14**] 06:00AM BLOOD Glucose-88 UreaN-11 Creat-1.0 Na-139
K-4.2 Cl-101 HCO3-28 AnGap-14
[**2184-6-8**] 11:41AM BLOOD Na-137 K-3.9 Cl-106
[**2184-6-14**] 06:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2
[**2184-6-9**] 04:18AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8
[**2184-6-8**] 11:41AM BLOOD Mg-1.5*
.
[**2184-6-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2184-6-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2184-6-12**] URINE URINE CULTURE-FINAL INPATIENT
[**2184-6-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2184-6-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2184-6-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2184-6-15**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY;
ANAEROBIC CULTURE-PENDING
.
Pathology Examination
Procedure date [**2184-6-8**]
DIAGNOSIS:
I. Ileum and right colon (B-O):
1. Numerous adenomas of the colon, up to 0.4 cm in diameter.
2. Multiple lymphoid nodules of the ileum and colon.
3. Appendix with fibrous obliteration of the tip.
II. Omentum (A):
Mature fibrofatty tissue, within normal limits.
III. Remainder of colon (P-X):
Numerous adenomas of the colon, up to 0.6 cm in diameter.
IV. Small bowel segment (Y-Z):
1. Multiple lymphoid aggregates, within normal limits.
2. No adenomas.
V. Anastomotic donut, confirmed by gross examination.
Note: There is no carcinoma. The features are consistent with
[**Location (un) **] syndrome.
Clinical: Familial polyposis coli, [**Location (un) **] syndrome.
.
RADIOLOGY Final Report
CT PELVIS W/CONTRAST [**2184-6-13**] 5:04 PM
HISTORY: 45-year-old male status post total abdominal colectomy
and ileorectal anastomosis, now with fevers and increased
abdominal pain.
IMPRESSION:
1. Status post total colectomy with ileorectal anastomosis.
While oral contrast does not reach the site of anastomosis, lack
of extraluminal gas at the site of anastomosis and intact suture
line make an anastomotic leak less likely. Fluid within the
pelvis and abdomen, and small pockets of air, consistent with
recent surgery.
2. Soft tissue mass along the right flank, nodular densities
along the left flank, and soft tissue stranding in the right
paraspinal region, unchanged.
3. Bibasilar atelectasis.
.
Brief Hospital Course:
On [**2184-6-8**] Mr [**Known lastname 22321**] [**Last Name (Titles) 1834**] total colectomy with ileorectal
anastomosis. The procedure was uncomplicated; please see
operative report for full details of the operation.
Postoperatively he was transferred to the ICU for observation
given his cardiac history. He was seen by electrophysiology,
who interrogated his ICD and found it to be functioning well.
His pain was well controlled with a PCA.
On POD 2 he was transferred to the floor and started on a clear
liquid diet. He developed some incisional erythema and was
febrile, so was started on Kefzol. Blood cultures and urine
cultures were sent, and were negative.
He regained bowel function on POD 3, and had some diarrhea so
was started on Immodium. He continued to have low grade fevers
and erythema of the wound. His antibiotics were changed to
Levaquin. His diet was advanced to low residue diet.
On POD [**6-15**] he had a CT scan to rule out anastomotic leak and
intraabdominal collections, which was negative for both. He was
restarted on low residue diet and continued on levaquin. His
stool was more formed.
On POD 8 his wound 5 staples were removed from his wound and it
drained some serous fluid. It was packed with wet to dry
dressing. Cultures from the wound were negative for organisms.
His erythema subsequently improved. He remained afebrile for
the next 24 hours, so was discharged home with 5 additional days
of Flagyl and VNA for wound care.
Medications on Admission:
Cardizem XR 240', Atenolol 25', Zocor 5', Zantac, Tylenol, ASA ,
Ativan prn
Discharge Medications:
1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Tablet(s)
4. Loratadine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 5 days: Take with food.
Disp:*15 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*35 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
9. Zantac 150 mg Tablet Sig: 0.5 Tablet PO once a day.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) as needed for loose stool: Do not exceed 16mg in 24
hours.
Disp:*60 Capsule(s)* Refills:*2*
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
Ulcerative colitis, refractory
Post-op atlectasis
Post-op incisional cellulitis
.
Secondary:
[**Location (un) 976**]??????s syndrome, Celiac disease, HOCM, Seasonal allergies,
hyperlipidemia, GERD
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment, and
steri strips will be applied.
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Wound care:
-Wash hands before removing dressing.
-Cleanse wound with warm water or saline if available, and dry
area well.
-Pack wound opening as instructed per Surgery team. Moisten
gauze with saline, and pack into wound with Q-Tip.
-Apply dry guaze on top, and secure with paper tape.
-Change at least once a day, and as needed. Be sure to keep
incision area as dry as possible.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 9**] Call to
schedule appointment in 2 weeks.
2. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] [**Telephone/Fax (1) **] in 1 week
and as needed.
Completed by:[**2184-6-17**]
|
[
"998.59",
"272.4",
"682.2",
"530.81",
"211.3",
"518.0",
"425.4",
"V45.02",
"579.0",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"45.8",
"99.77"
] |
icd9pcs
|
[
[
[]
]
] |
7043, 7094
|
4281, 5761
|
356, 392
|
7344, 7421
|
1589, 4258
|
9427, 9791
|
1167, 1282
|
5887, 7020
|
7115, 7323
|
5787, 5864
|
7445, 8587
|
8602, 9020
|
1297, 1570
|
227, 318
|
9032, 9404
|
420, 861
|
883, 1045
|
1061, 1151
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,533
| 137,211
|
40270
|
Discharge summary
|
report
|
Admission Date: [**2117-7-22**] Discharge Date: [**2117-7-29**]
Date of Birth: [**2078-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Coronary artery bypass graft x4, left internal mammary artery to
left anterior descending artery, saphenous vein grafts to
diagonal and posterior descending artery, and radial artery to
obtuse marginal artery.
History of Present Illness:
This 39 year old man HTN, DM2, and known three vessel CAD s/p
LAD stenting x 2 in [**2116-10-26**], referred for left heart
catheterization due to recurrent symptoms. He was initially
cathed at LGH where he was found to have three vessel disease.
He was transferred to [**Hospital1 18**] where he underwent placement of two
Promus DES to the proximal and mid LAD. His other vessels were
not treated.
He felt well for approximately two weeks following his PCI when
he began to notice a recurrence of substernal chest discomfort
radiating to the left arm. He underwent repeat catheterization
in [**Month (only) 404**] at [**Hospital3 **] where his LAD stents were
reported as patent but diagonal 80% stenosis, Cx with a ? 70%
stenosis, total occlusion after OM1 and RCA with diffuse disease
(per report).
Recently the frequency and intensity of his chest pain have been
increasing. He says that he gets chest pain everyday. The pain
occurs with minimal exertion and often occurs at rest
occasionally waking him from sleep. It usually resolves with 1-3
NTGs.
He was referred here for scheduled catheterization which showed
80% ostial stenosis of the LAD, 80% proximal D1, LCx 90%
starting before OM1 and extending into OM2, RCA with 60% distal
and 60% mid PDA occlusion. No stents were deployed as he has
surgical disease.
Past Medical History:
Hypertension
Dyslipidemia
Diabetes Type 2
Three vessel CAD, s/p LAD stenting x 2 in [**2115**], s/p CABG [**2117-7-23**]
Obesity
Obstructive sleep apnea (CPAP)
Depression
GERD
Social History:
-Tobacco history: 1ppd since age 15, but for the past 6 months
has been smoking 2 packs/month
-ETOH: occasional
-Illicit drugs: cocaine, last used 1 week ago
He has 12 children, is married and lives with his family. He is
currently unemployed.
Family History:
Many family members with DM2, HTN. Nobody with known CAD/MI or
CVA.
Physical Exam:
ADMISSION EXAM:
VS: T=98 BP=138/81 HR=83 RR=18 O2 sat= 97RA
GENERAL: WDWN Man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+ difficult to palpate femoral pulses
secondary to body habitus B/L
Left: DP 2+ PT 2+ difficult to palpate femoral pulses secondary
to body habitus B/L
Pertinent Results:
ADMISSION LABS:
[**2117-7-22**] 10:03AM WBC-4.3 RBC-4.24* HGB-12.8* HCT-35.7* MCV-84
MCH-30.2 MCHC-35.9* RDW-13.4
[**2117-7-22**] 10:03AM NEUTS-39.4* LYMPHS-51.3* MONOS-5.2 EOS-3.4
BASOS-0.8
[**2117-7-22**] 10:03AM TRIGLYCER-121 HDL CHOL-38 CHOL/HDL-3.8
LDL(CALC)-81
[**2117-7-22**] 10:03AM GLUCOSE-118* UREA N-13 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2117-7-22**] 10:03AM ALT(SGPT)-26 AST(SGOT)-21 ALK PHOS-59 TOT
BILI-0.3
[**2117-7-22**] 10:03AM ALBUMIN-4.0 CHOLEST-143
[**2117-7-22**] 10:03AM PT-12.9 PTT-31.3 INR(PT)-1.1
[**2117-7-29**] 05:11AM BLOOD WBC-9.1 RBC-2.99* Hgb-9.0* Hct-26.3*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.8 Plt Ct-308
[**2117-7-28**] 05:35AM BLOOD WBC-9.1 RBC-3.04* Hgb-9.6* Hct-27.0*
MCV-89 MCH-31.5 MCHC-35.4* RDW-15.1 Plt Ct-242
[**2117-7-29**] 05:11AM BLOOD Glucose-101* UreaN-22* Creat-0.7 Na-139
K-3.7 Cl-103 HCO3-27 AnGap-13
[**2117-7-28**] 05:35AM BLOOD Glucose-129* UreaN-20 Creat-0.7 Na-141
K-3.8 Cl-105 HCO3-25 AnGap-15
[**2117-7-23**] Intra-op TEE:
Conclusions
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.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%). He
has reduced e' indicative of early diastolic dysfunction.
Right ventricular chamber size and free wall motion are normal.
His PAP elevated consistent with CPAP/sleep apnea.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The [**Location (un) 109**] is 1.8cm2 with a mean transaortic
gradient of 8 mm of Hg.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results before surgical
incision.
POST-BYPASS:
Preserved biventricular systolic function.
LVEF 55 %.
Intact thoracic aorta.
No other new findings.
Brief Hospital Course:
Mr [**Known lastname 27491**] had a cardiac catheterization that showed 3 vessel
coronary artery disease more amenable to surgery. No
intervention was employed and he was taken back to the floor. He
was chest pain free after the procedure.
On [**2117-7-23**] he underwent Coronary artery bypass graft x4, left
internal mammary artery to left anterior descending artery,
saphenous vein grafts to diagonal and posterior descending
artery, and radial artery to obtuse marginal artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He did receive
two units of packed red blood cells post-operatively with an
appropriate rise in hematocrit. Extubation was attempted on POD
1 unsuccessfully. The patient became highly agitated,
tachypneic, tachycardic and hypoxic. Precedex was initiated
without improvement. He remained hemodynamically stable. Nitro
drip was started for radial artery harvest. The patient was
extubated on POD 3. Nitro drip was discontinued and PO
diltiazem started. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was not initiated due to patient's
cocaine use and risk for coronary spasm. He 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. He
was found to have H. Flu in his sputum as well as sternal
drainage and was started on antibiotics. By the time of
discharge on POD 6 the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged home in good condition with appropriate
follow up instructions.
Medications on Admission:
ACETAMINOPHEN-CODEINE - (Prescribed by Other Provider) - 300
mg-30 mg Tablet - 1 Tablet(s) by mouth as needed for pain
ARIPIPRAZOLE [ABILIFY] - (Prescribed by Other Provider) - 10 mg
Tablet - 10mg Tablet(s) by mouth 1 x daily
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
daily
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet -
500mg Tablet(s) by mouth twice daily
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
NAPROXEN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth 2-3 times per day as needed
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually prn chest pain
PAROXETINE HCL - (Prescribed by Other Provider) - 20 mg Tablet
-
Tablet(s) by mouth
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg
Capsule
- 1 Capsule(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth 1hs
TRAZODONE - (Prescribed by Other Provider) - 100 mg Tablet - 1
Tablet(s) by mouth 1x daily at bedtime
Medications - OTC
ASPIRIN, BUFFERED [BUFFERIN] - (Prescribed by Other Provider) -
325 mg Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
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. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
14. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
15. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO once a day for 3 months.
Disp:*180 Capsule, Ext Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Hypertension
Dyslipidemia
Diabetes Type 2
Three vessel CAD, s/p LAD stenting x 2 in [**2115**], s/p CABG [**2117-7-23**]
Obesity
Obstructive sleep apnea (CPAP)
Depression
GERD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2117-8-5**] 10:15 at
[**Hospital Unit Name 4081**]
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2117-9-1**] 1:00
Cardiologist: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2117-8-23**] 1:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 63099**] in [**3-30**] 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:[**2117-7-29**]
|
[
"041.5",
"285.9",
"458.29",
"327.23",
"401.9",
"414.01",
"305.60",
"996.72",
"278.00",
"411.1",
"272.4",
"250.00",
"V85.41",
"E879.0",
"307.9",
"305.1",
"599.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13",
"96.71",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
10303, 10318
|
5321, 7258
|
319, 555
|
10538, 10752
|
3196, 3196
|
11594, 12499
|
2388, 2457
|
8660, 10280
|
10339, 10517
|
7284, 8637
|
10776, 11571
|
2472, 3177
|
269, 281
|
583, 1910
|
3212, 5298
|
1932, 2110
|
2126, 2372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,174
| 192,946
|
51125
|
Discharge summary
|
report
|
Admission Date: [**2136-7-9**] Discharge Date: [**2136-7-16**]
Service: SURGERY
Allergies:
Band-Aid Clear Spots / Betadine Viscous Gauze / sertraline
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Trauma: fall
R posterior rib fx [**3-27**]
small R PTX
head laceration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 89 year old female who complains of
UNWITNESSED FALL. biba from home. unwitnessed fall. pt was
able to get up, get to phone to call dtr who called EMS. EMS
found pt seated in chair, c/o back pain, worse with deep
breath. no obvious deformities to extremities.
small lac to back of head- struck head on countertop when
chair tipped over.
a/ox3, biba from home. unwitnessed fall. pt was able to get
up, get to phone to call dtr who called EMS. EMS found pt
seated in chair, c/o back pain, worse with deep breath. no
obvious deformities to extremities.
small lac to back of head- struck head on countertop when
chair tipped over.
a/ox3,
Timing: Sudden Onset
Quality: Sharp
Severity: Moderate
Duration: 1 Hours
Location: mid back pain
Mod.Factors: Worse with movment and
breathing
Associated Signs/Symptoms: no LOC
Past Medical History:
1) Bronchiectasis with Mycobacterium avium - Treated [**2131**] for 2
weeks with imipenem for pseudomonas infection; pulmonary MAC -
Again [**12/2133**] treated with Cipro and Flagyl
2) C. diff infection [**2133-10-5**] Treated with Flagyl 1000 mg/day
X 10 days
3) s/p Pseudomonas bronchitis with prolonged treatment with
intravenous meropenem
4) s/p Pneumonia [**10/2119**], [**4-24**], [**1-28**]
5) GI bleed summer of [**2132**], with duodenal adenoma on endoscopy
6) GERD
7) Hypertension
8) Supraventricular arrythmia s/p ablation in [**2125**]
9) Depression
10) s/p hip replacement
11) s/p vertebroplasty [**2130**]
12) Back pain, gets lumbar epidural injectons at Pain Clinic
13) Fractured bone in the wrist
14) Osteoporosis
15) Arthritis
16) Pelvic fracture, [**2132-12-19**]
Social History:
no etoh, no smoking
Family History:
Mother died at 53 from colon CA.
Her father died at 94 from unknown causes.
No other known history of GI disease, heart disease, lung
disease.
Physical Exam:
PHYSICAL EXAMINATION
Temp: 97.8 HR: 68 BP: 191/83 Resp: 16 O(2)Sat: 93 Normal
Constitutional: cachectic female in mild distress but not
toxic
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
no cspine TTP
Chest: Clear to auscultation; right sided chest wall TTP
but no flail segment clinically
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nontender, Nondistended
Pelvic: No lesions
Rectal: pelvis stable to [**Doctor Last Name **] and NTP
Extr/Back: trace bipedal edema
Skin: Warm and dry, No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation; moves all 4 ext; gcs
15
Pertinent Results:
[**2136-7-9**]: L-spine x-ray:
IMPRESSION: Degenerative changes as detailed.
[**2136-7-9**]: chest x-ray:
IMPRESSION: Findings of tiny right apical pneumothorax and right
posterior
third rib fracture better assessed on the concurrently performed
CT C-spine.
Extensive interstitial disease compatible with known chronic
small airways
disease.
[**2136-7-9**]: cat scan of the head:
IMPRESSION: No acute intracranial process
[**2136-7-11**]: chest x-ray:
FINDINGS: In comparison with the study of [**7-10**], there is again
extensive
interstitial lung disease as seen on prior CT scan. No definite
pneumothorax is appreciated. Posterior rib fractures on the
right are difficult to identify and could better be seen on the
prior CT scan.
[**2136-7-14**] 05:25AM BLOOD WBC-7.1 RBC-3.26* Hgb-10.5* Hct-31.3*
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.0 Plt Ct-195
[**2136-7-13**] 05:30AM BLOOD WBC-8.9 RBC-3.49* Hgb-11.3* Hct-34.1*
MCV-98 MCH-32.4* MCHC-33.1 RDW-13.1 Plt Ct-199
[**2136-7-11**] 05:17AM BLOOD WBC-8.8 RBC-3.51* Hgb-11.4* Hct-33.7*
MCV-96 MCH-32.5* MCHC-33.9 RDW-13.2 Plt Ct-211
[**2136-7-14**] 05:25AM BLOOD Plt Ct-195
[**2136-7-13**] 05:30AM BLOOD Plt Ct-199
[**2136-7-16**] 05:45AM BLOOD Glucose-105* UreaN-15 Creat-0.5 Na-132*
K-5.0 Cl-91* HCO3-37* AnGap-9
[**2136-7-15**] 05:05AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-131*
K-4.7 Cl-91* HCO3-34* AnGap-11
[**2136-7-14**] 01:20PM BLOOD Na-127* K-4.4 Cl-91* HCO3-33* AnGap-7*
[**2136-7-16**] 05:45AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
[**2136-7-15**] 05:05AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
[**2136-7-14**] 05:25AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9
[**2136-7-15**] 05:05AM BLOOD Osmolal-270*
[**2136-7-14**] 01:20PM BLOOD Osmolal-265*
Brief Hospital Course:
89 year old female admitted to the acute care service after a
unwitnessed fall at home. Upon admission, she was made NPO,
given intravenous fluids and underwent radiographic imaging of
her head, chest, and spine. She was reported to have right
posterior [**3-27**] rib fractures with a small right apical
pneumothorax. She did note require chest tube placment. The
acute pain service was consulted regarding possible placment of
epidural or spinal lumbar block. Her rib pain was controlled
with intravenous and oral analgesics. Her head cat scan was
normal and her cervical spine films showed no acute cervical
spine fracture with stable anterolisthesis of C4 on C5.
Because of her rib fractures and her history of bronchiectasis,
she was admitted to the trauma intensive care unit for pulmonary
optimization. She was transferred to the surgical floor on HOD
#2. Palliative care was consulted regarding her DNI/DNR status
and she was followed by the Geriatric service.
Since her arrival to the surgical floor, her vital signs have
been stable. She is tolerating a regular diet. She has resumed
her home pulmonary medications. She was evaluated by physical
therapy and recommendations made for discharge to a extended
care facility because of her deconditioning. On hosptial day
HOD #4, she was noted to be hyperkalemic to 5.7 and
hyponatrremic to 125. The renal service was consulted and
recommendations made for fluid restriction and additional normal
saline infusion. Over the next 24 hours, her electrolytes were
monitored and normalized. Her current potassium is 5.0 and a
sodium of 132. Her creatinine is 0.5 with a BUN of 15.
She is preparing for discharge to a extended care facility. She
will continue to require monitoring of her potassium and sodium
every other day until she has normalized. She will need to
follow up with her primary care provider [**Last Name (NamePattern4) **] 1 week and with the
acute care service in 2 weeks.
Medications on Admission:
[**Last Name (un) 1724**]: citalopram 10', SYMBICORT 160 mcg-4.5 mcg/Actuation HFA 2
puffs qbedtime, lopressor 12.5', omeprazole ER 20',
triamcinolone, tylenol prn, CITRACAL + D 250 mg-200 unit daily,
Viactiv 500 mg-100 unit-[**Unit Number **] mcg daily,
DEXTROMETHORPHAN-GUAIFENESIN 400 mg-20 mg Tablet TID, colace 100
[**Hospital1 **], Vit D2 1gm', MOM 1 tspn qHS prn, senna
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
3. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. quinine sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for leg cramps.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gm/dose PO DAILY (Daily) as needed for constipation.
11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Trauma: fall
Injuries:
R posterior rib fx [**3-27**]
small R PTX
head laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after you fell at home. You
sustained right sided fractured ribs and a small right
pneumothorax. You did not require a chest tube for it. The
images of your head and neck were normal. You are now preparing
for discharge to a rehabilitation facility to help you regain
your baseline strength.
You are being discharged with the following instructions:
Your injury caused right sided [**3-27**] rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Please follow up with the acute care service in 2 weeks. You
can scheudule your appointment by calling # [**Telephone/Fax (1) 600**].
Please let them know that you will need a chest x-ray prior to
your visit.
Please schedule an appointment with your primary care provider,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in 1 week.
Completed by:[**2136-7-17**]
|
[
"V46.2",
"E884.2",
"799.4",
"276.7",
"807.06",
"733.00",
"530.81",
"564.00",
"494.0",
"V15.88",
"401.9",
"V10.83",
"276.1",
"V43.64",
"724.02",
"860.0",
"873.0",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8637, 8731
|
4845, 6808
|
338, 345
|
8857, 8857
|
3118, 4822
|
10657, 11034
|
2256, 2400
|
7235, 8614
|
8752, 8836
|
6834, 7212
|
9040, 10634
|
2415, 3099
|
225, 300
|
373, 1396
|
8872, 9016
|
1418, 2203
|
2219, 2240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,588
| 127,109
|
35469
|
Discharge summary
|
report
|
Admission Date: [**2148-2-29**] Discharge Date: [**2148-3-1**]
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Vfib arrest
Major Surgical or Invasive Procedure:
ECHO x2
History of Present Illness:
[**Age over 90 **] M with CAD s/p 4V-CABG [**2135**] and CRI had been doing well until
this AM when he was out walking with his wife. [**Name (NI) **] abruptly
syncopized and a bystander started CPR quickly. The local fire
department delivered two shocks without success. Then EMS came
and gave two more shocks and he went back into sinus. It is
unclear whether he regained consciousness. He was intubated but
the ET tube went into the esophagus. It was repositioned to the
trachea, then brought to [**Hospital1 18**] ED.
.
In the ED, his intial SBP was reported to be 110. Labs show K
2.7 and Hct 25. He was given 40mEq of KCL. On repeat labs, his
K normalized and his Hct was 33 without any blood. It is
unclear whether one of the labs was erroneous. NG lavage was
repeatedly grossly positive. GI did not want to do EGD until
his hemodynamics were more stable. With fluids, his BP
normalized and the vitals were recorded as: T=34.8, HR 62,
132/74, 18, 100% on AC 18x500, FiO2 100%. He was briefly cooled
by Artic Sun protocol but given his GIB, this was stopped.
.
Now the patient is still intubated and hemoadynamically stable
and transferred to the CCU. GI is currently doing EGD.
.
ROS: Per his wife, sons and PCP, [**Name10 (NameIs) **] was apparently in good
health. He does not have chest pain or SOB. He can walk a few
blocks and up the stairs without symptoms. Wife denies recent
fevers, abd pain, n/v, hematemasis, hematachezia or BRBPR. No
orthopena, PND or peripheral edema. No recent syncope or
lightheadedness. No h/o stroke or bleeding disorder. The
patient denies any chest pain or pressure, new exertional
dyspnea, orthopnea, PND or leg edema, palpitations or syncope,
claudication-type symptoms, melena, rectal bleeding, or
transient neurologic deficits. No change in weight, bowel habit
or urinary symptoms. No cough, fever, night sweats, arthralgias,
myalgias, headache or rash. All other review of systems
negative.
Past Medical History:
# CAD s/p MI and CABG [**2135**]
-- LIMA to LAD
-- SVG-D1
-- SVG-PDA
-- SVG-distal Lcx
-- EF 25% by cath
# Cardiomypathy
-- echo [**2142**]: EF 30%, mid to distal anterior septal HK,
inferoposterior wall HK, apex Hk. trace AR, trace MR, [**12-22**]+TR.
# CCY, h/o gallstone pancreatitis
# B12 deficiency, hct baseline 38
# Restless legs
# Glaucoma
Social History:
Quit tobacco 20+ years ago, no alcohol. Lives with wife.
Family History:
No family of early CAD or sudden death.
Physical Exam:
VITALS: T=35, 82, 127/55, 22, 99% on AC 18x500 Fi O2 100%
GEN: Intubated and sedated, shivering
HEENT: PERRL, eyes edematous
NECK: No JVD
CV: RRR, no M/G/R
PULM: Clear bilaterally
ABD: Soft, ND, +BS
EXT: Trace pedal edema. 2+ DP left, 1+ DP right. PT pulses not
palpable.
NEURO: Sedated.
Pertinent Results:
[**2148-2-29**] 09:28PM TYPE-CENTRAL VE TEMP-35 PO2-29* PCO2-39
PH-7.33* TOTAL CO2-21 BASE XS--5
[**2148-2-29**] 09:19PM CK(CPK)-395*
[**2148-2-29**] 09:19PM CK-MB-9 cTropnT-0.26*
[**2148-2-29**] 09:19PM HCT-29.9*
[**2148-2-29**] 04:14PM GLUCOSE-111* UREA N-15 CREAT-1.3* SODIUM-143
POTASSIUM-4.2 CHLORIDE-116* TOTAL CO2-21* ANION GAP-10
[**2148-2-29**] 04:14PM CK(CPK)-319*
[**2148-2-29**] 04:14PM CK-MB-7 cTropnT-0.27*
[**2148-2-29**] 04:14PM CALCIUM-6.8* PHOSPHATE-2.5* MAGNESIUM-1.4*
[**2148-2-29**] 04:14PM WBC-8.5# RBC-3.12* HGB-9.7*# HCT-29.6* MCV-95
MCH-31.2 MCHC-32.9# RDW-14.3
[**2148-2-29**] 04:14PM PLT COUNT-106*
[**2148-2-29**] 04:14PM PT-15.0* PTT-66.9* INR(PT)-1.3*
[**2148-2-29**] 01:03PM HGB-11.0* calcHCT-33
[**2148-2-29**] 12:15PM GLUCOSE-146* UREA N-16 CREAT-1.5* SODIUM-142
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-22 ANION GAP-12
[**2148-2-29**] 12:15PM estGFR-Using this
[**2148-2-29**] 12:15PM CK(CPK)-162
[**2148-2-29**] 12:15PM CK-MB-3
[**2148-2-29**] 11:45AM PO2-355* PCO2-49* PH-7.25* TOTAL CO2-23 BASE
XS--5
[**2148-2-29**] 11:45AM GLUCOSE-151* LACTATE-4.3* NA+-142 K+-3.1*
CL--109
[**2148-2-29**] 11:45AM freeCa-1.08*
[**2148-2-29**] 11:23AM TYPE-[**Last Name (un) **] PO2-110* PCO2-49* PH-7.17* TOTAL
CO2-19* BASE XS--10 COMMENTS-GREEN TOP
[**2148-2-29**] 11:23AM GLUCOSE-612* LACTATE-4.3* NA+-127* K+-2.7*
CL--104
[**2148-2-29**] 11:23AM HGB-9.5* calcHCT-29 O2 SAT-95 CARBOXYHB-2 MET
HGB-0
[**2148-2-29**] 11:23AM freeCa-0.96*
[**2148-2-29**] 11:22AM cTropnT-<0.01
[**2148-2-29**] 11:22AM VoidSpec-SUSPECT CO
[**2148-2-29**] 11:22AM WBC-5.6 RBC-UNABLE TO HGB-5.6* HCT-25.0*
MCV-UNABLE TO MCH-UNABLE TO MCHC-24.7* RDW-UNABLE TO
[**2148-2-29**] 11:22AM NEUTS-47.6* LYMPHS-48.0* MONOS-2.6 EOS-1.6
BASOS-0.2
[**2148-2-29**] 11:10AM URINE RBC-[**2-22**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0 TRANS EPI-[**5-29**]
[**2148-2-29**] 11:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
[**2148-2-29**] 11:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2148-2-29**] 11:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2148-2-29**] 11:10AM URINE GR HOLD-HOLD
[**2148-2-29**] 11:10AM URINE HOURS-RANDOM
[**2148-2-29**] 11:22AM FIBRINOGE-150
[**2148-2-29**] 11:22AM PT-17.3* PTT-43.8* INR(PT)-1.6*
[**2148-2-29**] 11:22AM PLT SMR-VERY LOW PLT COUNT-71*
[**2148-2-29**] 11:22AM NEUTS-47.6* LYMPHS-48.0* MONOS-2.6 EOS-1.6
BASOS-0.2
[**2-29**] The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild global left ventricular hypokinesis
(LVEF = 45-50 %). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
normal free wall contractility. The aortic root is mildly
dilated at the sinus level. The ascending aorta is moderately
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate ([**12-22**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mildly depressed global left ventricular function.
Mild to moderate aortic regurgitation. Mild mitral
regurgitation.
[**3-1**] The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with distal
septal hypokinesis. The remaining segments contract normally
(LVEF = 50%). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. Mild (1+) aortic regurgitation is seen. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild aortic regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2148-2-29**],
the findings are similar. Mild regional wall motion
abnormalities are present on both
[**2-29**] CXR IMPRESSION:
1. Bilateral apical opacities, which are nonspecific but may be
related to
aspiration or infiltrate.
2. Distal tip of the ET tube 9 cm from the carina and may be
advanced up to 6 cm.
3. Distal tip of NG tube at gastroesophageal junction. Recommend
advancement.
4. Multiple left-sided rib
Brief Hospital Course:
[**Age over 90 **]M with CAD s/p 4v-CABG, CHF, CRI admitted s/p vfib arrest with
GIB initially started on arctic sun cooling protocol.
.
# Vfib arrest. Unclear etiology for VFIb arrest since was
apparently well prior to this episode per family. Possibly from
scar since has h/o ischemia and MI in past. Less likely from
acute ischemia/ACS since no focal WMA on echo, EF improved c/w
prior and no preceding symptoms of chest pain. Not likely from
decompensated CHF since he is not on lasix at home and there is
no h/o weight gain or CHF symptoms. Possibly from electolyte
abnormality (K=2.7 on admission), but unclear if these lab
results were accurate since repeat set was normalized. Less
likely from GIB which was probably secondary to intubation
rather than GIB causing vfib arrest. He was initially started on
arctic sun cooling protocol with conservative target T=35 given
GIB. Given hypotension (discussed below) and bradycardia
overnight, cooling protocol was stopped and he was allowed to
rewarm. Electrolytes were monitored closely and repleted prn.
Shock was managed as discussed below and given refractory
hypotension, he was made DNR and terminally extubated per family
request.
.
# Hypotension: Pt initially normotensive on arrival SBPs
100s-110s. Blood pressure trended down throughout night. Low BP
initially attributed to cooling so cooling protocol was
discontinued and pt was allowed to rewarm. He was started on
levophed, then neosynephrine then dopamine and maxed out on 3
pressors. He had worsening lactic acidosis so he was given
bicarb and started on bicarb drip to correct acid base status to
allow pressors to work more effectively. Patient had rapid
decompensation overnight and it was unclear why he was so
hypotensive despite multiple pressors. Possible etiologies
include hypovolemic (secondary to volume/blood loss),
cardiogenic (although relatively preserved EF on echo) or septic
shock. He was started on broad spectrum antibiotics
(Vanco/Zosyn) and also given steroids for possible adrenal
insufficiency. He was tranfused 2 units PRBC for concern for
blood loss with GIB although HCT was stable. He remained
hypotensive with MAPs in 40s and progressively worsening lactic
acidosis despite multiple pressors. Family meeting was held in
am [**2148-3-1**] to discuss poor prognosis and decision was made to
make pt DNR and terminally extubate when all family was present.
He expired later that morning with family at bedside.
# CAD: s/p CABG as above. Had reversible defects on stress in
[**2142**]. No EKG change or +cardiac markers to suggest ACS. ASA held
in setting of GIB. Held beta blockers given hypotension.
# CHF: EF 45-55%. Relatively euvolemic on initial exam. CXR
without overt pulm edema.
.
# GIB: Pt had bright red blood NGT output after traumatic
esophageal intubation. Upon arrival to CCU, he had EGD which
showed active bleed from [**Doctor First Name 329**] [**Doctor Last Name **] tear vs. dieulafoy's
ulcer. This was cauterized with resultant hemostasis. He was
tranfused 2 units PRBC when later became hypotensive and HCT was
monitored and remained relatively stable. He was started on [**Hospital1 **]
PPI IV.
.
# RESP FAILURE: Intubated at scene. Kept intubated on cooling
protocol then later terminally extubated per family request.
.
# Htn: Held antihypertensives given hypotension
.
# ACCESS: RIJ and 2 18-gauge PIV, A line placed
.
# CODE: Initially full confirmed with wife and children. Code
status then changed to DNR/DNI and pt extubated per family
request with family at bedside.
Medications on Admission:
Cozaar 25
Digoxin 0.125
Flomax 0.4
Carbidopa-Levodopa 25-100 PRN QHS
Xalantan eye gtt QHS both eyes
Asa 325
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Vfib arrest
CAD
Hypotension
Sepsis
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
deceased
|
[
"403.90",
"530.7",
"427.41",
"286.9",
"428.21",
"427.5",
"530.82",
"585.9",
"518.81",
"428.0",
"458.9",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.07",
"42.33",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11559, 11568
|
7826, 11372
|
255, 265
|
11647, 11658
|
3086, 7803
|
11710, 11722
|
2720, 2761
|
11531, 11536
|
11589, 11626
|
11398, 11508
|
11682, 11687
|
2776, 3067
|
203, 217
|
293, 2256
|
2278, 2629
|
2645, 2704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,871
| 137,235
|
22959
|
Discharge summary
|
report
|
Admission Date: [**2109-8-22**] Discharge Date: [**2109-9-11**]
Date of Birth: [**2052-12-5**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
Advanced rectal carcinoma
Major Surgical or Invasive Procedure:
Resection of rectum with colostomy.
Cystoscopy and bilateral ureteral stent placement.
Cystoprostatectomy and urinary diversion into a colonic loop.
Bilateral nephrostomy placement.
Right nephrostomy exchange.
History of Present Illness:
56 year-old male with advanced rectal carcinoma. The patient
was admitted for low anterior resection of advanced rectal
carcinoma. The patient previously had a sigmoid colostomy with
[**Doctor Last Name 3379**] pouch without removal of the tumor burden. The
patient had been receiving neoadjuvant chemotherapy of FOLFOX
and Avastin. Avastin was held for the month prior to surgery.
Past Medical History:
-IDDM
-HTN
-Portal vein thrombosis
Social History:
He is a widower and lost his wife in '[**94**], has 7 adult children.
As of [**Month (only) 404**], he was on disability, previously worked as a
computer engineer, and denied smoking and drinking.
Family History:
No family hx of colon or prostate cancer.
Physical Exam:
T-SICU Exam:
VS: HR 90 BP 100/59 spo2 99%CMV (Fio2 50%,TV600,RR12,PEEP5)
HEENT: NCAT,PERRL2->1,nares patent,ETT in situ
CV:RRR,normal s1s2, no m/r/g appreciated
Lungs: CTA bilaterally without wheezes,rales,ronchi
Abdomen: decreased bowel sounds, colostomy stoma beefy red,
urostomy, abd obsese, ?distended, soft
Pertinent Results:
[**2109-8-22**] 03:40PM BLOOD WBC-6.1 RBC-3.13* Hgb-9.6*# Hct-28.1*#
MCV-90 MCH-30.6 MCHC-34.1 RDW-14.3 Plt Ct-125*
[**2109-9-9**] 06:12AM BLOOD WBC-7.4 RBC-3.21* Hgb-9.0* Hct-27.5*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.4 Plt Ct-802
[**2109-8-29**] 07:01AM JP drain Creat-82.5
[**2109-9-3**] 09:33AM JP drain Creat-41.7
Brief Hospital Course:
-GI/GU: The patient underwent a low anterior resection of the
rectum, bladder, and prostate. The portion of colon leading the
patient's previous colostomy (left abdomen) was used as a uretal
diversion pouch into which both ureters drained, converting the
colostomy into a urostomy. The remaining colon was brought as a
new colostomy, on the right side of the abdomen. The remaining
rectum and urethra were closed. The patient was afebrile and
ambulating post-op with good pain control. However, a urine
leak into the abdomen was identified by creatinine-positive
fluid coming from the [**Location (un) 1661**]-[**Location (un) 1662**] (JP) drain and by contrast
studies of the urinary diversion. After several days, left, and
later right, percutaneous nephrostomy tubes were placed to
promote closure of the leak. The right nephrostomy tube was
later exchanged under fluoroscopy because of low urine output.
Also, there was intermittant discharge from the anus, which was
thought to be mucus.
-Onc: During surgery, the tumor was noted to invade the bladder.
Pathology showed moderately differentiated adenocarcinoma of
rectum, 1.5 cm, with extension to bladder adventitia, but with
negative lymph nodes and no lymphovascular invasion. Staging was
T4aN0MX. Liver lesions were not evaluated.
-Psych: Psychiatry helped the patient with the difficult
adjustment post-op, and celexa was started. Group therapy was
encouraged as an outpatient, but not yet arranged.
-Dispo: The patient continued to do well clinically, and was
tolerating full diet, ambulating, and had appropriate colostomy
output at the time of discharge. However, urine continues to
drain from the JP drain, and the patient will follow up with
urology to monitor progress of leakage closure.
Medications on Admission:
1. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
2. Humulin L 100 unit/mL Suspension Sig: Thirty Five (35) units
Subcutaneous at bedtime.
Discharge Medications:
1. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
2. Humulin L 100 unit/mL Suspension Sig: Thirty Five (35) units
Subcutaneous at bedtime.
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: ONLY FOR EXTREME PAIN,
OTHERWISE TAKE TYLENOL/IBRUPROFEN/ALEVE.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Advanced colorectal carcinoma
Discharge Condition:
stable/good
Discharge Instructions:
Contact your doctor or return to the hospital if you get a
fever, develop abdominal pain, have problem with your surgical
drains, if your condition worsens. Please see nephrostomy
pamphlet (given) for nephrostomy care. Please take medications
as prescribed and a read warning labels carefully. Light
activities until seen by doctor on follow up visit. [**Month (only) 116**] shower,
please read pamphlet for instructions.
Followup Instructions:
Please see your primary care doctor or a psychiatrist to monitor
anti-depressant medication and adjustment to medical condition.
Please call Dr.[**Name (NI) 6433**] office ([**Telephone/Fax (1) 6449**] ([**Telephone/Fax (1) 6449**] to
be seen in [**1-27**] weeks.
Please call Dr.[**Name (NI) 13919**] office to be seen in [**1-27**] weeks ([**Telephone/Fax (1) 19071**] ([**Telephone/Fax (1) 4230**].
Provider [**Name9 (PRE) 17512**],[**First Name7 (NamePattern1) 8826**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Where:
[**Hospital6 29**] [**Hospital6 **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2109-10-8**] 10:00
Completed by:[**2109-9-11**]
|
[
"250.00",
"309.0",
"154.1",
"289.9",
"198.1",
"458.29",
"522.4",
"285.9",
"V44.3",
"197.7",
"996.39",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.71",
"48.62",
"48.23",
"46.52",
"99.04",
"56.71",
"99.07",
"59.8",
"55.03",
"47.19",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
4456, 4513
|
1986, 3753
|
340, 552
|
4587, 4600
|
1647, 1963
|
5074, 5779
|
1255, 1299
|
3964, 4433
|
4534, 4566
|
3779, 3941
|
4624, 5051
|
1314, 1628
|
275, 302
|
580, 967
|
989, 1025
|
1041, 1239
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,060
| 175,871
|
22701+57313
|
Discharge summary
|
report+addendum
|
Admission Date: [**2189-10-27**] Discharge Date: [**2189-11-11**]
Date of Birth: [**2138-8-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
right total hip arthroplasty
History of Present Illness:
The patient is a 51-year-old gentleman with a history
significant for CML s/p bone marrow transplant and chronic GVHD
was referred for right hip pain.
Orthopedically, he has severe progressive right hip avascular
necrosis related to longstanding prednisone therapy for a
matched unrelated donor bone marrow transplant in [**2182**] for
chronic myelogenous leukemia. The patient has suffered from
chronic graft versus host disease, typically oral and in the eye
as well.
He has been off and on large doses of prednisone as well as
CellCept. He had a contralateral left total hip replacement in
[**2188**] at [**Hospital 50878**], which was complicated by a flareup of
his
GVH. He has had a right total knee replacement in [**2186**] and a
left total knee replacement in [**2187**] again at [**Location (un) 511**] Medical
Center. All of these have been related to avascular necrosis
secondary to prednisone therapy. At this point, he is interested
in a right total hip replacement. He states that the pain is
presently [**10-26**] in the right hip with activity. He
intermittently uses a cane. The pain has markedly
worsened in the past 2 months, and he has noted decreased range
of motion as well. This all severely limits his ability to
remain active and gainfully employed as a commercial real estate
salesman in [**Doctor Last Name **].
Past Medical History:
Past Surgical History: Left herniorrhaphy, left total hip, left
total knee, and right total knee.
Current Medical Problems: Chronic graft versus host disease;
chronic myelogenous leukemia, chronic low back pain, avascular
necrosis of femoral heads and supracondylar femurs.
Social History:
Commercial real estate salesman, does not smoke,
does not drink, and tries to exercise 10-15 minutes a day as
pain
allows.
Family History:
non-contributory
Physical Exam:
Thin white male, 5 feet, 156 pounds. Has
an antalgic gait favoring the right side. He has a normal knee,
foot, and ankle exam. His lower extremities are equal in length.
He has markedly-diminished range of motion through the right hip
with no remaining internal or external rotation, can only abduct
20 degrees, and flex to about 85 degrees. He has good vascular
inflows bilaterally with 5/5 strength.
Pertinent Results:
[**2189-10-27**] 06:37PM GLUCOSE-158* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-21* ANION GAP-13
[**2189-10-27**] 06:37PM CALCIUM-8.3* PHOSPHATE-3.0
[**2189-10-27**] 06:37PM WBC-8.4 RBC-3.68* HGB-11.7*# HCT-33.2* MCV-90
MCH-31.7 MCHC-35.2* RDW-14.6
[**2189-10-27**] 06:37PM PLT COUNT-152
Brief Hospital Course:
51 year-old patient with PMH chronic GVHD and CML, underwent
right total hip arthroplasty on [**2189-10-28**] for right hip AVN. The
patient tolerated the procedure well. His postoperative course
was complicated by a GVHD exacerbation and by anemia.
Neurologic: Pain was initially managed with a morphine PCA
followed by oral Percocet
Respiratory: The patient's oxygen saturations gradually improved
and at the time of discharge they were weaned to room air.
Cardiovascular: The patient had no cardiac issues. He did have
some occasional low blood pressures early in his postoperative
course but these resolved after several transfusions.
Hematologic: The patient's hematocrit dropped to a low of 22
from 33, however after a transfusion it stabilized and was
stable at 27.7 at discharge. The patient was also started on
iron. Lovenox was started for DVT prophylaxis on post-operative
day number one.
Infectious Disease: The patient was given 48 hours of
Vancomycin for postoperative surgical prophylaxis.
Fluids/Electrolytes/Nutrition: The patient??????s electrolytes were
checked on post-operative day number one and were within normal
limits. He/she was tolerating a regular diet at discharge. The
Foley was removed on post-op day number 2.
Orthopedic: The patient worked with physical therapy and had a
achieved good ROM and was able to ambulate with minimal assist
at discharge, while still being compliant with the strict
restriction on 30% WB. The wound appeared clean, dry, and
intact, however, there was some increasing serous drainage
likely from a liquefying hematoma.
Medications on Admission:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MONDAY/WEDNESDAY/FRIDAY ().
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
for 3 weeks.
8. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q 24H (Every
24 Hours).
9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Triazolam 0.75 mg QHS
11. Prednisone 10 mg PO QAM
12. Prednisone 5 mg PO QPM
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MONDAY/WEDNESDAY/FRIDAY ().
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
8. Enoxaparin 40 mg/0.4mL Syringe Sig: Forty (40) Subcutaneous
DAILY (Daily) for 3 weeks.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q 24H (Every
24 Hours).
13. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
14. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
15. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for if patient is still awake at
0200.
16. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
18. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
19. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for pruririts.
Discharge Disposition:
Extended Care
Facility:
St. [**Doctor Last Name 11042**]
Discharge Diagnosis:
right hip avascular necrosis
Discharge Condition:
good
Discharge Instructions:
1) Please keep wound covered with dry sterile dressing. OK to
shower. Do not bathe.
2) Please continue taking all medications as taken prior to this
hospitalization. Please also complete full course of lovenox to
prevent blood clot, colace to prevent constipation, and percocet
for pain.
3) Do not drive or operate machinery while taking percocet.
4) Please follow-up with Dr. [**Last Name (STitle) **] as directed. Call doctor
sooner if you devlop fevers, shaking chills, or increasing wound
redness, drainage, or pain not controlled by pain medications.
Physical Therapy:
Activity: ambulate with assist tid
Pneumatic boots
Right lower extremity: Partial weight bearing
50% WB right lower extremity x 6 weeks, posterior hip
precautions (no adduction/internal rotation), *****PARTIAL
WEIGHT BEARING IS ESSENTIAL
Treatments Frequency:
Site: right hip
Type: Surgical
Dressing: Gauze - dry
Comment: please change daily and cover with dsd (abd with paper
tape)
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2189-11-3**] 1:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2189-11-13**]
10:00
Name: [**Known lastname 10833**],[**Known firstname 77**] Unit No: [**Numeric Identifier 10834**]
Admission Date: [**2189-10-27**] Discharge Date: [**2189-11-11**]
Date of Birth: [**2138-8-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 370**]
Addendum:
Mr. [**Known lastname **] was recovering well from his left total hip
arthroplasty and wound drainage had decreased markedly.
However, because the patient had failed on the acetabulum side
following that surgery and had gone into an unacceptable
protrusio position with loss of fixation of the cup, the patient
was taken back to the operating room on postoperative day number
eight for a resection arthroplasty. He tolerated this procedure
well. His postoperative course, however, was complicated by
acute arterial bleeding on postoperative day number one
following removal of the drain. The bleeding started about one
hour following drain removal. The patient was emergently
transferred to the ICU. This bleed was then treated with a
combination of massive transfusion and embolization by
interventional radiology. Drs. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Name5 (PTitle) 10835**] successfully
embolized with Gelfoam slurry a medial descending
(adductor)branch of the right profunda femoris artery and an
anteroinferior branch of the right hypogastric artery. In
addition the vascular surgery service was consulted and
dilligently followed the patient as did the hematology/oncology
service. The patient received a total of seven units of packed
red bloods cells, two units of FFP, and cryoprecipitate over two
days. His hematocrit dropped to as low as 22 from 27
preoperatively and then stabilized rather quickly in the low
30s. His electrolytes were also repleted meticulously.
Following a four day stay in intensive care the patient was
transferred to the floor.
The remainder of his postoperative course was
uncomplicated. He did have difficulty ambulating with the new
nonweight bearing requirement. However, he was able to transfer
effectively. He was started on coumadin for DVT prophylaxsis.
Given the long period during which he went without
anticoagulation in the setting of acute bleeding, DVT was ruled
out with bilateral lower extremity ultrasound. He received an
extended course of antibiotic prophylaxsis with Ancef. He did
continue to have significant pain, but this was treated with a
combination of oral oxycodone and IV dilaudid. He did complain
of a cough. However, chest xray was unremarkable and oxygen
saturations were within normal limits. Deep breathing, couging,
and incentive spirometry were encouraged. Finally, the patient
developed a red maculopapular rash on his buttocks and posterior
thighs. The dermatology service was consulted and the wound
care nurse also followed the patient. At the time of this
dictation dermatology recommendations were pending.
Major Surgical or Invasive Procedure:
right total hip arthroplasty
right hip resection arthroplasty
central line placement
pelvic artery angiography and embolization
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MONDAY/WEDNESDAY/FRIDAY ().
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q 24H (Every
24 Hours).
11. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for if patient is still awake at
0200.
14. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
15. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
16. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
17. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for pruririts.
18. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 6 weeks: Please check INR daily while in rehab and then
QMonday/Thursday for total of 6 weeks. Goal INR=2-2.5. Please
adjust dose as needed.
19. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
20. Hydromorphone 2 mg/mL Syringe Sig: 0.5-1.0 mg Injection
Q2-3H (every 2-3 hours) as needed for breakthrough pain.
21. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
right hip avascular necrosis
Discharge Condition:
good
Discharge Instructions:
1) Please keep wound covered with dry sterile dressing
underneath [**Location (un) **] Straps. Dressings should be changed [**Hospital1 **].
Do NOT bathe.
2) Please continue taking all medications as taken prior to this
hospitalization. Please also complete full 6 week course of
coumadin with goal INR=2.0-2.5 to prevent blood clot, colace to
prevent constipation, and percocet for pain.
3) Do not drive or operate machinery while taking percocet.
4) Please follow-up with Dr. [**Last Name (STitle) **] as directed. Call doctor
sooner if you devlop fevers, shaking chills, or increasing wound
redness, drainage, or pain not controlled by pain medications.
Physical Therapy:
Activity: ambulate with assist tid
Pneumatic boots
Right lower extremity: nonweight bearing
Treatments Frequency:
Site: right hip
Type: Surgical
Dressing: ABD pads held by [**Location (un) **] Straps
Comment: please change [**Hospital1 **] ABD pads underneath [**Location (un) **]
Straps
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6201**], MD Phone:[**Telephone/Fax (1) 3943**]
Date/Time:[**2189-11-3**] 1:30
Provider: [**Name10 (NameIs) 32**],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 10836**] Date/Time:[**2189-11-13**]
10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 809**] Call to schedule
appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 372**] MD [**MD Number(2) 373**]
Completed by:[**2189-11-11**]
|
[
"E878.1",
"733.42",
"V58.65",
"996.43",
"996.85",
"401.9",
"E878.0",
"276.52",
"244.9",
"998.11",
"715.35",
"V43.64",
"E932.0",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"80.05",
"88.47",
"99.07",
"81.51",
"99.29",
"99.02",
"78.05"
] |
icd9pcs
|
[
[
[]
]
] |
13909, 13952
|
2999, 4597
|
11736, 11865
|
14025, 14032
|
2652, 2976
|
15061, 15645
|
2193, 2211
|
11888, 13886
|
13973, 14004
|
4623, 5484
|
14056, 14720
|
1781, 2036
|
2226, 2633
|
14738, 14835
|
14858, 15038
|
280, 296
|
393, 1736
|
1758, 1758
|
2052, 2177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,767
| 173,388
|
52183
|
Discharge summary
|
report
|
Admission Date: [**2142-10-21**] Discharge Date: [**2142-10-27**]
Date of Birth: [**2074-9-16**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
ulcerating penile cancer
Major Surgical or Invasive Procedure:
Penectomy
History of Present Illness:
Patient presented to PCP who then referred patient to Dr. [**Last Name (STitle) **].
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] the patient and referred him to Dr. [**Last Name (STitle) 4229**]
Past Medical History:
NIDDM
HTN,
^chol.
CRI
penile carcinoma
obesity
severe claustrophobia
Sleep apnea
AF
s/p CABGx3 [**4-16**]
Social History:
+ TOB 1 PPD x 50 yrs
ETOH 3 drinks/ week - Quit [**4-16**]
Family History:
unknown
Pertinent Results:
[**2142-10-25**] 07:35AM BLOOD WBC-13.9* RBC-3.03* Hgb-7.5* Hct-24.2*
MCV-80* MCH-24.6* MCHC-30.8* RDW-18.7* Plt Ct-317
[**2142-10-24**] 04:27AM BLOOD WBC-15.0* RBC-3.05* Hgb-7.7* Hct-24.0*
MCV-79* MCH-25.2* MCHC-32.0 RDW-18.0* Plt Ct-265
[**2142-10-23**] 02:40AM BLOOD WBC-14.0* RBC-3.20* Hgb-8.0* Hct-25.1*
MCV-78* MCH-25.1* MCHC-32.0 RDW-17.8* Plt Ct-253
[**2142-10-22**] 05:58PM BLOOD WBC-12.0* RBC-3.38* Hgb-8.5* Hct-26.5*
MCV-78* MCH-25.2* MCHC-32.2 RDW-17.8* Plt Ct-278
[**2142-10-21**] 09:00PM BLOOD WBC-14.0* RBC-3.69* Hgb-9.2* Hct-29.5*
MCV-80* MCH-25.0* MCHC-31.4 RDW-17.5* Plt Ct-292
[**2142-10-25**] 07:35AM BLOOD Plt Ct-317
[**2142-10-23**] 02:40AM BLOOD Plt Ct-253
[**2142-10-22**] 05:58PM BLOOD Plt Ct-278
[**2142-10-22**] 05:58PM BLOOD PT-13.8* PTT-28.6 INR(PT)-1.2*
[**2142-10-21**] 09:00PM BLOOD Plt Ct-292
[**2142-10-21**] 09:00PM BLOOD PT-12.5 PTT-28.2 INR(PT)-1.1
[**2142-10-25**] 07:35AM BLOOD Glucose-88 UreaN-34* Creat-2.0* Na-130*
K-5.0 Cl-95* HCO3-27 AnGap-13
[**2142-10-21**] 09:00PM BLOOD Glucose-138* UreaN-51* Creat-1.8* Na-137
K-4.7 Cl-96 HCO3-34* AnGap-12
[**2142-10-25**] 07:35AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1
[**2142-10-24**] 04:27AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
[**2142-10-23**] 02:40AM BLOOD Calcium-8.7 Mg-2.1
[**2142-10-22**] 05:58PM BLOOD Calcium-9.1 Mg-1.8
[**2142-10-21**] 09:00PM BLOOD Calcium-9.8 Mg-2.0
[**2142-10-23**] 11:36AM BLOOD Type-ART pO2-70* pCO2-48* pH-7.43
calTCO2-33* Base XS-6
[**2142-10-22**] 02:25PM BLOOD Type-ART pO2-164* pCO2-53* pH-7.38
calTCO2-33* Base XS-5 Intubat-INTUBATED Vent-CONTROLLED
[**2142-10-23**] 09:45AM BLOOD Glucose-152* Lactate-1.0
[**2142-10-22**] 06:20PM BLOOD Lactate-1.4
[**2142-10-22**] 04:01PM BLOOD Glucose-90 Lactate-1.4 Na-136 K-3.8
Cl-101
[**2142-10-22**] 02:25PM BLOOD Glucose-114* Lactate-1.4 Na-135 K-3.9
Cl-98*
[**2142-10-22**] 04:01PM BLOOD Hgb-8.2* calcHCT-25
[**2142-10-23**] 09:45AM BLOOD freeCa-1.20
[**2142-10-22**] 06:20PM BLOOD freeCa-1.27
[**2142-10-22**] 02:25PM BLOOD freeCa-1.28
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2142-10-23**] 3:58 AM
CHEST (PORTABLE AP)
Reason: eval for CHF
[**Hospital 93**] MEDICAL CONDITION:
68M s/p total penectomy. R IJ CVL inserted during case.
REASON FOR THIS EXAMINATION:
eval for CHF
AP CHEST, 4:25 A.M. ON [**10-23**].
HISTORY: Right IJ central venous catheter.
IMPRESSION: AP chest compared to [**9-17**] through [**10-23**].
The tip of the right internal jugular line traversing an
introducer that ends at the thoracic inlet projects over the
upper SVC. No pneumothorax or mediastinal widening is present. A
small right pleural effusion may be present, and moderate right
basal atelectasis is unchanged since [**10-21**]. Heart size
normal. Mild pulmonary vascular engorgement is stable, but there
is no pulmonary edema. ET tube in standard placement.
Nasogastric tube ends in the stomach. No free subdiaphragmatic
gas.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2142-10-24**] 5:54 AM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2142-10-23**] 10:00 AM
CHEST (PORTABLE AP)
Reason: ETT location
[**Hospital 93**] MEDICAL CONDITION:
68M s/p total penectomy. R IJ CVL inserted during case.
REASON FOR THIS EXAMINATION:
ETT location
INDICATION: Status post total pancreatectomy. Status post
placement of right IJ central venous line. Assess for ETT
location.
Comparison is made to a radiograph obtained earlier the same
day.
AP SEMI-ERECT RADIOGRAPH OF THE CHEST: The endotracheal tube is
located approximately 8.6 cm above the carina at the upper level
of the clavicles. A right IJ catheter sheath is again seen
terminating in the upper SVC containing a catheter with the tip
projecting over the lower SVC. No pneumothorax is seen. Moderate
right basal atelectasis and small right pleural effusion is
stable. The heart size is within normal limits given technique.
Mild pulmonary vascular engorgement without pulmonary edema is
stable. A nasogastric tube is seen to the level of the lower
esophagus, however, the tip is not definitely visualized.
IMPRESSION: Endotracheal tube in appropriate position. Stable
right basal atelectasis and small right pleural effusion.
Cardiology Report ECG Study Date of [**2142-10-21**] 9:57:02 PM
Sinus rhythm. Baseline artifact. Delayed R wave progression.
Compared to the
previous tracing of [**2142-10-11**] no diagnostic interim change.
Read by: [**Last Name (LF) 578**],[**Known firstname **] [**Last Name (NamePattern1) 579**]
Brief Hospital Course:
POD0 ([**10-22**]): Mr. [**Known lastname **] [**Last Name (Titles) 1834**] penectomy for advanced
penile cancer. Surgical findings were locally invasive penile
cancer. A Foley catheter and 2 Penrose drains were inserted. EBL
was 300 cc. Antibiotics included nafcillin and levofloxacin.
Patient was sent to the SICU in stable condition. He was
evaluated by the cardiology and pulmonary services. He was
started on metoprolol. A CXR revealed appropriate placement of
patient's ETT. A RLL lopacity was unchanged from previous
studies. The right hemidiaphragm was elevated c/w known R
phrenic nerve paralysis.
POD1: Patient was extubated successfully in the afternoon. He
was noted to be sitting comfortably in a chair without
complaint. Pain was scant, and he experienced no dyspnea. On
examination, breath sounds were decreased in the RLL. S1 and S2
were distant . Abdomen was soft and nontender with positive
bowel sounds. Hematocrit was noted to be 25 (30 preop).
POD2: Incision was noted to be clean, dry, and intact. Penrose
drains produced scant serosanguinous fluid. Urine appeared
yellow and only slightly turbid. A diet of clear liquids was
commenced. Planning was instituted for administration fo 2 units
packed RBCs. Cardiology and pulmonary continued consultation. He
was noted to be well with some edema and was walking. Pulmonary
recommended verifying walking SaO2 on 2L. A stage II gluteal
pressure ulcer was noted and appropriate therapy was instituted.
POD3: The patient was transferred from the ICU to 12 [**Hospital Ward Name 1827**].
He continued to do very well without any problems. There was a
discussion about having the patient go to a rehab facility or
having a VNA come to the house. The patient insisted that the
VNA come to the house and refused to go to a continued care
facility. Plan for d/c the following day.
POD4: Patient still on 12 [**Hospital Ward Name 1827**] doing well. No major issues.
Both penrose drains d/c. Plan for d/c today, but the family
felt very uncomfortable about haveing the patient come home
without any VNA services on Saturday. Will go home on Saturday
instead. No active issues.
Medications on Admission:
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as
needed for edema for 1 doses.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
Discharge Medications:
1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*50 Capsule(s)* Refills:*0*
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as
needed for edema for 1 doses.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Penile Cancer
Discharge Condition:
Stable
Discharge Instructions:
You are safe to go home at this time per Dr. [**Last Name (STitle) 4229**] and the
Urology team.
1) [**Name8 (MD) **] MD or go to the emergency room if you have a fever
>101.5, chest pain, shortness of breath beyond your normal
baseline level, bleeding, or anything that concerns you.
2) The home visiting nurse will come by to provide wound care to
your leg, buttock area, and Foley catheter care. It is very
important that these services are utilized.
3) You have an Rx. for oral antibiotics, stool softeners, and
pain control. It is very important to take the antibiotics for
the full duration of the prescription to prevent any more
infections. Take the stool softener if your are taking the pain
medication.
4) Do not drink or drive while take the pain medication.
5) You will need to follow up with 2 different services on an
outpatient level: Urology and Cardiology. Call each of thost
departments to make an appointment.
6) To speed up your recovery, it is important not to sit around
all
Followup Instructions:
1) Urology: Dr. [**Last Name (STitle) 4229**] Please call office for an appointment on
Monday.
2) Cardiology: Please call to make an appointment.
Completed by:[**2142-10-27**]
|
[
"250.00",
"585.9",
"187.4",
"V45.81",
"707.8",
"414.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"64.3",
"58.0"
] |
icd9pcs
|
[
[
[]
]
] |
9372, 9430
|
5400, 7545
|
341, 353
|
9488, 9497
|
839, 2954
|
10553, 10733
|
811, 820
|
8315, 9349
|
4034, 4090
|
9451, 9467
|
7571, 8292
|
9521, 10530
|
277, 303
|
4119, 5377
|
381, 589
|
611, 718
|
734, 795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,822
| 160,011
|
35712
|
Discharge summary
|
report
|
Admission Date: [**2150-7-26**] Discharge Date: [**2150-8-22**]
Date of Birth: [**2088-2-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Left Heart Catheterization
Right Heart Catheterization
History of Present Illness:
62M w/ hx of PE, COPD, hep C, AICD, and bronchiolitis obliterans
presents with increasing dyspnea x1 week. Pulmonary problems
began after he started new interferon tx for HCV in 11/[**2148**]. He
has had multiple effusions tapped w/ no malignancy, bx showed
bronchiolitis obliterans. Last set of PFTs revealed: Vital
capacity is 3.92 liters, 80% predicted; his FEV1 is 1.63 liters,
48% predicted, the vital capacity has increased from 64%
predicted; FEV1 is increased from 41% predicted.
He started home oxygen in [**2150-3-29**]. In the last week, he
has had increasing dyspnea at rest, chest pain when dyspneic,
and increasing orthopnea. Requires home O2 of 2L, has had
decreasing sats at home, reported to 82% on RA. He thinks he has
gained more weight. Increasing cough in past 24 hrs, mildly
productive, but has been taking mucinex. No swelling in
extremities.
ROS: +DOE, orthopnea, subjective fever, pleuritic chest pain,
dry cough. Negative for PND, sick contacts, hemoptysis, chest
pain or recent travel.
Past Medical History:
COPD
HCV genotype 1 s/p treatment with
interferon/ribavirin/boceprevir, most recent viral load [**Numeric Identifier 4731**] in
[**5-/2150**]
cardiac arrest [**2131**] s/p ICD
AF s/p AV node ablation s/p BiV PPM
diastolic CHF (details unclear, no cardiology reports in our
system)
Cryptogenic organizing pneumonia (seen on biopsy of RLLobe mass)
Subsegmental PE on coumadin (for afib)
Social History:
Born in [**Location (un) **], moved to US in his 20s. Lives in [**Location 81241**]
NY with his wife. Until [**Name2 (NI) 404**] had been working as a bartender.
Former heavy smoker (40+ pack-years), quit 8 mos ago. No longer
drinks EtOH since HCV diagnosis, remote h/o cocaine use but none
for many years. No known mold exposures, no
chemicals/dusts/particles.
Family History:
Father had TB with pneumonectomy - prior to patient's birth.
Mother had emphysema.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.7 BP: 104/78 P: 62 R: 410 O2: 85%3LNC
General: Alert, oriented, thin older Caucasian genntleman in no
acute distress. Mildly dyspneic, some accessory muscle use.
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA, EOMI
NECK: supple, elevated JVP to the level of the jaw, no LAD
LUNGS: Clear to auscultation on right, crackles at left base
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEURO: A&O x3, CNs II-XII intact, 5/5 strength in upper and
lower extremities bilaterally, sensation grossly intact to light
touch. Reflexes 1+ bilaterally and symmetrically. Downgoing toes
bilaterally.
DISCHARGE PHYSICAL EXAM:
98.1 88/55-97/62 60-61 20 100% 4L
GENERAL- NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK- Supple, Prominent distend EJ, JVP 1/4 way up to angle of
jaw while sitting up.
CARDIAC- RRR, distant heart sounds, machine like systolic murmer
loudest at the apex. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Improved aeration
throughout lung fields, particularly mid and upper fields.
Bibasilar crackles present
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits. Extremities cool.
SKIN- No stasis dermatitis or ulcers
PULSES-
Right: radial 1+ DP 1+
Left: radial 1+ DP 1+
Pertinent Results:
ADMISSION:
[**2150-7-26**] 11:00AM BLOOD WBC-8.4 RBC-3.35* Hgb-10.4* Hct-31.4*
MCV-94 MCH-31.0 MCHC-33.1 RDW-18.1* Plt Ct-231
[**2150-7-26**] 11:00AM BLOOD Glucose-107* UreaN-36* Creat-0.8 Na-132*
K-3.6 Cl-97 HCO3-27 AnGap-12
[**2150-7-26**] 11:00AM BLOOD ALT-54* AST-57* AlkPhos-357* TotBili-0.8
[**2150-7-26**] 11:00AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.4 Mg-2.3
PERTINENT:
[**2150-8-3**] 06:20AM BLOOD calTIBC-313 Ferritn-321 TRF-241
[**2150-8-3**] 06:20AM BLOOD AFP-3.3
[**2150-8-9**] 01:26AM BLOOD Type-ART pO2-22* pCO2-55* pH-7.41
calTCO2-36* Base XS-6
[**2150-8-9**] 12:13PM BLOOD Type-ART pO2-48* pCO2-37 pH-7.52*
calTCO2-31* Base XS-6
[**2150-8-9**] 02:59PM BLOOD Type-ART pO2-99 pCO2-49* pH-7.47*
calTCO2-37* Base XS-10
[**2150-8-9**] 01:26AM BLOOD Lactate-2.8*
[**2150-8-9**] 12:13PM BLOOD Lactate-3.6*
[**2150-8-9**] 02:59PM BLOOD Lactate-1.1
[**2150-8-9**] 05:30PM BLOOD Lactate-2.0
DISCHARGE:
[**2150-8-22**] 07:10AM BLOOD WBC-6.2 RBC-2.92* Hgb-9.0* Hct-27.6*
MCV-95 MCH-30.9 MCHC-32.7 RDW-18.3* Plt Ct-253
[**2150-8-22**] 07:10AM BLOOD PT-16.8* INR(PT)-1.6*
[**2150-8-22**] 07:10AM BLOOD Glucose-95 UreaN-46* Creat-1.6* Na-129*
K-3.3 Cl-82* HCO3-40* AnGap-10
[**2150-8-22**] 07:10AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.6
STUDIES:
Admission ECG:
Atrial fibrillation with ventricular demand pacing
[**2150-7-26**] CXR:
IMPRESSION:
1. Unchanged small bilateral pleural effusions.
2. Possible mild pulmonary edema on background of emphysema.
3. Slight increase in left basilar opacity may indicate a
superimposed
infectious process.
[**2150-7-28**] CT Chest:
1. Since the recent CT scan from [**2150-7-13**], multiple lower
lobe pulmonary
nodules have slightly decreased in size with improvement in
ill-defined
subpleural and lower lobe opacities. No new nodules or
opacities are
identified.
2. Small left pleural effusion is essentially stable.
3. Severe emphysema is unchanged.
4. Stable mediastinal lymphadenopathy.
5. Nodularity of the liver, which may be consistent with
cirrhosis.
6. Substantial pericardial calcifications and severe aortic
valve
calcifications.
7. Enlarged pulmonary artery consistent with pulmonary
hypertension.
[**2150-7-28**] [**Month/Day/Year **]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with borderline normal free
wall function. The ascending aorta is mildly dilated. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (valve area 0.9 cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. There is mild functional mitral
stenosis (mean gradient 7 mmHg) due to mitral annular
calcification. Moderate to severe (3+) mitral regurgitation is
seen (after taking into consideration acoustic shadowing from
the severely calcified mitral annulus). 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. [In
the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2150-5-14**], the mitral regurgitation may be worse, but the
technically suboptimal nature of both studies precludes
definitive comparison. The pressure gradient across the mitral
valve is increased.
Carotid US:
There is less than 40% stenosis within the internal carotid
arteries bilaterally.
Abdominal US:
1. Coarse heterogeneous liver parenchyma consistent with
history of liver
fibrosis and HCV. No evidence of focal liver mass.
2. Normal Doppler evaluation of the hepatic vasculature.
3. Small left pleural effusion incidentally noted.
CXR [**2150-8-9**]:
Compared to the film from the prior day, the heart is slightly
larger. The left effusion is larger and the pulmonary vascular
redistribution
is worse. Alveolar infiltrate in the right lower lobe is also
slightly worse.
The overall impression is that of CHF which is worsened in the
interval. The
dual-lead pacemaker is unchanged.
Cardiac CT Study:
1. Aortic valve stenosis without evidence of aortic aneurysm.
Note that
significant misregistration artifact on this gated CT precludes
accurate
aortic valve measurements. Repeated scan can be offered with no
extracharge.
2. Near-complete right common femoral occlusion, severe
proximal left
subclavian narrowing.
3. Diffuse pulmonary abnormalities. Severe emphysema and
multiple pulmonary
nodules are similar to the prior exam seven days ago.
Vasculitis is favored
over cryptogenic organizing pneumonia, or, much less likely,
lymphoma.
4. 12mm hypodensity in the anterior of the spleen is new since
[**7-28**] and
may represent a small infarct.
5. Heavily calcified pericardium raises the possibility of
restrictive
physiology
Cath [**2150-7-31**]:
1. Mild non-obstructive coronary artery disease.
2. Severely elevated left and right sided filling pressures.
3. Severe pulmonary arterial systolic hypertension.
4. Depressed cardiac output and cardiac index.
5. Hemodynamic study sugegstive of constrictive/restrictive
physiology.
Pretest probability for restrictive physiology is reported as
low by the
referring cardiologist.
6. Severe aortic stenosis.
7. Moderate mitral stenosis.
8. Severely calcified stenotic lesion at origing of the R EIA.
Cath [**2150-8-20**]:
ASSESSMENT
1. Moderate to severe aortic stenosis with compensated left
ventricular filling pressures and aortic valve area 0.9 cm2.
2. Mild-moderate pulmonary hypertension
3. Mild pulmonary hypertension partially responsive to nitric
oxide
MEDICAL THERAPY
1. Consider sildenafil for pulmonary hypertension
2. Optimize fluid management
3. Consider pulmonary etiology for hypoxemia (FIO2 40% -->
sats 94%)
4. Medical therapy for aortic stenosis
5. Cardiac CT to evaluated aortic annulus diameter for
potential future therapy with transcatheter aortic valve
replacement
Brief Hospital Course:
62M w/ hx of PE, COPD, Hepatitis C with Grade III/IV fibrosis,
Atrial Fibrillation on coumadin, cardiac arrest s/p AICD
placement, cocaine induced cardiomyopathy (EF 55%), and
bronchiolitis obliterans presents with increasing dyspnea x1
week.
.
ACUTE
# Dyspnea: Pt has multiple reasons for dyspnea. He had been on
2L O2 since [**Month (only) **]. However, this had progressed over the
week leading up to admission. On admission, he required 4-5L on
nasal cannula. There was initial concern for pneumonia, and the
patient was treated with antibiotics. However, CT chest was not
convincing for pneumonia and antiobiotics were discontinued.
Pulmonary disease appeared largely unchanged per pulmonary based
on CT and no steroids were recommended for management of ? BOOP
that had been previously diagnosed. Patient was started on
duonebs, advair, and spiriva to optimize COPD management.
Pulmonary suggested echocardiogram to evaluate pump function.
There was evidence of severe AS and MR [**First Name (Titles) **] [**Last Name (Titles) 113**] combined with
severe pulmonary hypertension. Additionally, cardiac cath
confirmed valvular disease and elevated wedge pressure and
demonstrated restrictive physiology which was evident on CT with
pericardial calcifications. Combined, these issues prevented
him from augmenting his preload which contributed to his
profound dyspnea on exertion. At this point, the patient was
aggressively diuresed with bolus IV lasix given evidence of
volume overload on exam. He was placed on a salt and fluid
restriction. This did not improve his symptoms and O2
requirement continued at 4-5L. Cardiac surgery was consulted
for AVR but it was determined that he was not a candidate with
his severe lung disease and liver disease. Additionally,
interventional cardiology felt that he was not a candidate for
percutaneous valve replacement. Ultimately, despite aggressive
diuresis, the patient developed worsening respiratory distress
on the floor while on 5L face mask and required BiPAP in the
ICU. At this point, his code status was changed to DNR/DNI. He
was aggressively diuresed with bolus IV lasix in the CCU while
on BiPAP and ultimately was transferred back to the floor on his
baseline O2 requirement of 4-5L. At this point, we considered
if he might be candidate for aortic valvuloplasty. He was
aggressively diuresed with lasix gtt + metolazone. He was taken
again to cath lab and found to have a wedge of 12.
Nevertheless, his O2 sat was only 94% on 40% FiO2 indicating
that his lung disease was contributing to his hypoxia. He did
have significant pulmonary hypertension which was improved with
NO. Given these findings, valvuloplasty was not performed. The
patient was transitioned to torsemide 100 mg daily and started
on sildenafil 20 mg TID for pulmonary hypertension. He was
discharge with f/u with Dr [**Last Name (STitle) **]. He was advised to f/u with
his PCP and to consider finding a cardiologist closer to home.
.
Hypotension: Patients baseline systolic blood pressures ranged
from upper 90s to 100s. He experience multiple episodes of
hypotension in the setting of aggressive diuresis with IV lasix,
with the lowest SBP being in the 60s systolic. During these
episodes diuresis was held. No IV fluids were given out of
concern for development of volume overload. He was otherwise
asymptomatic during these episodes of hypotension.
.
Acute Kidney Injury: Cre rose to 1.7 at times during admission.
This was in the setting of aggressive diuresis to optimize
volume status. This resolved with holding of diuresis. On
discharge, his Cre was 1.6, trending down from 1.7.
.
CHRONIC
# Cryptogenic organizing pneumonia (seen on biopsy of RLLobe
mass): Pulmonary suggested that there was no role for steroids
currently given the uncertainty of the COP diagnosis. This
disease was stable on repeat CT and there was concern that
steroids would contribute to his worsening fluid retention.
.
# COPD: Patient has sever pulmonary hypertension based on FEV1.
This prohibited him from undergoing surgery for his valve
repair. He was continued on advair, spiriva, and duonebs.
.
# Pulmonary HTN: patient had grossly elevated pulmonary artery
pressures believed to be secondary to long standing COPD as well
as pulmonary edema. Management as above.
.
# HCV genotype 1: Patient was treated with
interferon/ribavirin/boceprevir. At one point, his viral load
was undetectable but he relapsed in [**2150-5-29**].
.
# AF s/p AV node ablation s/p BiV PPM on coumadin. Coumadin was
discontinued as it was thought that he may go to the OR. After
this plan was discontinued, he was restarted on coumadin. He
was discharged with an INR of 1.6 without heparin bridge. He was
continued on metoprolol for rhythm control during this
admission.
.
TRANSITIONAL ISSUES
-Steroid treatment of BOOP/COP deferred to outpatient
pulmonology.
-Resumption of Hep C treatment per [**Doctor Last Name **].
-INR and electrolytes check on Monday
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
2. Furosemide 80 mg PO BID
3. Tiotropium Bromide 1 CAP IH DAILY
4. Warfarin MD to order daily dose PO DAILY16
5. Vitamin B Complex 1 CAP PO DAILY
6. Ferrous Sulfate 140 mg PO DAILY
7. Potassium Chloride (Powder) Dose is Unknown PO Frequency is
Unknown
Hold for K >
8. Metoprolol Tartrate 12.5 mg PO TID
9. Albuterol Inhaler [**12-29**] PUFF IH Q4H:PRN SOB/wheezing
10. Multivitamins 1 TAB PO DAILY
11. Metolazone 2.5 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
3. Multivitamins 1 TAB PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Vitamin B Complex 1 CAP PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp<90, hr<55
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Once a Day
Disp #*30 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Once A Day Disp #*30
Tablet Refills:*0
8. Sildenafil 20 mg PO TID
hold for sbp < 90
RX *sildenafil [Revatio] 20 mg 1 tablet(s) by mouth Three Times
a Day Disp #*90 Tablet Refills:*0
9. Torsemide 100 mg PO DAILY
hold for SBP<90 and page H.O.
RX *torsemide 100 mg 1 tablet(s) by mouth Once A Day Disp #*30
Tablet Refills:*0
10. Outpatient Lab Work
Please Check INR and chem 10 panel on [**2150-8-24**] and fax results to
Oi, [**Female First Name (un) 81242**] at [**Telephone/Fax (1) 81243**]
ICD9: acute systolic heart failure
11. Morphine Sulfate IR 15 mg PO Q8H:PRN cramps
RX *morphine 15 mg 1 tablet(s) by mouth Every 8 hours Disp #*10
Tablet Refills:*0
12. Sodium Chloride Nasal [**12-29**] SPRY NU TID:PRN nasal dryness
RX *sodium chloride [Nasal Moisturizing] 0.65 % 1 spray each
nostril four times a day Disp #*1 Bottle Refills:*0
13. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
Peconic Bay Home Care
Discharge Diagnosis:
Primary: Aortic Valve Stenosis, COPD
Secondary: Pulmonary Hypertension, Atrial Fibrillation,
Cocaine-induced cardiomyopathy, Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 81244**],
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 18**]. You were admitted due to increased shortness of
breath. There were multiple reasons to explain your worsened
shortness of breath including obstructive lung disease,
pulmonary edema, pulmonary hypertension, and aortic stenosis.
Your lung function and breathing did improve somewhat with
aggressive diuresis. Unfortunately, you were not a candidate
for surgery or percutaneous valve repair. Therefore, we did our
best to optimize your respiratory status with inhalers and
nebulizers. You should follow-up with your PCP in [**Name9 (PRE) 531**] as
well as Dr [**Last Name (STitle) **] to optimize continue to work to improve your
lung function. Additionally, you may want to consider finding a
cardiologist that is closer to you in [**State 531**] so that you may
obtain more regular follow-up.
Please have your electrolytes (Chemistry 10 panel) and INR labs
drawn on Monday [**2150-8-24**] at your primary care doctor's office.
Followup Instructions:
Name: OI,[**Female First Name (un) **] M
Address: 4 [**Doctor First Name **] DR., PATCHOGUE,[**Numeric Identifier 81245**]
Phone: [**Telephone/Fax (1) 81246**]
****The office is working on an appt for you and will call you
at home with the appt. If you dont hear from them by Monday
afternoon, please call them directly to book.
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2150-8-27**] at 7:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2150-8-27**] at 8:00 AM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2150-8-27**] at 8:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"799.4",
"070.54",
"492.8",
"396.2",
"414.01",
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"276.8",
"423.2",
"425.9",
"V12.53",
"584.9",
"416.8",
"515",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
17517, 17569
|
10551, 15539
|
333, 389
|
17750, 17750
|
4030, 10528
|
19014, 19927
|
2240, 2324
|
16187, 17494
|
17590, 17729
|
15565, 16164
|
17933, 18991
|
2364, 3187
|
273, 295
|
417, 1436
|
17765, 17909
|
1458, 1844
|
1860, 2224
|
3212, 4011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,050
| 159,085
|
28553
|
Discharge summary
|
report
|
Admission Date: [**2144-12-18**] Discharge Date: [**2144-12-23**]
Date of Birth: [**2069-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Melena, acute HCT drop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 75 year-old Spanish-speaking male with metastatic
clear cell renal cell carcinoma and HTN who presented with
complaint of black stool. He had a CT scan [**12-2**] showing tumor
abutting and possibly eroding into duodenum and right colon. He
was noted to have guaiac positive stool last week with a drop in
Hct. He was transfused one unit pRBCs on [**12-11**] in [**Hospital **] clinic. He
saw GI on [**12-15**] with a plan for outpatient endoscopies. Today he
presented in clinic unscheduled with c/o black stools x 2
yesterday.
.
In ED his Hct was 23.7. Rectal exam showed melena. He was
crossmatched for 6 units and ordered for 2 units. GI and
Oncology consultants were called.
.
Or arrival to the ICU, he denies fevers, abdominal pain, BRBPR,
nausea, or hematemesis. No chest pain, palpitations, SOB,
dizziness, or LH. No NSAID or ASA use.
Past Medical History:
- clear cell renal cell carcinoma - dx [**2143-10-21**]. right kidney,
metastatic to lungs. was initially on Sorafenib and Avastin.
currently being treated with perifosine on study (started
[**2144-8-24**]). followed by Drs. [**Last Name (STitle) 39628**] and [**Name5 (PTitle) **].
- HTN
- BPH
- Bilateral cataract surgery
- Memory loss
- CRI - baseline Cr 1.8
Social History:
Married for 37 years, no children. Unemployed, prior
administrative work in [**Location (un) **], has lived in US for 4 years. Smoked
[**12-27**] cigarettes per day for 5 years, quit 5 years ago.
Family History:
Denies cancer in family members.
Physical Exam:
Vitals: AF, VSS
GEN: Pleasant, NAD, talkative
HEENT: PERRL, EOM intact, anicteric sclerae. OP clear with no
exudates, MMM
NECK: No LAD, JVD flat.
LUNGS: CTA bilaterally, with no rales, no rhonchi, no wheezing
HEART: Regular, nl S1/S2, no m/r/g
ABD: soft, non-tender, non-distended, BS+, No HSM.
EXT: No LE edema, 2+ DP pulses, warm to palpation
SKIN: No rash, no jaundice
NEURO:intact grossly
Pertinent Results:
.
EKG: NSR, nl axis, no acute ST or T-wave changes
.
CT Chest/Abd/Pelvis [**12-2**]:
1. Minimal interval increase in the size of an aortocaval lymph
node as described above.
2. Overall stable appearance of the right renal mass with
stable multistation intrathoracic lymphadenopathy. This renal
mass also abuts the right side of the colon and likely invades
the inferior surface of the liver.
3. Stable up to 3-mm pulmonary nodules.
.
.
[**2144-12-18**] 10:15AM WBC-5.1 RBC-2.52* HGB-7.9* HCT-23.7* MCV-94
MCH-31.4 MCHC-33.4 RDW-13.5
[**2144-12-18**] 10:15AM PLT COUNT-203
[**2144-12-18**] 10:15AM ALT(SGPT)-15 AST(SGOT)-16 LD(LDH)-182 ALK
PHOS-33* TOT BILI-0.3
[**2144-12-18**] 10:15AM GLUCOSE-121* UREA N-61* CREAT-2.2* SODIUM-143
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-29 ANION GAP-12
[**2144-12-18**] 10:49AM PT-11.8 PTT-24.7 INR(PT)-1.0
[**2144-12-18**] 09:56PM HCT-26.5*
[**2144-12-18**] 10:15AM BLOOD WBC-5.1 RBC-2.52* Hgb-7.9* Hct-23.7*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.5 Plt Ct-203
[**2144-12-18**] 09:56PM BLOOD Hct-26.5*
[**2144-12-19**] 04:27AM BLOOD WBC-5.0 RBC-2.65* Hgb-8.4* Hct-24.9*
MCV-94 MCH-31.8 MCHC-33.7 RDW-14.7 Plt Ct-181
[**2144-12-19**] 03:12PM BLOOD Hct-30.0*
[**2144-12-20**] 12:27AM BLOOD Hct-29.5*
[**2144-12-20**] 06:45AM BLOOD WBC-4.9 RBC-3.30* Hgb-10.3* Hct-30.5*
MCV-92 MCH-31.2 MCHC-33.8 RDW-14.8 Plt Ct-202
[**2144-12-20**] 04:52PM BLOOD Hct-31.0*
[**2144-12-21**] 07:20AM BLOOD WBC-6.0 RBC-3.79* Hgb-12.0* Hct-35.1*
MCV-93 MCH-31.7 MCHC-34.2 RDW-14.2 Plt Ct-214
[**2144-12-22**] 07:50AM BLOOD WBC-5.2 RBC-3.06* Hgb-9.6* Hct-28.3*
MCV-93 MCH-31.6 MCHC-34.1 RDW-14.4 Plt Ct-188
[**2144-12-22**] 06:00PM BLOOD Hct-29.1*
[**2144-12-23**] 07:00AM BLOOD WBC-6.9 RBC-3.26* Hgb-10.6* Hct-31.2*
MCV-96 MCH-32.6* MCHC-34.1 RDW-14.2 Plt Ct-193
[**2144-12-23**] 07:00AM BLOOD Glucose-98 UreaN-28* Creat-1.9* Na-141
K-4.1 Cl-110* HCO3-25 AnGap-10
[**2144-12-20**] 06:45AM BLOOD Calcium-8.8 Phos-4.6*
[**2144-12-18**] 10:15AM BLOOD ALT-15 AST-16 LD(LDH)-182 AlkPhos-33*
TotBili-0.3
[**2144-12-18**] 10:15AM BLOOD Lipase-95*
Brief Hospital Course:
This is a 75 yo Spanish speaking male with metastatic clear cell
renal carcinoma admitted with melena and drop in hematocrit to
23. He was admitted to the ICU for closer monitoring. He was
transfused 3 units of pRBCS with stabilization of his Hct. He
remained asymptomatic, without recurrent melena. GI
consultation was obtained and recommended serial Hct and
inpatient EGD and colonoscopy. He was transferred to the floor.
.
#GI Bleed: Melena on exam/history most consistent with upper GI
bleed. He received 1 u pRBCs on [**12-11**]. EGD showed 3 cm
submucosal mass in the second part of the duodenum, with
erosions and evidence fo bleeding. This was felt to be
consistent with extension of the primary renal tumor. Surgery
and radiation oncology were consulted for advice regarding
palliative options. The surgical team felt he was unlikely a
surgical candidate, given the extensive involvement of his
cancer and mets, and removal of the culprit duodenal tumor area
would likely involve total nephrectomy, Whipple, partial
hepatectomy. Radiation oncology had not given their opinion on
discharge, but will follow up with Dr. [**Last Name (STitle) **], the primary
oncologist. Mr. [**Known lastname 69158**] hematocrit was stable for several
days prior to discharge, but was counseled on the possibility of
re-bleeding and will return with symptoms.
#Renal Cell Cancer: will follow up with Dr. [**Last Name (STitle) **].
#Acute on Chronic Kidney disease - improved to baseline with
transfusion.
#HTN: baseline, benign HTN, on single [**Doctor Last Name 360**], resumed amlodipine
prior to discharge.
Medications on Admission:
amlodipine 10mg daily
prn compazine
MVI
perifosine study chemotherapy 100 mg QDay - stopped Friday [**12-11**]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Stage IV renal cell cancer
Discharge Condition:
stable
Discharge Instructions:
Please take all your medications. Do not continue your cancer
medications. Call your primary physician for any concerns or
questions. Return to the hospital if you have concerning
symptoms, such as lightheadedness, chest pain, dizziness or
dramatic bleeding.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-12-28**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-12-28**] 3:00 on [**Hospital Ward Name 23**] [**Location (un) **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-12-28**] 3:00
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9,710
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47753
|
Discharge summary
|
report
|
Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-4**]
Date of Birth: [**2105-10-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Reglan / Quinine Sulfate / Codeine / Augmentin /
Clindamycin / Dilaudid / Iodine
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
headache, weakness
Major Surgical or Invasive Procedure:
Esophagoduodenoscopy
History of Present Illness:
This is a 63 year old woman with multiple sclerosis, paraplegia,
DM, CAD s/p RCA stents in [**2165**], PVD, prior CVA, multiple DVTs on
warfarin, who presented to the with headache, fatigue, and
nausea. She says that her headache has been gradually increasing
over the past two days and is described as throbbing, like her
head is going to explode. She denies visual changes or
photophobia but is mostly blind. She denies neck stiffness,
fevers.
.
Ms. [**Known lastname 100774**] tells me her last bowel movement was Monday (3 days
ago) and was, to her recollection, normal. In particular she
denies bright red blood or black stool. She does endorse
light-headedness for several days. She denies any NSAID use but
does take warfarin and clopidogrel as prescribed.
.
In the ED, 98 106 133/63 18 100% 15L. Patient's labs were
significant for a Hct of 14.7 (baseline 25-28, most recently
checked 1 month ago) and INR 7.6. She was noted to have formed
guaiac negative brown stool on rectal exam. She was given 5mg po
Vit K, and startted on IV protonix . The patient refused NG
lavage. She initially refused head CT head but later consented.
This was normal. CT abdomen was attempted but the patient had a
panic attack in the scanner despite pre-treatment with 2 mg IV
Ativan. She was given 2U FFP and 2U pRBC.
.
On arrival to the MICU, the patient complains of ongoing
headache. She also complains of palpitations which she says are
chronic. Review of systems was negative for nausea, abdominal
pain, diarrhea, vomitting, fevers, chills.
Past Medical History:
# CAD -- ([**12-18**]) RCA stents x2, mild ICM.
-- Echo [**6-20**] with LVEF >55%
# History of recurrent DVTs
-- First DVT in [**2148**], given Coumadin for 6 months
-- Second DVT in [**2162**], given Coumadin then Plavix
-- Third DVT in [**2164-4-11**], now on Coumadin and Plavix
# MS diagnosed in [**2150**], wheelchair bound since [**2151**]
# CVA in [**2152**], h/o TIAs on Plavix [**Hospital1 **]
# PAD by angiogram ([**7-20**])
-- Significant left SFA, popliteal, and anterior tibial disease
-- Not amendable to stenting. Complicated by nonhealing LLE
ulcer.
# Left BKA ([**2167-9-28**]) for nonhealing ulcer
# Spinal cord compression
-- S/p C3-7 and T2-11 laminectomy and fusion surgeries
-- Residual paraparesis and absent sensation in bilateral LE.
-- No sensation below T10.
# Seizure disorder
# Diabetes Mellitus Type 2
# Hypertension
# Hypercholesterolemia
# Sarcoidosis
# Anemia
# Uterine/cervical cancer s/p radical hysterectomy
# Asthma/COPD
# Cardiac arrest after delivery (C-sect) of her 1st child
# OSA -- no BiPAP/CPAP use
# GI Bleed
([**12/2163**]) thought to be [**3-15**] ischemic colitis in setting of
hypotensive episode and supratherapeutic INR
([**9-/2168**]) Required 3 units pRBCs, patient declined endocscopy.
Social History:
She lives at home and is wheelchair bound and primarily
dependent on aides for her care (present daytime only). She is a
former alcoholic, sober since [**94**] y/o when pregnant. She also has
a 70 pack-year tobacco history, quit at 36 years old. She is [**Name Initial (MD) **]
retired RN at [**Hospital1 756**]. She is single. Daughter [**Name (NI) 7905**] very
involved in her care.
Family History:
Multiple relatives with DM, CAD, HTN, asthma, and cancers (at
least two with brain cancers). Mother died age 50 brain cancer
had DMII and "mild MIs", father died age 48 MI and had DMII. No
FH of MS, or DVT/PE. Brother deceased 53yo had 3 bypass surgery.
Physical Exam:
On admission:
Vitals: T: 97.5, HR 96, RR 13, O2 Sat 100% 2L
GEN: obese, hirsuit, friendly woman lying in bed
[**Name (NI) 4459**]: dry mucosa
NECK: unable to move (patient states chronic), no pain to
palpation
COR: regular, no murmur appreciated
PULM: lungs clear bilaterally
ABD: obese, soft, nontender, hyperactive bowel sounds, no
rebound or guarding
EXT: L BKA, no significant peripheral edema
NEURO: alert, oriented x 3, PERRL, CN 2-12 intact, moves
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
On discharge:
Vitals: T 98.9 HR 78 BP 108/54 RR 18 O2 sat 94%RA
GEN: obese, hirsuit, friendly woman lying in bed
[**Name (NI) 4459**]: moist mucous membranes
NECK: unable to move (patient states chronic), no pain to
palpation
COR: regular, no murmur appreciated
PULM: lungs clear bilaterally
ABD: obese, soft, nontender, no rebound or guarding
EXT: L BKA, no significant peripheral edema
NEURO: alert, oriented x 3, PERRL, CN 2-12 intact
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
On admission:
[**2168-12-29**] 06:03PM BLOOD WBC-9.7 RBC-1.85*# Hgb-4.7*# Hct-14.7*#
MCV-80* MCH-25.2* MCHC-31.8 RDW-19.6* Plt Ct-398
[**2168-12-29**] 06:03PM BLOOD Neuts-76.8* Lymphs-18.7 Monos-3.3 Eos-0.7
Baso-0.5
[**2168-12-29**] 06:03PM BLOOD PT-66.2* PTT-42.0* INR(PT)-7.6*
[**2168-12-29**] 06:03PM BLOOD Fibrino-484*
[**2168-12-30**] 01:04AM BLOOD Ret Man-6.0*
[**2168-12-29**] 06:03PM BLOOD Glucose-271* UreaN-48* Creat-1.1 Na-135
K-4.1 Cl-102 HCO3-23 AnGap-14
[**2168-12-29**] 06:03PM BLOOD ALT-21 AST-19 LD(LDH)-143 AlkPhos-46
TotBili-0.1 DirBili-0.0 IndBili-0.1
[**2168-12-29**] 06:03PM BLOOD cTropnT-<0.01
[**2168-12-29**] 06:03PM BLOOD Iron-11*
[**2168-12-30**] 01:04AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.9
[**2168-12-29**] 06:03PM BLOOD calTIBC-445 Hapto-199 Ferritn-9.7*
TRF-342
[**2168-12-29**] 06:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2168-12-29**] 06:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2168-12-29**] 06:50PM URINE RBC-0-2 WBC-[**4-15**] Bacteri-MOD Yeast-OCC
Epi-0-2
.
On discharge:
[**2169-1-4**] 04:58AM BLOOD WBC-9.4 RBC-3.04* Hgb-8.8* Hct-26.0*
MCV-86 MCH-28.9 MCHC-33.7 RDW-16.8* Plt Ct-393
[**2169-1-2**] 05:35AM BLOOD Glucose-94 UreaN-15 Creat-0.8 Na-142
K-4.0 Cl-106 HCO3-29 AnGap-11
[**2169-1-2**] 05:35AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0
.
Portable CXR [**2168-12-29**]:
FINDINGS: No consolidation or edema is evident. Calcification is
seen at the ascending aorta. The cardiac silhouette is enlarged
but stable. No effusion or pneumothorax is noted. Degenerative
changes are noted throughout the thoracic spine.
IMPRESSION: No acute pulmonary process.
.
CT Head w/o contrast [**2168-12-29**]:
FINDINGS: Study is limited by patient inability to lie flat and
large field of view used. There is significant underlying
hyperostosis totalis resulting in further degradation of image
quality. With this limitation in mind, there is no large
intracranial hemorrhage, large acute territorial infarction, or
large masses. Ventricles and sulci are stable in size and
configuration. There is no shift of midline structures.
Paranasal sinuses and mastoid air cells are within normal
limits. Diffuse hyperostosis is seen of the calvarium.
IMPRESSION: Limited study without gross evidence of acute
intracranial
process.
.
Abd Ultrasound [**2169-1-1**]:
FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**] evaluation of
the abdomen was performed. Evaluation of the liver is somewhat
limited due to patient's body habitus. However, there is no
intrahepatic biliary dilatation. No focal hepatic lesions are
identified. The gallbladder demonstrates sludge, but is
otherwise normal in appearance.
The right kidney measures 9.9 cm. The left kidney measures 12.8
cm. There is no hydronephrosis, stones or mass. The left kidney
demonstrates a cyst at the upper pole measuring up to 3 cm in
size.
The spleen measures up to 11.1 cm in size, which is unchanged
since the prior CT study of [**2165-9-30**]. The pancreas is not
well visualized due to overlying bowel gas.
IMPRESSION:
1. Spleen measuring 11.1 cm in size, within normal limits, and
unchanged
since the prior CT of [**2165-9-30**].
2. Sludge within the gallbladder. Gallbladder is otherwise
normal in
appearance.
.
EGD [**2169-1-3**]:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
.
Brief Hospital Course:
62 year old woman with multiple sclerosis, DM, CAD s/p RCA stens
in [**2165**], PVD, prior CVA, and multiple DVTs, h/o spinal cord
compression with no sensation below T10 who presented with
anemia with a Hct 14.7, hemodynamically stable.
#. Anemia: Presented with Hct 14.7, was 28 about a monht ago in
the setting of INR of 7.1 Was guaiac negative in the ED,
refused NG lavage and abd CT, and did not have abd, back, or
flank pain or ecchymosis to suggest RP bleed. Received 5 units
of PRBC and 2 units of FFP over hospital course and
anticoagulation, with plavix, aspirin, coumadin were held. GI
was consulted and recommended IV PPI and also EGD and
colonoscopy to evaluate for the source of what was likely a slow
GI bleed, considering her hemodynamic stability with profound
anemia. Hemolysis labs were negative and iron studies were
notable for iron deficiency.
Patient refused golytely prep for [**Last Name (un) **], but EGD was performed
with assistance from anesthesia considering her limited neck
mobility. EGD showed no source of bleed in the upper GI tract.
Hct remained stable at 25-26 after transfusions and INR was 1.1
on discharge, and she remained hemodynamically stable. She will
be discharged with PO pantoprazole [**Hospital1 **] for the next two weeks
and then once a day for presumed GI bleed. She will also have
weekly CBCs done by her VNA.
.
#. Headache: Iniitally presented to ED for headache. Pt reports
2 days of headache and nausea. No evidence of intracranial
pathology on noncon head CT. and she did not have fevers, neck
stiffness, photophobia or other symptoms of meningitis. No new
focal neuro findings. Headache improved during hospitalization
with tramadol. She will be discharged iwth tramadol PRN.
.
#. CAD ([**12-18**]) RCA stents x2, mild ICM. CE negative x1 and no
ECG changes. ASA and blood pressure meds were held. She was
discharged with plavix once a day, and coumadin will be
restarted as an outpatient.
.
# History of recurrent DVTs on coumadin. Plavix and warfarin
were held in the setting of likely bleeding.
.
# MS diagnosed in [**2150**], wheelchair bound since [**2151**]
.
# CVA in [**2152**], h/o TIAs on Plavix [**Hospital1 **] at home, which was held.
.
# Diabetes Mellitus Type 2: Continued home NPH, with dose
halved while she was NPO. she will be discharged with her home
insulin regimen.
.
# Hypertension: Home BP meds were held, and restarted on
discharge
.
# Hypercholesterolemia: Statin was held, restarted on discharge
Medications on Admission:
Atorvastatin 80 mg daily
Baclofen 10 mg TID
Carbamazepine 200 mg QID
Clopidogrel 75 mg [**Hospital1 **]
Fluticasone 110 mcg/Actuation [**Hospital1 **]
Lisinopril 5 mg daily
Metoprolol Tartrate 75mg [**Hospital1 **]
Mirtazapine 7.5 mg qhs
Warfarin 12.5mg daily
Albuterol Sulfate 2.5 mg /3 mL (0.083 %)q6:prn
Famotidine 10mg q12
Acetaminophen 1000 mg TID prn
Hydrocodone-Acetaminophen 5-500 mg 1-2 tabs q6prn
Isosorbide Mononitrate 90mg daily
NPH Insulin Human 85 units each morning and 25 units each
evening.
Insulin Regular Human 100 unit/mL 6U qam
Nystatin 100,000 unit/g powder [**Hospital1 **]
Discharge Medications:
1. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone 110 mcg/Actuation Aerosol Sig: Five (5) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
Disp:*20 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 2 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: Take
pantoprazole once a day after the first two weeks of taking
twice a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. NPH insulin human recomb 100 unit/mL Suspension Sig: Eighty
Five (85) units Subcutaneous QAM.
11. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous QPM.
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**2-13**] Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
14. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
15. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, headache: Do not exceed 4g
in 24 hours.
18. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
GI bleed
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 seen in the hospital for severe anemia. For this, you
received several blood transfusions and you had an EGD which
looked at your GI tract for a source of a bleed. These studies
showed a normal stomach and esophagus and no source of bleed.
You also had a headache initially, that improved with tylenol
and tramadol. A CT scan of your head didn't show a bleed or
other cause for your headache.
Changes to your medications:
Start taking tramadol as needed for your headache
Start taking plavix again, but only once a day
Stop taking Coumadin
Start taking pantoprazole twice a day for the next two weeks for
a GI bleed, and then after that take once a day.
Start taking iron for your anemia
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2169-1-9**] at 11:10 AM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2169-1-4**]
|
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] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13632, 13689
|
8413, 10917
|
371, 394
|
13761, 13761
|
4964, 4964
|
14663, 15429
|
3641, 3897
|
11565, 13609
|
13710, 13710
|
10943, 11542
|
13938, 14344
|
3912, 3912
|
6071, 8390
|
14373, 14640
|
313, 333
|
422, 1958
|
13729, 13740
|
4979, 6057
|
13776, 13914
|
1980, 3223
|
3239, 3625
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,636
| 179,420
|
989
|
Discharge summary
|
report
|
Admission Date: [**2189-3-13**] Discharge Date: [**2189-3-13**]
Date of Birth: [**2127-10-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
restrained driver high speed mvc
1. Massive chest trauma, avulsion of right pulmonary vein
from the left atrium.
2. Multiple rib fractures.
3. Multiple lung lacerations
Major Surgical or Invasive Procedure:
chest tube x 2
1. Exploratory laparotomy.
2. Clamshell thoracotomy
History of Present Illness:
Mr. [**Known lastname 6551**] is a 61 year old gentleman who was a
restrained driver in a high speed, head on motor vehicle
crash. After extrication by report, he was unstable at the
scene and he was brought to the [**Hospital1 18**] emergency room with
hypotension, tachycardia. His initial evaluation
demonstrated right flailed chest with crepitus and decreased
breath sounds. In the emergency room he had a right chest
tube placed after a needle decompression and large bore IV
access. He continued to have hypotension in the trauma bay
and was given 3000 liters of crystalloid and 2 units of
universal blood. A chest x-ray done at that point showed
left hemothorax and a left chest tube was placed. Both chest
tubes put out about 1000 cc blood before the rate of bleeding
slowed down significantly. At this point he again remained
hypotensive. A DPL was performed, which was positive for
blood and he was emergently brought to the operating room for
an exploratory laparotomy.
Past Medical History:
unknown
Physical Exam:
pupils 3+ b/l, equal and reactive
R chest crepitus, abrasions
ab - soft, FAST neg - DPL pos
pelvis - stable, no deformity
rectal - normal tone, guiac neg
ext - intact, no deformities, L knee abrasion
back - [**Doctor Last Name 6552**]-of @ L1, crepitus on back
Pertinent Results:
[**2189-3-13**] 12:45PM BLOOD WBC-6.5 RBC-3.21* Hgb-10.3* Hct-29.5*
MCV-92 MCH-32.2* MCHC-35.0 RDW-13.1 Plt Ct-218
[**2189-3-13**] 12:45PM BLOOD PT-16.6* PTT-47.5* INR(PT)-1.5*
[**2189-3-13**] 12:45PM BLOOD Plt Ct-218
[**2189-3-13**] 12:45PM BLOOD Fibrino-91*
[**2189-3-13**] 12:45PM BLOOD CK(CPK)-276* Amylase-67
[**2189-3-13**] 12:45PM BLOOD CK-MB-17* MB Indx-6.2* cTropnT-0.14*
[**2189-3-13**] 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-3-13**] 01:44PM BLOOD Type-ART pO2-27* pCO2-65* pH-7.03*
calHCO3-18* Base XS--16
[**2189-3-13**] 02:55PM BLOOD Type-ART pO2-60* pCO2-72* pH-6.98*
calHCO3-18* Base XS--17
[**2189-3-13**] 12:57PM BLOOD Glucose-264* Lactate-6.4* Na-139 K-3.6
Cl-104 calHCO3-26
[**2189-3-13**] 02:55PM BLOOD Glucose-383* Lactate-9.6* Na-141 K-5.5*
Cl-103
[**2189-3-13**] 01:44PM BLOOD Hgb-7.9* calcHCT-24
[**2189-3-13**] 02:55PM BLOOD Hgb-11.4* calcHCT-34
[**2189-3-13**] 12:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2189-3-13**] 12:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
RADIOLOGY Final Report
TRAUMA #2 (AP CXR & PELVIS PORT) [**2189-3-13**] 12:37 PM
TRAUMA #2 (AP CXR & PELVIS POR
Reason: TRAUMA
INDICATION: Trauma.
ONE VIEW CHEST: Patient is lying on a trauma board, limiting
evaluation. Heart size is within normal limits. The aortic knob
is not well visualized. There is increased opacity in the left
and right hemithoraces. There is a right apical pneumothorax.
Multiple rib fractures are noted on the right. There is
subcutaneous emphysema on the right.
ONE VIEW PELVIS: No evidence of fractures. The hip joints and
sacroiliac joints are well maintained.
IMPRESSION:
1. Right apical pneumothorax.
2. Multiple right rib fractures with associated subcutaneous
emphysema.
3. Bilateral diffuse opacities which may be secondary to
pulmonary contusion. A layering left pleural effusion cannot be
excluded.
CHEST PORT. LINE PLACEMENT [**2189-3-13**] 12:45 PM
CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN
Reason: S/P LINE PLACEMENT
INDICATION: Status post line placement.
PORTABLE AP CHEST:
The ET tube and NG tube are in good position. The NG tube
projects beyond the margin of the film. The right-sided chest
tube is in the right lower hemithorax. There are multifocal
opacities in the right lung indicative of consolidations.
Multiple right-sided rib fractures are noted. The heart size is
normal. There is mild pulmonary edema.
IMPRESSION:
1. Irregular opacities in the right lung, right-sided
consolidations could be likely secondary to
aspiration/effusions.
2. Mild pulmonary edema.
3. Multiple right-sided rib fractures.
4. Subacute emphysema on the right.
5. ET and NG tube are in good position
RADIOLOGY Final Report
-77 BY DIFFERENT PHYSICIAN [**2189-3-13**] 3:55 PM
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN
Reason: POST MORTEM INSTRUMENT COUNT
INDICATION: Postmortem instrument count.
COMPARISONS: Comparison is made to a plain film performed two
hours earlier the same day.
AP chest radiograph shows diffuse subcutaneous emphysema as well
as bilateral consolidations throughout both lungs. There is
evidence of multiple sequential rib fractures on the right side
along with flail chest. Two chest tubes are seen within the
right lung with tips pointed towards the right base. Right-sided
central line is seen overlying the area of the SVC. Endotracheal
tube is seen with the tip at the level of the clavicles. A
surgical staple is seen in the right neck. A linear metallic
shadow seen overlying the trachea above the level of the
clavicles, possibly representing needle.
AP film of the pelvis shows a left-sided femoral line. No
metallic hardware is identified on this film.
IMPRESSION: Metallic linear structure seen overlying the trachea
above the level of the clavicles, possibly representing a
needle. Surgical staples seen overlying the right neck.
Brief Hospital Course:
(please refer to op note)
Pateitn was taken emergently to the operating room an attempt to
provide cardiopulmonary bypass, The patient continued to
exsanguinate and evaluation of the
injury demonstrated that the right pulmonary veins had
avulsed from the left atrium and that there was massive
defect within the heart. All attempts to control bleeding,
achieve cardiopulmonary bypass and maintain resuscitation.
They were unable to maintain vital signs. After many attempts
to resuscitate, he had no myocardial function, no vitals and
he was pronounced at 3:15 p.m. by the trauma surgery
attending.
Discharge Disposition:
Expired
Discharge Diagnosis:
. Massive chest trauma, avulsion of right pulmonary vein
from the left atrium.
Discharge Condition:
expired
Completed by:[**2189-6-9**]
|
[
"E812.0",
"861.12",
"901.42",
"860.5",
"276.52",
"958.4",
"807.4",
"861.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.91",
"99.07",
"34.02",
"34.04",
"99.04",
"54.11",
"37.12",
"96.71",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
6518, 6527
|
5893, 6495
|
484, 552
|
6650, 6687
|
1890, 5870
|
6548, 6629
|
1609, 1871
|
276, 446
|
580, 1563
|
1585, 1594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,902
| 184,797
|
309
|
Discharge summary
|
report
|
Admission Date: [**2197-4-4**] Discharge Date: [**2197-4-8**]
Date of Birth: [**2157-1-25**] Sex: F
Service:
ADMISSION DIAGNOSES:
1. Chronic pelvic pain.
2. Enlarged multifibroid uterus.
3. Endometriosis.
DISCHARGE DIAGNOSES:
1. Chronic pelvic pain.
2. Enlarged multifibroid uterus.
3. Endometriosis.
INDICATIONS FOR ADMISSION: The patient had a longstanding
history of endometriosis with priory surgery dating back to
[**2186**]. She had gone on to develop an enlarged 12-week to
15-week size multifibroid uterus along with additional cystic
change of the ovary. She was not planning to have children,
and when consulted on the various options agreed to surgery
with a goal of removing the uterus and adnexa in an effort to
manage her chronic pelvic pain and bleeding.
BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admission,
she was taken to the operating room and underwent extensive
surgery
via laparotomy. The procedure was complicated by a left
ureteral transection which was repaired under the auspices of
the Urology Service ( a separate Operative Note was dictated
for that. Additionally, due to the intense fibrotic scarring
secondary to her endometriosis, consultation was requested
from Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2920**] [**Doctor Last Name 1022**] who graciously assisted in completing
dissection of the uterus and adnexa, ultimately resulting in
a total abdominal hysterectomy and bilateral
salpingo-oophorectomy which confirmed endometriotic changes.
There was a great deal of dissection involved in separating
the posterior uterine surface from the bowel, but no entry
into the bowel occurred.
Her intraoperative course was punctuated by receipt of two
units of transfused packed red blood cells. Due to
continuing anemia, she received an additional three units on
[**2197-4-7**]. Her lowest hematocrit appeared to be 24, and at
discharge had risen to 27.9.
Her postoperative course basically was smooth. She did
receive intravenous antibiotics. A urinary stent had been
placed in the left ureter which was to be removed
approximately 10 days postoperatively in the urologist's
office. She remained stable throughout the course and began
to pass gas within two to three days and had resumption of
bowel function. Pain control was managed with narcotic
analgesics.
She was discharged on her sixth postoperative day in stable
condition. She was afebrile with a hematocrit of 27.9. She
was to continue replacement iron and was to be seen the
following week for removal of the urinary catheter. She was
subsequently seen also in my office for scheduled
postoperative appointments and was making a uncomplicated
recovery at that point.
FINAL DISCHARGE DIAGNOSES:
1. Chronic pelvic pain.
2. Multifibroid uterus.
3. Endometriosis (severe stage 4).
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient will continue
to be followed at the [**University/College **] office of [**Hospital1 2921**].
[**First Name11 (Name Pattern1) 2922**] [**Last Name (NamePattern4) 2923**], M.D. [**MD Number(1) 2924**]
Dictated By:[**Last Name (NamePattern4) 2925**]
MEDQUIST36
D: [**2197-8-29**] 22:03
T: [**2197-9-2**] 04:46
JOB#: [**Job Number 2926**]
|
[
"E878.8",
"218.1",
"614.6",
"617.1",
"998.2",
"518.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.8",
"65.61",
"68.3",
"56.41",
"57.81"
] |
icd9pcs
|
[
[
[]
]
] |
246, 804
|
2884, 3272
|
833, 2735
|
146, 225
|
2762, 2849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,910
| 185,062
|
48978
|
Discharge summary
|
report
|
Admission Date: [**2132-7-28**] Discharge Date: [**2132-8-6**]
Date of Birth: [**2081-3-4**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINTS: End-stage renal disease, here for renal
transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
female with end-stage renal disease secondary to FSGS, status
post 3 renal transplants in [**2109**], [**2112**] and [**2130**]. All have
subsequently failed. The patient was diagnosed with FSGS in
[**2103**]. The patient was totally oliguric. First cadaveric
renal transplant lasted 10 years before chronic rejection.
She was treated with cyclosporin and Imuran at that time.
She was then on hemodialysis for 3 years and then was
retransplanted in [**2122**]. This failed 7 years after, secondary
to chronic rejection. She had a left sided transplant from
her husband and developed immediate hyperacute rejection.
That kidney was removed and she has been on hemodialysis ever
since. She has been on hemodialysis for 2 years via a right
subclavian hemodialysis catheter. She had denied any history
of fever, chills, nausea, vomiting, infections or other
infections. Approximately 1 month ago she had a swollen
cervical gland. She was treated with third generation
cephalosporin for 5 days. She denied any residual effects.
History of bilateral lower extremity neuropathy.
PAST MEDICAL HISTORY: Significant for thalassemia minor.
Status post MI in [**2129**] which was treated with PTCA, three
stents. She has a history of atrial fibrillation and
hypertension. Status post parathyroidectomy.
SURGICAL HISTORY: C-section in [**2108**]. Three renal transplant
surgeries in [**2109**], [**2122**] and [**2130**]. Incisional hernia in
[**2132-1-27**]. Two femoral head avascular necrosis.
Tonsillectomy.
SOCIAL HISTORY: Negative alcohol, smoking or drugs.
FAMILY HISTORY: Noncontributory.
ALLERGIES: Vancomycin, develops red man syndrome. She has
had vancomycin with slow infusion without problems. [**Name (NI) **] other
known allergies.
MEDICATIONS AT HOME: Levoxyl 200 mcg daily, Prilosec 20 mg
daily, Lipitor 10 mg q.p.m., multivitamin one daily,
Nafarelin 1 puff q. Daily. Oxycodone 10 mg tabs p.o. q.p.m.
p.r.n., aspirin 325 daily. Epogen 3x a week 13,000 units.
Tums with meals, 2 tabs. Midodrine 5 mg p.o. q.p.m. Zemplar 2
mcg three times a week and iron, ferrous sulfate once a week.
PHYSICAL EXAM: On admission she was alert and oriented. No
acute distress, moderately obese. HEENT: PERRL, EOMs intact.
Throat clear. No cervical lymphadenopathy. LUNGS: Regular
rate and rhythm. No murmurs, regurgitation or gallop. LUNGS:
Clear. ABDOMEN: Soft, nontender, nondistended, positive
bowel sounds, positive midline incision. Scar well healed.
EXTREMITIES: 4/5 strength bilaterally, upper and lower.
Neurologically alert and oriented. Decreased sensation in
extremities below the knees.
HOSPITAL COURSE: The patient was preopped. She was taken to
the OR on [**2132-7-28**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. She underwent a
cadaveric renal transplant and lysis of adhesions. EBL was
300 cc. Please see operative report for further details. She
received standard induction immunosuppression consisting of 1
gram of CellCept, ATG 100 mg IV and Solu-Medrol 500 mg x1.
Postoperatively, she was recovered in the PACU. Urine output
was 45 cc in the OR and then postoperatively in the PACU, she
had low urine output ranging between 0 and 80 cc per hour.
Her blood pressure was on the low side and she received
Levophed. She remained overnight in the PACU for blood
pressure control to keep her blood pressure elevated.
Of note, there was a long discussion between Dr. [**Last Name (STitle) 816**] and the
patient discussing the positive B-cell cross match by flow
cytometry. The patient was informed that this was a high risk
transplant. The patient understood the risks and signed
consent for transplant. The patient underwent hemodialysis
for several treatments for delayed graft function. Urine
output averaged approximately 87 to 85 cc per day on postop
days one through three. Gradually the urine output picked
up. Creatinine did not drop significantly and remained in
the range of 9.0-9.5. She continued on CellCept 1 gram
b.i.d. Her Solu-Medrol was tapered and then switched to
prednisone and then stopped on postop day #5. Prograf was
initiated on postop day #1. The dosage was adjusted per
levels and increased to 6 mg p.o. b.i.d. for level of 9.1.
Nephrology followed the patient closely throughout this
hospital course making suggestions. She received a total of
4 doses of ATG. The initial dose was 100 mg. She received 3
doses of 100 mg and 1 dose of 50 mg for a platelet count of
65. The dose was decreased to 50 mg. Levophed was stopped
as blood pressure stabilized when midodrine was resumed. The
patient had been on Midodrine at home.
She was started on IV Lasix 10 mg b.i.d. for low urine
output. The urine output increased with IV Lasix and she was
converted to Lasix 200 mg p.o. b.i.d. with a urine output of
approximately 2 liters per day. [**Last Name (un) **] was consulted for
hyperglycemia. A sliding scale was initiated. Her diet was
advanced gradually. Physical therapy assessed the patient
and felt she was safe for discharge to home.
Vital signs remained stable. She was afebrile. Blood pressure
was on the low side between 90-70 systolic and 70-60
diastolic. This improved as previously stated with
initiation of Midodrine 5 mg p.o. t.i.d. Hemodialysis was
stopped with the increased urine output. On postop day #5,
she had an episode of nonsustained V-tach 5-6 beat run. The
patient was asymptomatic. She remained on telemetry and had
no further events. Her hematocrit slowly trended down from
preop of 32 to 25.5 on postop day #7. Her calcium was noted
to be low at 5.9. Ionized calcium was 0.7. She was given 4
amps of calcium gluconate and started on calcium 1 gram p.o.
t.i.d.
The plan was to discharge the patient home on postop day #7,
alert and oriented, ambulatory. Her Foley was removed. She
was voiding without difficulty. Abdomen was soft, slightly
distended, nontender. Incision was clean, dry and intact. Her
right subclavian tunneled line remained in place. The plan
was to remove this in the outpatient clinic.
On postoperative day #6, the patient complained of thrush.
She had been on Nystatin swish and swallow. This was changed
to fluconazole 200 mg p.o. q. Day with notation that FK
levels might increase on the fluconazole. The plan was to
restart Epogen at home for her anemia.
CONDITION ON DISCHARGE: Stable. She will follow up in the
outpatient transplant clinic within 1 week and have twice
weekly labs.
DISCHARGE MEDICATIONS:
1. Bactrim single strength one p.o. daily.
2. Protonix 40 mg p.o. daily.
3. Colace 100 mg p.o. b.i.d.
4. CellCept 1 gram p.o. b.i.d.
5. Levoxyl 200 mcg p.o. daily.
6. Percocet 5/325 mg tabs 1-2 tablets p.o. p.r.n. q.4-6h.
7. Atorvastatin 10 mg p.o. daily.
8. Valcyte 450 mg p.o. daily.
9. Midodrine 5 mg p.o. t.i.d.
10. Lasix 200 mg p.o. b.i.d.
11. Fluconazole 200 mg p.o. daily.
12. Calcium carbonate 1 gram p.o. t.i.d. with meals.
13. Prograf 6 mg p.o. q. Daily.
She had follow-up appointments scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]
on [**2132-8-14**] and Dr. [**Last Name (STitle) **] on [**2132-8-19**].
DISCHARGE DIAGNOSES:
1. End-stage renal disease.
2. Hypertension.
3. Arrhythmia.
4. History of myocardial infarction.
5. Status post renal transplant on [**2132-7-29**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2132-8-6**] 11:52:07
T: [**2132-8-7**] 07:27:17
Job#: [**Job Number 102838**]
|
[
"250.00",
"788.5",
"427.1",
"582.1",
"403.91",
"112.0",
"E878.0",
"412",
"568.0",
"996.81",
"458.29",
"355.8",
"282.49",
"276.7",
"285.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"39.95",
"54.59",
"00.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
1868, 2040
|
7461, 7874
|
6772, 7440
|
2922, 6617
|
2062, 2398
|
2414, 2904
|
253, 1364
|
1387, 1797
|
1814, 1851
|
6642, 6749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,792
| 143,764
|
51002
|
Discharge summary
|
report
|
Admission Date: [**2138-6-25**] Discharge Date: [**2138-6-29**]
Date of Birth: [**2095-7-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is a 42 y/o F w/ metastatic cervical carcinoma here
w/ sudden SOB and tachycardia at home and increase in = abd.
pain. Pt. got central line [**1-30**] bad access. CTA w/ no evidence of
PE, but worsening pleural effusions. Pt. w/ new crit drop and
guiac +.
.
In the ED, also found to have a AG acidosis, coagulopathy, and
trace guiac + (and anemia, with HCT 21.9, (baseline 30). Getting
P RBC's,
. Tachycardia, O2 100% NBG (70% on RA)
On review of systems, the pt. denied recent fever or chills. +
PO without N/V. no BRBPR no Melana. + SOB and Orthopnea. +
baseline peripheral edema.
Past Medical History:
Metastatic cervical cancer as below.
Anemia associated with her chemotherapy requiring Procrit.
She has a history of depression but is currently not being
treated.
No prior surgeries. She has never had a mammogram.
She was HIV negative when tested in [**2134**].
ONC TREATMENT HISTORY: Initially diagnosed with locally advanced
cervical cancer in [**2134**], which was treated with chemoradiation,
which was completed in 01/[**2135**]. On [**2137-11-11**], she was diagnosed
with metastatic disease during an excision of right groin lymph
node. She was initially treated with cisplatin and topotecan.
She developed a platinum allergy and had disease progression
while on topotecan. Currently on Taxol 150mg/ml q 3wks for
palliative therapy.
Social History:
Social Hx: She has a greater than 20-pack-year history. She has
occasional heavy alcohol use and states that at the time of her
diagnosis of her recurrence, she was drinking approximately 1
bottle of wine per day, which she has since stopped. She
generally drinks alcohol socially as well.
Family History:
Family Hx: There is no family history of malignancy to her
knowledge. Her mother has heart problems and diabetes, and her
father died of MI and has a history of alcohol abuse.
Physical Exam:
Vitals: T:97.5 P:110 R:33 BP:117/58 SaO2:100% NRB
General: Very cachetic appearing female, somulent, c/o abd pain.
HEENT: NC/AT, PERRLA, EOMI without nystagmus, ++ scleral icterus
noted, MMdry, no lesions noted in OP
Neck: supple,
Pulmonary: Bibasilar crackles, poor AE
Cardiac: tachy, no M/R/G noted
Abdomen: very distened, mild diffuse tenderness but no rebound
opr guarding. Hypoactive BS. + flank dullnmess to percussion
Extremities: 4+ Pitting edema.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Pertinent Results:
labs on admission:
ABG: PO2-32* PCO2-38 PH-7.33* TOTAL CO2-21 BASE XS--6
COMMENTS-SOURCE IS
GLUCOSE-34* UREA N-49* CREAT-1.2* SODIUM-135 POTASSIUM-3.6
CHLORIDE-94* TOTAL CO2-13* CALCIUM-8.0* PHOSPHATE-5.5*#
MAGNESIUM-1.6
ALT(SGPT)-36 AST(SGOT)-123* LD(LDH)-340* ALK PHOS-257*
AMYLASE-13 TOT BILI-10.2* LIPASE-15
WBC-7.1# RBC-2.35*# HGB-7.5*# HCT-21.9*# MCV-93 MCH-31.7#
MCHC-34.0 RDW-23.2* PLT COUNT-14*#
-NEUTS-86* BANDS-5 LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-0
METAS-1* MYELOS-0 NUC RBCS-1*
- HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-NORMAL MACROCYT-2+
MICROCYT-1+ POLYCHROM-NORMAL
PT-27.2* PTT-38.4* INR(PT)-2.8*
CXR: 1. Bilateral pleural effusions including loculated right
pleural effusion.
2. Improving pulmonary edema.
3. Retrocardiac opacity representing atelectasis versus
pneumonia.
CT torso (with CTA chest:)
1. No evidence for pulmonary embolus.
2. Interval increase in the size of the bilateral pleural
effusions.
3. Interval increase in size and number of multiple low-density
liver lesions
consistent with progression of metastatic disease.
4. Increased free fluid within the abdomen and pelvis, and
diffuse
subcutaneous edema consistent with anasarca.
5. Unchanged right hydronephrosis and right hydroureter.
6. Unchanged size of right pelvic mass
7. Unchanged lymphadenopathy within the chest.
Brief Hospital Course:
Ms. [**Known lastname 449**] is a 42yo woman with widely metastatic cervical cancer
who presented to [**Hospital1 18**] with increased dyspnea. She was found to
be in respiratory distress and to have an anion gap acidosis.
She was sent to the ICU, where an extensive conversation was had
with the patient and her family (son [**Name (NI) **], and the patient
decided to change her code status to DNR/DNI with comfort as a
priority. The case manager began to look into hospice options
for the patient, but it was felt she would likely pass before
hospice became available. She became stable on O2 by nasal
cannula, however she desatted with even slight movement in bed,
and was called out to the floor. The following day the
patient's dyspnea worsened and she discussed with Dr. [**Last Name (STitle) 2244**]
changing her code status to CMO and beginning a morphine drip.
Her pain was well controlled, however dyspnea remained difficult
to control until the patient was somewhat sedated.
She passed away in the early morning of [**2138-6-29**]. She was
pronounced by Dr. [**Last Name (STitle) **] and her family was notified.
Medications on Admission:
Morphine 60 mg Tablet PO Q8H
Pantoprazole 40 mg PO Q24H
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four hours.
Prochlorperazine 10 mg PO Q6H PRN
Compazine 10 mg One Tablet PO every [**4-3**] PRN
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
metastatic cervical cancer
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
Completed by:[**2138-6-30**]
|
[
"V10.41",
"707.03",
"511.9",
"196.5",
"197.0",
"285.22",
"286.6",
"276.2",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
5613, 5628
|
4198, 5330
|
335, 341
|
5698, 5708
|
2847, 2852
|
5761, 5918
|
2057, 2235
|
5584, 5590
|
5649, 5677
|
5356, 5561
|
5732, 5738
|
2250, 2828
|
276, 297
|
369, 965
|
2866, 4175
|
987, 1733
|
1749, 2041
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,115
| 188,447
|
53016
|
Discharge summary
|
report
|
Admission Date: [**2105-10-22**] Discharge Date: [**2105-11-8**]
Date of Birth: [**2034-4-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hydrochlorothiazide / Iodine; Iodine Containing / Shellfish
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SSCP after vomiting, new orthopnea
Major Surgical or Invasive Procedure:
[**2105-10-29**] CABG X 3 (LIMA>LAD, SVG>OM, SVG>PDA)
History of Present Illness:
The patient is a 71M with h/o CAD with 2 BMS to LAD and Cx, DM,
HTN, gastroparesis who was referred to the ED by his PCP ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]) with 3 weeks of worsening SOB, non-exertional CP
radiating to the left arm after vomiting, and 4 pillow
orthopnea. He has had episodes of vomiting after eating often,
but associated SSCP is new. No LLE but pulmonary edema on exam
with crackles [**12-30**] of the way up. EKG showed ST depressions in
lateral leads V2 - V6 with flipped deep Ts. CP free in ED. Trop
positive. Cards was called and cath recommended. In ED got 600
Plavix, heparin gtt, integrillin gtt. No O2 in ED.
.
Cardiac cath showed left main disease (90% distal) that was not
intervened upon and poor LV function (EF 20%) and cardiac
surgery was consulted for CABG.
Past Medical History:
PAST MEDICAL HISTORY:
Diabetes, Dyslipidemia, Hypertension
Percutaneous coronary intervention, in [**3-30**] showing left main
30% stenosis, patent LAD stents, 30% restenotic circumflex
lesion in the distal aspect of the stent, jailed OM1 ostium with
60% stenosis, RCA ostially occluded.
-- transient ischemic attack in [**2091**], status post recurrent
event, status post cardiac endarterectomy under the care of Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2102-12-28**] complicated by slow flow and
involving stroke, urgent angiography by Dr. [**First Name (STitle) **] revealing
brachiocephalic stenosis 90%, status post angioplasty stenting
at that time
-- status post stenting of the brachiocephalic artery into the
subclavian artery for rescue of the right upper extremity for
upper extremity claudication, now with resolution
-- history of posterior circulation syndrome, this resolved
following subclavian stenting
-- peripheral [**First Name (STitle) 1106**] disease status post lower extremity
revascularizations by way of atherectomy in [**Month (only) 1096**] and [**Month (only) 359**]
of [**2102**], Rutherford-[**Doctor Last Name **] scale is zero
-- pseudogout
-- gallbladder surgery
Social History:
Social history is significant for the current tobacco use (~[**12-30**]
ppd), he has smoked for about 60 years as much as 3ppd in the
past. There is no history of alcohol abuse and he denies illicit
substance use. He is retired and previously worked selling men's
clothing. He is divorced and lives alone.
Family History:
His brother had CABG 2 years ago and also smoked. Mother and
sister with breast cancer. He has 3 children, no history of
breast cancer in them. His son had gynecomastia with onset at
age 12, which required surgical excision
Physical Exam:
PHYSICAL EXAMINATION:
.
BP 169/75 HR (reg) 85 RR 20 Temp 97.9 O2Sat 94% 2L 194 lbs
.
Gen: well developed, well nourished and well groomed. The
patient was oriented to person, place and time. The patient's
mood and affect were not inappropriate.
.
HEEN: no xanthalesma, conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
.
Neck: supple, JVP of 10 cm. The carotid waveform was normal.
There was no thyromegaly.
.
Chest: no chest wall deformities, scoliosis or kyphosis.
.
Pulm: respirations were not labored and there were no use of
accessory muscles. CTAB, normal BS and no adventitial sounds or
rubs.
.
Cor: PMI located in the 5th intercostal space, mid clavicular
line. no thrills, lifts or palpable S3 or S4. normal S1S2, no
rubs, murmurs, clicks or gallops.
.
Abd: abdominal aorta was not enlarged by palpation, no
hepatosplenomegaly, NT, soft, ND
.
Ext: no pallor, cyanosis, clubbing or edema.
.
Skin: no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses: no abdominal, femoral bruits. Carotid bruits b/l
.
Right: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+
.
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+
Pertinent Results:
Admit Labs
[**2105-10-22**] 01:30PM BLOOD WBC-11.0 RBC-4.20* Hgb-14.2 Hct-39.7*
MCV-95 MCH-33.8* MCHC-35.8* RDW-14.0 Plt Ct-254 Neuts-72.0*
Lymphs-22.2 Monos-4.5 Eos-1.0 Baso-0.3
PT-13.0 PTT-57.2* INR(PT)-1.1
Glucose-62* UreaN-29* Creat-1.3* Na-140 K-3.8 Cl-102 HCO3-27
AnGap-15
.
ECG- NSR@74, nl axis, IVCD, LVH, ST depressions and deep
inverted T waves in V3-V6
.
Cardiac Cath
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systolic and diastolic ventricular dysfunction.
3. Severe pulmonary hypertension.
4. Moderate aortoiliac arterial disease.
.
ECHO
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Resting regional wall motion
abnormalities include basal inferior akinesis and lateral
hypokinesis. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
CT Chest
1. Heavy calcified aorta and its major branches including the
aneurysmatic dilatation of the brachiocephalic trunk.
2. Centrilobular emphysema, mild.
3. Subpleural areas of honeycombing suggesting long-standing
lung fibrosis such as IPF.
4. Bilateral pleural effusions right more than left, small.
5. Heavy coronary calcifications with insertion of the stent in
the LAD.
6. Status post cholecystectomy and gastroesophageal junction
surgery.
.
Abd Dopplers
1. Patent celiac and SMA arteries with slightly increased
systolic peak in the celiac axis. If there is clinical suspicion
for celiac axis stenosis, this could be better evaluated by MRA
or CTA.
2. Left-sided pleural effusion.
.
[**2105-11-7**] 05:10AM BLOOD WBC-8.4 RBC-2.93* Hgb-9.4* Hct-27.2*
MCV-93 MCH-32.2* MCHC-34.7 RDW-16.7* Plt Ct-305
[**2105-11-8**] 04:15AM BLOOD PT-18.1* PTT-30.3 INR(PT)-1.7*
[**2105-11-7**] 05:10AM BLOOD PT-18.3* PTT-83.0* INR(PT)-1.7*
[**2105-11-7**] 05:10AM BLOOD Glucose-149* UreaN-22* Creat-1.1 Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
Brief Hospital Course:
71M w/ CAD, DM, HTN, hypercholesterolemia, PVD p/w stuttering
CP, sent for cath and found to have left main disease. Carotid
u/s showed < 40% [**Country **], 50-60% [**Country **]. He underwent celiac and L
subclavian stenting on [**10-27**]. On [**2105-10-29**] he went to the
operating room where he underwent a CABG x 3. He was transferred
to the SICU in critical but stable condition. He awoke and was
extubated by POD #1. He was weaned from his nitroglycerine and
tansferred to the floor on POD #2. He did well post operatively.
He was seen by physical therapy. He was started on heparin and
coumadin for paroxysmal afib. He continued to have a sternal
click with no fevers, white count, drainage or erythema. He was
seen in consultation by cardiology for his continued bursts of
afib, they recommended continuing with lopressor,
anticoagulation, and increasing his ACE-I. He was ready for
discharge on [**11-8**].
Medications on Admission:
aspirin 325mg qd
nifedipine 30mg qhs
enalapril 20mg qhs
chlorthalidone 25mg qam
Lipitor 40mg qam
metoprolol 25mg [**Hospital1 **]
Metformin 850mg [**Hospital1 **]
Centrum qhs
Folic acid 400mcg qhs
Novolin N 36U qam, 18U qpm
Novlin R 18U qam, 6U qpm
loperimide 2mg prn
indomethacin 25mg tid prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 3 weeks.
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 months.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
check protime, INR Monday ([**2105-11-9**]) and Thurs ([**2105-11-12**]) and
then as needed afterwards. Please call results to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Hospital1 18**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
PMH: s/p mesenteric/celiac stents ([**10-27**]), PCI ([**2102**]), multiple
peripheral stents, TIA, HTN, DM-2, gout, PVD, RHD, chronic
diarrhea, ? gastroparesis
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Please call to schedule these appointments:
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**First Name (STitle) **] 2 weeks
Already scheduled appointments:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-3-9**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2106-3-9**] 4:00
Completed by:[**2105-11-9**]
|
[
"585.9",
"410.71",
"997.1",
"403.00",
"V12.59",
"272.0",
"492.8",
"412",
"428.0",
"536.3",
"V45.82",
"274.9",
"447.1",
"414.01",
"427.31",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"00.41",
"39.61",
"36.15",
"00.55",
"88.72",
"36.12",
"88.56",
"37.23",
"39.50",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
9265, 9323
|
6585, 7506
|
361, 417
|
9532, 9540
|
4266, 4646
|
9825, 10305
|
2864, 3089
|
7851, 9242
|
9344, 9511
|
7532, 7828
|
4663, 6562
|
9564, 9802
|
3104, 3104
|
3126, 4247
|
287, 323
|
445, 1269
|
1313, 2525
|
2541, 2848
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,199
| 133,427
|
28218
|
Discharge summary
|
report
|
Admission Date: [**2160-6-2**] Discharge Date: [**2160-6-9**]
Date of Birth: [**2106-11-30**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Strawberry
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L3-5
History of Present Illness:
Mr. [**Known lastname 12303**] has a long history of back and leg pain. He has
attempted conservative therapy but has failed. He now presents
for surgical intervention.
Past Medical History:
Knee osteoarthritis, obesity (BMI 34.2), anxiety, headaches, and
chronic low back pain having received ESI at [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center.
Social History:
Married, salesman for a beverage company. Never has been a
smoker, drinks alcohol infrequently.
Family History:
Noncontributory.
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2160-6-6**] 03:13AM BLOOD WBC-11.1* RBC-3.31* Hgb-9.5* Hct-29.6*
MCV-89 MCH-28.6 MCHC-32.0 RDW-13.6 Plt Ct-198
[**2160-6-5**] 06:29PM BLOOD WBC-12.2* RBC-3.45* Hgb-9.9* Hct-31.5*
MCV-91 MCH-28.7 MCHC-31.4 RDW-13.8 Plt Ct-188
[**2160-6-5**] 02:40AM BLOOD WBC-14.8* RBC-3.29* Hgb-9.7* Hct-29.5*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.7 Plt Ct-167
[**2160-6-4**] 01:30PM BLOOD WBC-12.6* RBC-2.98* Hgb-8.6* Hct-26.7*
MCV-90 MCH-28.9 MCHC-32.2 RDW-13.7 Plt Ct-173
[**2160-6-4**] 05:51AM BLOOD WBC-15.1* RBC-3.44* Hgb-10.1* Hct-31.5*
MCV-91 MCH-29.2 MCHC-32.0 RDW-14.1 Plt Ct-217
[**2160-6-3**] 06:30AM BLOOD WBC-13.3*# RBC-4.30* Hgb-12.6* Hct-39.0*
MCV-91 MCH-29.3 MCHC-32.3 RDW-14.1 Plt Ct-227
[**2160-6-6**] 03:13AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-137
K-3.7 Cl-101 HCO3-28 AnGap-12
[**2160-6-5**] 02:40AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-133
K-3.9 Cl-102 HCO3-24 AnGap-11
[**2160-6-3**] 06:30AM BLOOD Glucose-111* UreaN-16 Creat-0.9 Na-139
K-4.7 Cl-103 HCO3-27 AnGap-14
[**2160-6-6**] 03:13AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.9
[**2160-6-5**] 02:40AM BLOOD Calcium-7.6* Phos-1.5* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname 12303**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2160-6-2**] and taken to the Operating Room for L3-5 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 he returned to the operating room for a
scheduled L3-5 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was low and he was
transfused with good effect.. A bupivicaine epidural pain
catheter placed at the time of the posterior surgery remained in
place until postop day one.
POD 2 & 1 he developed tachycardia that was unresponsive to the
transfusions. A medical consult was obtained and both a
retoperitoneal bleed and a PE were ruled out with CT. He was
tranferred to the unit for close monitoring. There he was
started on a beta-blocker which he will follow up with his
primary care.
He was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#2
from the second procedure. He was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
oxycodone
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for muscle spasm.
Disp:*90 Tablet(s)* Refills:*0*
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for muscle spasm.
Disp:*90 Tablet(s)* Refills:*0*
6. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar spondylosis and stenosis
Acute post-op blood loss anemia
Post-op tachycardia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
As tolerated
Treatments Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2160-6-9**]
|
[
"785.0",
"285.1",
"721.3",
"V85.34",
"799.02",
"278.00",
"E878.1",
"722.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"81.07",
"84.51",
"81.06",
"03.90",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
5485, 5491
|
2566, 4430
|
284, 345
|
5619, 5626
|
1444, 2543
|
7716, 7795
|
891, 909
|
4490, 5462
|
5512, 5598
|
4456, 4467
|
5650, 5749
|
924, 1425
|
7611, 7624
|
7646, 7693
|
5785, 5978
|
235, 246
|
6014, 6481
|
6493, 7593
|
373, 545
|
567, 760
|
776, 875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,246
| 189,379
|
18024
|
Discharge summary
|
report
|
Admission Date: [**2132-3-19**] Discharge Date: [**2132-3-25**]
Date of Birth: [**2084-10-31**] Sex: M
Service: SURGERY
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Chronic pancreatitis with biliary stricture and steatorrhea
Major Surgical or Invasive Procedure:
1. Puestow procedure
2. Roux-en-Y biliary bypass (choledochojejunostomy)
3. Open cholecystectomy
4. Intraoperative ultrasound.
History of Present Illness:
Mr. [**Known lastname 12130**] is a 47-year-old male with a past medical history
significant for
alcoholic pancreatitis. He complains of steatorrhea, episodic
abdominal pain, back pain and inability to gain weight despite a
very voracious appetite. Advancement of pancreatic enzyme
supplements was done but with only minor improvement in his
symptoms as he required six to eight tablets every meal. Given
the chronic nature of his stented duct and dilated mid-body
pancreatic duct (up to 8 mm with significant calcification and
atrophy elsewhere) a Puestow drainage procedure was suggested in
order to improve his steatorrhea.
Of note, he has been followed for many years by Dr. [**First Name (STitle) 15501**] [**Name (STitle) 10108**]
for a biliary stricture from the destruction of the head of his
pancreas. He had an indwelling stent for the better duration of
2 years that was frequently exchanged by Dr. [**Last Name (STitle) 10108**], and he has
a tight intrapancreatic biliary stricture demonstrated on ERCP.
Past Medical History:
history of alcohol abuse
chronic pancreatitis secondary to alcohol
DM secondary to pancreatitis
BPH
pancreatic mass
depression/anxiety
Social History:
History of alcohol abuse, still drinks but describes decreased
amount; smokes two packs per day for several years. Denies
intravenous drug use.
Family History:
Mother had a cerebral aneurysm.
Physical Exam:
Vitals: T=98.2, P=82, BP=138/71, R=18, SpO2=99%RA
Gen: NAD, no jaundice
HEENT: PERRL, EOMI, no LAD, supple neck, sclera anicteric
CVS: RRR
Pulm: CTA bilaterally
Abd: soft, NT/ND, +BS
Ext: No CCE
Pertinent Results:
Brief Hospital Course:
Mr. [**Known lastname 12130**] was admitted to Dr.[**Name (NI) 2829**] care on [**2132-3-19**] at
[**Hospital1 18**]. He was taken to the OR that day and underwent a Puestow
procedure, Roux-en-Y biliary bypass (choledochojejunostomy),
open cholecystectomy, and an intraoperative ultrasound. For
further details of the procedure, please see operative note.
Immediately post-operatively, the patient was placed on CIWA
protocol for concerns of alcoholic withdrawal given his
longstanding history of alcoholism. He, however, was without
incident and did well after his procedure.
The patient's post-operative course was relatively benign. On
POD 2 some agitiation was noted but was otherwise controlled
with low-dose ativan. On POD 4, however, Mr. [**Known lastname 12130**]
complained of "dragging his feet" and numbness to the dorsum of
both feet. An Acute Pain Service evaluation was intiated but
did not attribute his symptoms to his epidural. The following
day, POD #5, a Neurology consult was obtained. Their assessment
was that venodyne compression caused a peroneal nerve palsy, and
his symptoms would abate over time. Physical therapy was
consulted and recommended home Physical Therapy until Mr.
[**Known lastname 12130**] fully recovered from these symptoms.
On POD #6, Mr. [**Known lastname 12130**] was eating a low-fat meal, had excellent
pain control on PO medications (started on POD 5) and was
ambulating with the use of a walker. He was deemed fit to
return home and was that same day with services in stable
condition.
Medications on Admission:
Protonix
Viokinase
Trazadone qhs prn
Flexeril TID prn
Zoloft
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).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
3. traZODONE HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while using percocets.
5. Cyclobenzaprine HCl 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) as needed for back spasms.
6. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Puestow procedure, Roux-en-Y biliary bypass
(choledochojejunostomy), Open cholecystectomy, Intraoperative
ultrasound.
common bile duct stricture
alcohol abuse
BPH
anxiety
depression
DM Type 2
chronic pancreatitis
Discharge Condition:
Good
Discharge Instructions:
If you have any intense belly pain, nausea/vomiting,
fevers/chills, oozing/redness at your incision site, chest pain,
or difficulty breathing, seek medical attention.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**2-10**] weeks, call for an appointment:
[**Telephone/Fax (1) 4775**]
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call for an appointment:
[**Telephone/Fax (1) 49873**]
|
[
"263.9",
"303.90",
"600.00",
"575.11",
"591",
"250.00",
"357.5",
"300.4",
"576.2",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.96",
"51.22",
"51.36"
] |
icd9pcs
|
[
[
[]
]
] |
4415, 4421
|
2134, 3684
|
330, 459
|
4682, 4688
|
2111, 2111
|
4903, 5139
|
1846, 1880
|
3796, 4392
|
4442, 4661
|
3710, 3773
|
4712, 4880
|
1895, 2091
|
230, 292
|
487, 1509
|
1531, 1668
|
1684, 1830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,232
| 101,695
|
40055+58347
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-12-16**] Discharge Date: [**2155-1-2**]
Date of Birth: [**2071-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2154-12-24**] 1.Coronary artery bypass grafting x3 with left internal
mammary artery, left anterior descending coronary;
reverse saphenous vein single graft from aorta to first
obtuse marginal coronary artery; reverse saphenous vein
single graft from aorta to the distal right coronary
artery.
2. Bilateral pulmonary vein isolation using the [**Company 1543**]
BP2 irrigated bipolar RF system with resection of left
atrial appendage.
3. Endoscopic left greater saphenous vein harvesting.
4. Epiaortic duplex scanning.
History of Present Illness:
83yo man admitted to [**Hospital6 10443**] 6 days prior to transfer with dyspnea on exertion. He
had history of COPD and was presumed to be having COPD
exacerbation. CT revealed effusion and the patient had
thoracentesis. He also had stress test that showed normal
perfusion w/o defects. Following the stress test he develped
chest pain and had ST depression in V2-6. During this episode
the
patient was noted to be in atrial fibrillation. He had cardiac
catheterization today that revealed 3VD with preserved EF.
Referred for surgery.
Past Medical History:
CAD
COPD
HTN
Atrial fibrillation
Past Surgical History: Laparoscopic Cholecystectomy
Social History:
Lives with: widowed-lives alone
Occupation:currently works as driver
Tobacco: Quit 35 yrs ago/105pack year hx
ETOH:none
Family History:
non-contrib.
Physical Exam:
Pulse: 85 Resp: 22 O2 sat: 96%-2LNP
B/P Right: 110/60 Left:
Height: 66 in Weight: 160lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs diminished w/o rales or wheezing
Heart: RRR [x] Irregular [] Murmur-no
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x]
Edema: [**12-29**]+ bilat
Varicosities: None [x]
Neuro: Grossly intact, non focal exam
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit none Right: Left:
Pertinent Results:
Conclusions
PRE BYPASS The left atrium is moderately 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 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 ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. 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 (1+) 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 BYPASS The patient is being a paced. There is normal
biventricular systolic function. The left atrial appendage has
been resected. There is mild to moderate tricuspid
regurgitation. Other valvular function is unchanged from the
pre-bypass study. The thoracic aorta is intact s/p
decannulation.
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) **] [**2154-12-24**] 13:35
Brief Hospital Course:
Mr. [**Known lastname 30620**] was admitted on [**12-16**] from an outside hospital and
his pre-op work-up was done. Over the next several days he was
diuresed and had thoracentesis by Dr. [**Last Name (STitle) **] for a pleural
effusion. He also had a plavix washout. Antibiotics also were
started as well as BP med titration. He underwent coronary
artery bypass, MAZE, and left atrial appendage ligation with Dr.
[**Last Name (STitle) 914**] on [**12-24**] and was transferred to the CVICU in stable
condition on phenylephrine and propofol drips. He extubated
later that day and remained in the CVICU over the next few days
for aggressive pulmonary conditioning. His atrial fibrillation
returned and he was treated with amiodarone. A renal consult was
requested for acute renal failure with highest creat 3.8. He
also had an ileus but was ultimately transferred to the floor on
POD #6 to begin increasing his activity level. His beta blockade
was titrated. Coumadin was not started for atrial fibrillation
per Dr. [**Last Name (STitle) 914**] [**Name (STitle) 88067**] to fall risk. By post-operative day
nince he was ready for discharge to rehab per Dr. [**Last Name (STitle) 914**]. All
follow-up appointments were advised.
Medications on Admission:
Medications at home:
Prilosec 20 [**Hospital1 **]
ASA 81 QD
Combivent 2 puffs QID
Ativan 0.5 HS-prn
Symbicort 160/45 1 puff [**Hospital1 **]
Losartan 50 QD
Colace 100 [**Hospital1 **]
Meds on Transfer:
Tylenol 650 Q4-prn
Lactinex 2 abs TID
Maalox 30cc Q$-prn
Combivent 2 puffs QID
ASA 81 QD
Symbicort 160/4.5 1 puff [**Hospital1 **]
Plavix 75 QD
Colace 100 [**Hospital1 **]
Pepcid 20 QD
Lasix 40 QD
Levaquin 250 QD
Ativan 0.5 QHS-prn
Cozaar 50 [**Hospital1 **]
MOM-prn
Metoprolol 25 [**Hospital1 **]
NTG 0.4 sl-prn
MSO4 2 IV-PRN
Senna 1 tab [**Hospital1 **]
Ocean spray nasal spray QID-prn
Calan SR 180 QD
Plavix - last dose:[**12-16**]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units SQ Injection TID (3 times a day): until ambulating
regularly.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks: [**Date range (1) 33500**] (400 mg daily), then 200 mg daily starting
[**1-8**].
10. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): 75mg [**Hospital1 **].
Disp:*90 Tablet(s)* Refills:*2*
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*30 ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12564**] hospital
Discharge Diagnosis:
Severe 3-vessel coronary diseases s/p Coronary artery bypass
grafting x3(left internal mammary artery, left anterior
descending coronary;
reverse saphenous vein single graft from aorta to first obtuse
marginal coronary artery; reverse saphenous vein single graft
from aorta to the distal right coronary artery).
2. History of atrial fibrillation.
3. Severe chronic obstructive pulmonary disease.
4. acute renal failure
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema ............
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**] on [**2155-1-21**] at 1:30pm # [**Telephone/Fax (1) 170**]
Cardiologist:Dr.[**Last Name (STitle) **] on [**2155-1-30**] at 2:15pm
Please call to schedule appointments with your:
Primary Care Dr.[**Last Name (STitle) 5239**] in [**12-29**] 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:[**2155-1-2**] Name: [**Known lastname 13958**],[**Known firstname 6712**] R Unit No: [**Numeric Identifier 13959**]
Admission Date: [**2154-12-16**] Discharge Date: [**2155-1-2**]
Date of Birth: [**2071-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine
Attending:[**First Name3 (LF) 1543**]
Addendum:
Mr. [**Known lastname **] was discharged to [**Hospital3 1933**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 6841**] hospital
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2155-1-2**]
|
[
"410.71",
"424.2",
"V14.5",
"518.0",
"496",
"560.1",
"428.0",
"427.31",
"530.81",
"414.01",
"V15.82",
"584.5",
"V14.2",
"458.29",
"V70.7",
"401.9",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"37.36",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9945, 10159
|
3944, 5176
|
312, 863
|
7776, 8016
|
2424, 3921
|
8940, 9922
|
1693, 1707
|
5867, 7233
|
7334, 7755
|
5202, 5202
|
8040, 8917
|
5223, 5387
|
1508, 1539
|
1722, 2405
|
269, 274
|
891, 1429
|
1451, 1485
|
1555, 1677
|
5405, 5844
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,643
| 178,527
|
2179
|
Discharge summary
|
report
|
Admission Date: [**2190-11-2**] Discharge Date: [**2190-11-21**]
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right lower extremity wound dehiscence
Major Surgical or Invasive Procedure:
[**2190-11-4**] Right lower extremity gastrocnemius flap reconstruction
[**2190-11-8**] Exploratory laparotomy with left hemicolectomy and
splenorrhaphy with transverse end-colostomy and Hartmann's
pouch, for ischemic colon
History of Present Illness:
On admission ([**2190-11-2**], by Plastic Surgery): Mrs. [**Known lastname **] is an 88
year old woman with history of right femur/tibial plateau
fracture ([**2173**]) complicated by multiple revisions/repairs, most
recently with right total knee arthroplasty on [**9-27**],
complicated by wound dehiscence, who was now admitted for right
knee gastroc muscle flap reconstruction.
On transfer to medicine ([**2190-11-18**]), 88F with HTN,
hyperlipidemia, and hypothyroidism, s/p TKR [**2190-9-27**], who was
initially admitted on [**2190-11-2**] for non-healing right knee wound.
She underwent gastrocnemius flap reconstruction, with
split-thickness skin graft [**2190-11-4**]. Her post-operative course
was complicated by septic shock (thought initially to be from
C.diff given high WBC and daughter with h/o recent c.diff) from
necrotic splenic flexure, for which she underwent resection of
the splenic flexure with colostomy on [**2190-11-8**]. This was
complicated by splenic laceration which was repaired
intraoperatively. Given sepsis, patient was started on
flagyl/vanc/cefe/cipro which were peeled off on [**11-12**] (cefepime
d/c'd [**11-8**]). The patient had return of bowel function on [**11-13**],
at which point her diet was advanced. She had persistent
leukocytosis, which was investigated with CT abdomen/pelvis on
[**11-15**]. This showed no evidence of intraabdominal abscess. U/A
showed WBC 8, with negative nitrates. Of note, the CT
abdomen/pelvis also showed ascites and anasarca. Currently, the
patient is tachypneic to about 30 but not dyspneic, O2 sat
95%/RA. Exam notable for bronchial breath sounds at left base
and trace bilateral LE edema. CXR shows large left pleural
effusion with smaller right pleural effusion and patient is
complaining of persistent cough.
.
Upon transfer, vitals were 97.3, 139/60, 88, 22, 95%RA. Looking
comfortable, breathing slightly fast but denies any dyspnea.
States knee pain is well controlled. Bothered only by persistent
cough. Denies recent fevers, chills, abdominal pain, changes in
bowel movements, subjective dyspnea.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Thyroid nodules
- Glaucoma
- History of bilateral femur fracture and pelvic fracture after
motor vehicle collision ([**2173**])
Social History:
She is a retired secretary and does not currently smoke or
drink.
Family History:
Non-contributory
Physical Exam:
Discharge Exam:
96.8, 115/47, 82, 18, 98%RA
GA: AOx3, elderly woman resting comfortably in bed in NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: bronchial breath sounds bilaterally, worse at left base.
No wheezes or rales. somewhat increased rate of breathing, good
resp effort
Abd: with pink healthy looking ostomy in LLQ, and large linear
stapled scar down midline abdomen, soft, NT, ND, +BS. no g/rt.
neg HSM.
GU: foley in place, minimal dark urine
Extremities: wwp, 1+ edema bilaterally. PTs 2+.
Neuro/Psych: CNs II-XII grossly intact. sensation intact to LT
in toes bilaterally, though decreased on the right
Pertinent Results:
Admission Labs:
[**2190-11-2**] 04:10PM BLOOD WBC-9.7 RBC-3.71* Hgb-11.0* Hct-33.4*
MCV-90 MCH-29.5 MCHC-32.8 RDW-16.2* Plt Ct-395
[**2190-11-2**] 04:10PM BLOOD PT-10.4 PTT-30.2 INR(PT)-1.0
[**2190-11-2**] 04:10PM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-131*
K-4.6 Cl-95* HCO3-29 AnGap-12
[**2190-11-2**] 04:10PM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.1 Mg-2.0
Iron-44
[**2190-11-2**] 04:10PM BLOOD calTIBC-311 Ferritn-452* TRF-239
Labs on [**11-8**] (day of abdominal surgery):
[**2190-11-8**] 04:23AM BLOOD WBC-19.0* RBC-3.47* Hgb-10.2* Hct-31.0*
MCV-89 MCH-29.4 MCHC-32.9 RDW-15.5 Plt Ct-365
[**2190-11-8**] 04:23AM BLOOD Neuts-77* Bands-3 Lymphs-8* Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2190-11-8**] 05:12PM BLOOD PT-13.9* PTT-50.2* INR(PT)-1.3*
[**2190-11-8**] 09:46AM BLOOD Glucose-135* UreaN-36* Creat-1.9* Na-130*
K-5.8* Cl-98 HCO3-15* AnGap-23*
[**2190-11-8**] 04:23AM BLOOD Calcium-9.9 Phos-6.1* Mg-3.9*
[**2190-11-8**] 01:43PM BLOOD Type-ART pO2-264* pCO2-32* pH-7.42
calTCO2-21 Base XS--2 Intubat-INTUBATED
[**2190-11-8**] 04:39AM BLOOD Lactate-4.0*
[**2190-11-8**] 01:43PM BLOOD Glucose-126* Lactate-3.2* Na-128* K-4.2
Cl-101
[**2190-11-8**] 03:30PM BLOOD Glucose-109* Lactate-2.5* Na-129*
[**2190-11-8**] 04:37PM BLOOD Glucose-118* Lactate-2.6* Na-129*
[**2190-11-8**] 08:29PM BLOOD Lactate-3.2*
[**2190-11-8**] 01:43PM BLOOD Hgb-8.0* calcHCT-24
[**2190-11-8**] 03:30PM BLOOD freeCa-1.09*
Thoracentesis:
[**2190-11-18**] 10:16PM PLEURAL WBC-3100* RBC-5250* Polys-76* Lymphs-2*
Monos-0 Macro-22*
[**2190-11-18**] 10:16PM PLEURAL TotProt-2.0 Glucose-127 LD(LDH)-312
Amylase-60 Cholest-38
Discharge Labs:
[**2190-11-21**] 05:50AM BLOOD WBC-15.3* RBC-3.07* Hgb-8.4* Hct-27.2*
MCV-89 MCH-27.5 MCHC-31.1 RDW-15.7* Plt Ct-680*
[**2190-11-21**] 05:50AM BLOOD Glucose-84 UreaN-12 Creat-0.5 Na-130*
K-4.5 Cl-95* HCO3-30 AnGap-10
[**2190-11-19**] 05:03AM BLOOD ALT-7 AST-18 LD(LDH)-189 AlkPhos-45
TotBili-0.3
[**2190-11-21**] 05:50AM BLOOD Calcium-7.4* Phos-2.7 Mg-2.3
Microbiology: [**2190-11-18**] blood cultures pending. previous blood,
urine, c.diff cultures negative.
Imagaing:
[**2190-11-7**] ECG: rate 88, Sinus rhythm. Delayed precordial R wave
transition as recorded on [**2190-11-12**] without diagnostic interim
change.
[**2190-11-7**] CXR: Given the decrease in lung volumes, bibasilar
opacification is more likely atelectasis than pneumonia. Upper
lungs are clear. Pleural effusion is minimal if any. Heart size
normal.
[**2190-11-8**] CXR: One supine portable AP view of the chest. Low lung
volumes. The left lower lobe opacity likely represents
atelectasis. There is a small left pleural effusion, if any. No
opacities concerning for pneumonia. Heart size is difficult to
evaluate, but likely normal. Mediastinal and hilar contours are
normal. No pneumothorax.
[**2190-11-9**] ECHO (prelim): Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). A
mid-cavitary gradient is identified. Right ventricular chamber
size and free wall motion are normal. No mitral regurgitation is
seen. No aortic stenosis or regurgitation. IMPRESSION:
Suboptimal image quality. Preserved biventricular function.
[**2190-11-9**] CXR: The ET tube sits 5 cm above the carina. The
endogastric tube side port tip sits well below the GE junction.
A right IJ central line tip sits in the lower SVC. The heart
size is within normal limits. The mediastinal contours
demonstrate calcified atherosclerotic disease of the aortic
knob. There is a small to moderate left pleural effusion with
associated atelectasis. There is no pneumothorax. Severe
degenerative changes are seen in the left glenohumeral joint.
IMPRESSION: 1. Lines and tubes in place. 2. Small to moderate
left pleural effusion with associated atelectasis.
[**2190-11-11**] CXR: 1. Left pleural effusion appears unchanged and
right pleural effusion is likely increased. Assessment is
slightly limited due to different positioning of patient. 2.
Mild pulmonary vascular congestion.
[**2190-11-11**] LENI: No evidence for DVT.
[**2190-11-12**] KUB: Air filled dilated loops of large and small bowel
are most
consistent with an ileus.
[**2190-11-15**] CT abd: 1. Splenorrhaphy, with mild perisplenic
hemorrhage and Surgicel packing. 2. Small pleural effusions,
mild ascites, and anasarca. No evidence of intra-abdominal
abscess, within limitations of a non-contrast study. 3. Left
colectomy and transverse colostomy, without complications.
[**2190-11-16**] There has been interval removal of the right IJ central
venous
catheter tip. The heart size is large. The mediastinal and hilar
contours
are unchanged. There is a moderate left pleural effusion with
underlying
atelectasis. Mild right basal atelectasis with a small pleural
effusion is
also present. IMPRESSION: Bilateral pleural effusions, left
greater than right, with associated atelectasis.
[**2190-11-18**] CXR: Assessment of the heart size is limited by the
large left and small right pleural effusions with associated
atelectasis; an additional component of pneumonia, particularly
on the left cannot be excluded. Within that limitation, the
heart size likely continues to be enlarged. There is no fluid
overload. There is no pneumothorax.
[**2190-11-18**] Comparison is made with prior study performed the same
day earlier. Moderate left pleural effusion has markedly
decreased. Adjacent atelectases have decreased. There is a new
left basal pigtail catheter. There is no evident pneumothorax.
mild-to-moderate right pleural effusion with adjacent
atelectasis, is unchanged. Cardiomediastinal contours are
partially obscured by pleuroparenchymal abnormalities.
.
Brief Hospital Course:
Hopsital course: Patient admitted to plastic surgery service
[**11-2**] in anticipation of gastrocnemius flap to RLE chronic wound
dehiscence. Preoperative workup completed 12/6-7 uneventfull
and patient taken to OR for flap procedure [**11-4**]. Tolerated
procedure well and was transferred to CC6 for further
management. Recovery proceeded uneventfully until [**11-7**] when
patient demonstrated altered mental status, nausea, vomiting and
increasing abdominal distention. Transferred to MICU [**11-8**] for
these symptoms and surgery consult obtained for concern of
altered mental status and worsening abdominal distention (See
ACS Consult note for further details). Patient taken to OR by
ACS for colonoscopy with assistance of GI given concern for
sigmoid/cecal volvulus. Colonoscopy failed to demonstrate
volvulus and exploratory laparotomy was undertaken which
revealed necrotic splenic flexure. Left colectomy was performed
with mid transverse colon ostomy and long Hartmann's pouch.
Patient tolerated procedure well and was brought to TSICU for
further management under ACS service. Post-operatively, the
patient was brought to the TSICU intubated/sedated. Patient
extubated successfully [**11-9**] and IV pain regimen initiated prn.
This was carried out with good effect and adequate pain control.
When tolerating oral intake, the patient was transitioned to
oral pain medications. She was then transfered to the floor on
[**11-11**]. She had urinary retention issues and a foley was placed
which stayed in throughout hospital course as she failed 2
voiding trials. She was given methylnatrexone x1 and was started
on a regular diet. However, she had some emesis and a KUB showed
ileus. She began to produce stool in her ostomy on [**11-13**] and her
diet was advanced to regular which she tolerated well. Her WBC
began to rise so a CT abd/pelvis was performed to r/o abscess
and no intra-abdominal abscesses were identified. She had a
chest x-ray on [**11-16**] which showed bilateral pleural effusions.
She continued to have a cough and medicine was consulted to
evaluate. Thoracentesis was performed and 1.5 liters of
exudative fluid was drained (LDH 312, WBC 3100). Pigtail
catheter was placed which drained minimal serosangeous fluid.
This was thought to be related to the abdominal surgery and
resultant inflammation of the LUQ. Her WBC dropped from 20.8 to
14.5 with the thoracentesis. Patient remains feeling well
without and is without fevers off all antibiotics.
.
Pulmonary: Pulmonary toilet including incentive spirometry and
early ambulation were encouraged. The patient was stable from a
pulmonary standpoint; vital signs were routinely monitored. CXR
on [**2190-11-16**] showed bilateral pleural effusions L>R. She
continued to have a cough and will be transferred to the
medicine service for further evaluation and management.
Thoracentesis was performed and 1.5L transudative fluid was
drained, effectively resolving her cough. WBC dropped from 20.8
to 14.5 with the procedure. Patient remained tachypneic, and
given her vascular congestion on xray, she was administered
lasix with good urinary output. No antibiotics were
administered, as there was no clear infection to be treated
(afebrile, feeling well off antibiotics). Pleural fluid studies
were consistent with effusion secondary to adrenergic state
likley [**12-30**] splenic flexure infarct and splenic laceration. Rpt
chest X-ray showed improving pleural effusion s/p thoracentesis
and her lung exam continued to improve until the day of
discharge.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced to sips [**11-10**] and
regular diet [**11-11**]. Patient demonstrated some nausea w emesis
12/15PM and was made NPO. Advanced from sips to clears [**11-13**]
which was tolerated well. Given methylnaltrexone [**11-12**]. Had gas
and stool in ostomy [**11-13**]. She was also started on a bowel
regimen to encourage bowel movement. She was started on a
regular diet on [**11-13**] which she continued to tolerate well.
.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cephalexin on POD#2. The patient's
temperature was closely watched for signs of infection. Her WBC
began to slowly uptrend, for which a clear source was not
identified. She was given roughly 4 days of
cipro/flagyl/vanc/cefepime, all of which were discontinued
around [**11-12**]. U/A blood, urine, and c.diff was negative, her
graft site did not appear infected, CT ab/pelvis on [**2190-11-15**] was
negative for any intra-abdominal abscess, and CXR was signficant
only for bilateral pleural effusions L>R. No antibiotics were
administered as patient did not have a clear source of
infection. All culture data was negative, she continued to be
afebrile and VS were stable. Her WBC was fluctuating and also
with a reactive thrombocytosis. Given no objective signs of
infection antibiotics were never started.
.
# Reactive thrombocytosis: likely in relation to inflammatory
state from necrotic bowel, recent operations and pleural
effusions irritating the pleural lining. This will need to be
trended with repeat CBC within 1 week.
.
# Hyponatremia: Patient admitted with Na+ 129, corrected to 139,
now 129. Thought to be SIADH vs. hypervolemic hyponatremia as
patient appears somewhat overloaded on exam (1+edema with
ascites and large pleural effusion). Serum osm is low (262),
however urine lytes suggested patient was prerenal. Given IV
lasix for fluid overload and sodium initially trended up to 130,
but then decreased to 126. There was likely a combine picture.
Lasix were stopped and the patient equilibrated to 130 at time
of discharge. She will need repeat lab work within 1 week to
re-evaluate Na levels.
.
# Urinary Retention: Patient failed trial of voiding twice while
inpatient. Urology was consulted and they felt that given
recent operations and shock likel state it may take some time
for her bladder to regain function. She will be discharged with
her Foley in place and follow up with urology within 1-2 weeks
for another trial of voiding.
.
#. [**Last Name (un) **]- Patient had transient [**Last Name (un) **] to 1.9 on [**11-8**], when she was
septic and necrosing her bowel. Creatinine improved with fluids
and was likely prerenal in etiology given her septic physiology.
.
# Anemia: remained at basline over admission (28-31). No signs
of bleeding. Iron borderline low and ferritin high, MCV normal
(89). Possibly anemia of chronic disease. Hct trended.
.
#. HTN: continued HCTZ, lisinopril, diltiazem, ASA
.
#. HL: continued atorvastatin, ASA
.
#. Hypothyroidism: continued levothyroxine
.
#. Glaucoma: continued latanoprost, dorzolamide
.
Transitional Issues:
- At the time of discharge on POD 15, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, with foley in place, and pain well controlled.
Patient failed 2 voiding trials, and is being discharged home
with foley in place. She will have oruology follow up within
1-2weeks of discharge for voiding trial.
- Will also need stitches removed on [**2190-11-26**]
- will need repeat CBC and chem-7 in 1 week to evaluate
leukocytosis, reactive thrombocytosis and sodium level
Medications on Admission:
-alendronate 70 mg by mouth weekly
-atorvastatin 10 mg by mouth once a day
-cephalexin 500 mg by mouth four times a day take with food
-diltiazem HCl 90 mg Extended Release by mouth once a day
-hydrocodone-acetaminophen 5 mg-500 mg by mouth at night as
needed for pain
-latanoprost eye drops
-levothyroxine 75 mcg by mouth once a day
-aspirin 81 mg by mouth once a day
-B complex vitamins daily
-calcium/vitamin D3 by mouth twice a day
-cholecalciferol 1,000 unit by mouth once a day
-hydrochlorothiazide 50 mg by mouth once a day
-multivitamin by mouth once a day
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. diltiazem HCl 90 mg Capsule,Extended Release 12 hr Sig: One
(1) Capsule,Extended Release 12 hr PO once a day.
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Vitamin B Complex Tablet Sig: One (1) Tablet PO once a
day.
7. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
9. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every four (4)
hours as needed for pain: Hold for RR<12, Sedation.
16. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 100**] Senior Life [**Location (un) 2312**]
Discharge Diagnosis:
Primary Diagnosis:
- Right TKR would dehiscence
- Infarcted large bowel at splenic flexure
- Partially infarcted spleen
- Right sympathetic pleural effusion
- Urinary retention
- Anemia of chronic disease
- Reactive leukocytosis
- Hyponatremia
Surgical Procedures:
- Right lower extremity gastrocnemius flap reconstruction
- Exploratory laparotomy with left hemicolectomy and
splenorrhaphy with transverse end-colostomy and Hartmann's pouch
- Right thoracentesis and pig-tail catheter placement
Secondary Dignosis:
- bilateral femur fracture s/p periprosthetic femur fracture
Secondary diagnosis:
- Traumatic pelvic and bilateral femur fractures
- Osteoporosis
- Hypothyroidism
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- Glaucoma
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were initially admitted for a nonhealing
wound for which you had a skin flap reconstruction. This healed
well, however you developed poor perfusion to your bowel and had
to have a colon resection with a colostomy (Hartmann's pouch).
Part of your spleen was additionally resected. You remained in
the hospital for some time as you had an elevated white blood
count (usually a sign of infection) and fluid around your lungs
that was making you breathe faster than normal. The fluid was
drained from around your left lung and your white blood count
began to return to normal and your breathing improved. You are
safe for discharge to [**Hospital **] rehab for further care..
.
The following medications were started:
Docusate 100mg by mouth twice a day
senna 1 tab by mouth twice a day
tylenol 650mg by mouth three times a day
tamsulosin 0.4mg by mouth at bedtime
trazadone 25mg by mouth as needed for sleep.
Followup Instructions:
Please call the number below to schedule an appt with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1022**] in 2 weeks.
[**Hospital1 18**] Division of Plastic Surgery
[**Hospital Unit Name 11610**]
[**Location (un) 86**], [**Numeric Identifier 11611**]
Phone: [**Telephone/Fax (1) 4652**]
Fax: [**Telephone/Fax (1) 11612**]
.
Please call the number below to schedule an appt with Dr. [**Last Name (STitle) **]
in 2 weeks.
[**Hospital Unit Name 11613**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 6429**]
Fax: [**Telephone/Fax (1) 11614**]
.
Urology appointment:NEEDED
Please arrange new physician appointment with the Urology
Department @ [**Hospital1 69**] within 2 weeks
from your discharge from the hospital
Phone: [**Telephone/Fax (1) 164**]
.
Please call your Primary Care Doctor - Dr. [**Last Name (STitle) 5482**] at
[**Telephone/Fax (1) 5483**] to schedule an appt when you are discharged from
[**Hospital 100**] Rehab.
|
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7,613
| 196,983
|
8440+55946
|
Discharge summary
|
report+addendum
|
Admission Date: [**2127-1-31**] Discharge Date: [**2127-3-9**]
Date of Birth: [**2059-4-20**] Sex: M
Service: SURGERY
Allergies:
Imipenem/Cilastatin Sodium / Nsaids / Aspirin
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
ischemic right colon
Major Surgical or Invasive Procedure:
ex lap
right colectomy
end ileostomy
mucus fistula
jejunostomy feeding tube placement
CVL placement
quentin HD catheter placement & removal
VAC placement
open tracheostomy
ERCP
bronchoscopy
TEE
History of Present Illness:
67M multiple medical problems including morbid obesity,
bilateral lymphedema, a fib s/p pacer, CHF, who was transferred
from an outside facility on [**2127-1-31**] with worsening septic shock
following a severe allergic reaction to imipenem. X ray imaging
here revealed free air, and the patient was taken to the OR on
the night of [**1-31**] for an exploratory laparotomy.
Past Medical History:
morbid obesity
bilateral lymphedema
a fib s/p pacer
CHF
CRI (creat ~ 3.0)
dyslipidemia
sleep apnea
iron deficiency anemia
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
- ON ADMISSION -
Morbidly obese, intubated
coarse breath sounds
obese tense abdomen
2+ lymphedema
- AT TIME OF DICTATION -
awake, alert
+trach
L SCV TLC
Cor: irreg, no JVD
Lungs: coarse
Abd: open midline wound with VAC in place; RLQ colostomy (pink,
+gas/stool); LUQ mucus fistula pink; LUQ jejunostomy tube; large
pannus with inguinal fungal rashes
Extr: 2+ edema, venous stasis changes along calves, no signs of
superinfection or purulent drainage
Pertinent Results:
refer to carevue for pertinent lab values
Brief Hospital Course:
PROLONGED ICU COURSE SUMMARIZED BY ORGAN SYSTEM
[**1-31**] ex lap/right colectomy, end ileostomy, mucus fistula, J
tube
[**2-15**] open tracheostomy
[**2-25**] ERCP for hyperbilirubinemia - biliary & pancreatic stents
placed
[**2-26**] HD catheter & CVL pulled because of MRSE sepsis
NEURO: sedated with propofol & benzos postop, gradually weaned
off after trach. now responding appropriately, no neuro
deficits. pain controlled with narcotics.
CARDS: baseline a fib. TEE obtained to r/o embolic source for
colon ischemia (negative for thrombus, EF > 55%). required
significant pressors after surgery for hypotension & oliguria.
midodrine started with good effect. weaned off pressors
completely by last weekend. coumadin had been restarted for a
fib maintenance, but stopped after patient became septic with
transaminitis & supratherapeutic INR (~12).
RESP: open trach performed 2 weeks postop. weaning vent.
requires extra PEEP/PSV to help with respiratory drive (lower
rate with higher driving pressures). bronch'd. currently bring
treated for retrocardiac pneumonia with levaquin (day 4 of 7).
FEN: ATN complicated postop course. renal following daily.
originally treated with CVVHD x 2 wks, but line removed for GPC
bacteremia. creatinine to 5.5 now (from 1.5 after HD), but
renal not interested in starting hemodilaysis yet. transplant
surgery aware, in case permacath or long term dialysis access
needed.
GI: prolonged ileus postop, but now ostomy functioning fine.
was initially on TPN but now tolerating tube feeds without
issue. NGT placed during last week's sepsis now removed.
developed line sepsis last week, with GPC bacteremia but also
marked transaminitis & hyperbili. given h/o TPN, RUQ US showed
biliary sludge & distended CBD. ERCP was unremarkable but
stents placed in CBD & panc duct resulted in improved bile
excretion.
HEME: multiple transfusions given (see blood bank record). was
anticoagulated briefly for a fib, but developed supratherapeutic
INR in setting of sepsis-induced liver failure. coumadin since
held. hepSC being given
ID: 2 week course of postop broad spectrum antibiotics
(including fluconazole). although TEN resulted from imipenem
administration, patient tolerated cefepime without incident.
currently on vanco (day 5 of 7) for GPC bacteremia & levo (day 4
of 7) for retrocardiac pneumonia.
ENDO: blood sugars well controlled with RISS. 2 separate [**Last Name (un) 104**]
stim tests showed no adrenal insufficiency ([**Last Name (un) 104**] stim +9 both
times)
DISPO: family well involved. phone numbers in chart.
Medications on Admission:
clinda, flagyl, lidex, lasix, cardizem, digoxin, q-var, zantac,
vitamin E, cozaar, coumadin, lipitor, calcium, vitamin D, MVI
Discharge Medications:
VANC, LEVOFLOXACIN, combivent, dilaudid, hydrocerin, RISS,
reglan, midodrine, protonix, ambien
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
ischemic colitis
morbid obesity
hyperalimentation
acute tubular necrosis
acute on chronic renal failure
hemodialysis
pneumonia
bacteremia
wound infection
venous stasis disease
sacral decubitus ulcer
respiratory failure
septic shock
Discharge Condition:
critical
Discharge Instructions:
transferred to MICU service
Followup Instructions:
crimson surgery will follow to assist with wound care & any
other issues
Completed by:[**2127-3-3**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 5200**]
Admission Date: [**2127-1-31**] Discharge Date: [**2127-3-9**]
Date of Birth: [**2059-4-20**] Sex: M
Service: MEDICINE
Allergies:
Imipenem/Cilastatin Sodium / Nsaids / Aspirin
Attending:[**First Name3 (LF) 1015**]
Addendum:
The patient was transferred from the surgical service to the
medical ICU to continue care of his medical issues. With
respect to these, the following course ensued:
1. renal failure: a tunneled R hemodialysis line was placed on
[**3-5**] in the OR by the transplant surgery team. The following
day ([**3-6**]) the patient was started on HD. He was dialyzed on the
29th, 30th, and 31st. Dialysis should continue at rehab three
days per week (every other day, ie MWF vs TThSa, etc).
Vancomycin level should be checked prior to each dialysis, with
dosing of 1000mg IV x 1 given for a level of 15 or less. He has
5 days remaining of vancomycin treatment.
2. respiratory failure: We continued to wean the patient's vent,
coming down to cpap/ps 8/5 with Fio2 of 40%. He contineud on his
trach ventilation with nebulization treatment. We began
hemodialysis as above to remove excess fluid in hopes to also
improve his respiratory status.
3. ?pneumonia: the patient completed a course of levofloxacin
for possible pneumonia seen on CXR, although this appeared
resolved on subsequent XRs. He no longer requires levofloxacin
4. Coag Neg Staph bacteremia: The patient was continued on
vancomycin for a total 14 day course. The day of discharge
([**2127-3-8**]) is day 10, so this should continue for another 5 days.
5. leg wounds/possible cellulitis: The patient continued to have
excellent wound care to his lower extremities. Although these
were not believed to be infected, they were empirically covered
with the vancomycin he was already being treated with for his
bacteremia.
6 atrial fibrillation: the patient has afib with a pacemaker. he
did not require rate control during his stay, however notably as
an outpatient he was on both digoxin 0.125 and cardizem 180qday.
Digoxin should be held in the setting of his renal function,
however if needed for rate control diltiazem may be needed at
rehab.
7 dilated CBD and elevated LFTs: The patient had an ERCP after
elevation in his LFTs, which showed common bile duct dilation. A
common bile duct stent was placed empirically with mprovement in
LFTs. A pancreatic stent was placed prophylactically to prevent
post-ERCP pancreatitis. This was removed on repeat ERCP on the
day prior to discharge.
8. s/p R hemicolectomy: the patient was found to have guaiac
positive output in his ostomy. Per surgery ,this was to be
expected after surgery and was not concerning. His Hct remained
stable on daily check. His abdominal wound was cared for with
wound vac and q3 day dressing changes by the surgical team.
Chief Complaint:
transfer from TICU for ARF
Major Surgical or Invasive Procedure:
see previous surgery d/c summary
History of Present Illness:
67 yo male with h/o morbid obesity, afib s/p PM placement,
cellulitis who has had a complex hospital course. He was
originally admitted to [**Hospital3 5201**]on [**1-22**] for hyperkalemia
to 7.1 with Creatinine at that time at his baseline of possibly
1.6. He was treated with kayexalate and his potassium
supplements and spirinolactone were stopped, with good
resolution of hyperkalemia. During that first admission he
was also noted to have LE cellulitis, right greater than left.
He was treated with imipenem/cilastin and developed a rash on
his back, which was thought to be [**1-10**] to these antibiotics. He
was monitored for several days on this medication with some
improvement in the cellulitis. Wound was cultured and per
report grew myoides, Acinetobacter Lwoffi, Campylobacter
violacemum,which were all sensitive to levaquin. Upon discharge
his abx were chagned to clindamycin and flagyl (started for
diarrhea and concern for possible c.diff). Of note during that
admit he was transfused 2 units PRBCs for iron deficiency
anemia. He was sent to [**Hospital6 5202**] on [**1-26**].
.
On [**1-28**] patient returned to the hospital with lethargy, diffuse
rash SOB, and O2 sats 85-86% on 3L. ABG on arrival was
7.16/79/222. He was started on bipap and sats improved to the
mid to high 90s. Pt thinks his rash started while he was at the
rehab facility. During the admit his wounds were re-cultured and
his abx were switched from Clindamycin to levaquin. He was also
started on solumedrol and duonebs. Due to ARF with Cr up to 2.9
(per report baselin 1.6) his cozaar was held. He was seen by
renal for oliguric renal failure, thought to be ATN.
Additionally INR was 5 on [**1-29**] so coumadin was held.
.
He was transferred to [**Hospital1 8**] with cellulitis c/b worsening
oliguric renal failure, COPD exacerbation, and drug rxn (rash)
to imipenem.
He was initially admitted to the MICU for SOB, and on CXR was
noted to have free air. He then went to the OR with Dr.
[**Last Name (STitle) 700**] who then found that patient had a necrotic R colon.
Patient had a colectomy w/ end ileostomy amd j-tube placement.
He was then transferred to the TICU. Pathology from the surgery
showed kayexalate crystals.
.
In the TICU he has recovered well from his operation with a
ostomy appliance and a wound vac down to the fascia. His wound
vac and appliance need to be changed Q3 days by surgery. His
main issues include his renal failure which has followed a
waxing and [**Doctor Last Name 2364**] course, with periods of improvement
(creatinine, uop) followed by worsening. Renal has been
consulted and is following. He also has
wounds on his legs, which were being followed by vascular
surgery, and are now being followed by the wound care nurse. He
also required levophed as recently as 2-3 days ago for SBP in
the 80's. Given that his main issue is now medical, he is
transferred today to the MICU for further care.
Past Medical History:
morbid obesity
bilateral lymphedema
a fib s/p pacer
CHF
CRI (creat ~ 3.0)
dyslipidemia
sleep apnea
iron deficiency anemia
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
Gen: Obese male trached, NAD
HEENT: PERRLA, OP clear, MMM, trach in place
Neck: obese, supple
Cardio: RRR, nl S1 S2
Pulm: difficult to assess [**1-10**] vent, scattered wheezes
Abd: soft, obese, NT, hypoactive BS, diffuse macular as well as
non-blanching petechial rash
Ext: b/l LE wrapped, no pedal edema, 2+ DP pulse RLE, 1+ DP
pulse LLE
Neuro: awake, responding appropropriately to questions, moves
all extremities
Skin:diffuse macular rash on legs, trunk, arms, face
Pertinent Results:
labs on arrival:
GLUCOSE-141* UREA N-60* CREAT-3.4* SODIUM-139 POTASSIUM-3.7
CHLORIDE-106 TOTAL CO2-22
ALT(SGPT)-11 AST(SGOT)-26 LD(LDH)-163 CK(CPK)-177* ALK PHOS-92
TOT BILI-0.4
PT-18.2* PTT-35.9* INR(PT)-1.7*
WBC-11.8* RBC-3.76* HGB-10.4* HCT-32.6* MCV-87 MCH-27.6
MCHC-31.8 RDW-16.9* PLT COUNT-203
- NEUTS-88.6* LYMPHS-7.4* MONOS-2.8 EOS-1.0 BASOS-0.2
labs on day prior to discharge [**2127-3-7**]:
WBC-10.5 RBC-2.86* Hgb-8.2* Hct-24.9* MCV-87 MCH-28.6 MCHC-32.9
RDW-18.6* Plt Ct-241
Glucose-84 UreaN-92* Creat-5.3*# Na-139 K-4.2 Cl-106 HCO3-21*
ABG [**2127-3-6**] Type-ART pO2-85 pCO2-43 pH-7.31* calTCO2-23 Base
XS--4
[**2127-3-5**] TotBili-1.9* from peak of 3.0
[**2127-2-26**] ALT-32 AST-83* AlkPhos-575* Amylase-67 TotBili-7.0*
DirBili-5.2* IndBili-1.8 Lipase-154*
ERCP [**2-25**]: Five spot fluoroscopic images were obtained by the
gastroenterologist during performance of ERCP without a
radiologist present. These images are limited by motion
artifact and underpenetration. The common duct was cannulated
and contrast injected demonstrating mild diffuse dilatation of
the common bile duct. No definite filling defects to suggest
choledocholithiasis are identified. The final image
demonstrates a plastic stent within the lower common duct. By
report, a main pancreatic ductal stent was also placed. For
further details reference to the gastroenterologist's ERCP
report of the same date is suggested.
CT abd/pelvis [**2127-2-10**]:
1. Technically difficult examination due to patient body
habitus and lack of IV contrast.
2. Significant ascites but no focal collection.
3. Multiple retroperitoneal and inguinal lymph nodes noted.
4. Contrast in the descending colon. Has this patient had a
recent contrast examination? Otherwise may represent a fistula.
5. Gallstones.
6. Left inguinal hernia containing fluid.
7. Pacemaker in situ.
8. Old healed rib fractures on right side.
9. ? sponge in between buttocks folds versus decubitus ulcer
versus rectal fistula.
Echo [**2127-2-4**]: 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. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
systolic function is normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are
seen on the aortic valve. There is no aortic valve stenosis.
Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. There is
no pericardial effusion.
Brief Hospital Course:
The patient was transferred from the surgical service to the
medical ICU to continue care of his medical issues. For his
hospital course prior to ICU stay, please see original DC
summary (this is written as an addendum to the d/c summary).
With respect to his ongoing medical issues in the MICU, the
following course ensued:
1. renal failure: a tunneled R hemodialysis line was placed on
[**3-5**] in the OR by the transplant surgery team. The following
day ([**3-6**]) the patient was started on HD. He was dialyzed on the
29th, 30th, and 31st. Dialysis should continue at rehab three
days per week (every other day, ie MWF vs TThSa, etc).
Vancomycin level should be checked prior to each dialysis, with
dosing of 1000mg IV x 1 given for a level of 15 or less. He has
5 days remaining of vancomycin treatment.
2. respiratory failure: We continued to wean the patient's vent,
coming down at his lowest support to cpap/ps 8/5 with Fio2 of
40%. At the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] fdischarge he was on cpap/ps [**7-20**] with FiO2
of 30%. He continued on his trach ventilation with nebulization
treatment. We began hemodialysis as above to remove excess
fluid in hopes to also improve his respiratory status.
3. ?pneumonia: the patient completed a course of levofloxacin
for possible pneumonia seen on CXR, although this appeared
resolved on subsequent XRs. He no longer requires levofloxacin
4. Coag Neg Staph bacteremia: The patient was continued on
vancomycin for a total 14 day course. The day of discharge
([**2127-3-8**]) is day 10, so this should continue for another 5 days.
5. leg wounds/possible cellulitis: The patient continued to have
excellent wound care to his lower extremities. Although these
were not believed to be infected, they were empirically covered
with the vancomycin he was already being treated with for his
bacteremia.
6 atrial fibrillation: the patient has afib with a pacemaker. he
did not require rate control during his stay, however notably as
an outpatient he was on both digoxin 0.125 and cardizem 180qday.
Digoxin should be held in the setting of his renal function,
however if needed for rate control diltiazem may be needed at
rehab.
7 dilated CBD and elevated LFTs: The patient had an ERCP after
elevation in his LFTs, which showed common bile duct dilation. A
common bile duct stent was placed empirically with mprovement in
LFTs. A pancreatic stent was placed prophylactically to prevent
post-ERCP pancreatitis. This was removed on repeat ERCP on the
day prior to discharge.
8. s/p R hemicolectomy: the patient was found to have guaiac
positive output in his ostomy. Per surgery ,this was to be
expected after surgery and was not concerning. His Hct remained
stable on daily check. His abdominal wound was cared for with
wound vac and q3 day dressing changes by the surgical team.
Medications on Admission:
Meds on transfer from TICU:
1. Insulin SC
2. Albuterol-Ipratropium 6 PUFF IH Q4H
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Artificial Tear Ointment
5. Levofloxacin 250 mg IV Q48H last dose 3/30 or [**3-8**] (depending
when q48 dosing falls)
6. Artificial Tears 1-2 DROP BOTH EYES PRN
7. Magnesium Sulfate 2 gm / 100 ml NS IV PRN Mag < 2.0
ICU sliding scale
8. Calcium Gluconate 2 gm / 100 ml NS IV PRN Ionized < 1.1
Sliding Scale
9. Metoclopramide 10 mg IV Q8H
10. Epoetin Alfa 8000 UNIT SC QMOWEFR
11. Miconazole Powder 2% 1 Appl TP PRN
12. HYDROmorphone (Dilaudid) 1-4 mg IV Q3-4H:PRN pain
13. Midodrine 10 mg PO TID
14. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP
>60
15. Potassium Chloride IV Sliding Scale
16. Heparin 5000 UNIT SC TID
17. Zolpidem Tartrate 5-10 mg PO HS
18. Hydrocerin 1 Appl TP [**Hospital1 **] To both legs
Discharge Medications:
1. White Petrolatum-Mineral Oil Cream [**Hospital1 1649**]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 1649**]: One (1) Cap
PO DAILY (Daily).
3. Metoclopramide 5 mg/mL Solution [**Hospital1 1649**]: Two (2) mL Injection Q8H
(every 8 hours).
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 1649**]: One (1)
Appl Ophthalmic PRN (as needed).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 1649**]: [**12-10**]
Drops Ophthalmic PRN (as needed).
6. Miconazole Nitrate 2 % Powder [**Month/Day (2) 1649**]: One (1) Appl Topical PRN
(as needed).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Month/Day (2) 1649**]: Six
(6) Puff Inhalation Q4H (every 4 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) 1649**]: One (1) mL
Injection TID (3 times a day).
9. Zolpidem 5 mg Tablet [**Month/Day (2) 1649**]: 1-2 Tablets PO HS (at bedtime).
10. Calcium Acetate 667 mg Capsule [**Month/Day (2) 1649**]: One (1) Capsule PO TID
(3 times a day).
11. Hydromorphone 2 mg/mL Syringe [**Month/Day (2) 1649**]: 1-4 mg Injection Q3-4H
(Every 3 to 4 Hours) as needed for pain.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. insulin
please give according to enclosed slide scale
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) 1649**]: One
(1) ML Intravenous DAILY (Daily) as needed: 10 ML NS followed by
1mL of 100 units/mL heparin each lumen qday adn prn. inspect
site every shift.
15. sodium chloride flush for line care
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
16. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) 1649**]: 1000 (1000) mg
Intravenous qHD for 5 days: dose if vancomycin level is < or
equal to 15.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) **]
Discharge Diagnosis:
coag negative staph bacteremia
ischemic colon s/p hemicolectomy with ostomy
anaphylaxis to imipenem
atrial fibrillation
renal failure requiring HD
morbid obesity
biliary duct obstruction with hyperbilirubinemia s/p stent
placement
bilateral leg cellulitis
Discharge Condition:
trach in place on ventilator CPAP/PS and being weaned as
tolerated. HD tunneled cath in placen ad tolerating HD.
afebrile. afib rate controlled.
Discharge Instructions:
Please continue all medications as directed.
Please perform HD three times per week. Last HD was day of
discharge ([**2127-3-8**]).
Please continue abdominal wound care with vac dressing changed
q3 days.
Please continue to wean vent as tolerated and maintain trach
care. Please continued chest PT and nebulizers.
Please maintain standard line care of L HD tunneled catheter
line.
If the patient developes rapid heart rate consider restarting
his diltiazem for rate control of afib (has been on hold as rate
has been under control on own).
Please continue wound care for bilateral lower extremities in
order to prevent infection.
If you have fever, chest pain, increased infection or other
concerning symptoms please call your doctor or come to the
emergency room.
Followup Instructions:
Please call Dr.[**Name (NI) 5203**] office (surgery) for a follow up
appointment in the next 2-3 weeks. [**Telephone/Fax (1) 701**]
If you cannot be followed by a nephrologist at your rehab
facility please call our nephrology department for a follow up
appointment in the next 2 weeks. [**Telephone/Fax (1) 2593**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**]
Completed by:[**2127-3-8**]
|
[
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"278.01",
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"518.5",
"780.57",
"570",
"459.81",
"996.62",
"569.83",
"427.31",
"457.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"93.90",
"97.56",
"96.72",
"38.95",
"39.95",
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] |
icd9pcs
|
[
[
[]
]
] |
20510, 20590
|
14783, 17655
|
8130, 8164
|
20890, 21037
|
11856, 14760
|
21855, 22330
|
11333, 11350
|
18567, 20487
|
20611, 20869
|
17681, 18544
|
21061, 21832
|
11365, 11837
|
8064, 8092
|
8192, 11138
|
11160, 11283
|
11299, 11317
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,046
| 149,921
|
18535
|
Discharge summary
|
report
|
Admission Date: [**2187-11-5**] Discharge Date: [**2187-11-15**]
Date of Birth: [**2106-7-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE and increasing fatigue
Major Surgical or Invasive Procedure:
[**2187-11-9**] Mitral valve replacement (27mm [**Company 1543**] Mosaic Porcine
Valve), MAZE procedure
History of Present Illness:
81 yo female with history of MR [**First Name (Titles) **] [**Last Name (Titles) **]. Admitted to [**Hospital1 3325**] in [**Month (only) **]. for A fib which was treated with cardioversion
and amiodarone. Echo then showed severe MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] AI. Cath
revealed 40% LAD and a patent OM stent with EF 50%. Referred for
evaluation of MVR/ ?AVR and Maze.
Past Medical History:
elev. chol.
MR
[**First Name (Titles) **]
[**Last Name (Titles) 1902**]
Afib
[**Last Name (Titles) **]
stress incontinence
right femoral artery pseudoaneurysm treated with thrombin
PTCA /stent OM2003
appendectomy
T and A
Social History:
no tobacco use
one drink per week
lives with husband
no [**Name2 (NI) 50923**]. drug use
Family History:
non-contrib.
Physical Exam:
HR 84 RR 16 right 136/80 left 140/80
5'1" 71 kg
NAD
NC/AT
ecchymosis right groin
EOMI,PERRL
CTAB
neck supple, full ROM, no JVD
irregular, distant heart sounds, I/VI murmur
soft/NT/ND/ +BS
warm, well-perfused, trace edema
superficial spider veins
MAE, alert and oriented X3, non-focal neuro exam
1+ bil. fem/DP/PT; 2+ radials bil.
no carotid bruits
Pertinent Results:
[**2187-11-14**] 06:10AM BLOOD WBC-5.3# RBC-2.65* Hgb-8.4* Hct-24.6*
MCV-93 MCH-31.6 MCHC-34.0 RDW-15.0 Plt Ct-198#
[**2187-11-15**] 05:50AM BLOOD Hct-27.2*
[**2187-11-14**] 06:10AM BLOOD Plt Ct-198#
[**2187-11-15**] 05:50AM BLOOD PT-13.0 INR(PT)-1.1
[**2187-11-15**] 05:50AM BLOOD Glucose-92 UreaN-9 Creat-0.6 Na-140 K-3.5
Cl-102 HCO3-29 AnGap-13
[**2187-11-11**] 03:05PM BLOOD ALT-32 AST-37 LD(LDH)-366* AlkPhos-64
Amylase-18 TotBili-1.3
[**2187-11-11**] 03:05PM BLOOD Lipase-22
[**2187-11-5**] 03:58PM BLOOD %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE
[**2187-11-5**] 03:58PM BLOOD Digoxin-0.9
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 50924**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 50925**] (Complete)
Done [**2187-11-9**] at 10:58:19 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-7-26**]
Age (years): 81 F Hgt (in):
BP (mm Hg): 120/56 Wgt (lb):
HR (bpm): 39 BSA (m2):
Indication: Intraoperative TEE for MVR, ?AVR
ICD-9 Codes: 396.9, 427.31, 440.0
Test Information
Date/Time: [**2187-11-9**] at 10:58 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2006AW4-: Machine: Siemens
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.9 cm <= 5.2 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Valve Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - Pressure Half Time: 117 ms
Mitral Valve - MVA (P [**1-1**] T): 1.8 cm2
Findings
LEFT ATRIUM: [**Month/Day (2) **] LA enlargement. Elongated LA. Good (>20
cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Cannot assess
regional RV systolic function. Prominent moderator
band/trabeculations are noted in the RV apex.
AORTA: Normal ascending aorta diameter. Mildly dilated
descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AS. Mild to [**Month/Day (2) 1192**] ([**1-1**]+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
MS (MVA 1.5-2.0cm2). Due to co-existing AR, the pressure
half-time estimate of mitral valve area may be an OVERestimation
of true area. Mild to [**Month/Day (2) 1192**] ([**1-1**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was under
general anesthesia throughout the procedure. Suboptimal image
quality - poor echo windows. Results were personally reviewed
with the MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE CPB The left atrium is moderately dilated and elongated. No
atrial septal defect is seen by 2D or color Doppler. The right
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is normal (LVEF>55%). There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened, the left and right coronary
cusps are partially fused with calcification present in the all
three valve tips, but aortic stenosis is not present. Mild to
[**Month/Day (2) 1192**] ([**1-1**]+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is mild mitral
stenosis. Mild to [**Month/Day (2) 1192**] ([**1-1**]+) mitral regurgitation is seen.
POST CPB The patient is receieving epinephrine by infusion.
There is normal biventricular systolic function. A bioprothesis
in the mitral postion is well seated. Leaflet function appears
normal. Maximum and mean pressure gradients are unremarkable.
Small amounts of perivalvular suture leak are present. The strut
of the bioprosthesis extends into the left ventricular outflow
tract. There is some turbulence noted with color doppler
interrogation but poor echo windows prevent measurement of an
outflow tract gradient.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Known lastname 50924**],[**Known firstname **] T: [**Hospital1 18**] Cath Detail - CCC Record #[**Numeric Identifier **]
[**Numeric Identifier 50926**] - CCC
PROCEDURE DATE: [**2187-10-17**]
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class III, stable. Prior
PTCA
[**2183**]. Exercise stress testing is notable for reversible
anteroapical
wall defect.
FINAL DIAGNOSIS:
1. No significant obstructive [**Year (4 digits) **] with patent CX OM stent.
2. Severe mitral regurgitation.
3. Mild systolic ventricular dysfunction.
4. Normal diastolic ventricular function.
COMMENTS:
1. Coronary angiography revealed a right dominant system with
single
vessel coronary artery disease. The LMCA had no stenoses. The
LAD
showed a discrete midsegment 40% stenosis with no evidence of
flow
limitation. The LCx showed no significant stenoses as well as a
widely
patent stent in a large OM1 branch. The RCA had no stenoses.
2. Resting hemodynamic studies demonstrated normal right atrial
filling
pressures of 9 mmHg and normal pulmonary capillary wedge mean
pressure
of 13 mmHg; there were prominent V waves suggestive of severe
mitral
regurgitation. There were no pressure gradients to suggest
mitral or
aortic stenosis. Cardiac output was moderately to severely
depressed
with cardiac index of 1.9 L/min/m2.
3. Left ventriculography demonstrated mild systolic dysfunction
with
estimated ejection fraction of 50%, with hypokinesis of the
anterolateral and apical walls. There was severe (3+) mitral
regurgitation.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 39 minutes.
Arterial time = 27 minutes.
Fluoro time = 8.9 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 66 ml,
Indications - Hemodynamic
Premedications:
Fentanyl 25mcg
Versed 0.5mg
Anesthesia:
1% Lidocaine subq.
Cardiac Cath Supplies Used:
150CC MALLINCRODT, OPTIRAY 150CC
100CC MALLINCRODT, OPTIRAY 100CC
- ALLEGIANCE, CUSTOM STERILE PACK
FINAL REPORT
INDICATION: Pleural effusions, S/P MVR.
COMPARISON: CXR [**2187-11-13**].
FINDINGS: PA and lateral chest radiograph. Multiple midline
surgical clips
and sternotomy wires are stable. Cardiomediastinal silhouette
again appears
enlarged but is unchanged. Unfolding of the aorta is again seen.
Small
bilateral pleural effusions are stable in size. No pneumothorax
is
identified. Previously identified kyphotic curvature of the
spine and
degenerative changes are seen.
IMPRESSION: Stable small bilateral pleural effusions. No changes
compared to
previous study.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2187-11-15**] 3:21 PM
Procedure Date:[**2187-11-14**]
?????? [**2183**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted [**2187-11-5**] for pre-op anticoagulation with heparin while
off coumadin. Carotid US revelaed no sig. stenoses and bilat.
antegrade vert. flow. When INR normalized, went to OR for
MVR/Maze on [**11-9**]. Transferred to the CSRU in stable condition
on epinephrine and propofol drips. Extubated that evening and
transferred to the floor on POD #1 to begin increasing her
activity level. Chest tubes and pacing wires removed without
incident.Coumadin restarted for Afib on POD #3. Beta blocakde
resumed on POD #4. Cleared for discharge to home on POD #6. Pt.
to make all follow-up appts. as per discharge instructions.First
blood draw [**11-17**] with results to be called to Dr. [**Last Name (STitle) 5310**]
who will be following coumadin dosing.
Medications on Admission:
lipitor 10 mg daily
lasix 40 mg daily
isosorbide 60 mg daily
KCL 10 mEq daily
coumadin 5 mg daily LD [**11-1**]
digoxin 0.125 mg daily
ASA 81 mg daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Mitral regurgitation, Atrial fibrillation
Hypercholesterolemia, Hypertension, Congestive heart failure,
Right femoral artery aneurysm, Coronary artery disease s/p PTCA
stent
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
[**Last Name (NamePattern4) 2138**]p Instructions:
Please see Dr. [**Last Name (Prefixes) **] in [**4-5**] weeks. Make an appointment
([**Telephone/Fax (1) 11763**].
Please see your PCP [**First Name4 (NamePattern1) 12395**] [**Last Name (NamePattern1) **] in [**1-1**] weeks ([**Telephone/Fax (1) 50927**].
Please see your cardiologist Dr. [**Last Name (STitle) 5310**] in [**1-1**] weeks.
Completed by:[**2187-11-27**]
|
[
"414.01",
"398.91",
"401.9",
"396.3",
"V45.82",
"427.31",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"35.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11523, 11584
|
9689, 10448
|
315, 421
|
11802, 11809
|
1619, 5252
|
1215, 1229
|
10650, 11500
|
11605, 11781
|
10474, 10627
|
7142, 8271
|
11833, 12114
|
12165, 12538
|
5301, 6934
|
1244, 1600
|
8290, 9666
|
6967, 7125
|
249, 277
|
449, 848
|
870, 1093
|
1109, 1199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,461
| 161,866
|
18976
|
Discharge summary
|
report
|
Admission Date: [**2106-9-3**] Discharge Date: [**2106-9-8**]
Service: INTERNAL MEDICINE
CHIEF COMPLAINT: Coffee-ground emesis.
HISTORY OF PRESENT ILLNESS: Eighty-five year old woman who
on day of admission had an episode of nausea and vomiting.
Patient vomited clear emesis initially. This was followed by
greater than five episodes of coffee-ground emesis. She
believes that she vomited a half gallon of fluid. She felt
weak, and came to the Emergency Department.
In the Emergency Department, her vital signs were stable.
Blood pressure 142/65, pulse of 60, O2 saturation 98% on room
air. Gastric lavage showed bright red blood that did not
clear after 700 cc of lavage. She received urgent
Gastroenterology consult and urgent upper endoscopy which
will be detailed later in this discharge summary.
PAST MEDICAL HISTORY:
1. Abdominal aortic aneurysm 6 cm.
2. Patient is status post pacemaker placement in [**2106**] at
[**Hospital6 2561**] for tachycardia/bradycardia syndrome.
3. Patient has had multiple skin cancers resected.
MEDICATIONS AT HOME:
1. Aspirin 81 mg q day.
2. Metoprolol 25 mg [**Hospital1 **].
3. Patient is noncompliant with digoxin 0.125 mg q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient smoked [**4-20**] cigarettes per day for 50
years, quit this year. She does not drink. She lives alone.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.8, pulse
60, blood pressure 142/80, respiratory rate 18, and O2
saturation 98% on room air. In general, a thin elderly woman
in no apparent distress. HEENT: Oropharynx is dry. Chest
was clear to auscultation bilaterally. Cardiovascular:
Regular, rate, and rhythm, no murmurs, rubs, or gallops.
Abdomen is soft and nontender with a large central pulsatile
mass. Extremities with trace edema. Rectal examination is
heme positive.
LABORATORY STUDIES ON ADMISSION: White blood cells 12.1,
hematocrit 34.1, platelets 189. PT/PTT 12.6/25.3, INR 1.0.
Sodium 140, potassium 4.7, chloride 108, CO2 19, BUN 76,
creatinine 1.2, platelets 123.
Patient's hematocrit had fallen to 25.0 12 hours after
admission. She was transfused 5 units of red blood cells and
hematocrit remained stable from 33 to 35 over the next four
days.
IMAGING STUDIES: A chest x-ray was performed which was
normal, and showed the presence of a pacemaker. A CT scan of
the abdomen was performed showing a 6 x 5.4 cm infrarenal
aneurysm in the anterior abdominal wall as well as a 4.3 x
4.0 cm aneurysm in the right common ileac artery. The CT
scan also showed diverticulosis.
Laboratory studies is also significant for a serum positive
for H. pylori antibody.
IMPRESSION AND PLAN: A generally healthy 85-year-old woman
presenting with acute onset of apparent upper
gastrointestinal bleeding. In terms of her issues:
1. Gastrointestinal bleeding: Patient had two large bore IVs
placed, and was transfused 5 units of packed red blood cells
on the first 24 hours of admission. Hematocrit subsequently
remained stable. Two upper endoscopies were done which
showed multiple ulcers in the antrum as well as the lesser
curvature of the stomach. They were injected with
Epinephrine.
Patient also had serum H. pylori antibodies sent which was
positive, therefore she was started on antibiotic therapy
with amoxicillin and clarithromycin. She was also started on
Protonix on arrival to the hospital.
2. H. pylori infection: Patient is to complete a two week
course of amoxicillin 1,000 mg [**Hospital1 **] and clarithromycin 500 mg
[**Hospital1 **]. She should receive Protonix indefinitely. She is also
advised that she may not take aspirin again.
3. Abdominal aortic aneurysm: Patient's abdominal aortic
aneurysm is stable compared to her known baseline. Patient
wishes conservative management at this time, and will not
pursue surgery at this time.
4. Hypertension: Patient was hypertensive her last few days
on the hospital floor in light of her hypertension as well as
her abdominal aneurysm, her metoprolol dose was increased
from 25 mg [**Hospital1 **] to 50 mg [**Hospital1 **] for better hypertension control.
MEDICATIONS ON DISCHARGE:
1. Amoxicillin 1,000 mg [**Hospital1 **].
2. Clarithromycin 500 mg [**Hospital1 **] (to complete a two week course).
3. Protonix 40 mg q day.
4. Digoxin 0.125 mg q day.
5. Metoprolol 50 mg [**Hospital1 **].
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleeding.
2. Anemia requiring transfusion.
3. Gastric ulcer disease.
4. Hypertension.
5. Abdominal aortic aneurysm.
6. Right common ileac aneurysm.
PROCEDURES PERFORMED DURING HOSPITALIZATION: Upper
gastrointestinal endoscopy x2 with chemical cautery.
CONDITION ON DISCHARGE: The patient is discharged to home in
good condition. One of her relatives will be moving in with
her home permanently to help care for her. Patient is to
followup with her primary care physician.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2106-10-12**] 13:49
T: [**2106-10-14**] 09:56
JOB#: [**Job Number 51867**]
|
[
"V10.82",
"441.4",
"041.86",
"V45.01",
"287.5",
"531.00",
"427.31",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
4376, 4657
|
4147, 4355
|
1073, 1230
|
117, 140
|
169, 821
|
1883, 2241
|
843, 1052
|
1247, 1383
|
4682, 5150
|
2259, 4121
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,664
| 173,918
|
33651
|
Discharge summary
|
report
|
Admission Date: [**2201-7-15**] Discharge Date: [**2201-7-30**]
Date of Birth: [**2178-10-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
abdominal pain and UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In [**Month (only) 958**] the patient underwent sigmoid colectomy w/end colostomy
for malrotation & megacolon limited to the rectosigmoid in a
combined procedure with OB/Gyn performing a TAH/RSO for pelvic
abscess. She recovered from that operation and was doing well
until she presented last month with a small bowel obstruction
neccesitating extensive adhesiolysis, enterectomy and completion
subtotal colectomy with an end ileostomy on [**2201-6-11**] with Dr.
[**Last Name (STitle) 468**]. She recovered and was seen in clinic Monday appearing
healthy, vibrant and eating well. This morning ~8am she was
noted to be much more "fussy" according to her mother and
appeared to be distressed about some lower abdominal pain.
Although she was tolerating oral intake, it was felt to be
somewhat diminished. She was not experiencing any fevers,
nausea or vomiting, however. Of note, her ostomy output was not
significantly diminished (albeit somewhat thin) and had copious
gas in her appliance.
Past Medical History:
Trisomy 13 Mosaicism
Mentral Retardation - nonverbal at BL
Cardiomyopathy - Unknown status. Had ECHO last at NEM (pending).
PDA (congenital, closed per mother without OR)
"Slow heartbeat"
Aspiration PNA
Neck anatomic deformity with inverted crichoid/hypoid. Pt
assists herself with her fingers on the outside of her throat to
pass food.
GYN HISTORY: LMP: [**2201-4-11**], regular menses with cramping
OB HISTORY:G:0
PAST SURGICAL HISTORY: Fundoplication
end colostomy (hartmans pouch), R salpingoophrectomy, TAH,
removal of pelvic mass [**2201-4-17**]
Social History:
SOCIAL HISTORY: No T/ETOH/IV drugs
Family History:
Breast cancer
Physical Exam:
PE: 98.9 114 119/84 18 93%/RA
Gen: NAD, A&Ox3, MM dry, (-)scleral icterus
Pul: CTAB
Cor: tachy, regular
Abd: soft/ND (+)mild suprapubic tenderness (-)guarding(-)tympani
stoma viable (-)stricture or prolapse on digital exam
Pertinent Results:
36.2 12 138 101 12 Lactate 1.2
11.2 >---- --< 1.0 ---|---|--< 111 UA(+)LE/NO3; WBC>50
221 27 4.6 28 0.4
AXR: mildly dilated small bowel with scant air-fluid levels
[**7-16**] CXR Limited, but no acute cardiopulmonary process.
Brief Hospital Course:
1) Recurrent Aspiration complicated by Aspiration PNA:
The patient required 3L O2 via NC in the AM of HD2 and was
slowly weaned off to RA. Then around noon of HD 2 on [**7-17**], she
developed hypoxemia to the 70's and was triggered. ECG showed
sinus tachycardia, CXR showed some fluid, and ABG showed
hypoxemia. The patient was placed on 100% NRB and given 20IV
lasix. The patient responded well and started to saturate in
the low 90's on NRB. The patient was then given digoxin IV and
another dose of lasix with minimal response. She continued to
decompensate and was transferred to the SICU. She was intubated
for hypoxic respiratory failure and started on Vanco/Zosyn IV.
A bronchoscopy and BAL was performed while she was intubated
which showed growth of oropharnygeal flora as well as a right
lower lobe opacification and mucous plugging of the right main
stem
bronchus suggesting post-obstructive pneumonia. Given no growth
of MRSA or hx of such, she was mainatined on a 10day course of
IV Zosyn for this aspiration PNA which was completed during her
hospitalization. She continued to require supplemental oxygen
following this slowly resolving aspiration event and was
discharged home with home o2.
2) Abdominal Pain
Initially admitted to the surgical service with abdominal pain
and concern for a partial SBO on imaging. She continued to have
good ostomy output and she was managed conservatively. Her
abdominal pain resolved and at discharge she continued to have
good ostomy output.
3) UTI:
On admission to the surgical service, had dirty U/A that was
treated with 3 days of PO cipro (no culture sent). Her sx's
resolved and subsequent U/As were negative.
4) FEN/aspiration risk:
Pt known to have constant aspiration risk. She is well known to
the S&S eval team here at [**Hospital1 18**]. A repeat S&S eval showed risk
of aspiration for all consistencies. She was kept NPO and
mainatined on TFs through an NGT during her stay. A discussion
regarding the results of her S&S eval was had with her HCP
mother who emphasized that she is careful about having her sit
upright at all times while eating at home and that she has not
had an episode of aspiration at home and rather felt that her
aspiration events while hospitalized were in the setting of her
acute illness. A family meeting during her hospitalization was
held with attending Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], speech/swallow team, and
case management. A full discussion regarding her risks of
aspiration were discussed as well as the option of having a PEG
placed for enteral nutrition. Her mother [**Name (NI) 382**] did not want PEG
tube placement at this time, but did state that if she developed
aspiration events at home she will consider this in the future.
She was maintained on a pureed diet with thickened liquids under
strict supervision by the RNs along with always sitting straight
upright to prevent aspiration. The speech/swallow team had
multiple teaching sessions with the parents to attempt to
minimize aspiration. She should consider bringing her back for
outpatient video S&S again in 3 months when she is healthy to
assess her swallow function when she is home and healthy.
5) ARF:
Developed acute renal failure while hospitalized, felt due to
temporary hypoxia and ATN while being intubated along with
contrast nephropathy. A workup including urine eos to exclude
AIN and renal U/S to exclude hydronephrosis was performed and
negative. Her Cr trended back down to normal range and on day of
discharge her Cr had normalized.
6) CHF:
Known underlying cardiomyopathy, EF 35%. Takes Lasix at home
but due to her NPO status through much of her stay and
anticipated difficulty maintaining hydration at home, lasix has
been held. Discussed with pt's family, recommend re-evaluation
as an outpt to determine when and if lasix should be restarted.
Discharge letter has been written to her PCP
DISPO - Discharged home on supplemental oxygen to follow up with
her PCP.
Medications on Admission:
enalapril 10', digoxin 0.25', lasix 10', sertraline 50', miralax
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Miralax 100 % Powder Sig: One (1) packet PO once a day as
needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Digoxin 50 mcg/mL Solution Sig: Two (2) mL PO once a day.
5. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Home Oxygen
Please provide continous 2-6 liters of oxygen at all times.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
) Severe aspiration pneumonia
2) Hypoxic respiratory failure requiring intubation
3) Recurrent aspiration
4) Possible early or partial small bowel obstruction, resolved
without intervention
5) Urinary tract infection
6) Acute renal failure secondary to contrast nephropathy,
resolved
Secondary:
Trisomy 13 Mosaicism
Mentral Retardation - nonverbal at BL
Cardiomyopathy - Unknown status. TTE [**4-11**] LVEF 30-35%
PDA (congenital, closed per mother without OR)
"Slow heartbeat"
Aspiration PNA
Hx neck anatomic deformity with inverted crichoid/hypoid. Pt
assists herself with her fingers on the outside of her throat
to
pass food.
hx sigmoidectomy with end colostomy for malrotation and
megacolon
s/p TAH/RSO for removal of pelvic mas [**4-11**]
hx SBO s/p enterectomy and subtotal colectomy with end
ileostomy [**6-11**]
Discharge Condition:
Stable for discharge home with oxygen
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to difficulty maintaining
hydration on your restricted diet.
* 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 have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Please resume all regular home medications and take any new meds
as ordered.
Please follow up with your appointments as below.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 28118**] after discharge to schedule a follow up
appointment 7-10 days after discharge - please discuss whether
to resume your Lasix as this is being held when you go home.
PLEASE FOLLOW UP WITH THE BELOW SCHEDULED APPOINTMENTS:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2201-11-23**]
10:45
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2201-7-31**]
|
[
"V46.2",
"518.81",
"319",
"423.9",
"560.9",
"V44.3",
"758.1",
"425.4",
"584.9",
"428.0",
"041.19",
"038.9",
"276.51",
"995.91",
"428.22",
"599.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7191, 7262
|
2593, 6612
|
340, 347
|
8128, 8168
|
2309, 2570
|
9027, 9559
|
2020, 2035
|
6727, 7168
|
7283, 8107
|
6638, 6704
|
8192, 9004
|
1835, 1951
|
2050, 2284
|
277, 302
|
375, 1371
|
1393, 1812
|
1983, 2004
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,914
| 190,948
|
11598
|
Discharge summary
|
report
|
Admission Date: [**2119-8-23**] Discharge Date: [**2119-8-29**]
Date of Birth: [**2085-10-29**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old
male who is status post coiling of an aneurysm in the
vertebrobasilar junction in [**2118**], and he also has a small
second aneurysm of the anterior communicating artery. He has
complaints including headaches in the back of his head as
well as a funny feeling in his right hand and right leg,
almost like a numbness; though, he says his strength is
normal. He started taking clonazepam in [**Month (only) 404**] of this year
for anxiety associated with the potential of subarachnoid
hemorrhage and dying. His father died in [**2117-12-24**]
after a ruptured aneurysm.
PAST MEDICAL HISTORY:
1. Coiling of posterior communicating aneurysm in [**2118-12-24**].
2. Complaint of reflux and ingestion.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: He takes clonazepam for anxiety.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, the
patient was alert and oriented times three. His speech was
fluent. His memory was intact. Cranial nerves II through
XII were intact. On motor, he had normal bulk and normal
tone. No drift. His strength was [**5-28**] bilaterally in the
upper and lower extremities. Deep tendon reflexes were 2+ in
the upper and lower extremities and were symmetric. He had
downgoing toes. He had a normal sensory to pinprick and
light touch in the upper and lower extremities.
HOSPITAL COURSE: The patient was taken to the operating
room on [**2119-8-23**], where an anterior communicating artery
aneurysm was clipped. Estimated blood loss was 300 cc.
There were no complications during the case. The patient
received 5000 cc of crystalloid. The patient was taken to
the Postanesthesia Care Unit in stable condition.
Postoperatively, the patient was drowsy but opened his eyes
to voice, moved all extremities, and followed commands.
Pupils were 1.5 mm to 2 mm reactive bilaterally. The right
was slightly larger than the left. His strength was [**5-28**]
globally except hand grip which was 4+ bilaterally. He had
no pronator drift.
The [**Hospital 228**] hospital course was unremarkable from a
neurologic standpoint, though he did spike a fever on
postoperative day two. He was encouraged to use incentive
spirometry as well as take walks. He did get a chest x-ray
which was negative for pneumonia. He also got a urinalysis
and urine culture which was positive for Escherichia coli
urinary tract infection. He was started on
ciprofloxacin 250 mg p.o. q.d.
On postoperative day four, the patient's hematocrit continued
to hover around 26 but was stable. The patient was very
fatigued. He was transfused 2 units of packed red blood
cells with an increase in hematocrit to 35.
DISCHARGE DISPOSITION: The patient was discharged on
postoperative day six after greater than 24 hours of being
afebrile.
DISCHARGE FOLLOWUP: The patient was to have his staples
removed this [**Last Name (LF) 2974**], [**9-1**], and was to call Dr.[**Name (NI) 9224**]
office for a follow-up appointment.
MEDICATIONS ON DISCHARGE: He was discharged on Percocet one
to two tablets p.o. q.4-6h. as needed and the remaining dose
of ciprofloxacin 250 mg for his urinary tract infection.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 36841**]
MEDQUIST36
D: [**2119-8-29**] 11:26
T: [**2119-9-5**] 08:28
JOB#: [**Job Number 36842**]
|
[
"437.3",
"599.0",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
2867, 2967
|
3179, 3588
|
962, 1525
|
1544, 2842
|
2988, 3152
|
157, 759
|
781, 935
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,189
| 132,123
|
51821
|
Discharge summary
|
report
|
Admission Date: [**2202-2-18**] Discharge Date: [**2202-2-28**]
Date of Birth: [**2158-6-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Bactrim / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
bacteremia
Major Surgical or Invasive Procedure:
colonoscopy [**2202-2-22**]
History of Present Illness:
PCP: [**Name10 (NameIs) 107283**] [**Name11 (NameIs) **]
ID: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
HEME/ONC: [**Doctor Last Name **]- (had been [**Doctor Last Name **] in the past)
GI: [**Doctor Last Name 8494**]
Liver: [**Doctor Last Name 497**]
GYN: [**Doctor Last Name 1022**]
Surgery: Fulgalson
43 yo F with complicated PMH of CVID, [**Doctor First Name **], ITP, lymphoma in [**2198**]
treated with CHOP who presents with bacteremia. She has had
fatigue for a long time and night sweats for a long time. In the
last two weeks however, she has developed more severe and more
frequent (nightly) night sweats which drench the sheets. She is
being followed by [**Hospital **] clinic outpatient and blood cultures were
sent on [**2202-2-15**] as part of the work up. The cultures returned
today with GPR and GNR and she was referred to the ED. She has
taken her temperature at home and denies any fevers, chills. No
CP. +chronic SOB no change recently. No recent travel or sick
contacts. [**Name (NI) **] recent URI, cough, headache, dysuria, hematuria,
change in vision. She has noted worsening to her chronic LE
edema. Also notes a change in her bowel habits. She has chronic
diarrhea and occasional BRBPR which has been worked up and
attributed to hemrrhoids per the patient. Recently the stool has
significant mucous not noted previously. Still brown stool but
occult blood positive in [**Hospital **] clinic recently per the patient.
.
In the ED, her vitals were T 99.6, BP 90/56, HR 88, RR 16, O2sat
96% RA. She was given IVF for the low BP (asymptomatic). She was
given gentamycin 80mg IV x1 and blood clutures were sent prior
to abx.
.
Currently, she feels "fine." Does note the increased edema in
her legs (chronically R more than L). No pain. No SOB, CP, n/v,
diarrhea, fever, dysuria. She does have chronic abdominal
distention but says it is not worse than her norm.
Past Medical History:
LYMPHADENOPATHY
CMV INFECTION
IRON DEFICIENCY ANEMIA
IDIOPATHIC THROMBOCYTOPENIA PURPURA s/p splenectomy and
incidental finding of lymphoma
LARGE B-CELL LYMPHOMA [**2198**] s/p RCHOP
COMMON VARIABLE IMMUNODEFICIENCY SYNDROME
PRIMARY CMV ADENITIS
HPV
MYCOBACTERIUM AVIUM INTRACELLULAR on chronic abx
levofloxacin/clarithromycin
VULVAR CONDYLOMATA [**2183**]
Large liver- unknown cause
esophagitis
herpes
chronic active colitis- likely from CVID
S/P biopsy of L axillary LN showing lymphoid hyperplasia
S/P Liver biopsy [**2198-11-6**]
S/P splenectomy [**9-28**]
S/P hysterectomy 5/'[**97**]
S/P multiple cervical perianal biopsies/resections
Social History:
lived with male partner for 9 years. Denies tobacco or drug use.
Drinks couple drinks on weekend days
.
Family History:
Twin sister also had CVID and died from metastatic anal
carcinoma
Older brother also with some type of immune deficiency
[**Name (NI) **] brother with no illness
Mother died at age 52 from lymphoma
Father with HTN
Physical Exam:
vitals T 98.6, BP 90/50, HR 89, O2sat 94% 2L
General: NAD, pleasant, interacting
HEENT: anicteric sclera; pale conjunctiva, MMM, PERRL, EOMI,
CV: RRR with 3/6 SEM
Lungs: course BS but clear. no wheezing
Abdomen: +BS, soft but distended. Well healed midline scar.
Non-tender; +hepatomegaly
Ext: 1+ BLE edema
Skin: no rashes
Pertinent Results:
Her WBC ranged from 12 to 22 throughout admission.
HCT was initially 39 and nadered at 24.9 with the LGIB.
LFTs were elevated but at her baseline: ALT-34 AST-89*
AlkPhos-246* TotBili-0.7
[**2202-2-20**] 08:20AM BLOOD IgG-758 IgA-LESS THAN IgM-28*
[**2202-2-25**] 01:42PM BLOOD IgG-574* IgA-5* IgM-14*
[**2202-2-27**] 07:50AM BLOOD IgG-1219 IgA-8* IgM-13*
STUDIES:
[**2202-2-19**] ECHO: Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. 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 no
pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Trace aortic regurgitation. No discrete vegetations
identified.
Compared with the prior study (images reviewed) of [**2201-5-7**],
the findings are similar.
[**2202-2-22**] Patology from colon biopsies:
Colonic mucosal biopsy, two:
A. Ascending:
Mild focally active inflammation, non-specific.
No features of lymphocytic or collagenous colitis.
B. Descending:
Fragment of adenoma.
Multiple fragments of colonic mucosa, within normal limits.
[**2202-2-25**] CXR: FINDINGS: No previous images. The cardiac silhouette
is within normal limits. No evidence of vascular congestion or
acute pneumonia. Elevation of the left hemidiaphragm is seen. It
is unclear whether this is related anyway to the surgical clips
in the left upper quadrant of the abdomen.
[**2202-2-26**] KUB: Single AP supine view of the abdomen is obtained
[**2202-2-26**] at 17:33 hours. It is compared with the most recent study
of [**2202-2-24**] at 10:32 hours. The level of the hemidiaphragms is not
included on the current examination. Scattered air is seen in
the bowel with a nonobstructive pattern. A diffuse haziness to
the abdomen may possibly represent some ascites. Sclerotic focus
in the right acetabulum is unchanged. Scattered clip type
devices seen overlying the abdomen. No obvious pneumoperitoneum
in this supine view, but if this is a strong clinical suspicion
then an upright should be obtained.
Brief Hospital Course:
43 yo F with CVID, [**Doctor First Name **] on chronic abx, h/o lymphoma s/p RCHOP in
[**2198**] who presented with increased constitutional symptoms to [**Hospital **]
clinic and was found to have a bacteremia. Her hospital course
is described below and was complicated by a MICU stay for GI
bleeding after colonoscopy and multiple biopsies. Her hospital
course is described below by problem:
# bacteremia: GNR and GPR growing in anaerobic bottles of two
different sets of cultures which turned out to be bacteroides
and clostridium. This was thought to be from her bowel and
concern for another colitis- possible [**Doctor First Name **] related. ID was
following and she was treated with flagyl for this. Her
subsequent cultures before and after antibiotics were negative
for any bacterial growth. Given her PMH and her murmur which may
have been louder recently, she had an TTE which did not show any
vegitations- it was unlikely anyway given the GNR and GPR (done
before speciation). She continued to have nightsweats and
fatigue but remained afebrile. Per ID recommendations, she is
to complete a two week course of flagyl to end on [**2202-3-3**]. She
will follow up with Dr. [**Last Name (STitle) 724**] in [**Hospital **] clinic on [**2202-3-4**].
# night sweats/constitutional symptoms: could be related to this
bacteremia and will treat as such. Differential diagnosis also
included her h/o lymphoma (monitor in heme/onc clinic and no
recent relapse on scans), liver disease of unknown origin
(followed by Dr. [**Last Name (STitle) 497**], [**Doctor First Name **] recurrence, CMV recurrence (less
likely given negative CMV titer two days ago). She had a
leukocytosis but this is actually her baseline per OMR. The main
concern was for reactivation on her [**Doctor First Name **] affecting the bowel
causing a colitis. She had noted a change to her bowels with
stool that had mucous and sometimes blood streaked mucous. Given
these symptoms, she had an inpatient colonoscopy and stool
cultures were sent. All stool cultures remained negative
(including yersinia, E. coli O157:H2, camplyobacter, shigella,
salmonella, cyclospora, microsporidia, O&P x3, C. diff)- AFB
still pending.
# acute blood loss anemia: The colonoscopy showed several
abnormal areas including rectal colitis and thickened folds
throughout. Multiple sites were biopsied. She had a history of
bleeding after colonic biopsy but had not required tranfusions
in the past. The day after colonoscopy she developed BRBPR with
clots and her HCT dropped from 36 to 25 in 24 hours. She was
moved to the MICU for closer monitoring and was transfused a
total of 9 units of PRBCs. After stabilization from
transfusions, a second colonoscopy was performed and 14 clips
were placed to stop the bleeding. Her HCT remained stable around
25 after that. She was sent home with iron supplementation.
# [**Doctor First Name **]: on levofloxacin and clarithromycin at home for maintance
therapy. She was continued on these via ID recs. As above,
there is some concern for reactivation. Several AFB cultures to
monitor for recurrence were pending at time of discharge.
# h/o CMV: continued on valgancyclovir
# Long QT: on telemetry she was noted to have a long QT around
490msec. EKG confirmed this prolongation. It remained stable and
could be from her chronic use of levofloxacin. She should have
further EKG checks as an outpatient.
# CVID: followed by immunologist at a different institution.
Received her usual dose of 35g q3 weeks of IVIG on Saturday
[**2202-2-20**]. Repeat Ig levels were low and she was given
another 35g on [**2202-2-26**]. Repeat levels prior to discharge
showed an IgG of over 1000.
# hepatomegaly: hepatitis of unknown origin. She had elevated
LFTs and Alk phos but at her baseline; followed by Dr. [**Last Name (STitle) 497**].
# LE edema: chronic but increased currently per patient. Monitor
closely. No signs of PE (no tachycardia, hypoxia, tachypnea). No
need for LENI at this time given well documented edema in the
past OMR notes.
# lymphoma: [**2198**] s/p RCHOP. monitored in heme/onc clinic without
recurrence. Found incidentally with splenectomy for ITP
# depression: continued on fluoxetine and ritalin
# code: full
Medications on Admission:
valgancyclvir 450mg [**Hospital1 **]
prozac 80mg daily
ritalin 10mg qAM and qnoon
trazadone 50mg-100mg qhs prn
fluticasone nasal spray
prilosec
claritin D
levofloxacin
clarithromycin
IVIG 35mg every three weeks- due this Saturday [**2202-2-20**]
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): 8am and noon.
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Claritin-D 24 Hour 10-240 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. IVIG Sig: Thirty Five (35) g as directed.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
13. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
14. Iron 325 mg (65 mg Iron) Tablet Sig: 1-2 Tablets PO once a
day: Start by taking one per day. After 1 week, increase to
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
TL Connections
Discharge Diagnosis:
bacteremia with bacteroides and clostridium
CVID with IVIG transfusions given
[**Doctor First Name **] infection
acute blood loss anemia requiring 9 units of PRBC
Secondary diagnosis:
s/p lymphoma s/p RCHOP
hepatomegaly of unknown cause
Discharge Condition:
stable hct. afebrile.
Discharge Instructions:
You were admitted with bacteremia- bacteria in the blood stream.
You have been treated with metronidazole (flagyl) for this
infection. You should continue to take this medication until
[**2202-3-3**] for a total 2 week course. You had an ECHO
(ultrasound of the heart) which was normal. You also had a
colonoscopy with biopsies which lead to bleeding. You were given
9 units of PRBCs and your blood level is now stable. You should
take iron, one tab per day to start. Increase to 1 tab twice a
day after 1 week. Be aware that iron can make your stool black
and can make you constipation.
You should continue your IVIG- dose was given [**2202-2-20**] and
[**2202-2-26**].
You should follow up with your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] to the emergency
room if you have fevers >101, chills, extensive nausea,
vomiting, bleeding or trouble breathing or any other symptoms
which are concerning to you.
Followup Instructions:
Dr. [**Last Name (STitle) 724**] [**Hospital **] clinic on [**2202-3-4**] at 1pm.
GYN: [**Name6 (MD) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2202-3-4**] 9:00
GI: GI [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2202-3-8**] 2:00
GI: [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2202-3-8**]
2:00
you should follow up with Dr. [**Last Name (STitle) 497**] in hepatology clinic
Completed by:[**2202-2-28**]
|
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icd9cm
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[]
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[
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icd9pcs
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[
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3684, 6118
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,557
| 168,163
|
40531+40532
|
Discharge summary
|
report+report
|
Admission Date: [**2129-6-2**] Discharge Date: [**2129-6-5**]
Date of Birth: [**2104-5-20**] Sex: F
Service: MEDICINE
Allergies:
naproxen
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
25 F with h/o IV heroin use (last 2 weeks ago), presents to OSH
([**Hospital1 **] in Tauton [**Telephone/Fax (1) 88755**]) on the day prior to presentation
after sudden onset of headache, nontraumatic LBP, and chills at
home. Reports was in USOH until the night of presentation to
the OSH when she was driving and noted acute onset of headache.
This increased to [**10-3**] severity. She also developed some low
back pain without any trauma. She was brought to the ED in
[**Hospital1 **] by her fiance. There, she complained of low abdominal
pain so she had a pelvic exam performed and when that proved
benign given vancomycin and pipercillin-tazobactam and
transferred here given concern for epidural abscess.
.
In the ED, initial vs were: 98.5, 100, 91/58, 20, 99/RA. Labs
significant for WBC 9.5 with 10% bandemia, Hct 34.3, Platelets
122. Lactate of 2.3. Urine opiate was positive. She had a neg UA
for UTI. Creatinine was 1.3, K 3.2. ALT 162, AST 139, TB 1.6.
INR 1.5. U preg at OSH negative. CXR showed no acute CPP. MRI
spine showed no acute process or epidural abscess. CT abd/pelvis
showed no acute process. She received a second dose of
pipercillin-tazobactam as well as lorazepam 2mg, Morphine 4mg,
hydromorphone 1mg, ondansetron 4 mg, Mag 2 mg. Initial plan was
to admit to medicine but due to SBPs 80-90 she was sent to the
ICU after after her blood pressures did not significantly
improve with fluids. A CVL was placed at that point and request
was made for ICU bed. She did not require pressors.
.
On transfer other VS 98.1, 80s, 103/66, 18, 100/RA. She
complained of headache.
Past Medical History:
HCV
Hypothyroidism
GERD
IVDU
Social History:
She lives with her father and her fiance. Smokes about 1 ppd.
Rare alcohol use. h/o IVDU (opiate positive at admission),
though patient stated last use ~2 weeks ago. She is using again
after 8 yrs sobriety. Also with ongoing legal issues, currently
on bail and has court date [**2129-6-9**].
Family History:
Mental health issues
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.7 BP: 101/60 P:83 R:22 18 O2:97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
Vitals: 98.4, 110/72, 60s, 16, 99% RA
General: comfortable appearing, NAD
Neck: supple
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ DP pulses, mild edema L foot with
small degree of ecchymosis
Back: non-tender to palpation
Neuro: strength 5/5 in bilateral lower extremities, sensation
intact to light touch bilaterally
Pertinent Results:
ADMISSION LABS:
[**2129-6-2**] 01:55AM BLOOD WBC-9.5 RBC-3.76* Hgb-12.0 Hct-34.3*
MCV-91 MCH-31.9 MCHC-35.0 RDW-13.4 Plt Ct-122*
[**2129-6-2**] 01:55AM BLOOD Neuts-86* Bands-10* Lymphs-3* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2129-6-2**] 01:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2129-6-2**] 01:55AM BLOOD PT-16.7* PTT-33.3 INR(PT)-1.5*
[**2129-6-2**] 01:55AM BLOOD Glucose-114* UreaN-15 Creat-1.3* Na-141
K-3.2* Cl-109* HCO3-22 AnGap-13
[**2129-6-2**] 01:55AM BLOOD ALT-162* AST-139* AlkPhos-48 TotBili-1.6*
[**2129-6-2**] 01:55AM BLOOD Lipase-17
[**2129-6-2**] 01:55AM BLOOD Albumin-3.6 Mg-1.4*
[**2129-6-2**] 11:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.044*
[**2129-6-2**] 11:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2129-6-2**] 06:40AM URINE UCG-NEGATIVE
[**2129-6-2**] 06:40AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
OTHER PERTINENT LABS:
[**2129-6-3**] 12:07PM BLOOD HIV Ab-NEGATIVE
[**2129-6-2**] 02:46PM BLOOD CK(CPK)-31 DirBili-0.6*
[**2129-6-3**] 04:05AM BLOOD ALT-261* AST-186* LD(LDH)-272* AlkPhos-55
TotBili-0.5
[**2129-6-4**] 06:10AM BLOOD ALT-291* AST-162* AlkPhos-57 TotBili-0.3
[**2129-6-5**] 06:00AM BLOOD WBC-8.0 RBC-4.35 Hgb-13.8 Hct-39.9 MCV-92
MCH-31.8 MCHC-34.6 RDW-13.5 Plt Ct-196
[**2129-6-3**] 04:05AM BLOOD Neuts-75.3* Lymphs-17.7* Monos-2.5
Eos-3.7 Baso-0.9
DISCHARGE LABS:
[**2129-6-5**] 06:00AM BLOOD Glucose-89 UreaN-9 Creat-0.9 Na-139 K-3.8
Cl-102 HCO3-25 AnGap-16
[**2129-6-5**] 06:00AM BLOOD ALT-253* AST-97* AlkPhos-69 TotBili-0.5
[**2129-6-5**] 06:00AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.2
MICROBIOLOGY:
OSH Blood cx [**2129-6-1**]: 1/4 bottles positive for YEAST
Blood cx [**2129-6-2**]: pending
Urine cx [**2129-6-2**]: negative
Blood cx [**2129-6-3**]: pending
HCV Viral load [**2129-6-3**]: 360,000 IU/mL.
HIV Viral load [**2129-6-3**]: pending
IMAGING:
ECG [**2129-6-2**]: Sinus rhythm. Normal tracing. No previous tracing
available for comparison. Rate 80.
MRI C/T/L Spine [**2129-6-2**]: FINDINGS:
CERVICAL SPINE: The cervical spine vertebral body alignment,
heights and
marrow signal are maintained. There is desiccation of the C2-C3,
C3-C4 and
C4-C5 disc spaces without disc space height loss. There is no
evidence of
disc herniation, spinal canal or neural foraminal narrowing. No
abnormal
epidural or intradural fluid collection or mass or enhancement.
The cervical cord is normal in signal and caliber. No abnormal
osseous or soft tissue STIR signal is present. The paraspinal
and prevertebral soft tissues are grossly unremarkable.
THORACIC SPINE: The thoracic spine vertebral body heights,
alignment, and
marrow signal are normal. There is no evidence of disc
herniation, spinal
canal or neural foraminal narrowing. The disc spaces are normal
in height
with normal signal. No abnormal post-contrast enhancement is
identified.
LUMBAR SPINE: The lumbar spine vertebral body heights,
alignment, and marrow signal are maintained. The intervertebral
discs are normal in signal and height. No evidence of disc
herniation, spinal canal or neural foraminal narrowing. No
abnormal post-contrast enhancement. The spinal cord and cauda
equina are normal in signal and caliber. The conus medullaris
terminates at approximately L1-L2. The paravertebral soft
tissues are unremarkable.
IMPRESSION: Normal MRI pre- and post-contrast of the total
spine. No
evidence of epidural abscess is identified.
CXR [**2129-6-2**]: No acute cardiothoracic process including no
evidence of
pneumonia.
CT ABD/PELVIS [**2129-6-2**]:
CT OF THE ABDOMEN: Lung bases are clear. There are no focal
hepatic lesions. The gallbladder is normal. There is no intra-
or extra-hepatic biliary dilatation. The pancreas demonstrates
fatty replacement in the head. The spleen, bilateral adrenal
glands and kidneys are normal.
There is no retroperitoneal or mesenteric lymphadenopathy. The
portal venous, systemic venous and systemic arterial system of
the abdomen
and pelvis is normal. There is no free air and no free fluid.
The esophagus, stomach, small and large bowel, including the
appendix are
normal. There is moderate amount of stool in the rectum and
sigmoid colon. No evidence of bowel obstruction.
PELVIS: The urinary bladder, uterus and ovaries are normal.
There are no pelvic hernias, there is no pelvic free fluid and
there is no
pelvic lymphadenopathy.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION: No acute process of the abdomen and pelvis.
Brief Hospital Course:
25 F with HCV, hypothyroidim, presents with fever and back pain,
transfered to [**Hospital1 18**] for concern of epidural abscess by exam,
hypotensive in ED.
# septic shock/fever: With initial [**Doctor First Name 48**] (unclear baseline),
hypotension and fevers concerning for septic shock. Differntial
includes infectious. Localizing sxs for patient are low back and
headache in the setting of fever. Also has abd pain with nl CT
scan which did not detect heaptobiliary or renal acute process.
CXR and UA WNL here. Differential includes endocarditis if
persists given history of IVDU. Patient's OSH blood cultures
were negative for first 48hrs, was afebrile in ICU and did not
have meningeal signs, so antibiotics were stopped. Meningitis
was felt to be unlikely with her history and physical exam.
Given LFT elevation and body pains, felt initially to be more
likely due to viral process. HIV was sent. CT abd and MRI final
reads were negative. On [**2129-6-5**], OSH blood cultures turned
positive 1/4 bottles for yeast, but patient chose to leave
against medical advice, understanding the risks of fungemia.
Her fiance convinced her to return later in the evening to the
ED.
.
# back pain: unclear etiology. No pyelonephritis on exam or CT
and MRI final was negative. Morphine was used for pain in the
ICU.
.
# [**Doctor First Name 48**]: unclear baseline. Differential includes hypovolemia,
septic emboli from endocarditis, ATN from hypotension. As
responded to fluids in the ICU, felt most likely to be
hypovolemia.
.
# elevated LFTs: unclear baseline. HCV VL and HIV were sent.
# Prophylaxis: Subcutaneous heparin
# Communication: Patient, father [**Name (NI) **] [**Telephone/Fax (1) 88756**]
# [**Name2 (NI) **]al: placed SW consult as patient noted that father had
unintentionally run over her foot and broken her right pinky toe
while they were having an argument
Medications on Admission:
Nexium
Levothyroxine
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fungemia
Fever
Hypotension
Back pain
Headache
Foot pain
IV drug use
Secondary:
Anxiety
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 88757**],
You came to the hospital because you were experiencing fevers,
severe headache, back pain and chills. There was a concern that
you might have a serious life threatening infection related to
your IV drug use. Your blood pressure became very low and you
were admitted to the ICU; you received intensive supportive care
and antibiotics. Your fever resolved and your blood pressure
improved. You were transferred to the general medical flood,
and antibiotics were stopped after your blood cultures here had
been negative for 2 days. However, we have learned that your
blood cultures from [**Hospital3 **] show there is a yeast
infection in your blood.
Yeast in the blood is a very serious and life threatening
condition. If untreated, you may be at risk for fevers, low
blood pressure, yeast infection affecting the brain, heart,
lungs, eyes or other organ systems, and even death. We do not
feel it is safe for you to leave the hospital, and strongly
urged to you to stay. We would like you to be evaluated by our
Infectious Disease specialists and started on medication to
treat the yeast infection. However, you stated that you
understand the risks of leaving without further evaluation and
treatment, and you decided to leave AGAINST MEDICAL ADVICE. You
are aware of the significant risks associated with this
decision, including the possibility of death from this
infection.
Please return to the hospital immediately if you begin to
experience worsening fevers, fatigue, confusion, dizziness or
any other symptoms that concern you.
YOU SHOULD STOP USING IV DRUGS IMMEDIATELY. CONTINUING TO USE IV
DRUGS SUCH AS HEROIN WILL RESULT IN SERIOUS, LIFE-THREATENING
HEALTH CONSEQUENCES AND YOU COULD DIE.
No changes were made to your home mediations. You may continue
with your home dose of esomeprazole and levothyroxine.
Please be sure to keep all follow-up appointments with your
primary care doctor and other health care providers.
Followup Instructions:
Please be sure to keep all follow-up appointments with your
primary care doctor and other health care providers.
Given that you are leaving against medical advice, it is
essential that you call your primary care doctor, Dr. [**Last Name (STitle) **],
tomorrow and be seen again as soon as possible. We will also
contact Dr. [**Last Name (STitle) **] about your hospital course to let her know
that you left against medical advice, and that we are very
concerned for your health.
Completed by:[**2129-6-6**] Admission Date: [**2129-6-5**] Discharge Date: [**2129-6-8**]
Date of Birth: [**2104-5-20**] Sex: F
Service: MEDICINE
Allergies:
naproxen
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fungemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is 25 yo woman with PMHx sig. for IV heroin use (last
use ~2 weeks ago) who was first admitted to [**Hospital3 **] with
fever, headache and back pain, transferred from [**Hospital3 **]
to [**Hospital1 18**] ICU on [**6-1**], left AMA today from floor. At the time of
leaving AMA, patient was aware that [**12-28**] blood cultures from [**6-1**]
drawn at presentation to [**Hospital3 **] was positive for yeast.
Patient was called by PCP to return.
In summary, she presented to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 88758**] on [**6-1**] w/sudden
onset of headache, nontraumatic lower back pain, fevers, and
chills at home. Pt reportedly was in usual state of health until
that night when she developed acute headache, [**10-3**], and low
back pain while driving. Her fiance brought her to ED in [**Hospital1 **]
where she continued to have low back pain that radiated to lower
abdomen/hip area bilaterally. Pt received vancomycin and
pipercillin-tazobactam and transferred to [**Hospital1 18**] on [**2129-6-2**] given
concern for epidural abscess given IVDU and reportedly a
fever/chills.
At [**Hospital1 18**], MRI spine showed no acute process or epidural abscess.
LP was not performed as she clinically improved. CT abd/pelvis
showed no acute process. She initially had hypotension, was
admitted to the MICU, where her blood pressure stabilized and
she was transferred to the floor, where she left AMA.
In the ED, initial VS were: 96.8 93 103/67 18 100%. Labs were
notable for WBC 8, transaminitis.
Currently, she has a headache [**2128-4-29**], much improved compared to
previously. Her headache is located above both eyes, L ear pain
and sensation of being blocked. No sore throat, sinus problems,
vision changes. + rhinorrhea. She had an episode of nausea,
vomiting, bilious. No abdominal pain, diarrhea, constipation.
Back pain is now [**2127-12-27**]. NO further fevers, chills at home
today.
Review of Systems:
(+) Per HPI plus urinary frequency with IVFs, pain in fractured
toe (occurred 3-4 days ago)
(-) Denies chest pain or tightness, palpitations. Denies cough,
shortness of breath. No dysuria. Denies rashes. No
numbness/tingling or muscle weakness in extremities. All other
review of systems negative.
Past Medical History:
Hypothyroidism
HCV
GERD
PTSD
Social anxiety
Depression/Anxiety
Social History:
She lives with her father and her fiance. She is on disability
from mental issues. She has legal issues and is currently on
bail.
- Tobacco: 1 ppd
- Alcohol: <1 drink per week
- Illicits: last used IV heroin (last [**2129-5-31**]), occ. marijuana
Family History:
Aunt died of brain aneurysm. Grandmother died of lung cancer
(smoker).
Physical Exam:
Vitals: 98.1, 120/85, 76, 18, 100RA
Gen: NAD, AOX3
HEENT: PERRL, EOMI, MMM, sclera anicteric, not injected
Neck: no LAD, no JVD
Cardiovascular: RRR normal s1, s2, no murmurs appreciated
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: normoactive bowel sounds, soft, mildly suprapubic
tenderness, non distended
Extremities: No edema, 2+ DP pulses, embolic phenomenon on
fingers and toes (limited to nail polish on toes)
Neurological: CN II-XII intact
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, anxious, tremulous
Pertinent Results:
Admission labs:
[**2129-6-5**] 06:00AM WBC-8.0 RBC-4.35 HGB-13.8 HCT-39.9 MCV-92
MCH-31.8 MCHC-34.6 RDW-13.5
[**2129-6-5**] 06:00AM PLT COUNT-196
[**2129-6-5**] 06:00AM GLUCOSE-89 UREA N-9 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
[**2129-6-5**] 06:00AM CALCIUM-9.3 PHOSPHATE-4.7* MAGNESIUM-2.2
[**2129-6-5**] 06:00AM ALT(SGPT)-253* AST(SGOT)-97* ALK PHOS-69 TOT
BILI-0.5
CHEST (PA & LAT) Study Date of [**2129-6-2**]
IMPRESSION: No acute cardiothoracic process including no
evidence of
pneumonia.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2129-6-2**]
IMPRESSION: No acute process of the abdomen and pelvis.
MR [**Name13 (STitle) **] W& W/O CONTRAST Study Date of [**2129-6-2**]
IMPRESSION: Normal MRI pre- and post-contrast of the total
spine. No
evidence of epidural abscess is identified.
Brief Hospital Course:
25 yo woman with PMHx sig. for IV heroin use (last use ~2 weeks
ago), known HCV, hypothyroidism who was first admitted to [**Hospital1 9191**] with fever, headache and back pain, transferred from
[**Hospital3 **] to [**Hospital1 18**] ICU on [**6-1**], left AMA from medical [**Hospital1 **]
on [**2129-6-4**], called and convinced to come back to [**Hospital1 18**] for
positive blood cultures for yeast (from [**Hospital3 **] lab
report). Infectious disease team consulted.
This proved to be C. Lusitaniae. Surveillance cultures were
negative. Ophthalmologic examination negative for any evidence
of fungal infection. TTE negative for endocarditis. She was
initially treated with Micafungin IV daily until speciation
obtained. She was transitioned to oral voriconazole once
speciation completed.
While in the hospital, she complained of anxiety and withdrawal
from heroin. She was managed with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and
withdrawal symptoms were treated with oral clonidine as
indiated. She was counseled on cessation of tobacco and heroin
use.
covering MD Dr. [**Last Name (STitle) 31**]. I explained plan for follow up and
plan of antifungal therapy, and need for follow up on LFTs, HIV
VL. I explained to pt need to stop smoking tobacco and to stop
using heroin. She vocalized that she understood and plans to
quit.
Medications on Admission:
levothyroxine 150 mcg PO DAILY
esomeprazole magnesium 40 PO once a day
Trazodone 100 mg qhs (reported from a detox)
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. voriconazole 200 mg Tablet Sig: see below Tablet PO twice a
day for 11 days: Two tablets by mouth twice daily for one day,
then one tablet by mouth twice daily for 10 days. First dose to
begin on [**2129-6-9**]. .
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Fungemia due to [**Female First Name (un) 564**] species (C. Lusitaniae). We susptect
that you obtained this infection through intravenous drug abuse.
Hepatitic C viral infection, chronic (also likely from
intravenous drug abuse)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
see below. You must follow up with Dr. [**Last Name (STitle) **] as described
below.
Followup Instructions:
With your primary MD: [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 69074**]:
I have spoken with Dr. [**Last Name (STitle) 31**] (covering for Dr. [**Last Name (STitle) **]
today) at her clinic - we have arranged an appointment for you
on:
[**Last Name (LF) **], [**6-13**] at: 9:45am with Dr. [**Last Name (STitle) **] for: LFT test
(ALT/AST), follow up on how you are doing, and, the final
results of HIV testing that we have performed here at [**Hospital1 18**].
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Discharge summary
|
report+report+addendum
|
Admission Date: [**2199-8-2**] Discharge Date: [**2199-8-11**]
Date of Birth: [**2122-10-7**] Sex: M
Service: MEDICINE [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: Patient is a 76-year-old male
who presented to the Emergency Room on [**2199-8-2**] with
weakness and nausea upon arrival. Patient also reported
black stools. The patient was in his usual state of health
until two days prior to admission when he began to feel
weakness. He reported that his back felt weak and "heavy
load on shoulders." The weakness progressed and on the day
prior to admission, the patient reported that he could not
urinate while standing secondary to weakness. On the day of
admission, the patient awoke feeling "not good." The
patient's wife instructed him to go to the Emergency Room.
The patient reported nausea this morning of admission, which
had resolved. The patient had denied vomiting. Reported
diaphoresis. The patient denied back pain now, but questions
whether he had it on the day prior to admission. The patient
denied abdominal pain. Denied diarrhea or constipation. In
the Emergency Room, the patient was found to have a blood
pressure of 111/55, pulse of 59, and he was diaphoretic.
Blood pressures dropped to 100, and he was given 1 liter of
normal saline with blood pressure response into the 110s.
The patient was admitted to the MICU for further evaluation.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
with RCA PTCA in [**2192**], status post lateral wall ST elevation
myocardial infarction with stent in [**2198-7-30**].
2. Diabetes mellitus.
3. Congestive heart failure, ejection fraction in [**2198-7-30**] 30-40%.
4. Hypertension.
5. Hypercholesterolemia.
6. Hypothyroidism.
7. Guaiac positive stools on aspirin.
8. Depression/anxiety.
9. Chronic renal insufficiency, baseline creatinine of 1.7 to
1.8.
10. Chronic obstructive pulmonary disease.
11. Urinary retention.
12. Macular degeneration.
ALLERGIES: Aspirin causes bleeding.
MEDICATIONS:
1. Digoxin 0.0625 q day.
2. Glipizide 2.5 [**Hospital1 **].
3. Metoprolol 62.5 q am and 50 q pm.
4. Synthroid 75 q day.
5. Protonix 40 q day.
6. Alprazolam 0.5 q6 prn.
7. Lasix 40 mg q day.
8. Fluoxetine 20 mg q day.
9. Avandia 8 mg q am.
10. Enalapril 25 [**Hospital1 **].
11. Flomax 0.4 q hs.
12. Magnesium oxide 400 q day.
13. Lipitor.
14. Nitroglycerin.
SOCIAL HISTORY: The patient lives with his wife and
daughter, is a retired salesman. Has a 100 pack year smoking
history. He quit in [**2192**]. Denies alcohol use.
On admission to the Emergency Room, vital signs were as
previously noted including a temperature of 98.5, blood
pressure 111/55, pulse of 59, and patient is sating 96% on
room air. This is a elderly gentleman pale in no acute
distress. HEENT: Conjunctivae were pale, no icterus.
Cardiac examination: Regular, rate, and rhythm, 2/4 systolic
ejection murmur at the left upper sternal border, one with
crackles at the bases and decreased air movement on the
right. Abdominal examination was soft, nontender,
nondistended, good bowel sounds, no palpable masses. Rectal
examination was guaiac positive per the Emergency Room.
Extremity examination revealed trace lower extremity edema,
good dorsalis pedis pulses.
LABORATORIES ON ADMISSION: Significant for a hematocrit of
18.6, white count of 8.9, platelets of 20. He is found to
have an INR of 1.3.
An electrocardiogram done on admission revealed normal sinus
rhythm [**Company 96461**]-wave inversions in aVL, V5, and V6, possibly
old, also with poor R-wave progression, ST depressions, 1 mm.
The patient was admitted to the MICU for severe anemia and
hypotension and presumed GI bleed.
CT of abdomen was negative for aortoenteric fistula, aortic
dissection, or abdominal aortic aneurysm.
SUMMARY OF HOSPITAL COURSE:
1. Anemia: Anemia was deemed likely secondary to an acute
gastrointestinal bleed also on top of chronic picture. The
patient was transfused initially 10 units of packed red blood
cells while in the MICU for a goal hematocrit of greater than
28. The patient had a normal hematocrit three months prior
to admission. See GI section on further information
regarding GI bleeding.
Patient's anemia was deemed to be acute on chronic with acute
being the GI bleed, chronic issue of anemia in addition to
thrombocytopenia. For this, Hematology/Oncology consult was
obtained. They recommended holding the proton-pump inhibitor
secondary to thrombocytopenia as a possible inciting [**Doctor Last Name 360**].
I also recommended bone marrow biopsy to further assess for
possible bone marrow etiologies. A bone marrow biopsy was
performed during this admission which revealed
myelodysplastic syndrome as the likely etiology of his now
chronic anemia. Also revealed pale red blood cells
indicating a possible component of iron despite normal iron
studies.
Patient was transfused multiple times even after his transfer
to the floor on [**2199-8-5**]. The patient remained
hemodynamically stable, however, with serial hematocrit
checks would be found to have a hematocrit of 25.9 or lower.
The patient was transfused to maintain a hematocrit at least
greater than 28.
On the day of discharge, the patient's hematocrit was stable
at 32. Patient had remained transfusion free for nearly 48
hours prior to discharge.
2. Thrombocytopenia: Possible etiologies included
medication-induced, ITP, TTP, hemolysis. Once again, the
patient was seen by Hematology/Oncology. Patient was
screened for DIC and hemolysis as well, these were
unrevealing. A bone marrow biopsy once again gave unifying
diagnosis with a diagnosis of myelodysplastic syndrome. The
patient was transfused platelets for a goal platelets greater
than 50. On the day of discharge, the patient had platelet
count reaching the 130s. The patient had not required
transfusion of platelets for three days prior to discharge.
3. Hematology: Per above, the patient was diagnosed with
myelodysplastic syndrome. Per their recommendations of
Hematology/Oncology, the patient was started on prednisone 80
mg q day for a two week course. The patient will follow up
in [**Hospital **] clinic for further monitoring of his
myelodysplastic syndrome, and thrombocytopenia, and anemia.
They will also adjust his steroid course as needed for
appropriate taper and treatment of MDS. In addition to this,
they recommended multivitamin and folate supplements in
addition to iron supplementation to the patient's diet.
4. GI: The patient was also found to have an acute GI bleed.
He had a nasogastric lavage which was positive for return of
blood. Once the patient's hematocrit and platelet counts
were stabilized, the patient was prepared for endoscopy. The
endoscopy revealed multiple areas of gastritis and small
patchy angiectasias. In the duodenum, additional small
angiectasias were seen. Electrocautery was used to achieve
hemostasis in this region. In addition to this, they also
found an extrinsic compression of the mid esophagus by a
pulsating structure, however, a prior CT scan of the abdomen
had been unrevealing for aortic aneurysm. This was possibly
just due to a large cardiac chamber.
The patient had an additional EGD while in-house given his
decrease in hematocrit after the first procedure, however,
this did not yield any further areas of bleeding to be
cauterized. Also during his admission, the patient noted
large black bowel movements consistent with old blood likely
from his upper GI source. Patient did not have a colonoscopy
while in-house. This would be recommended as a followup for
this patient's complete GI workup.
Patient had originally been held from taking his proton-pump
inhibitor, however, this was once deemed safe and not the
cause of this thrombocytopenia, and this was restarted, and
the patient was discharged on his proton-pump inhibitors.
The patient was kept NPO until after the endoscopy. After
endoscopy, the patient's diet was advanced and he tolerated
this well. There was no additional nausea or vomiting.
5. Cardiac: During his course in the MICU, he had an episode
which the patient was severely anemic. The patient was noted
to have low back pain. An electrocardiogram was obtained
which revealed 3 mm ST segment depressions. This was treated
with sublingual nitrogen with resolution of the pain and also
subsequent resolution the electrocardiogram findings back to
baseline of 1 mm depressions. This was deemed to be due to a
demand ischemia episode. The patient's cardiac enzymes were
cycled. The patient did bump his troponins to 0.29. On
additional check later in the [**Hospital 228**] hospital course, this
trended down.
DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766
Dictated By:[**Name8 (MD) 12502**]
MEDQUIST36
D: [**2199-8-10**] 22:09
T: [**2199-8-15**] 11:47
JOB#: [**Job Number 96462**]
Admission Date: [**2199-8-2**] Discharge Date: [**2199-8-11**]
Date of Birth: [**2122-10-7**] Sex: M
Service: [**Location (un) 259**] MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
male with a history of coronary artery disease, congestive
heart failure, chronic renal insufficiency, and diabetes, who
was doing well until two days prior to admission when he
began to feel weak. Patient reported that he felt weak, and
had a "heavy load on his shoulders." The same thing had
happened the day prior to admission and progressed to the
point, where he could not urinate standing up secondary to
weakness.
On the day of admission, the patient awoke feeling "not good"
and his wife brought him to the Emergency Room. The patient
reported nausea on the morning of admission which had
resolved by the time he had been to the Emergency Room.
Denied vomiting. He did report diaphoresis. He denied back
pain and abdominal pain at the time of admission. He also
denied diarrhea or constipation.
In the Emergency Room, his vital signs were found to be blood
pressure of 111/55, pulse of 59. Patient was somewhat
diaphoretic. His blood pressures dropped to the 100s and he
was given 1 liter of normal saline with good blood pressure
response. A nasogastric lavage returned evidence of blood
and MICU evaluation was consulted, and the patient was
admitted to the MICU.
REVIEW OF SYSTEMS: On review of systems, the patient
reported he sleeps on two pillows secondary to discomfort,
but denied PND. The patient can walk several feet, but has
trouble beyond that. The patient denied night sweats.
Denied viral symptoms. Denied any new medications except
starting vitamins.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
x2 with anginal equivalent of jaw pain or back pain.
2. Diabetes type 2.
3. Congestive heart failure with an ejection fraction of
[**8-31**] with 30-40%.
4. Hypertension.
5. Hypercholesterolemia.
6. Hypothyroidism.
7. Guaiac positive stools on aspirin.
8. Depression/anxiety.
9. NSVT.
10. CRF: Creatinine 1.7-1.8.
11. Chronic obstructive pulmonary disease.
12. Urinary retention.
13. Macular degeneration.
ALLERGIES: Aspirin which causes bleeding.
MEDICATIONS:
1. Digoxin 0.0625.
2. Glipizide 2.5 [**Hospital1 **].
3. Metoprolol 62.5 q am, 50 q pm.
4. Synthroid 75.
5. Protonix 40.
6. Alprazolam 0.5 q6 prn.
7. Lasix 40 q day.
8. Fluoxetine 20 q day.
9. Avandia 8 mg q am.
10. Enalapril 2.5 mg [**Hospital1 **].
11. Flomax 0.4 q hs.
12. Potassium chloride 20 qod.
13. Magnesium oxide 400 q day.
14. Lipitor.
15. Sublingual nitroglycerin prn.
SOCIAL HISTORY: The patient lives with his wife and
daughter. Lives on the 11th floor apartment. He is a
retired salesman. Smoked 50 years at two packs per day, but
quit in [**2192**] and denies any alcohol use.
PHYSICAL EXAMINATION: On admission, temperature is 98.5,
blood pressure 111/55, pulse is 59, respiratory rate 13, and
sating 95% on room air. In general, this was an elderly
male, who is pale in no acute distress. HEENT: Pupils are
equal, round, and reactive to light. Pale conjunctivae, but
no icterus. Jugular venous pressure at 10 cm.
Cardiovascular: Regular, rate, and rhythm, 2/4 systolic
ejection murmur at the left upper sternal border, no
radiation. Lungs with crackles at the bases bilaterally.
Rectal examination was guaiac positive per the Emergency
Room. Abdominal examination: Soft, nontender, nondistended,
good bowel sounds, and no palpable masses. Extremities
revealed trace lower extremity edema, 2+ dorsalis pedis
pulses.
ELECTROCARDIOGRAM: Revealed normal sinus rhythm, normal
intervals, T-wave inversions which were old in aVL, V5, and
V6, and poor R-wave progression. He had slight ST
depressions 1 mm as well.
LABORATORY VALUES ON ADMISSION: Hematocrit of 18.6, white
count 8.4, platelets 20. Chem-7 was also unremarkable.
Also on admission the patient had a CT scan of his chest and
abdomen. This was negative for aortic dissection or
aortoenteric fistula.
SUMMARY OF HOSPITAL COURSE:
1. Anemia: The anemia was felt likely to be secondary to an
acute on chronic picture. Chronic being anemia of chronic
disease and in a setting of acute exacerbation namely a GI
bleed. In addition, it was also considered that there maybe
another source of his anemia given the fact that the patient
also had thrombocytopenia.
The patient was transfused for a goal hematocrit over 28,
ideally over 30. The patient was originally admitted to the
MICU and given 10 units of packed red blood cells. The
patient was later transferred to the floor and monitored
there. He had required multiple transfusions. Please see GI
section for further details on GI bleed.
The patient's anemia was stable at the time of discharge. He
had a stable hematocrit for about 48 hours prior to
discharge. His discharge hematocrit was 33.7.
2. Thrombocytopenia: The differential for the patient's
thrombocytopenia included medication induced, consumption
with DIC, hemolysis, ITP, TTP, and primary bone marrow issue.
The patient's Protonix was originally held on admission as
this was believed to be possible for causing
thrombocytopenia, however, the patient was restarted on this
prior to discharge when it was ruled out from the
differential diagnosis. The patient had no evidence of
active hemolysis or DIC. Question remained whether this was
ITP.
A bone marrow biopsy was performed on the patient which
revealed myelodysplastic syndrome. It was believed that the
myelodysplastic syndrome accounted for portions of both the
patient's anemia and thrombocytopenia. The patient was
transfused platelets as needed. The patient had a stable
platelet count for at least 48 hours prior to discharge. On
discharge, the platelet count was 165.
3. MDS/Hematology: As stated above, the patient was both
anemic and thrombocytopenic. The patient was found to have
MDS on bone marrow biopsy with a question of MDS and ITP.
The patient was treated for his MDS per Hematology/Oncology
recommendations. This included high-dosed steroids of
prednisone 80 mg q day. This also included B12, iron, and
folic acid supplementation.
4. GI bleed: Patient was found to have an active GI bleed
with a positive nasogastric tube lavage. Once the patient's
hematocrit and platelet counts were stable, he underwent an
endoscopy to evaluate his upper GI bleed. The patient was
found to have a significant amount of gastritis and also
duodenitis. Several areas were cauterized at the original
endoscope for better hemostasis.
On the day after the endoscopy, the patient returned to the
Endoscopy Suite for re-evaluation if the patient had
decreased his hematocrit overnight, however, there were no
further sites of active bleeding found. Colonoscopy was
considered while in-house, however, it was deemed that the
sight of GI bleeding in the stomach and duodenum was
sufficient to account for the patient's blood loss. The
patient should have a colonoscopy as a followup.
Patient's hematocrit was again stable for 48 hours prior to
discharge. It was deemed that the GI bleeding was under
control at this time of discharge with a negative endoscope
and also stable hematocrit. Although the patient's
proton-pump inhibitor had originally been held, it was
started prior to discharge with an alternate diagnosis for
thrombocytopenia had been found.
5. Cardiac: Patient has an extensive cardiac history. While
in the MICU, the patient developed back pain. An
electrocardiogram obtained at that time revealed ST segment
depressions to 3 mm which has increased over the baseline of
1 mm for this patient. The patient was given sublingual
nitroglycerin with relief of back pain and also the ST
segment depressions. Serial enzymes were also checked at
that time, and the patient ruled in for myocardial
infarction.
Given the fact that the electrocardiogram changes had
resolved, and the patient was asymptomatic after sublingual
nitroglycerin, it was deemed that this was due to demand
ischemia given the patient's low hematocrit at the time. The
patient was transfused to maintain a hematocrit greater than
30 to prevent further episodes.
Dr. [**Last Name (STitle) **], the patient's cardiologist was aware of the
admission, and will follow up with the patient as an
outpatient.
6. Congestive heart failure: Patient with a history of
congestive heart failure and mild volume overload on
examination on admission. The patient's medications for
hypertension were re-evaluated and medication changes made as
needed, for instance decreased dosage of the beta blocker.
The patient was given Lasix IV, and after blood transfusion
was given 20 mg IV to avoid further congestive heart failure
exacerbation. The patient remained with good oxygen
saturations while in-house, and on examination the patient's
lungs remained clear.
A chest x-ray was obtained two days prior to discharge, which
showed no evidence of congestive heart failure.
7. Diabetes mellitus: The patient's oral medications were
originally held as the patient was NPO for procedure for his
GI bleeding. The patient was maintained on a regular
insulin-sliding scale. Starting the prednisone 80 mg q day,
the patient had significant increase in his daily
fingersticks with blood sugars in the 250s. At this time,
the patient had also begun a regular diet. The patient's
oral hypoglycemics were once again restarted, and the patient
was still covered with a regular insulin-sliding scale. This
is a regimen the patient will maintain when he returns home
on the prednisone.
8. Hyperparathyroidism: The patient was appropriately
replaced for his decreased thyroid function and Synthroid was
continued.
9. Depression/anxiety: Patient was continued on his Prozac
and alprazolam.
10. Chronic renal insufficiency: Patient's creatinine was
slightly increased on admission with a creatinine of 2.0
throughout his admission. This is gradually decreased to his
baseline of 1.7 to 1.8. The original 2.0 was likely
secondary to hypovolemia. With the administration of packed
red blood cells for the hypovolemia, his creatinine had
returned to baseline.
11. Chronic obstructive pulmonary disease: The patient was
not on any medications for this. Examination was followed
throughout the hospital course. He required no treatment.
12. FEN: The patient was originally kept NPO for his
gastrointestinal bleeding, however, prior to discharge, the
patient resumed a cardiac and renal healthy diet without
issue. There was no nausea and no vomiting while in-house.
The patient had reported a large black stool prior to his
endoscopy. Prior to discharge, the patient resumed normal
bowel movements.
13. Code: DNR/DNI.
DISCHARGE STATUS: To home.
CONDITION ON DISCHARGE: Stable. Patient with upper GI bleed
now under control. Patient with stable hematocrit and
platelet count over 48 hours prior to discharge. Patient
with new diagnosis of myelodysplastic syndrome on high-dosed
steroids for this. The patient was discharged to home with
VNA services.
DISCHARGE DIAGNOSES:
1. Anemia.
2. Upper gastrointestinal bleed.
3. Thrombocytopenia.
4. Myelodysplastic syndrome.
5. Coronary artery disease.
6. Chronic renal insufficiency.
7. Coronary artery disease/myocardial ischemia.
8. Congestive heart failure.
MEDICATIONS ON DISCHARGE:
1. Regular insulin-sliding scale.
2. Levothyroxine 75 mcg.
3. Pantoprazole 40 mg [**Hospital1 **].
4. Prednisone 80 mg q day for two weeks. Follow up with
Hematology/Oncology.
5. Sucralfate 1 gram 4x/day.
6. Rosiglitasone 8 mg q day.
7. Lisinopril 10 mg q day.
8. Glipizide 2.5 mg [**Hospital1 **].
9. Ferrous gluconate 300 mg q day.
10. Pyridoxine 100 mg [**Hospital1 **].
11. Folic acid 1 mg q day.
12. Metoprolol 25 mg [**Hospital1 **].
13. Digoxin 0.0625 q day.
14. Atorvastatin 40 mg q day.
15. Alprazolam 1 mg [**Hospital1 **] prn.
16. Fluoxetine 20 mg q day.
17. Furosemide 40 mg q day.
FOLLOW-UP PLANS: The patient was instructed to followup with
his primary care doctor, Dr. [**Last Name (STitle) 41364**]. Patient is
instructed to call the day after discharge to arrange an
appointment. The patient was also instructed to have his
blood counts followed within the next week. There were
outpatient laboratories given to the patient so this could be
done with home VNA. These will be sent to patient's primary
care physician for followup. The patient was also instructed
to followup with Hematology/[**Hospital **] Clinic, specifically Dr.
[**Last Name (STitle) 6160**] on [**8-26**] at 11 am. Patient will also arrange
with his primary care doctor for his GI bleeding and also
possibility of further explorations such as colonoscopy.
DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766
Dictated By:[**Name8 (MD) 12502**]
MEDQUIST36
D: [**2199-8-13**] 08:48
T: [**2199-8-19**] 10:12
JOB#: [**Job Number 96463**]
Name: [**Known lastname 15309**], [**Known firstname 1495**] Unit No: [**Numeric Identifier 15310**]
Admission Date: [**2199-8-2**] Discharge Date: [**2199-8-11**]
Date of Birth: [**2122-10-7**] Sex: M
Service: [**Location (un) 571**]-M
ADDENDUM:
This is a Discharge Summary Addendum to a previously dictated
Discharge Summary covering hospital days [**2199-8-2**] to
[**2199-8-10**].
The prior discharge summary was terminated prior to
completion. Please see additional Discharge Summary addendum
for completion of hospital course.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-766
Dictated By:[**Name8 (MD) 2450**]
MEDQUIST36
D: [**2199-8-10**] 22:22
T: [**2199-8-10**] 22:35
JOB#: [**Job Number 15313**]
|
[
"535.51",
"250.00",
"244.9",
"285.1",
"410.91",
"238.7",
"593.9",
"537.83",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"41.31",
"45.30"
] |
icd9pcs
|
[
[
[]
]
] |
20037, 20269
|
20295, 20891
|
13009, 19705
|
11804, 12746
|
20909, 22663
|
10348, 10634
|
9113, 10328
|
12761, 12981
|
10656, 11564
|
11581, 11781
|
19730, 20016
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
378
| 105,908
|
7348+55825
|
Discharge summary
|
report+addendum
|
Admission Date: [**2109-10-31**] Discharge Date: [**2109-11-13**]
Date of Birth: Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 71-year-old gentleman
who experienced a presyncopal episode and was admitted to the
[**Hospital 1474**] Hospital Emergency Department.
There, the patient had an exercise tolerance test which was
positive and was then transferred to [**Hospital1 190**] for cardiac catheterization. Cardiac
catheterization revealed an ejection fraction of 33%, left
ventricular end-diastolic pressure of 25, and severe 3-vessel
coronary artery disease; including left main with mild
disease, the left anterior descending artery with 70% to 80%
proximal to mid stenosis, the left circumflex with 95%
proximal, 70% at the second obtuse marginal, and the right
coronary artery which was nondominant with a 99% stenosis.
The patient was then referred for coronary artery bypass
grafting.
PAST MEDICAL HISTORY: (The patient's past Medical History
includes)
1. Non-insulin-dependent diabetes mellitus.
2. Hypertension.
3. Hypercholesterolemia.
4. Former heavy smoker.
5. He drinks alcohol; he has had more to drink recently.
6. History of Alzheimer's disease/dementia.
7. Status post appendectomy.
8. Status post motor vehicle accident as a child.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: (His medications on admission
included)
1. Glyburide 5 mg by mouth twice per day.
2. Aricept 10 mg by mouth at hour of sleep.
3. Lipitor 10 mg by mouth once per day.
4. Zestril.
5. Effexor 75 mg by mouth once per day.
6. Lopressor 25 mg by mouth twice per day.
7. Aspirin by mouth every day.
8. Plavix 75 mg by mouth once per day.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) 1139**] and alcohol as above.
REVIEW OF SYSTEMS: The patient's review of systems was
noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient was an alert and oriented
pleasant gentleman. He was in no apparent distress. His
neurologic examination revealed the patient to be grossly
intact. He did have a right carotid bruit, but no left
carotid bruit was noted. The patient's lungs were clear to
auscultation bilaterally. His heart was regular in rate and
rhythm. No murmur was noted. His abdomen was benign. The
abdomen was nontender and nondistended. Extremity
examination revealed his extremities were warm and well
perfused with no varicosities.
PERTINENT LABORATORY VALUES ON PRESENTATION: His laboratory
values revealed his white blood cell count was 7.8, his
hematocrit was 37.8%, and his platelet count was 167,000.
His INR was 1.2. His sodium was 138, potassium was 3.9,
chloride was 105, bicarbonate was 25, blood urea nitrogen was
15, creatinine was 0.8, and blood glucose was 128. His liver
function tests were within normal limits.
PERTINENT RADIOLOGY/IMAGING: His electrocardiogram showed a
normal sinus rhythm with no acute ischemia.
His echocardiogram showed mild mitral regurgitation, trace
tricuspid regurgitation, no aortic regurgitation, and global
hypokinesis.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient underwent a
carotid ultrasound which showed moderate plaque in the right
and left internal carotid artery with narrowing of the right
internal carotid artery to 60% to 69% and the left 40% to
59%. His vertebrals were noted to be normal.
The patient had no events while awaiting surgery. On
[**2109-11-4**] the patient underwent coronary artery bypass
grafting times three with a left internal mammary artery to
the left anterior descending artery, a saphenous vein graft
to the second obtuse marginal, and a saphenous vein graft to
the third obtuse marginal.
The surgery was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] with Dr.
[**Last Name (STitle) 16398**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] assistants. The surgery was
performed under general endotracheal anesthesia. There was a
cardiopulmonary bypass time of 82 minutes and a cross-clamp
time of 72 minutes. The patient tolerated the procedure well
and was transferred to the Coronary Care Unit in a normal
sinus rhythm. The patient was on epinephrine,
nitroglycerin, insulin, and propofol drips. The patient had
two atrial and two ventricular pacing wires and two
mediastinal and one left pleural chest tube.
Initially, on the first operative night, the patient was
noted to have a low cardiac index and a low ejection fraction
on epinephrine. This was eventually weaned off, and he did
have some ventricular ectopy. He was also given 500 cc of
crystalloid for a low cardiac index. Therefore, the patient
was not extubated on his first operative night. The patient
was eventually A-paced to help with his cardiac index.
In the morning on postoperative day one, the patient was
extubated without difficulty. Over postoperative day one,
the patient was weaned off all of his drips. By late in the
day, he was transferred to the surgical floor.
On postoperative day two, he had his chest tubes discontinued
without incident. He was started on Lopressor twice per day
and encouraged to ambulate.
On postoperative day three, his cardiac pacing wires were
discontinued without incident. During that day, he had his
Foley catheter discontinued, but he did fail to void.
Therefore, his Foley catheter was replaced that night. His
Foley catheter was removed the following day, and he was able
to void without difficulty.
On postoperative day four, the patient was complaining of
having multiple loose stools. Flagyl was started
empirically, and Clostridium difficile cultures were sent.
Subsequently, the Clostridium difficile cultures sent were
all negative. The Flagyl was discontinued. His loose stools
did resolve on their own.
Throughout the remainder of his hospital course, he continued
to work with Physical Therapy to increase his strength and
ambulation. By postoperative day eight, it was felt that he
would be ready for discharge to home with a visiting nurse
and physical therapy services on postoperative day nine.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's physical
examination revealed the patient to be alert and oriented
times three. In no apparent distress. The lungs were clear
to auscultation bilaterally. His heart was regular in rate
and rhythm. No murmurs, rubs, or gallops. His wounds were
clean, dry, and intact. His sternum was stable. His abdomen
was soft, nontender, and nondistended. His extremities
revealed no signs of edema.
PERTINENT LABORATORY VALUES ON DISCHARGE: His discharge
laboratories will be dictated in an Addendum.
His discharge chest x-ray showed small bilateral effusions,
but no sign of infiltrate or pneumothorax.
CONDITION AT DISCHARGE: The patient's condition on discharge
was good.
PRIMARY DISCHARGE DIAGNOSIS: Status post coronary artery
bypass grafting times three on [**2109-11-4**].
SECONDARY DISCHARGE DIAGNOSES:
1. Diabetes mellitus.
2. Alzheimer's disease/dementia.
3. Hypertension.
4. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Enteric-coated aspirin 325 mg by mouth every day.
2. Glyburide 5 mg by mouth twice per day.
3. Effexor-XR 75 mg by mouth once per day.
4. Lipitor 10 mg by mouth once per day.
5. Aricept 10 mg by mouth at hour of sleep.
6. Lopressor 50 mg by mouth twice per day.
7. Percocet one to two tablets by mouth q.4h. as needed.
8. Lasix 20 mg by mouth twice per day (times seven days).
9. Potassium chloride 20 mEq by mouth twice per day (times
seven days).
10. Multivitamin one tablet by mouth once per day.
11. Iron sulfate 325 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) 27098**] in one to two weeks.
2. The patient was instructed to follow up with his
cardiologist (Dr. [**First Name (STitle) **] in two to three weeks.
3. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] in four weeks.
4. The patient was instructed to continue an 1800-calorie
American Diabetes Association diabetic diet with low sodium
and low cholesterol.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Dictator Info 3114**]
MEDQUIST36
D: [**2109-11-12**] 16:57
T: [**2109-11-12**] 17:16
JOB#: [**Job Number 27099**]
Name: [**Known lastname 4658**],[**Known firstname **] Unit No: [**Numeric Identifier 4659**]
Admission Date: [**2082-1-26**] Discharge Date: [**2109-11-13**]
Date of Birth: Sex: M
Service: CARDIOTHORACIC
ADDENDUM: The only changes that need to be made to the
discharge summary are:
1. The patient's Glyburide dose is changed from 5 mg po
b.i.d. to 5 mg po q.d. one dose in the a.m.
2. The patient instead of being discharged to home with
visiting nurse care he is going to be discharged to a
rehabilitation facility.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern1) 4660**]
MEDQUIST36
D: [**2109-11-13**] 02:32
T: [**2109-11-18**] 05:52
JOB#: [**Job Number 4661**]
|
[
"285.9",
"331.0",
"414.01",
"780.2",
"250.00",
"294.10",
"272.0",
"401.9",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"88.53",
"88.56",
"37.22",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
7085, 7187
|
6977, 7064
|
7213, 7817
|
1409, 1749
|
7850, 9508
|
3222, 6242
|
6899, 6955
|
6709, 6884
|
1879, 3193
|
181, 961
|
984, 1383
|
1766, 1859
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,779
| 125,403
|
32964
|
Discharge summary
|
report
|
Admission Date: [**2124-1-19**] Discharge Date: [**2124-2-2**]
Date of Birth: [**2046-5-21**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
became unresponsive
Major Surgical or Invasive Procedure:
intubated, Cerebral Angio, MERCI and IA tPA
History of Present Illness:
Pt. is a 77 y/o with a hx of CAD, s/p 5 vessel CABG 5 days ago,
HTN, Ulcerative colitis, who is brought in after suddenly
becoming unresponsive this morning. History is her his
daughter, who was present during the incident.
Daughter reports that she woke her father up around 8:30 this
morning. He said "gee, you'd think I'd feel better after a good
night's sleep," and she assumed he was having incisional pain.
Otherwise he seemed himself, and was talking normally, answering
her questions. Then all of the sudden his eyes rolled back in
his head and he became unresponsive. He seemed to be snoring or
grunting through his nose, and his arms curled in to his body
and tensed up. His body seemed rigid. She got scared and
called 911 immediately. We have no EMS report available, but
her daughter's report they checked his pulse and it was
initially strong, but then got more thready. They started
bagging him. By the time they started moving him to the
ambulance around 8:50 he didn't seem rigid anymore (she's not
sure how long this lasted, but guesses 10-15 minutes) and
actually slumped to the side when they put him in a wheelchair.
He was intubated in the ambulance on the way to the ER. When he
arrived here the ED found that he was unresponsive and that his
pupils were fixed at 6 mm. A Head CT was performed, which was
negative for any evidence of hemorrhage, and we were consulted.
His daughter reports that he's been recovering well after his
surgery, and has been up to the bathroom by himself. When his
visiting nurse came yesterday she heard some crackles at the
bases, but he had no fever.
Past Medical History:
CAD s/p silent IMI, recent 5 vessel CABG [**2124-1-13**]
HTN
Ulcerative Colitis x 20+ yrs, well controlled on Mesalamine
HTN
Basal Cell CA on face
L rotator cuff repair
No Hx of stroke or seizure
Social History:
lives with and cares for his wife, who has alzheimers, very
active at baseline, helps take care of grandkids, retired from
GE in [**Location (un) **] 13 yrs ago, where he worked for 45 yrs as a design
analyst for jet engines, quit smoking 30 yrs ago (25 PY hx),
drinks 4-5 beers/day
Family History:
sister with a pacemaker, brother with cardiac stents, brother
had a stroke at 80, brother with valve replacement
Physical Exam:
T- 99.8 BP- 120/63 HR- 88 RR- 18 O2Sat- 100% on vent
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
Neck: supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally anteriorly
aBd: +BS soft
ext: no edema
Neurologic examination:
Mental status: intubated, no sedation for 30 min prior to exam,
does not open eyes to voice or noxious stimuli, does posture
with stimulation
Cranial Nerves: pupils 6 mm, unreactive bilaterally. No EOM
with dolls or cold calorics R or L. + corneals bilaterally. No
obvious facial assymetry (difficult with ETT) No gag with
manipulation of ETT, coughs with deep suction.
Motor/Sensory: Extensor posturing of both arms with pain,
triple flexion of both legs with pain
Reflexes:
+2 and symmetric throughout UE, 1+ at patella bilaterally,
absent at achilles bilaterally. Toes upgoing bilaterally
Pertinent Results:
[**2124-1-19**] 09:25AM BLOOD WBC-9.8 RBC-2.89* Hgb-10.1* Hct-28.8*
MCV-100* MCH-35.2* MCHC-35.2* RDW-12.7 Plt Ct-354
[**2124-1-21**] 01:41AM BLOOD WBC-8.7 RBC-2.93*# Hgb-9.7* Hct-27.2*
MCV-93 MCH-33.3* MCHC-35.8* RDW-15.2 Plt Ct-332
[**2124-1-19**] 09:25AM BLOOD PT-12.0 PTT-24.4 INR(PT)-1.0
[**2124-1-20**] 12:14PM BLOOD Ret Aut-5.0*
[**2124-1-21**] 01:41AM BLOOD Glucose-129* UreaN-10 Creat-0.9 Na-135
K-3.8 Cl-104 HCO3-22 AnGap-13
[**2124-1-20**] 12:14PM BLOOD ALT-15 AST-20 LD(LDH)-261* AlkPhos-52
TotBili-0.6
[**2124-1-19**] 09:25AM BLOOD CK-MB-4 cTropnT-0.35*
[**2124-1-19**] 03:28PM BLOOD CK-MB-4 cTropnT-0.22*
[**2124-1-19**] 09:48PM BLOOD CK-MB-4 cTropnT-0.23*
[**2124-1-20**] 01:46AM BLOOD CK-MB-4 cTropnT-0.20*
[**2124-1-20**] 01:46AM BLOOD Calcium-7.4* Phos-3.0 Mg-1.8 Cholest-103
[**2124-1-20**] 12:14PM BLOOD calTIBC-199* VitB12-GREATER TH
Folate-15.5 Ferritn-323 TRF-153*
[**2124-1-20**] 01:46AM BLOOD %HbA1c-5.5
[**2124-1-20**] 01:46AM BLOOD Triglyc-75 HDL-31 CHOL/HD-3.3 LDLcalc-57
[**2124-1-20**] 12:14PM BLOOD TSH-0.48
[**2124-1-19**] 09:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
TEE:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. The interatrial septum
is aneurysmal. Color-flow imaging of the interatrial septum
raises the suspicion of an atrial septal defect, but this could
not be confirmed on the basis of this study. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of intracardiac
thrombus. There is a dynamic interatrial septum, although a
septal defect was not well visualized.
MRI Brain:
Extensive bilateral PCA infarctions as well as left cerebellar
acute infarcts. Apparently restored flow to the tip of the
basilar artery, although evaluation is limited by motion
degradation on the MRA.
CTA:
1. Findings consistent with a basilar tip thrombus. The thrombus
covers the origins of the posterior cerebral and superior
cerebellar arteries bilaterally.
2. CT perfusion images support a bilateral PCA territory
ischemia, particularly given the CTA finding and clinical
history.
3. Atherosclerotic calcifications most prominent at bilateral
carotid artery bifurcations.
Brief Hospital Course:
Mr. [**Known lastname 68224**] was taken emergently to the neurointerventional
suite and underwent a cerebral angiogram. The occlusion of the
top of the basilar artery was visualized and IA tPA was given in
attempt to dissolve the clot. MERCI was also attempted and part
of the thrombus was removed, however there was residual
occlusion of the L PCA. He was then transferred to the ICU for
further management.
He was maintained with a SBP of 130-170. Shortly after
admission, he began to have intermittent afib. This was
therefore felt to be the mechanism for his infarction.
Anticoagulation was not an option given his recent CABG.
Therefore a TEE was done the following day which showed no
thrombus. He was started on aspirin. His screening labs were
checked and his A1c was 5.5, HDL was 31 and LDL was 57. He was
maintained normothermic and normoglycemic. An MRI was done that
evening. It showed extensive infarction of bilateral PCA
distributions.
On admission, CE were done which showed a mild troponin bump of
0.35 at the peak. This gradually tended down and his ECG showed
no dynamic changes. He was started on aspirin 81mg again after
24 hours.
Over the first 24 hours of his admission, his HCT dropped to 22.
It remained stable and iron studies were consistent with chronic
disease. His retic count was also appropriately elevated. He was
transfused 2 units PRBC with a good response.
On admission, a CXR was done which showed a retrocardiac
opacification. He was also febrile but had a normal white count.
He was started on levoquin and pan cultured. This was treated
for 7 days but he still had a LLL infiltrate and fevers
intermittently. He was cultured repeatedly and grew out coag
negative staff in [**12-24**] sets which was felt to be likely
contaminant. None the less, he was treated with Vanco and the
art line was removed.
During his hospital course, his neurologic exam remained
essentially [**Date Range 1506**]. He did not have further episodes of afib
and was not anticoagulated. Several meetings took place with the
Daughter (HCP) who initially leaned towards making him CMO.
Another family meeting occurred between the CT surgeon, TSICU,
Neurology and both the daughter and son. The CT surgeon
suggested waiting 30 days to evaluate his potential for
improvement. Neurology explained that this was extremely
unlikely. The family considered the options and decided to
proceed with PEG and Trach.
These were placed. He continued to require ventilatory
assistance via his trach and by discharge his respiratory
support was CPAP with pressure support with PEEP of 5 and PS of
5.
Pt tolerated his Gtube feeds without difficulty.
He became afebrile with improvement in his WBC. His cultures
remained negative and antibiotics were discontinued. Pt
remained afebrile with normal WBC for >72hrs prior to discharge.
Medications on Admission:
Ranitidin 150 mg [**Hospital1 **]
Plavix 75 mg QD
Metoprolol 75 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Lipitor 10 mg QD
KCl 20 meq QD x 5 day (start [**1-18**])
Lasix 40 mg QD x 5 day (start [**1-18**])
Percocet 1-2 tabs Q4H PRN pain
ASA 81 mg QD
Mesalamine 800 mg TID
Monopril 40 mg QD
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for t > 100.4.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed for wheeze.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for wheeze.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
12. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for fever.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
15. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl
Topical Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Top of the basilar artery occlusion
Discharge Condition:
critical
Discharge Instructions:
please follow up with primary cardiologist as previously
determined. please call primary neurologist/cardiologist for
worsening neurologic exam.
Followup Instructions:
follow with neurology in 1 month. Dr. [**Last Name (STitle) **] attending: ([**Telephone/Fax (1) 76682**] to arrange appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2124-2-2**]
|
[
"568.89",
"414.01",
"410.71",
"997.02",
"V15.82",
"412",
"556.9",
"486",
"285.29",
"433.01",
"427.31",
"V45.81",
"518.0",
"V10.83",
"518.82",
"433.31",
"401.9",
"434.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"87.03",
"38.91",
"43.11",
"31.1",
"88.41",
"99.10",
"96.6",
"33.21",
"88.72",
"96.72",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
10817, 10917
|
6240, 9082
|
292, 337
|
10996, 11007
|
3551, 6217
|
11201, 11454
|
2522, 2637
|
9432, 10794
|
10938, 10975
|
9108, 9409
|
11031, 11178
|
2652, 2906
|
233, 254
|
365, 1985
|
3089, 3532
|
2945, 3073
|
2930, 2930
|
2007, 2205
|
2221, 2506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,523
| 184,937
|
9766
|
Discharge summary
|
report
|
Admission Date: [**2195-5-4**] Discharge Date: [**2195-5-10**]
Date of Birth: [**2150-6-8**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Morbid obesity
Major Surgical or Invasive Procedure:
[**2195-5-4**]:
1. Laparoscopic converted to open Roux-en-Y gastric bypass.
2. Resection of small intestine with anastomosis.
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight 290.1 lbs,
height 71 inches and BMI 40.5. His previous weight loss efforts
[**Street Address(1) 32919**] visits, Slim-Fast, HMR, and Weight Watchers.
He has not taken prescription weight loss medications or used
over-the-counter ephedra-containing appetite suppressants/herbal
supplements. He stated he developed significant [**Last Name 4977**] problem
at age 27 and cites as factors contributing to his excess weight
large portions, genetics, too many carbohydrates and saturated
fats and lack of exercise. He does walk 30-60 minutes several
times a week. He denied history of eating disorders or
depression.
Past Medical History:
Past Medical History:
1. Hypertension.
2. Type 2 diabetes with hemoglobin A1c of 8.2.
3. Dyslipidemia with elevated triglycerides.
4. Obstructive sleep apnea, on CPAP.
5. History of penile candidiasis.
6. Fatty liver by ultrasound.
Past surgical history includes a ventral hernia repair in [**2184**]
by
Dr. [**Last Name (STitle) **] at which time he placed a [**Doctor Last Name 4726**]-Tex mesh.
Social History:
He denies tobacco or recreational drug use, has alcohol on
social occasions and drinks both caffeinated and carbonated
beverages.
Family History:
Father deceased at age 45 with diabetes, hyperlipidemia, and
obesity. Mother living, age 69, with arthritis. Brother
living, age 39, with asthma. Grandfather deceased at age 65 of a
stroke and diabetes.
Physical Exam:
VS: 97.9 91 137/65 20 98 RA
Constitutional: comfortable, NAD
Neuro: EOMI
Cardiac: RRR, no M/R/G, clear S1, S2
Lungs: CTAB
Abdomen: obese, soft, non-tender to palpation
Wounds: no erythema or drainage, incision well-healed
Ext: no unilateral swelling or peripheral edema
Pertinent Results:
[**2195-5-4**] 12:38PM WBC-13.3*# RBC-4.79 HGB-14.6 HCT-39.8* MCV-83
MCH-30.4 MCHC-36.6* RDW-15.4
[**2195-5-4**] 12:38PM GLUCOSE-339* UREA N-20 CREAT-1.5* SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
CXR [**2195-5-6**]: There is interval development of mild vascular
congestion but no overt pulmonary edema. The lung volumes are
low. Bibasilar opacities, left more than right are most likely
consistent with areas of atelectasis. Left and right
costophrenic sulci were not included in this field of view, thus
smaller or larger pleural effusion cannot be excluded. There is
no pneumothorax.
Brief Hospital Course:
The patient presented to pre-op on [**2195-5-4**]. Pt was evaluated by
anaesthesia, and his blood sugars were significantly elevated
preoperatively. He was taken to the operating room for
laparoscopic gastric bypass, which was converted to an open
gastric bypass. Pt was extubated, taken to the PACU until
stable, then transferred to the [**Hospital1 **] for observation.
Neuro: The patient was alert and oriented throughout her
hospitalization; pain was initially managed with a PCA and then
transitioned to oral Roxicet once tolerating a stage 2 diet.
CV: Patient was in sinus tachycardia postoperatively. On POD#1,
pt went into new-onset atrial fibrillation with rapid
ventricular rate and was transferred to the ICU. Cardioversion
with amiodarone was first attempted and, after this failed, he
was electrically cardioverted on POD#2. He returned to [**Location 213**]
sinus rhythm following cardioversion, and remained in normal
sinus rhythm for the remainder of his hospital stay. He
remained in sinus tachycardia for the remainder of his stay,
which was initially managed with IV lopressor but this was
discontinued. His heart rate remained 90-110 in normal sinus
rhythm on diltiazem. He was switched from extended release to a
normal diltiazem formulary given the fact that he will need to
crush this medication. His HCTZ remains held perioperatively,
and his lisinopril dose was decreased to 20 daily, which can be
increased if necessary at his postoperative PCP [**Name Initial (PRE) **]. He did
have intermittent bursts of ventricular tachycardia. Cardiology
recommended optimization of electrolytes, and this resolved. We
have recommended close follow-up for his cardiac issues.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: He was initially kept NPO until an upper GI study was
performed on post-operative day 1 and was negative for a leak,
Therefore, his diet was advanced to a bariatric stage 1 diet,
which was advanced sequentially to stage 3, and well tolerated.
Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Endo: The patient was initially placed on an IV insulin drip
postoperatively for blood sugars >250. After his blood sugars
returned to [**Location 213**], he was placed on Lantus plus a sliding
scale, which was closely managed by the [**Last Name (un) **] team. He is
being discharged on Lantus, metformin, and an insulin sliding
scale, and will have close follow-up with [**Last Name (un) **] diabetes as an
outpatient.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled. His drain was removed and staples left in place.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
The cardiology service recommended restarting his home dose of
diltiazem, and restarting lisinopril at a lower dose of 20 daily
instead of 20 twice daily. They also recommended restarting
hydrochlorothiazide. The patient was instructed to follow up
with his PCP for [**Name Initial (PRE) **] blood pressure check and, at that time, his
lisinopril dose may be increased to his preoperative dose as
needed. His hydrochlorothiazide may also be restarted at that
time. He should be continued on the usual formulary for
diltiazem, rather than the extended release version, given the
fact that he will be crushing this medication.
Medications on Admission:
Acarbose 100 mg TID
Diltiazem 240 mg ER daily
Folic acid 1000 mg daily
Gemfibrizol 600 mg [**Hospital1 **]
Glargine 40 units [**Hospital1 **]
Insulin aspart sliding scale
Lisinopril 40 mg q am, 20 mg q pm
Simvastatin 40 mg daily
Omega 3 6,000 mg daily
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for Pain.
Disp:*300 ML(s)* Refills:*0*
2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2
times a day).
Disp:*600 mL* Refills:*2*
4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for Constipation.
Disp:*300 mL* Refills:*1*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Insulin sliding Scale
insulin sliding scale: as attached
9. Lantus 100 unit/mL Solution Sig: Seventeen (17) units
Subcutaneous at bedtime: hold for blood sugar < 130.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diabetes mellitus type 2.
2. Morbid obesity.
3. Hyperlipidemia.
4. Hypertension.
5. Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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.
You had a rapid heart rate, atrial flutter, during this
hospitalization which responded to electrical cardioversion. You
also intermittently had short bursts of a rhythm called
ventricular tachycardia, which resolved with optimization of
your electrolytes. You should have close follow-up with your PCP
who will determine whether you should continue to see a
cardiologist as an outpatient. Your blood sugar was also
difficult to control throughout this hospitalization. With the
help of the [**Last Name (un) **] diabetes team, we have optimized your blood
sugar control, but you should continue to work with your primary
care physician to better manage your diabetes.
DO NOT TAKE THE EXTENDED RELEASE VERSION OF DILTIAZEM OR ANY
OTHER MEDICATION. CRUSHING AND TAKING THIS MEDICATION CAN BE
VERY DANGEROUS AND POTENTIALLY LETHAL. We have prescribed the
standard diltiazem formulary. You should continue with this.
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 will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. 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 [**9-26**] 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 Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2195-5-21**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2195-5-21**] 3:45
We have scheduled a follow-up appointment with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 2903**], on [**2195-5-22**] at 12:15pm.
You have a follow-up appointment with endocrinology at [**Last Name (un) **]
with Dr. [**Last Name (STitle) 32920**] on [**2195-5-12**] at 9am. The phone number is
[**Telephone/Fax (1) 32921**].
It is also recommended that you schedule an appointment to see a
cardiologist at [**Hospital1 18**] after discharge. Please call [**Telephone/Fax (1) 62**]
to schedule an appointment.
|
[
"427.1",
"V64.41",
"571.8",
"427.89",
"250.02",
"V85.41",
"401.9",
"272.4",
"327.23",
"278.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"45.62",
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
8135, 8141
|
2896, 6950
|
316, 444
|
8292, 8292
|
2255, 2873
|
11514, 12349
|
1742, 1949
|
7252, 8112
|
8162, 8271
|
6976, 7229
|
8467, 9950
|
1964, 2236
|
262, 278
|
11157, 11491
|
472, 1149
|
9975, 11145
|
8307, 8419
|
1193, 1578
|
1594, 1726
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,659
| 137,744
|
26476
|
Discharge summary
|
report
|
Admission Date: [**2182-5-9**] Discharge Date: [**2182-5-21**]
Date of Birth: [**2107-2-13**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
PNA, aortic stenosis
Major Surgical or Invasive Procedure:
[**2182-4-30**] Intubation at other hospital
[**2182-5-8**] Bronchoscopy at other hospital
[**2182-5-14**] Tracheostomy
[**2182-5-14**] PEG tube placement
History of Present Illness:
75F h/o COPD, severe AS, admitted [**4-29**] to OSH with 1 week of
weakness, shortness of breath, and decreased oral intake. She
was ultimately found to have RLL PNA, GPC bacteremia, and CHF,
resulting in transfer to the ICU and subsequent intubation. She
is transferred to [**Hospital1 18**] because of difficulty extubating.
.
As above, she presented on [**4-29**], VS= 98.0 138/70 78 18. CXR
revealed RLL consolidation and bilateral pleural effusions. WBC
17.4, HGB 11.8, Na 121, Cre 0.8. She was admited to the medical
floor for treatment of PNA and hyponatremia, with
CTX/azithromycin, and gentle IVF hydration.
.
On [**4-30**], pt desaturated to the the 80s, with BP 180-200, she was
placed on BiPaP and transferred to the ICU and ultimately
intubated. Blood cultures from [**4-29**] returned positive for GPCs x2
sets (strep salivaria), for which ID consult obtained, and
patient started on vancomycin 1g Q12H, azithromycin stopped. Per
discharge summary, she was intermittently diuresed in the ICU
with lasix.
.
Cardiology consult was obtained given concern for CHF on CXR and
known severe aortic stenosis. Recs were to rule out endocarditis
with TTE, and obtain renal and pulmonary consults. TTE on [**4-30**]
was obtained which revealed normal LV function and critical AS
(0.2cm). Repeat TTE on [**5-7**] raised concern for mitral valve
vegetation. After discussion of possible valvular intervention,
pt was referred to [**Hospital1 18**] given her previous valvular surgery
here.
.
On [**5-8**] pt was noted to have moderate amounts of blood from her
ET tube. An emergent bronchoscopy was performed, while pt was on
coumadin and lovenox, which revealed bleeding from the inferior
segment of the lingula on teh left, into which 10mL of
epinephrine were injectied in addtion to cautery. An area of
exposd vessel was also noted at the carina beween the anterior
an lateral subsegement of the LLL was also cauterized. CXR at
that time revealed an effusion on teh right side which was
drained via thoracentesis, removing 800cc of yellow fluid.
.
A urology consult was obtained given hydronephrosis [**2182-4-30**] (R
kidney 10.9, left 10.2, with mild hydronephrosis), which
recommended monitoring the patients creatinien and consideration
of CT ABD/PEVLIS.
.
Pt was transferred to [**Hospital1 18**] today given difficulty weaning from
the ventilator, concern for contribution from critical AS, and
consideration of valve surgery.
.
Upon arrival to the MICU, pt is off all sedation, and pulling at
tube. She was given propofol to facilitate sedation.
Past Medical History:
- H/o aortic stenosis
- COPD (not on home O2)
- S/p resection of cardiac atrial myxoma [**2177**]
- H/o aortic valvular thrombus - chronically anticoagulated
- Autoimmune hepatitis
- Hypertension
- Hyperlipidemia
- Peri-rectal abscess [**11-2**]
- Anxiety
- Osteoporosis
- "Inflammation of stomach" w/neg EGD.
Social History:
Has smoked 1ppd x 30y. Denies EtOH or IVDU.
Family History:
NC
Physical Exam:
Vitals: 96.6 67 145/69 14 100% AC 50% 500x12 PEEP 10
General: Intubated, sedated.
HEENT: PERRL
Neck: Supple, no LAD, JVP 12-14cm laying flat.
Lungs: Bronchial breath sounds bilaterally, no wheezes, rales,
ronchi.
CV: Regular rate, normal S1 + S2, 3/6 SEM @ RSB, no rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. No TTP RUQ,
negative [**Doctor Last Name **] sign.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2182-5-9**] 06:57PM BLOOD WBC-22.4*# RBC-3.59* Hgb-10.9* Hct-33.4*
MCV-93# MCH-30.5 MCHC-32.8 RDW-15.6* Plt Ct-95*#
[**2182-5-9**] 06:57PM BLOOD Neuts-96.9* Lymphs-1.5* Monos-1.3*
Eos-0.1 Baso-0.1
[**2182-5-9**] 06:57PM BLOOD PT-19.5* PTT-48.7* INR(PT)-1.8*
[**2182-5-9**] 06:57PM BLOOD Glucose-241* UreaN-67* Creat-1.5* Na-143
K-3.7 Cl-101 HCO3-32 AnGap-14
[**2182-5-9**] 06:57PM BLOOD Albumin-2.7* Calcium-8.1* Phos-4.8*
Mg-2.5
[**2182-5-9**] 06:57PM BLOOD ALT-65* AST-67* LD(LDH)-404* CK(CPK)-39
AlkPhos-230* TotBili-1.7*
[**2182-5-9**] 07:21PM BLOOD Lactate-2.0
[**2182-5-9**] 07:21PM BLOOD Type-ART pO2-111* pCO2-61* pH-7.37
calTCO2-37* Base XS-8
.
6/11-13/09 Bcx: No growth.
[**Date range (1) 65421**] Bcx: NGTD.
.
[**2182-5-9**] ECG: Sinus rhythm with frequent atrial premature beats
and occasional atrial bigeminy. Left anterior fascicular block.
Possible prior anteroseptal myocardial infarction. Compared to
the previous tracing of [**2178-10-28**] there is frequent atrial
ectopy. The other findings are generally similar.
.
[**2182-5-9**] CXR:
1. ET tube in standard position.
2. Findings consistent with pulmonary edema and emphysema and
persistent
right pleural effusion.
[**2182-5-10**] Abd U/S:
1. Gallbladder sludge with wall thickening, which may be
secondary to the patient's low albumin. No cholelithiasis. No
specific sign of cholecystitis.
2. Urothelial thickening involving the renal pelves bilaterally,
right
greater than left, and given the bilateral findings, this may
represent
chronic urinary tract infections, particularly fungal. Clinical
correlation is recommended. Also increased echogenicity of the
kidneys bilaterally, likely reflecting chronic medical renal
disease.
3. Subtle diffuse hepatic nodularity, suggesting the possibility
of chronic liver disease.
4. Bilateral pleural effusions and minimal ascites.
.
[**2182-5-10**] TTE:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF 70%). The right ventricular cavity is dilated with
focal hypokinesis of the apical free wall. The aortic valve
leaflets are severely thickened/deformed. The mitral valve
leaflets are moderately thickened. There is a large globular
mass on the posterior mitral valve leaflet. There is severe
mitral annular calcification. There is moderate thickening of
the mitral valve chordae. There is mild functional mitral
stenosis due to mitral annular calcification. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the findings of the prior study (images reviewed) of [**2178-10-20**], the left atrial myxoma is no longer present. There is now
a mass on the posterior mitral leaflet consistent with
endocarditis.
.
[**2182-5-10**] CT CHEST:
Gravity-dependent consolidative opacities bilaterally with high
attenuation material in the left base suggestive of hemorrhage.
This is consistent with combination of atelectasis, hemorrhage,
and infection.
.
[**2182-5-17**] CT HEAD W/O CONTRAST:
.
[**2182-5-17**] CT NECK W/O CONTRAST:
.
[**2182-5-17**] MRI BRAIN:
There are multiple small areas of acute infarct seen in both
supra- and infratentorial regions. In both cerebral hemispheres,
multiple small areas of infarcts are seen in the frontal,
parietal and occipital lobes as well as in the periventricular
region and both thalami. In the posterior fossa in both
cerebellar hemispheres, left middle cerebellar peduncle and
right side of the pons demonstrate foci of acute infarct seen.
There is a small area of blood product seen in the left parietal
subcortical region as seen on the previous CT. There is no
midline shift or hydrocephalus. Mild brain atrophy is seen.
Suprasellar and craniocervical regions are normal on the
sagittal images. Fluid is seen in both mastoid air cells which
could be related to intubation. IMPRESSION: Multiple bilateral
acute infarcts in the supra- and infratentorial region. Given
the widespread distribution, likely are embolic.
.
[**2182-5-17**] MRA OF THE HEAD: Head MRA demonstrates bilateral fetal
posterior cerebral artery with consequent small vertebrobasilar
system. No vascular occlusion or stenosis seen. IMPRESSION: No
significant abnormalities on MRA of the head.
Brief Hospital Course:
75F with h/o aortic stenosis, COPD, admitted to OSH with
pneumonia, complicated by hypoxic respiratory failure requiring
intubation, ARF, transferred for difficulty weaning and question
of valvuloplasty
.
# Hypoxia: Likely multifactorial, with contributions from
apparent RLL PNA, pulmonary edema 2/2 systolic CHF requiring
intermittent diuresis, RLL pleural effusion s/p 800cc
thoracentesis (transudative), and an episode of pulmonary
hemorhhage felt [**12-31**] anticoagulation. She continued a course for
HAP with vanc/zosyn. She was intermittently diuresed for volume
overload and kept net even daily thereafter. CT Chest showed
hemorrhage, atelectasis and evidence of severe COPD. For the
COPD, she was continued on prednisone taper and bronchodilators.
Sputum cultures grew only yeast which was thought to be
contaminant. Bronchoscopy was performed and showed blood near
lingula -> likely from suction trauma in setting of high INR. No
interventions other than cold saline injections were done. Hct
was followed and remained stable. Weaning of vent attempted
without success. She eventually underwent tracheostomy on
[**2182-5-14**].
.
# Mitral valve endocarditis: Shown on TTE here. Cultures from
OSH grew Strep salivarius sensitive to PCN, and abx switched
from Vanc to PCN on [**2182-5-11**]. ID consulted and recommended
continuing PCN x 6 weeks with evaluation of oral cavity for
abscess. Panorex not done as pt unable to stand for study. All
blood cx here neg to date.
.
# Aortic stenosis: Report of critical AS on TTE at OSH. Unclear
what her baseline functional status is, as per her husband, she
does not have regular angina, or syncope. She had been "sleeping
all the time" the past few weeks, so unclear if she has been
having symptoms of CHF. Per OSH discharge summary, she was
transferred here for discussion of valve surgery/valvuloplasty.
TTE here showed critical AS with valve area of 0.5 and peak
gradient of 151. Thought this may be contributing to difficulty
in weaning off vent. Cardiology was consulted and recommended
diuresis. Pt was started on low rate lasix gtt. Cardiology
evaluationed for valvuloplasty and felt that she was extremely
high risk and recommended not to proceed with valvuloplasty.
# ARF: No known renal dysfunction. Found to have mild left
hydronephrosis at OSH, and seen by urology with plan to follow
clinically. ddx currently includes pre-renal [**12-31**] diuresis vs
aortic stenosis, AIN [**12-31**] antibiotics, vs obstruction. Renal u/s
showed potential chronic UTI, especially fungal. Urine cx grew
yeast despite foley changes; ID recommended no further treatment
as the fungal infection would only return in 14 days after
treatment.
# Anemia: Hct slowly trended down over several days in the
hospital. Hemolysis labs negative. Likely from oozing from trach
site. heparin gtt discontinued. Transfused two units pRBCs with
appropriate bump in hct.
# Transaminitis: H/o autoimmune hepatitis, baseline unclear.
LFTs normal on admission to OSH, and on discharge ALT 49, AST
AST 51, amylase 238. Abdominal U/S and CT abd/pelvis at OSH
without evidence of RUQ process, although though elevated INR
and low albumin suggest cirrhosis. RUQ U/S here consistent with
chronic liver disease and LFTs remained stable throughout stay.
# RUE weakness: Patient was noted to stop moving RUE on [**2182-5-17**]
in the AM. Unclear when this started but could move all
extremities the day before. Head CT showed likely emboli, and
MRI showed multiple foci of emboli. Neurology was consulted and
said may need to reassess the need for CT surgery. CT surgery
was consulted who felt that she was not a surgical candidate for
multiple reasons including HIT positivity, recent embolic
events, renal failure, operative mortality for two valves, and
significant aortic valvular calcifications.
# Thrombocytopenia: HIT positive here, serotonin release assay
returned marginally positive. All heparin products were held.
Thrombocytopenia improved somewhat, although platelets slowly
trending down again prior to discharge.
# H/o aortic valvular thrombus: Chronically anticoagulated,
although held in the setting of significant pulmonary
hemhorrage. Anticoagulation was discontinued here after TTE
showed no atrial thrombus.
# C. Difficile Colitis - Prior to discharge, she was found to be
C. difficile positive and started on po vancomycin since she was
not actively having diarrhea. It is recommend she continue on po
vancomcyin until her course of pencillin is completed.
# Sacral decub: Admitted with stage 2 sacral decub. Was placed
on air mattress. Wound care was consulted and recommended
dressing changes.
.
# OA: Receiving morphine 2mg po prn pain. Per husband, she takes
percocet at home for pain, but he is unsure for what. A
rheumatology note indicates she takes percocet for chronic
intermittent chest wall pain. Continued morphine 0.5mg iv q6hr
prn pain.
.
# Anxiety: per husband, takes anti-anxiety medications at home,
and receiving lorazepam 0.5-2mg q1hr prn agitation at OSH.
Continued prn ativan, and monitored for s/sx of withdrawl.
.
# Elevated FSBS: no known history of DM, but on steroids, with
elevated FSBS. covered with HISS.
.
# H/o SVT: Cardizem in setting of severe AS.
.
# Goals of Care: Family was presented with the poor prognosis of
mitral valve endocarditis in the setting of critical aortic
stenosis. Since the patient is not a surgical candidate, even if
medical management of the mitral valve endocarditis is
successful, her prognosis given the critical aortic stenosis is
poor. We discussed with family plan to complete 6 weeks of IV
antibiotics and attempt ventilator titration but possibility of
a transition to a more palliative care approach. They will
continue to discuss this decision as her clinical course plays
out in rehab and would benefit from a palliative care consult in
the future.
# FEN: PEG was placed on [**2182-5-14**] and TFs were initiated.
.
# Prophylaxis: Pneumoboots.
.
# Access: PICC placed [**2182-5-13**]
.
# Code: FULL CODE
.
# Communication: Son [**Name (NI) **] [**Name (NI) 32475**] is health care proxy
[**Telephone/Fax (1) 65422**]
Medications on Admission:
Medications at home:
- vitamin d 400 units daily
- folic acid 1 mg po qdaily
- cardizm 240mg po qdaily
- lisinporil 20mg po qdaily
- zantac 150mg po qdaily
- lasix 20 mg po qdaily
- coumadin
- lorazepam 0.5mg po tid
- percocet prn pain
- advair 250/50 1 INH [**Hospital1 **]
- prozac 10mg po qdaily
.
Meds on transfer:
- pneumoboots
- heparin 500 U sc tid
- prednisone 60mg po qdaily
- xopenex inhaler q4hrs
- morphine 2mg po prn pain
- 300cc free water boluses
- lorazepam 0.5-2mg q1hr prn agitation
- cardizem 60mg po q6h (for h/o SVT)
- nitroglycerin paste 1inch q6h prn SBP > 140
- HISS
- mvi
- protonix 40mg iv qdaily
- vancomycin 1gm iv qdaily
- zosyn (unknown start date)
- diamox
- theophylline
- coumadin
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for wheezing.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2)
Puff Inhalation QID (4 times a day).
5. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: as directed
units Injection ASDIR (AS DIRECTED): Q6H .
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
2-6 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Fentanyl 50 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): continue to titrate down as
tolerated.
9. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day
for 3 days: transition to 5mg po every other day for 6 days then
off.
11. Diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every
twenty-four(24) hours: transition off as tolerated.
12. Vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours): continue until penicillin course completed.
13. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
[**Last Name (STitle) **]: One (1) pack Intravenous every four (4) hours: please
continue until [**2182-6-11**].
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC non heparin dependant. Flush with 10 ml normal saline
daily and prn per lumen
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
- Critical aortic stenosis
- Strep Salivarius endocarditis on posterior mitral valve
- Right lower lobe pneumonia
- Bacteremia
- Acute on chronic systolic congestive heart failure
- Pulmonary hemorrhage
- Acute renal failure
- Thrombocytopenia
- HIT-antibody positive
- clostridium deficile colitis
Secondary
- COPD (not on home O2)
- S/p resection of cardiac atrial myxoma
- H/o aortic valvular thrombus on chronic anticoagulation
- Autoimmune hepatitis
- Hypertension
- Hyperlipidemia
- Peri-rectal abscess [**11-2**]
- Anxiety
- Osteoporosis
- "Inflammation of stomach" w/neg EGD.
Discharge Condition:
Hemodynamically stable. On ventilator.
Discharge Instructions:
You were transferred from another hospital for further
management of your acute respiratory failure. You were able to
come off the breathing machine for short periods of time but
still sometimes need it at night. You had a tracheostomy placed
so you could have the tube in your throat pulled. You had a
pneumonia that was treated for 14 days with antibiotics. You had
some trouble with your kidneys. It has been stable for many days
but they are still not functioning completely normally. You had
bacteria in your blood. This was from a bacterial collection on
one of your heart valves. You were started on penicillin to
treat this bacteria and should continue the penicillin for 6
weeks. You were also diagnosed with c. difficile colitis and
started on oral vancomycin.
.
Please take all medications as prescribed.
Please call your doctor of 911 if you develop chest pain,
difficulty breathing, fever >101, worsening confusion,
dizziness, bleeding, or any other concerning symptoms.
Followup Instructions:
Please schedule follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22552**],
within 1 week of your discharge from rehab. His office number is
[**Telephone/Fax (1) 4475**].
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"33.22",
"45.13",
"43.11",
"31.1",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
17514, 17586
|
8633, 14771
|
295, 452
|
18223, 18264
|
4001, 4001
|
19298, 19542
|
3448, 3452
|
15535, 17491
|
17607, 18202
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14797, 14797
|
18288, 19275
|
14818, 15098
|
3467, 3982
|
235, 257
|
480, 3038
|
8398, 8610
|
4015, 8381
|
3060, 3371
|
3387, 3432
|
15116, 15512
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,851
| 144,544
|
30305
|
Discharge summary
|
report
|
Admission Date: [**2193-4-1**] Discharge Date: [**2193-5-2**]
Date of Birth: [**2130-5-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Mycotic Anuerysm
Major Surgical or Invasive Procedure:
[**4-10**] OR: EVAR across contained rupture with persistent ?Type IV
leak
[**4-14**] OR: resection of ruptured mycotic aortic aneurysm, repair
of aneurysm with tube graft, L2-L3 vertebrectomy and arthrodesis
History of Present Illness:
62yo M, h/o HTN/Hyperlipidemia, presented with back/abd pain at
[**2196-7-28**], no radiation of the pain; constipation and no bm for 8
days. Also poor appetite, no N/V; wt loss 20lbs/last month.
Denied fever/chills. No weakness/numberness of LE; denied
bladder retention or incontinence. No recent infection other
than UTI Rxed with Bactrim/cipro. Txfed from OSH with CT showing
AAA and lumbar discitis. His ABD/pelvis CTA today confirmed AAA
mycotic measuring 3.5x4.7x7.2cm, L2-3 discitis/osteomyelitis
posterior to AAA, and possible epidural abscess.
Past Medical History:
PMH: htn, etoh abuse (recently stopped drinking 1 month ago),
hyperlipidemia
PSH: bilateral inguinal hernias
Social History:
pos smoker
pos drinker
Family History:
n/c
Physical Exam:
PHYSICAL EXAM:
O: T: 98.9 BP: 157/95 HR: 88 R 19 O2Sats 97%
Gen: mildly distressed by abd discomfort.
HEENT: Pupils: PERRLA EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, tenderness lower abd, no rebound tenderness, BS+, no
mass.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
No tenderness to palpation or percussion of thoracic/lumbar
spine.
Motor:
D B T grip IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, including perianal area
bilaterally.
Reflexes: brisk knee jerk bilat, unremarkable with
Bicep/tricep/ankle jerks bilat. No clonus.
Toes downgoing bilaterally
Rectal exam normal sphincter control.
Pertinent Results:
[**2193-4-30**] 04:19AM BLOOD
WBC-7.2 RBC-3.01* Hgb-9.3* Hct-27.1* MCV-90 MCH-30.9 MCHC-34.3
RDW-16.0* Plt Ct-300
[**2193-4-17**] 02:22AM BLOOD
PT-16.4* PTT-31.8 INR(PT)-1.5*
[**2193-4-26**] 04:56AM BLOOD
Plt Ct-400
[**2193-5-2**] 04:45AM BLOOD
Glucose-143* UreaN-48* Creat-2.1* Na-143 K-4.5 Cl-108 HCO3-26
AnGap-14
[**2193-4-26**] 06:08PM BLOOD Vanco-19.2
RADIOLOGY Final Report
HISTORY: 62-year-old male status post mycotic AAA repair,
anterior L2-L3 fusion/debridement with review of intraoperative
reports noting large amount of retroperitoneal bleed and chyle
leak. Assess fluid collections.
CT OF THE ABDOMEN WITHOUT INTRAVENOUS OR ORAL CONTRAST: Limited
examination of the lung bases displays moderate sized simple
pleural effusions (left greater than right) with compression
atelectasis within the bases bilaterally as well as scattered
areas of subsegmental atelectasis within the right lower lobe.
No significant pericardial effusion is identified.
Evaluation of the abdomen demonstrates two separate fluid
collections within the retroperitoneum. One which appears to be
simple fluid is noted to extend within the retroperitoneum in
the periaortic bed approximately 16 cm sagitally displacing the
pancreatic neck and head anteriorly down to the region of the
aortic bifurcation. The second larges retroperitoneal collection
contains hyperdense pockets likely consistent with blood, and is
noted to extend through the anterior and posterior leaves of
Gerota's fascia measuring 21.5 cm sagitally, displacing the left
kidney anteriorly and extending into the left psoas and iliacus
muscle. A mild amount of simple intraabdominal fluid is noted
surrounding the liver, spleen, and extending into the paracolic
gutters down into the pelvis. The patient has underwent
subsequent placement of a Dacron graft with limited examination
on this non- contrast study of the aortic lumen appearing
unremarkable. The liver, gallbladder, spleen, adrenal glands,
and kidneys appear otherwise normal. No free air is noted within
the abdominal cavity as no pathologically enlarged lymph nodes
identified. A small anterior wall fascial defect is noted along
the midline surgical incision site.
CT OF THE PELVIS WITH AND WITHOUT INTRAVENOUS OR ORAL CONTRAST.
Simple free fluid is noted within the pelvic cavity with the
intrapelvic bowel, and prostate appearing unremarkable. Air is
noted within the urinary bladder, likely related to recent
instrumentation. No pathologically enlarged pelvic lymph nodes
are identified. There is a mildly prominent anterior abdominal
wall and inguinal lymphadenopathy, likely reactive. Punctate
calcifications are noted along the penile shaft, which may be
vascular in origin or represent underlying Peyronie's disease.
BONE WINDOWS: No suspicious blastic or lytic lesions are
identified. The patient has undergone interval partial
vertebrectomy and discectomy with placement of an anterior L2-L3
arthrodesis device. Degenerative changes of the spine are
grossly unchanged.
IMPRESSION:
1. Large left-sided retroperitoneal hematoma within Gerota's
fascia, likely represents known postoperative hemorrhage as
mentioned in operative reports, with acute hemmorhage less
likley given stable Hct levels.
2. Simple appearing fluid collection mostly surrounding the
periaortic bed as described above may represent collection from
lymphatic injury as mentioned in history.
3. Moderate amount of simple appearing intraabdominal fluid and
bilateral pleural effusions with atelectasis.
4. No focal aortic aneurysmal dilatation noted on this limited
non-contrast examination.
5. Air within the urinary bladder, likely related to recent
instrumentation.
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2193-4-25**] 9:06 AM
HISTORY: Abdominal Aorta aneurysm status post endovascular
repair. New right subclavian central venous catheter.
FINDINGS: An AP portable supine chest radiograph shows a new
central venous catheter extending from the right subclavian
region across the mediastinum and ending in the region of the
left brachiocephalic vein. No pneumothorax is seen. Obscuration
of the left hemidiaphragm with consolidation at the left base
and some hazier consolidation in the right middle lobe are
unchanged findings. Right deviation of the lower trachea is also
unchanged from other postoperative exams. PICC line tubing is
seen extending from the right and ending at the expected
location of both superior vena cava.
CONCLUSION: Right-sided subclavian central venous catheter tip
crossing mediastinal veins to end at location of left
brachiocephalic vein or subclavian vein. Findings called to
clinical center 6 at time of dictation, but patient not listed
residing there.
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2193-4-2**] 7:11 PM
Reason: MRI with STIR to evaluate for osteomyelitis, disc
inflammmat
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with
HISTORY: 62-year-old male with mycotic abdominal aortic aneurysm
and spondylodiscitis.
There is increased T2 signal and enhancement of the L2/3 disc
with moderate loss of the disc space height. The adjacent end
plates are eroded. These findings are consistent with
spondylodiscitis. There is an epidural abscess starting at the
L2/3 level and extending inferiorly to the level of the midbody
of L3 which measures approximately 0.6 cm in AP, 1.4 cm in
transverse and 1 cm in the craniocaudal dimensions. This
epidural abscess is narrowing the spinal canal by approximately
40-50%. There is also enhancing soft tissue in the perivertebral
region at the L2/3 level which extends anterior to the spine and
abuts the posterior wall of the abdominal aorta. Abdominal
aortic aneurysm is seen with thickened walls but this is only
partially imaged due to the spatial saturation pulse. For full
description of the aortic findings, please refer to the CT of
the abdomen from [**2193-4-1**]. Along the left aspect of the abdominal
aorta, there is a tubular hypointense structure which does not
show enhancement. This may represent a dilated vein.
There is increased T2 signal and enhancement of the psoas
muscles bilaterally consistent with myositis.
There is moderate left foraminal stenosis at the L2/3 level.
At L4/5, there is moderate disc bulge as well as a right central
to foraminal disc protrusion. There are also degenerative
changes of the ligamentum flavum and facet joints bilaterally.
These findings are causing moderate canal stenosis including
stenosis of the subarticular zones bilaterally. There are mild
bilateral foraminal stenoses.
At L5/S1, there is increased T1 and T2 signal of the adjacent
endplates consistent with degenerative type 2 [**Last Name (un) 13425**] change.
There is also a mild disc bulge without canal stenosis. There is
mild left foraminal stenosis.
IMPRESSION:
1. Spondylodiscitis at the L2/3 level with a medium sized
epidural abscess causing approximately 40-50% narrowing of the
spinal canal at this level. There is also a perivertebral
phlegmon, which extends anteriorly to abut the posterior wall of
the abdominal aortic aneurysm. There is also bilateral psoas
muscle myositis.
2. For full description of the abdominal aortic aneurysm, please
refer to the CTA of the abdomen from [**2193-4-1**].
3. Multilevel degenerative changes as described above with
moderate canal stenosis at the L4/5 level.
Cardiology Report ECHO Study Date of [**2193-4-3**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: *3.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.8 cm (nl <= 3.4 cm)
Aorta - Arch: *3.1 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 1.11
Mitral Valve - E Wave Deceleration Time: 159 msec
TR Gradient (+ RA = PASP): *30 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality as the patient was
difficult to position.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2193-4-23**] 3:45 pm PERITONEAL FLUID
GRAM STAIN (Final [**2193-4-23**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2193-4-26**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2193-4-29**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2193-4-24**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2193-4-14**] 12:10 pm SWAB ABDOMINAL ABSCESS.
GRAM STAIN (Final [**2193-4-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2193-4-19**]):
ESCHERICHIA COLI. RARE GROWTH.
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final [**2193-4-20**]):
PRESUMPTIVE PROPIONIBACTERIUM ACNES. RARE GROWTH.
[**2193-4-3**] 2:30 pm FLUID,OTHER Site: LUMBAR PUNCTURE L2-3
DISC.
GRAM STAIN (Final [**2193-4-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2193-4-9**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) 4599**] [**Last Name (NamePattern1) 72145**] [**2193-4-5**] AT 1:25PM.
ESCHERICHIA COLI. RARE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on request.
BACILLUS SPECIES. RARE GROWTH. UNABLE TO IDENTIFY FURTHER.
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
FUNGAL CULTURE (Final [**2193-4-26**]): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2193-4-4**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
CTA PELVIS W&W/O C & RECONS [**2193-4-1**] 8:55 AM
COMPARISON: None.
AORTIC CT ANGIOGRAM: Located just below the single renal
arteries bilaterally at the level of L2/3, there is a complex
multilobulated irregular aneurysm with thick walls. The aneurysm
measures up to 3.5 x 4.7 cm in greatest axial dimension, with
aortic wall thickening extending approximately 7.2 cm from
beneath the renal arteries. Contrast material fills multiple
lobulated extra- luminal collections. There is no frank active
extravasation. Multiple enlarged venous varicosities are seen to
the left of the aneurysm. Smaller varicosities are seen to the
right. There is also an enlarged adjacent retroperitoneal lymph
node measuring 11 mm in short axis at the level of L2. The soft
tissue thickening about the ascending aorta extends to the
aortic bifurcation. Both iliacs are patent and normal in
caliber. There is moderate tortuosity and mild atherosclerotic
disease. Both renal arteries remain patent. Celiac axis anatomy
is conventional. The origins of the SMA and [**Female First Name (un) 899**] are patent. The
distance between the aortic wall thickening to the right renal
artery is approximately 1 cm. There is approximately 8 mm to the
origin of the left renal artery.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is
dependent atelectasis in both lower lobes. There is no pleural
or pericardial effusion. There is a small hiatal hernia.
Assessment of the liver is limited with only single phase
imaging. Allowing for limitations, no overt hepatic mass is
identified. This spleen, pancreas, adrenal glands, kidneys, and
small bowel loops are unremarkable. The gallbladder contains
dense material likely vicariously excreted contrast from prior
imaging studies.
There is extended retroperitoneal stranding about the irregular,
thick walled aneurysm with adjacent lymphadenopathy and venous
varicosities. Destructive endplate changes are seen at the L2/3
of both the superior and inferior endplates. There is associated
enhancing epidural soft tissues. There is low-density
rim-enhancing collection extending into the right psoas muscle
which is too small for percutaneous drainage with a maximal
lesion size of 13 x 11 mm. There is no ascites.
CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: The distal
ureters are unremarkable. The bladder wall appears very thick
but is collapsed about a Foley balloon. There is a trace amount
of free fluid in the pelvis. Sigmoid colon contains scattered
diverticuli, but no evidence of acute diverticulitis. There are
no enlarged inguinal or pelvic lymph nodes. The prostate does
not appear overly enlarged. Incidental note is made of vascular
calcifications in the corpora cavernosa.
BONE WINDOWS: Destructive endplate changes are seen at the L2/3
level. There is enhancing epidural soft tissue posterior to the
L3 vertebral body as well as anterior retroperitoneal soft
tissue thickening extending about the aorta. No destructive
changes are seen at other imaged endplate levels.
CT RECONSTRUCTIONS: Coronal and sagittal reformatted images were
essential in evaluating the aneurysm and spine.
CTA MEASUREMENTS:
Maximal axial aneurysm dimensions: 2.9 x 4.4 cm
Aneurysm volume: 83 cc
Distance from R renal artery: 10 mm
Distance from L renal artery: 8.4 mm
Distance from inferior renal artery to L iliac bifurcation: 16.3
cm
Distance from inferior renal artery to R iliac bifurcation: 15.7
cm
IMPRESSION:
1. Complex multilobulated thick-walled aneurysm measuring 3.5 x
4.7 x 7.2 cm, consistent with known history of mycotic aneurysm.
2. L2/3 discitis/osteomyelitis immediately posterior to
aneurysm, which is likely the cause of the mycotic aneurysm.
There is associated epidural soft tissue enhancement concerning
for epidural phlegmon/abscess both anterior to the vertebral
bodies well as indenting the thecal sac. MRI of the L-spine is
recommended to further assess the neurological structures.
3. Right psoas abscess extending from area of
discitis/osteomyelitis.
4. No frank active extravasation from complex multilobulated
aneurysm.
5. Thick bladder wall. This could be due to chronic outlet
obstruction, although the prostate is not overly enlarged.
Continued followup is recommended.
Brief Hospital Course:
62yo M, h/o HTN/Hyperlipidemia, presented with back/abd pain at
[**2196-7-28**], no radiation of the pain; constipation and no bm for 8
days. Also poor appetite, no N/V; wt loss 20lbs/last month.
Denied fever/chills. No weakness/numberness of LE; denied
bladder
retention or incontinence. No recent infection other than UTI
Rxed with Bactrim/cipro. Txfed from OSH with CT showing AAA and
lumbar discitis. His ABD/pelvis CTA today confirmed AAA mycotic
measuring 3.5x4.7x7.2cm, L2-3 discitis/osteomyelitis posterior
to AAA, and possible epidural abscess.
Broad spectrum Antibiotics started.
Nuerosurgery consult obtained / ID consult obtained - they
followed the patient throughtout the hospital course.
Nuerosurgery - Vertebrectomy, L2 and L3., 2. Fibular allograft
structural-free anterior arthrodesis, L2-L3, with structural
allograft. No sequele from surgery. When pt is OOB or sits up,
he must wear TLSO brace
ID - followed cx's, E-coli from both lumbar abcess and fluid
from aortic anuerysm. Pt to have vancomycis and zosyn IV. [**Month (only) 116**]
require [**Male First Name (un) **] term suppression antibiotics when IV antibiotics are
completed.
[**4-10**] - Endovascular repair of mycotic aneurysm with modular
stent graft. / Tolerated the procedure well. No complications
noted. Post operative on day 3 pt c/o acute abdominal pain. CTA
obtained showed expanding anuerysm.
Pt immediatly taken for the below procdure / also at this time
NS decided to take pt to OR for below the procedure.
[**4-14**] - Conversion from endovascular to open repair of ruptured
abdominal aortic aneurysm, debridement of infected aorta.
[**4-14**] - 1. Vertebrectomy, L2 and L3., 2. Fibular allograft
structural-free anterior arthrodesis, L2-L3, with structural
allograft
Pt tolerated both procedures well, no complications note. Pt
transfered to the floor instable condition. Pt had Hemovac from
surgical case. This was pulled post operative day 6. Pt
continued to have drainage from the site. This sent to the lab /
diagnosed as chyle leak. Pt made NPO at this time. TPN started.
On DC chyle has slowed down. Pt to be continued on TPN untill
follow-up with Dr [**Last Name (STitle) **].
Pt also had ARF with a high creat of 2.4 / On Dc pt creat is
stable with creat of 2.1. Nephrotoxins were DC. ( ace inhibitor
). Pt had urine lytes / correspomnding with pre-renal. Pt still
on Vancomycin. this must be monitered carefully in the setting
of renal failure.
Pt required blood transfusions after his second surgery. Pt HCT
is stable on DC. Please see pertinant results
Medications on Admission:
[**Last Name (un) 1724**]: lipitor 20', lisinopril 20', MVI, asa 81'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-26**]
hours as needed. Tablet(s)
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q48H (every 48 hours).
7. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours).
8. picc line
Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. electrolytes
follow electrolytes / chem 10 while on tpn three times a weekk
11. TPN
Volume(ml/d) - 1800, Amino Acid(g/d) - 105, Branched-chain
AA(g/d) - 0, Dextrose(g/d) - 350, Fat(g/d) - 36
Trace Elements will be added daily
Standard Adult Multivitamins:
NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc
0 40 10 30 50 0 6 12
Insulin(units)
8
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16844**] Hospital - [**Location (un) 1157**]
Discharge Diagnosis:
mycotic AAA due to L2-3 discitis/osteomyelitis
[**Country 25091**] leak post operative
blood transfusion post operative anemia
Discharge Condition:
Stable. NPO. BP 130/60, HR 71, afebrile
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? 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 [**2-23**]
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 [**4-26**] weeks for
post procedure check and CTA
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 or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Call Dr.[**Name (NI) 5695**] office to schedule appointment to be seen
in 2 weeks. [**Last Name (NamePattern1) 72146**] 5B [**Location (un) 86**], [**Numeric Identifier 718**]
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2193-5-27**] 9:00
Completed by:[**2193-5-2**]
|
[
"441.3",
"457.8",
"996.62",
"511.9",
"041.4",
"722.93",
"272.4",
"567.31",
"324.1",
"401.9",
"584.5",
"998.11",
"730.08",
"731.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.99",
"39.49",
"81.62",
"99.15",
"99.07",
"81.06",
"80.39",
"39.71",
"38.93",
"38.44",
"77.77",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
22657, 22740
|
18651, 21227
|
329, 540
|
22911, 22953
|
2273, 7157
|
25560, 25941
|
1312, 1317
|
21346, 22634
|
7194, 12137
|
22761, 22890
|
21253, 21323
|
22977, 24980
|
25006, 25537
|
1347, 1651
|
14277, 18628
|
12170, 14241
|
273, 291
|
568, 1123
|
1666, 2254
|
1145, 1256
|
1272, 1296
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,220
| 117,549
|
43221
|
Discharge summary
|
report
|
Admission Date: [**2151-12-28**] Discharge Date: [**2152-1-3**]
Date of Birth: [**2069-3-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
coronary artery bypass x 2, mitral valve repair, repair of right
femoral artery [**2151-12-28**]
History of Present Illness:
The patient is an 82 year old male who developed chest pain
while snow-blowing and called 911. He presented to the [**Hospital1 18**],
[**Location (un) 620**] and was transferred to [**Location (un) 86**] for catheterization. He
ruled in for non-ST elevation myocardial infarction.
Past Medical History:
coronary artery disease
hypertension
benign prostatic hyperplasia
hyperlipidemia
polyps of vocal cords
Social History:
semi-retired
lives with wife
denies tobacco
drinks red wine daily
denies recreational drugs
Family History:
no history of premature coronary disease
Physical Exam:
Admission:
VS: 116/56, 80, 23
Gen: NAD
HEENT: unremarkable
Neck: supple, full ROM
Chest: lungs CTAB
Heart: RRR
Abd: +BS, soft, non-tender, non-distended
Ext: warm, well-perfused, no edema
Neuro: grossly intact
Pertinent Results:
[**2152-1-3**] 06:40AM BLOOD WBC-8.0 RBC-3.17* Hgb-9.6* Hct-27.6*
MCV-87 MCH-30.2 MCHC-34.7 RDW-14.0 Plt Ct-390#
[**2152-1-3**] 06:40AM BLOOD Glucose-125* UreaN-39* Creat-1.1 Na-142
K-4.4 Cl-105 HCO3-30 AnGap-11
[**2152-1-2**] 06:45AM BLOOD Mg-2.9*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 93124**] (Complete)
Done [**2151-12-28**] at 6:09:50 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2069-3-11**]
Age (years): 82 M Hgt (in): 68
BP (mm Hg): / Wgt (lb): 180
HR (bpm): BSA (m2): 1.96 m2
Indication: Chest pain. Coronary artery disease. Left
ventricular function. Right ventricular function. Valvular heart
disease.
ICD-9 Codes: 410.91, 440.0, 413.9, 414.8, 424.1, 424.0
Test Information
Date/Time: [**2151-12-28**] at 18:09 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW0-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.3 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.1 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 58 ms
Mitral Valve - MVA (P [**12-10**] T): 3.8 cm2
Mitral Valve - [**Last Name (un) **]: 0.38 cm2
Mitral Valve - Regurgitation Volume: 55 ml
Pulmonic Valve - Peak Velocity: 0.7 m/sec <= 1.5 m/sec
Pericardium - Effusion Size: 1.0 cm
Findings
LEFT ATRIUM: Mild LA enlargement.
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. Top
normal/borderline dilated LV cavity size. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Mildly dilated aortic sinus. Normal ascending aorta
diameter. Normal aortic arch diameter. Mildly dilated descending
aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild to
moderate ([**12-10**]+) AR.
MITRAL VALVE: Partial mitral leaflet flail. Eccentric MR jet.
Moderate to severe (3+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Small to moderate 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-BYPASS: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. 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 diameters of ascending aorta and arrch levels
are normal. The aortic root is mildly dilated at the sinus
level. The descending thoracic aorta is mildly dilated. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild to moderate ([**12-10**]+) aortic
regurgitation is seen. There appears to be flail of the P3
leaflet of the mitral valve. An eccentric jet of moderate to
severe (3+) mitral regurgitation is seen. There is a small to
moderate sized pericardial effusion.
POST BYPASS: The patient is AV paced and on an infusion of
phenylephrine. Left and right ventricular function is preserved.
The aorta is intact. A mitral valve repair has been performed
and an annuloplasty band placed. There is now no MR. Mild to
moderate AR persists. The remainder of the examination is
unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2151-12-29**] 09:51
?????? [**2145**] CareGroup IS. All rights reserved.
Brief Hospital Course:
The patient was brought to the operating room emergently due to
bleeding in the right groin at the site of the intraortic
balloon pump. He underwent CABG x 2, mitral valve repair with
28mm [**Doctor Last Name **] [**Last Name (un) 3843**] Band and repair of the right femoral
artery (by Dr. [**Last Name (STitle) 1391**]. Please see operative report for
further details. Overall the patient tolerated the procedure
well and was transferred to the CVICU post operatively for
further monitoring. On POD 1 the patient remained intubated and
hemodynamics were supported with phenylephrine, norepinephrine
and epinephrine. Within 24 hours of surgery, the patient was
extubated and the balloon pump was discontinued. Vasoactive
drips were weaned off. The patient was transferred to the
telemetry floor on POD 3. Chest tubes and pacing wires were
discontinued without complication. The patient was gently
diuresed toward his preoperative weight. Social work consult
was obtained for family's concern of patient's history of
emotional/verbal abuse towards family members, including wife
who recently had a stroke. Additionally, geriatrics consult was
obtained for further management of this issue. The geriatrics
team will continue to follow the patient when he is discharged
to rehab. The patient made reasonable progress
post-operatively. He was discharged to the [**Hospital 100**] Rehab on POD
6.
Medications on Admission:
sertraline 50mg daily
lisinopril 2.5mg daily
simvastatin 20mg daily
diovan 80mg daily
doxazosin
lipitor 10mg daily
clonazepam
finasteride 5mg daily
glucosamine chondroitin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
12. Ayr Saline Gel Spray, Non-Aerosol Sig: One (1) Nasal
once a day.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
coronary artery disease
PMH:
hypertension
benign prostatic hyperplasia
vocal cord polyps
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 week
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] in [**1-11**] weeks [**Telephone/Fax (1) 14148**]
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2152-1-3**]
|
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"998.11",
"293.0",
"401.9",
"414.01",
"301.9"
] |
icd9cm
|
[
[
[]
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[
"35.32",
"39.31",
"37.23",
"36.15",
"37.61",
"88.56",
"39.61",
"35.12",
"36.11"
] |
icd9pcs
|
[
[
[]
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] |
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|
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|
353, 452
|
10094, 10101
|
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|
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|
8354, 9857
|
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|
8158, 8331
|
10125, 10618
|
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|
282, 315
|
480, 766
|
788, 892
|
908, 1001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,587
| 172,072
|
42400
|
Discharge summary
|
report
|
Admission Date: [**2104-2-4**] Discharge Date: [**2104-2-12**]
Date of Birth: [**2052-7-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname 8182**] was admitted as "[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]," a 51 y/o male with
unknown past medical history who was found wandering in an
aptartment building with 2 empty needles on him, appeared
"altered" by EMS, not conversant.
.
In the ED, initial VS were: 96 110/70 16 100%. They described
him as a 68M found down by police with needles on persons,
unable to provide any history, not responding to questions,
agitated, requiring restraints for safety, did not have any
identifying information on persons, smelled of alcohol. Unclear
how pt was known to be 68, as pt was non-verbal, had no ID, and
appears younger. He received narcan, 2mg ativan IV, 10mg IV
haldol in ED. HE was still combative so got additional 2mg
ativan IV. A nasal trumpet was placed for airway protection. His
PE was notable for clonus in lower extremities bilaterally,
small lac on posterior head with small hematoma, recent track
marks on right arm with hematoma, scar on left shoulder, left
forearm with old skin graft from left thigh, tachycardic. LFTs,
serum tox, urine tox, and a head CT were performed.
.
On arrival to the MICU, pt was acutely hypertensive, with
systolic BP 220. Pt was initially completely unresponsive, with
nasal trumpet in place. Became increasingly agitated, but became
oriented to self, being able to state that his name was [**Known firstname **].
PT was not able to answer other questions in either English or
Spanish.
Past Medical History:
initially unknown, unable to obtain [**1-3**] no identifiers and AMS.
Determined to have
HTN,
EOTH abuse
HCV
Cocaine abuse
Heroin user
Seizure d/o
psychosis nos
Social History:
Homeless (intermittently living [**Street Address(1) 29735**] Inn), unemployed.
Emigrated to the US from [**Country 5976**]. Wife passed away years ago.
Patient admits to recent alcohol abuse and cocaine use. History
of heroin use.
Family History:
unknown
Physical Exam:
Admission Exam:
General: Somnolent, with periods of agitation, fighting
restraints but not coherent or conversant
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
poor dentition, reactive pupils w/ anisocorea L>R, small
well-approximated lac to posterior occiput w/ surrounding
hematoma, no gaping, no active bleed
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, alternating loud coarse upper airway sounds but no apnea
Abdomen: soft, non-tender, non-distended, bowel sounds present\
GU: foley in place, no lesions
Ext: warm, well perfused, 2+ pulses, + clubbing, no edema
Neuro: equal strength to upper and lower extremities, withdraws
all extremities to pain. + unprovoked clonus to lower
extremities
.
Discharge physical exam:
VS: 98.3 142/90 89 20 97RA
Gen: Alert and awake, lying in bed comfortably. Calm, no acute
distress.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Chest: TTP under left breast
Lungs: CTAB.
Abdomen: Soft, non-tender, non-distended, normoactive bowel
sounds
Ext: Warm, well perfused, 2+ pulses, + clubbing, no edema
Neuro: Awake, alert. Oriented to self and hospital in [**Location (un) 86**].
CNs II-XII intact. Sensation to light touch intact. Strength in
upper and lower extremities [**4-5**]. No tremors or clonus. Follows
instructions.
Pertinent Results:
Admission Labs:
[**2104-2-4**] 09:20AM BLOOD WBC-2.8* RBC-3.99* Hgb-13.0* Hct-34.3*
MCV-86 MCH-32.5* MCHC-37.8* RDW-13.5 Plt Ct-220
[**2104-2-4**] 09:20AM BLOOD Neuts-57.8 Lymphs-34.4 Monos-5.3 Eos-0.6
Baso-1.9
[**2104-2-4**] 09:20AM BLOOD PT-11.3 PTT-29.9 INR(PT)-1.0
[**2104-2-4**] 09:20AM BLOOD Glucose-102* UreaN-9 Creat-0.9 Na-146*
K-3.3 Cl-103 HCO3-27 AnGap-19
[**2104-2-4**] 09:20AM BLOOD ALT-51* AST-106* CK(CPK)-154 AlkPhos-142*
TotBili-0.2
[**2104-2-4**] 09:20AM BLOOD Lipase-41
[**2104-2-4**] 08:38PM BLOOD cTropnT-<0.01
[**2104-2-4**] 09:20AM BLOOD cTropnT-<0.01
[**2104-2-4**] 09:20AM BLOOD Albumin-4.2 Calcium-9.0 Phos-2.1* Mg-1.8
[**2104-2-4**] 09:20AM BLOOD Osmolal-320*
[**2104-2-4**] 09:20AM BLOOD ASA-NEG Ethanol-93* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2104-2-4**] 11:47AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2104-2-4**] 11:47AM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
.
Relevant Labs:
[**2104-2-7**] 04:39AM BLOOD ALT-29 AST-48* AlkPhos-114 TotBili-0.5
[**2104-2-11**] 06:38AM BLOOD HIV Ab-NEGATIVE
.
Discharge Labs:
[**2104-2-11**] 06:00AM BLOOD WBC-5.2 RBC-3.24* Hgb-10.4* Hct-29.3*
MCV-90 MCH-32.1* MCHC-35.4* RDW-13.7 Plt Ct-216
[**2104-2-11**] 06:00AM BLOOD Glucose-85 UreaN-16 Creat-0.9 Na-142
K-4.0 Cl-104 HCO3-31 AnGap-11
[**2104-2-11**] 06:00AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
.
Microbiology:
[**2104-2-4**] Urine culture: no growth
[**2104-2-4**] MRSA screen: negative
[**2104-2-4**] Blood culture: no growth
.
Imaging:
CT Head ([**2104-2-4**]):
Non-contrast head CT was performed with axial, coronal, and
sagittal reformations. Please note, due to patient motion,
several image acquisitions were attempted. There is no
intracranial hemorrhage, edema, shift of normally midline
structures, or evidence of acute major vascular
territorial infarction. The ventricles and sulci are normal in
overall
configuration. There is no acute fracture. The imaged paranasal
sinuses are well aerated. The nasal bones appear intact. Mastoid
air cells and middle ear cavities are well aerated.
.
CXR ([**2104-2-4**]): No acute intrathoracic process.
Brief Hospital Course:
Mr. [**Known lastname 8182**] is a 51 year old gentleman, with PMH of
alcohol/cocaine/heroin abuse, refractory HTN, seizure disorders
and psychosis NOS, who was admitted with encephalopathy.
Admission was complicated by hypertension, transaminitis and
conjunctivitis.
.
.
ACTIVE PROBLEMS:
# Encephalopathy: Most likely secondary to polysubstance
intoxication vs. withdrawal. Patient was found disheveled with
empty syringes and unable to give a history of events. PCP
records show longstanding history of polysubstance abuse, and
patient's tox screen was positive for ETOH level 93 and +urine
cocaine. Cocaine and alcohol would explain some of his AMS, but
would not explain clonus that he had on initial presentation.
DDx in addition to known ingestions includes synthetic opioids,
which would not be picked up by tox screen. However, pt did not
have pinpoint pupils and did not respond to Naloxone.
Serotonergic intoxication with seratonin syndrome possible,
given clonus, but unclear if pt took such drugs. NMS was less
likely given that he is afebrile and with a normal CK. His
glucose was normal, and BP was high, making B-blocker/CCB
ingestion unlikely. He had no urine ketones. Toxic alcohols are
unlikely, given no anion gap, no acidosis, no ketones, and no
OSM gap. Tox screen picked up no acetaminophen, MAOIs,
Tricyclics, amphetamines. GBS, PCP, [**Name10 (NameIs) 71715**] are all
possibilities. Bath salts are possible as well. Head CT was
negative for acute findings. In the MICU, patient was initially
treated with very frequent CIWA checks and benzodiazepene
dosing, and subsequently developed some degree of benzo toxicity
prior to transfer to the Medicine floor. Once on the Medicine
floor, mental status continued to clear. CIWA protocol was
discontinued. His mental status improved. He was A&Ox3 and was
able to express strong motivation to use resources provided to
quit drinking and abusing drugs.
.
# ETOH: Patient's alcohol level was 93 in the ED. He has a known
history of active abuse. He was treated with Ativan on a q1h
CIWA initially, which was then changed to diazepam and spaced
out to 6 hours. CIWA was eventually discontinued, as patient was
thought to be in benzo toxicity. He also received high dose
thiamine, as well as folate, MVI daily.
.
# Cocaine: Cocaine use raises the risk of vasospasm and cardiac
ischemia. PT had EKG with no signs of ischemia, and two sets of
cardiac enzynes were negative.
.
# HTN: PT hypertensive to 220s on intake to MICU. Pressure
responded to 160s with ativan, but rebounded and was
unresponsive. He received hydralazine IV for HTN in the unit. Pt
has LVH on EKG, but normal renal function. Per PCP records,
patient has a history of refractory hypertension, and was being
treated with clonidine, lisinopril and amlodipine. These
medications were restarted on the general medicine floor, with
good control of his blood pressure subsequently.
.
# Transaminitis: Labs initially demonstrated AST/ALT 106/51,
with 0.2 Tbili and alk phos 142. This hepatocellular pattern is
most consistent with acute liver injury from alcohol. Over the
course of admission, transaminases trended down.
.
# Conjunctivitis: Patient was found to have purulent discharge
and conjunctival erythema from both eyes, R>L on HD2. Pt was
started on ciprofloxicin opthalmic drops, with resolution of
conjunctivitis by HD4.
.
.
CHRONIC ISSUES:
# Seizure disorder: Discovered when PCP records were obtained.
Patient was restarted on his home depakote and phenytoin.
.
# Social situation: Patient homeless prior to this admission.
Worked with case management and social work to try to set him up
with resources as outpatient.
.
# Depression: Patient on citalopram as outpatient. This was
restart once out of the MICU.
.
# GERD: Continued home omeprazole 40mg [**Hospital1 **].
.
.
TRANSITIONAL ISSUES: none
Medications on Admission:
-clonidine 0.2 mg tab PO BID
-lisinopril 40 mg PO daily
-amlodipine 10 mg PO daily
-citalopram 20 mg PO daily
-HCTZ 25 mg PO daily
-Depakote EC 250 mg PO BID
-gabapentin 400 mg PO TID
-Flovent HFA 220 mcg 2 puffs [**Hospital1 **]
-Dilantin 400 mg PO qHS
-Prilosec OTC 20 mg PO daily
-Seroquel 200-300 mg PO qHS
-doxepin 100 mg PO qHS
-mirtazapine 45 mg PO qHS
-loratadine 10 mg PO daily
Discharge Medications:
1. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
6. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. gabapentin 400 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*0*
8. Flovent HFA 220 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*0*
9. Dilantin Extended 100 mg Capsule Sig: Four (4) Capsule PO at
bedtime.
Disp:*120 Capsule(s)* Refills:*0*
10. Seroquel 100 mg Tablet Sig: 2-3 Tablets PO at bedtime.
Disp:*90 Tablet(s)* Refills:*0*
11. doxepin 100 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*0*
12. mirtazapine 45 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
13. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO Q 12H (Every 12 Hours).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Encephalopathy
Alcohol abuse
Cocaine abuse
.
Secondary diagnoses:
Hypertension
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 8182**],
It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted for confusion
and altered mental status. We believe your symptoms were due to
alcohol and cocaine that you had before you were admitted to the
hospital. You improved gradually over the course of your
hospitalization.
Please continue to take all of your home medications as you had
prior to this admission.
It is very important that you follow up with your primary care
doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 91823**], at the appointment listed below.
Please stop using drugs.
Wishing you all the best!
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 2064**]
Location: [**Hospital6 **] - FAMILY MEDICINE
Address: 1 [**Hospital6 **] PLACE, [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 65318**]
Appointment: MONDAY [**2-18**] AT 9AM
**You will be seeing Dr [**Last Name (STitle) 91824**] nurse at this appointment.**
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,245
| 188,748
|
38699
|
Discharge summary
|
report
|
Admission Date: [**2167-12-18**] Discharge Date: [**2167-12-24**]
Date of Birth: [**2114-10-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex / Penicillins / Codeine / Albuterol Sulfate / Demerol /
Xanax / Monosodium Glutamate / Sulfa (Sulfonamide Antibiotics) /
Dilaudid
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia
Major Surgical or Invasive Procedure:
[**2167-12-18**]: Right thoracotomy and tracheoplasty with mesh,
right main stem bronchus/bronchus intermedius bronchoplasty
with mesh, left main stem bronchus bronchoplasty with mesh.
History of Present Illness:
Ms. [**Known lastname 85974**] is a 53-year-old woman who has had multiple
admissions for respiratory trouble. She was found to have
severe, diffuse tracheobronchomalacia. She underwent stent trial
and her dyspnea improved. She had undergone a fundoplication for
GERDwhich she tolerated well; but had no effect on her airway
symptoms. She is being admitted for trachaelplasty.
Past Medical History:
right breast cancer s/p lumpectomy (clear margins) and radiation
[**2166**]
fibrocystic breast disease
Irritable bowel syndrome
fybromyalgia
gastroesophageal reflux disease
asthma (on daily Prednisone)
tracheobrochomalacia - as above; triggered by exercise, yelling,
weather changes; had a recent negative exercise stress test (due
to work-up of recent chest discomfort)
anxiety disorder
depression
insomnia
iron deficiency anemia
B12 deficiency anemia
Hysterectomy [**2137**]'s
umbilical hernia repair [**2157**]
Social History:
Used to be a medical assistant. Lives with husband and [**Name2 (NI) **]
in [**Name (NI) **]. Has children, all healthy. Denies tobacco, EtOH
or illicits.
Family History:
Mother was diagnosed with thyroid cancer
Father was diagnosed with coronary artery disease in his 60's
(s/p 3vCABG), also DM and prostate CA
Brother has HTN
Physical Exam:
VS: T 97.6, BP 136/84, HR 95 reg, O2 sat 98% RA, wt 181.6 lbs,
ht
167 cm
Physical Exam:
Gen: pleasant in NAD
Lungs: clear t/o
CV: fast RRR S1, S2 no MRG or JVD
Abd: soft, NT, ND, incisions healed.
Ext: warm without edema
Pertinent Results:
[**2167-12-23**] WBC-3.6* RBC-3.13* Hgb-8.5* Hct-25.0* MCV-80* MCH-27.3
MCHC-34.1 RDW-15.0 Plt Ct-283#
[**2167-12-21**] WBC-3.8* RBC-3.25* Hgb-8.8* Hct-25.6* MCV-79* MCH-26.9*
MCHC-34.2 RDW-14.5 Plt Ct-175
[**2167-12-18**] WBC-5.1 RBC-3.86* Hgb-10.2* Hct-30.5* MCV-79* MCH-26.4*
MCHC-33.4 RDW-14.9 Plt Ct-203
[**2167-12-23**] Glucose-88 UreaN-8 Creat-0.6 Na-140 K-4.1 Cl-106
HCO3-26
[**2167-12-22**] Glucose-84 UreaN-8 Creat-0.6 Na-137 K-3.9 Cl-102
HCO3-28
[**2167-12-18**] Glucose-148* UreaN-13 Creat-0.7 Na-140 K-3.7 Cl-107
HCO3-26
[**2167-12-23**] Calcium-8.4 Phos-3.8# Mg-2.0
[**2167-12-23**] CK(CPK)-528*
[**2167-12-19**] CK(CPK)-2454*
[**2167-12-18**] CK(CPK)-925*
Micro:
[**2167-12-20**] BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2167-12-20**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2167-12-20**] BLOOD CULTURE Source: Catheter.
Blood Culture, Routine (Pending):
[**2167-12-20**] Urine Culture negative
CXR:
[**2167-12-23**]: There are bilateral small pleural effusions with
postoperative
changes again seen in the right upper zone. No definite vascular
congestion or acute focal pneumonia. Atelectatic changes are
seen at the left base.
[**2167-12-21**]: New small-to-moderate right pleural effusion, some of
which is fissural, could be blood, pus, or [**Last Name (LF) 85975**], [**First Name3 (LF) **] indicate
new bronchopleural connection. Stable small left pleural
effusion.
[**2167-12-19**]: There is no evidence of abnormality of the
hemidiaphragm that is seen throughout the entire length on the
lateral view. There is right and left pleural effusion. No
appreciable pneumothorax is demonstrated.
[**2167-12-18**]; 1. Minor interstitial lines in the left base
consistent with mild edema. Right hilar prominence may represent
a small postoperative hematoma or perihilar atelectasis. No
evidence of effusion or pneumothorax.
Brief Hospital Course:
Mrs. [**Known lastname 85974**] is a 53 year-old female admitted following Right
thoracotomy and tracheoplasty with mesh, right main stem
bronchus/bronchus intermedius bronchoplasty
with mesh, left main stem bronchus bronchoplasty with mesh. She
was extubated in the operating room and transferred to the ICU
for close respiratory monitoring.
Respiratory: aggressive pulmonary toilets, nebs, incentive
spirometer and good pain control her respiratory status improved
with oxygen saturations of 97% RA.
Chest tube: right chest tube was removed [**2167-12-19**].
Chest films: serial chest films showed bibasilar atelectasis
Cardiac: sinus rhythm 80-100's stable on Lopressor 25 mg [**Hospital1 **]
GI: PPI, bowel regime and tolerated a regular diet
Renal: Cycled CK Pk 2450 trended down. Renal function normal
with good urine output.
Electrolytes replete as needed.
Pain: difficult pain management. Titrated MSO4 IV then converted
to PO MSO4. Toradol was given with moderate pain control. She
transitioned to Motrin, Oxycodone, muscle relaxant and lidoderm
patch with good control.
ID: spiked a fever 101 on [**2167-12-21**]. Pan-cultured. BC x 2 1
bottle w/GPC Vancomycin was started empirically in a patient
with mesh, once final culture grew COAG neg staph likely
contaminate the Vanco was discontinued.
Neuro: antidepressant medications were continued.
Disposition: Home with husband on [**Name2 (NI) **] 6. She will follow-up
with Dr. [**Last Name (STitle) **] as an outpatient
Medications on Admission:
Advair 250-50 mcg [**Hospital1 **]
[**Doctor First Name **] 60 mg [**Hospital1 **]
Ambien 10 mg QHS
Clonazepam 0.5 mg [**Hospital1 **]
Calcium carbonate/Vit D 500 mg QD
Singular 10 mg Daily
Tricor 145 mg daily
Venlafaxine XR 300 mg daily
Xopenex NEbs [**3-26**] x day
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. venlafaxine 150 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Cut
patch in half and place on each side of your incision.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
13. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronchomalacia.
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage.
-Shower daily. Wash incisions with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lifting greater than 10 pounds until seen
-No driving while taking narcotics. Take stool softners with
narcotics
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**] Date/Time:[**2167-12-30**]
2:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Location (un) **] Neurology
3A
Chest X-Ray [**Location (un) **] Radiology [**Hospital Ward Name 517**] Clinical Center
Completed by:[**2167-12-24**]
|
[
"785.0",
"V15.3",
"780.62",
"790.99",
"519.19",
"327.23",
"707.04",
"564.1",
"272.4",
"707.21",
"338.12",
"V45.3",
"280.9",
"729.1",
"V10.3",
"493.90",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
7446, 7452
|
4244, 5743
|
428, 616
|
7530, 7530
|
2165, 2905
|
8222, 8556
|
1751, 1909
|
6062, 7423
|
7473, 7509
|
5769, 6039
|
7681, 8199
|
2012, 2146
|
2949, 3213
|
3247, 4221
|
366, 390
|
644, 1024
|
7545, 7657
|
1046, 1562
|
1578, 1735
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,977
| 179,185
|
50109
|
Discharge summary
|
report
|
Admission Date: [**2174-2-1**] Discharge Date: [**2174-2-7**]
Date of Birth: [**2113-3-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain/lightheadedness/SOB/worsening fatigue
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2174-2-1**]
Aortic valve replacement (mechanical) [**2174-2-1**]
History of Present Illness:
60 yo with known bicuspid aortic valve with aortic stenosis and
regurgitation s/p Ascending Aortic repair in [**2168**] in [**State 12000**].
She reports exertional chest pain, orthopnea, and PND in the
past month and was referred for nuclear
stress test and [**State 461**]. Nuclear stress test was normal,
however echo revealed severe aortic stenosis with [**Location (un) 109**] 0.6cm2.
She is referred to Dr. [**First Name (STitle) **] for evaluation for Redo
sternotomy/Aortic valve replacement
Past Medical History:
Hypertension
Hyperlipidemia
Bicuspid Aortic Valve
Osteoarthritis of hands and knees
Osteoporosis
Scoliosis
colon polyps
s/p Ascending Aortic Aneurysm repair [**2168**] at the [**Hospital 104612**] Hospital
s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**] Rod for scoliosis [**2145**]
s/p Hysterectomy for fibroid uterus
Social History:
Lives with:divorced, lives with sister and 15 year old adopted
son; has 3 adult biological children
Occupation:Unemployed on disability
Tobacco:denies
ETOH:denies
Family History:
Family History:NC
Physical Exam:
Physical Exam
Pulse:48 Resp:16 O2 sat: 99% RA
B/P Right: 122/73 Left: `126/75
Height: 5'4" Weight:172 #
General:SOB and very fatigued
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable;
dentures in place
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]; well-healed sternotomy
Heart: RRR [x] Irregular [] 5/6 SEM radiates throughout
precordium to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
Neuro: Grossly intact; MAE 4.5 /5 strengths; nonfocal exam
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 :murmur radiates loudly to bil. carotids
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 104613**] (Complete)
Done [**2174-2-2**] at 11:15:53 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Right ventricular chamber size and free wall motion are normal.
The appearance of the ascending aorta is consistent with a
normal tube graft.
There are simple atheroma in the descending thoracic aorta.
The aortic valve is bicuspid. There is critical aortic valve
stenosis (valve area <0.8cm2).
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Aortic valve replaced with 23mm mechanical valve; new valve is
well seated with trace aortic regurgitation within struts, peak
gradient 8mmHg.
There is no aortic dissection seen.
Trace mitral regurgitation, no [**Male First Name (un) **] seen.
Preserved biventricular systolic function.
These results were communicated to the surgical team at the time
of exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**]
TWO-VIEW CHEST [**2174-2-6**]
COMPARISON: Radiograph of one day earlier.
INDICATION: Pneumothorax.
FINDINGS: Small left apical pneumothorax is slightly decreased
in size and
there has been slight improvement in aeration at the lung bases.
There is
otherwise no substantial change since the recent radiograph.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SUN [**2174-2-6**] 12:06 PM
[**2174-2-6**] 07:45AM BLOOD WBC-7.1 RBC-3.64* Hgb-9.7* Hct-29.6*
MCV-81* MCH-26.6* MCHC-32.8 RDW-15.8* Plt Ct-162
[**2174-2-6**] 07:45AM BLOOD PT-25.8* INR(PT)-2.5*
[**2174-2-5**] 05:00PM BLOOD PT-28.1* INR(PT)-2.8*
[**2174-2-4**] 06:10AM BLOOD PT-14.9* PTT-32.4 INR(PT)-1.3*
[**2174-2-6**] 07:45AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-141
K-3.8 Cl-107 HCO3-24 AnGap-14
[**2174-2-7**] 07:40AM BLOOD PT-29.6* INR(PT)-2.9*
Brief Hospital Course:
Admitted after cardiac catheterization for preoperative
evaluation. On [**2174-2-1**] Ms. [**Known lastname **] was brought to the
operating room and underwent aortic valve replacement. See
operative note for details. She was brought from the operating
room to the ICU intubated. She weaned from ventilator and was
extubated without difficulty on POD#1. She had recieved IV
morphine for pain and became confused. Her narcotics were
discontinued and her mental status cleared over the next 24hrs.
Her pain was well controlled on tylenol and motrin. She was
started on betablockers and diuretics and couamdin for her
mechanical aortic valve. Crestor was resumed. She was
transferred to the step down unit on POD#2. Chest tubes and
temporary pacing wires were removed per protocol. She was
evaluated and treated by physical therpay and cleared for
discharge to home on POD#5.
Medications on Admission:
Crestor 20mg po daily
[**Last Name (un) 28031**] (Norvasc/Olmesartan) 10/40mg po daily
Bystolic 10mg po daily
Alendronate 70 mg q Sunday
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
Disp:*4 Tablet(s)* Refills:*0*
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dose
will change daily for goal INR [**3-16**]. Dr. [**First Name (STitle) **]/ [**Hospital 3052**] to manage.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
serial PT/INR
dx: mechanical aortic valve ([**2174-2-2**])
goal INR [**3-16**]
Results to [**Hospital 104614**] [**Hospital3 **] fax [**Telephone/Fax (1) 3534**]
(managed by Dr. [**First Name (STitle) 9466**] [**Name (STitle) **])
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic stenosis s/p Aortic valve replacement ( 23 St. [**Male First Name (un) 923**]
mechanical)
HTN, Hyperlipidemia, Bicuspid AV, Osteo Arthritis hands and
knees, Osteoporosis, Scoliosis, colon polyps, s/p Ascending
Aortic Aneurysm repair [**2168**], s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**] Rod for scoliosis
[**2145**], s/p Hysterectomy for fibroid uterus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol and motrin prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 303**] (for Dr. [**First Name (STitle) 9466**] [**Name (STitle) **]) [**2174-2-21**]
2:45pm [**Telephone/Fax (1) 250**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Your INR will be checked on [**2174-2-8**] and results faxed to
[**Telephone/Fax (1) 3534**] [**Hospital3 **] (for Dr. [**First Name (STitle) **] for coumadin
dosing.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-3-2**] 1:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-3-2**]
11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-2-7**]
|
[
"512.1",
"V45.4",
"458.29",
"733.00",
"E878.2",
"401.9",
"737.30",
"715.89",
"285.9",
"272.4",
"746.4",
"424.1",
"423.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.07",
"39.61",
"88.56",
"35.22",
"88.72",
"37.12",
"99.05",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
7242, 7300
|
4759, 5634
|
368, 462
|
7730, 7836
|
2438, 4736
|
8461, 9413
|
1566, 1570
|
5822, 7219
|
7321, 7709
|
5660, 5799
|
7860, 8438
|
1585, 2419
|
279, 330
|
490, 991
|
1013, 1354
|
1370, 1535
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,884
| 197,918
|
3509
|
Discharge summary
|
report
|
Admission Date: [**2171-10-4**] Discharge Date: [**2171-10-15**]
Date of Birth: [**2118-12-16**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Simvastatin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
[**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**2171-10-7**] Pericardial Window
History of Present Illness:
52 year old male with Hypertension, hyperlipidemia and with a
recent diagnosis of pericarditis ([**2171-9-22**]) who presented
[**2171-10-4**] with daily fevers, myalgias, shortness of
breath/dyspnea on exertion. History dates to [**2171-9-19**] before
which he was feeling entirely well. That evening he notes acute
onset of mild chest pain which he attributed to "regular chest
pain" meaning something of GI etiology. He went to sleep and
felt well the next morning ([**9-20**]). The pain returned that night,
and worsened throughout the night to the point that it was
"excruciating chest pressure" prompting presentation to ED,
where he was admitted. The diagnosis of pericarditis was made
based on EKG, and echo showed small-moderate pericardial
effusion. CTA of the chest had not demonstrated PE. He was
discharged with NSAIDS and asked to followup as an outpatient.
Between [**9-24**] and [**10-4**] he developed fevers at night that made it
difficult for him to sleep. The pain was controlled with NSAIDS
and it was the [**Month/Year (2) **] that prompted his presentation. He measured
it to 100.7 at most but felt subjectively very warm. When he had
the fevers the chest pain seemed to get worse and he would also
develop shoulder ache.
.
On readmission, he was found to have an 8 point HCT drop from
[**9-24**] discharge to admit [**10-4**]. Initial echo demonstrated
moderate effusion with loculation and he was scheduled for a
pericardiocentesis on [**10-7**]. Overnight [**10-6**] his clinical status
worsened with increasing chest pain, shortness of breath and
increased pulsus from 3 to 10 mm Hg. Repeat echo demonstrated
"significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling and elevated intrapericardial pressures and
suggestive of early tamponade." He underwent pericardiocentesis
of 650 cc of fluid and pericardial window on [**2171-10-7**]. Drain was
pulled [**2171-10-9**].
.
He continues to have daily fevers occurring between 3pm and
10pm. Tmax [**10-9**] was 101.3. He is on vancomycin, levofloxacin
and flagyl and all cultures to date have been negative. ID is
following the patient, and rheum was consulted today. He reports
improved exercise tolerance with walking, but continues to have
pleuritic chest pain. No other localizing signs/symptoms for
infection. He is transferred back to the medicine service for
further evaluation of his ongoing fevers.
.
ROS: denies rash, denies abdominal pain, had mild visual changes
today (rainbow color in right visual field - patient relates
this to blood sugar elevated to 140), no change in hearing. No
joint pains other than mentioned above. Difficulty sleeping
(because of fevers). Subjective weakness
Past Medical History:
hypertension
hyperlipidemia
previous TIA
pericarditis [**9-22**]
OSA (does not use his cpap)
Social History:
No tobacco, EtOH, drugs. Works in construction.
Born and raised in [**Country 3515**]; came to US 20 years ago; no travel
outside of [**Location (un) 86**] area for last year. Married; lives with wife
and two children (age 25, 18). No sick contacts. [**Name (NI) **] pets; no
animal contacts.
Family History:
family history of HTN. No history of cancer,
rheumatic diseases.
Physical Exam:
GENERAL: Sitting in bed, cooperative, able to communicate well.
VITALS: Tm 100.0 Tc 97.8 BP 116/64 HR 71 RR 20 98%RA
Repeat Pulses: +2
SKIN: no rashes, no lesions
HEENT: Anicteric, EOMI, PERRL, MMM
CHEST: decreased breath sounds at bases, otherwise clear
HEART: RRR, 2/6 SEM
BACK: No CVA Tenderness, No spinal tenderness
ABDOMEN: +BS, soft, Tender to palpation in mid-epigastric
region, no rebound/guarding
EXT: No clubbing/cyanosis/edema. Good Pulses.
NEURO: A+Ox3
Pertinent Results:
[**2171-10-4**] 07:50PM BLOOD WBC-8.7 RBC-3.11* Hgb-9.4* Hct-26.7*
MCV-86 MCH-30.1 MCHC-35.0 RDW-13.0 Plt Ct-345#
[**2171-10-7**] 08:10PM BLOOD WBC-11.2* RBC-3.53* Hgb-10.5* Hct-30.7*
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.6 Plt Ct-427
[**2171-10-15**] 06:50AM BLOOD WBC-6.4 RBC-3.84* Hgb-11.2* Hct-33.5*
MCV-87 MCH-29.2 MCHC-33.5 RDW-14.0 Plt Ct-458*
[**2171-10-4**] 07:50PM BLOOD Neuts-69.5 Lymphs-18.5 Monos-8.1 Eos-3.2
Baso-0.6
[**2171-10-8**] 02:29AM BLOOD Neuts-84.1* Bands-0 Lymphs-9.3* Monos-6.2
Eos-0.4 Baso-0.1
[**2171-10-12**] 05:40AM BLOOD Neuts-60.9 Lymphs-27.6 Monos-5.7 Eos-5.5*
Baso-0.2
[**2171-10-4**] 07:50PM BLOOD PT-13.4* PTT-25.6 INR(PT)-1.2*
[**2171-10-7**] 08:10PM BLOOD PT-16.9* PTT-28.7 INR(PT)-1.6*
[**2171-10-11**] 07:00AM BLOOD PT-15.0* PTT-27.0 INR(PT)-1.3*
[**2171-10-4**] 07:50PM BLOOD Glucose-123* UreaN-20 Creat-1.2 Na-138
K-3.8 Cl-104 HCO3-23 AnGap-15
[**2171-10-11**] 07:00AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-141
K-4.8 Cl-106 HCO3-29 AnGap-11
[**2171-10-15**] 06:50AM BLOOD Glucose-107* UreaN-17 Creat-1.0 Na-140
K-4.8 Cl-106 HCO3-27 AnGap-12
[**2171-10-5**] 06:10AM BLOOD ALT-176* AST-56* CK(CPK)-63 AlkPhos-200*
Amylase-42 TotBili-0.5
[**2171-10-11**] 07:00AM BLOOD ALT-97* AST-72* AlkPhos-138* TotBili-0.3
[**2171-10-12**] 05:40AM BLOOD ALT-90* AST-49* LD(LDH)-246 AlkPhos-135*
TotBili-0.3
[**2171-10-15**] 06:50AM BLOOD ALT-57* AST-21 AlkPhos-123* TotBili-0.2
[**2171-10-5**] 06:10AM BLOOD Lipase-32
[**2171-10-5**] 06:10AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.7* Iron-22*
[**2171-10-5**] 06:10AM BLOOD calTIBC-194* Hapto-330* Ferritn-1026*
TRF-149*
[**2171-10-14**] 02:33PM BLOOD %HbA1c-6.0*
[**2171-10-10**] 01:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
[**2171-10-14**] 07:15AM BLOOD IgM HBc-NEGATIVE
[**2171-10-10**] 01:58PM BLOOD ANCA-NEGATIVE B
[**2171-10-13**] 05:10AM BLOOD RheuFac-7
[**2171-10-10**] 01:20PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:80
[**2171-10-8**] 02:29AM BLOOD IgG-1211 IgM-50
[**2171-10-10**] 01:20PM BLOOD HCV Ab-NEGATIVE
[**2171-10-7**] 05:32PM BLOOD Type-ART pO2-72* pCO2-37 pH-7.52*
calTCO2-31* Base XS-6 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2171-10-8**] 12:58AM BLOOD Type-ART pO2-118* pCO2-38 pH-7.45
calTCO2-27 Base XS-3
[**2171-10-8**] 05:57AM BLOOD Type-ART pO2-78* pCO2-31* pH-7.48*
calTCO2-24 Base XS-0
ACE level: 4
Cocksackie B1-6 antibodies: <1:8
Mycoplasma IgG: neg IgM: 14
Anti-sm antibodies: <0.2 (negative)
Anti-RNP anti-ro anti la: pending
.
PA AND LATERAL CHEST RADIOGRAPHS: There is no evidence of
pneumonia. In the interval there has been development of small
bilateral pleural effusions with a mild amount of fluid noted
within the left major fissure. Adjacent probable compression
atelectasis is present within the lower lobes bilaterally.
Globular cardiomegaly is unchanged. There is no evidence of
pulmonary edema, pneumothorax and hilar contours are within
normal limits.
IMPRESSION:
1. Interval development of small bilateral pleural effusions
with mild adjacent compression atelectasis. No evidence of
pneumonia.
2. Unchanged globular cardiac silhouette likely representing
combination of pericardial effusion and cardiomegaly.
.
LIVER ULTRASOUND: The liver parenchyma is normal without
evidence of mass lesions. The portal vein is patent with
hepatopetal flow. The gallbladder is not distended. There is no
evidence of stones, pericholecystic fluid or gallbladder wall
edema to suggest acute cholecystitis. The common bile duct
measures approximately 4.5 mm. There is no evidence of intra- or
extrahepatic biliary dilatation. A small right pleural effusion
is noted. There is perihepatic and perisplenic fluid collections
that are better evaluated on CT abdomen and pelvis done the same
day.
IMPRESSION:
1. No evidence of acute cholecystitis.
2. Perihepatic and perisplenic fluid collections as well as a
small right pleural effusion are noted and are better evaluated
on CT abdomen and pelvis performed the same day.
.
FINDINGS: There has been marked enlargement of the known
pericardial effusion, now measuring at least 2.5 cm in
circumference along the left lateral wall. There are small
pleural effusions, left greater than right with associated
atelectasis. No focal consolidative airspace disease or nodule.
The liver is slightly enlarged with a tiny amount of perihepatic
ascites. Gallbladder is decompressed. Spleen, pancreas and
adrenal glands are unremarkable. The kidneys excrete contrast
symmetrically without hydronephrosis.
PELVIS: Bowel loops are unremarkable, and contrast has passed to
the colon. No dilated bowel loops. No free air or free fluid.
Small retroperitoneal lymph nodes, not meeting CT criteria for
pathologic enlargement. Vascular structures are intact.
Review of bone windows demonstrates no suspicious lytic or
blastic lesions.
IMPRESSION:
1. Marked enlargement of known pericardial effusion, now quite
large (2.5 cm in diameter). Echocardiography advised to assess
for potential tamponade.
2. No evidence for retroperitoneal hematoma or other source of
recent drop in hematocrit.
This was discussed with Dr. [**Last Name (STitle) 2026**] at the time of initial
interpretation.
.
Echo ([**10-5**]):
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets appear
structurally normal with good leaflet excursion. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a moderate sized pericardial
effusion measuring 2cm inferolateral and lateral to the left
ventricle and anterior to the right atrium with <1cm anterior to
the right ventricle and around the apex. The effusion appears
circumferential but sttranding is visualized c/w
organization/loculation. No right atrial or right ventricular
diastolic collapse is seen but there is accentuation of
respirtatory variation in the transtricuspid E wave velocity.
Compared with the prior study (images reviewed) of [**2171-9-24**],
the effusion is much larger and mild increase in pericardial
pressure is suggested.
Clinically correlation and serial evaluation is suggested
.
CXR ([**10-6**])
Two views. Comparison with [**2171-10-4**]. There is continued evidence
of small bilateral pleural effusions. There is increased density
in the retrocardiac area consistent with atelectasis and/or
consolidation. The cardiac silhouette is enlarged, as before.
Mediastinal structures are otherwise unremarkable. The bony
thorax is grossly intact.
IMPRESSION: Bilateral pleural effusions and atelectasis or
consolidation at the left base. Cardiomegaly. No significant
interval change
.
Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS
Pericardial Tissue:
DIAGNOSIS:
Pericardium, excision:
Organizing fibrinous pericarditis.
ADDENDUM:
Gram and GMS stains performed on blocks A and B are negative for
bacterial and fungal organisms, respectively.
.
[**10-7**] Echo (pre-drainage)
The left atrium is normal in size. The estimated right atrial
pressure is 16-20 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Right ventricular chamber size and free wall motion are
normal. There is abnormal septal motion/position. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a large pericardial effusion. The effusion appears
loculated. Stranding is visualized within the pericardial space
c/w organization. No right atrial or right ventricular diastolic
collapse is seen. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling and elevated intrapericardial
pressures.
Compared with the prior study (images reviewed) of [**2171-10-5**],
the pericardial effusion is slightly larger. This echo is
suggestive of early tamponade.
.
[**10-7**] Echo (post-drainage)
No spontaneous echo contrast is seen in the body of the left
atrium. No spontaneous echo contrast is seen in the body of the
right atrium. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is mild to moderate
global left ventricular hypokinesis (LVEF = 40-45 %). The right
ventricular cavity is mildly dilated. There is moderate global
right ventricular free wall hypokinesis. There is abnormal
septal motion/position. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is a large pericardial effusion. The effusion appears
loculated. Stranding is visualized within the pericardial space
c/w organization. The pericardium appears thickened. There are
no echocardiographic signs of tamponade.
After drainage, there is only small remnants of the pericardial
effusion - a small pocket located inferolaterally and another
next to the right atrium. The left pleural effusion has also
been drained. The left ventricular systolic function actually
seems somewhat improved after drainage. The right ventricle is
still moderately globally depressed.
.
[**10-12**] Chest CT
CT OF THE CHEST WITHOUT IV CONTRAST: The central airways are
patent to the subsegmental levels, bilaterally. Linear opacities
in the left lung consistent with subsegmental atelectasis. There
is no pleural effusion. The patient is status post pericardial
window. A small amount of left chest wall subcutaneous emphysema
and a tiny loculated air pocket presumabily in the subpleural
space.
Unchanged small pericardial effusion. There is no evidence of
consolidation. No evidence of mediastinal or hilar
lymphadenopathy. Numerous axillary lymph nodes are noted, not
pathologically enlarged by CT criteria.
This study is not designed for subdiaphragmatic evaluation,
however, the imaged portions of the upper abdomen are
unremarkable. No bone findings suspicious for malignancy.
IMPRESSION:
1. Status post pericardial window with post-surgical changes as
described above. Small pericardial effusion.
2. Atelectatic changes in the left lung without evidence of
consolidation.
.
RLE u/s: FINDINGS: Grayscale, color, and Doppler ultrasound
images demonstrate a tortuous venous structure without flow in
the right lateral calf consistent with a thrombosed varix.
IMPRESSION: Superficial thrombosed varix
Brief Hospital Course:
Mr. [**Known lastname **] was admitted under medical team d/t [**Known lastname **] with
unclear etiology but thought possibly related to recent
pericarditis. Cardiology was consented and pt underwent
echocardiogram on [**10-5**]. Echo revealed pericardial effusion
thought to be larger than prior echo with mild increase in
pericardial pressure. Also underwent Liver/GB US d/t epigastric
pain and elevated LFTs which showed no cholecystitis. Plus
underwent an Abd/Pelvic CT for the epigastric pain and low HCT
upon admission which showed marked enlargement of known
pericardial effusion, but no evidence for retroperitoneal
hematoma or other source of recent drop in hematocrit. Patient
was medically managed over next couple of days and planned for
pericardiocentesis. Cardiac surgery was consulted on [**10-6**] for
possible pericardial window. Underwent repeat echo on [**10-7**]
which revealed the pericardial effusion was slightly larger and
suggestive of early tamponade. ID was consulted and later on
this day he was brought to the operating room where he underwent
a pericardial window. Following surgery he was transferred to
the CVICU in stable condition. Shortly after surgery he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was transferred to the SDU for further
care. Chest tube was removed on post-op day two.
.
# [**Month/Year (2) **]:
Etiology unclear, initially suspecting infectious etiologies,
and then had Gram positive rods growing in anaerobic pericardial
fluid culture which speciated as P. acnes. Unclear if this is
contaminant or real infection as per ID, pathologist reports no
neutrophilic infiltrate in tissues. Fungal stains negative. He
received broad spectrum antibiotic coverage while here with
vancomycin/levofloxacin/metronidazole, which was then narrowed
to 14d course of vancomycin, but overall P. acnes felt to be
more likely a contaminant.
As infectious etiologies of [**Month/Year (2) **] began to be ruled out, fevers
were controlled with tylenol pre-treatment each evening.
Had chest CT to evaluate possible retrocardiac opacity as source
of fevers, only atelectasis noted.
Infectious disease service followed patient throughout
hospitalization. Concerning infectious etiologies were ruled
out and it was felt that patient could go home with close
followup.
Rheumatology also involved in patient's care and felt that he
had few other symptoms to suggest systemic rheumatologic
disease. They considered a diagnosis of adult Still's disease
but left this as a diagnosis of exclusion once ID workup
completed and recommended bone marrow biopsy and lymph node
biopsy to search for other causes. Also suggested other causes
of periodic fevers such as familial
mediterrean [**Month/Year (2) **], TNF receptor related periodic syndrome but
thought it would be difficult to make this diagnosis on the
basis of only 2 weeks of fevers.
He will see rheumatology in followup.
.
# Pericardial effusion: received pericardial window as above.
Loculated fluid suggested chronic infection. Although patient
began to be relatively hypotensive in the days prior to
discharge, he was not tachycardic and did not have an increased
pulsus paradoxus so reaccumulation of fluid and tamponade were
not thought to be at play. Given loculated effusion, this was a
concern. HCTZ was stopped and he was discharged with followup
of blood pressure and consideration of further elimination of
lisinopril. (given recent weight loss it was felt that his
antihypertensive requirements may have been reduced).
#R leg mass
patient noted to have a 1cm superficial nodular mass on right
calf which was nontender and mobile. Ultrasound showed it to be
a thrombosed superficial varix. No further evaluation was
pursued.
.
#.Abnormal LFTs
low-grade elevation on admission of uncertain etiology, but most
likely a manifestation of systemic ilness such as a viral
syndrome. they were trending down throughout hospital course.
They were not high enough to suggest acute hepatitis, hepatitis
serologies show HCV negative, HAV ab positive (likely old), and
HBV surface Ag and Ab negative but core IgG positive suggesting
either window period or old infection with decline in surface Ab
titers. Core IgM negative suggesting this was more likely old
HBV infection with declining surface antibody titers
.
#Anemia
HCT initially low on admission, received 1uPRBCs during this
admission. Thought had been bleed into pericardium versus GI
bleed given NSAID use. Stools were guiac negative x2 (at
least). Now has stabilized, pericardium would seem to be most
likely site of bleeding. Ferritin high, iron low - may also
have element of ACD, which would be in keeping with ongoing
inflammatory state. HCT was stable ~31-33 for several days
prior to discharge.
.
# Hyperlipidemia: continued pravastatin
Medications on Admission:
Ibuprofen 800 mg TID
Aspirin 325 mg qday
lisinopril/hctz 10/12.5
Atenolol 25mg daily
Clonapin 0.5mg prn
Pravastatin 20mg daily
MVI
Discharge Medications:
1. Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for incisional pain for 4 weeks.
Disp:*15 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
vancomycin trough level on [**10-18**], please send results to
Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 8499**] at [**Telephone/Fax (1) 7976**]
7. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q12H (every 12 hours) for 6 days.
Disp:*12 gram* Refills:*0*
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed for 6 days: flush 10 mL
NS followed by 2mL of 100units/ml heparin (200 units heparin).
Disp:*1200 units* Refills:*0*
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for sleep.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation: Stool softener for
constipation while taking narcotic pain medications.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
IV Infusions
Discharge Diagnosis:
Pericardial Effusion s/p Pericardial Window
PMH: h/o Pericarditis [**9-22**], Hypertension, Hyperlipidemia, h/o
TIA, Sleep Apnea
Discharge Condition:
Good
Discharge Instructions:
You were admitted with an inflammation around the heart which
led to fluid build up. It is still unclear if this is due to an
infection or an inflammatory disease. We believe that the
reason for this fluid build up will become clear over time but
that you do not have to sit in the hospital as you have
continued to be stable and have only low-grade fevers which are
controlled with tylenol. You should continue with one of the
antibiotics, vancomycin, for 6 more days and we have arranged
for an intravenous antibiotic company to administer this to you.
We have scheduled a number of followup appointments for you (see
below)
For your incision:
Call your doctor [**First Name (Titles) 151**] [**Last Name (Titles) **], redness or drainage from incision.
No driving while taking narcotic pain medicine.
You can shower, no baths until incision is closed. No lotions,
creams or ointments on incision.
Medication changes:
Vancomycin IV as above
Stopped atenolol, stopped hydrochlorothiazide. Continued
lisinopril at 10mg (you were previously on a combination pill of
hydrochlorothiazide and lisinopril). You should have your blood
pressure checked on thursday at Dr.[**Name (NI) 11509**] office, if it
is low, she should call Dr. [**Last Name (STitle) 8499**] to consider reducing
your lisinopril dose.
Please return to the emergency room if you experience a racing
heart rate, difficulty breathing, worsening chest pain,
lightheadedness or fevers that are not controlled by tylenol.
Followup Instructions:
Please have your blood pressure checked with a nurse [**Hospital 16122**] Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2171-10-17**] 11:00
Please call the cardiac surgery office at ([**Telephone/Fax (1) 1504**] to
schedule followup with Dr. [**Last Name (STitle) **] of cardiac surgery in
approximately 4 weeks.
Please followup with Dr. [**Last Name (STitle) 73**] of cardiology on [**2171-11-13**] at
9am in the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name **] on the [**Location (un) 436**].
([**Telephone/Fax (1) 1920**]
Friday [**11-15**] at 10:00am - Infectious Disease clinic
(located in basement of [**Last Name (NamePattern1) **]) ([**Telephone/Fax (1) 4170**]
[**Hospital 2225**] clinic followup - [**Last Name (NamePattern1) **], [**Hospital Unit Name **] [**11-18**] 10am. Call ([**Telephone/Fax (1) 1668**]. Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 12434**]
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20,009
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45101
|
Discharge summary
|
report
|
Admission Date: [**2190-11-5**] Discharge Date: [**2190-11-10**]
Date of Birth: [**2112-3-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Thrombosed Access
Hyperkalemia
Major Surgical or Invasive Procedure:
Right arm arterio-venous hemodialysis graft placement [**2190-11-9**]
L tunneled cath placed under fluoroscopy. Placement right at the
vena caval-atrial junction
History of Present Illness:
Patient is a known Hemodialysis patient, ESRD since [**2187**] who
presented for thrombectomy of Left upper arm AVF. During pre-op
evaluation, Labwork revealed hyperkalemia, with a K of 9.3.
Femoral line placed for hemodialysis, admitted from the pre-op
holding area to the SICU where emergent hemodialysis was
performed.
Past Medical History:
ESRD on HD since [**5-19**] - Dr. [**Last Name (STitle) **], [**Hospital1 1426**] [**Location (un) 4265**] MWF
Dementia
Had transplant w/u and declined
Hypertensive nephrosclerosis
Hypertension x >20 years
BPH
MRSA Bacteremia
Chronic low back pain [**2-18**] spinal stenosis on vicodin PRN
Anemia in past with normal iron studies
Social History:
Pt. is right handed, a native of [**Doctor First Name 26692**], and has 15
years of education. He worked as a commercial plumber for many
years before retiring ten years ago. He lives with wife and 2
children in [**Location (un) 686**] in family owned home. Retired plumber.
His wife still works full time but she is primary caregiver. [**Name (NI) **]
h/o ETOH or tobacco or elicit drug use.
Family History:
no h/o CAD
Physical Exam:
On Admission:
VS: 96.1, 200/91, 61, 13, 97% RA
General: Agitated, combative
CV: RRR
Lungs: CTA bilaterally
Abd: + Bowel sounds, soft, non-distended, no rebound or
guarding.
Extr: feet warm, no edema, palpable DP and PT pulses
Pertinent Results:
[**2190-11-5**] 04:12PM GLUCOSE-146* UREA N-96* CREAT-15.9*#
SODIUM-135 POTASSIUM-5.9* CHLORIDE-87* TOTAL CO2-27 ANION
GAP-27*
[**2190-11-5**] 04:12PM CALCIUM-9.6 PHOSPHATE-4.9*# MAGNESIUM-2.7*
[**2190-11-5**] 04:12PM WBC-6.4 RBC-3.55* HGB-12.7* HCT-38.2*
MCV-108* MCH-35.8* MCHC-33.3 RDW-17.6*
[**2190-11-5**] 04:12PM PLT COUNT-174
[**2190-11-5**] 04:12PM PT-12.6 PTT-28.5 INR(PT)-1.1
[**2190-11-5**] 01:34PM K+-9.3*
[**2190-11-5**] 02:34PM K+-7.5*
Following HD:[**2190-11-5**] 07:17PM POTASSIUM-4.3
On D/C: Gluc 157* BUN: 62* Creat: 12.1 Na:134 K:4.9 Cl:95*
CO2:21*
Brief Hospital Course:
77 y/o male on hemodialysis T-TH-S with ESRD since [**2187**]
presented for thrombectomy to Left AVF when he was found to have
hyperkalemia on pre-op labs. K of 9.3 was treated with emergent
placement of femoral line and transfer to SICU for emergent
hemodialysis.
Patient received HD on [**11-6**] and [**11-8**] as well through the
femoral line.
On [**11-9**] the patient had a Right brachiocephalic loop AV Graft
placed which is + Bruit and thrill on assessment [**11-10**], as well
as a tunnelled hemodialysis catheter in the left chest under
fluoroscopy with placement right at the vena caval-atrial
junction.
HD performed on [**11-10**] using Left Catheter with consistent blood
flows of 300.
Next treatment will be at [**Location (un) **] [**Location (un) **] on Saturday.
Medications on Admission:
Lanthanum 1000''' with meals, cinacalcet 30', B complex-vit
C-folic acid 1', amlodipine 2.5', metoprolol 25'', levothyroxine
12.5'
Discharge Medications:
1. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Lanthanum 250 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Right arm arterio-venous hemodialysis graft placement [**2190-11-9**]
left tunnelled hemodialysis catheter placement
ESRD
hyperkalemia
Discharge Condition:
Stable
Discharge Instructions:
Please continue outpatient hemodialysis per your regular
schedule.
Continue medications at home as usual
Renal diet as recommended by your hemodialysis caregivers
Dialysis unit will change dressing to the chest dialysis
catheter.
Check the new left arm graft daily to make sure it has a thrill
("buzzing") If this is not present, please call [**Telephone/Fax (1) 673**] and
ask for [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2190-12-2**]
8:30
Completed by:[**2190-11-10**]
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"285.21",
"996.73",
"403.91",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.27",
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
4096, 4102
|
2535, 3317
|
346, 510
|
4281, 4290
|
1921, 2512
|
4795, 4980
|
1644, 1656
|
3499, 4073
|
4123, 4260
|
3343, 3476
|
4314, 4772
|
1671, 1671
|
276, 308
|
538, 861
|
1685, 1902
|
883, 1214
|
1230, 1628
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,650
| 153,351
|
10034
|
Discharge summary
|
report
|
Admission Date: [**2166-8-8**] Discharge Date: [**2166-8-20**]
Date of Birth: [**2081-11-27**] Sex: M
Service: SURGERY
Allergies:
Metoprolol
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
History of emphysematous cholecystitis.
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
Laparoscopic cholecystectomy - [**2166-8-8**].
History of Present Illness:
In summary, Mr. [**Known lastname 33561**] is a 84 year old Arabic-speaking
gentleman with a history of a lengthy admission downtown for
emphysematous cholecystitis. This was managed with a
percutaneous cholecystostomy tube by one of my colleagues prior
to his care being turned over to myself. He required ICU care
and multiple antibiotic courses for bacteremia and sepsis.
During his hospital stay, he improved with regard to the
cholecystitis. Subsequent imaging failed to show any further
gas in the wall of the gallbladder. The percutaneous
cholecystostomy tube did have to be replaced secondary to this
being displaced. He also had acute-on-chronic renal failure.
He has some baseline renal insufficiency, but did require CVVH
and then dialysis during his hospital stay. He typically
follows with Dr. [**Last Name (STitle) 4090**] for his renal disease. During
the prior hospital stay, he also had diastolic CHF, which
responded to diuresis, which was continued upon discharge. He
has had an additional brief admission for hyperkalemia but was
again discharged to [**Hospital1 **] where he is having his
rehabilitation. According to him and his daughter, he has been
eating well, tolerating a diet. He has been moving his bowels.
He has been beginning to walk with help at the rehabilitation
facility. He has no abdominal pain and no complaints. He was
admitted for planned laparoscopic cholecytectomy.
Past Medical History:
Sepsis, respiratory Failure --> Gangrenous Gallbladder ([**2166-5-28**]
- [**2166-6-17**]), Hypertension, Type 2 DM, Hyperlipidemia, Benign
Prostatic Hyperplasia, Chronic Renal Insufficiency, Left
inguinal hernia, E. coli urosepsis in [**11/2159**], Cataracts, Gout.
Social History:
[**Hospital3 2558**] resident since prolonged admission for septic
shock (7/9-21/09). Previously lived with wife in [**Name (NI) 1411**],
retired, immigrated from [**Country 1684**] 12 years ago. No recent travel
abroad. Denies alcohol and tobacco.
Family History:
[**Name (NI) **] wife denies any heart problems in family.
Physical Exam:
Pre-Operative Physcial:
.
On physical exam, elderly gentleman, in no apparent distress,
pleasant and appropriate.
HEENT: Normocephalic, atraumatic. PERRL, equal ocular movement
intact. Moist mucous membranes. No scleral icterus.
Neck: No JVD. Carotids full without bruit.
Heart: Regular rate and rhythm, normal S1, S2. PMI
nondisplaced. No murmurs/rubs/gallops.
Chest: Rales at bilateral bases, no wheeze or rhonchi.
Abdomen: Soft, benign, nontender, and nondistended.
Extremities: with trace bilateral lower extremity edema. Good
distal pulses. Neuro: is intact, good strength in all four
extremities.
.
At Discharge:
AVSS/afebrile.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **]. No JVD.
LUNGS: CTA(B) with few rales at bases.
COR: RRR
ABD: Lap. incisions with steri-strips c/d/i. BSx4. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal. Language barrier (Arabic, no English).
Pertinent Results:
[**2166-8-8**] 10:25AM GLUCOSE-154* UREA N-70* CREAT-4.5* SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-23 ANION GAP-15
[**2166-8-8**] 10:25AM CALCIUM-8.1* PHOSPHATE-5.3* MAGNESIUM-2.5
[**2166-8-8**] 10:25AM HCT-26.8*
[**2166-8-8**] 08:50AM TYPE-ART PO2-213* PCO2-42 PH-7.35 TOTAL
CO2-24 BASE XS--2
[**2166-8-8**] 08:50AM GLUCOSE-139* LACTATE-0.9 NA+-137 K+-4.4
CL--102
[**2166-8-8**] 08:50AM HGB-9.1* calcHCT-27 O2 SAT-99
[**2166-8-8**] 08:50AM freeCa-1.16
[**2166-8-9**] 09:12AM BLOOD WBC-11.5* RBC-3.19* Hgb-8.8* Hct-29.0*
MCV-91 MCH-27.4 MCHC-30.2* RDW-16.7* Plt Ct-246
[**2166-8-8**] 10:25AM BLOOD Glucose-154* UreaN-70* Creat-4.5* Na-141
K-4.4 Cl-107 HCO3-23 AnGap-15
[**2166-8-9**] 09:12AM BLOOD ALT-17 AST-41* AlkPhos-112 TotBili-0.3
.
SPECIMEN SUBMITTED: gallbladder.
DIAGNOSIS:
Gallbladder:
- Chronic cholecystitis.
- Cholelithiasis, pigment type.
- Adherent cauterized benign liver parenchyma.
Clinical: Cholelithiasis.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname 33561**], [**Known firstname 33564**]" and the medical record number and
"gallbladder." It consists of an already disrupted gallbladder
measuring overall 6.8 x 3 x 1.6 cm. There is significant cautery
on the external surface. No cystic duct lymph node is
identified. The opened gallbladder contains no bile and
gallstones numbering approximately 20. The stones are of the
pigment type and measure 2.4 x 1.2 cm in aggregate. The
gallbladder mucosa is erythematous and velvety. The gallbladder
wall measures to be 0.7 cm in greatest dimension. The
gallbladder wall is thickened but soft. The specimen is then
represented as follows: A = cystic duct mucosa and sections of
gallbladder wall, B = additional sections of gallbladder wall.
.
[**2166-8-10**] Renal U/S:
RENAL ULTRASOUND: There is no evidence of hydronephrosis in the
kidneys.
There are multiple bilateral renal cysts, the largest on the
right measuring up to 9.1 x 8.3 x 6.5 cm. The right kidney
measures 15.4 cm which includes measurement of the exophytic
cyst at the lower pole. The left kidney measures 10.6 cm. The
bladder is decompressed by Foley catheter, incompletely
evaluated.
IMPRESSION:
1. No evidence of hydronephrosis.
2. Bilateral renal cysts, not significantly changed from prior.
.
[**2166-8-12**] ECG:
Sinus tachycardia, rate 108. Left ventricular hypertrophy. Left
anterior
hemiblock. Consider biatrial enlargement. Poor R wave
progression. Non-specific ST-T wave changes in leads I, aVL and
leads V5-V6. Compared to the previous tracing of [**2166-8-5**] the rate
has increased and the lateral T wave changes are slightly more
prominent.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
108 172 98 330/414 54 -44 107
.
[**2166-8-16**] CXR:
FINDINGS: Cardiac silhouette is mildly enlarged but has
decreased in size
with associated improvement in reported pulmonary vascular
congestion. Lung volumes are slightly greater in the interval,
and there has been marked improved aeration at the left base.
There remains a confluent area of opacification in the right
retrocardiac region, as well as small bilateral pleural
effusions.
IMPRESSION:
1. Right basilar retrocardiac opacification, which could reflect
pneumonia in the appropriate clinical setting.
2. Near-resolution of left basilar opacity.
3. Small pleural effusions, with improvement on the right.
Brief Hospital Course:
The patient was admitted to the General [**Month/Day/Year 2947**] Service for
evaluation of the aforementioned problem. On [**2166-8-8**], the
patient underwent a laparoscopic cholecystectomy, which went
well without complication (reader referred to the Operative Note
for details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating a clear liquid diet, on
IV fluids, with a foley catheter and JP drain in place, and
Percocet PO and Morphine IV PRN for pain control. He received
two doses of IV Ciprofloxacin peri-operatively. The patient was
hemodynamically stable.
POD#1: Pain well controlled on Percocet. Tolerated clear to
regular diet. Failed to void after foley discontinued; foley
replaced. JP discontinued.
POD#2: Experienced two episodes emesis; diet returned to NPO.
Given Zofran. IVF restarted. Renal Service consulted for
progressively increase creatinine in context of the patient's
history of chronic renal insufficiency. Renal Ultrasound
performed -no hydronephrosis, bladder decompressed by foley.
Acute on chronic renal failure believed secondary to post-renal
obstruction from BPH. Later in evening, became agitated and
confused. Temporary limb restraints applied. Lasix discontinued.
NGT replaced. Patient self-discontinued.
POD#3: Continued agitation, confusion overnight. Again required
restraints and frequent re-orientation. Given fluid bolus for
low urine output with good response. Renal followed closely.
POD#4: Triggered for diaphoresis, SOB, and tachypnea. Transfered
to the TICU for respiratory acidosis and acute respiratory
failure with fluid overload. ECHO revealed Grade II (moderate)
LV diastolic dysfunction with LVEF >55%. Diuresis with Lasix
continued. Oxygen by face mask. EKG and serial troponins. Renal
followed.
POD#5: Respiratory status significantly improved. Urine output
adequate. Renal functions improved. TICU plan continued. Renal
followed; no dialysis at this time.
POD#6: CXR with mildly improved pulmonary edema and (R) basilar
atelectasis. Transferred back to floor NPO except medications,
on IV fluids, oral medications, and a foley catheter in place.
Hemodynamically stable.
POD#7: Diet advanced to clears. Pain well controlled. PT & OT
consulted. Aggressive respiratory toilet.
POD#8: Diet advanced to renal regular. Minimal post-operative
pain; well controlled. CXR showed right basilar retrocardiac
opacification, which could reflect pneumonia. U/A and UCx sent
for question UTI. Started on IV Levofloxacin.
POD#9: Hemodynamically stable. No complaints. Ambulated with PT
and Nursing. Renal following.
POD#10: Loose bowel movement; cdiff sent. Remained stable.
POD#11: Tolerated diet. Pain well controlled. Foley
discontinued; voided adequately. Urine culture revealed VRE UTI
senstive to Linazolid; started on Linezolid for 2 week course.
rehabilitation screen underway.
POD#12: Tolerating diet. Pain well controlled. Continued on
Levofloxacin and Linezolid. Voided adequately without problem.
At the time of discharge on [**2166-8-20**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
renal regular diet, ambulating with assistance, voiding without
assistance, and pain was well controlled. The patient was
discharged to a rehabilitation facility. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO Every other
day.
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day.
15. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
17. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
18. B Complex-Vitamin C-Folic Acid 0.9 mg/15 mL Syrup Sig: One
[**Age over 90 **]y (120) mL PO twice a day.
19. Procrit 10,000 unit/mL Solution Sig: 10,000 units Injection
Every 10 days: Hold for HGB greater than/ equal to 10.
20. Miralax 17 gram Powder in Packet Sig: Seventeen (17) gm (1
PKT) in 8oz water or juice PO once a day as needed for
constipation.
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO Every other
day.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-3**]
hours as needed for fever or pain.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
15. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day.
16. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
17. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
18. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
19. B Complex-Vitamin C-Folic Acid 0.9 mg/15 mL Syrup Sig: One
[**Age over 90 **]y (120) mL PO twice a day.
20. Procrit 10,000 unit/mL Solution Sig: 10,000 units Injection
Every 10 days: Hold for HGB greater than/ equal to 10.
21. Miralax 17 gram Powder in Packet Sig: Seventeen (17) gm (1
PKT) in 8oz water or juice PO once a day as needed for
constipation.
22. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
23. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO every
other day for 13 days: For pneumonia. Completion Date: [**2166-9-2**].
24. Linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 13 days: For VRE UTI. Completion Date: [**2166-9-2**].
25. Lantus 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
26. Insulin Lispro 100 unit/mL Solution Sig: 2-12 units
Subcutaneous As directed per Humalog Insulin Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Primary:
1. Prior emphysematous cholecystitis
2. Acute on chronic renal failure
3. Acute respiratory failure - resolved.
4. (R) basilar pneumonia - continued on Levofloxacin
5. VRE UTI - continued on Linezolid
.
Secondary:
1. BPH
2. Type II DM
3. Diastolic heart failure
Discharge Condition:
Stable.
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 is 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 [**4-6**] 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 [**Month/Year (2) **] 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:
Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) **] (Surgery) in [**12-31**] weeks.
.
Please call ([**Telephone/Fax (1) 1921**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 5717**] (PCP) in [**12-31**] weeks.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. (Cardiology) Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2167-1-27**] 10:00
.
Please call ([**Telephone/Fax (1) 4923**] to arrange a follow-up appointment
with Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**], MD (Renal) in [**12-31**] weeks.
Completed by:[**2166-8-20**]
|
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"428.33",
"486",
"518.5",
"550.90",
"V13.02",
"600.01",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23"
] |
icd9pcs
|
[
[
[]
]
] |
14673, 14714
|
6822, 10255
|
15029, 15039
|
3424, 6799
|
17058, 17748
|
2402, 2462
|
12150, 14650
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14735, 15008
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10281, 12127
|
15063, 16517
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16533, 17035
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2477, 3092
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|
231, 378
|
406, 1828
|
1850, 2119
|
2135, 2386
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,540
| 174,430
|
7466+55838+55839
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2171-8-13**] Discharge Date: [**2171-8-21**]
Date of Birth: Sex: F
Service:
ADMITTING DIAGNOSIS: C. difficile colitis.
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
female with a past medical history of "diastolic
dysfunction", left ventricular hypertrophy, hypertension,
hypothyroidism, who presented from [**Location (un) 3844**] with a
temperature of 99, white blood cells of 26 and complaints of
weakness. The patient denied any cough, dysuria, headache,
photophobia, stiff neck, or diarrhea. However, the patient
reported decreased p.o. intake over the four weeks prior to
admission, though she takes 40 of p.o. Lasix q. day. In [**Location (un) 7498**] the patient was recently treated for pneumonia with
levofloxacin x 1 week and a urinary tract infection with
Macrodantin.
She was admitted to [**Hospital1 69**] and
noted right foot pain. Osteomyelitis was not evidence on
x-ray of her foot. The patient was treated for gout with
prednisone, and urinary retention with straight
catheterization.
In the Emergency Department she had blood pressure of 75/38.
The patient received four liters of normal saline and blood
pressure increased to 105-110 systolic. A urine culture was
drawn and she was admitted to the [**Hospital Unit Name 153**].
PAST MEDICAL HISTORY: 1. Pulmonary hypertension. 2.
Diastolic dysfunction. 3. Left ventricular hypertrophy. 4.
Hypertension. 5. Hypothyroidism. 6. Osteoarthritis. 7.
Osteoporosis. 8. Irritable bowel syndrome. 9. Pancreatitis.
10. Status post appendectomy. 11. Status post
cholecystectomy. 12. Peptic ulcer disease. 13.
Diverticulosis. 14. Venous insufficiency. 15. Diabetes.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: 1. Atenolol 100 q. day. 2. Calcitonin nasal
spray 200 q. day. 3. Ambien 5 q.h.s. 4. Aspirin 81 q. day.
5. Amlodipine 10 q. day. 6. Lisinopril 10 q. day. 7.
Regular Insulin sliding scale. 8. Iron sulfate. 9. Lasix 40
q. day. 10. Synthroid 60 q. day.
PHYSICAL EXAMINATION: On admission heart rate was 62, blood
pressure 108/75, temperature maximum 96.3, 98% on room air.
General: No apparent distress, sitting. HEENT: Extraocular
movements intact. Neck: Jugular venous distension 4 cm,
supple. Cardiovascular: Regular rate and rhythm, S1 and S2,
2/6 systolic ejection murmur at the left lower sternal
border. Chest: Crackles at the bilateral bases, 1/5 up.
Abdomen: Soft, mildly tender, nondistended. Extremities:
No cyanosis, clubbing or edema. Neurologic: Awake, alert,
oriented x 3. Cranial nerves II-XII were intact.
Musculoskeletal: Left heel dressing, painful bilateral knees
and ankles, left knee full and warm, pain with motion.
LABORATORY DATA: CBC showed WBC of 26.3. Chest x-ray showed
no congestive heart failure, no infiltrates. EKG showed
sinus rhythm at 66 with a normal axis, and left ventricular
hypertrophy.
HOSPITAL COURSE: 1. Leukocytosis: The patient was found to
have C. difficile colitis. The patient throughout
hospitalization had decreasing abdominal pain until on
discharge was able to tolerate a p.o. diet and had no
abdominal pain. The patient's white blood cells decreased
throughout the hospitalization. The patient was sent home
with metronidazole 500 mg t.i.d. x 10-14 days. The patient
was also kept on C. difficile precautions throughout the
hospitalization.
2. Urinary retention: The patient has had several trials in
the [**Hospital Unit Name 153**] in which the patient's Foley catheter was
discontinued and the patient was not able to urinate. She
failed several voiding trials. The patient was also not on
any anticholinergics. Urology was consulted and stated to
follow up with Dr. [**Last Name (STitle) 9125**] in one to two weeks for a voiding
trial as an outpatient.
3. Knee pain: The patient was status post two attempted knee
taps, failed by rheumatology. The patient's pain was well
controlled with scheduled Tylenol and Ultram p.r.n. This was
felt to be most likely secondary to osteoarthritis. The
patient had no increasing warmth or swelling during the last
few days of hospitalization.
4. Hypothyroidism: The patient was stable throughout the
hospitalization on her thyroid replacement regimen.
5. Anemia: Her hematocrit was stable throughout the
hospitalization, will need outpatient iron studies.
6. Hypotension: The patient's blood pressures were stable
over the last few days of hospitalization. The patient's
atenolol was increased slowly throughout hospitalization to
25 mg q. day. The patient was on atenolol 100 q. day as an
outpatient. Will need follow up for titrating blood pressure
medications.
7. Coronary artery disease: The patient was started on
Plavix and stopped aspirin secondary to increased troponin
levels and recommendation of staff.
A beta blocker was increased as tolerated. The patient was
also ruled out for an myocardial infarction during this
hospitalization.
DISCHARGE DIAGNOSES:
1. C. difficile colitis.
2. Anemia.
3. Coronary artery disease.
4. Urinary retention.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient may be discharged to
rehabilitation.
DISCHARGE STATUS: The patient remained DNR/DNI throughout
the hospitalization.
DISCHARGE MEDICATIONS:
1. Calcitonin 200 units q. day.
2. Trazodone 25 mg p.o. q.h.s. p.r.n. sleep.
3. Famotidine 20 mg p.o. b.i.d.
4. Thyroid 60 mg p.o. q. day.
5. Vitamin D 400 units p.o. q. day.
6. Calcium carbonate 500 mg t.i.d.
7. Metronidazole 500 mg p.o. t.i.d. x 14 days.
8. Tylenol 500 mg p.o. q. 6 h.
9. Tramadol 50 mg p.o. t.i.d. p.r.n.
10. Docusate 100 mg p.o. b.i.d.
11. Senna one tablet p.o. b.i.d. p.r.n.
12. Plavix 75 mg p.o. q. day.
13. Metoprolol 25 mg p.o. b.i.d.
FOLLOW-UP PLANS:
1. The patient is to follow up with primary care physician in
one to two weeks.
2. The patient is to follow up with urology in one to two
weeks.
Dictated By:[**Last Name (STitle) 27342**]
MEDQUIST36
D: [**2171-8-17**] 09:20
T: [**2171-8-17**] 09:47
JOB#: [**Job Number 27343**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 4721**]
Admission Date: [**2171-8-13**] Discharge Date: [**2171-8-21**]
Date of Birth: [**2086-5-3**] Sex: F
Service:
Patient continued to stay in the hospital over the weekend
due to rehab placement issues. Some changes in her
medications were made including one for anemia since her B12,
folate, and ferritin levels were fine, her anemia was most
likely secondary to anemia of chronic disease. Patient was
started on Epogen 20,000 units subQ x1 and additionally q
week.
Patient had a few mental status changes over the weekend,
however, on day of discharge, patient was at baseline. All
of her psychotropic medications including famotidine and
tramadol were discontinued.
Clostridium difficile colitis: The patient had increasing
diarrhea over the weekend, a few days before discharge.
Patient was also given p.o. K-Phos and most likely was due to
the p.o. K-Phos. Her white count continued to decrease and
abdominal exams were benign. KUB were also negative.
Patient was continued on Flagyl and her Senna and Colace were
discontinued.
General care: The patient was also started on a
multivitamin.
DISCHARGE MEDICATIONS:
1. Calcitonin 200 unit spray one nasal q.d.
2. Thyroid 60 mg p.o. q.d.
3. Cholecalciferol 400 units one tablet p.o. q.d.
4. Calcium carbonate 500 mg p.o. q.i.d.
5. Metronidazole 500 mg p.o. t.i.d. x8 days.
6. Plavix 75 mg p.o. q.d.
7. Metoprolol 25 mg p.o. b.i.d.
8. Acetaminophen 500 mg p.o. q.6h.
9. Multivitamin one capsule p.o. q.d.
10. Erythropoietin 20,000 units q Tuesday.
11. Lovenox 40 mg subQ q.d.
FOLLOW-UP APPOINTMENTS:
1. Urology followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2028**] on [**2171-9-2**] at 9:30
am for outpatient voiding trial.
2. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4722**] on [**2171-9-3**] at 3
o'clock pm, the [**Hospital Ward Name **] Center.
3. Additional followup includes followup with Dr. [**Last Name (STitle) 3781**],
Gastroenterology on [**2171-9-12**] at 10:15 am.
4. Dr. [**First Name (STitle) 4723**], Rheumatology, on [**2171-10-24**] at 9:45 am.
Dictated By:[**Last Name (STitle) 4724**]
MEDQUIST36
D: [**2171-8-20**] 09:49
T: [**2171-8-20**] 10:16
JOB#: [**Job Number 4725**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 4721**]
Admission Date: [**2171-8-13**] Discharge Date: [**2171-8-21**]
Date of Birth: [**2086-5-3**] Sex: F
Service:
UPDATED PROBLEMS:
1. ID: The patient had continued low-grade fevers on
discharge. Possible sources is ongoing Clostridium
difficile, choledocholithiasis with sludge, heel ulcers, or
sacral decube. The patient had funguria in the past, only
[**1-21**] white blood cells on urinalysis and discharge. The
patient will need followup of her urine culture from [**2171-8-21**]
and positive funguria will need to be treated with
fluconazole.
2. Acute coronary syndrome: The patient has a history of
troponin leak. Patient, therefore, was started on Plavix and
increasing doses of beta blocker. Patient's medications are
changed from atenolol to metoprolol in light of history of
several episodes of renal failure. The patient will need
close followup of her blood pressure medications as she came
in on amlodipine 10 mg q.d., lisinopril 10 mg q.d., and
furosemide 40 mg q.d., and atenolol 100 mg q.d., and patient
is being discharged on metoprolol 50 mg b.i.d. Patient's
blood pressures can be increased as tolerated as an
outpatient.
3. Anemia: The patient was started on Epogen 20,000 units q
week. The patient was also started on folate on date of
discharge. Patient will need complete blood count checks q
week and if hematocrit greater than 34, patient should stop
her Epo.
4. Increasing alkaline phosphatase which is isolated: If
alkaline phosphatase persist to increase, [**First Name8 (NamePattern2) **] [**Doctor First Name **] may need to
be checked. Patient will need outpatient followup. Patient
also has a history of a cholecystectomy at age 28.
5. Decubitus ulcer: The patient was started on zinc and
vitamin C to help wound healing on day of discharge.
An updated list of her discharge medications:
1. Calcitonin 200 units nasal q.d.
2. Thyroid 60 mg p.o. q.d.
3. Cholecalciferol vitamin E 400 units one tablet p.o. q.d.
4. Calcium carbonate 500 mg patient q.i.d.
5. Flagyl 500 mg p.o. t.i.d. x8 days.
6. Plavix 75 mg p.o. q.d.
7. Metoprolol 50 mg p.o. b.i.d. with holding parameters
systolic blood pressure less than 100, heart rate less than
55.
8. Acetaminophen 500 mg p.o. q.6h.
9. Multivitamin one capsule p.o. q.d.
10. Epoetin alpha 20,000 units subQ q week, q Thursday.
11. Enoxaparin 40 mg subQ q.d.
12. Pantoprazole 40 mg p.o. q.d.
13. Zinc sulfate 220 mg p.o. q.d.
14. Vitamin C 500 mg p.o. b.i.d.
15. Regular insulin-sliding scale.
OUTPATIENT LABORATORY WORK: Complete blood count q week. If
hematocrit greater than 34, the patient can discontinue the
epoetin.
Patient is also to have followup on urine culture from
[**2171-8-21**]. If funguria persists, patient is to be treated
with fluconazole as an outpatient.
FOLLOWUP: Patient has Urology followup, PCP followup,
followup with Gastroenterology, Rheumatology, and her
cardiologist, Dr. [**Last Name (STitle) **].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 77**] 12-ADF
Dictated By:[**Last Name (STitle) 4724**]
MEDQUIST36
D: [**2171-8-21**] 14:22
T: [**2171-8-22**] 04:28
JOB#: [**Job Number 4726**]
|
[
"788.20",
"008.45",
"707.0",
"428.32",
"276.5",
"584.9",
"715.96",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4998, 5085
|
10390, 11701
|
2952, 4977
|
7745, 10367
|
2061, 2934
|
5770, 7289
|
200, 1322
|
148, 171
|
1345, 2038
|
5110, 5269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,344
| 167,481
|
43164
|
Discharge summary
|
report
|
Admission Date: [**2169-3-3**] Discharge Date: [**2169-3-10**]
Date of Birth: [**2102-7-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy, total abdominal colectomy with end
ileostomy
History of Present Illness:
66yo male presented with acute onset epigastric and
periumbilical pain. He describes the pain as constant and
nonradiating. +episode of emesis, -fever. Last BM three days
prior to presentation.
Past Medical History:
-CAD s/p MI 9 yrs ago
-HTN
-hypercholesterolemia
Social History:
-+tobacco 1ppd 50 pack years
-no EtOH abuse, 7 drinks/week
-works as a building manager
Family History:
-father deceased at 71y MI
-mother deceased at 50y MI
Physical Exam:
Gen awake alert nad
Heent perrl, eomi, nares patent, oropharynx without
erythema/exudate
Neck supple no masses
CV rrr, no m/r/g
Resp CTA bilaterally
Abd soft NTND incision c/d/i
Ext trace LE edema
Neuro aao x 4
Pertinent Results:
[**2169-3-7**] 05:14AM BLOOD WBC-10.6 RBC-2.36* Hgb-7.4* Hct-21.9*
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.6 Plt Ct-194
[**2169-3-6**] 02:39AM BLOOD WBC-14.0* RBC-2.42* Hgb-7.7* Hct-22.2*
MCV-92 MCH-31.9 MCHC-34.6 RDW-13.6 Plt Ct-173
[**2169-3-5**] 04:00PM BLOOD WBC-13.3* RBC-2.41* Hgb-7.8* Hct-22.4*
MCV-93 MCH-32.2* MCHC-34.8 RDW-13.7 Plt Ct-160
[**2169-3-5**] 02:44AM BLOOD WBC-12.4* RBC-2.59* Hgb-8.3*# Hct-24.0*#
MCV-93 MCH-32.1* MCHC-34.6 RDW-14.0 Plt Ct-152
[**2169-3-4**] 03:07AM BLOOD WBC-11.8* RBC-3.39* Hgb-11.4* Hct-32.3*
MCV-95 MCH-33.7* MCHC-35.3* RDW-13.6 Plt Ct-220
[**2169-3-7**] 05:14AM BLOOD Plt Ct-194
[**2169-3-6**] 02:39AM BLOOD Plt Ct-173
[**2169-3-6**] 02:39AM BLOOD PT-12.8 PTT-30.2 INR(PT)-1.1
[**2169-3-5**] 04:00PM BLOOD Plt Smr-NORMAL Plt Ct-160
[**2169-3-5**] 04:00PM BLOOD PT-13.6* PTT-32.2 INR(PT)-1.2*
[**2169-3-4**] 03:07AM BLOOD Plt Ct-220
[**2169-3-7**] 05:14AM BLOOD Glucose-105 UreaN-19 Creat-0.9 Na-143
K-3.5 Cl-111* HCO3-28 AnGap-8
[**2169-3-6**] 02:39AM BLOOD Glucose-91 UreaN-12 Creat-0.8 Na-142
K-3.6 Cl-110* HCO3-25 AnGap-11
[**2169-3-5**] 04:00PM BLOOD Glucose-104 UreaN-12 Creat-0.9 Na-141
K-3.4 Cl-110* HCO3-25 AnGap-9
[**2169-3-5**] 02:44AM BLOOD Glucose-88 UreaN-14 Creat-0.9 Na-140
K-3.7 Cl-111* HCO3-22 AnGap-11
[**2169-3-4**] 02:54PM BLOOD UreaN-16 Creat-0.9 Na-140 K-4.6 Cl-115*
HCO3-19* AnGap-11
[**2169-3-4**] 10:34AM BLOOD CK-MB-5 cTropnT-<0.01
[**2169-3-7**] 05:14AM BLOOD Calcium-7.1* Phos-2.9 Mg-1.9
[**2169-3-6**] 10:42AM BLOOD Albumin-2.2* Iron-24*
[**2169-3-6**] 02:39AM BLOOD Calcium-7.2* Phos-1.8* Mg-2.0
[**2169-3-5**] 04:00PM BLOOD Calcium-7.3* Phos-1.8* Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 93026**] was admitted and underwent an exploratory laparotomy
for his peritonitis where his colon was found to be infarcted
and nonviable from the cecum to the rectosigmoid. He underwent a
total colectomy with ileostomy. He was transferred intubated to
the SICU where he remained stable with an NGT in place. He was
resuscitated and remained stable in the ICU. POD2 he was
extubated without complication. His stoma site was noted to be
mildly ischemic and dusky, however, this resolved during his
hospitalization. He was transferred to the floor on POD3 and was
started on parenteral nutrition. He continued to do well, his
ostomy was pink and was functioning appropriately. His NGT was
discontinued and he completed a week course of ampicillin/zosyn
and flagyl. His diet was slowly advanced and he was discharged
on POD 8 when his ostomy output had decreased and he was able to
keep himself hydrated and eat a regular diet.
Medications on Admission:
asa 325', viagra
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days.
Disp:*6 Tablet(s)* Refills:*0*
4. Levofloxacin Intravenous
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
peritonitis
infarcted colon
Discharge Condition:
good
Discharge Instructions:
-please come to the emergency room if you have fever >101.4F,
nausea or vomiting, dizziness or weakness, persistent redness or
oozing from your surgical site, or shortness of breath.
-no lifting anything heavier than a telephone book for 3 weeks.
-you may shower normally but no tub bathing or swimming for 6
weeks.
-keep your abdominal incision clean and dry.
-do not drive while taking pain medications
-please keep up with your fluids while you are at home.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in [**1-20**] weeks. Call [**Telephone/Fax (1) 2998**]
for an appointment.
|
[
"305.1",
"401.9",
"272.0",
"275.41",
"285.9",
"557.0",
"276.2",
"275.2",
"V17.3",
"567.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"46.23",
"38.93",
"45.8",
"45.95"
] |
icd9pcs
|
[
[
[]
]
] |
4196, 4253
|
2763, 3711
|
328, 399
|
4325, 4332
|
1117, 2740
|
4841, 4976
|
816, 871
|
3778, 4173
|
4274, 4304
|
3737, 3755
|
4356, 4818
|
886, 1098
|
274, 290
|
427, 622
|
644, 695
|
711, 800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,012
| 138,125
|
33300
|
Discharge summary
|
report
|
Admission Date: [**2144-2-1**] Discharge Date: [**2144-2-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
85 y/o woman transfered from [**Hospital3 4107**]. She presented with
lethargy and altered mental status. Her WBC was 35 with 15%
bands. An LP performed showed 1000 WBC/4000 RBC in the first
tube. Head CT was negative. She was given meningitic doses of
Vanc/CTX/Amp and then transfered to [**Hospital1 18**] (patient treated at
[**Hospital1 336**] but no ICU beds there).
In the ED her vital signs were initially 100.4, 136, 156/60, 18,
100% on 2L. She was given Acyclovir. She had an episode of
tachycardia to ~200 while at CT and was given 5mg dilt IV with
decrease in HR to 118. She was found to have guaiac positive
stool and subsequently coffee ground emesis on NG lavage. She
was transfered to the ICU where a central line and arterial line
were placed.
Past Medical History:
from [**Hospital **] Hosp records and discussed with grandson)
DM - on oral hypoglycemics
HTN
chronic Hepatitis B
Hepatocellular Carcinoma (not biopsied diagnosed)
Pancreatic mass (son was not aware of this)
History of bowel perforation 5 years ago with operation c/b
perioperative MI and peri-op atrial fibrillation - not
anticoagulated
Recently diagnosed myelodysplastic syndrome which is supported
by transfusions of pRBCs and epogen in recent months
No h/o cirrhosis or varices
Social History:
Lives with her daughter and son-in-law, nonsmoker, no EtOH
Family History:
NC
Physical Exam:
97.7, 132, 134/65, 20, 100% 2L NC
GEN: lethargic, minimally arousable to voice and tactile
stimulation
HEENT: PERRL, MM dry
CV: tachy, RR, nl S1S2, II/VI flow murmur RUSB
RESP: tachypneic, coarse breath sounds bilaterally
ABD: +BS, diffusely tender, +guarding, no rebound
EXT: no c/c/e
Brief Hospital Course:
A/P; 85 y/o female with DM, HTN, known liver masses, pancreatic
mass, admitted with altered mental status, tachycardia, and
possible GI bleed.
1. Sepsis: The patient was transferred to the ICU [**2-6**] after
developing fluid-refractory hypotension on the floor and an
increasing oxygen requirement. Her urine output had been
dropping off prior to transfer and was minimal after transfer.
Her albumin was 1.5 and she third spaced most of the volume.
She ultimately required four pressors to maintain her BP as well
as stress steroids. The source of sepsis was unclear, but
likely a urinary or GI source. Final read of CT abdomen
demostrated SBO. She developed fulminant liver failure, DIC and
hemolytic anemia. She was intubated for resp distress and became
increasingly hypoxic, likely related to effusions and ascites.
The patient was made CMO by her family and expired at 3:05 pm on
[**2144-2-8**].
.
2. Altered MS: meningitis by CSF studies at OSH. Gram stain and
culture negative, but continued on empiric treatment. MS
improved until MICU transfer (see 1).
.
3. Abdominal cancer: unclear primary. Initially thought to be
HCC, but AFP was low. Mass at porta hepatis extending from liver
to pancreas therefore pancreatic AC vs. cholangiocarcinoma vs.
other. Had extensive retroperitoneal and mesenteric
lymphadenopathy. The family decided against further work up and
treatment.
.
4. ARF/Hydronephrosis: right hydro seen on initial CT scan and
urology thought not to intervene unless creatinine worsened.
Resolved on subsequent CT scan. Patient became anuric at
transfer to ICU. Renal team following, and thought patient would
require CVVH, but family opted for CMO.
.
5. GIB: Hematocrit followed, guaiac positive through
hospitalization. GI consulted and wanted ID situation stabilized
then would consider endoscopy. Her HCT remained stable after
initial 2 u prbc transfusions until she developed hemolytic
anemia related to sepsis.
.
6. Atrial fibrillation: intermittent periods of atrial
fibrillation, some with associated hypotension. Initially
responded to IV diltiazem. Had AF with RVR in setting of
sepsis, was cardioverted and put on amiodarone.
Medications on Admission:
(per discharge summary [**2144-1-18**]):
lisinopril 10mg po qd
colchicine 0.6mg po q48h
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Multiorgan system failure
Disseminated intravascular coagulation
Hemolytic anemia
Gastrointestinal bleeding
Meningitis
Urinary tract infection
Acute renal failure
Right hydronephrosis
Metastatic cancer, abdominal
Small bowel obstruction
Hypoalbuminemia
Distributive shock
Altered mental status
Respiratory failure
Relative adrenal insufficiency
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"038.9",
"286.6",
"199.1",
"238.75",
"070.32",
"560.9",
"427.31",
"518.81",
"401.9",
"320.9",
"584.9",
"591",
"599.0",
"250.00",
"785.52",
"578.9",
"995.92",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4362, 4371
|
2024, 4191
|
281, 305
|
4766, 4775
|
4831, 4953
|
1694, 1698
|
4330, 4339
|
4392, 4745
|
4217, 4307
|
4799, 4808
|
1713, 2001
|
220, 243
|
333, 1096
|
1118, 1602
|
1618, 1678
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,395
| 196,876
|
52164
|
Discharge summary
|
report
|
Admission Date: [**2159-5-30**] Discharge Date: [**2159-6-8**]
Date of Birth: [**2105-2-6**] Sex: F
Service: [**Hospital Unit Name 153**]
HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old
female with a history of breast cancer with known brain mets,
history of PE, recent radiation therapy and steroids who
presented in [**2159-4-2**] with myopathy presumed secondary to
sterids, which have been given for her brain mets. She was
later sent to rehab, but returned early in [**Month (only) 547**] with
increased cough with exertion with fever to 101. She was
treated with Levaquin given her temperatures and differential
diagnosis of increased PE burden load, infections or
pneumonia and questionable lymphangitic spread of her cancer.
The patient did not experience improvement in her symptoms
and was readmitted on [**5-21**] with continued dyspnea and fevers.
Review of CTA showed no PE, but there was ground glass
opacities on CT, so PCP was considered highly unlikely given
her recent history of steroid use. Her induced sputum was
negative and BOL was done and also negative. Sputum cultures
were negative. She was given Bactrim and she had improvement
in the shortness of breath after her Bactrim was started and
improved room air sats and was sent home on Bactrim. She
then continued to do poorly and then returned on [**5-29**]. She
presented on clinic on [**5-30**] with hypotension for which she
was given intravenous fluids. She spiked a fever to 103 with
blood pressures hypertensive into the systolic 80s and with
rigors. Chest x-ray showed a question of left lung opacity.
The patient was given Vancomycin and a gram of intravenous
fluids. Today, the patient was found in the bathroom and
became hypoxic with saturations in the 80s and was responsive
to oxygen, but was still tachypneic without improvement and
was placed on nonrebreather. Currently the patient is
admitted to the Intensive Care Unit for further medical care.
Currently the patient is short of breath without chest pain
or dysphagia.
PAST MEDICAL HISTORY:
1. Breast cancer left side diagnosed in [**2129**] status post
[**2150**] mastectomy with 5 out of 9 positive lymph nodes. She
was treated with chemotherapy and bone marrow transplant and
then later with Tamoxifen from [**2151**] to [**2156**]. In [**2158**] she had
mediastinal lymphadenopathy treated with Taxol and changed to
Navelbine on [**3-7**]. She had diagnosed brain mets in [**2159-3-4**] right side cerebella and parietal for which she was
treated with chemotherapy, radiation therapy and Decadron.
2. History of pulmonary embolism in [**2159-4-2**] treated with
only aspirin secondary to brain mets.
3. Asthma.
4. Gastritis.
5. Questionable history of _______________.
MEDICATIONS ON TRANSFER:
1. Protonix 40 mg q day.
2. Megace 400 q day.
3. Colace 200 b.i.d.
4. Aspirin.
5. Heparin subq.
6. Prednisone 40 q day.
7. ___________ 30 q day.
8. Clindamycin 900 q 8.
9. Levaquin 500 q day.
ALLERGIES: Penicillin.
SOCIAL HISTORY: She is an emergency room physician at the
[**Name9 (PRE) 882**]. She is married with three children.
PHYSICAL EXAMINATION: On examination on transfer to the
Intensive Care Unit she is febrile with a low grade
temperature of 100.1, tachycardic to 110, hypotensive 85/49,
tachypneic into the 50s and 60s, 95% on nonrebreather. In
general, she is extremely tachypneic, difficulty in speaking
words. Her heart is regular without murmurs, rubs or
gallops, slightly tachycardic. Her pulmonary examination
shows she has bronchial breath sounds with dry crackles at
the bases. Abdominal examination was benign. Extremities no
clubbing, cyanosis or edema. She is alert and following
commands.
LABORATORY: White blood cell count 3.2, hematocrit 26.6,
platelets 130, chemistry is 131, potassium 3.0, chloride 105,
bicarb 17, BUN 10, creatinine 0.5, glucose 105. Calcium 7.3,
phos 1.8, magnesium 1.5. She had a gas showing 7.36, 31, 96.
She had a CT from the 29th of her abdomen and pelvis showing
marked increased consolidations at the left lung base and
question of new left sided pleural effusion.
HOSPITAL COURSE:
1. Pulmonary: The patient was transferred to the Intensive
Care Unit for respiratory distress and febrile hypotension
with a question of a new infiltrate on her chest x-ray. The
exact etiology of the patient's respiratory distress was
presumed to be questionable multifactorial. There was
concern about possible pneumonia. Also she had a history of
PE and also there was concern about possible lymphangitic
spread of her breast CA. Given her fevers and shortness of
breath the patient was treated with broad spectrum
antibiotics initially started on Ceptaz, Levaquin and
__________ and Clindamycin. Lab two antibiotics were added
considering the patient was thought to be a relatively high
risk for PCP [**Name Initial (PRE) 1064**]. The patient was initially trialed on
BiPAP, but the patient was increasingly dyspneic, increased
respiratory stress and ultimately needed to be intubated on
[**6-1**]. Earlier during her Intensive Care Unit course she
underwent bronchoscopy, which was sent for cytology and
multiple bacterial pathogens all of which were negative.
Ultimately her Intensive Care Unit course continued and she
began to defervesce and her bacterial studies particulaly
from BAL lavage were found to be negative. The patient had
multiple antibiotics withdrawn. Clindamycin and
_______________ was discontinued early in hospital course.
Her PCP was thought to be negative. In addition, Vancomycin,
Levaquin were also discontinued. She was later continued on
Ceftazidine and Clindamycin for possible gram negative
infection and also for possible post obstructive picture that
she would be at risk for given her pulmonary anatomy. As the
[**Hospital 228**] hospital course went on the patient's respiratory
did not show mild improvement on the ventilator. She was
able to oxygenate originally. Unfortunately her mental
status failed to improve despite having been off all sedative
medications for several days. Later in her Intensive Care
Unit course family meetings took place and given the
patient's overall poor prognosis with decreased mental status
it was decided that the patient would become CMO.
Subsequently she was extubated on [**6-7**]. The patient
continues to actually ventilate well off of the respiratory.
However, she is CMO and will not be intubated for respiratory
distress.
2. Cardiovascular: The patient was initially transferred to
the Intensive Care Unit thought to be exhibiting septic
physiology, respiratory distress and hypotensive. She
required aggressive intravenous fluids and later required
pressor support with neo-synephrine. Later during her
Intensive Care Unit course she was felt to be somewhat
overloaded and intravenous fluids were cut back. It was
quite difficult weaning her off of neo-synephrine. She was
also given stress dose steroids. Later in her hospital
course she also had an echocardiogram for question of new ECG
findings in her inferior leads. Her echocardiogram, however,
was essentially normal with an ejection fraction of 55%
without any gross wall motion abnormalities or valvular
pathology. As mentioned above the patient's hemodynamic
status was tenuous throughout her hospital course as it was
difficult to wean the patient off of neo-synephrine. By [**6-7**], however, the patient had been off of neo-synephrine, but
at this time as mentioned above the patient was deemed to be
CMO per discussion with physicians and her husband/health
care proxy.
3. Hematology: Patient with a history of known malignancy
and also a history of pulmonary embolisms from [**2159-4-2**].
Earlier in her Intensive Care Unit course the team was
concerned about possible pulmonary embolisms as a possible
source of the patient's respiratory decompensation. However,
the patient also had brain metastasis and at this point
anticoagulation was thought to be a contraindication given
risk for hemorrhage into these tumors. She did have lower
extremity doppler ultrasounds, which were negative.
4. Infectious disease: As mentioned above patient initially
hypotension, febrile and in respiratory distress presumed to
be septic source likely pulmonary. Initially the patient was
treated with broad spectrum antibiotics including Vancomycin,
Ceptaz, Levaquin, Clindamycin and _________. All of her
cultures are negative to date. She was negative for PCP and
subsequently _____________ was continued and Clindamycin was
changed for anaerobic coverage. In addition her Vancomycin
and Levaquin were also discontinued. The patient remained
afebrile during the majority of her hospital course. By
virtue of discussions on [**6-7**] the patient was deemed to be
CMO and all antibiotics were withdrawn at this point.
5. Gastroenterology: The patient had an abdominal CT
earlier in her Intensive Care Unit course, which was
essentially negative for an intraabdominal pathology. She
was initially supported with tube feeds during her Intensive
Care Unit course, but at this point the patient is CMO and
tube feeds have been subsequently discontinued.
DISPOSITION: The patient's attending physician was in
constant communication with the [**Hospital 228**] health care proxy
her husband. As her Intensive Care Unit course continued and
the patient showed minimal signs of meaningful improvement,
continued discussions were had with the family about possibly
changing code status. Ultimately it was decided by [**6-7**]
that the patient had shown minimal improvement and minimal
evidence of improvement status, it was decided at this point
for the patient to be extubated and to move toward CMO care.
Subsequently all antibiotics, blood draws and supportive
blood pressure medications were withdrawn. Currently she is
comfortable with morphine and Ativan prn. Currently plans
are in the making for arranging for the patient to have home
hospice care.
Please see discharge addendum for further developments in the
patient's care.
DISCHARGE DIAGNOSES:
1. Metastatic breast cancer end stage.
2. Respiratory failure unclear etiology, presumed secondary
to possible pneumonia, questionable lymphangitic spread.
3. Sepsis presumed pulmonary source.
DISCHARGE CONDITION: Grim.
DISCHARGE MEDICATIONS:
1. Morphine prn.
2. Ativan prn.
3. Tylenol prn.
4. Albuterol and Atrovent nebs prn.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 5539**]
MEDQUIST36
D: [**2159-6-8**] 01:15
T: [**2159-6-8**] 05:47
JOB#: [**Job Number 107927**]
|
[
"359.4",
"198.3",
"486",
"276.5",
"197.0",
"518.81",
"196.1",
"584.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"38.93",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10312, 10319
|
10093, 10290
|
10342, 10693
|
4158, 10072
|
3164, 4141
|
188, 2056
|
2794, 3021
|
2078, 2769
|
3038, 3141
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,500
| 166,308
|
33862
|
Discharge summary
|
report
|
Admission Date: [**2187-7-22**] Discharge Date: [**2187-7-25**]
Date of Birth: [**2139-6-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Admitted to MICU for etoh detox/withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Name14 (STitle) 78258**] is a 48 yo man recently admitted to [**Hospital1 36497**] for EtOH detoxification who was transferred to [**Hospital1 18**]
for concerns regarding his gait and confusion.
.
In the ED, his initial VSs were 97.9, 85, 138/81, 18, 97%RA. Per
ED records, he was initially A&O x3 with horizontal nystagmus
and listing to the left with ambulation. He was evaluate by
neurology, but became combative and agitated during their exam
requiring sedation with benzodiazepines.
.
He received lorazepam 3 mg IV, diazepam 30 mg IV and folic acid,
thiamine and multivitamins IV.
.
He was transferred to the MICU for further management.
.
On arrival to the MICU, the pt was A&Ox2. Further history or
review of systems was unobtainable.
Past Medical History:
EtOH abuse with ? h/o withdrawal seizures
Schizoaffective d/o
Social History:
Per records, drinks a 12-pack of beer, a bottle of wine and some
shots of hard liquor daily. + h/o cocaine abuse.
Family History:
NC
Physical Exam:
Vitals: T: 96.1 BP: 137/69 P: 96 R: 19 SaO2: 96%RA
General: Sleeping, easily rousable, NAD, cooperative
HEENT: NCAT, PERRL but slow, EOMI, no scleral icterus, MMM
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 2 (does not know place). Squeezes
fingers, wiggles toes on command.
Pertinent Results:
Head CT: There is no evidence of intracranial hemorrhage,
hydrocephalus, shift of normally midline structures, or edema.
The [**Doctor Last Name 352**]-white matter differentiation appears intact throughout.
The visualized paranasal sinuses and mastoid air cells are
clear.
[**2187-7-22**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2187-7-22**] 05:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2187-7-22**] 05:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2187-7-22**] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-7-22**] 05:30PM WBC-12.5* RBC-4.61 HGB-14.0 HCT-41.5 MCV-90
MCH-30.4 MCHC-33.7 RDW-14.7
[**2187-7-22**] 05:30PM NEUTS-64.2 LYMPHS-27.3 MONOS-5.0 EOS-3.0
BASOS-0.4
[**2187-7-22**] 05:30PM PLT COUNT-380
[**2187-7-22**] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-7-22**] 05:30PM ALT(SGPT)-116* AST(SGOT)-224* ALK PHOS-85 TOT
BILI-0.5
[**2187-7-22**] 05:30PM GLUCOSE-92 UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
[**2187-7-22**] 10:56PM PT-11.8 PTT-35.9* INR(PT)-1.0
[**2187-7-25**] 05:54AM BLOOD WBC-9.1 RBC-4.27* Hgb-13.3* Hct-39.2*
MCV-92 MCH-31.2 MCHC-33.9 RDW-14.6 Plt Ct-326
[**2187-7-25**] 05:54AM BLOOD Glucose-90 UreaN-12 Creat-0.9 Na-142
K-3.9 Cl-106 HCO3-27 AnGap-13
[**2187-7-25**] 05:54AM BLOOD ALT-49* AST-43* LD(LDH)-202 AlkPhos-85
TotBili-0.6
Brief Hospital Course:
48M with significant EtOH history initially admitted to MICU
from detox with confusion, altered gait.
Hospital course:
Seen in the ED with stable vitals. Found to have horizontal
nystagmus and some gait ataxia. He was seen by neurology, but
was combative and agitated. He was given large doses of IV
Diazepam and admitted to the MICU for etoh withdrawal. He was
placed on a CIWA scale and given thiamine/folate. A Head CT was
obtained which was normal. Neurology was consulted who had
difficulty evaluating him due to his intoxication/sedative meds,
but felt there may be a focal component and recommended an MRI
Brain/Neck when he could tolerate the study.
.
On HD #1, received 100mg Valium in first 24 hrs. An abd u/s was
obtained which did not show any ascites and normal liver
echotexture. His transaminitis was felt to be due to baseline
NASH and alcoholic liver disease. On HD#2, received 20mg Valium
over 24 hrs. On HD#3 he was transferred to general medicine
floors. He was continued on Valium CIWA scale with thiamine and
folate. Social work was consulted for ETOH counseling. MRI
brain/cervical spine was ordered as the patient appeared more
stable, but the patient left the hospital against medical advice
before this could be obtained and before treatment of withdrawal
was complete.
Medications on Admission:
Paroxetine 40 mg daily
Quetiapine 100 tid
Aripiprazole 10 mg daily
Lorazepam prn
Discharge Medications:
1. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Facial droop, ? CVA
Discharge Condition:
LEAVING AGAINST MEDICAL ADVICE.
Discharge Instructions:
You are leaving AGAINST medical advice. You were originally
admitted to the hospital for alcohol withdrawal. You have been
only partially treated and are leaving prior to completing your
medical workup.
Followup Instructions:
Please follow up with a doctor as soon as possible
Completed by:[**2187-9-6**]
|
[
"571.1",
"291.0",
"781.2",
"303.91",
"300.00",
"295.70",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5345, 5351
|
3616, 3719
|
355, 362
|
5434, 5468
|
2024, 2024
|
5721, 5802
|
1373, 1377
|
5045, 5322
|
5372, 5413
|
4940, 5022
|
3736, 4914
|
5492, 5698
|
1392, 2005
|
273, 317
|
390, 1141
|
2033, 3593
|
1163, 1226
|
1242, 1357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,476
| 135,532
|
1982
|
Discharge summary
|
report
|
Admission Date: [**2182-6-27**] Discharge Date: [**2182-7-3**]
Date of Birth: [**2105-9-27**] Sex: M
Service: CARDIOTHORACIC
CHIEF COMPLAINT: The patient is a postoperative admission.
He was admitted directly to the Operating Room where he
underwent coronary artery bypass grafting.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10905**] is a 76 year-old
man who has had an myocardial infarction in [**2164**] and has
been stable since that time. He had a positive exercise
tolerance test in [**Month (only) 404**] of this year without symptoms, but
with 2 to [**Street Address(2) 2051**] depressions in V4-V6 and 1 to 1.[**Street Address(2) 1755**]
depressions in the inferior leads, which resolved after three
minutes. He had slight decrease in blood pressure at that
time and an echocardiogram showed baseline hypokinesis. He
underwent cardiac catheterization on [**2182-6-19**], which
revealed left main 40% occlusion, left anterior descending
coronary artery 80% occlusion, circumflex with 90% occlusion,
obtuse marginal two 70%, right coronary artery 70% and an EF
of 60%. At that time he was allowed to go home and was
readmitted for coronary artery bypass grafting on the 26.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
diabetes mellitus, sleep apnea, benign prostatic hypertrophy
and a history of hepatitis up to 35 years ago with poor
documentation.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Aspirin 325 q.d.
2. Metformin 1000 b.i.d.
3. Simvastatin 20 mg po q.d.
4. Tiazac 240 mg q.d.
5. Terazosin 5 mg q.h.s.
6. Lisinopril 10 mg q.d.
SOCIAL HISTORY: No tobacco use. Rare alcohol use. Lives at
home with his wife.
PHYSICAL EXAMINATION PRIOR TO ADMISSION: No acute distress.
Lungs are clear bilaterally. Cardiovascular regular rate and
rhythm. S1 and S2 with no murmurs, rubs or gallops. Abdomen
is soft and nontender. Positive bowel sounds. No masses or
hepatosplenomegaly. Neck is supple. No lymphadenopathy.
Carotids are 2+ bilaterally with no bruits. Extremities warm
and well perfuse with no clubbing, cyanosis or edema and no
varicosities. Neurological is a nonfocal examination.
HOSPITAL COURSE: On the 26th the patient was admitted to the
Operating Room where he underwent coronary artery bypass
grafting. Please see the full Operating Room report for full
details. In summary, the patient had a coronary artery
bypass graft times four with a left internal mammary coronary
artery to the left anterior descending coronary artery,
saphenous vein graft to the right posterior descending
coronary artery and saphenous vein graft to the obtuse
marginal and saphenous vein graft to the diagonal. He
tolerated the operation well and was transferred from the
Operating Room to the cardiothoracic Intensive Care Unit. At
the time of transfer the patient was A paced at a rate of 80.
He had a mean arterial pressure of 64 and CVP of 7 with
nitroglycerin at 0.5 micrograms per kilogram per minute and
Propofol at 10 micrograms per kilogram per minute. The
patient did well in the immediate postoperative period. He
was weaned from all cardioactive drugs. His neurological was
reversed. He was weaned from the ventilator and successfully
extubated. On postoperative day one the patient remained
hemodynamically stable and he was transferred from the
Cardiothoracic Intensive Care Unit to Far Two for continuing
postoperative care and cardiac rehabilitation.
On postoperative day two the patient's chest tubes and
epicardial pacing wires were removed with the assistance of
the nursing staff and physical therapy. Over the next
several days the patient's activity level was increased. On
postoperative day it was noted that the patient had a
slightly tender abdomen. A KUB at that time revealed a fair
amount of stool in the bowel. The patient at that point was
given a laxative with good results and the abdominal
tenderness resolved. On postoperative day six it was decided
that the patient was stable and ready for transfer to a
rehabilitation center for continuing postoperative care.
DISCHARGE PHYSICAL EXAMINATION: Vital signs temperature 99.
Heart rate 54 sinus rhythm. Blood pressure 111/62.
Respiratory rate 18. O2 sat 94% on 2 liters. Weight
preoperatively is 84.5 kilograms. At discharge it is 82
kilograms. Laboratory had a white blood cell count of 12,
hematocrit 28, platelets 367, sodium 136, potassium 4.4,
chloride 98, CO2 28, BUN 32, creatinine 1.0, glucose 141.
Alert and oriented times three. Moves all extremities,
follows commands. Respirations clear to auscultation
bilaterally. Heart regular rate and rhythm. S1 and S2.
Sternum is stable. Incision with Steri-Strips open to air,
clean and dry. Abdomen is soft, nontender, nondistended.
Normoactive bowel sounds. Extremities are warm and well
perfuse with no clubbing, cyanosis or edema. Lower extremity
vein harvest site with Steri-Strips, no erythema.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg q.d. times seven days.
2. Potassium chloride 20 milliequivalents q.d. times seven
days.
3. Colace 100 mg po b.i.d.
4. Aspirin 325 mg q.d.
5. Metformin 1000 mg b.i.d.
6. Simvastatin 20 mg po q.d.
7. Lisinopril 10 mg q.d.
8. Pantoprazole 40 mg q.d.
9. Metoprolol 25 mg b.i.d.
10. Regular insulin sliding scale.
11. Percocet 5/325 one to two tabs q 6 hours prn.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times four with a left internal mammary
coronary artery to the left anterior descending coronary
artery, saphenous vein graft to the posterior descending
coronary artery, saphenous vein graft to the obtuse marginal
and saphenous vein graft to the diagonal.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes mellitus.
5. Benign prostatic hypertrophy.
6. Questionable history of hepatitis.
The patient is to have follow up with Dr. [**Last Name (STitle) 70**] in six
weeks and then follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3444**] in three to
four weeks following his discharge from rehabilitation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 9076**]
MEDQUIST36
D: [**2182-7-3**] 09:20
T: [**2182-7-3**] 09:32
JOB#: [**Job Number 10906**]
|
[
"272.0",
"997.1",
"412",
"600.0",
"401.9",
"427.1",
"414.01",
"423.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5418, 6434
|
4979, 5365
|
2204, 4112
|
1468, 1621
|
4135, 4956
|
164, 306
|
335, 1217
|
1240, 1447
|
1638, 2186
|
5390, 5397
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,797
| 127,928
|
21752+21753
|
Discharge summary
|
report+report
|
Admission Date: [**2175-8-21**] SUMMARY Date: [**2175-8-24**]
Date of Birth: [**2175-8-21**] Sex: F
Service: NB
INTERIM SUMMARY
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] number one was
born at 11:12 a.m. on [**8-21**] to a 22-year-old, gravida
1, para 0. She is a mono-mono twin who had cesarean section
performed on the day of delivery secondary to growth
restriction in twin number two.
Prenatal labs were as follows: Blood type B positive,
antibody screen negative, hepatitis B surface antigen
negative, RPR nonreactive, rubella immune, unknown GBS
status. She had received a complete course of Betamethasone
in [**Month (only) 216**].
Twin number one emerged vigorous. Apgar scores were 7 and 8.
Her birth weight was 1770 g, 50th percentile. Her length was
43.5 cm, 50th percentile, and her head circumference was 31.5
cm, 75th percentile.
PHYSICAL EXAMINATION: Physical examination upon admission
demonstrated a pink, appropriate for gestational age, alert
and active premature baby girl with grunting and retractions.
Her head and neck examination were unremarkable. Her
respiratory examination was notable for grunting and
decreased air entry. Her cardiovascular examination was
normal without murmurs. Her abdominal examination was
benign. Her neurologic examination showed tone within normal
limits.
HOSPITAL COURSE: Respiratory: She was intubated after being
brought to the NICU secondary to respiratory distress. She
received two doses of surfactant by ET tube. She was weaned
on the ventilator and extubated on day of life two. She has
been on room air since with no apneic or bradycardiac spells.
Cardiovascular: She has been cardiovascularly stable with no
murmurs since admission. Her blood pressures and perfusion
are normal.
Fluids, electrolytes, and nutrition: She was initially NPO
on intravenous fluids with normal glucoses and electrolytes.
We initiated feedings on day two of life. She is currently
at 65 cc/kg of Special Care 20 cal/oz. She is advancing 15
cc/kg twice a day. She did have a sodium of 150 today. Her
feeding volume was increased to 240 cc/kg/day.
Gastrointestinal: She has had no feeding intolerance thus
far. She is on phototherapy for a bilirubin that has peaked
at 8.2. Most recent bilirubin was 8.1 on day of life number
three, the day of this interim summary.
Hematology: She had an initial hematocrit that was 38
percent.
Infectious disease: She had a complete blood count that was
sent upon admission with a total white blood cell count of
8.3 with 13 polys and no bands. She was started on
Ampicillin and Gentamicin. She had a repeat CBC that was
sent on day of life two which showed a total white blood cell
count of 5.9 and 35 polys with no bands and 61 percent
lymphocytes. Her platelets were 276,000.
She continued on Ampicillin and Gentamicin for a total course
of 48 hours. Her blood culture was negative at that time,
and she has had no other infectious issues.
Neurology: Her neurologic examination has been normal.
CONDITION AT TIME OF SUMMARY: Good.
INTERIM DIAGNOSIS: Prematurity.
Twin gestation.
Hyperbilirubinemia.
Presumed sepsis.
REVIEWED BY: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 57160**]
MEDQUIST36
D: [**2175-8-24**] 19:02:05
T: [**2175-8-24**] 20:22:09
Job#: [**Job Number 57161**]
Admission Date: [**2175-8-21**] Discharge Date: [**2175-9-22**]
Date of Birth: [**2175-8-21**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **], twin number one, is a 32 and [**1-29**]
week gestation female infant, delivered at 11:12 a.m. on the
morning of [**8-21**]. Mother is a 22 year old, Gravida I,
Para 0 now II Mom. Estimated date of confinement [**2175-10-13**]. Mom had been followed very closely and was
referred early in the pregnancy to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] because of
a diagnosis of monochorionic monoamniotic pregnancy. This
pregnancy was also complicated by growth restriction of twin
number two. Maternal prenatal screens: Blood type B
positive; antibody negative; hepatitis B surface antigen
negative, RPR nonreactive, Rubella immune, group beta strep
status unknown. Betamethasone was given in [**Month (only) 216**]. This
mother was followed with serial ultrasounds. Because of the
high risk associated with monoamniotic pregnancy and twin B's
growth restriction, the babies were delivered electively at
32 and 3/7 weeks gestation. Delivery was an uncomplicated
cesarean section. Apgars were seven at one minute and eight
at five minutes of age.
PHYSICAL EXAMINATION: Weight 1770 grams (50th percentile);
length 43.5 cm (50th percentile); head circumference 31.5 cm
(75th percentile). Vital signs: Heart rate 150; respiratory
rate 80; blood pressure 44/23, mean arterial pressure of 29.
HEAD, EYES, EARS, NOSE AND THROAT: Anterior fontanel soft
and flat. Pupils equal and reactive to light. Small
pupillary membrane remnant. Palate intact. Respiratory:
Breathing with retractions, grunting, reduced air entry.
Cardiovascular: Normal S1 and S2. No murmur. Fairly good
perfusion. Abdomen soft with no distention. Genitourinary:
Average for gestational age; normal female external
genitalia. Neurologic: Tone within normal limits.
Extremities: Moving all extremities well. Hips with
increased laxity but not dislocatable.
HOSPITAL COURSE:
Respiratory: The infant was intubated shortly after
admission to the newborn Intensive Care Unit. She received
two doses of Surfactant. She was extubated to room air on day
of life one. She has been in room air for the remainder of
her hospitalization. She had occasional oxygen saturation
drifts but no apnea of prematurity. No methylxanthines were
initiated.
Cardiovascular: This infant received one normal saline bolus
at birth for a low blood pressure. Her blood pressure has
remained stable for the remainder of her hospitalization. No
pressor support required. Heart rate has been in the 140 to
160 range. No murmurs.
Fluids, electrolytes and nutrition: Intravenous fluids of D-
10-W were started at 80 cc/kg per day upon admission to the
Neonatal Intensive Care Unit. Enteral feeds were started on
day of life one. She advanced to full volume feeds of breast
milk at 150 cc per kg per day without incident by day of life
six. Caloric density was advanced to breast milk 26 calories
per ounce with ProMod.
Currently she is feeding p.o. ad lib of breast milk 24 cals/oz
or NeoSure 24 cals/oz. Last electrolytes on day of life
seven were a sodium of 143; potassium of 4.9; chloride of 110
and bicarbonate of 28. Weight at the time of transfer was
2,500 grams; length 47 cm and head circumference 35 cm.
Gastrointestinal: Phototherapy was started on day of life
one for a bilirubin of 6.6. Phototherapy was discontinued on
day of life six for a bilirubin of 6.5. A rebound bilirubin
of 5.8 on day of life seven.
Infectious disease: A CBC with differential and a blood
culture were drawn upon admission to the Neonatal Intensive
Care Unit. White blood cell count was 8,300. Hematocrit was
38.5. Platelet count was 278,000 with 13 percent polys and 0
percent bands. Blood culture was negative at 48 hours. The
infant was started on Ampicillin and Gentamycin upon
admission to the Neonatal Intensive Care Unit and was
discontinued at 48 hours with the negative blood culture.
This infant's sister's surface cultures are positive for MRSA.
Neurology: A head ultrasound was performed on day of life
seven and at one month, both of which were normal.
Sensory: A hearing screen was performed before discharge and
she passed in both ears. Eyes were examined most recently on
[**9-11**], revealing immaturity of the retinal vessels but
no ROP as of yet. A follow-up examination should be scheduled
for the week of [**10-2**].
Psychosocial: Parents are involved and [**Hospital1 190**] social work has been involved with the family.
The contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT TIME OF DISCHARGE: Excellent. Day of life 32,
corrected gestational age of 37 and 1/7 weeks' gestation.
DISCHARGE DISPOSITION: To Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44793**], [**Location (un) 37540**]
Pediatrics. [**Last Name (un) **]. [**Hospital1 **], [**Numeric Identifier **] Phone:
[**Telephone/Fax (1) 37546**].
CARE/RECOMMENDATIONS:
1. Feedings: 24 calories breast milk with NeoSure powder or
NeoSure 24 cal/oz.
2. Medications: Ferrous sulfate (25 mg/ml concentration) 0.2
cc daily.
3. State newborn screen status: Last newborn screen was
sent on [**9-4**]. No abnormal results have been reported.
The 6 week state screen is due [**2175-10-2**].
4. IMMUNIZATIONS: The infant received her first hepatitis B
vaccine on [**9-8**]. No others have been given.
5. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] to [**Month (only) 547**] for infants who meet any
of the following three criteria: 1. ) Born at less than 32
weeks. 2.) Born between 32 and 35 weeks with two of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings. Or, 3.) With chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW UP: Follow-up appointment with ophthalmology should
be scheduled for the week of [**10-2**]. Dr. [**Last Name (STitle) **] is the
following ophthalmologist.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 and 3/7 weeks.
2. Respiratory distress syndrome.
3. Transient hypotension.
4. Rule out sepsis.
5. Hyperbilirubinemia.
6. Immature retinas.
7. Sibling with MRSA colonization.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern4) 56994**]
MEDQUIST36
D: [**2175-9-12**] 02:25:25
T: [**2175-9-12**] 04:33:26
Job#: [**Job Number 57162**]
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8652
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Discharge summary
|
report
|
Admission Date: [**2125-12-24**] Discharge Date: [**2126-1-8**]
Date of Birth: [**2054-1-15**] Sex: M
Service: MEDICINE
Allergies:
Ticlid / Integrilin / Zocor / Zetia
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
CHF exacerbation, admitted directly from [**Hospital **] clinic
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 30233**] is a 71-year-old man with end-stage ischemic
cardiomyopathy with class IV symptoms whose functional status
has worsened in the past month. He was seen in advanced heart
failure clinic 1 week ago by Dr. [**Last Name (STitle) 30292**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who
felt he was in decompensated systolic heart failure. At that
point he complained of worsening dyspnea at rest and daytime
somnolence with feeling dizzy after taking his morning blood
pressure medications. They recommended he decrease his Toprol to
50 mg a day to see if he might feel better with less
beta-blockade, to discontinue his Imdur if he has substantial
headache or feels dizzy and noted that if his symptoms persist,
he may need to be admitted at his follow up appointment this
week for inotropic-assisted diuresis with the consideration for
palliative therapy with home inotropic treatment. They also
asked him to discontinue Lipitor secondary to muscle cramps. He
was seen for follow up in the clinic this morning and reported
an 8 lb weight gain over the past week, increasing LE edema,
dyspnea at rest, persistent orthopnea and difficulty sleeping.
He was admitted directly from clinic for diuresis and CHF
management.
ROS: in addition to above symptoms + for baseline intermittent
non-radiating CP on exertion which resolves with nitro, 2 pillow
orthopnea, decreased appetite past 2 months, dizziness with
activity, easy fatigueability, mild muscle cramps. negative for
cough, abd pain, N/V/D, fever, chills, passed BM q 2 days, no
BRBPR or hematuria or difficulty urinating.
.
Past Medical History:
-CAD s/p s/p CABG [**2096**] (SVG-LAD, SVG-OM, SVG-RCa), Re-do CABG
[**2110**] (LIMA-D1, SVG-OM, SVG-RCA), and numeropus
angioplasties/stenting procedures to the native arteries as well
as the bypass grafts:
-recent cath [**2-4**] showed all native vessels proximally occluded.
The LIMA to D1 graft is patent with 50% disease after the
touchdown, SVG to LAD graft had 70% lesion treated with a
drug-eluting stent, and SVG to OM1 graft is patent with 90%
disease in the AV groove circumflex artery.
-s/p biventricular AICD placed [**2-4**] after VF arrest
-Thrombus on AICD wire, on coumadin
-s/p ventricular tachycardia eblation [**2125-11-20**]
-Chronic systolic and diastolic heart failure: severe LV
dysfunction with an EF of 15%
Renal insufficiency, creat 3.0
PVD s/p external iliac artery stent [**6-3**]
Gastritis
Hypertension
Hyperlipidemia
BPH- no longer on flomax
Social History:
Originally from [**Country 18084**], lives in [**Location 47**] with his wife.
Used to work designing signs. Smoked 1/2-1 ppd x 50 years, quit
in 4/[**2124**]. 1 glass wine with dinner. has son and daughter in the
area.
Family History:
Father with HTN, MI in his 60s, mother with stomach CA, sister
with some type of nasal cancer.
Physical Exam:
VS - T95.5 BP 112/78 HR 88 RR 20 95% on 3L NC
Gen: WDWN elderly male in NAD but occasionally stops talking to
take his breath. 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 to angle of jaw
CV: RR, normal S1, S2. ?s3. no murmurs appreciated. No thrills,
lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Midline
chest scar well healed. Resp were slightly labored, no accessory
muscle use. Decreased BS L>R, crackles at R base, no wheezes or
rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: 2+ pitting edema to shins.
Skin: dried flaky skin on legs, no ulcers, or xanthomas.
Pertinent Results:
[**2125-12-24**] 07:00PM BLOOD WBC-8.0 RBC-4.15* Hgb-11.9* Hct-36.7*
MCV-89 MCH-28.6 MCHC-32.4 RDW-16.1* Plt Ct-243
[**2125-12-30**] 03:57AM BLOOD WBC-19.4* RBC-3.93* Hgb-11.4* Hct-34.3*
MCV-87 MCH-29.0 MCHC-33.2 RDW-16.6* Plt Ct-193
[**2126-1-5**] 07:24AM BLOOD WBC-9.6 RBC-3.43* Hgb-9.7* Hct-29.7*
MCV-87 MCH-28.2 MCHC-32.6 RDW-16.8* Plt Ct-281
[**2125-12-24**] 07:00PM BLOOD Neuts-84.7* Lymphs-6.5* Monos-6.0 Eos-2.5
Baso-0.2
[**2125-12-30**] 04:58PM BLOOD Neuts-93.0* Lymphs-3.4* Monos-3.2 Eos-0.3
Baso-0.1
[**2126-1-3**] 03:59AM BLOOD Neuts-86.0* Lymphs-5.7* Monos-7.3 Eos-0.9
Baso-0
[**2125-12-24**] 07:00PM BLOOD PT-15.9* PTT-23.5 INR(PT)-1.4*
[**2125-12-30**] 04:58PM BLOOD PT-26.7* PTT-35.2* INR(PT)-2.7*
[**2126-1-5**] 07:24AM BLOOD PT-28.0* PTT-35.3* INR(PT)-2.8*
[**2125-12-24**] 07:00PM BLOOD Glucose-110* UreaN-71* Creat-2.6* Na-131*
K-3.7 Cl-89* HCO3-29 AnGap-17
[**2125-12-30**] 04:58PM BLOOD Glucose-206* UreaN-78* Creat-3.6* Na-119*
K-3.8 Cl-73* HCO3-35* AnGap-15
[**2126-1-5**] 07:24AM BLOOD Glucose-135* UreaN-97* Creat-2.9* Na-119*
K-5.0 Cl-83* HCO3-26 AnGap-15
[**2125-12-24**] 07:00PM BLOOD Calcium-9.1 Phos-4.7* Mg-2.3
[**2126-1-5**] 07:24AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.7*
[**2125-12-30**] 03:57AM BLOOD TSH-2.3
[**2125-12-30**] 03:57AM BLOOD Cortsol-42.3*
[**2125-12-30**] 03:57AM BLOOD Osmolal-276
.
[**2126-1-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2126-1-2**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
NGTD
[**2126-1-2**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NGTD
[**2126-1-1**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NGTD
[**2126-1-1**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NGTD
[**2125-12-31**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NGTD
[**2125-12-31**] BLOOD CULTURE AEROBIC BOTTLE-FINAL NGTD; ANAEROBIC
BOTTLE-FINAL {STAPH AUREUS COAG +} INPATIENT
[**2125-12-30**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} INPATIENT
[**2125-12-30**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2125-12-30**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL {STAPH AUREUS COAG +} INPATIENT
[**2125-12-29**] URINE URINE CULTURE-FINAL INPATIENT
[**2125-12-29**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} INPATIENT
[**2125-12-29**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}
[**2125-12-29**] 8:14 am BLOOD CULTURE Source: Line-iv.
**FINAL REPORT [**2126-1-1**]**
AEROBIC BOTTLE (Final [**2126-1-1**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2126-1-1**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Hospital Ward Name **] 6B 21:35 [**2125-12-29**].
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
ECG Study Date of [**2125-12-24**] 5:28:36 PM
Ventricular paced rhythm with ventricular premature beats.
Compared to tracing of [**2125-11-21**] no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 124 158 394/453 44 -111 55
.
[**2125-12-24**] PA and lateral chest compared to [**9-21**]:
Mild pulmonary edema, progressive pulmonary vascular
engorgement, moderate left and small right pleural effusion are
all new since [**9-21**]. Heart size is partially obscured but
probably larger as well. Transvenous right atrial and left
ventricular pacer leads and right ventricular pacer
defibrillator leads are unchanged in their respective positions.
There is no pneumothorax.
.
[**2125-12-29**] Portable upright chest radiograph obtained and compared
to prior study. There is marked cardiomegaly. Patient is status
post median sternotomy. An ICD/pacer is present in the left
chest wall. Three leads terminate within the right atrium and
right ventricle. The right lung is clear. The left lung
demonstrates a mildly loculated pleural effusion as well as left
lower lobe atelectasis versus consolidation. Since the prior
study, the right lung appears to have cleared. The left lung
remains the same.
[**2126-1-2**] CHEST (PORTABLE AP) In comparison with the study of
[**1-1**], the lung volumes have decreased. However, there is little
change in the enlargement of the cardiac silhouette with
pulmonary vascular congestion. Pacemaker device remains in
place.IMPRESSION: Little change.
[**2126-1-5**] 8:03 AM CHEST (PORTABLE AP) Comparison to [**2126-1-4**]. The radiographic appearance is almost unchanged. Moderate
cardiomegaly, left-sided pacemaker, and right-sided central
access. No evidence of cardiac decompensation, suprabasal linear
atelectasis, unchanged minimal cardiac effusion. No evidence of
pneumonia. IMPRESSION: Unchanged radiograph as compared to
[**2126-1-4**].
.
SHOULDER [**3-3**] VIEWS NON TRAUMA LEFT PORT [**2125-12-30**] 2:04 PM
Two views of the left shoulder are obtained. Left chest wall
pacer/AICD is present. This partially obscures visualization of
the left glenoid. There is normal mineralization. There is
moderate osteoarthritis of the acromioclavicular joint. The
humeral head is high riding, consistent with longstanding
rotator cuff tear. There are mild degenerative changes in the
glenohumeral joint as well.IMPRESSION:Moderate degenerative
changes of the acromioclavicular joint. Chronic radiographic
findings of longstanding rotator cuff tear. Mild degenerative
changes of glenohumeral joint.
.
TTE [**2125-12-31**]- The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. There is mild global right ventricular 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. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild to moderate ([**1-30**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: No valvular vegetations seen.
.
UNILAT UP EXT VEINS US [**2126-1-3**] 11:04 AM
FINDINGS: Ultrasound evaluation of the left upper extremity deep
venous system using grayscale, color, and pulsed wave Doppler
reveals the veins to be fully compressible with normal color
flow, augmentation, and respiratory variation in flow.
IMPRESSION: No evidence of DVT involving the left upper
extremity.
Brief Hospital Course:
71 y o M with end-stage ischemic cardiomyopathy with class IV
symptoms admitted for diuresis. Hospital course by problem:
.
#. Acute on Chronic systolic and diastolic heart failure EF 15%:
Patient has class IV heart failure symptoms. He was diuresed 6
liters on the floor as inpatient but suffered a drop in his
sodium in the setting of diuresis with lasix and [**Last Name (LF) 30293**], [**First Name3 (LF) **] he
was transferred to the CCU for a trial on milrinone for
diuresis. This was ineffective and his sodium continued to drop,
renal was consulted who recommended hypertonic saline to correct
sodium, with a sodium nadir of 117. Hypertonic saline was d/c'd
when sodium was 126. He was transferred to a PO regimen of
lasix 60mg po daily (home dose was 40mg po daily) and home dose
of spironolactone. The patient is fluid overloaded but given
his end stage heart failure he was unable to be diuresed any
further, he has peripheral edema and pulmonary edema- his LUE
has worse edema but there is no upper extremity DVT on
ultrasound. Patient should not receive [**First Name3 (LF) 30293**] in the future,
but can receive lasix. The patient has a very poor prognosis and
this was explained to him. After repeated discussions the
patient decided to turn off his ICD functioning and in a family
meeting it was determined he would be DNR/DNI. The goals of care
were determined to be for him to return home with hospice care
with the goal of making him comfortable. He was transferred back
to the cardiology floors where he was continued on lasix 60mg
and spironolactone and he was kept comfortable on 2-3L O2. No
further labs are to be drawn.
.
#. Hyponatremia- He had a low baseline Na due to end stage CHF
but this became more profound with diuresis. He was given
hypertonic saline, which improved the sodium only transiently.
Diuresis was limited by hyponatremia and renal failure and
repletion of Na was limited by his heart failure. Renal was
consulted and agreed with above. He was initially severely
fluid restricted to 1L, but given his request to drink and the
goal shifting to comfort this restriction was loosened to 1.5L
daily.
.
#. Bacteremia: 4/4 bottles from [**12-29**], and [**4-3**] from [**12-30**] had MRSA
in blood. No positive cultures from [**1-1**] thru [**1-3**]. Unclear
source for infection, possibly an infiltrated IV site in his
hand, but given pacer/indwelling hardware, we chose to
aggressively treat. TTE did not show evidence of vegitation and
a TEE was deferred. ID was consulted, IV vancomycin was started
on [**12-29**] and a PICC was placed on [**1-1**]. The plan is to continue
the patient on vancomycin for a 6 week course for palliation.
#. Coronary artery disease:
He was continued on his outpatient regimen of aspirin, plavix,
statin, imdur 30mg daily, hydralazine 50mg po q6hrs. Lopressor
50mg po bid. On discharge his statin was discontinued given this
is for long-term prevention and his prognosis was poor.
.
#Rhythm: Biventricularly paced, tachycardia and ectopy mildly
improved since admission, though frequent PVCs. S/p VT ablation
in [**11-4**]. Apparently has been intermittently on amiodarone after
his Vfib arrest in [**2-4**]. He was continued on Metoprolol 50 mg
po bid and Coumadin 2mg daily.
#. History of ICD wire thrombus. Goal INR [**3-3**], he was
anticoagulated with coumadin. He was kept on his outpatient
regimen of 2mg daily coumadin. No further labs are to be drawn.
.
#. Acute on Chronic renal insufficiency, baseline Cr ~2.6. His
Cr improved initially with diuresis likely from improved forward
flow, but then bumped as diuresis was limited as explained above
.
#. Gastritis- He was continued on ranitidine and PPI
.
#Anemia: Normocytic. Iron-deficient in [**2-4**] and currently on
iron supplementation. Likely also from renal disease. Hct was
stable. He was continued iron replacement though this was
discontinued to simplify his home regimen.
.
#. [**Name (NI) 30294**] Pt did not complain of symptoms, currently not on any
meds for this.
.
#. LE muscle cramping- Pt cramps improved w/flexeril but returns
occasionally. [**Month (only) 116**] be secondary to hypokalemia. Pain was also
managed with oxycodone.
#. Code Status: DNR/DNI
Communication: patient and HCP wife [**Name (NI) **] [**Telephone/Fax (1) 30295**] (h);
[**Telephone/Fax (1) 30296**] (o); ([**Telephone/Fax (1) 30297**] (c)
Dispo: home with hospice care
.
Medications on Admission:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) PO DAILY
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: as needed for
chest pain.
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Hexavitamin One (1) Cap PO DAILY
7. Ferrous Sulfate 325 (65) mg Tablet PO DAILY
8. Folic Acid 1 mg (1) Tablet PO DAILY
9. Atorvastatin 40 mg (1) Tablet PO DAILY (changed last week
from 80)
10. Toprol XL 50 mg PO daily (changed last week from 100)
11. Prilosec 40 mg Capsule, Delayed Release(E.C.)po daily
12. Ranitidine HCl 150 mg Tablet (1) Tablet PO HS
13. Warfarin 4 mg PO DAILY (Daily)--->confirm
14. Fish Oil 1,000 mg PO daily
15. Spironolacton-Hydrochlorothiaz 25-25 mg, 0.5 Tablet PO daily
16. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous Q 24H (Every 24 Hours) for 33 days: start date
[**2125-12-29**], 6 week course.
Disp:*33 gm* Refills:*0*
3. heparin flush
heparin flush per protocol of NEHT
4. normal saline flush
normal saline flush per protocol of NEHT
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day) as needed for muscle cramps.
Disp:*30 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP<100 hr<55.
Disp:*60 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours): hold for SBP<100.
Disp:*240 Tablet(s)* Refills:*2*
14. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
15. 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*
16. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 30298**] Home Therapies
Discharge Diagnosis:
Primary:
End stage acute on chronic systolic heart failure
Methicillin-resistant staph aureus bacteremia
Secondary:
Acute on chronic renal failure
Peripheral vascular disease status post external iliac artery
stent
Gastritis
Hypertension
Hyperlipidemia
Status post biventricular pacemaker and AICD placement
History of thrombus on AICD wire
Discharge Condition:
Home with hospice care, afebrile, breathing comfortably on 3L
O2.
Discharge Instructions:
You were admitted to the hospital for severe heart failure. We
gave you diuretics and tried to optimize your medical management
but were limited by your low sodium levels and worsening kidney
function. In addition, you developed a blood infection for which
we have given you IV antibiotics. After discussions with you and
your family it was determined that you would go home with
hospice care and your defibrillator was turned off.
.
Please take your medications as prescribed. Please go to your
follow up appointments.
.
If you develop chest pain, difficulty breathing, or any other
concerning symptoms, please contact your hospice care provider
or physician.
Followup Instructions:
Infectious disease Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) **]:[**Telephone/Fax (1) 457**] Date/Time:[**2126-2-5**] 11:00
.
Cardiologist: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2126-1-21**] 10:30
Completed by:[**2126-1-8**]
|
[
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"V09.0",
"280.9",
"V15.82",
"403.91",
"V58.61",
"414.8",
"V45.81",
"276.1",
"428.43",
"440.20",
"V45.01",
"041.11",
"584.9",
"535.40",
"585.6",
"428.0",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19225, 19296
|
11794, 11888
|
368, 376
|
19681, 19749
|
4116, 11771
|
20458, 20819
|
3191, 3288
|
17084, 19202
|
19317, 19660
|
16231, 17061
|
19773, 20435
|
3303, 4097
|
265, 330
|
11916, 16205
|
404, 2039
|
2061, 2937
|
2953, 3175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,180
| 180,754
|
33696
|
Discharge summary
|
report
|
Admission Date: [**2112-8-21**] Discharge Date: [**2112-8-31**]
Date of Birth: [**2030-4-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Chief complaint:Altered mental status
.
MICU admit for:Somnolence, respiratory acidosis
Major Surgical or Invasive Procedure:
Intubation/Mechanical ventilation
Lumbar puncture
thoracostomy and drainage of pleural fluid
History of Present Illness:
82 yo M with DM, AFib, HTN, throat CA s/p resection 20 years
ago, who had a massive GI bleed this spring with subtotal
colectomy complicated by pneumonia and respiratory failure,
peritonitis, who was most recently discharged to rehab on
[**2112-8-8**] after hospitalization for AMS with pleural effusion; now
w/ 5 days twitching and 2 days visual hallucinations. Per ED
sign-out, no loss of continence, only new med is Vit D.
Neurology was consulted and thought twitches were myoclonic
jerks, recommended MRI and EEG but no medications at this point.
ED VS 97.7 101 117/64 22 99%/2L. CXR notable for LLL collapse
with effusion, stable from earlier this month. Head CT without
ICH. No urine sample obtained. No medications or IVF were given
in the ED.
.
Upon arrival to the floor, VS 96.2, 134/84, 97, 18, 100/3L.
Patient is minimally responsive. With loud voice or sternal rub,
opens eyes mom[**Name (NI) 11711**] and moans to answers. Only able to obtain
that he prefers being called '[**Known firstname **]'. Initial ABG (presumed
VBG) pH
7.28, pCO2 70, pO2 47, HCO3 34, BaseXS 3. Repeat ABG pH 7.27,
pCO2 75, pO2 126, HCO3 36, BaseXS 5. Patient also observed to
have intermittent apneic spells. ICU transfer requested.
.
Per discussion with his daughter, [**Name (NI) **], upon transfer to ICU.
Previously very healthy gentleman prior to GIB in Spring with
resultant colectomy. He had an anastomic leak with resultant
peritonitis. Discharged to rehab. The admitted for AMS to MICU
at [**Hospital1 3278**] for AMS. Had trach at that time, so was ventilated
given hypercarbia. Developed pleural effusion, tapped, negative
cytology. Then went to L-tac at [**Doctor Last Name 1263**], began hallucinating.
Palimdronate given for hypercalcemia. Had respiratory distress
that responded to Bipap. Back to rehab. Went back to [**Hospital1 **], had
thoracentesis that removed 1100 mL. During that admisison on
video swallow eval pt noted to be aspirating, strict NPO status
recommended, G-tube placed. Returned to [**Hospital3 **] on
discharge [**8-8**]. He was active, working on rehab, ambulating with
walker, playing cards. Began downward trend the day prior to
admission. Began having hallucinating and become angry when
confronted about it. At 5am, called family members about car
accidents. At 8am, was out of him for a couple hours, then was
fine again. By afternoon, started having more hallucinations and
myoclonic jerks. Took him to the ED. Family left him for about
30 minutes. Then returned to [**Location **] and he was difficult to arrouse.
Family requested blood gas, which was not pursued. Daughter is
an ICU nurse with husband an [**Name (NI) **] physician.
.
On arrival to ICU pt somnolent but arousable with stimuli, able
to state his full name, month and year. Repeat gas showed pH7.38
pCO254 pO278 HCO333 BaseXS4. Was started on a trial of bipap.
Past Medical History:
#. LGIB [**2112-3-29**] - course complicated by need for subtotal
colectomy, anastamotic leak requiring revision, Afib with RVR,
MRSA PNA/Klebsiella Bacteremia, ARF requiring CVVHD, PE and
stroke
#. HTN
#. Hyperlipidemia
#. DM2 diet controlled
#. History of Afib with RVR - not currently anticoagulated per
patient choice despite history of stroke
#. Stroke - Left parietal subcortical infarct [**2112-4-28**]
- probable subacute right posterior temporal and occipital
infarcts as well
#. History of PE - at OSH, concern for HIT - Serotonin release
assay negative
#. History of throat cancer s/p resection + xrt '[**89**]
#. s/p empyema w/ CT drainage
#. legally blind right eye secondary to injury
Social History:
The patient is widowed. He previously lived alone independently
in [**Location (un) 686**] although more recently has been in extended care
facilities. He previously worked for [**Doctor Last Name **] milk as a machinist.
Has three involved daughters.
Family History:
Non-contributory
Physical Exam:
Vitals: T:97.5 BP:161/69 P:101 R: 20 SaO2:100% 2LNC
General: Somnolent, arousable, answers questions and commands.
HEENT: NCAT, chronically dilated right pupil, left constricts
Neck: s/p tracheostomy, trach tube removed, residual opening
with scant mucous at ostomy, no BS audible.
Pulmonary: Decreased effort, dull to percussion L base.
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: s/p colostomy with G-tube in LUQ, some sl drainage from
g-tube site with surrounding erythema. Central abdominal
granulation tissue/secondary wound closure. +BS, no
rebound/guarding.
Extremities: LLE slightly larger than RLE, no pitting edema or
tenderness. Pulses present.
Neurologic: Somnolent, arousable to loud voice or sternal rub.
slight dysarthria. Able to state full name, date. Doesn't know
where he is but with prompting knows he is in hospital where
"doctors" are. chronically dilated right pupil with normally
reactive left pupil. Moves all extremities. Diffuse myoclonic
jerks. No cogwheeling.
Pertinent Results:
[**2112-8-21**] 03:10PM WBC-9.0 RBC-3.43* HGB-9.8* HCT-30.1* MCV-88
MCH-28.6 MCHC-32.6 RDW-14.9
[**2112-8-21**] 03:10PM NEUTS-69.7 LYMPHS-23.8 MONOS-4.3 EOS-1.8
BASOS-0.3
[**2112-8-21**] 03:10PM UREA N-52* CREAT-1.5* SODIUM-133
POTASSIUM-6.6* CHLORIDE-95* TOTAL CO2-30 ANION GAP-15
.
Brief Hospital Course:
82 y/o M with h/o HTN, diabetes, AFib, recent PE, recent CVA,
s/p subtotal colectomy for large LGIB [**3-/2112**] with long hospital
course at [**Hospital1 18**] and d/c to rehab p/w altered mental status and
hypercarbic respiratory failure of unclear cause.
# AMS: Head CT and MRI unremarkable for new neurologic process.
LP unrevealing except for single oligoclonal band; ddx for this
include CNS lymphoma, Waldenstroms and amyloidosis. No clear
source of infection or metabolic derangement other than
hypercarbia. At this point the theory is that pt??????s progressive
and possibly long standing accumulation of C02 due to chronic
hypoventilation may be the culprit, especially in light of his
rapid recover on mechanical ventilation. Question of
neuromuscular process vs decreased ventilation w/ reaccumulated
effusion.
In the MICU, nightly CPAP was continued and a sleep study was
obtained.
-Pt to get limited set of inpatient PFTs with functional vital
capacity and sitting MIP/MEPs to evaluate for a neuromuscular
component of his hypoventilation-demonstrated an
obstructive/restrictive pattern. However, he cannot have the
supine portion of the exam done on the [**Hospital Ward Name **] PFT lab.
Neuro to follow-asked to comment on MRI and possibility of
inflammatory process causing changes, and feel it is more
consistent with small vessel disease. Do not see utility of EMG
to eval monoclonal band in CSF. The will follow as outpatient.
.
# Pleural effusion. The pt has had chronic, recurring pleural
effusion, location as isolated on left, making it unusual.
Fluid is exudative. 1.1L removed on [**2112-8-24**]. Question potential
malignancy vs SLE (pt has been [**Doctor First Name **] & DS DNA + in past).
-bronched [**2112-8-24**], cytology negative
# Hypercarbic respiratory failure: Resolved. Pt extubated.
Cause still not entirely clear. Pt does become hypopneic &
desaturates while sleeping w/ rise in C02. At time of transfer
from MICU, plan for CPAP at night with overnight pulse oximetry.
- Sleep study tonight (will be limited study, so will
need full outpt study scheduled before dc??????email sleep fellow
[**Doctor First Name 77983**] [**Doctor Last Name **] to arrange for this)-patient noted to desat to
70-80 overnight during apneic periods. Improved upon waking and
with supplemental oxygen.
- Pulm c/s to follow on wards
-Concern for hospital aquired pneumonia in MICU, was started on
Vanc and CTX for 7 day course. Finished course of antibiotics
at time of discharge.
-Do not feel patient is candidate for pigtail or pleurovax at
this time until etiology of effusion is uncovered.
#ARF - Thought to be pre-renal in etiology. Pt's baseline Cr
~1.1-1.4. With TFs and hydration, has returned to baseline..
#? J-tube site cellulitis ?????? Had evidence stranding on CT around
site. Wound care was consulted and is following. The pt is being
treated with Vanc and CTX for a total of a 7 day course. TF
restarted without complications. Pt had repeat video swallow
this exam and is strictly NPO??????silent aspirator. Patient
finished course of antibiotics at time of discharge.
.
# DM: Stable.
- Regular sliding scale, follow FSBS.
.
# s/p subtotal colectomy: Was previously seen by surgery as
inpatient. Previously followed by Dr.[**Name (NI) 1482**] team. Wound
care per surgery recommendations.
# AF: Continue BB. No coumadin per pt preference and in light
of recent severe GIB.
.
# HTN: Continue BB. BP persistently elevated, HCTZ started.
Continue to monitor and titrate regimen.
Medications on Admission:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Name (NI) **]: [**12-30**]
Drops Ophthalmic PRN (as needed).
3. Miconazole Nitrate 2 % Cream [**Month/Day (2) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet, Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: One (1) dose PO Q6H
(every 6 hours) as needed.
6. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One
(1)dose PO BID (2 times a day).
7. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: One (1) dose PO BID (2
times a day): Note: 500 mg PGT [**Hospital1 **]. Disp:*2 * Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
9. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
6. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical PRN
(as needed).
11. Hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
12. Oxygen
Patient will require continuous 2 L oxygen via nasal cannula
when sleeping.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Hypercarbia
Altered mental status now resolved
Respiratory acidosis/failure
Pulmonary effusion
Acute renal failure
Uncontrolled DM2
Discharge Condition:
Hemodynamically stable, tolerating tube feeds.
Discharge Instructions:
You should return to the emergency department if you develop
fever, chills, nausea, vomiting, difficulty breathing, chest
pain, confusion, worsening of you symptoms or other symptoms
concerning to you.
Of note, daughter was concerned the clinical picture has been
repeated with increasing confusion, agitation and anger,
followed by respiratory depression and failure and improved
after drainage of the effusion. If these symptoms are noted,
please seek medical attention immediately, as drainage may
prevent further respiratory distress and intubation.
Followup Instructions:
Please follow up in sleep clinic with Dr. [**Last Name (STitle) 34890**]. He will call
to make an appointment at a facility which can handle your
medical condition.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 19961**]
in [**12-30**] weeks you may call [**Telephone/Fax (1) 33016**] to schedule an
appointment.
Please follow up with Dr. [**Last Name (STitle) **]/Fenhel in [**1-31**] months. You
can call [**Telephone/Fax (1) 541**] to schedule an appointment.
Please follow up with pulmonary-Dr. [**Last Name (STitle) **] in clinic [**11-7**] at 3:30 PM. Please get chest x ray 1 hour prior to your
appointment at 2:30 PM by coming to the same office.
Completed by:[**2112-8-31**]
|
[
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"427.31",
"569.61",
"599.0",
"584.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"33.24",
"34.91",
"03.31",
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] |
icd9pcs
|
[
[
[]
]
] |
11840, 11910
|
5789, 9343
|
403, 498
|
12086, 12135
|
5474, 5766
|
12740, 13491
|
4399, 4417
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10474, 11817
|
11931, 12065
|
9369, 10451
|
12159, 12717
|
4432, 5455
|
291, 365
|
526, 3390
|
3412, 4113
|
4129, 4383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,001
| 181,537
|
39057
|
Discharge summary
|
report
|
Admission Date: [**2178-4-24**] Discharge Date: [**2178-5-8**]
Date of Birth: [**2114-5-23**] Sex: F
Service: SURGERY
Allergies:
Amitriptyline / Protonix
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Breast Cancer
Major Surgical or Invasive Procedure:
Left modified radical mastectomy
History of Present Illness:
Ms. [**Last Name (un) 86590**] is a 63 year-old F w/ CAD w/ DES--> LAD c/b
in-stent restenosis on [**Last Name (un) **], BRCA s/p R-lumpectomy '[**63**] w/
chemo-XRT, ovarian CA s/p partial hysterectomy '[**43**], hep C from
blood x-fusion, admitted to [**Hospital Unit Name 153**] for post-operative management
after having L-breast modified radical mastectomy c/b large
hematoma for which pt was taken back to OR for surgical
evacuation of 200cc blood and drainage w/ wound-vac placement
(that is draining frank blood currently). Patient has been
hemodynamically stable throughout her surgical and PACU course,
and was sent to [**Hospital Unit Name 153**] for further monitoring of her
pain/hemodynamics. Pain has been controlled on Dilaudid PCA.
Past Medical History:
1. CAD s/p MI [**2177-6-15**] w /DES--> LAD c/b in-stent restenosis on
[**Year (2 digits) **]
2. Hepatitis C (from blood transfusion)
3. hiatal hernia
4. GERD
5. anxiety
6. depression
7. R-breast lumpectomy [**2163**] s/p chemo XRT
8. uterine cancer s/p partial hysterectomy [**2143**]
9. Hypertension
10. Hyperlipidemia
Social History:
She is currently living with her daughter in [**Name (NI) 4288**]. She
moved here from [**State 108**], where she was in an abusive
relationship w/ her husband for the past 14 years, which
affected her access to health care. With regards to her history
of abuse, she is currently seeing a social worker at [**Name (NI) 61**]; however, she does not have any psychologist involved in
her care to help her
deal with her anxiety and depressive symptoms. She denies any
alcohol use. She has smoked one pack per day for 40 years;
however, there has been no smoking since [**74**]/[**2176**].
Family History:
Diabetes and breast CA.
Physical Exam:
VS: afebrile, HR 77 BP 127/84 SaO2 95% on NC
GEN: chronically ill-appearing thin F appearing much older than
stated age (looks 80 i/o 60) in mod distress [**1-6**] pain
HEENT: PERRLA, no scleral icterus
CV: regular rate and rhythm
LUNGS: anterior clear, wound vac in place over left breast w/
large area of ecchymoses and soft tissue swelling
ABD: +BS soft ND NT
EXT: distal pulses palpable
NEURO: alert, awake, in pain, answering questions
Pertinent Results:
[**2178-4-24**] 06:54PM BLOOD WBC-14.1*# RBC-3.54* Hgb-10.6* Hct-31.8*
MCV-90 MCH-30.0 MCHC-33.4 RDW-12.7 Plt Ct-218
[**2178-4-25**] 02:41AM BLOOD PT-13.7* PTT-31.1 INR(PT)-1.2*
[**2178-4-25**] 02:41AM BLOOD Glucose-107* UreaN-12 Creat-0.5 Na-132*
K-4.7 Cl-98 HCO3-27 AnGap-12
[**2178-4-25**] 02:41AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.3*
STUDIES:
[**4-25**] CXR: There are no old films available for comparison. A
drain is seen
overlying the left anterior chest. Coronary stent is visualized.
There is
some minimal biapical scarring. Right axillary clips are
visualized. The
heart is upper limits normal in size. There is no infiltrate or
effusion.
Pathology:
[**4-24**] Breast tissue: ****
Brief Hospital Course:
63 y/o F w/ CAD on [**Month/Year (2) **]/[**Month/Year (2) **], hx ovarian CA, hep C, BRCA s/p
modified radical mastectomy c/b hematoma, on wound vac.
# S/P MRM: Patient tolerated procedure w/o complication. Has
wound VAC in place after removing out ~200cc blood from
hematoma. Her HCT was monitored carefully in setting of recent
[**Month/Year (2) **] administration. Pain was controlled with PCA. She was
given post-op cefazolin 2g IV for 3 doses. While in the [**Hospital Ward Name 332**]
ICU, she was transfused a total of 2 units of packed RBCs, with
a subsequent hematocrit of 29.7. She was subsequently
transferred to the surgical floor. Her HCT continued to be
stable for the remainder of her admission and her wound VAC
output and her wound were monitored for evidence of further
hematoma or bleeding, of which none was demonstrated. The
patient continued to do well and on POD 6 was taken back to the
OR where a split thickness skin graft from her left thigh was
placed on the surgical wound. This was held in place using an
additional wound VAC on low continuous suction (50mmHg), and was
removed on POD6. During the dressing change, the skin graft was
well granulated and continued to appear viable.
# CAD: DES to LAD c/b instent re-stenosis, crucial to continue
[**Hospital Ward Name **] even during surgery as cardiac risks are significant.
Patient was continued on [**Last Name (LF) **], [**First Name3 (LF) **], carvedilol, and high-dose
statin. She was followed throughout the admission.
# ATRIAL FIBRILLATION: On [**4-25**], the patient was nearing transfer
out of the ICU, but subsequently developed atrial fibrillation
with rapid ventricular response, with a heart rate in the high
130s. She was given normal saline boluses, occasional doses of
intravenous metoprolol, and the dose of her standing carvedilol
was increased. She was not symptomatic from these episodes, and
her heart rate was subsequently under good control, for the rest
of her stay in the [**Hospital Unit Name 153**]. She did continued to require increased
doses of carvedilol compared to admission for rate control of
her atrial fibrillation.
# CHRONIC PAIN: Patient was continued on methadone 10mg QID,
oxycodone 60mg IR TID, and standing Tylenol q6 hours. A
hydromorphone PCA was added on [**4-25**]. She was seen by the chronic
pain service for further assistance with her regimen, and was
eventually stabilized on a regimen of methadone QID
(15mg,10mg,10mg,15mg respectively) and Dilaudid 2-8mg PO q3hrs
prn with good results. The patient did require IV pain control
(Dilaudid) along with Ativan for dressing changes, but did not
require additional pain medications at other times. Upon
discharge an EKG was preformed at the recommendation of the
chronic pain service to evaluate the patient's QT interval after
increasing her methadone dose. The QTc interval was prolonged
however this appeared to be the patient's baseline. Chronic pain
was consulted again over the phone related to this finding and
advised that the patient return to her home dose of methadone
10mg four times daily and be seen in follow up by her primary
care provider. [**Name10 (NameIs) 6**] appointment with the patient's primary care
provider was made and the provider was called and made aware of
the need for a follow-up EKG. She was discharge home with this
dose of Methadone as well as Dilaudid as needed by mouth.
# DECONDITIONING: ON HD5 the patient was seen by physical
therapy who recommended several inpatient visits and training,
and this was performed while the patient was admitted.
#Social Work and Discharge Plan: The patient is followed by
[**Hospital1 18**] social work on an outpatient basis and the inpatient
social worker connected with this provider during the [**Hospital 228**]
hospital stay related to coping and home safety. Due to some
social situations at home the surgical team requested that
social work to assess the safety of the patient home environment
and social work evaluated the patient's situation and reported
it appropriate for her return. Visiting nursing services were
coordinated and will be following the patient's progress and
preforming daily dressing changes to the left breast.
Medications on Admission:
Carisoprodol 350mg [**Hospital1 **]
Carvedilol 12.5mg [**Hospital1 **]
[**Hospital1 **] 75 mg daily
Methadone 10mg QID
Oxycodone 60mg TID
Simvastatin 80 mg daily
[**Hospital1 **] 81mg daily
MVI
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Methadone 10 mg Tablet Sig: One (1) Tablet PO four times a
day for 14 days: please hold for sedation.
Disp:*56 Tablet(s)* Refills:*0*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours for 5 days: please do not take if you are sleepy, or
confused.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left breast infiltrating ductal carcinoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgical treatment of
cancer in your left breast. You had a mastectomy of the left
breast on [**2178-4-24**]. After this procedure because of the blood
thinning medication you take for the stent in your heart, you
had some bleeding under the skin at the surgical site. This
bleeding was stopped and the blood was washed out from the skin.
The wound was left open after this procedure and a VAC dressing
was placed, this allowed for the tissue at the base of the wound
to be kept clean and begin to grow. After some time with the VAC
dressing a split thickness skin graft. You know will be able to
go home with a xeroform dressing with a dry gauze sterile
dressing over the skin graft on the left breast which will be
monitored and changed daily by a visiting nurse who will come to
your home. The donor site on your left tigh can be left with a
xeroform dressing and dry sterile dressing. The xeroform will
eventually dry and lift off but this will happen on its own, it
is important that you let this dressing fall off on its own, the
skin is healing underneath. If you notice any signs and symptoms
of infection near or around the wound such as: green or white
discharge, swelling, increasing redness around the wound,
increased pain, foul odor, or you develop a fever, please call
the office or if severe go to the emergency room. If the wound
opens or bleeds please call the office or seek medical attention
if severe. If you notice the area that has been skin grafted is
turning dark in color please call the office.
Please eat small frequent meals high in protien to encorage your
wound to heal. Keep yourself well hydrated. You should not
shower, just sponge baths for now until your follow-up
appointment with Dr. [**Last Name (STitle) 519**] and he will give you new instructions.
Please use your left are as little as possible, preventing
pressure on the left arm pit area. You may lift your arm up and
down, just avoid heavy lifting.
You will continue your current chronic pain regimen at home.
Your primary care doctor as well as the chronic pain team has
been working with you to atempt to decrease these doses and you
should follow-up with them in 2 weeks to monitor your progress.
Please follow the directions on the prescription bottles, the
regimen has been changed. We have made an appointment with you
with your primary care doctor as written below. You have not
been taking your Carisoprodol, please do not take this until you
have folowed up with your primary care provider.
Followup Instructions:
Please seek Dr. [**Last Name (STitle) 519**] in his office in 1 week, Provider: [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**] Date/Time:[**2178-5-18**] 2:30
Please make an appointment with your Primary Care Provider
[**Name Initial (PRE) 176**] 2 weeks. An appointment has been made for you as listed
below. If this is not convient for you you may have it changed
however you will need refills on your methadone in 2 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-5-19**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 83742**], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2178-6-26**] 1:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2178-5-11**]
|
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"300.4",
"E878.1",
"401.9",
"V58.63",
"V45.82",
"V15.41",
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"304.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"85.82",
"85.43",
"39.98"
] |
icd9pcs
|
[
[
[]
]
] |
8430, 8488
|
3295, 6892
|
297, 331
|
8575, 8575
|
2579, 3272
|
11287, 12237
|
2078, 2103
|
7750, 8407
|
8509, 8554
|
7532, 7727
|
8726, 11264
|
2118, 2560
|
244, 259
|
359, 1111
|
8590, 8702
|
6908, 7506
|
1133, 1455
|
1471, 2062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 175,347
|
15325
|
Discharge summary
|
report
|
Admission Date: [**2140-5-17**] Discharge Date: [**2140-5-20**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
Feeling unwell, Hypertensive urgency
Major Surgical or Invasive Procedure:
dialysis
History of Present Illness:
Pt is a 22 yo female with Lupus, end-stage renal disease on HD,
HTN, multiple other medical problems as below who presents with
feeling unwell and found to be in hypertensive urgency. Pt
states that last Thursday, five days ago, she started to feel
unwell. States that she had chills, no fever, a "weird feeling
in my stomach" with cramps, and no cough. No diarrhea. No
dysuria. Pt missed her dialysis session on Saturday because she
was feeling unwell (3 days ago). Per patient she started to feel
better that day, but today, started to feel unwell with the same
symptoms. No sick contacts.
.
In the ED, VS on arrival were: HR: 73; BP: 222/128, 100% RA. She
was given labetalol 20 mg IV, 40 mg IV, and then started on a
labetaolol gtt.She was also calcium gluconate 1 am IV,
kayexalate 30 mg po x 1, 10 units of insulin IV, and 1 amp of
d50.
.
Of note, pt was recently admitted to [**Hospital1 **] at the end of [**Month (only) 547**] for
Left uveitis/endophthalmitis. She the developed [**Female First Name (un) **]
endophthalmitis and had her L eye enucleation. She states that
she went to her appt at [**Hospital **] 5 days ago. They said
that her eye "looked good" and she was to continue on the same
amount of prednisone that she is on.
.
Her last admission she was also noted to have coag negative
staph bacteremia. She was discharged on 14 day course of
vancomycin but she somehow did not receive this at dialysis. She
has now had 4 sets bld cx + for coag negative staph and was
started on vancomycin.
Past Medical History:
1. Lupus - [**2134**]. Diagnosed after she began to have swolen
fingers, a rash and painful joints.
2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Awaiting living donor transplant from
mother.
3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1
hypertensive crisis that precipitated seizures in the past.
4. Uveitis secondary to SLE - [**4-15**]
5. HOCM - per Echo in [**2137**]
6. Vaginal bleeding [**2139-9-20**]
7. Mulitple episodes of dialysis reactions
8. Anemia
9. Coag neg. Staph bacteremia and HD line infection - [**6-15**]
10. H/O UE clot, was on coumadin, but no longer
Social History:
Lives in [**Location 669**] with mother and 16 year old brother. Graduated
[**Name2 (NI) **] School and then got sick so currently is not working or
attending school. Denies any T/E/D.
Family History:
No family history of SLE. GF: HTN. No clotting disorders in
family. No history of autoimmune disease.
Physical Exam:
VS: T: 97.8; BP: 203/133; HR: 100; RR: 15; O2: 100 RA
Gen: Speaking in full sentences in NAD
HEENT: Left eye patch. Refuses to let examine/look. Right eye
reactive. Sclera anicteric. OP clear.
Neck: No LAD
CV: RRR S1S2. No M/R/G
Lungs: CTA b/l with good air entry and flow
Abd: Soft, NT, ND.
Back: No spinal, paraspinal, or CVA tenderness
Ext: No edema. DP 2+
Neuro: A&O x 3, MS intact.
Pertinent Results:
EKG: sinus at 75. Normal axis. Normal intervals. Early
repolarization in anterior precordium. No acute changes. LVH.
.
Radiology:
CXR PA/LAT [**2140-5-17**]-
Large-bore inferior approaching right-sided dialysis catheter is
unchanged in position terminating within the right atrium. The
lungs are clear and cardiomediastinal silhouette, hilar
contours, and pleural surfaces are normal. No evidence of
pneumothorax or pulmonary edema.
.
[**2140-5-17**] 06:20AM WBC-7.4 RBC-3.85*# HGB-11.2*# HCT-35.3*#
MCV-92 MCH-29.1 MCHC-31.8 RDW-20.9*
[**2140-5-17**] 06:20AM NEUTS-91.1* LYMPHS-7.7* MONOS-1.1* EOS-0.1
BASOS-0
[**2140-5-17**] 06:20AM PLT COUNT-202
.
[**2140-5-17**] 06:20AM GLUCOSE-100 UREA N-40* CREAT-5.2* SODIUM-138
POTASSIUM-6.3* CHLORIDE-109* TOTAL CO2-18* ANION GAP-17
.
[**2140-5-17**] 04:10PM WBC-5.6 RBC-3.47* HGB-10.3* HCT-31.4* MCV-91
MCH-29.6 MCHC-32.7 RDW-20.6*
.
[**2140-5-17**] 04:10PM CALCIUM-9.1 PHOSPHATE-3.6# MAGNESIUM-2.3
[**2140-5-17**] 04:10PM LIPASE-54
[**2140-5-17**] 04:10PM ALT(SGPT)-20 AST(SGOT)-38 ALK PHOS-74
AMYLASE-267* TOT BILI-0.3
[**2140-5-17**] 04:10PM GLUCOSE-89 UREA N-40* CREAT-4.9* SODIUM-139
POTASSIUM-5.2* CHLORIDE-109* TOTAL CO2-20* ANION GAP-15
.
[**5-17**] and [**5-18**] with blood cultures 4/4 + coag negative
staphylococcus. [**5-19**] and [**5-20**] bld cultures no growth to date.
.
Ecchocardiogram: Severe symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Hyperdynamic LVEF >75%.
Moderate resting LVOT gradient. LVOT gradient increases with
Valsalva.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. No 2D or Doppler evidence
of distal arch coarctation. AORTIC VALVE: Normal aortic valve
leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve
leaflets with trivial MR. No MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Echocardiographic results were reviewed with
the
houseofficer caring for the patient.
Conclusions:
The left atrium is elongated. The estimated right atrial
pressure is 0-5mmHg. There is severe symmetric left ventricular
hypertrophy with normal cavity size and dynamic systolic
function (LVEF>80%). Regional left ventricular wall motion is
normal. There is a moderate (25mmHg peak) resting left
ventricular outflow tract obstruction that increased (64mmHg)
with the Valsalva manuever. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. Trace
aortic regurgitation is seen. 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.
IMPRESSION: Marked symmetric left ventricular hypertrophy with
dynamic
systolic function and resting LVOT gradient that increased with
Valsalva.
Compared with the prior study (images reviewed) of [**2137-12-4**],
the severity of left ventricular hypertrophy has increased and
trace aortic regurgitation is now identified. Dynamic LV
systolic function and the resting intracavitary gradient are
similar.
.
UE ultrasound
1. Abrupt occlusion of the right internal jugular vein and its
distal most aspect as it joins with the distal subclavian vein.
2. Recanalization of the left subclavian vein with some
peripheral residual clot. Recommend analysis of the SVC,
central subclavians and internal jugular veins with dedicated
magnetic resonance venography, which can be performed without
intravenous contrast for a global assessment of the venous
patency.
Brief Hospital Course:
Pt is a 22 yo female with SLE, ESRD on HD, amongst other
problems who presented with symptoms likely [**2-12**] bacteremia.
Found to be in hypertensive urgency after missing a run of
dialysis. She is now transferred to the floor for further
managment after dialysis x 1 and starting vancomycin.
.
In the MICU she was started kept briely on a labetalol gtt, and
then restarted on her home antihypertensives and dialyzed x 1
with resolution of hypertension. She was found to be bacteremic
and was started on vancomycin. She felt well and was transferred
to the floor.
.
1. Hypertensive urgency- Pt with long history of very
difficult-to-control HTN. She was initially on a labetalol gtt
as above, was dialyzed with resolution of her HTN urgency. She
was then transitioned to her her outpatient medication regimen
of valsartan, lisinopril, clonidine, labetalol, terazosin, and
nicardipine at max doses, but because of persistent HTN to the
180's she was started on hydralazine 50mg po tid on discharge.
.
2. Coag negative staph bacteremia: most likely source is line
sepsis. She was started on vancomycin and her blood cultures
cleared after 2 days in the hospital. The patient felt strongly
about keeping her HD line, which was felt to be reasonable
because her infection was coag negative staph. Ecchocardiogram
did not show any valvular vegitations. She will continue on
vancomycin for 3 weeks at hemodialysis.
.
3. ESRD on dialysis-euvolemic clinically. Had dialysis inhouse.
Continued sevelamer.
.
4. Left uveitis/endopthalmitis-Continued prednisone 30 mg po
qday. Will also continue bacitracin-polymyxin b.
.
5. Lupus- not on any other medications than above.
.
F/E/N- insists on regular diet
.
Access: Right dialysis catheter
.
Prophylaxis: Heparin sc, PPI per outpatient
.
Code Status: Full Code
Medications on Admission:
Nephrocaps 1 CAP PO DAILY
Vancomycin 1000 mg IV HD PROTOCOL
Vancomycin 1000 mg IV X1 Duration: 1 Doses
DiphenhydrAMINE 25 mg PO Q6H:PRN
Labetalol 600 mg PO TID
Heparin 5000 UNIT SC TID
Acetaminophen 325-650 mg PO Q4-6H:PRN
OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN
Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES Q8H
Terazosin HCl 8 mg PO BID
Gabapentin 100 mg PO QTUESDAY, THURSDAY, SATURDAY
Sevelamer 800 mg PO TID
NiCARdipine 40 mg PO Q8H
PredniSONE 30 mg PO DAILY
Sulfameth/Trimethoprim DS 1 TAB PO QMONDAY, WEDNESDAY, FRIDAY
Lorazepam 1 mg PO Q4-6H:PRN
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Clonidine TTS 3 Patch 1 PTCH TD QFRI
Lisinopril 40 mg PO BID
Valsartan 320 mg PO DAILY
Ondansetron 4 mg IV Q8H:PRN
Oxycodone SR (OxyconTIN) 70 mg PO Q8H
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMONDAY, WEDNESDAY, FRIDAY ().
4. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Nicardipine 20 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Terazosin 2 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed.
10. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: 3.5
Tablet Sustained Release 12 hrs PO every eight (8) hours.
11. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUESDAY,
THURSDAY, SATURDAY ().
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous per hemodialysis for per hd days: per hemodialysis.
15. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUESDAY,
THURSDAY, SATURDAY ().
18. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
19. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): 1g Q dialysis.
21. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
Hypertensive urgency
Coagulase negative Staphylococcus Bacteremia
Secondary diagnosis:
Lupus
ESRD
s/p L eye enucleation
Discharge Condition:
Good. Blood pressure is in the 130s-150s systolic. Her vitals
are stable, she is ambulatory, and taking in PO
Discharge Instructions:
Please follow up as below; I have also made a new cardiology
appointment for you
.
Take all medications as prescribed; Other than giving you
vancomycin we have added hydralazine (a blood pressure
medicine), but otherwise we have not changed any of your
medicines. If you have fevers, chills, light-headedness, or
other problems then you should contact your doctor because this
may be a sign that your infection is not resolving.
You should go for hemodialysis as scheduled Saturday where they
should give you vancomycin.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2140-5-30**] 1:00
Dr. [**Last Name (STitle) 4883**] [**Telephone/Fax (1) 60**]
Tuesday [**5-31**] at 3pm with Dr. [**Last Name (STitle) **] in Cardiology.
[**Telephone/Fax (1) 5003**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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|
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|
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|
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|
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|
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2631, 2817
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,421
| 130,786
|
50955
|
Discharge summary
|
report
|
Admission Date: [**2176-1-28**] Discharge Date: [**2176-1-31**]
Date of Birth: [**2106-11-15**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 69 yo M with a history of COPD, CAD s/p CABG, HTN,
Etoh abuse who presents with dyspnea. At baseline patient
requires 3L of O2. However he complains that over the last [**2-28**]
weeks he has had chills, worsening cough, and shortness of
breath. He produces a small amount of sputum. He has also had
new lower extremity edema over this time. He notices that he
doesn't sleep well because he has to wake up 2-3 times per night
to urinate.
He mentions that over a longer period of time he has had a
general decline in his health. His shortness of breath has
gotten worse, where he can't leave the house to do activities as
a result. He uses his albuterol inhaler 5-6 times per day.
Patient mentions that his balance has been off, and his wife
complains that he has become more forgetful over the last 6
months. He also complains of black stools x several months.
Denies abdominal pain or BRBPR.
.
In the ED, initial vs were: T 97.6 P82 BP124/69 R20 O2 sat 95%
on 3L. Patient was given 60mg po prednisone, 500mg po
azithromycin, Albuterol nebs x3, 40mg IV lasix. An ABG was done
7.44/39/55. This was thought to be a VBG. His CXR was without
acute process. He was started on Bipap. Vitals prior to transfer
were HR 84 BP 127/75 RR 21 95% on Bipap with Peep of 5, FiO2
30%.
.
On the floor, patient is no longer requiring Bipap is on home 3L
NC, and feels markedly improved. Denies any pain or discomfort.
Pt ruled out CEs x3, and improved with steroids, albuterol nebs,
as pt had likely COPD flare. Now stable and called out to floor.
.
Past Medical History:
1. COPD with FVC of 3.12 (71%), FEV1 1.35 (45%), Ratio 43 (63%)
[**3-1**], on home O2 3L by NC.
2. CAD status post CABG.
3. Hypertension.
4. Depression.
5. Right upper lung nodules.
6. Peptic ulcer disease status post GI bleed status post colon
resection. (5 yrs ago)
7. Nephrolithiasis, horseshoe kidney.
8. Etoh abuse
Social History:
He currently lives with his wife.
- Tobacco: Smoking 90-pack-year history, currently smokes [**5-30**]
cigaretters/day
- Alcohol: Alcoholic. Has been sober x1 year
- Illicits: None
Family History:
Significant for CAD and alcholism
Physical Exam:
Vitals: T: 99.2 BP:136/83 P:91 R: 19 O2: 93% on 3L nc
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 2cm above clavicle, no LAD
Lungs: faint wheezing b/l. Poor air movement. No crackles or
ronchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 1+
LE edema
Pertinent Results:
[**2176-1-29**] 04:15AM BLOOD WBC-5.7 RBC-4.66 Hgb-14.0 Hct-42.9 MCV-92
MCH-30.0 MCHC-32.6 RDW-13.7 Plt Ct-217
[**2176-1-28**] 02:15PM BLOOD WBC-5.6 RBC-4.63 Hgb-14.3 Hct-42.7 MCV-92
MCH-30.9 MCHC-33.5 RDW-13.7 Plt Ct-159
[**2176-1-28**] 02:15PM BLOOD Neuts-59.4 Lymphs-25.8 Monos-6.8 Eos-7.0*
Baso-1.1
[**2176-1-30**] 05:50AM BLOOD Glucose-99 UreaN-16 Creat-0.6 Na-139
K-4.2 Cl-107 HCO3-22 AnGap-14
[**2176-1-29**] 02:14PM BLOOD K-5.0
[**2176-1-29**] 04:15AM BLOOD Glucose-135* UreaN-14 Creat-0.6 Na-138
K-5.2* Cl-106 HCO3-26 AnGap-11
[**2176-1-28**] 02:15PM BLOOD Glucose-100 UreaN-11 Creat-0.7 Na-138
K-4.4 Cl-105 HCO3-26 AnGap-11
[**2176-1-29**] 04:15AM BLOOD CK(CPK)-83
[**2176-1-28**] 08:49PM BLOOD CK(CPK)-77
[**2176-1-28**] 02:15PM BLOOD ALT-17 AST-19 CK(CPK)-79 AlkPhos-83
TotBili-0.2
[**2176-1-29**] 04:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-57
[**2176-1-28**] 08:49PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-1-28**] 02:15PM BLOOD cTropnT-<0.01
[**2176-1-30**] 05:50AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0
[**2176-1-29**] 04:15AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.9
[**2176-1-28**] 04:30PM BLOOD Type-ART pO2-55* pCO2-39 pH-7.44
calTCO2-27 Base XS-1 Intubat-NOT INTUBA
[**2176-1-28**] 02:24PM BLOOD Lactate-1.3
.
.
EKG
Normal sinus rhythm, rate 78. Borderline first degree A-V block.
Intraventricular conduction delay. Possible anteroseptal
myocardial infarction
of indeterminate age. Compared to the previous tracing of
[**2173-12-23**] subtle
lateral ST segment depression is no longer appreciated.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 [**Telephone/Fax (3) 105885**]/423 8 13 33
.
.
Final Report
PA AND LATERAL CHEST, [**2176-1-28**] AT 1529 HOURS.
HISTORY: Dyspnea on exertion.
COMPARISON: Multiple priors, the most recent dated [**2174-11-6**].
FINDINGS: Similar to the prior exam, there is evidence of prior
median
sternotomy and CABG. Numerous fractured sternal wires are again
present and
unchanged. No focal consolidation or superimposed edema is
identified. There
is minimal tortuosity of the thoracic aorta with calcified
plaque identified
at the arch. The cardiac silhouette is within normal limits for
size. No
effusion or pneumothorax is seen. The bones are diffusely
osteopenic with a
slight exaggerated kyphosis noted in the lower thoracic spine.
Underlying
lung hyperexpansion is suggestive of emphysema. There are
deformities of
numerous upper right ribs likely indicating remote trauma.
IMPRESSION: Underlying emphysema. No superimposed acute
pulmonary process.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: [**First Name8 (NamePattern2) **] [**2176-1-28**] 5:50 PM
.
.
.
TTE
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic 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. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. 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. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild aortic regurgitation. Dilated ascending aorta.
Brief Hospital Course:
69M with history of COPD, CAD s/p CABG who presents with dyspnea
likely COPD exacerbation, initially in MICU for BIPAP then
quickly weaned to home 3L O2.
.
#. Dyspnea: Exam and course most consistent with COPD
exacerbation, was initially in MICU for BIPAP, but weaned off
within approx 24 hrs to his home 3L O2 after initiation of nebs,
IV steroids, azithromycin. Patient has 90+ pack year smoking
history, and has not been taking anything more than albuterol at
home (pt likely not med compliant due to cost). Given history of
CAD and LE edema initially was concerning for CHF, but no
history of orthopnea or PND and TTE showed nl global systolic
function, EF>55% although it was a study limited by image
quality. No pneumonia seen on CXR, no leukocytosis. PE lower on
the differential. On the floor we started the pt on prednisone
60 mg to be tapered by 10mg every 2 days. He was also sent home
to complete his course of azithromycin, and to take ipratropium,
salmeterol, fluticason, albuterol inhalers (all generics for
less cost). He will f/u with pulmonary as an outpatient.
.
# CAD s/p CABG: Pt never had CP. EKG unchanged from baseline.
CEs neg x3. Pt states he no longer takes any cardiac meds due to
cost. He was started on simvastatin and baby aspirin. We held
initiation of beta blocker given his severe COPD.
.
# HTN: pt has been hypertensive with diastolic BP around 100
recently. may be secondary to prednisone. pt not on any
anti-hypertensives at home. he was started on amlodipine 5mg
daily.
.
# Dark stools: Patient has h/o GI bleed secondary to PUD. There
were no active issues. We continued his home omeprazole.
.
# h/o Etoh abuse: Abstinent for one year. No issues.
.
# Med noncompliance: appears to be due to financial constraints.
we changed his meds to generic for cost control.
.
# Code: DNR/DNI (confirmed with patient)
.
Medications on Admission:
(per what the patient can remember):
Pantoprazole 40 mg Tablet one tablet Q24hours -stopped taking
because ran out
Lunesta
Trazadone
Aleve
Albuterol inhaler
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
6. Prednisone 10 mg Tablet Sig: see below for taper Tablet PO
once a day: Please take 50mg on [**2176-2-1**], 40 mg on [**1-9**]; 30 mg
on [**1-14**]; 20 mg on [**2-2**]; 10 mg on [**2-28**]; then
stop taking prednisone.
Disp:*25 Tablet(s)* Refills:*0*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
9. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*1 Disk with Device(s)* Refills:*2*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation four times a day as needed for shortness of
breath or wheezing.
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. home O2
patient is on home O2 3L
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
COPD exacerbation
.
Secondary:
CAD
Hypertension
peptic ulcer disease
.
Discharge Condition:
afebrile, stable vitals, tolerating POs
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted due to difficulty breathing which was due to a
COPD exacerbation. Your heart echo did not show any evidence of
heart failure. You were treated and improved with nebulizers,
steroids, and antibiotics. You will be sent home to complete a
course of azithromycin, and prednisone taper. You were also
started on simvastatin and aspirin for heart protection. You
were also ordered to have ipratropium, fluticasone, and
salmeterol inhalers. Finally, for better BP control you were
started on amlodipine 5mg daily. Your medications are generic so
they should be more affordable for you. It is imperative that
you take all your medications as prescribed given the severity
of your disease.
.
Please take all medications as prescribed.
Please attend all appointments below.
Please do not hesitate to return to the hospital if you have any
concerning symptoms at all.
Followup Instructions:
Please follow up with the following providers:
PCP: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**Telephone/Fax (1) 2205**], [**2176-2-8**] 1215pm
Pulmonologist: Dr. [**Last Name (STitle) 575**], [**2176-2-29**], 730AM, [**Hospital Ward Name 23**] 7,
[**Telephone/Fax (1) 612**]
.
|
[
"V45.81",
"414.00",
"401.9",
"491.21",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10490, 10496
|
6734, 8583
|
294, 301
|
10620, 10660
|
3019, 6711
|
11736, 12109
|
2432, 2467
|
8790, 10467
|
10517, 10599
|
8609, 8767
|
10837, 11713
|
2482, 3000
|
247, 256
|
330, 1874
|
10674, 10813
|
1896, 2218
|
2234, 2416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
835
| 193,827
|
51028
|
Discharge summary
|
report
|
Admission Date: [**2151-11-24**] Discharge Date: [**2151-11-27**]
Date of Birth: [**2069-3-20**] Sex: M
Service: MEDICINE
Allergies:
Lovastatin / Propranolol / Elavil / Niacin / L-Arginine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
left/right heart catherization
History of Present Illness:
82 yo M w/ PMHx of DM w/ peripheral neuropathy, HTN, HL, CHF (EF
~30%) s/p ICD, OSA, CKD, gout and CAD who presented to the ED
with chest pain at rest and tachycardia to 140s. Approximately
at 8:30 PM on the evening of presentation, he developed gradual
onset of achy chest pain associated with diaphoresis. He denied
palpitations, SOB. EMS was called and enroute he received SL
nitroglycerin without improvement in chest pain and induction of
hypotension.
.
In the ED, initial vitals were 96.7 156 123/87 16 99%RA. He was
noted to have signficant ST depressions with tachycardia and
without tachycadia. Troponin trended up to 0.18 and CK to 404
and echo done in ED by the fellow showed no segmental wall
motion abnormalities, but EF decreased from prior at 15-20%.
Integrellin gtt, heparin gtt, asa 325mg , plavix 600mg were
initiated and he was taken to the cath lab.
.
In the cath lab, he received 60mg IV lasix and heparin was
discontinued. He received 25mcg fentanyl, 0.5mg versed, 185cc
contrast, and 200cc NSb during the procedure. A swan was placed
which induced ectopy and broke the SVT. LCx had 90% ISR and pt
received PCI w/ a DES. He was noted to be presistently
hypotensive (SBP 80-90s) and a balloon pump was placed prior to
admission to the CCU.
.
In the CCU, he was chest pain free and his only complaint was
his chronic neck and back pain.
.
On review of systems, he reports recent rhinnitis and
non-productive cough not associated with fevers or chills. He
denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: [**2128**], redo in [**2146**] (see further interventions below)
- s/p AVR (tissue) '[**46**]
- CHF EF: 22-30%
-PERCUTANEOUS CORONARY INTERVENTIONS:
.
-[**10/2128**] cardiac cath, EF 63%, 80% AM, 70% RPL, 80% LM, 80% LAD,
50% D1, 95% LCX. He underwent a CABG x4 with LIMA to LAD, VG to
D1, VG to OM and VG to PDA
.
-[**3-/2136**]: Cardiac cath for recurrent angina. Patent LIMA to LAD and
patent VG to RCA, occluded vein grafts to D1 and OM, 80% LM
lesion, attempt at PTCRA of LM, unable to pass wire
successfully,
PTCA performed.
.
-[**4-/2141**]: PTCA and stent to LM. Echo done at that time showed
significant aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.0cm2.
.
-[**5-/2141**]: cath for atypical chest discomfort and cath revealed
patent LM with 40% restenosis.
.
-[**2142-2-9**]: Cath: 90% SVG to PDA and instent restenosis of
the stent to the left main. S/P stent placement to the svg to
pda
and s/p rota and stent to LM.
.
-[**5-8**] cath for continued pain/pre surgery: patent LIMA and SVG
to
PDA, mild AS.
.
-[**2146-6-3**] cath/MI: SVG to PDA totally occluded, high thrombus
burden. S/p thrombectomy and 4 stents to PDA graft.
.
-[**2-12**]: cath: native CAD with occluded RCA and LAD and 90% LCX.
BMS to mid Cx lesion, patent SVG-PDA and LIMA-LAD
.
-PACING/ICD: [**Company 1543**] ICD
OTHER PAST MEDICAL HISTORY:
CHF with EF 30% s/p ICD
nephrolithiasis
gout
DM II w/peripheral neuropathy
OSA
CKD - baseline creatinine 1.5
Social History:
Pt lives with his wife in [**Name (NI) 620**] and is an architect. Does not
smoke, drink, or use any illicits. He has had numerous [**Name (NI) **]
transfusions.
Family History:
Father - AMI in his 80's
Mother - "enlarged" heart
Physical Exam:
VS: afebrile BP=112/43 HR=79 RR= 18 O2 sat= 99% on 5L NC
GENERAL: WDWN, obese male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, unable to visualize JVP 2/2 body habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. + accessory sounds from IABP.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. right venous/arterial sheath in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral groin sheath in place Popliteal 2+ DP
1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2151-11-26**] 06:40AM [**Month/Day/Year 3143**] WBC-7.9 RBC-3.60* Hgb-9.9* Hct-29.7*
MCV-83 MCH-27.5 MCHC-33.4 RDW-15.0 Plt Ct-150
[**2151-11-24**] 06:07AM [**Month/Day/Year 3143**] PT-12.7 PTT-50.3* INR(PT)-1.1
[**2151-11-26**] 06:40AM [**Month/Day/Year 3143**] Glucose-135* UreaN-35* Creat-2.2* Na-136
K-4.1 Cl-105 HCO3-20* AnGap-15
[**2151-11-23**] 09:45PM [**Month/Day/Year 3143**] CK(CPK)-200*
[**2151-11-23**] 09:45PM [**Month/Day/Year 3143**] cTropnT-0.02*
[**2151-11-24**] 12:50AM [**Month/Day/Year 3143**] CK(CPK)-404*
[**2151-11-24**] 12:50AM [**Month/Day/Year 3143**] CK-MB-21* MB Indx-5.2
[**2151-11-24**] 12:50AM [**Month/Day/Year 3143**] cTropnT-0.18*
[**2151-11-24**] 06:07AM [**Month/Day/Year 3143**] CK(CPK)-770*
[**2151-11-24**] 06:07AM [**Month/Day/Year 3143**] CK-MB-94* MB Indx-12.2* cTropnT-2.08*
[**2151-11-24**] 01:41PM [**Month/Day/Year 3143**] CK(CPK)-1388*
[**2151-11-24**] 01:41PM [**Month/Day/Year 3143**] CK-MB-197* MB Indx-14.2*
[**2151-11-24**] 08:27PM [**Month/Day/Year 3143**] CK(CPK)-1221*
[**2151-11-24**] 08:27PM [**Month/Day/Year 3143**] CK-MB-152* MB Indx-12.4* cTropnT-3.50*
[**2151-11-25**] 04:13AM [**Month/Day/Year 3143**] ALT-30 AST-106* CK(CPK)-879* AlkPhos-123*
TotBili-0.7
[**2151-11-25**] 04:13AM [**Month/Day/Year 3143**] CK-MB-88* MB Indx-10.0* cTropnT-3.14*
[**2151-11-26**] 06:40AM [**Month/Day/Year 3143**] ALT-21 AST-48* LD(LDH)-427* AlkPhos-123*
TotBili-0.6
[**2151-11-24**] 06:07AM [**Month/Day/Year 3143**] %HbA1c-7.9*
[**2151-11-24**] 06:07AM [**Month/Day/Year 3143**] Triglyc-178* HDL-27 CHOL/HD-4.6
LDLcalc-60
EKG [**11-23**]: Probable atrial tachycardia with variable block.
Borderline intraventricular
conduction delay. Inferior lead QRS configuration raises
consideration of
prior inferior myocardial infarction, although it is
non-diagnostic. Delayed
R wave progression with late precordial QRS transition. ST-T
wave
abnormalities. Findings are non-specific. Clinical correlation
is suggested.
Since the previous tracing of the same date ventricular response
is now
irregular and slower, precordial lead QRS configuration shows
delayed R wave progression but is less suggestive of anterior
myocardial infarction and further precordial lead ST-T wave
changes are present.
.
TTE [**11-24**]: The left atrium is dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is severe regional
left ventricular systolic dysfunction with akinesis of the
inferior and inferolateral walls, hypokinesis of the anterior
wall and septum. The lateral wall has relatively preserved
function. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %). with borderline normal free wall
function. The ascending aorta is mildly dilated. A bioprosthetic
aortic valve prosthesis is present. The prosthetic aortic valve
leaflets are thickened. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2150-11-24**],
image quality is better. The aortic prosthesis can be seen and
appears to work well. Wall motion can be adequately assessd on
the current study.
.
CTA chest [**11-23**]:
1. No evidence of pulmonary embolism or acute aortic pathology.
.
2. Coronary artery disease with prior coronary bypass surgery
and aortic
valve replacement.
.
CXR [**11-23**]:
No acute cardiopulmonary process. Stable moderate cardiomegaly.
.
LHC/RHC [**11-24**]:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated three vessel disease. The LMCA had mild plaquing
throughout. The LAD had a proximal/ ostial occlusion. The Cx had
a 90%
in stent restenosis in the mid portion of the vessel. The RCA
was known
to be totally occluded and was not visualized.
2. Arterial conduit angiography revealed the LIMA to be widely
patent.
The SVG to the R-PDA was widely patent. The SVGs from the
patients
previous CABG were known to be occluded and not visualized.
3. Limited resting hemodynamics revealed elevated left and right
sided
filling pressures. The LVEDP was 33 mmHg and the RA A wave was
28 mmHg.
The PASP was moderately elevated at 49 mmHg. There was systemic
hypotension with an central aortic pressure of 81/50 mmHg. The
cardiac
index was low at 1.7 l/min/m2.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate left ventricular diastolic dysfunction.
3. Moderate pulmonary hypertension.
4. Decreased cardic index.
5. Systemic Hypotension
Brief Hospital Course:
# Coronary Artery Disease: Known 3vCAD Presenting with NSTEMI
found to have in stent restenosis of Left Cx (BMS placed in
[**2148**]) s/p angioplasty and placement of Drug eluting stent. ECHO
showed depressed EF 25%, essentially unchaged from previous.
CK's peaked at 1388 with trop 3.5. Pt tol cardiac
catheterization and placement of intra aortic balloon pump well,
right groin with only mild ecchymosis and no hematoma. SBP has
been borderline low, 90's-110's, so initiation of ACE and
Metoprolol has been slow. Imdur was started for intermittant
chest pain that was relieved with SL NTG. Currently on full dose
aspirin, clopidigrel, atorvastatin and Metoprolol succinate.
Lisinopril was restarted on the day of transfer. Pt should
increase his metoprolol and lisinopril as tolerated. Pt should
take aspirin and Plavix daily indefinitely to prevent in stent
stenosis. HDL 27, LDL 60.
.
# Acute on Chronic Systolic Congestive Heart Failure: Prior EF
25-30% s/p ICD placement and IABP for hypotension. Now EF 25%
after NSTEMI. High filling pressures in cath lab, rec'd Lasix IV
x1 and restarted Lasix PO. Currently has no peripheral edema or
O2 requirement, needs to be assessed with activity. He should be
weighed daily before breakfast and weight gain or more than 3
pounds in 1 day or 6 pounds in 3 days should be reported to
provider. [**Name10 (NameIs) **] needs to follow a 2 gram sodium diet, he has been
very non-compliant in the past. Fluid restrict to 1500cc/day. He
is on Spironolactone as before.
.
# RHYTHM: On presentation in SVT, now in sinus since right heart
cath in the lab.
.
# Acute on CKD - Baseline creatinine 1.5, elevated to 1.9 on
presentation and 2.2 currently. Consistent with prerenal state
for poor forward flow from acute MI and contrast nephropathy
from cardiac catheterization and CTA. Foley pulled yesterday
and replaced for no urine output in 8 hours. He has a history of
urinary difficulty but has not been treated in the past. Flomax
was started and Foley will be left in upon transfer. Pt has an
appt with urologist in 10 days for further evaluate. Should have
lytes done QOD until stable, then weekly thereafter.
.
# Type II Diabetes Mellitus with complications, on insulin at
home, very non-compliant per son. His [**Name2 (NI) **] sugars are
moderately well controlled on 32 units of Glargine here (home
dose 30 units) with Humalog sliding scale. A1C 7.9. [**Month (only) 116**] need to
uptitrate Glargine further.
.
# Chronic Normocytic Anemia - baseline HCT 35, admitted above
baseline but drifing down after procedures and phelbotomy.
Currently 29.7 and stable, no signs of bleeding. Pt will need
colonoscopy if he is not current in last 5 years once clinically
more stable.
.
# Gout - continue renally dosing of allopurinol. Was taking
Colchicine 0.6mg [**Hospital1 **] at home, renally dosed at 0.3mg daily here.
No signs of flare at present.
.
# Chronic Neck/Back Pain - Sees orthopedic physician [**Name Initial (PRE) **] (Dr.
[**Last Name (STitle) **] Uses conservative measures at home w/ soft cervical collar
and special pillows. Was on nabumetome and possibly Ibuprofen at
home, held because of ARF. Lidocaine patch was continued.
Narcotics tend to make pt confused, would use high dose tylenol
instead.
.
COMM: [**Name (NI) **] - [**Name (NI) **] [**Name (NI) 106004**]; [**Telephone/Fax (1) 106005**]
.
Medications on Admission:
Allopurinol 100 mg Tablet
1 Tablet(s) by mouth once a day
Amoxicillin 500 mg Tablet
4 Tablet(s) by mouth x 1 prn as needed for 1 hr prior to dentist
BD ultrafine pen needles
Colchicine 0.6 mg Tablet
one Tablet(s) by mouth twice a day
Insulin Glargine [Lantus] 100 unit/mL Cartridge
30 units once a day
Lidocaine [Lidoderm] 5 % (700 mg/patch) Adhesive Patch,
Medicated
apply once a day as needed for apply in morning and remove after
12 hrs
Lisinopril 5 mg Tablet
1 Tablet(s) by mouth once a day
Metoprolol Succinate [Toprol XL] 25 mg Tablet Sustained Release
24 hr
one Tablet(s) by mouth once a day
Nabumetone 500 mg Tablet one Tablet(s) by mouth twice a day
Simvastatin 80 mg Tablet
1 Tablet(s) by mouth once a day
Spironolactone 25 mg Tablet 1 Tablet(s) by mouth once a day
Venlafaxine [Effexor XR] 37.5 mg Capsule, Sust. Release 24 hr 1
Capsule(s) by mouth once a day
Aspirin 325 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth once a day
Guar Gum [Benefiber Sugar Free(Guar Gum)] Powder by mouth prn
(OTC) Ibuprofen 200 mg Capsule two Capsule(s) by mouth
twice a day
Omeprazole 20 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*2*
10. 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*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Benefiber Sugar Free(Guar Gum) Powder Sig: One (1)
packet PO once a day.
13. Effexor XR 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
14. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: apply to neck or back for
total of 12 hours per day.
Disp:*30 patches* Refills:*2*
15. Colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
17. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
18. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for back/neck pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Non St Elevation Myocardial Infarction
Acute on chronic congestive heart Failure
Acute on chronic Kidney disease
Hypertention
Urinary Retention
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You had a heart attack and required a drug eluting stent be
placed in your left Circumflex artery. You will need to take
Plavix every day for at least one year, do not stop taking
Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you to. This is
to prevent the stent from clotting off again and causing another
heart attack. You also had trouble urinating after we took out
the Foley catheter. The catheter was put back in and you will
need to keep it in until you see Dr. [**Last Name (STitle) **], a urologist, in 10
days.
New Medicines:
1. Flomax: to help shrink the prostate so you can urinate
without the catheter.
2. Plavix: to prevent the stent from clotting off and causing
another heart attack.
3. continue to take Aspirin daily along with the Plavix.
4. STOP taking Ibuprofen and Nabumetome
5. START taking Flonase to stop your runny nose
6. Start Imdur, a long acting nitroglycerin to prevent chest
pain
7. Take Metoprolol succinate 1 tablet per day and titrate up as
tolerated.
8. Start taking Furosemide to prevent fluid build up.
9. restarted lisinopril at 2.5 mg po daily
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Follow a low sodium diet.
Followup Instructions:
Orthopedics:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2152-4-21**] 9:00
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] M. Phone: [**Telephone/Fax (1) 53711**] Date/time: Please make an
appt after you get to your new home.
.
Cardiology:
[**Name6 (MD) **] [**Name8 (MD) 50213**], MD Phone: [**Telephone/Fax (1) 4105**] Date/Time: Office will
call you with an appt.
.
Urology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 470**], [**Hospital Ward Name 516**],
[**Hospital1 18**]. Phone:([**Telephone/Fax (1) 772**] Date/time: [**2151-12-6**] at 11:45am.
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,061
| 168,919
|
28557
|
Discharge summary
|
report
|
Admission Date: [**2121-6-17**] Discharge Date: [**2121-7-2**]
Date of Birth: [**2065-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
atrial flutter RVR, possible GIB, leukocytosis, fever
Major Surgical or Invasive Procedure:
intubated [**2121-6-21**]
central venous line [**2121-6-21**]
History of Present Illness:
55yo M previously unknown to this hospital presented initially
to OSH with progressive low back pain. In [**2119-1-12**] pt underwent
L3L4 laminectomy for epidural abcess. Pain recurred after
discontinuation of 6 week post-op course of antibiotics
(organism and Abx unknown at this time). Pt apparently admitted
to OSH for similar back pain prior to transfer. Pt was prepared
for discharge at OSH, but then collapsed, became lethargic, was
found to be in flutter vs fib w/ RVR, with WBC of 40, and
producing copious dark stools. Sequence of events and chronicity
not entirely clear. Prior to transfer to [**Hospital1 18**] for further
evaluation, pt received vanco, zosyn, and dilt 35mg. 4L NS were
given by EMS in transit, per their flowsheet, pt was never
hypotensive (all SBP>120).
.
In the ED, initial vs were: T98.7 P114 BP114/67 R40 O2 sat99 on
4L. Pt continued to produced dark stools (guiaic +). Patient was
given 4L NS with total UOP of 1200cc. His Hct remained stable. 3
peripheral IVs were placed. Tachycardia did not resolve with
fluids--interpreted as flutter with variable block. NSGY eval in
the ED for low back pain as they thought he had a laminectomy in
[**2121-1-12**] for epidural abcess, if fact, laminectomy was in [**2118**].
Pt seen by GI in ED and considering EGD.
.
Pt markedly tachypneic, initial ABG in ED 7.47, 28, 96 on 2L.
Repeat ABG five hours later showed 7.47, 27, 67 on room air.
.
Review of systems:
(+) Per HPI
(-) unable to provide reliable ROS
Past Medical History:
-Prior PNA
-septic shock [**1-13**] septic shoulder [**2120-2-10**] (MRSA)
-Epidural abcess (organism unknown) tx with 6 weeks Abx
post-laminectomy in [**2119-1-12**]
-Hep C
-A fib not on coumadin
Social History:
Hx of IVDU; no use per pt for several months. Denies ETOH abuse.
Family History:
UNABLE TO ELICIT
Physical Exam:
Discharge exam:
Vitals: T: 99.4 BP: 120/80 P: 88 R: 20 O2: 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Slightly decreased lung sounds throughout. 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
Back: large healing surgical incision in lumbar sign, some
erythema but no swelling or discharge.
Ext: Warm, well perfused, 2+ pulses throughout, no clubbing,
cyanosis or edema. Limited ROM in right shoulder and elbow [**1-13**]
pain. Small cut in left foot from incision in drainage
expressing serosanguinous fluid, no frank pus. Dressing
clean/dry/intact.
Neuro: aaox3, 5/5 strength b/l and throughout, sensation intact.
Able to transfer himself from chair to walker, but requires arm
assistance.
Pertinent Results:
Labs on Admission: [**2121-6-17**]
WBC-35.2* RBC-3.79* Hgb-11.9* Hct-34.5* MCV-91 MCH-31.3 Plt
Ct-185
Neuts-87* Bands-5 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0
Metas-2* Myelos-1*
PT-16.0* PTT-27.9 INR(PT)-1.4*
Glucose-110* UreaN-65* Creat-1.3* Na-138 K-3.6 Cl-109* HCO3-19*
AnGap-14
ALT-16 AST-30 LD(LDH)-306* CK(CPK)-42 AlkPhos-192* TotBili-1.5
Albumin-2.0* Calcium-7.2* Phos-3.0 Mg-1.7
Hapto-328*
HIV Ab-NEGATIVE
freeCa-1.09*
Lactate-1.2
.
[**2121-6-17**] 09:11AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-6-17**] 02:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
.
[**2121-6-17**] Blood culture
STAPH AUREUS COAG +
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2121-6-22**] 11:40 pm SWAB Site: BACK DEEP LUMBAR.
.
**FINAL REPORT [**2121-6-27**]**
.
GRAM STAIN (Final [**2121-6-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
.
WOUND CULTURE (Final [**2121-6-25**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 277-2104F
[**2121-6-23**].
.
ANAEROBIC CULTURE (Final [**2121-6-27**]): NO ANAEROBES ISOLATED.
.
[**2121-6-23**] 1:02 pm SWAB Source: L 2nd toe.
.
**FINAL REPORT [**2121-6-27**]**
.
GRAM STAIN (Final [**2121-6-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
.
WOUND CULTURE (Final [**2121-6-25**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 277-1942F
[**2121-6-22**].
.
ANAEROBIC CULTURE (Final [**2121-6-27**]): NO ANAEROBES ISOLATED.
.
[**2121-6-22**] 11:49 pm TISSUE LAMINA AND EPIDURAL PHLEGMON.
.
GRAM STAIN (Final [**2121-6-23**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
.
TISSUE (Final [**2121-6-26**]):
STAPH AUREUS COAG +. SPARSE 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 ([**6-/2418**])
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---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
ANAEROBIC CULTURE (Final [**2121-6-27**]): NO ANAEROBES ISOLATED.
.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
Blood Cultures [**Date range (1) 34617**] - No Growth
.
MRI Lumber Spine [**2121-6-19**]
1. Abnormal STIR hyperintense collection within the ventral
epidural space
tracking along the posterior margin of the L5 vertebral body and
sacrum
resulting in complete effacement of the ventral sac with
abnormal clumping of the nerve roots at these levels. Given the
patient's clinical history and adjacent right-sided
paravertebral collections, findings are suspicious for epidural
phlegmon or abscess. Distinction cannot be made on this limited
non-contrast enhanced examination. 2. Limited evaluation of
multilevel degenerative disc disease with disc bulges as
detailed above. Slightly elevated signal within multiple
endplates and discs are likely degenerative, but underlying
discitis/osteomyelitis cannot be excluded by this limited
imaging. There remains high clinical concern, repeat MRI with
increased sedation or correlation with nuclear scintigraphy exam
should be considered.
.
MRI Left Foot [**2121-6-21**]
Dorsal dislocation of the second metatarsophalangeal joint,
extensive,
loculated and enhancing fluid collections centered at the second
metatarsophalangeal joint, extending proximally to the second
metatarsal base and first tarsometatarsal joint, consistent with
the second
metatarsophalangeal septic arthritis and associated abscesses in
the more
proximal forefoot. Mild edema in the distal second metatarsal
without
definitive changes of osteomyelitis.
.
[**2121-6-21**] TEE
Valves are very well visualized. No valvular vegetations,
abscess or pathologic regurgitation seen.
.
[**2121-6-27**] CT head
IMPRESSION: Small vessel ischemic disease, no sign of abscess.
.
[**2121-6-29**] MRI Shoulder
INDICATION: 55-year-old man with history of MRSA of right
shoulder, question
septic arthritis and osteomyelitis.
.
COMPARISON: None.
.
TECHNIQUE: Imaging was performed at 1.5 Tesla using the shoulder
coil.
Sequences include true axial and coronal T1, STIR, and
post-gadolinium images
of the right shoulder.
.
FINDINGS: There is a massive effusion extending through a torn
rotator cuff
from the joint to the subdeltoid/subacromial bursa and
subscapularis recess
containing debris and septations. There is marked edema within
the head and
neck of the humerus as well as the glenoid with loss of cortical
definition. A
focal area of T2 hyperintensity measuring 12 (AP) x 12 (TV) x 16
(CC) mm with
thick peripheral enhancement (series 15:25) located in the
proximal humeral
metadiaphysis is consistent with an intraosseous abscess. There
is edema
within the muscles of the rotator cuff, especially the
subscapularis muscle. A
peripherally enhancing 12 x 8 mm abscess (series 13:38) is seen
in the
subscapularis muscle.
.
While not dedicated to evaluation of the rotator cuff, there is
a complete
tear of the supraspinatus tendon, as well as tears of the
infraspinatus and
subscapularis tendons. There is a tear of the superior labrum
(series 11:16).
The biceps labral anchor complex is destroyed.
.
IMPRESSION:
1. Complex fluid collection in the shoulder joint communicating
with the
subacromial/subdeltoid bursae and subscapularis recess with
diffuse marrow
edema and loss of cortical definition of the humeral head,
proximal humeral
metadiaphysis and glenoid.
.
2. Discrete peripherally enhancing interosseous abscess.
.
3. Small intramuscular abscess within the subscapularis muscle.
Overall, the
findings are concerning for osteomyelitis, interosseous abscess,
and septic
joint.
.
Brief Hospital Course:
1. MRSA Sepsis: Was initially placed on broad covg with
vanco/zosyn/cipro. Blood cx showed MRSA bacteremia on [**2121-6-17**].
Pt placed on vancomycin and zosyn/cipro stopped. TTE and TEE
without vegetation. Pt also developed back pain and L toe pain
which were felt to be likely seeded from MRSA bacteremia. He
was electively intubated for MRI, which showed epidural abscess.
MR of the foot also showed septic arthritis. Patient had a
Lumbar laminectomy to drain an epidural abscess, L4-S1 on
[**2121-6-22**] which he tolerated well. Podiatry did an incision and
drainage at the bedside which he tolerated well. After these
procedures the patient had occasional temperature spikes. Each
time he was recultured (no growth on cultures after [**6-22**]). MRSA
sepsis has cleared with foci of infection in left foot, pelvis,
lumbar spine, and right shoulder. MR shoulder showed
osteomyelitis, septic joint and interosseous abscess.
Orthopedics did a tap of the shoulder that was dry, and their
assessment was that there was no discrete abscess that would
benefit from an open shoulder washout. Will continue vancomycin
1000mg Q12H to complete an 8 week course. He will follow up
with ID and orthopedics as an outpatient for continued
management.
.
2. DVT Right UE: presented with a painful and increasingly
swollen elbow. Initial UE u/s did not show DVT. Initial elbow
tap by [**Month/Year (2) **] was dry. Pt states pain is improving, but
clinically edema is worsened. CT elbow showed small (<1cm) fluid
in biceps and small joint effusion without osteo. Clinical
suspicion high for clot given degree of swelling on exam. Repeat
u/s [**6-26**] showed brachial vein clot with 8x10cm complex cyst in
shoulder, concerning for an abscess. Did not start coumadin in
setting of recent laminectomy and ?GI bleed, started heparin gtt
goal PTT 50-60. Discharged with lovenox 120mg daily.
.
3. Swollen right shoulder: as per patient report, he went to OSH
for shoulder pain, on discharge for OSH he collapsed and was
transfered here. He has a history of MRSA in the joint with
chronic swelling. MRI showed osteomyelitis, septic joint and
abscess. Will follow up with orthopedics in the outpatient
setting for further management of the shoulder. See above for
orthopedics assessment of shoulder.
.
4. Guiaic positive stools: Guiaic positive but not melena,
especially considering that Hct has [**Doctor First Name **] stable despite large
amounts of dark stool. Given marked leukocytosis, concern for
CDIFF. However, toxin neg here. Empiric po vanco stopped once
toxin neg. Patient refused colonoscopy and EGD and understood
the risks of not working up a guiaic positive stool. His hct
has been stable for >1 week
.
5. Anemia: Patient had iron studies consistent with anemia of
chronic inflammation/disease. Pt reticulocyte count 3.9%,
corrected retic index ~1%, which is not appropriate with his
anemia and consistent with this diagnosis. The patient had
guiaic positive stools and the original plan was to perform an
EGD and colonoscopy, however the patient declined the procedure.
He was informed of the risk that he was undertaking of
continued bleeding from declining the procedures.
.
6. Tachycardia: Atrial tachyarrhtymia. Hemodynamically
tolerating elevated rate. Rate not indicative of intravascular
depletion. Was rate controlled, as this was felt to be separate
physiology from his sepsis. Corrected to normal sinus rhythm
after sepsis resolved. Discharged on metoprolol extended
release 50mg daily.
.
7. Hypoalbuminemia: urine negative for protein, probably not a
liver synthesis problem as [**Name (NI) 3539**] not elevated and only slight
INR increase. Most likely malnutrition, nutrition consulted.
Eating a regular diet.
.
8. Poor dentition: has ~3 teeth, very loose and discolored.
Dental consult earlier in course to eval for source of
infection, they rec panorex and likely oral surgery. Given
outpatient information for follow up.
Medications on Admission:
none
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. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
4. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours): discontinue upon discharge
from rehab.
Check platelets weekly.
5. Vancomycin 1,000 mg Recon Soln Sig: One (1) 1000 mg
Intravenous every twelve (12) hours: day1 = [**6-22**]
total 8 week duration.
6. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
7. Morphine 10 mg/mL Solution Sig: 2-4 mg Intravenous Q4H (every
4 hours) as needed for pain.
8. Outpatient Lab Work
Please draw weekly BUN, creatinine, CBC with differential to
monitor renal function and treatment response to vancomycin, and
platelets to monitor for acute marked drop from lovenox.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
Primary: MRSA sepsis, septic toe, septic shoulder, epidural
abscess, pelvic soft tissue infection, DVT right brachial vein,
atrial fibrillation with rapid ventricular response
Secondary: hepatitis C, IV drug abuse, prior epidural abscess,
prior septic shoulder
Discharge Condition:
Hemodynamically stable. MRSA controled and no evidence of
bacteremia.
Discharge Instructions:
You were admitted with a MRSA infection in your blood. MRSA is a
bacteria that can cause severe infections, and is difficult to
treat because it is resistant to many antibiotics. As a result
of this you also got MRSA infections in your foot, shoulder,
pelvis and lumbar spine. You were treated with IV vancomycin,
and will continue to need IV vancomycin for at least 8 weeks,
with antibiotics by mouth after that.
Your stool was positive for blood was tested. This is concerning
for a possibly bleed in your stomach or bowels. You refused to
have a colonoscopy or upper scope. You understood the risk of
not getting these procedures and were comfortable with not
having them done.
You also developed a clot in the vein of your right arm. As a
result of this you had swelling and pain your right elbow. You
were treated for this with heparin, which was an medicine that
you recieved in the hospital through an IV. This has been
discontinued, but you will continue to need shots for
anticoagulation at rehab as well as after you are discharged
from rehab. This is for your safety and to dissolve the clot,
and you will need to have these shots for 3 months.
When you came from the outside hospital your heart was beating
in an irregular rhythm - atrial fibrillation with rapid
ventricular response. This was caused by the MRSA infection in
your blood. You were given metoprolol to help with control your
heart rate. We are adding a new medication metoprolol XL, please
be sure to take this everyday.
During your stay a dentist saw you and thought your teeth needed
to be pulled. Please call one of the following numbers to make
an appointment for continued dental care and treatment.
If you experience chest pain, shortness of breath, fevers,
chills, tremors, abdominal pain, swollen red joints, dizzyness
or any other symptom that is concerning to you, please call your
doctor or go to the nearest emergency room.
Followup Instructions:
You are scheduled to follow up with orthopedic surgery at the
[**Hospital3 **] Hospital [**Hospital Ward Name 23**] Building on [**7-30**] at the times
below:
1. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2121-7-30**] 11:55AM [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]
2. Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2121-7-30**] 12:15PM [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]
You are also scheduled to follow up with infectious disease
clinic at the time below:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2121-7-16**] 2:30PM at [**Hospital Ward Name 517**], [**Last Name (NamePattern1) 439**],
Basement
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2121-8-5**] 9:00 at [**Hospital Ward Name 517**], [**Last Name (NamePattern1) 439**],
basement
Completed by:[**2121-7-2**]
|
[
"521.00",
"995.91",
"728.89",
"070.70",
"280.0",
"711.01",
"038.11",
"682.2",
"578.9",
"304.21",
"730.22",
"427.31",
"427.32",
"709.2",
"785.0",
"228.09",
"348.39",
"785.6",
"453.40",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.09",
"54.91",
"88.72",
"96.04",
"81.91",
"03.02",
"38.93",
"83.21"
] |
icd9pcs
|
[
[
[]
]
] |
15220, 15291
|
10099, 14054
|
366, 429
|
15596, 15669
|
3315, 3320
|
17639, 18815
|
2261, 2279
|
14109, 15197
|
15312, 15575
|
14080, 14086
|
15693, 17616
|
2294, 2294
|
2311, 3296
|
6561, 10076
|
1894, 1942
|
273, 328
|
457, 1875
|
3334, 6528
|
1964, 2162
|
2178, 2245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,064
| 107,572
|
46551
|
Discharge summary
|
report
|
Admission Date: [**2145-5-25**] Discharge Date: [**2145-5-28**]
Date of Birth: [**2079-3-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Cough, fevers, melena
Major Surgical or Invasive Procedure:
Upper Endoscopy x 2
History of Present Illness:
Mr. [**Known lastname **] is a 66 year old male with a history of severe
gastroesophageal reflux disease s/p Nissen fundoplication in
[**2132**] who presented to [**Hospital 191**] clinic on the day of presentation with
cough and fevers for four days. The patient reports that he
felt well the week prior to admission. He developed fevers to
101 degrees associated with a dry cough for the past four days.
He did not have associated nasal congestion, sinus pressure, or
sore throat. He did not have any chest pain or shortness of
breath. He happened to note that for one day prior to admission
he had been having black bowel movements. He has been admitted
for gastrointestinal bleeding in the past but does not remember
ever having black stools. He denies abdominal pain, nausea,
vomiting, hematemasis or bright red blooid per rectum. He
denies lightheadedness, dizziness, or decreased urine output.
He does note that he had taken two ibuprofen the week of
admission for his fevers. In [**Hospital 191**] clinic his blood pressure was
112/70, heart rate of 88 and temperature of 100.7. His stool
was guaiac positive on exam.
In the emergency room his initial vitals were T: 99.0 HR: 79 BP:
137/72 RR: 20 O2: 97% on RA. He underwent NG lavage which was
grossly positive for 500 cc of bright red blood. He had a chest
xray which showed a possible right lower lung opacity. His
initial hematocrit was 40. His blood pressures transiently
dropped to the 80s systolic from the 110s and was responsive to
fluids. He received 2 L of normal saline, 40 mg IV protonix and
was admitted to the medical ICU.
In the medical ICU he underwent emergent upper endoscopy which
revealed old blood in the stomach and a large clot in the fundus
but no active bleeding. He has since been hemodynamically
stable. His hematocrit on transfer to the floor was 31.8. He
has not required any blood transfusions. He did undergo a chest
CT which showed likely aspiration pneumonia with reactive
lymphadenopathy. He was started on levofloxacin and flagyl.
On review of systems the patient currently denies
lightheadedness, dizziness, chest pain, shortness of breath,
nausea, vomiting, abdominal pain, dysuria, hematuria, low urine
output, leg pain or swelling. He notes fevers at home as above
with non-productive cough and melena. All other review of
systems negative in detail.
Past Medical History:
Gastroesophageal Reflux s/p Nissen fundoplication in 10/95
Upper Gastrointestinal Bleeding in [**2131**] and [**2132**]
Sensorimotor axonal neuropathy
Anxiety and Depression
Social History:
Works as a clerk. He lives with his wife and has no children.
He does not drink, smoke or use IV drugs.
Family History:
No history of coronary artery disease or diabetes. His brother
had "esophageal problems" but he cannot specify.
Physical Exam:
VS: T: 99.4 HR: 72 BP: 130/60 RR: 20 O2 sat: 97% on 2L
GENERAL: well appearing male in no acute distress
HEENT: sclera anicteric, slight conjunctival injection in right
eye with mild crusting, pupils equal and round, dry MM
NECK: supple, no LAD
LUNGS: bronchial breath sounds at bases, no wheezes or rales
CARDIAC: RRR, nl S1 S2, no m/r/g
ABDOMEN - distended, soft, non-tender, hypoactive BS
EXT - no cyanosis, clubbing, edema
Neuro: A&Ox3, no focal deficits
Pertinent Results:
Hematology:
[**2145-5-25**] 05:30PM WBC-10.1 RBC-4.42* HGB-13.7* HCT-40.0 MCV-90
MCH-31.0 MCHC-34.3 RDW-13.7
[**2145-5-25**] 05:30PM NEUTS-83.3* LYMPHS-11.0* MONOS-4.1 EOS-1.1
BASOS-0.3
[**2145-5-25**] 05:30PM PLT COUNT-247
[**2145-5-25**] 07:35PM PT-12.2 PTT-24.5 INR(PT)-1.0
[**2145-5-28**] 06:20AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.5* Hct-33.4*
MCV-90 MCH-31.2 MCHC-34.5 RDW-13.5 Plt Ct-316
Chemistries:
[**2145-5-25**] 05:30PM GLUCOSE-105 UREA N-26* CREAT-0.9 SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
Urinalysis:
[**2145-5-25**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2145-5-25**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Imaging:
CHEST (PA & LAT): Again noted are multiple healed right-sided
rib
fractures. An opacity in the right lower lung most likely
represents middle lobe atelectasis, which is slightly more
pronounced than on the prior study. An infectious process cannot
be entirely excluded. There are no effusions and no
pneumothorax. Cardiomediastinal silhouette is unremarkable.
CT CHEST W/CONTRAST [**2145-5-26**]
This examination is limited due to extensive motion artifact
limiting the sensitivity for small nodules and ground-glass
opacities. There are few prominent though non-pathologically
enlarged lymph nodes along the left lower paratracheal station
measuring 9 and 8 mm in width. There is an enlarged right hilar
lymph node, 16 x 14 mm. There is no pericardial or pleural
effusion. There is a moderate-sized area of consolidation within
the left lower lobe and a smaller area of peribronchiolar
ground-glass opacity within the right lower lobe. These findings
along with history of GERD are in keeping with aspiration
pneumonia. Right middle lobe linear atelectasis is noted. There
is a small amount of airway secretions, within the mid trachea.
There is a peripheral hypodensity within the right lobe of the
liver of approximately 1 cm. There is a 3.5 x 3.0 cm cystic
pancreatic head lesion which (based on prior report -- imaging
unavailable on PACS at this time) has not changed. There are
similar-appearing bilateral simple renal cysts. Suture material
is seen at the gastroesophageal junction consistent with history
of fundoplication.
IMPRESSION:
1. Likely aspiration pneumonia with reactive lymphadenopathy.
2. Recommend two-month followup CT post treatment to evaluate
for resolution of right hilar lymph nodes.
Upper Endoscopy [**2145-5-25**]:
A large adherent blood clot was seen in the stomach fundus,
unable to remove with suction or flushing. Area under the clot
not visualized.
Old blood was seen in the stomach, no fresh blood or bleeding
site was seen. Otherwise normal EGD to second part of the
duodenum.
Upper Endoscopy [**2145-5-27**]:
Esophagus: Mucosa: Slightly irregular z-line of the mucosa was
noted throughout the esophagus.
Stomach:
Lumen: Evidence of a previous Nissen fundoplication was seen.
Mucosa: Patchy erythema of the mucosa without bleeding was noted
in the fundus and stomach body. These findings are compatible
with gastritis.
Excavated Lesions Multiple superficial non-bleeding ulcers
ranging in size from 3mm to 5mm were found circumferentially
around the pylorus. Cold forceps biopsies were performed for
histology and to rule out h. pylori at the stomach antrum. A
single superficial non-bleeding 6mm ulcer was found in the
antrum.
Microbiology:
[**2145-5-26**] 4:49 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2145-5-29**]**
GRAM STAIN (Final [**2145-5-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2145-5-29**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
[**2145-5-27**] 7:05 am SEROLOGY/BLOOD HELI ADDED TO ACC#[**Serial Number 98851**]R.
**FINAL REPORT [**2145-5-28**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2145-5-28**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
Brief Hospital Course:
Mr. [**Known lastname **] is a 66 year old male with a history of severe
gastroesophageal reflux disease s/p Nissen fundoplication in
[**2132**] who presents with cough, fevers and melena.
Upper Gastrointestinal Bleeding: Patient presented to his
primary care physician noting melena. His hematocrit was 40.0
on admission but this dropped to 33.6 the following morning. NG
lavage in the emergency room was positive for gross blood. He
underwent emergent upper endoscopy which revealed old blood in
the stomach but no active bleeding. He did not require any
blood transfusions. He was treated with bowel rest and high
dose intravenous proton pump inhibitor. He underwent repeat
upper endoscopy two days later which revealed multiple
non-bleeding ulcers in the stomach. H. pylori serologies were
negative. He was advised to discontinue his aspirin and any
NSAIDs. He was discharged on omeprazole 40 mg daily. He will
follow up with his primary care physician.
Aspiration Pneumonia: On admission the patient had a CXR which
was concerning for an infiltrate. He underwent chest CT which
showed evidence of aspiration pneumonia and reactive
lymphadenopathy. Sputum cultures were positive for H. flu. He
was started on levofloxacin and flagyl for a ten day course.
This was switched to moxifloxacin on discharge. He should
undergo repeat imaging of his chest in two months to ensure that
the lymphadenopathy has resolved.
Conjunctivitis: The patient had evidence of mild conjunctival
injection on the right side with crusting on admission.
Although it was felt that this was unlikely to represent a
bacterial infection, given his systemic illness, he was treated
with erythromycin ointment for five days.
Anxiety/Depression: No active inpatient issues. He was
continued on citalopram.
Medications on Admission:
Citalopram 20 mg daily
Multivitamin
Aspirin 81 mg daily
Advil Occassionally
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
4. Erythromycin 5 mg/g Ointment Sig: 0.5 strip Ophthalmic QID (4
times a day) for 3 days: To right eye.
Disp:*1 tube* Refills:*0*
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper Gastrointestinal Bleeding
Aspiration Pneumonia
Conjunctivitis
Discharge Condition:
Stable. Ambulating without assistance. Breathing comfortably
on room air.
Discharge Instructions:
You were seen and evaluated for your black stools. You had an
upper endoscopy and were found to have ulcers in your stomach.
You also were found to have pneumonia and were treated with
antibiotics.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take levofloxacin 500 mg once a day for 7 more days
2. Please take flagyl 500 mg three times a day for 8 more days
3. Please take omeprazole 40 mg once a day
4. Please stop taking aspirin and advil until you see Dr. [**9-7**]. Please use erythromycin ointment in your right eye four times
a day for three more days for conjuncivitis
Please keep all your follow up appointments as scheduled.
Please seek immediate medical attention if you experience any
fevers > 101.5 degrees, chest pain, difficulty breathing,
worsening abdominal pain, persistent black stools or bloody
stools or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**] in
one week. Someone from his office will call you to help
schedule an appointment. His office phone number is
[**Telephone/Fax (1) 250**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"285.1",
"458.9",
"372.30",
"507.0",
"531.90",
"578.1",
"300.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.16",
"96.33",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
10840, 10846
|
8223, 10026
|
336, 358
|
10967, 11045
|
3704, 8200
|
12026, 12375
|
3094, 3209
|
10152, 10817
|
10867, 10946
|
10052, 10129
|
11069, 12003
|
3224, 3685
|
275, 298
|
386, 2759
|
2781, 2956
|
2972, 3078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,724
| 185,693
|
19792
|
Discharge summary
|
report
|
Admission Date: [**2108-5-12**] Discharge Date: [**2108-5-16**]
Date of Birth: [**2054-10-28**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Trazodone
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Fall and altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 53486**] is a 53 year old male with HCV and alcohol
mediated liver cirrhosis with varices status-post banding and
TIPS, multiple admissions for hepatic encephalopathy, who is
transferred to the MICU for managment of somnolence. He
originally presented with altered mental status s/p fall. Last
night around 8pm, he was found with several clonazepam pills in
his mouth. He had a bottle containing 25, 2mg clonazepam pills.
.
His vital signs upon evaluation on the floor were T 101.7, BP
146/90, HR 85, RR 24, Saturation 93% on 2LNC. This was his first
fever. He was barely arousable to vigorous sternal rub. His
pupils were 3mm and reactive. He had paradoxical breathing with
accessory muscle use.
.
Upon arrival to the floor his BP 129/67, HR 76, Sat 95% on NC.
He was slightly arousable with sternal rub.
Past Medical History:
- cirrhosis due to hepatitis C (genotype 3) and prior alcohol
abuse; course complicated by esophageal variceal bleeds treated
with banding at [**Hospital1 2025**] and TIPS in [**3-/2105**]; recent EGD [**12/2106**] with
only one cord of grade 1 varices; multiple prior episodes of
hepatic encephalopathy; denied liver transplant at [**Hospital1 18**] because
of history of relapse, was also turned down by [**Hospital3 2358**] for
same reason
- hepatitis B
- prior polysubstance abuse including clonazepam, alcohol and
daily IV heroin
- diabete mellitus on insulin; diagnosed over 20 yrs ago
following an episode of severe pancreatitis; complicated by
diabetic neuropathy
- ulcerative colitis
- hypertension
- cocaine-induced MI in [**2083**]
- prior hernia repair
- prior unilateral orchiectomy
- anxiety
- post-traumatic stress disorder
- benign prostatic hyperplasia
- s/p cholecystectomy
Social History:
Lives alone; VNA comes in twice daily. Has 2 grown children. On
SSI for disability and also disable veteran since the late '80s.
Intermittent smoking history, had recently quit for 8 months but
re-started over the summer [**2106**]. H/o polysubstance abuse. Was
abusing Vicodin up until 3/[**2104**]. Quit heroin in '[**92**] or '[**93**].
Admits to drinking alcohol [**2108-4-12**], none since. Most recent
drug abuse was with clonazepam. Used to own pizza restaurant in
[**Hospital3 4414**].
Family History:
Diabetes in both parents. Mother with leukemia. His father had
[**Name (NI) 2481**] disease. No family history of substance abuse.
Physical Exam:
Upon admission:
General: Sleeping, awakens to voice and touch but unable to stay
awake for long.
HEENT: Pupils equal and reactive to light and accomodation;
small abrasion over the right eye.
Neck: Supple, no lymphadenopathy.
Heart: Regular rate and rhythm, normal s1s2, no murmurs.
Lungs: Clear to auscultation bilaterally anterior fields.
Abdomen: Soft, mild tenderness diffusely to palpation, no
guarding or rebound, normal bowel sounds.
Extremities: Warm, well-perfused, 1+ bilateral symmetric pitting
edema without erythema or skin changes.
Neurological: +Asterixis; moving all extremities; oriented to
self.
At discharge:
Vitals: 97.2 128/79 76 18 97% on RA
FS: 117-159-158-165-209
I/O: 300/150+BR +1BM 1800/530+2BM
General: Middle-aged man in no acute distress. He is oriented to
person, year, hospital and city. He is oriented to current
events. He has difficulty with concentration and attention.
HEENT: sclera anicteric, MMM no lesions
Heart: Regular rate and rhythm, normal s1s2.
Lungs: Clear bilaterally anterior fields.
Abdomen: No rebound or guarding.
Extremities: 1+ bilateral lower extremity swelling.
Neurological: No asterixis.
Pertinent Results:
Admission Labs:
=================
[**2108-5-12**] 10:55AM GLUCOSE-198* LACTATE-1.7 K+-4.7
[**2108-5-12**] 10:48AM GLUCOSE-208* UREA N-19 CREAT-0.8 SODIUM-129*
POTASSIUM-5.5* CHLORIDE-95* TOTAL CO2-28 ANION GAP-12
[**2108-5-12**] 10:48AM estGFR-Using this
[**2108-5-12**] 10:48AM ALT(SGPT)-206* AST(SGOT)-265* ALK PHOS-132*
TOT BILI-1.8*
[**2108-5-12**] 10:48AM LIPASE-31
[**2108-5-12**] 10:48AM CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-2.1
[**2108-5-12**] 10:48AM AMMONIA-144*
[**2108-5-12**] 10:48AM OSMOLAL-281
[**2108-5-12**] 10:48AM WBC-4.8 RBC-3.76* HGB-12.4* HCT-36.0* MCV-96
MCH-33.1* MCHC-34.5 RDW-14.4
[**2108-5-12**] 10:48AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-5-12**] 10:48AM NEUTS-67.8 LYMPHS-17.8* MONOS-10.0 EOS-4.0
BASOS-0.4
[**2108-5-12**] 10:48AM PLT SMR-LOW PLT COUNT-87*
Discharge Labs:
==================
CBC: 2.9/11.9/35.1/79 MCV 99
Chem 7: 132/3.6/100/27/18/0.7< 208
Chem 10: Ca: 7.8 Mg: 1.6 P: 4.0 ∆
ALT: 172 AST: 210 AP: 133 Tbili: 0.8
PT: 14.7 INR: 1.3
Imaging:
==================
[**5-12**] CT C-SPINE: There is normal alignment to the cervical spine
without fracture, or dislocation. No prevertebral fluid is
present. The visualized outline of the thecal sac appears
normal, although CT is unable to provide intrathecal detail
comparable to MRI. There are mild degenerative changes most
pronounced at C6-7 with a small posterior disc osteophyte
complex causing a mild degree of central canal narrowing. The
visualized lung apices are clear. There is a coarse
calcification within the right lobe of the thyroid and a
heterogeneous nodule may be present within the right lobe of the
thyroid. IMPRESSION: 1. No evidence for traumatic injury to the
cervical spine. 2. Possible right thyroid nodule for which
ultrasound could be performed on a non-emergent basis.
[**5-12**] CT HEAD: Despite repeated attempts the study is somewhat
limited by motion, particularly in the posterior fossa. Within
these limitations no hemorrhage, edema, mass effect, or evidence
for acute vascular territorial infarction is present. There is
no shift of normally midline structures and [**Doctor Last Name 352**]-white matter
differentiation appears well preserved. The size and
configuration of the ventricles appear within normal limits.
Osseous structures are intact. There is minimal mucosal
thickening of the ethmoid air cells. Remaining sinuses are
clear. IMPRESSION: 1. Study is somewhat limited by motion but no
acute intracranial injury.
[**5-12**] RUQ US: There is diffuse coarse echotexture to the liver
but no focal
worrisome lesions are identified. An anechoic 1.4 x 1.4 x 1.5 cm
cyst is
present within the left lobe of the liver unchanged. A TIPS
stent is present with wall-to-wall flow identified. In the
distal portion of the TIPS stent velocities measure 122 cm/sec,
previously 118 cm/sec. In the mid TIPS stent in a similar
position to the previous study the mid velocities currently are
123 cm/sec, previously 126 cm/sec. Proximally velocities
measured 154 cm/sec, previously 134 cm/sec. The main portal vein
is patent and the hepatic vein confluence is patent and the IVC
is patent. No ascites is present. The spleen measures 18 cm.
IMPRESSION: 1. Patent wall-to-wall flow within the TIPS stent
with velocities similar to the previous examination. 2. No
ascites. Splenomegaly. 3. Coarse echotexture to the liver with a
stable cyst.
[**2108-5-13**] CXR: There are low inspiratory volumes, limiting
assessment of cardiomediastinal silhouette and vascular
markings. Prominence of the upper zone vessels medially may
relate to low inspiratory volumes. No definite pneumonic
infiltrate or CHF. There is right greater than left subsegmental
atelectasis. ?small right-sided effusion.
[**2108-5-14**] CXR: In comparison with the study of [**5-13**], there is
minimal atelectasis at the bases, though no evidence of acute
focal pneumonia. Slightly improved lung volumes. No evidence of
vascular congestion, pneumothorax or pleural effusion.
Brief Hospital Course:
53-year-old man with HCV and EtOH-cirrhosis with varices
status-post banding and TIPS and multiple admissions for hepatic
encephalopathy, admitted for hepatic encephalopathy.
# Hepatic Encephalopathy: His somnolence was a combination of
intoxication from clonazepam while admitted and hepatic
encephalopathy secondary to lactulose noncompliance and urinary
tract infection. He went to the MICU where he was watched while
he was somnolent. His lactulose was uptitrated and he was
continued on rifaximin. All sedating medications were held.
Psychiatry was consulted and were going to touch base with his
outpatient psychiatrist.
# Urinary Tract Infection: Patient had one fever during
admission, and received one time doses of cefepime and
vancomycin. His urine grew enterococcus at last admission, and
was sent home with a prescription. However, he did not complete
his full course. Urine culture with residual enterococcus during
this admission. Sensitivities were still pending at discharge,
so the patient was given a repeat 10 day course of amoxicillin
based on the prior sensitivities. Blood cultures are still
pending at the time of discharge.
# HCV/EtOH Cirrhosis: Previously complicated by hepatic
encephalopathy and variceal bleed. Patient is not a transplant
candidate given his history of relapse and poor compliance. INR
is at baseline. TBili was slightly elevated, but was
downtrending prior to discharge. He was continued on
lactulose/rifaxmin and his home diuretics.
# Hyponatremia: He was euvolemic on exam, so a free water
restriction to 1500cc daily was initiated.
# Hypertension: Currently hypertensive. He was continued on
diuretics and flomax.
# Diabetes mellitus, insulin dependent: He was continued on
long acting NPH and ISS with meals.
# Chronic Thrombocytopenia: Likely due to combination of splenic
sequestration and alcohol.
# Macrocytic Anemia: Likely due to chronic liver disease and
anemia of chronic disease.
# Ulcerative colitis: He was continued on his home mesalamine.
# Anxiety: His psychotropic medications were held while mental
status is altered. He was restarted on risperidone and
citalopram prior to discharge. Psychiatry saw the patient, felt
he was safe to go home, and will be in touch with his outpatient
provider.
# Thyroid nodule: Possible right thyroid nodule seen on CT
c-spine for which ultrasound could be performed on a
non-emergent basis.
Medications on Admission:
- lactulose 30 mL q6h
- rifaximin 550 mg [**Hospital1 **]
- furosemide 40 mg [**Hospital1 **]
- spironolactone 25 mg daily
- citalopram 40 mg daily
- mesalamine 1600 mg tid
- omeprazole 40 mg daily
- risperidone 0.5 mg daily
- tamsulosin 0.4 mg daily
- calcium and vitamin D
- ferrous sulfate 325 mg three times daily
- Novolin sliding scale
- NPH insulin 5 units twice daily
- Vitamins: thiamine, folate, multivitamin - started during
previous admission
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day) as needed for titrate to 4 bowel movments daily.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO once a day.
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO three times a day.
12. NPH insulin human recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous twice a day.
13. NPH insulin human recomb 100 unit/mL Suspension Sig: AS DIR
units Subcutaneous four times a day: per sliding scale.
14. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours) for 9 days: [**Date range (1) 53489**].
Disp:*25 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
Primary Diagnosis: Hepatic Encephalopathy, Urinary Tract
Infection, Substance Abuse
Secondary Diagnosis: Hepatitis C Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for confusion called hepatic encephalopathy.
This is a result of build up of toxins in your body that your
liver is unable to clear. This is a result of not taking enough
lactulose at home to have three bowel movements per day.
In addition, you were found to have a persistent UTI. This is a
result of not finishing your course of antibiotics at home. You
are being given a new prescription for a second course of
antibiotics. Please take this antibiotic course in its
entirity.
The following changes were made to your medication list:
START amoxicillin for 9 days
Followup Instructions:
Please attend the following appointments that were made for you:
Department: LIVER CENTER
When: THURSDAY [**2108-5-24**] at 2:00 PM
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: [**Hospital3 249**]
When: THURSDAY [**2108-5-24**] at 4:00 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
With: [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**], MD
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. After this visit, you will see Dr. [**Last Name (STitle) **] in follow
up.
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"401.9",
"599.0",
"V15.81",
"357.2",
"250.60",
"300.00",
"287.5",
"241.0",
"070.44",
"556.9",
"276.1",
"V58.67",
"571.2",
"041.04",
"281.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12305, 12366
|
8006, 10421
|
324, 331
|
12536, 12536
|
3947, 3947
|
13382, 14438
|
2632, 2765
|
10926, 12282
|
12387, 12387
|
10447, 10903
|
12686, 13359
|
4819, 5819
|
2780, 2782
|
3409, 3928
|
253, 286
|
359, 1189
|
5828, 7983
|
12492, 12515
|
3963, 4803
|
12406, 12471
|
2796, 3395
|
12551, 12662
|
1211, 2104
|
2120, 2616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,731
| 168,020
|
46876+58957
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-6-15**] Discharge Date: [**2139-6-20**]
Date of Birth: [**2087-2-26**] Sex: M
Service: HEPATOBILIARY SURGERY SERVICE
HISTORY OF PRESENT ILLNESS: The patient is a 52 year-old
gentleman with a history of hepatitis C Child's class A,
portal hypertension who had a recent gastrointestinal bleed
due to gastric varices and portal gastropathy. He was sent home
on the medical therapy of Nadolol, however, opted to have a
surgical treatment. In the recent works the patient denies
fevers or chills, nausea, vomiting.
PAST MEDICAL HISTORY:
1. Hepatitis C, Child's class A, portal hypertension,
variceal bleed.
2. IBDA.
3. ETOH quit [**2138-9-11**].
4. Methadone maintenance.
PAST SURGICAL HISTORY: None
MEDICATIONS:
1. Nadolol 40 mg po q.d.
2. Imdur 60 mg po q.d.
3. Prn Methadone 30 mg po q.d.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2139-6-15**] where a side to side portacaval shunt,
cholecystectomy and liver biopsy was performed. Please see
operative note for details. The patient tolerated the
procedure well and was transferred to Intensive Care Unit.
On postoperative day one the patient was afebrile. He was
somewhat hypertensive up to 180. Pain was relatively well
controlled with prn morphine on top of his usual Methadone
dose. He started to ambulate and was transferred to the
floor. On postoperative day number two the patient is
afebrile and vital signs are stable. His pain is better
controlled. He is ambulating with help. He was started on
sips, advanced to clears, which he is tolerating well. On
postoperative day three the patient is afebrile and vital
signs are stable. His intravenous fluids were discontinued.
His Foley was removed without complications. The patient was
advanced to a regular diet, which he was tolerating well.
His medication was switched to Dilaudid po. The patient had
portal vein duplex, which showed reversal of flow to the IVC
and otherwise normal vessels. Postoperative day number four
the patient is afebrile, vital signs are stable, tolerating a
regular diet and passing flatus. His wound is clean, dry and
intact. His liver function tests consistently turning down,
ambulating and pain is well controlled.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2139-6-19**] 11:43
T: [**2139-6-19**] 12:07
JOB#: [**Job Number 99452**]
Name: [**Known lastname 15930**], [**Known firstname **] A Unit No: [**Numeric Identifier 15931**]
Admission Date: [**2139-6-15**] Discharge Date: [**2139-6-20**]
Date of Birth: [**2087-2-26**] Sex: M
Service:HEPATOBILIARY SURGERY SERVICE
ADDENDUM:
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient is discharged home with VNA for
methadone administration. The patient should continue on a
regular diet. Steri-Strips should stay on. The patient will
follow-up with Dr. [**Last Name (STitle) **] on [**2139-6-24**] at 10:00 a.m.
MEDICATIONS ON DISCHARGE:
1. Methadone 30 mg p.o. t.i.d.
2. Dilaudid 2-4 mg p.o. q. four hours p.r.n.
3. Colace 100 mg p.o. b.i.d.
4. Protonix 40 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Hepatitis C cirrhosis.
2. Portal hypertension.
3. Gastrointestinal bleed, status post end-to-side porta
caval shunt.
4. Former ETOH use.
5. Intravenous drug abuse, on methadone therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D.,PH.D.[**MD Number(3) 9110**]
Dictated By:[**Last Name (STitle) 7947**]
MEDQUIST36
D: [**2139-6-19**] 01:25
T: [**2139-6-19**] 20:01
JOB#: [**Job Number 15932**]
|
[
"571.2",
"303.90",
"572.3",
"578.0",
"456.1",
"571.1",
"456.8",
"305.53"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.11",
"88.49",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
3287, 3756
|
3126, 3266
|
865, 2807
|
745, 847
|
191, 559
|
581, 721
|
2832, 3100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,338
| 166,076
|
10806
|
Discharge summary
|
report
|
Admission Date: [**2175-5-20**] Discharge Date: [**2175-6-14**]
Date of Birth: [**2097-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Low Back Pain
Major Surgical or Invasive Procedure:
open spinal biopsy
History of Present Illness:
77 year old Male s/p L ureteral stent removal [**5-18**], s/p foley
removal & then replaced after failing voiding trial, who
presents with 10/10 sharp back pain radiating to lower abdomen
since yesterday. He also notes a 30lb weight loss since [**Month (only) 404**]
[**2175**].
In the ED, a Foley was placed with 400cc UOP. UA was positive.
CT abd/pelvis without contrast (Cr 1.9) showed new left
hydroureteronpehrosis, also spinal/pelvic lytic lesions
consistent for prostate cancer vs. myeloma. Urology was
consulted in the ED and noted that some hydroureter is expected
s/p stent removal, and he has had positive urinalysis before.
On the floor, he was not in pain as long as he lay still in the
bed but would have occasional bursts of excrutiating lower back
pain that spontaneously resolved within a second or two with
cough or movement, almost bringing him to tears. He reports that
he has had this pain for the past 3 days. He denied SOB, F/C,
pain other than his back pain. He reports decreased appetite
recently and increasing fatigue.
The patient had a recent admission for acute on chronic renal
failure, recurrent hematuria, and abdominal pain during which he
developed lower back pain. At that time he was started on
Flexeril which reportedly seemed to help.
Past Medical History:
PMHx:
1. CAD, s/p MI & CABG
2. NIDDM
3. Carotid stenosis s/p L CEA
4. COPD
5. CKD Stage IV
6. PVD
7. BPH
8. HTN
9. Retinopathy
10. Neuropathy
11. Atrophic R kidney
12. Splenic infarct
13. Diverticulosis
14. Bilateral hydronephrosis with ureteral stricture s/p L
ureteral stenting
.
PSurgHx:
1. 3vessel CABG [**72**]
2. AAA Repair
3. Aortobifem bypass [**2169**]
4. L CEA
5. Vocal Cord Polypectomy [**2167**]
6. Laser eye surgery [**2165**]
7. Open cholecystectomy
8. Cystoscopy, bladder biopsy & fulguration
.
Social History:
Social Hx: had a 180 pack year smoking history quit [**1-10**], no
etoh or ivdu.
Family History:
Family Hx: Father MI at 65, mother PE at 50
Physical Exam:
ROS:
GEN: - fevers, - Chills, 30lb Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, + Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, Severe Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98.9, 140/56, 77, 18, 93%
GEN: NAD
Pain: [**10-13**]
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L, occ rhonchi clear with cough
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Right Upgoing Babinsky, Left Foot Drop (old), 3+
b/l patellar reflex
DERM: Chronic post-inflammatory changes b/l shins
Pertinent Results:
[**2175-5-20**] 07:35AM BLOOD WBC-11.6* RBC-3.17* Hgb-9.4* Hct-28.1*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.3 Plt Ct-413
[**2175-5-19**] 09:50PM BLOOD Neuts-79.1* Lymphs-14.6* Monos-5.9
Eos-0.3 Baso-0.2
[**2175-5-19**] 10:10PM BLOOD PT-13.2 PTT-37.8* INR(PT)-1.1
[**2175-5-20**] 07:35AM BLOOD Glucose-155* UreaN-25* Creat-1.9* Na-134
K-4.3 Cl-102 HCO3-24 AnGap-12
[**2175-5-19**] 09:50PM BLOOD ALT-8 AST-13 CK(CPK)-52 AlkPhos-124*
Amylase-33 TotBili-0.6
[**2175-5-19**] 09:50PM BLOOD Lipase-11
[**2175-5-20**] 07:35AM BLOOD TotProt-6.4 Calcium-10.2 Phos-3.3 Mg-1.7
[**2175-5-20**] 03:23AM BLOOD Lactate-1.2
CHEST (PORTABLE AP) [**2175-5-20**] 6:17 AM
IMPRESSION: Limited study for purposes of PICC line placement,
reveals left PICC line terminating at the cavoatrial junction.
Recommend repeat film for further evaluation of interstitium.
.
CT ABDOMEN W/O CONTRAST [**2175-5-20**] 12:22 AM
1. New left moderate hydroureteronephrosis, with no obstructing
stone
visualized.
2. Multiple new lytic circular lesions within the
pelvis and spine highly concerning for malignancy, notably
myeloma.
This finding was placed in the Radiology critical result queue
for direct communication to Dr. [**Last Name (STitle) **].
3. No aneurysm or evidence of leak. Lack of IV contrast limits
evaluation for dissection or penetrating ulcer.
.
EKG [**2175-5-20**]: Sinus rhythm. First degree A-V block. Otherwise, no
other significant diagnostic abnormality. Compared to the
previous tracing of [**2175-5-2**] there is no significant diagnostic
change.
.
[**2175-5-21**]: CT spine
IMPRESSION: Multiple lytic lesions seen throughout the cervical
spine compatible with metastasis.
.
[**2175-5-21**] MRI SPINE:
IMPRESSION:
1. Multiple lesions throughout the spine, particularly in the
thoracic and lumbar spines, may be consistent with multiple
myeloma or metastases.
2. Complete myelomatous or metastatic replacement of the T8
vertebral body with compression fracture and epidural
involvement at this level which encases the spinal cord, without
evidence of compression.
3. Mild superior endplate compression at L3.
.
[**2175-5-22**] echo:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%)
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. 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 aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.
[**5-24**] LE doppler:
IMPRESSION:
1. No evidence of DVT in either lower extremity.
.
urine [**2175-5-26**]: NEGATIVE FOR MALIGNANT CELLS.
NO UROTHELIAL CELLS SEEN.
.
[**5-25**] T spine BX:TECHNIQUE: After obtaining informed consent, the
patient was brought to the interventional neuroradiology suite
and placed in the biplane table in the prone position. A
preprocedure timeout was performed using two patient
identifiers. Moderate sedation was utilized with 200 mcg of
fentanyl and 4 mg of Versed administered in divided doses
throughout the 1 hour and 20 minute intraservice time during
which the patient's hemodynamic parameters were continouously
monitored. The lower back was prepped and draped in the usual
sterile fashion. Using AP and lateral fluoroscopic technique,
the L4 vertebral body was localized at the site for tissue
sampling. This was also after reviewing prior MRIs and CT scans.
Initially, two 22-gauge spinal needles were placed in the region
of the right and left pedicles of the L4 vertebral bodies.
Position and orientation of the needles were confirmed with
dynamic CT scan on the fluoroscopic table. After orientation was
confirmed two 11-gauge needles were placed along the orientation
of the spinal needles into the pedicle of the L4 vertebral body.
Using the dynamic CT scan, the positions of the needles were
confirmed to be within the vertebral body and in the location of
the lesions. Using 22-gauge Franseen needles which were advanced
over the trocar several samples through both pedicles into the
vertebral body were obtained. In addition, using [**First Name8 (NamePattern2) **] [**Last Name (un) 16095**]
needle, a core tissue sample was obtained through the left
pedicle. At this point, the needles and trocars were removed and
the procedure was terminated. The patient tolerated the
procedure well without immediate complications. Samples were
sent to pathology for additional testing.
.
[**5-31**]:abd xray:The current radiograph demonstrates normal
distribution of the bowel gas within the large and small bowel
including the rectosigmoid. No evidence of dilated bowel loops
is present. No evidence of free air is demonstrated within the
limitation of this supine radiograph.
.
Renal U/S [**6-1**]: IMPRESSION: Interval resolution of left-sided
hydronephrosis. Atrophic right kidney.
.
DIAGNOSIS:
I. T8 vertebral lesion, biopsy (frozen section) (A-B):
Metastatic squamous cell carcinoma involving soft tissue and
bone.
II. T8 vertebral lesion, biopsy (C):
Metastatic squamous cell carcinoma involving bone.
Note: The tumor cells express p63 and cytokeratin CK7, but are
negative for CK20, CDX2, TTF-1 and PSAP. The site of origin
cannot be determined, but lung and head and neck should be
considered.
.
[**6-5**] CTA chest:IMPRESSION:
1. No evidence of pulmonary embolus or aortic dissection.
2. Bilateral pleural effusions and associated atelectasis.
3. Previous right lower lobe consolidation not well evaluated
given pleural effusion with atelectasis.
4. Severe diffuse bilateral emphysema.
5. Multiple spinal lytic lesions and replacement/collapse of T9
vertebral body as previously identified.
.
Bone scan [**6-5**]: IMPRESSION: No discrete foci of increased
radiotracer uptake. Combined withprior MRI and CT images, this
finding suggests purely lytic metastases, such as from multiple
myeloma.
.
CT head/neck:IMPRESSION:
1. No evidence of large neck mass, although study is limited by
lack of IV contrast administration.
2. Bilateral pleural effusions, associated atelectasis, and
severe emphysematous changes redemonstrated.
3. Multiple lytic lesions seen in the lower cervical and upper
thoracic spine. There may be minimally displaced fracture of the
posterior process of T1 where there is underlying lytic lesion.
There is also suggestion of fracture of indeterminate age along
the posterior left second rib, where there is also underlying
lytic lesion.
.
IMPRESSION:
1. Two regions of hypodensity may represent sequela from
ischemic disease or may represent edema from underlying lesions.
Comparison with prior studies is recommended and MR may be
performed for further evaluation.
2. 5-mm lytic lesion in the occipital bone is concerning for
metastasis in this patient with multiple known lytic bone
lesions.
.
MRI t-spine:IMPRESSION:
1. Compared to [**2175-5-21**], there is worsening of the compression
fracture in the T8 vertebral body which demonstrates complete
metastatic replacement. There is increased retropulsion of the
posterior portion of the fracture into the spinal canal with
associated new moderate-to-severe compression of the spinal cord
at this level.
2. Multiple lesions are redemonstrated throughout the spine.
However, there appears to be increase replacement of the L2
vertebral body with new compression deformity with approximately
40% height loss centrally. There also appears to be increased
anterior wedge compression of the T7 vertebral body.
3. Moderate right pleural effusion.
Brief Hospital Course:
A/P: 77M w/ h/o recurrent hematuria requiring bladder irrigation
leading to urinary retention, who presented with 10/10 sharp
back pain radiating to lower abdomen, s/p hemoptysis, hypoxia
found to have multiple lytic spine lesions c/w metastatic
squamous cell carcinoma.
.
# Back pain from metastatic carcinoma complicated by cord
compression: Likely from compression fx at T8 as well as
multiple lytic lesions seen on MRI/CT from C.spine-L.spine.
Etiologies included multiple myeloma, metastatic renal cell,
thyroid ca, lymphoma. s/p biopsy of L4 on [**5-25**], with
non-specific pathology results. Repeat biopsy T spine [**6-1**]
showed metastatic sq cell carcinoma. Biopsy was performed by
spine surgery who followed the patient. Tumor markers CEA, Ca
19.9, 27.29 and PSA were found to be within normal limits.
Oncology was consulted and after a family meeting it was decided
that the patient did not want chemotherapy and only wanted
therapy geared toward pain control and quality of life. On [**6-7**]
pt was found to have cord compression, confirmed by neurology
consult as well as repeat T-spine MRI. Pt was started on
steroids and began emergent radiation that evening. He recieved
5 sessions of palliative radiation to his spine with excellent
effect. Palliative care was also involved in patient's care to
help with pain control as well as nausea. Pt had has a PCA as
well as IV narcotics. Currently, pt is getting liquid oral
concentrated morphine with excellent effect and minimal side
effects. It will be extremely important for pt to continue this
current pain regimen when his leaves the hospital. Pt is also on
antiemetics and an aggressive bowel regimen. It will also be
very important for pt to receive scheduled anti-emetics for
nausea control. If zofran and phenergan do not work, may
consider small doses of haldol or zyprexa INSTEAD of phenergan
for nausea. He was also given calcitonin to help with symptoms
of bony pain.
.
#altered mental status/delirium - Pt found to be somnolent a few
days back. Pt also found to have apparent leg contractures.
Otherwise, pt's vitals were stable. Etiologies included
medication effect (got 0.25mg ativan that night), he is on
chronic narcotics so doubtful this was due to pain control.
Other possibilities included stroke/intracranial bleed or mets
to the brain, however CT scans negative for acute process. This
issue has since resolved. Pt has been oriented and alert.
Infectious work up was negative and ABG did not show
hypercarbia. That same day pt was found to have cord compression
after neuro consult and repeat MRI of the T-spine. Pt was
started on steroids/ and a 5 day course of radiation therapy.
.
# Hypoxia due to bacterial pneumonia - PT has had episodoes of
hypoxia. Pt had hemoptysis and ?consolidation on Chest CT while
in ICU. Also has h.o COPD. O2 requirement has improved initially
with diuresis. Spiked temp on [**5-28**], pancultured. Suspected
pulmonary source given some cough and O2 requirement. LENI's
negative and CTA negative for PE. Pt currently without an O2
requirement. Pt is s/p course of treatment for HAP with
Vancomycin and Zosyn. He did not display signs of aspiration.
CXR showed small effusions with ?RLL consolidation. PT did not
display symptoms to suggest a COPD flair. However, he was
continued on his advair and eventually treated with steroids for
cord compression.
.
# Hypercalcemia: Likely secondary to lytic bone
disease/malignancy, PTH low, Calcium now normalized. Pt recieved
a dose of palmidronate on [**5-5**]. PTHrp was found to be normal.
Calcium levels were trended and have been normal.
.
# Hypotension: Resolved with blood and fluid. Pt with systolic
BP (asymptomatic) transiently in 70's. Pt was given IVF and 1
unit of b lood. Etiologies included narcotic overdose (but
AAOx3/though sleepy), acute bleed (s/p OR [**6-1**]-has anemia at
baseline/being transfused), sepsis (no white count/fever or
other localizing symptoms), PE-on anticoagx2, CTA negative,
ACS-EKG unchanged, CXR grossly unchanged. This issue resolved
and has not been a recurrent issue.
.
# Acute on chronic renal dx: Thought to be originally secondary
to diabetes. Acute component in setting of diuresis +/-
polyclonal gammopathy. Pt's creatinine has appeared to fluctuate
recently. However, baseline appears to be ~1.7-2.2. SPEP showing
polyclonal gammopathy. Upep was neg for Bence [**Doctor Last Name **] protein.
Recent renal U/S showing resolution of L.sided hydronephrosis
and an atrophic R.kidney. Medications were renally dosed. Pt's
creatinine was trended and remained baseline for the remainder
of the hospitalization.
.
#Hemoptysis: One episode of hemoptysis on [**5-21**]. DDX includied
infection, malignancy, cardiogenic, vasculitic. Hct stable, has
not had any other episodes. Likely thought to have been
cardiogenic in etiology. CT chest showed a possible RLL
pneumonia with bronchograms, vs BAC. Repeat CT chest with A did
not show PE, but did show RLL consolidation. Of note,pt had a
recent egd ([**2175-4-4**]) which didnt show any source of bleeding,
so unlikely to be GI source. ANCA neg, anti-GBM neg to r/o a
pulmonary-renal syndrome as a cause. Pt recieved a course of
antibiotics.
.
# Urinary retention: Thought to be from extended Foley for
bladder irrigation for hematuria, s/p ureteral stent and
removal. Pt was evaluated by urology and it was determined that
pt's foley should remain in place. Pt also has BPH and he was
continued on his BPH medications.
.
# anemia: Found to be ACD picture, baseline 25-27. Pt underwent
daily HCT, iron studies showed anemia of chronic dx, lysis labs
were within normal limits.
.
# CAD. Pt was continued on atorvastatin, metoprolol, imdur,
lisinopril (d/cd due to Cr. ASA, Plavix held during prior
admissions for hematuria, if HCT remains stable can consider
restarting.
.
# HTN: continued on metoprolol, Imdur
.
# DM-continued on NPH, humalog sliding scale.
.
# hypothyroidism: continued on levoxyl
.
# Access: indwelling PICC
.
# Code: DNR/DNI no central line/no pressors.
HCP-wife/daughter [**Telephone/Fax (1) 35268**] Plan for transition to hospice.
Goal is comfort and palliation oriented.
Medications on Admission:
cyclobenzaprine 5mg tid prn
Imdur 60mg qd
levothyroxine 25mcg qd
Protonix 40mg qd
finasteride 5mg qd
polyethylene glycol 1 packet qd
lopressor 75mg [**Hospital1 **]
colace 100mg [**Hospital1 **]
senna 1 tab [**Hospital1 **]
Advair 250/50 1 puff, q12h
simvastatin 80mg qd
NPH 9 Units qam, 7 Units qpm
Tylenol 650mg q4h prn
Maalox 30mL q6h prn
Tucks medicated pads to rectum tid prn
dulcolax 10mg suppository, qd prn
milk of magnesia 300mg qd
doxazasin 6mg qhs
lidoderm patch 2 topically q12h on, q12h off
Ultram 50mg 1-2 tablets q6h prn
Cipro 500mg [**Hospital1 **] (Day #[**2-5**])
lisinopril 5mg qd
Discharge Medications:
1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID PRN ().
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for PRN .
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q1H (every hour) as
needed.
17. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO QID
(4 times a day): very important pt receives this medication. It
has been controlling his pain with good effect and minimal side
effects.
18. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO TID
(3 times a day) as needed for pain.
19. 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.
20. 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. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
22. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
23. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN as
needed for anxiety: hold for sedation, respiratory depression.
24. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
25. Promethazine 25 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for nausea: please try zofran 1st.
26. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
sliding scale Subcutaneous QIDACHS.
27. Dexamethasone 4 mg Tablet Sig: Four (4) Tablet PO Q8H (every
8 hours): Please start with 4mg TID. day 2+3 taper to 2mg TID.
Day 4+5, taper to 2mg [**Hospital1 **], Day 6+7 taper to 1mg [**Hospital1 **]. Days 8+9,
1mg daily. day 10, 0.5mg and stop.
28. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 9 units
QAM, 7 units QHS see above Subcutaneous see above: NPH 9units
QAM and 7units QHS.
29. Morphine 15 mg Tablet Sig: One (1) Tablet PO four times a
day: PT may refuse. This is ONLY to be given if morphine oral
concentrate is NOT available.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Major: metastatic squamous cell carcinoma
back pain secondary to metastatic cancer
spinal cord compression
hypoxia
Minor: Acute on chronic renal failure
hypercalcemia
urinary retention
diabetes
hemoptysis-resolved, likely cardiac
Discharge Condition:
stable
Discharge Instructions:
You were admitted for back pain and were found to have multiple
lesions in the bones throughout your body. You were taken to
the operating room for biopsy which found metastatic squamous
cell cancer. The primary source was not found despite
evaluation. You also developed a condition called cord
compression for which you were started on steroids and received
5 doses of radiation therapy to your spine with good effect.
You also had some episodes of hypoxia for which you were ruled
out for a blood clot in the lungs and were treated for a
possible pneumonia.
.
If you develop fevers/chills, shortness of breath, chest pain,
new weakness of the arms/legs, numbness/tingling of the arms or
legs or any other concerning symptom please call your doctor or
go to the emergency room.
.
Please take your medication as prescribed and follow up with
necessary appointments.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2175-6-8**]
1:00
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 35266**] [**Telephone/Fax (1) 35269**] as
needed.
.
Neurology: You may contact ([**Telephone/Fax (1) 2528**] if you need to get in
contact with neurology service. You were seen by Dr. [**Last Name (STitle) **]
this admission.
.
You may contact ([**Telephone/Fax (1) 21188**] if you need to get in touch with
oncology services.
.
You may contact Radiation Oncology [**Hospital Ward Name 332**] Basement FNB25 [**Hospital1 18**]
([**Telephone/Fax (1) 8082**] if you need to get in touch with radiation
oncology.
|
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icd9cm
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[
[
[]
]
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[
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icd9pcs
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[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,968
| 170,229
|
38325
|
Discharge summary
|
report
|
Admission Date: [**2128-7-21**] Discharge Date: [**2128-7-26**]
Date of Birth: [**2062-4-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nifedipine / Diphenhydramine Tannate / pollen/dust
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
rectus sheath hematoma
Major Surgical or Invasive Procedure:
IR angioembolization for RIMA and branch of inferior epigastric
artery, [**7-22**]
History of Present Illness:
66F HCV cirrhosis, HCC, listed for liver transplantation,
and on lovenox for portal vein thrombosis presents with a two
day
history of worsening abdominal pain and nausea. She has chronic
abdominal pain "[**2-6**]" due to her cirrhosis and ascites and has
had "[**8-6**]" pain for the last two days. Of note, she fell and
hit
her head two days ago and was seen in the ED for this (head CT
was negative). She does not recall hitting her abdomen and at
the time did not have abdominal pain. She reports no other
history of potential trauma to her abdomen.
Currently reports pain is tolerable and she has felt better with
the pain medications. She is very anxious about her condition.
She has an unfortunate medical history consisting of obtaining
HCV during the course of a blood transfusion in the [**2095**] and
has
since developed cirrhosis and ESLD. She was diagnosed with HCC
in [**5-/2127**] and has since undergone TACE twice and was recently
started on cyberknife therapy (her first session of three was
yesterday).
Past Medical History:
HCV cirrhosis (HCV from prior blood transfusion) c/b portal
HTN, esophageal varices (no UGIB), intermittent encephalopathy
and most recently HCC s/p TACE [**8-/2127**] (segment V-VIII lesion)
and
[**4-/2128**] (Segment III) and most recently s/p 1 treatment of
cyberknife therapy, portal vein thrombosis on lovenox diagnosed
[**5-/2128**]
PSH: C-section x 2, hysterectomy > 30 years ago, breast biopsy
[**Last Name (un) 1724**]: ativan 0.5 HS PRN, xifaxin 550'', lactulose 30'''', lovenox
80'', lasix 20', spironolacton 50', ranitidine 150'', gen-teal
eye drops 0.3%, polyvinyl alcohol eye drops 1.4%, clotrimazole
PO
10''''
Social History:
-Married with two adult daughters, one in NJ and GA with five
grandchildren.
-No etoh currently or in past
-no tobacco currently or in past
-no IVDA ever
-Retired from daycare work in [**2123**]
Family History:
-Father: CAD at 68
-mother: deceased, unkonwn cause
-six siblings; one brother deceased from pancreatic cancer at
65.
One sister died at age 73 of leukemia. [**Name (NI) 53767**] (son of sister)
deceased of pancreatic cancer at age 48. Strong family hx of HTN
and DMII
Physical Exam:
Admission:
Vitals: 98.4 95 114/52 20 96RA
NAD but uncomfortable, AAOx3
RRR, unlabored respirations
abdomen protuberant, tender and firm to palpation right abdomen,
scattered ecchymosis diffusely over mid abdomen (sites of
lovenox
injections)
ext no edema
Discharge Exam:
Vitals: 98.6 119/52 80 97%RA
Gen: No acute distress. Sitting upright in chair eating
breakfast
HEENT: No scleral icterus. OP pink/moist
CV: RRR. NS1&S2. 3/6 SEM heard best at RUSB
REsp: CTAB. Good air flow
GI:Moderate abdominal distension. Soft. Moderate diffuse TTP
Ext:2+ pitting edema of BLE
Pertinent Results:
ADMISSION LABS:
[**2128-7-21**] 01:00PM BLOOD WBC-5.5 RBC-2.95* Hgb-10.7* Hct-32.9*
MCV-111* MCH-36.3* MCHC-32.5 RDW-14.9 Plt Ct-163
[**2128-7-21**] 02:00PM BLOOD PT-13.3* PTT-39.7* INR(PT)-1.2*
[**2128-7-21**] 02:00PM BLOOD Glucose-156* UreaN-11 Creat-0.7 Na-129*
K-4.5 Cl-99 HCO3-22 AnGap-13
[**2128-7-21**] 02:00PM BLOOD ALT-20 AST-135* AlkPhos-145* TotBili-1.5
[**2128-7-21**] 02:00PM BLOOD Lipase-12
[**2128-7-21**] 02:00PM BLOOD Albumin-2.5*
.
Discharge Labs:
[**2128-7-26**] 05:40AM BLOOD WBC-6.7 RBC-2.49* Hgb-8.3* Hct-24.5*
MCV-99* MCH-33.4* MCHC-33.8 RDW-20.9* Plt Ct-113*
[**2128-7-26**] 05:40AM BLOOD PT-16.5* INR(PT)-1.6*
[**2128-7-26**] 05:40AM BLOOD Glucose-118* UreaN-21* Creat-0.7 Na-131*
K-3.8 Cl-102 HCO3-26 AnGap-7*
[**2128-7-26**] 05:40AM BLOOD ALT-22 AST-130* AlkPhos-121* TotBili-3.1*
DirBili-1.6* IndBili-1.5
[**2128-7-26**] 05:40AM BLOOD Albumin-2.4* Calcium-7.6* Phos-1.9*
Mg-2.3
.
Studies:
[**2128-7-21**] CT Abdomen/Pelvis:
IMPRESSION:
1. Very large right rectus sheath hematoma with layering
hematocrit and
evidence of active extravasation.
2. Small left rectus hematoma without active extravasation.
3. Large amount of simple peritoneal ascites, increased since
the prior CT
without evidence for hemorrhagic component.
4. Decrease in the size of a nonocclusive portal vein
thrombosis.
5. Cirrhotic liver with unchanged appearance of previously
treated
hepatocellular carcinomas; known hepatoma in the the left lobe
is not well
evaluated on this single phase CT.
6. Trace right pleural effusion with bibasilar atelectasis.
.
[**2128-7-24**] CXR: Decreased right pleural effusion and improved
aeration at right lung base. Residual bibasilar atelectasis,
right greater than left.
.
Micro:
[**2128-7-24**] BLOOD CULTURE Routine-FINAL INPATIENT
[**2128-7-24**] BLOOD CULTURE Routine-FINAL INPATIENT
[**2128-7-22**] URINE URINE CULTURE-FINAL INPATIENT
[**2128-7-22**] BLOOD CULTURE Routine-FINAL INPATIENT
[**2128-7-22**] BLOOD CULTURE Routine-FINAL INPATIENT
[**2128-7-21**] BLOOD CULTURE Routine-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2128-7-21**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL
Brief Hospital Course:
Active Issues:
# Rectus sheath hematoma: Found on imaging after bloody
peritoneal tap. Ms. [**Known lastname **] was admitted to the ICU from the ED.
She had a central line through her right IJ and a foley catheter
placed in the ICU. Interventional radiology was consulted and
recommended serial hct checks with potential intervention if her
Hct fails to stabilize. After presenting with an Hct of 32, her
Hct gradually trended downwards overnight despite receiving 2
units of PRBC. She was taken to the IR suite for
angioembolization where they coil embolized the right internal
mammary artery and a branch of the inferior epigastric artery.
She was transfused one unit post procedure and her Hct
responeded appropriately to 28. She remained stable throughout
the night into the next morning and was transfused another unit
the next afternoon ([**2128-7-22**]) for an Hct of 27. Her repeat Hct
was 25. She was transfused another 2 units of PRBC and 1 of
FFP. Her repeat Hct was 27.7 and she remained with stable Hcts
throughout the night. She did not require additional
transfusions, her urine output remained excellent. She was
transferred to the floor where her HCT remained stable.
.
#bacteremia: on HD2, her blood cultures from admission grew
GPCs; her antibiotic coverage initially just ceftriaxone for SBP
prophylaxis was broadened to vanc/cefepime. It was felt that she
did not have SBP and cefepime was discontinued when cultures
showed only 1/2 bottles of coag negative staph. As she improved
this was felt to be a contaminant and vanc was discontinued.
Upon transfer out of the ICU, she was alert and oriented x 3 (on
rifaximin and lactulose), mildy tachycardic in the low 100s-110s
(started on metoprolol 5IVQ4), had no acute respiratory issues,
was NPO with IVF, on vanc and cefepime and with a right IJ CVL.
.
Chronic Issues:
.
#HCV cirrhosis - [**1-29**] hepatitis C, with concurrent HCC see below.
Cirrhosis previously complicated by ascites and hepatic
encephalopathy, pt on transplant list. [**4-8**] EGD with small
varices. AAOx3 and no asterixis. Transaminases normal with
exception of bili at 2.3. Her home spironolatone and lasix were
restarted after her hematocrit remained stable for several days.
.
#Portal Vein Thrombosis - she had been on lovenox for PVT which
was likely the cause of the rectus sheath hematoma.
Anticoagulation was discontinued on presentation.
.
#hepatic encephalopathy - Her second night in the ICU she became
encephalopathic and confused and pulled out her A-line. After
administration of lactulose she began stooling and mental status
cleared. On transfer to the floor she was fully oriented with no
asterixis. Lactulose and rifaxamin were continued on discharge
.
#HCC - currently undergoing cyberknife treatments.
.
#hyperglycemia- well controlled
.
#hyponatremia - pt at baseline - in fact was much lower at 125
in [**Month (only) 596**]. Likely secondary to overactivation of renin-[**Male First Name (un) 2083**] system
in setting of cirrhosis.
.
PT was maintained as FULL CODE throughout the course of this
hospitalization.
Medications on Admission:
ativan 0.5 HS PRN,
rifaxamin 550 [**Hospital1 **]
lactulose 30 QID
lovenox 80 [**Hospital1 **]
lasix 20mg dialy
spironolacton 50 mg daily
ranitidine 150 [**Hospital1 **]
gen-teal eye drops 0.3%, polyvinyl alcohol eye drops 1.4%,
clotrimazole PO 19 mg tid
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lactulose 30 mL PO QID
3. Clotrimazole 1 TROC PO QID
4. Rifaximin 550 mg PO BID
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN abdominal pain
hold for rr<12 or sedation
6. Ranitidine 150 mg PO BID
7. Outpatient Lab Work
Please check chem-7 prior to next GI appt
8. Lorazepam 0.5 mg PO HS:PRN insomnia
9. GenTeal Mild to Moderate *NF* (artificial tear
(hypromellose)) 0.3 % OU daily
10. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY
rectus sheath hematoma
SECONDARY
hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You came to the emergency department with
abdominal pain and we discovered a large blood collection in the
abdomen, most likely because you had been using blood thinning
medication at home. You required a procedure to block the
arteries that were bleeding, which was called embolization.
After this your blood count remained stable and we felt it was
safe for you to go home.
We held your medication to thin your blood because of your
recent stomach bleed. Please do not restart this at home. You
have an [**Location (un) 648**] scheduled with your gastroenterologist.
Please discuss restarting your anticoagulation medicine at this
time.
We have increased the dosages of medications to help treat your
liver disease. These medications can cause changes in your
body's chemical composition. Please have your your blood drawan
for an electrolyte check prior to your next doctors [**Name5 (PTitle) 648**].
Medications to CHANGE:
INCREASE Furosemide 20mg daily to 40mg daily
INCREASE Spironolactone 50mg daily to 100mg daily
Medications to CONTINUE:
rifamixin 550 twice a day
lactulose 30mg three times a day
ranitidine 150mg twice a day
clotrimazole 19mg three times a day
Medications to STOP:
lovenox 80mg twice a day
Followup Instructions:
Department: TRANSPLANT
When: THURSDAY [**2128-7-29**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Location (un) 2274**] [**Location (un) **], Internal Medicine 4
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appt: [**8-10**] at 10:30am
|
[
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"998.12",
"729.92",
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"571.5",
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"572.3",
"V49.83",
"V58.61",
"452",
"070.70",
"567.23",
"155.0",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"39.79",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9593, 9653
|
5562, 5562
|
348, 432
|
9761, 9761
|
3253, 3253
|
11357, 11958
|
2372, 2644
|
8957, 9570
|
9674, 9740
|
8676, 8934
|
10038, 11334
|
3719, 5539
|
2659, 2919
|
2935, 3234
|
286, 310
|
5577, 7393
|
460, 1492
|
3269, 3703
|
9902, 10014
|
7409, 8650
|
1514, 2143
|
2159, 2356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,789
| 177,083
|
3621
|
Discharge summary
|
report
|
Admission Date: [**2157-12-30**] [**Month/Day/Year **] Date: [**2158-1-1**]
Date of Birth: [**2105-8-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 16474**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
this is a 52 y.o female w/ pmhx of poorly controlled DM type 1
last HbA1c 11.9%, chronic back pain, recent ankle fracture,
depresion and other psychiatric history p/w decreased
responsiveness to the ED.
.
Patient reports that the night of [**2157-12-29**] and into [**2157-12-30**]
morning, due to a recent change in her pain medication regimen,
she took two extra pills of morphine because she lost track of
whether she had already taken the correct dosage or not. Did
not endorse pain greater than usual, denies SI, did not have
general confusion, did not purposefully take extra pills. At
baseline takes 30 mg morphine extended release and 15 mg
morphine Q6H PRN for breakthrough pain. Does not remember what
kind of extra pills she took or exactly how many. No nausea,
vomiting, diarrhea, or other symptoms at the time.
.
On [**2157-12-30**] morning, was at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] seminar and noted to be
lethargic. She does not remember the incident. Sent to the ED
who found her with decreased respiratory rate, GCS 10, slurred
speech, still awake to painful stimuli, much more awake with .2
mg Narcan pointing to morphine overdose. Serum tox negative,
urine tox not performed. Admitted to MICU.
.
Of note, had a recent admission for ankle fracture on [**2157-12-17**]
after a fall in the setting of hypoglycemia. Has had frequent
admissions for trouble controlling blood sugars. Significant
pyschiatric history including depression, cluster B personality
traits, PTSD.
.
Currently, reports [**11-7**] pain in knee and ankle. Her knee pain
she has had for several months and had arthoscopy performed.
Ankle pain is new. Denies back pain, abd pain, chest pain, N/V,
lightheadedness, confusion. Endorses many social stressors in
her life including strained relationship with husband who
recently got a new job but won't return her calls, and
frustration with her health and another admission to the
hospital. Denies SI, denies this was a suicide attempt.
.
ROS otherwise negative for fever, chills, night sweats, recent
weight loss or gain, headache, URI symptoms, shortness of
breath, chest pain, palpitations, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits,
dysuria.
Past Medical History:
Past Medical History:
- Diabetes type I, s/p islet cell transplants and failed
cadaveric pancreas transplant
- Diabetic peripheral neuropathy
- Diabetic autonomic neuopathy
- Gastroparesis
- Hypothyroidism
- Hypercholesterolemia
- Migraines
- Chronic neck/back pain s/p cervical disc surgery in [**2155-12-30**]
- Carpal tunnel syndrome
- Breast calcifications
- Hx of drug-seeking behaviors per OMR
- Chronic cervicalgia
Past Surgical History:
- Left carpal tunnel release [**2150**]
- Right carpal tunnel release [**2152**]
- Cadaveric pancreas transplant [**2152-11-16**]
- Exploratory laparotomy, transplant pancreatectomy, jejunal
resection and jejunojejunostomy [**2152-11-24**]
- CCY [**2154-12-3**]
- Anterior cervical diskectomy and fusion C5/C6 with carbon
fiber cage and bone marrow aspirate on [**2156-1-8**] for degenerative
disc disease with compression at C5/C6.
- R arthroscopy [**2157-3-10**] for medial mesiscus tear
Past Psychiatric History:
- Axis I - Major Depressive D.O. NOS, Substance induced Mood
disorder.
- Axis II -Passive aggressive traits. Borderline traits.
- Axis III -AN instability, DM, Hyppthyroid.
- Axis IV -Multiple, home based, medical, psych
- Axis V -30
- Therapist: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16468**] [**Telephone/Fax (1) 16469**]
- Psychiatrist: previously Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 16470**] at [**Last Name (un) **], scheduled
to see Dr. [**Last Name (STitle) 16471**] at the end of [**Month (only) **]
- Multiple psychiatric diagnoses including depression, PTSD
(related to childhood sexual abuse), subclinical eating
disorder, borderline personality disorder
- Lorazepam OD in [**5-7**]
- Unintentional OD on Fiorcet-taking 27 pills, followed by [**Hospital1 18**]
psych consult service in [**4-/2156**] -subsequent OD on 8 Fiorcet tabs
in [**5-/2156**]
- Remote history of cutting
- Had trial of ECT (about 4 treatments) at [**Hospital1 18**] in [**2146**]
- SA in [**11/2156**] leading to Deac4 admission
Social History:
(From Records) Smokes 1 ppd. lives with husband. occasional etoh
(but reports that her family has been concerned in the past in
regards to her etoh intake, but she denies excessive use). No
drugs.
Family History:
- Sister with type II DM,
- uncle with type I DM
- Both parents and sister with HTN.
- Father died of alcoholic cirrhosis.
- Mother had mouth/throat cancer.
- Grandfather had lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, cast on right lower extremity.
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
.
[**Year (4 digits) 894**] PHYSICAL EXAM:
Vitals: 97.9 140/82 71 18 100%/RA
General: Well appearing woman, alert, oriented, tearful,
expressing frustration, more pleasant than yesterday
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, no rebound tenderness
or guarding, no masses or HSM
Ext: No tenderness to palpation on right knee when distracted,
mild tenderness when not distracted, warm, well perfused, no
clubbing, cyanosis, edema, or erythema, cast on right lower
extremity.
Neuro: A&Ox3, CNII-XII intact, pupils 5 mm, symmetric and
reactive to light, end-gaze nystagmus on left side, EOMI, right
foot motor and sensory grossly intact, sensation and strength
grossly intact throughout.
.
Pertinent Results:
admission labs
[**2157-12-30**] 04:35PM ALT(SGPT)-30 AST(SGOT)-21 ALK PHOS-108* TOT
BILI-0.3
[**2157-12-30**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2157-12-30**] 12:24PM COMMENTS-GREEN TOP
[**2157-12-30**] 12:24PM GLUCOSE-310* K+-4.3
[**2157-12-30**] 12:00PM GLUCOSE-342* UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-30 ANION GAP-11
[**2157-12-30**] 12:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2157-12-30**] 12:00PM WBC-5.9# RBC-4.16* HGB-12.4 HCT-38.8 MCV-93
MCH-29.9 MCHC-32.0 RDW-12.4
[**2157-12-30**] 12:00PM NEUTS-70.8* LYMPHS-19.0 MONOS-4.5 EOS-5.2*
BASOS-0.4
[**2157-12-30**] 12:00PM PLT COUNT-357
.
STUDIES:
CXR [**2157-12-30**] - IMPRESSION: No acute cardiopulmonary abnormality.
[**Month/Day/Year **] labs
[**2158-1-1**] 06:44AM BLOOD WBC-4.3 RBC-4.13* Hgb-12.1 Hct-37.3
MCV-90 MCH-29.4 MCHC-32.6 RDW-12.3 Plt Ct-323
[**2158-1-1**] 06:44AM BLOOD Glucose-197* UreaN-13 Creat-0.6 Na-137
K-3.5 Cl-104 HCO3-26 AnGap-11
[**2158-1-1**] 06:44AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
Brief Hospital Course:
52 y.o female w/ pmhx of poorly controlled DM type 1, chronic
pain, and complex psychiatric history presenting with altered
mental status to the ED.
.
In the MICU, vitals were HR 67, RR 15, BP 145/79, O2Sat 99%RA,
she was placed on 24 hr Narcan drip, had marked clinical
improvement with GCS to 15, patient alert, interactive, tearful.
On the floor she was stable and sent home within 24 hours.
.
# Opiate overdose - Altered mental status related to overuse of
her prescribed morphine given response to Narcan. After Narcan
drip, was alert with mental status at baseline. There were no
further signs of opiate overdose/withdrawal during admission.
She was told to stop taking her long acting morphine, and to
flush it down the toilet. She should be on morphine IR 15mg PO
q6H PRN severe pain.
.
# Ankle fracture - Recent admission on [**12-17**] for this. It
caused intermittent [**11-7**] pain per patient. Small dose opiates
of 5 mg oxycodone amd gabapentin were used for pain management.
Previous to [**12-17**] admission, was on morphine 15 mg short acting
Q6H PRN, and she was discharged on this. Long-acting 30 mg
morphine [**Hospital1 **] was discontinued.
.
# Psych - Patient has multiple recent social stressors. Denies
current SI and denies this was a suicide attempt. Husband not
returning her phonecalls, strained relationship with mother, and
financial issues. We continued klonopin and effexor during
admission and psychiatry was consulted for evaluation and
coping. Social work was consulted and offerred coping and
medication compliance support.
.
#Diabetes - Patient had serum glucoses ranging 197 to 366. She
was kept on an insulin sliding scale and diabetic diet.
.
TRANSITIONAL ISSUES:
- Followup appointment with PCP and revisit pain medication
regimen.
- Outpatient ortho followup for ankle fracture.
- Outpatient psych followup.
- Outpatient pain clinic for management of chronic pain issues.
Medications on Admission:
1. Wheelchair with elevating leg rests
2. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
3. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous qam.
4. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous before breakfast, before lunch, before dinner,
before bedtime: per insulin sliding scale.
5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. midodrine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for low blood pressure, dizziness.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain: please hold for sedation,
respiration<12/min, heart rate<50/min.
10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
11. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One
(1) Capsule,Extended Release 24 hr PO QHS (once a day (at
bedtime)).
12. topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
14. venlafaxine XR 300mg daily
15. clonapin 1mg [**Hospital1 **]
[**Hospital1 **] Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
3. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
4. insulin glargine 100 unit/mL Solution Sig: 12 units .
Subcutaneous QAM.
5. Humalog 100 unit/mL Cartridge Sig: Per sliding scale .
Subcutaneous .
6. midodrine 5 mg Tablet Sig: 0.5 Tablet PO once a day.
7. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for dizziness.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One (1)
Capsule,Extended Release 24 hr PO once a day.
10. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO once a day.
11. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. topiramate 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. trazodone 50 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for insomnia.
[**Hospital1 **] Disposition:
Home
[**Hospital1 **] Diagnosis:
Morphine overdose
[**Hospital1 **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Hospital1 **] Instructions:
Dear Ms. [**Known lastname 16472**],
You were admitted because of lethargy and unresponsiveness at
your [**Last Name (un) **] appointment after ingesting extra pills of morphine
at home. In the emergency department you got Narcan which made
you awake and alert. You did have a morphine overdose and it is
very important to take your medications as prescribed to prevent
life-threatening situations.
.
We made the following changes to your medications:
**STOPPED MORPHINE - 30 mg Tablet Extended Release - 1 Tablet(s)
by mouth every 12 hours ** long acting. Please flush any
leftover previous medication of this in the toilet
.
You will only be on the short acting morphine pills.
.
Please followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], as
listed below, for further pain management.
Please attend your otherwise scheduled orthopedic appointments.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2158-1-3**] at 7:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2158-1-3**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2158-1-10**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"309.81",
"V49.86",
"965.09",
"250.01",
"292.81",
"300.4",
"338.29",
"V42.83",
"V15.51",
"E850.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7812, 9506
|
339, 346
|
6688, 7789
|
13452, 14315
|
4933, 5122
|
9766, 11109
|
3108, 4702
|
5791, 6669
|
9527, 9740
|
12977, 13429
|
277, 301
|
12282, 12288
|
11139, 12252
|
374, 2640
|
12379, 12491
|
12316, 12364
|
2684, 3085
|
4718, 4917
|
12522, 12948
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,198
| 118,070
|
24640
|
Discharge summary
|
report
|
Admission Date: [**2141-4-12**] Discharge Date: [**2141-4-16**]
Date of Birth: [**2074-3-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
s/p fall, s/p L3 laminectomy/discectomy
Major Surgical or Invasive Procedure:
L3 laminectomy/discectomy
History of Present Illness:
Ms. [**Known lastname 62201**] is a 67 year-old woman with Diabetes mellitus, end
stage renal disease on hemodialysis, morbid obesity, coronary
artery disease, and known L4-5 disc herniation who presented
with right leg weakness, increased back pain, and worsening disc
protrusion at L3-4. Immediately after a fall at [**Hospital **] rehab
one day prior to admission here, patient experienced increased
back pain with radiation down her leg and more difficulty moving
her right leg.
.
Evaluation at [**Hospital6 2561**] included an MRI which showed
worsening L3-4 disc protrusion. She also demonstrated some
myoclonus/asterixis on exam and received some iv ativan (amount
unclear). She was then transferred here for emergent
neurosurgical evaluation.
.
Exam in the ED here notable for decreased rectal tone and
decreased sensation in the medial thigh. She had leg weakness
more prominent on the right side, some decreased sensation on
right leg in an L3-4 distribution, and absent DTRs in the RLE.
MRI revealed 1)Epidural hematoma extending from L2-L3 level to
L4-L5 level resulting in marked mass effect on the thecal sac
and as a result, compression of the nerve roots. 2) Moderate
disc bulge at L4-L5 resulting in moderate stenosis of the spinal
canal at that level. 3) Small disc herniation at L5-S1 level
does not appear to cause significant spinal stenosis. There are
bilateral facet degenerative changes at these levels which
resulted in severe left sided neural foraminal narrowing.
.
Pt underwent emergent L3 laminectomy/discectomy [**4-12**] given
concern for cauda equina syndrome. She remained intubated and
was monitored overnight in the ICU. After dialysis removing 2L
followed by successful extubation to CPAP with weaning to nasal
cannula oxygen supplementation, pt was transferred to the
medicine service in stable condition.
Past Medical History:
-Diabetes mellitus x 40 years
-ESRD on HD w/RUE AV fistula, followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 29966**] s/p MI in [**2131**] (had chest pain with her MI)
-CHF
-Hypothyroidism
-Glaucoma
-Hypertension
-Anemia - baseline HCT 27-32
-Cataracts
-Fractured wrist in her 20s
-Morbid obesity
Social History:
-Retired, used to work in electronics
-Had lived with sister but most recently has been at [**Name (NI) **]
rehab
-No recent alcohol or tobacco use
-PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Family History:
-Brother with diabetes
-Brother with [**Name2 (NI) 499**] ca
-Sister with breast cancer
Physical Exam:
Vitals: 97.1 75 137/58 18 99% 3L NC 1047/1826 24H [**Telephone/Fax (1) 62202**] today
Tele: NSR, occas PVCs
General: Morbidly obese, lying in bed, NAD
Neck: Obsese
Lungs: CTA bl anteriorly
CV: RRR, no murmur
Abdomen: Soft, Non-tender
Ext: 1+edema
Neurologic Examination: AOx3, MAEW, RLE weakness, no focal loss
sensation
Pertinent Results:
[**2141-4-13**] Admission Labs:
WBC-22.6* RBC-2.99* Hgb-9.5* Hct-27.9* MCV-93 MCH-31.8 MCHC-34.1
RDW-14.1 Plt Ct-195
PT-13.4 PTT-23.8 INR(PT)-1.1
Glucose-161* UreaN-42* Creat-6.8*# Na-142 K-4.9 Cl-103 HCO3-23
AnGap-21*
[**2141-4-12**]: ALT-28 AST-95* AlkPhos-36* TotBili-0.3
.
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2141-4-12**]
1) Epidural hematoma extending from L2-L3 level to L4-L5 level
resulting in marked mass effect on the thecal sac and as a
result, compression of the nerve roots.
2) Moderate disc bulge at L4-L5 resulting in moderate stenosis
of the spinal canal at that level.
3) Small disc herniation at L5-S1 level does not appear to cause
significant spinal stenosis. There are bilateral facet
degenerative changes at these levels which resulted in severe
left sided neural foraminal narrowing.
.
Brief Hospital Course:
A/P: 67 year-old woman POD 1 s/p L3-5 laminectomy/discectomy for
above worsening lumbar disease s/p fall; extubated, s/p dialysis
and breathing comfortably on oxygen supplementation per nasal
cannula.
.
s/p L3 Laminectomy/Discectomy and Hematoma Evacuation s/p Fall:
Stable, now off steroids. Very deconditioned, needs aggressive
PT. Pt wished to return to [**Hospital1 **]. Pain mgmt with percocet and
IV morphine PRN.
.
Leukocytosis: Afebrile, no signs/sx infection. Likely [**1-18**]
steroids, which have been discontinued.
.
DM: stable
.
ESRD on HD qMWF: stable
.
CAD s/p MI: stable
.
CHF: EF unknown (? records). Now well-compensated.
.
[**Female First Name (un) 564**]: nystatin w/dry gauze drsg [**Name5 (PTitle) **] [**Name5 (PTitle) 62203**]; aloe [**Doctor First Name **] 2 in
1 ointment around open areas
.
Hypothyroidism: stable on levothyroxine
.
Glaucoma: timolol gtt
Comm: Daughter [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62204**] Cell [**Telephone/Fax (1) 62205**]. Lives
with sister [**Name (NI) **] [**Telephone/Fax (1) 62206**].
Medications on Admission:
Medications:
-Glipizide 5mg PO once daily
-Lopressor 50mg PO BID
-Levothyroxine 25mcg PO daily
-Timolol eye gtt OU [**Hospital1 **]
-Nephrocaps
.
Meds added on at rehab
-PhosLo
-Colace
-Dulcolax
-Heparin sc
-Tylenol
-Naprosyn
-Oxycodone
-Sliding scale insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
lumbar hematoma
s/p fall
Diabetes mellitus x 40 years
ESRD on hemodialysis
Anemia of chronic disease
s/p fall, s/p L3 laminectomy and discectomy
[**Female First Name (un) 564**] albicans skin infection
Secondary:
CAD s/p MI in [**2131**]
CHF
Hypothyroidism
Glaucoma
Hypertension
Cataracts
Fractured wrist in her 20s
Morbid obesity
Discharge Condition:
hemodynamically stable, tolerating oral diet, breathing
comfortably on room air
Discharge Instructions:
Please take medications as prescribed. Call your doctor or go to
the ED if you have increased leg weakness, back pain, bowel or
bladder incontinence, shortness of breath, or rapid weight gain.
Your surgical staples should be removed in 2 weeks on [**2141-4-27**].
Please continue your previous medications. Additionally, take a
daily aspirin as prescribed to help protect from worsening heart
disease or stroke.
Followup Instructions:
Please follow up with your regular doctor. Please call Dr.
[**Last Name (STitle) **] at ([**Telephone/Fax (1) 62207**] to make an appointment.
Please follow up in the neurosurgery clinic with Dr.
[**Last Name (STitle) **] on Wednesday, [**6-1**] at 1:45pm. Phone
([**Telephone/Fax (1) 11314**] with any questions.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2141-4-16**]
|
[
"250.00",
"414.01",
"365.9",
"244.9",
"428.0",
"V45.1",
"585",
"278.01",
"344.60",
"722.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5543, 5622
|
4128, 5232
|
354, 381
|
5997, 6078
|
3279, 3295
|
6541, 7008
|
2831, 2921
|
5643, 5976
|
5258, 5520
|
6102, 6518
|
2936, 3184
|
275, 316
|
409, 2254
|
3311, 4105
|
3208, 3260
|
2276, 2585
|
2601, 2815
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,267
| 164,870
|
20707
|
Discharge summary
|
report
|
Admission Date: [**2199-5-13**] Discharge Date: [**2199-5-19**]
Date of Birth: [**2119-5-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Darvon / Robaxin / Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pain, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2199-5-13**] Coronary artery bypass graft times three (LIMA to LAD,
SVG to OM, SVG to PDA), mitral valve replacment (27 [**Company **]
mosaic porcine valve), removal of a right sternal lipoma
History of Present Illness:
[**Known firstname **] [**Known lastname 55278**] is a 79 year old female who was diagnosed with
three vessel coronary artery disease in [**2189**] and opted for
medical management at that time. Since that time she has
experienced worsening shortness of breath and underwent stenting
in [**2196-2-22**]. She recently agreed to surgical
revascularization.
Past Medical History:
3 vessel coronary artery disease
mitral regurgitation
congestive heart failure
hypertension
hyperlipidemia
insulin dependent diabetes mellitus
chronic renal insufficiency
arthritis
hysterectomy/appendectomy
cholecystectomy
partial thyroidectomy
s/p bilateral cataract surgery
s/p vitrectomy of both eyes
Social History:
Ms. [**Known lastname 55278**] is retired. She denies tobacco or alcohol use.
Family History:
[**Known firstname **] [**Known lastname 55278**] reports that her father died at age 50 of a
cerebral vascular accident.
Physical Exam:
At the time of discharge, [**Known firstname **] [**Known lastname 55278**] was in no acute
distress. She was awake, alert, and oriented. Her lungs were
clear to auscultation, but diminished bilaterally at the bases.
Her heart was of irregular rhythm but without murmurs, clicks,
or rubs. The sternal incision was without erythema or drainage.
Her sternum was stable. Her abdomen was soft, non-tender, and
non-distended. She had a bowel movement on [**5-16**]. Her
extremities were warm, but she was noted to have [**12-25**]+ edema
bilaterally. Her left endovascular harbest site was clean, dry,
and intact. A left-sided IJ double-lumen was in place.
Brief Hospital Course:
On [**2199-5-13**] [**Known firstname **] [**Known lastname 55278**] underwent a coronary artery bypass
graft times three (LIMA to LAD, SVG to OM, SVG to PDA), mitral
valve replacement (27mm [**Company 1543**] Mosaic Porcine valve), and
removal of a right sternal lipoma. This procedure was performed
by Dr. [**Last Name (STitle) **]. Please see the operative note for details.
The patient tolerated this procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit on levophed, epinephrine, milrinone, insulin and propofol
drips.
In the surgical intensive care unit she progressed well. She
was weaned form her pressors. By post-operative day two she was
extubated. Her chest tubes and epicardial wires were removed.
Post-operative day three she was noted to convert into atrial
fibrillation, for which she was placed on amiodarone and her
beta blockade was increased. While she did not convert with
this regimen, her rate was controlled in the 80s. On the
following day she was transferred in stable condition to the
step down floor.
Her course on the step down floor was unremarkable. She
continued in controlled atrial fibrillation and was therefore
started on coumadin. She was seen in consultation by physical
therapy and by post operative day #5 she was ready for discharge
to a rehabilitation facility. Target INR is 2.0-2.5 for postop A
fib. Pt. is to make all discharge appts. as per discharge
instructions.
Medications on Admission:
Novolin NPH 38 units qam
Novolin NPH 15 units qpm
Novolog 6 units qam
Novolog 15 units q dinner
Thyroxine 150 mcg
Atenolol 50 qam
Atenolol 25 qpm
Aspirin 325
HCTZ 25
Enalapril 10
Lipitor 10
Vitamin C
Vitamin E
MVI
Nitropatch every morning
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Coronary artery disease, mitral regurgitation
congestive heart failure, hypertension, hyperlipidemia, insulin
dependent diabtese mellitus, chronic renal insufficiency,
arthritis, postop A fib
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see [**Doctor Last Name **] [**Last Name (Prefixes) **] in [**3-29**] weeks ([**Telephone/Fax (1) 14832**].
Please see your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3291**] in [**12-25**] weeks
([**2198**].
Please see your cardiologist Dr. [**Last Name (STitle) **] in [**12-25**] weeks.
Call to make all appointments.
Completed by:[**2199-5-18**]
|
[
"244.0",
"401.9",
"414.01",
"599.0",
"716.99",
"427.31",
"V45.61",
"214.1",
"V45.82",
"250.60",
"362.01",
"357.2",
"285.9",
"250.50",
"593.9",
"272.4",
"428.0",
"287.5",
"997.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"35.23",
"89.60",
"38.93",
"86.3",
"99.07",
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
3930, 4001
|
2171, 3641
|
324, 521
|
4237, 4244
|
4573, 4966
|
1348, 1471
|
4022, 4216
|
3667, 3907
|
4268, 4550
|
1486, 2148
|
253, 286
|
549, 908
|
930, 1236
|
1252, 1332
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,921
| 155,578
|
50977
|
Discharge summary
|
report
|
Admission Date: [**2143-5-30**] Discharge Date: [**2143-6-6**]
Date of Birth: [**2098-9-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Nausea, Vomiting, Headache
Major Surgical or Invasive Procedure:
Dialysis catheter placed [**2143-6-3**]
Hemodialysis on [**2143-6-3**], [**2143-6-4**], and [**2143-6-5**].
History of Present Illness:
44 y/o female with h/o poorly controlled HTN with multiple
admissions for hypertensive crisis due to poor medical
compliance, CRI, anemia, and hypokalemia, who presents with a 4
day h/o N/V, SOB, HA, and CP. Pt states that on Saturday stopped
taking her BP meds for unclear reasons. She started to c/o
N/V/HA on Sunday with inability to tolerate POs. She then
continued to forgo taking her BP meds and presented to the ED
tonight with increasing SOB, HA, blurry vision, and CP. Pt also
c/o abdominal pain. Pt was non-cooperative and unwilling to
answer questions upon arrival to MICU.
.
ED Course: Pt's initial BP 211/p, 272/140. She was started on a
Nipride gtt at .5mcg/kg/min without improvement in her BP. She
was then started on boluses of IV lopressor 5mg IV x3. SBP
remained >180s. The nipride gtt was titrated to as high as
6mcg/kg/min w/resolution of CP and Blurry vision. EKG without
signs of ischemia, no dynamic ST segment changes. CE cycled and
elevated with the following trend Tn-T 0.16, .14, .11; CK 304,
224, 188 and flat MB 4, 4 and 3. Pt was given ASA 325mg x1. Also
with ARF Cr 10.5 (Baseline Cr. 2.7-3.5 since [**12/2142**]) prior Cr
0.9 in [**2141**]. Pt was hydrated with NS at 250cc/hr w/20mEq KCL for
hypokalemia. Also received 2UPRBC for unclear reasons as no
signs of bleeding. Initial HCT 23 with increase to 25 post TRF.
Head CT negative, Abdominal U/S unremarkable, and HCG negative.
Pt was transferred to MICU with SBP 180/126. Upon arrival to
MICU BP 142/94 HR 72.
Past Medical History:
#1. HTN - Pt with poorly controlled HTN, recurrent admissions
for HTN urgency/emergency. Complete secondary w/u (-) including
nml TSH, cortisol, and [**Male First Name (un) 2083**] levels; MRI/A abd neg for adrenal
masses; renal U/S c dopplers with no evidence of RAS. Has been
hypoaldo in the past.
#2. CRI- since [**12/2142**] Cr baseline 2.7-3.5 (in [**2141**] Cr 0.9)
#3. Schizophrenia - Diagnosed approximately 4-5 years ago.
Followed at [**Hospital **] Hospital, where she receives risperidone IM
injections every 2 weeks.
#4. Hyperprolactinemia?????? Found to have elevated (micro)prolactin
level to 229 in [**Month (only) 359**], in context of missed menses in
[**Month (only) **] and galactorrhea. Pituitary MRI was negative. Her
risperidone dose was adjusted, and for the past several months
(since [**Month (only) **]), she has been having regular menses and no
galactorrhea.
#5. Anemia-baseline Hct 23-30.0 not transfusion dependent per
OMR
Social History:
Patient has been working at Old Navy for the past 4-5 years, and
she just completed a certificate program to work as a medical
office assistant. She lives alone in [**Location (un) **], but she
occasionally spends the night with her mother in the [**Location (un) 4398**]
when she works nights. She has been in a monogamous,
heterosexual relationship for the past 10 months. She stopped
taking her OCP??????s in [**Month (only) **], but she reports condom use most
of the time. She smoked approximately [**4-6**] cigarettes/day for one
year and quit 1 1/2 months ago. She denies alcohol or drug use.
Family History:
Mother, 65, has refractory hypertension and glaucoma. Relatives
on mother??????s side also have hypertension. No known family history
of psychiatric illness (depression, bipolar, schizophrenia),
diabetes, renal disease, rheumatologic disease, stroke, or
sudden cardiac death.
Physical Exam:
Admission
VS: 99.3 138/89 64 25 98% ILNC
GEN: NAD, Uncooperative
HEENT: PERRL, EOMI, Anicteric sclera, supple neck, no
thyromegaly,
CV: Reg, nml S1,S2, no M/R/G
RESP: CTA BL, No crackles, no wheezing
ABD: Soft ND/NT upon distracting, no guarding, no rebound,
hypoactive BS
EXT: Warm, no edema, 2+DP pulses B/L
NEURO: A&OX3
Pertinent Results:
[**2143-5-30**] 02:40AM WBC-8.6# RBC-2.76* HGB-8.6* HCT-23* MCV-84
MCH-31.1 MCHC-37.2* RDW-18.9*
.
[**2143-5-30**] 02:40AM NEUTS-80.3* LYMPHS-14.2* MONOS-3.9 EOS-1.5
BASOS-0.1
.
[**2143-5-30**] 02:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2143-5-30**] 02:40AM CK-MB-4 cTropnT-0.16*
[**2143-5-30**] 02:40AM LIPASE-44
[**2143-5-30**] 02:40AM ALT(SGPT)-20 AST(SGOT)-29 CK(CPK)-304* ALK
PHOS-78 AMYLASE-48 TOT BILI-0.6
[**2143-5-30**] 02:40AM GLUCOSE-124* UREA N-65* CREAT-10.5*#
SODIUM-135
POTASSIUM-2.5* CHLORIDE-92* TOTAL CO2-27 ANION GAP-19
[**2143-5-30**] 03:52AM PT-11.8 PTT-22.9 INR(PT)-1.0
[**2143-5-30**] 04:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2143-5-30**] 04:00AM URINE RBC-[**5-11**]* WBC-0-2 BACTERIA-MOD
YEAST-NONE EPI-[**10-21**]
[**2143-5-30**] 09:05AM HCT-22.0*
[**2143-5-30**] 09:05AM cTropnT-0.14*
[**2143-5-30**] 09:05AM CK-MB-4
[**2143-5-30**] 09:05AM CK(CPK)-224*
[**2143-5-30**] 12:31PM CALCIUM-7.6* PHOSPHATE-4.1 MAGNESIUM-2.0
[**2143-5-30**] 04:40PM CK-MB-3 cTropnT-0.11*
[**2143-5-30**] 04:40PM CK(CPK)-188*
[**2143-5-30**] 02:40AM BLOOD WBC-8.6# RBC-2.76* Hgb-8.6* Hct-23*
MCV-84 MCH-31.1 MCHC-37.2* RDW-18.9* Plt Ct-43*#
[**2143-5-30**] 09:05AM BLOOD Hct-22.0*
[**2143-5-30**] 12:31PM BLOOD WBC-8.1 RBC-2.89* Hgb-8.9* Hct-25.0*
MCV-86 MCH-30.8 MCHC-35.7* RDW-18.4* Plt Ct-38*
[**2143-5-31**] 12:10AM BLOOD WBC-9.6 RBC-3.04* Hgb-9.4* Hct-25.6*
MCV-84 MCH-31.0 MCHC-36.8* RDW-18.6* Plt Ct-62*#
[**2143-5-31**] 10:20AM BLOOD WBC-9.9 RBC-3.05* Hgb-9.3* Hct-25.9*
MCV-85 MCH-30.4 MCHC-35.8* RDW-19.0* Plt Ct-64*
[**2143-6-1**] 03:21AM BLOOD WBC-10.1 RBC-2.84* Hgb-8.7* Hct-24.4*
MCV-86 MCH-30.7 MCHC-35.8* RDW-18.8* Plt Ct-76*
[**2143-6-2**] 06:25AM BLOOD WBC-7.4 RBC-2.78* Hgb-8.8* Hct-24.1*
MCV-87 MCH-31.5 MCHC-36.3* RDW-19.0* Plt Ct-108*
[**2143-6-3**] 07:15AM BLOOD WBC-7.9 RBC-2.93* Hgb-9.0* Hct-25.3*
MCV-86 MCH-30.8 MCHC-35.7* RDW-18.7* Plt Ct-174#
[**2143-6-4**] 06:30AM BLOOD WBC-5.7 RBC-2.72* Hgb-8.6* Hct-23.8*
MCV-87 MCH-31.5 MCHC-36.1* RDW-19.3* Plt Ct-185
[**2143-6-5**] 06:20AM BLOOD WBC-6.9 RBC-2.91* Hgb-8.9* Hct-26.2*
MCV-90 MCH-30.7 MCHC-34.2 RDW-19.1* Plt Ct-252
[**2143-6-6**] 05:27AM BLOOD WBC-5.1 RBC-2.31* Hgb-7.2* Hct-20.3*
MCV-88 MCH-31.0 MCHC-35.3* RDW-19.0* Plt Ct-210
[**2143-6-6**] 09:20AM BLOOD Hct-26.8*#
[**2143-5-30**] 12:31PM BLOOD Neuts-85.4* Bands-0 Lymphs-10.7*
Monos-2.9 Eos-0.7 Baso-0.4
[**2143-6-6**] 05:27AM BLOOD Plt Ct-210
[**2143-5-31**] 10:20AM BLOOD FDP-10-40
[**2143-5-31**] 10:20AM BLOOD Fibrino-352
[**2143-6-2**] 06:25AM BLOOD Glucose-87 UreaN-81* Creat-10.7* Na-134
K-3.5 Cl-97 HCO3-19* AnGap-22*
[**2143-6-3**] 07:15AM BLOOD Glucose-85 UreaN-81* Creat-10.6* Na-135
K-3.5 Cl-98 HCO3-20* AnGap-21*
[**2143-6-5**] 06:20AM BLOOD Glucose-80 UreaN-39* Creat-5.9*# Na-138
K-3.6 Cl-103 HCO3-26 AnGap-13
[**2143-6-6**] 05:27AM BLOOD Glucose-82 UreaN-30* Creat-5.4* Na-141
K-3.7 Cl-102 HCO3-27 AnGap-16
[**2143-6-6**] 09:20AM BLOOD LD(LDH)-291*
[**2143-6-6**] 05:27AM BLOOD Calcium-8.8 Phos-3.6# Mg-1.7
[**2143-6-3**] 02:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2143-6-3**] 07:15AM BLOOD HBsAg-NEGATIVE
[**2143-6-1**] 12:30AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 Cntromr-NEGATIVE
[**2143-5-30**] 02:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2143-6-3**] 02:20PM BLOOD HCV Ab-NEGATIVE
[**2143-6-1**] 12:30AM BLOOD SCLERODERMA ANTIBODY-Test
Imaging:
.
Head CT [**5-30**]: No evidence of acute intracranial hemorrhage.
Findings concerning for edema related to hypertensive
encephalopathy, in addition to chronic changes of microvascular
infarction. An MRI is recommended.
.
RUQ U/S [**5-30**]: Gallbladder wall edema, without gallstones. No
biliary ductal dilatation. Given the patient's underlying renal
failure, as well as clinical status of being afebrile and
without an elevated white count. This could be due to third
spacing. However, if clinically indicated, a HIDA scan should
be performed, as acute cholecystitis cannot be excluded given
these findings.
.
CXR [**5-30**]: Mild cardiomegaly. No evidence of congestive heart
failure.
.
EKG: NSR, RBBB pattern, no dynamic ST segment changes, flat TW
lateral precordial leads V4-V6 unchanged, long QTc 476
.
ECHO [**1-/2143**]:
EF 60%, Mild LVH, mild LA enlargement, PASP 25-28
Brief Hospital Course:
44 y/o female with h/o HTN who p/w headache, chest pain,
shortness of breath w/ pressure 270s/120s. Pt. received nipride
and lopressor. Now CP free. HA free.
.
1. Hypertensive Emergency: Due to poor med compliance. Has h/o
of repeated admissions for med non-compliance per PCP and other
[**Name9 (PRE) **] admit notes. Signs of CNS, renal, cardiac involvement with
microvascular changes notes, CRI, and mild LVH respectively. No
focal neurological deficits noted. The patient was controlled
with PO meds: amlodipine 10mg po qd, labetolol 600mg po bid, and
terazosin 6mg po bid. She continued to be slightly hypertensive
prior to starting hemodialysis because am meds held until after
HD. Subsequently, BP meds were given prior to HD and her BP
improved. She was maintained on the above 3 drug regimen for her
HTN while in the hospital and was discharged home that same
regimen. Further management and modification of her BP will be
done as an OP via her PCP. [**Name10 (NameIs) 3003**] to discharge, she was given one
final dose of her BP meds and told to resume her daily regimen
the day after discharge.
.
2. CKD: CKD with ARF secondary to hypertensive emergency with
poor PO intake, volume overloaded on CXR after hydration, with
hyperphosphatemia. The patient had a tunneled catheter placed on
[**2143-6-3**] and was started on hemodialysis the same day. She
received three sessions of HD from [**2143-6-3**] to [**2143-6-5**]. She was
given zemplar for an elevated PTH (440) during HD and also epo
during HD. She was started on fosrenol 500mg oral [**Hospital1 **]. Magnesium
containing compounds (such as Maalox) were avoided during her
hospital stay. After discharge, she will continue to follow with
her nephrologist, Dr. [**Last Name (STitle) 28606**], at [**Last Name (un) **], and be on a T, TH, Sat
HD schedule.
.
#. Anemia: Multifactorial, ACD, Anemia of renal disease not EPO
dependent, baseline HCT 23-30.0. No signs of active bleeding.
Her HCT was monitored each day. Received 2 units PRBCs during
hospital admission.
.
#. Hyperglycemia: No known DX of DM per OMR. BS 483 in ED, no
gap, accu checks highest 109, hgb A1C 5.1%.
.
#. Schizophrenia: Followed at [**Hospital **] Hospital, risperdone
consta 25mg IM due on [**6-7**] (Friday). Patient was aware that
she was due and the plan was reviewed for her to receive her
injection the day after discharge.
Medications on Admission:
-Hytrin 6mg [**Hospital1 **]
-Labetolol 600mg [**Hospital1 **]
-KCL 20mEQ [**Hospital1 **]
-Spironolactone 25md daily
-Risperdal 25mg/2ml q2wks
-Norvasc
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO twice a day.
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day.
5. Terazosin 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary-Hypertensive Emergency
Secondary
ESRD
Schizophrenia
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with
appropriate follow-up.
Discharge Instructions:
Please return to the ED or call your primary care physician
([**Telephone/Fax (1) 72092**]) if you have chest pain, SOB, vision changes, or
severe headache.
Followup Instructions:
Please follow up with your new PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) **] , on
Friday, [**2143-6-14**] at 2:30PM [**Company 191**] East South Suite.
Please follow up with dialysis on Saturday, [**2143-6-8**] at [**Hospital Ward Name 121**]
7 at 7:00AM. Another session of dialysis will be on Tuesday,
[**2143-6-11**] at [**Location (un) **] [**Location (un) **] at 11:15AM and you will be on
a Tuesday, Thursday, Saturday dialysis schedule.
Follow-up with Dr. [**First Name (STitle) 805**] of nephrology in 1 week. Please call
to make appointment [**Telephone/Fax (1) 673**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2143-6-10**]
|
[
"276.8",
"285.21",
"403.01",
"295.62",
"V15.81",
"584.9",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11772, 11778
|
8719, 11093
|
340, 451
|
11883, 11972
|
4242, 8696
|
12177, 12971
|
3600, 3879
|
11296, 11749
|
11799, 11862
|
11119, 11273
|
11996, 12154
|
3894, 4223
|
274, 302
|
479, 1979
|
2001, 2964
|
2980, 3584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,815
| 164,998
|
15502+15503+56666
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2178-11-9**] Discharge Date: [**2178-11-17**]
Date of Birth: [**2113-11-28**] Sex: M
Service: Hepatobiliary Surgery Service
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
male with a past medical history of ulcerative colitis and
primary sclerosing cholangitis who was initially evaluated by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the outpatient clinic on [**2178-10-14**].
By report, the patient has a history of jaundice requiring
initial stent placement times three in [**2166**], with subsequent
stent removal in [**2171**] and cholecystectomy in [**2172**].
Surveillance liver function study tests by the patient's
primary care physician demonstrated an increased alkaline
phosphatase earlier this year; follow-up endoscopic
retrograde cholangiopancreatography was notable for minimally
and common bile duct narrowing, consistent with primary
sclerosing cholangitis.
The patient's liver function tests were noted to acutely
worsen in [**2178-9-15**], with a subsequent second endoscopic
retrograde cholangiopancreatography conducted on [**2178-9-23**] which demonstrated distorted intrahepatic and
extrahepatic ducts and focal narrowing of the right, left and
common hepatic duct near the cystic duct remnant.
The patient was subsequently recommended for bilateral PTC
stenting and drainage prior to a Roux-en-Y
hepaticojejunostomy. PTC placement was attempted on [**2178-10-20**], at which point a right-sided drain was placed
successfully, but a left-sided drain placement was
complicated by biliary obstruction.
Following this attempted placement, the patient was
subsequently admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]
from [**10-20**] for further workup. A CT scan of
the abdomen and pelvis dated [**2178-10-21**] was notable for
intrahepatic bile duct dilatation and atrophic left hepatic
lobe.
A needle core biopsy conducted the same day demonstrated
features consistent with primary sclerosing cholangitis and
no evidence of malignancy. An esophagogastroduodenoscopy was
conducted on [**2178-10-22**] for investigation of an
incidental CT finding of soft tissue density in the
esophagus; this soft tissue was determined to be grade I
varices at the lower one-third of the esophagus and at the
gastroesophageal junction.
A repeat esophagogastroduodenoscopy on [**2178-11-3**]
demonstrated persistent varices with an additional finding of
a hiatal hernia, antral gastritis, and a reactive
inflammation of the mediastinal lymph nodes.
The patient was subsequently scheduled for an exploratory
laparotomy, left hepatic resection, and Roux-en-Y hepatic
jejunostomy for [**2178-10-16**].
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Primary sclerosing cholangitis.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. Hypothyroidism.
6. Bilateral biliary stent placement and removal in the
distant past.
7. Status post cholecystectomy.
8. Endoscopic retrograde cholangiopancreatography times two.
9. Recent right percutaneous transluminal coronary
angioplasty and drain placement.
10. Status post left carotid endarterectomy.
11. Status post colonoscopy with colonic polyp removal.
MEDICATIONS ON ADMISSION: Levoxyl, Univasc, Prilosec,
Celebrex, ursodiol, ciprofloxacin.
SOCIAL HISTORY: No history of alcohol abuse, reportedly
smoked a pack a day of cigarettes as a youth but quit
approximately 40 years ago, no history of intravenous drug
use, marijuana use, tatoos, hepatitis or pierced ears. The
patient is a retired automobile mechanic. The patient
reportedly sold his business, but still works regularly. The
patient is married and has two sons, aged 41 and 38.
HOSPITAL COURSE: On [**2178-11-9**], the patient underwent
a left hepatic lobectomy, common bile duct excision,
Roux-en-Y hepaticojejunostomy to the right anterior hepatic
duct and right posterior hepatic duct. The patient tolerated
the procedure well with an estimated blood loss of 1,400
intraoperatively.
The patient required two units of packed red blood cells
intraoperatively and took 7,000 cc of crystalloid through the
course of his operation. Intraoperatively, the patient also
demonstrated a total urine output of approximately 630 cc.
Postoperatively, the patient was noted to be stable and was
subsequently transferred to the Intensive Care Unit for
further monitoring and admitted to the Blue Surgery service
under the direction of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
The patient was placed on postoperative antibiotics
vancomycin 1 gm q.12h. and ciprofloxacin 400 mg b.i.d.; deep
vein thrombosis prophylaxis was provided via heparin s.c.
5,000 q.8h. and pain control via an epidural managed by the
anesthesia service. Postoperatively, the patient was noted
to be afebrile with stable vital signs. The patient was
administered a 500 cc bolus of normal saline secondary to a
transiently diminished systolic blood pressure, at which
point his epidural rate was adjusted from 8 cc to 6 cc per
hour.
On exam, the patient's central venous line was noted to be
intact and patent. His abdomen was noted to be soft and
appropriately tender, with dressings clean, dry and intact.
The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drains, both medial and lateral,
were noted to be intact and patent and right and left biliary
drainage were noted to be intact and patent as well.
The patient continued to progress well clinically, through
postoperative day number two, at which point the patient was
transferred to the floor within incident. On postoperative
day number two, the patient's nasogastric tube was
discontinued without complication and the patient was
subsequently noted to be ambulating well independently.
On the evening of postoperative day number two, the patient
was noted to have transient elevations in temperature with a
maximum temperature of 101.1. At this point, his wound
dressing was removed and his suture line examined; wound
evaluation revealed a clean abdominal incision with intact
staples with mild serous drainage from the floor right extent
of the wound.
The patient also demonstrated mild pericarp-incisional
erythema and subsequently had a vancomycin dosage increased
to 1,21 mg every 12 hours for the duration of his stay.
On postoperative day number three, the patient was
successfully transitioned to oral pain medication, provided
via Percocet, The patient was also transfused two units of
blood for a hematocrit of 26.4 and demonstrated an
appropriate post transfusion hematocrit increased to 33.1 on
subsequent blood draw.
Near the completion of receipt of his second unit of blood,
the demonstrated a transient increase in his temperature to
109.9. Due to the timing of this fever episode in relation
to the patient's transfusion schedule, it was felt that this
fever was unlikely to be secondary to a transfusion reaction.
Two sets of blood cultures and one set of urinary cultures
were subsequently obtained; as of the time of this dictation,
the patient's urine culture demonstrated no growth and his
blood cultures are still pending.
The patient continued to progress well clinically well
through postoperative day number four, at which point, he
was advanced to a regular diet after passing flatus. The
patient was subsequently transitioned to an oral medication
regimen with the exception of his intravenous vancomycin,
eosinophils complication.
The patient continued to progress well clinically through
postoperative day number five, at which point he was noted to
be afebrile with stable vital signs. His abdominal
examination demonstrated a soft, nontender and nondistended
abdomen; the patient's dressing was noted to be clean, dry
and intact with no drainage or saturation. Incisional
examination demonstrated decreasing peri-incisional erythema
with no evidence of active drainage and staples intact. The
[**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain and biliary drain were noted to
be intact and patent throughout. In addition, the patient
was noted be tolerant of a full regular diet and was
producing urine independently.
This discharge summary will be concluded under a separate
dictation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 44931**]
MEDQUIST36
D: [**2178-11-14**] 18:00
T: [**2178-11-14**] 17:15
JOB#: [**Job Number 44932**]
Admission Date: [**2178-11-9**] Discharge Date: [**2178-11-17**]
Date of Birth: [**2113-11-28**] Sex: M
Service: Hepatobiliary Surgery Service
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
male with a history of ulcerative colitis for 15 years and
primary sclerosing cholangitis for 12 years with a history of
multiple biliary obstructions and abdominal pain with
jaundice. The patient was referred to the [**Hospital3 **]
Initially endoscopic retrograde cholangiopancreatogram
[**2178-9-23**] was performed and a stent was placed. The
patient's bilirubin decreased from 8 to 1.2. The patient was
then scheduled for placement of a percutaneous transhepatic
cholangiogram drain and was referred to Dr. [**Last Name (STitle) **] for
additional follow up.
stent, but was unable to access the left biliary system. The
patient was admitted for further work up at that time. The
patient then presented to [**Hospital1 188**] under the care of Dr. [**Last Name (STitle) **] on [**2178-11-9**] for treatment
of the primary sclerosing cholangitis. The patient was
admitted and brought to the Operating Room with the initial
diagnosis of primary sclerosing cholangitis, right and left
hepatic duct strictures.
PAST MEDICAL HISTORY:
1. Primary sclerosing cholangitis for 12 years.
2. Ulcerative colitis for 15 years.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. Hypothyroidism.
PAST SURGICAL HISTORY:
1. Status post endoscopic retrograde cholangiopancreatogram
with stent placement multiple times.
2. Status post right TH biliary drain.
3. Status post bilateral arthroscopic surgery on his knees.
ALLERGIES: Questionable allergy to Penicillin.
MEDICATIONS:
1. Celebrex.
2. Prilosec.
3. Univasc.
4. Sulfasalazine.
5. Levoxyl.
6. Ursodiol.
SOCIAL HISTORY: Patient denies history of tobacco and
alcohol use.
INITIAL PHYSICAL EXAMINATION: Heart rate 103, blood pressure
121/55, respiratory rate 18, 95% on room air. In general is
in no acute distress, normocephalic. Head, eyes, ears, nose
and throat: Pupils are equal, round and reactive to light
and accommodation. Extraocular muscles are intact.
Respiratory was clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, II/VI murmur. GI:
Soft, nontender, nondistended, positive bowel sounds.
Extremities: Palpable pulses. Neurologic: Grossly intact.
HOSPITAL COURSE: The patient was admitted and brought to the
OR with primary diagnosis of primary sclerosing cholangitis,
right and left hepatic duct strictures. He had a left
hepatic lobectomy with common duct excision, Roux-en-Y
hepaticojejunostomy to the right hepatic duct. The patient
tolerated the procedure well. Required two units of pack red
blood cells and [**Pager number **] cc of Crystalloid. The patient was
transferred to the ICU in stable condition.
The patient was initially admitted to the ICU in stable
condition. On postoperative day #2, the patient was out of
bed to the chair and using his incentive spirometer. His
drains were intact and his dressing was also intact. The NG
tube put out roughly 60 cc.
On the 27th, the patient continued to do well. He was up and
walking around. NG tube was discontinued and the epidural
was continued at 4 cc. On the 28th, the epidural and Foley
were discontinued. Diet was advanced and dressings were
changed.
On the 29th the patient still continued with Vancomycin and
Cipro which were continued from the OR. He continued to do
well with no major events. On the 30th it was decided that
the patient would have an cholangiogram on [**11-16**] at 11 AM.
For the remainder of the [**Hospital 228**] hospital stay, the patient
was stable and ambulating well. The cholangiogram on the 2nd
showed no leak. At that time it was decided the patient
could be discharged home.
DISCHARGE PHYSICAL EXAMINATION: T max 92.0 F, 78, 142/72,
18, 95% on room air, 470 p.o., 1320 out in urine. JP
#1 75 cc. JP #2 30 cc. Cardiovascular: Regular rate and
rhythm. Respiratory: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended. Drains are intact.
DISCHARGE DIAGNOSIS:
1. Status post left hepatic lobectomy with common duct
excision and Roux-en-Y hepaticojejunostomy to right hepatic
duct.
2. Primary sclerosing cholangitis for 12 years.
3. Ulcerative colitis for 15 years.
4. Hypertension.
5. Gastroesophageal reflux disease.
6. Hypothyroidism.
7. The patient is status post multiple endoscopic retrograde
cholangiopancreaticograms with stent placements.
CONDITION ON DISCHARGE: Good and stable to home with VNA.
The patient met with [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] prior to discharge and upon
meeting with the patient, she thought that the patient would
benefit from a visiting nurse. Page 1 was filled at that
time and VNA set up.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Percocet one to two tabs p.o. q. four to six hours p.r.n.
Patient will be discharged with drains and will monitor the
output. The patient will be able to shower and change his
own dressings p.r.n.. The patient will follow up with Dr.
[**Last Name (STitle) **] in the office.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern4) 44933**]
MEDQUIST36
D: [**2178-11-22**] 10:40
T: [**2178-11-25**] 10:16
JOB#: [**Job Number 44934**]
Name: [**Known lastname 8264**], [**Known firstname 947**] Unit No: [**Numeric Identifier 8265**]
Admission Date: [**2178-11-9**] Discharge Date: [**2178-11-16**]
Date of Birth: [**2113-11-28**] Sex: M
This is a discharge summary addendum dictation for Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] regarding [**Known firstname **] [**Known lastname **].
DISCHARGE SUMMARY ADDENDUM: The patient had a cholangiogram
anastomotic junctions. The patient otherwise did well and
tolerated the regular diet. The patient was discharged on
[**2178-11-17**].
DISCHARGE MEDICATIONS:
1. Levoxyl 200 mcg b.i.d.
2. Ursodiol 300 mg b.i.d.
4. Celebrex 200 mg q.d.
FOLLOW UP INSTRUCTIONS: The patient is to follow up with Dr.
[**Last Name (STitle) **] in one weeks time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D.,Ph.D. 02-366
Dictated By:[**First Name3 (LF) 8266**]
MEDQUIST36
D: [**2178-11-18**] 11:37
T: [**2178-11-18**] 11:46
JOB#: [**Job Number 8267**]
|
[
"530.81",
"576.1",
"401.9",
"V45.82",
"244.9",
"556.9",
"576.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.63",
"87.54",
"50.3",
"51.37"
] |
icd9pcs
|
[
[
[]
]
] |
14774, 15227
|
12818, 13213
|
3318, 3382
|
11076, 12514
|
10116, 10466
|
12537, 12797
|
8861, 9909
|
9931, 10093
|
10483, 10543
|
13238, 13532
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,785
| 183,076
|
10949+10960
|
Discharge summary
|
report+report
|
Admission Date: [**2161-7-21**] Discharge Date: [**2161-8-2**]
Date of Birth: [**2095-10-22**] Sex: M
Service: Cardiothoracic Surgery
NO DICTATION
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 35548**]
MEDQUIST36
D: [**2161-8-1**] 14:05
T: [**2161-8-1**] 15:25
JOB#: [**Job Number 35549**]
Admission Date: [**2161-7-21**] Discharge Date: [**2161-8-2**]
Date of Birth: [**2095-10-22**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
male with a history of hypertension, positive for shortness
of breath with diaphoresis and chest pain. The chest pain
decreased with sublingual Nitrogen but the pain recurred
after the patient was transferred to the Intensive Care Unit.
The patient was noted to have decreased ST segments on
electrocardiogram. The electrocardiogram was increased at
1900 and his troponin N was greater than 80. The patient
received 2 units of packed red blood cells to help treat the
shortness of breath. The patient also during the first
hospital day stay in the Intensive Care Unit had increased
agitation which was treated with Haldol. The patient had a
catheterization done at an outside hospital showing an
ejection fraction of 37%, a right coronary artery between 70
and 80% and left axis 90% left anterior descending at 60 to
70%. The patient was then referred for coronary artery
bypass graft at [**Hospital6 256**].
PAST MEDICAL HISTORY: Initially, systemic lupus
erythematosus, hypertension
MEDICATIONS: Zestril, Norvasc, Plaquenil, Lipitor, Aspirin,
intravenous Nitroglycerin, Ativan
SOCIAL HISTORY: 100 pack per year tobacco history and
positive ethyl alcohol for six to seven beers per day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Initial physical examination showed
temperature maximum 102, pulse 78, blood pressure 102/46,
respiratory was coarse breathsounds. Cardiovascular was
regular rate and rhythm. S1 and S2 with no murmurs. Abdomen
was nontender, positive bowel sounds and peripheral showed no
edema. No varicosities shown.
LABORATORY DATA: Initial laboratory data showed white blood
cell count 4.6, hematocrit 28, platelets 172, sodium 132,
potassium 4.8, chloride 102, carbon dioxide 20, BUN 21,
creatinine 1.3, and glucose of 104. CK was 90 to 1100 to
1900, MB was maximum of 290, troponin was maximum greater
than 50. PT was 11.9 with an INR of .97, PTT 74.
Electrocardiogram showed ST depressions in V2 through V4 and
no Q waves.
HOSPITAL COURSE: The patient was admitted on [**7-21**], to the
Internal Medicine Coronary Care Service. The patient was
noted to be a fairly large alcohol drinker and was started on
Ativan and Serax for delirium tremens prophylaxis. The
patient was monitored for coronary artery disease, scheduled
for a coronary artery bypass graft. On [**7-28**] the patient
was transferred to Cardiothoracic Surgery for coronary artery
bypass graft. The patient was transported to the Operating
Room with initial diagnosis of three vessel coronary artery
disease, unstable angina, hypertension and systemic lupus
erythematosus. The patient had a coronary artery bypass
graft times four with left internal mammary artery to left
anterior descending, saphenous vein graft to the right
coronary artery, obtuse marginal 1, and obtuse marginal 2.
The patient tolerated the procedure well and was transported
to the Cardiothoracic Intensive Care Unit. The patient did
well postoperative day #1 and was transferred to the floor.
On postoperative day #1 the patient was also continued on his
delirium tremens prophylaxis. On postoperative day #2 the
patient continued to do well and increased his ambulation.
On postoperative day #2, the patient's nurse complained of
mild agitation and symptoms of delirium. The patient had a
sitter for the night and on postoperative day #3 the sitter
mentioned that the patient slept almost 90% of the night and
wound up getting out of bed only once to go to the bathroom.
Hence, the sitter was discontinued. On postoperative day #3
the patient also continued to cough up sputum and was sent
for a chest x-ray and a sputum culture. On postoperative day
#4 the Gram stain came back as +1 gram positive cocci in
pairs and in chains. The culture came back as positive for
oropharyngeal Flora, yet still pending. The patient was
started on Levaquin 500 mg p.o. q.d. times ten days and will
be reassessed after the final cultures are back. The patient
was also assessed on postoperative day #4 for rehabilitation
and will be transferred to a rehabilitation center on [**8-2**].
DISCHARGE PHYSICAL: Temperature 99.2, pulse 96, respiratory
rate 20, blood pressure 114/72, respiratory rate 20,
saturated oxygen 96% on 4 liters +1 kg. Cardiovascular:
Regular rate and rhythm. Respiratory is clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended. Extremities: Mild swelling. Incision is
clean, dry and intact, both chest and lower extremities.
COMPLICATIONS: Gram positive sputum for which the patient
was started on Levaquin.
DISCHARGE MEDICATIONS:
1. Serax 50 mg p.o. q. 8 prn
2. Plaquenil 20 mg p.o. t.i.d.
3. Levaquin 500 mg p.o. q.d. times ten days
4. Lopressor 100 mg p.o. b.i.d., hold for systolic blood
pressure less than 100, heartrate less than 60
5. Lasix 40 mg q.d.
6. Calcium chloride 20 mg b.i.d.
7. Docusate 100 mg p.o. b.i.d.
8. Aspirin 81 mg p.o. q.d.
9. Ibuprofen 400 mg prn p.o. q. 4 to 6 hours
10. Tylenol 650 mg p.o. q. 4 to 6 hours prn
11. Albuterol nebulizers q. 4
12. Percocet one to two tabs p.o. q. 4 to 6 hours prn pain
DISCHARGE STATUS: Stable to rehabilitation.
FOLLOW UP: The patient will follow up with Dr.[**Doctor Last Name **]
office in three to four weeks.
PRIMARY DISCHARGE DIAGNOSIS:
1. Coronary artery bypass graft times four
SECONDARY DIAGNOSIS:
1. Systemic lupus erythematosus
2. Hypertension
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 35548**]
MEDQUIST36
D: [**2161-8-1**] 14:41
T: [**2161-8-1**] 15:54
JOB#: [**Job Number 35570**]
|
[
"593.9",
"507.0",
"710.0",
"285.9",
"291.0",
"041.89",
"401.9",
"303.91",
"410.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"96.72",
"36.15",
"39.63",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5232, 5785
|
5917, 5962
|
2647, 5209
|
5797, 5896
|
1907, 2629
|
616, 1561
|
5983, 6297
|
1584, 1735
|
1752, 1884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,358
| 149,942
|
20193
|
Discharge summary
|
report
|
Admission Date: [**2183-10-7**] Discharge Date: [**2183-10-19**]
Date of Birth: [**2125-8-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Grafting x4 (LIMA-LAD, SVG-OM, SVG-DG,
SVG-PDA) [**2183-10-13**]
left and right heart catheterization, coronary angiography
transesophageal echocardiogram
History of Present Illness:
This 58 year old male with a history of hypertension, type II
diabetes and known coronary disease presents from another
institution with worsening dyspnea for 6 weeks. He was admitted
to [**Hospital3 **] on [**10-7**] with these symptoms and found to
have troponin I of 0.74, without significant EKG changes. He was
started on heparin , ASA, plavix and lasix and transferred for
cardiac catheterization. He was also noted to have mild CHF on
x-ray and BNP 507 and was diuresed with IV lasix.
Past Medical History:
obesity
noninsulin dependent diabetes mellitus
coronary artery disease
hypertension
hypercholesterolemia
s/p coronary angioplasty
s/p appendectomy
chronic systolic heart failure
Social History:
Social history is significant for the absence of current tobacco
use. 15 pack years of smoking 15 years prior. There is no
history of alcohol abuse.
Family History:
Pt had 3 uncles who died of myocardial infarctions in their 50s.
Physical Exam:
Discharge:
97.9 150/96 74 95% RA 107.1 KG
General: pleasant, answers questions appropriately
Lungs: CTAB
Cor: Nl s1s2. Sternum stable
Abdomen: soft, nontender. Normoactive bowel sounds.
Extremities: warm. Trace bilateral edema. 2+ distal pulses
Pertinent Results:
Cardiac Cath:
[**10-7**] - 1. Selective coronary angiography of this right dominant
system revealed
three vessel disease. The LMCA was widely patent. The LAD had a
70%
stenosis in the mid-vessel involving the bifurcation of D1. The
LCx had
a 70% mid-vessel stenosis, subtotal occlusion of a small OM1
branch, and
95% stenosis of a large OM2 branch. The RCA had patent stents
proximally; there was a 95% complex proximal PDA lesion, 95% RPL
lesion,
and 90% mid PDA lesion with distal vessel filling from
left-right
collaterals.
2. Resting hemodynamics revealed mildly elevated right heart
filling
pressures with a mean RA of 7mmHg. There was moderate pulmonary
hypertension with a PASP of 40mmHg. The mean PCWP was initially
only
mildly elevated at 15mmHg but increased to 25mmHg by the end of
the
case. The cardiac index was preserved at 2.3l/min/m2.
3. Left ventriculography demonstrated 1+ mitral regurgitation.
The
estimated LVEF was 25% with global hypokinesis.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systolic and moderate diastolic ventricular
dysfunction.
TTE:
[**10-8**] - 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. The left ventricular cavity size
is top normal/borderline dilated. There is moderate regional
left ventricular systolic dysfunction with thinning and akinesis
of the mid to distal inferior and inferolateral segments and
hypokinesis of the basal inferior and inferolateral segments and
of the lateral wall. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Moderate regional LV systolic dysfunction consistent
with ischemic heart disease. Diastolic dysfunction with raised
filling pressures. Mild aortic regurgitation.
[**2183-10-18**] 07:45AM BLOOD WBC-10.2 RBC-4.06* Hgb-12.8* Hct-37.3*
MCV-92 MCH-31.6 MCHC-34.4 RDW-13.0 Plt Ct-219
[**2183-10-7**] 06:04PM BLOOD WBC-6.0 RBC-4.12* Hgb-12.9* Hct-36.1*
MCV-88 MCH-31.3 MCHC-35.8* RDW-12.6 Plt Ct-149*
[**2183-10-19**] 06:05AM BLOOD PT-18.5* INR(PT)-1.7*
[**2183-10-8**] 06:20AM BLOOD PT-14.1* PTT-32.0 INR(PT)-1.2*
[**2183-10-18**] 07:45AM BLOOD Glucose-230* UreaN-33* Creat-1.2 Na-136
K-4.3 Cl-100 HCO3-26 AnGap-14
[**2183-10-7**] 06:04PM BLOOD Glucose-128* UreaN-16 Creat-0.6 Na-142
K-3.3 Cl-107 HCO3-23 AnGap-15
[**2183-10-8**] 06:20AM BLOOD ALT-15 AST-14 AlkPhos-53 TotBili-0.9
[**2183-10-7**] 06:04PM BLOOD ALT-13 AST-14 CK(CPK)-60 AlkPhos-43
[**2183-10-17**] 09:10AM BLOOD Mg-1.9
[**2183-10-8**] 06:20AM BLOOD Phos-3.2 Mg-1.8 Iron-78 Cholest-156
[**2183-10-8**] 06:20AM BLOOD %HbA1c-6.9*
[**2183-10-8**] 06:20AM BLOOD Triglyc-117 HDL-46 CHOL/HD-3.4 LDLcalc-87
Brief Hospital Course:
Cardiac catheterization revealed triple vessel disease with
normal right heart pressures. A transesophageal echo
demonstrated left ventricular dysfunction with an ejection
fraction of 25%. Diuresis was continued. He was referred for
surgical intervention.
On [**10-13**] he went to the operating room where quadruple
bypass grafting was performed. See operative note for details.
Postoperatively he did well, weaned from the ventilator easily
and remained stable. He was severely hyperglycemic, requiring an
extra day in the ICU for glucose management. Oral agents were
resumed and sliding scale regular insulin with glargine insulin
were given to facilitate weaning from the insulin infusion.
He was transferred to the floor on POD2 in stable condition.
Diuretics were continued and beta blockade was resumed.
Vancomycin was administered perioperatively as he had been
hospitalized for a week prior to surgery. [**Last Name (un) **] was consulted
for elevated blood sugars. He was continued on his PO meds and
Lantus was added with improvement in his blood sugars. On POD 4
he was noted to have a possible cellulitis at the site of
infiltrated amiodarone. He was placed on Keflex 500mg QID x5
days and warm compresses. He was cleared by PT and was
discharged to home on POD 5.
Medications on Admission:
Heparin gtt
KCl 40
ASA 81
Metformin
Glipizide 5
Metoprolol 50
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take if you take Percocet.
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(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:*0*
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please call Dr [**Last Name (STitle) 17369**] as instructed to check INR and adjust
dose.
Disp:*30 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous At lunch.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x 4 (LIMA-LAD, SVG-OM, SVG-Dg,
SVG-PDA) [**10-13**]
obesity
noninsulin dependent diabetes mellitus
hypertension
hypercholesterolemia
s/p coronary angioplasty
s/p appendectomy
Discharge Condition:
good
Discharge Instructions:
no lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever greater than 100.5
report any drainage from, or redness of incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr.[**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**Last Name (STitle) 4469**] in 2 weeks ([**Telephone/Fax (1) 4475**])
Dr. [**Last Name (STitle) 17369**] in [**12-25**] weeks ([**Telephone/Fax (1) 17368**]please call for
appointment.
Please Call Dr [**Last Name (STitle) 17369**] [**Name (STitle) 766**] ([**2183-10-20**]) re: coumadin as he has
followed in past and will continue to follow.
Completed by:[**2183-10-19**]
|
[
"413.9",
"414.01",
"250.92",
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"428.22",
"401.9",
"V15.82",
"300.00",
"428.0",
"E879.8",
"999.39",
"278.00",
"272.0",
"427.32",
"682.3",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"88.56",
"36.15",
"37.23",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
8199, 8218
|
5124, 6412
|
330, 510
|
8495, 8502
|
1765, 2734
|
8907, 9357
|
1415, 1481
|
6525, 8176
|
8239, 8474
|
6438, 6502
|
2751, 5101
|
8526, 8884
|
1496, 1746
|
283, 292
|
538, 1032
|
1054, 1233
|
1249, 1399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,860
| 190,308
|
14414
|
Discharge summary
|
report
|
Admission Date: [**2192-8-24**] Discharge Date: [**2192-9-7**]
Date of Birth: [**2125-3-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
slowly increasing right upper lobe nodule
Major Surgical or Invasive Procedure:
bronchoscopy, videoassisted thoracoscopy, right thoractomy for
lung mass, nonsmall cell lung cancer wedge resection, and right
upper lobectomy and several bronchoscopies post-op
History of Present Illness:
Mr. [**Known lastname **] is a 67-year-old gentleman who has a history of CNS
lymphoma and also is status post a right thoractomy with biopsy
of pleaural mass and lung nodule, the pathology of which
revealed a nonnecrotizing granulomas. Since that time, he has
been followed with serial CT scans following the discovery of
the right upper lobe nodule after a bout of pnuemonia. In
addition he has been followed for bronchiectasis, most
prominently noted in the left lung. The right upper lobe nodule
in retrospect has been present since [**2190-10-22**] and it was found
to have a increasing in size. So he presents for diagnosis and
possible treatment with lobectomy.
Past Medical History:
1. CNS lymphoma - followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
-Dx'd by biopsy on [**2188-6-4**] - B-cell CD20+ CNS lymphoma
-Tx'd w/methotrexate high dose IV and intrathecal
-Relapse [**8-11**] tx'd w/induction Rituxan and temozolomide
immunotherapy
-Completed 12 cycles of maintenance temozolomide chemotherapy
[**8-13**]
2. Polymyalgia rheumatica
3. Stage I seminoma in the right testicle treated with
orchiectomy and
irradiation in [**2159**]
4. Waldenstrom's macroglobulinemia - per notes stable. His serum
IgM
from [**2191-2-17**] was 432 (range 20-230). + hypogammaglobulinemia
5. Squamous Cell Carcinoma of the Skin: followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]
s/p electron-beam irradiation for squamous cell carcinoma to
his right neck and mid-back from [**2190-12-28**] to [**2191-1-27**].
6. Bronchiectasis and Granulomatous Lung Mass: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**], M.D.
7. Neurocognitive Dysfunction: Stable on Ritalin LA and Namenda.
8. Low Testosterone on adrogel
9. S/p DVT, IVC placement on lovenox therapy
10. Bovine atrial valve replacement 3 yrs ago at [**Hospital1 112**]
Social History:
Patient lives with his wife and son. [**Name (NI) **] manages auto dealership.
He has >60 pkyr smoking history, quit 20 yrs ago. He ~30yrs ago
he previously was a heavy drinker but now drinks one to two
alcoholic drinks a month. He denies illicit drug use. His only
exposure history is that related to radiation that he had for
his squamous cell and seminoma.
Family History:
Father died of colon cancer at the age of 80. Mother died of CVA
at the age of 94. No family history of lung cancer.
Physical Exam:
VITAL SIGNS: Temperature 99.9, pulse 88, blood pressure 96/36,
respiratory rate 18, and oxygen saturation 93% on room air.
GENERAL: Well-nourished, well-developed gentleman, in no
apparent distress.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: No clubbing, cyanosis, or edema.
Pertinent Results:
[**2192-8-24**] 10:35 am TISSUE RT UPPER LOBE.
GRAM STAIN (Final [**2192-8-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2192-8-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2192-8-30**]): NO GROWTH.
ACID FAST SMEAR (Final [**2192-8-25**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 42688**],[**Known firstname **] T [**2125-3-15**] 67 Male [**-5/3646**] [**Numeric Identifier 42689**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: RIGHT UPPER LOBE WEDGE (6).
Procedure date Tissue received Report Date Diagnosed
by
[**2192-8-24**] [**2192-8-24**] [**2192-8-29**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/lo??????
Previous biopsies: [**-5/3106**] COLONOSCOPY (1).
[**-4/3743**] SKIN LT EYEBROW
[**-3/4189**] MID BACK SKIN EXC.
[**-3/3816**] RIGHT NECK SHAVE.
(and more)
DIAGNOSIS:
1. Lung, right upper lobe, wedge resection (A-C):
A. Squamous cell carcinoma, well-differentiated. See
synoptic report.
B. Focal calcification.
2. Lymph node, level 10, biopsy (D):
One lymph node, no malignancy identified.
3. Lymph node, level 12, biopsy (E):
Two lymph nodes, no malignancy identified.
4. Lung, right upper lobe, lobectomy (F-K):
A. No residual carcinoma seen.
B. Fibrosis and focal ossification of lung parenchyma.
C. Atelectasis and alveolar hemorrhage, likely related to
procedure.
5. Lymph node, level 4 R, biopsy (L-M):
Four lymph nodes, no malignancy identified.
6. Lymph node, level 7, biopsy (N):
Five lymph nodes, no malignancy identified.
Lung Cancer Synopsis
MACROSCOPIC
Specimen Type: Wedge resection. Lobectomy.
Laterality: Right.
Tumor Site: Upper lobe.
Tumor Size
Greatest dimension: 1.0 cm.
MICROSCOPIC
Histologic Type: Squamous cell carcinoma.
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor 3 cm or less in greatest dimension,
surrounded by lung or visceral pleura, without bronchoscopic
evidence of invasion more proximal than the lobar bronchus (ie,
not in the main bronchus).
Location: Level 10.
Number examined: 1.
Number involved: 0.
Location: Level 12.
Number examined: 2.
Number involved: 0.
Location: Level 4R.
Number examined: 4.
Number involved: 0.
Location: Level 7.
Number examined: 5.
Number involved: 0.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 40 mm. Specified margin:
bronchial margin
Direct extension of tumor: None.
Venous invasion (V): Absent.
Clinical: right upper lung lobe nodule.
Gross:
Part 1 is received fresh labeled with "[**Known firstname **] [**Known lastname **]" and the
medical record number and "right upper lobe wedge" and consists
of a 5.5 x 2.0 x 1.2 cm wedge of lung with a red and smooth
pleura. The specimen is sectioned to reveal a nodule measuring
up to 1 cm with a red maroon cut surface. A portion of the
nodule is frozen, and frozen section diagnosis by Dr. [**Last Name (STitle) **]
is "non small cell, favor squamous process." The frozen section
remnant is entirely submitted in A and the remainder of the
specimen with the exception of the stapled parenchyma is
entirely submitted in B-C.
Part 2 is additionally labeled "level 10" and consists of a
single lymph node measuring up to 1.8 cm entirely submitted in
cassette D
Part 3 is additionally labeled "level 12" and consists of an
aggregate of tan-brown and focally anthracotic lymph nodes
measuring 1.5 x 1.0 x 0.5 cm entirely submitted in cassette E.
Part 4 is additionally labeled "right upper lobe" and consist of
a lobe of lung measuring 13 x 10 x 4 cm. There are multiple
suture and staple lines identified, representing the site of
prior biopsy. The pleural surface is predominantly smooth, with
no areas of puckering identified. The pleural surface is inked
black and the specimen is bread-loafed to reveal a hemorrhagic
appearing lung parenchyma, without discrete lesions identified.
The bronchus resection margin is frozen and frozen section
diagnosis by Dr. [**Last Name (STitle) 9885**] is: "Bronchial margin: squamous
metaplasia with focal atypia. No invasive carcinoma seen". The
specimen is represented as follows: F = frozen section remnant,
G = deeper sections through bronchus, H-I = representative
sections through collapsed appearing area of lung lying 4 cm
from the bronchial resection margin, J = sections adjacent to
the stapled area corresponding to site of prior biopsy, K =
sections through normal appearing lung.
Part 5 is additionally labeled "level 4R" and consists of
multiple lymph node fragments aggregating 2 x 2 x 2 cm entirely
submitted in cassettes L-M.
Part 6 is additionally labeled "level 7" and consists of a 2 x 2
x 0.5 cm aggregate of lymph node fragments entirely submitted in
cassette N.
[**2192-8-31**] 9:36 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2192-9-2**]**
GRAM STAIN (Final [**2192-8-31**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2192-9-2**]):
~1000/ML OROPHARYNGEAL FLORA.
YEAST. ~1000/ML.
[**Month/Day/Year 706**] Preliminary Report
CHEST (PA & LAT) [**2192-9-7**] 10:42 AM
CHEST (PA & LAT)
Reason: eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
67 year old man s/p RUL lobectomy-worse cxry [**9-6**] CPT q4h for
secretions clearance
REASON FOR THIS EXAMINATION:
eval for interval change. NEEDS to be at 10am
INDICATION: 67-year-old man status post right upper lobe
lobectomy, evaluate for interval change.
CHEST, THREE VIEWS: Comparison is made to a prior study of
[**2192-9-6**]. Heart size is difficult to evaluate but is likely
normal. The patient is status post right upper lobectomy. The
right hemidiaphragm is elevated. There is improved aeration in
the right lung. The right-sided pleural effusion is improved as
well. The left lung is unremarkable. The pulmonary vasculature
is normal. There is no left pleural effusion.
IMPRESSION: Status post right upper lobectomy with significant
improvement in the aeration of the right lung. Decrease in the
right pleural effusion is also noted.
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
[**2192-9-7**] 06:45AM BLOOD WBC-9.1 RBC-3.39* Hgb-9.9* Hct-28.7*
MCV-85 MCH-29.2 MCHC-34.5 RDW-15.7* Plt Ct-335
[**2192-9-7**] 06:45AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-139
K-4.5 Cl-104 HCO3-26 AnGap-14
[**2192-9-7**] 06:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.6
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2192-8-24**] to do an elective flexible
bronchoscopy, reoperative video-assisted thoracic surgery of
right lobectomy, right upper lobe wedge, mediastinal
lymphadenectomy, and intrapleural adhesiolysis. Pain was well
controlled with an epidural. On POD 2 Mr. [**Known lastname **] was noted to
have an hematocrit drop of approximately 10 points from the
intraoperative to the postoperative state.
The chest tube output itself totaled approximately 600 cc, but
was quite serous in nature. However, due to the hematocrit drop
and the chest x-ray finding, it was not possible to rule out a
possible intrapleural bleed. A chest CT scan was obtained and
there was a fair amount of lung collapse on that CT scan, but it
was not entirely possible to distinguish between what was
consolidated or collapsed lung, and what possibly was pleural
effusion or hemothorax. Because of this, it was decided to take
him to the operating room and perform a flexible bronchoscopy
and right exploratory thoracoscopy. It was found that he did not
have much clot intrapleurally and instead there was mucus plugs
and atelectasis. On [**8-27**] he had his chest tube put to waterseal.
He then got a bronchoscopy on [**8-16**], [**8-31**], [**9-1**], and [**9-4**]
for continued mucus plugs, and thick secretions filling his
right main bronchus. He slowly improved with numerous bronchs,
aggressive chest physical therapy, nebulizer treatment,
aggressive diuresis and ambulation. On [**8-28**], he did not tolerate
his bronchoscopy so he was transferred to the CSRU due to
broncho-spasm. His chest tube was taken out on [**8-29**] and his
bulb was put to suction. On [**9-2**] his [**Doctor Last Name **] was pulled out. He
failed three voiding trials but each time it seemed to be due to
low urine in his bladder rather than a functional problem so on
the day of discharge his bladder was infused with saline and
then his foley was taken out. He voided after this trial. Also
on the days leading up to discharge he was able to cough up his
mucus plugs with the help of aggressive chest physical therapy
and ambulation. On the day of discharge it looked like he no
longer need to be bronch and could bring up his secretions on
his own.
Medications on Admission:
1. Crestor 10 mg PO once a day
2. Neurontin 300mg PO once a day
3. Namedia 10mg PO BID
4. AndroGel once a day
5. Lopressor 50mg PO BID
6. Lasix 20 mg PO once a day
7. diltiazem 360 mg PO once a day
8. Ritalin 40 mg PO once a day
9. Ritalin 5mg PO BID
10. Lovenox 60mg SQ [**Hospital1 **]
11. Pulmicort IH [**Hospital1 **]
12. Fosamax 35 Qwk
13. Protonix 40 mg PO once a day
14. coumadin (held)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
6. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Methylphenidate 20 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO MRX1 () as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
12. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*1*
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*qs 1 box* Refills:*0*
14. oxygen
1-2 L/min continuous for portability pulse dose system
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*qs neb* Refills:*0*
16. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-12**] Sprays Nasal
QID (4 times a day) as needed.
18. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
19. Lopressor 50 mg Tablet Sig: 1 [**12-14**] Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
20. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed.
21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
25. overnight oximetry
overnight oximetry on room air
26. nebulizer
nebulizer machine
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CNS lymphoma, chemotherapy, polymyalgia rheumatica,
Waldenstroms macroglobulinemia, porcine heart valve replacement
[**2185**], stage I testicular seminima s/p orchiectomy and
irradiation '[**59**], pneumonia, bronchiectasis, squamous cell cancer
of back and neck, DVT s/p IVC filter, COPD,
hypercholesterolemia, HTN, SVT, lower GI bleed, lung mass-
nonsmall cell lung cancer wedge resection> right upper lobectomy
Discharge Condition:
good
Discharge Instructions:
CAll Dr.[**Name (NI) 42690**] office/ Thoracic Surgery office for:
fever, shortness of breath, chest pain, excessive foul smelling
drianage form incision sites, or excessive sputum production w/
shortness of breath and fever.
Chest Physical Therapy, Physical Thereapy and VNA services at
home
Pulmonary Rehab at [**Hospital1 18**] w/ [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 788**] appointments --[**2192-9-11**]
1:45pm.
After [**Hospital **] Rehab appt, go to [**Hospital **] [**Location (un) **] clinical center
for CXRY and tehn to Thoracic Surgery Clinic [**Location (un) **] for 3pm
appt w/ Dr. [**Last Name (STitle) **].
Continue positional drainage 2-3 times per day at home to help
get rid of secretions.
Followup Instructions:
Provider: [**Name (NI) **] [**Doctor Last Name 4508**], PT, CCS Date/Time:[**2192-9-11**] 1:45
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2192-9-11**] 3:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2192-10-18**]
8:30
Completed by:[**2192-9-9**]
|
[
"511.0",
"V10.83",
"202.81",
"934.1",
"V42.2",
"162.3",
"518.0",
"401.9",
"273.3",
"496",
"725"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.21",
"32.29",
"33.39",
"32.4",
"33.24",
"96.05",
"40.3",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
15963, 16012
|
10676, 12942
|
362, 543
|
16470, 16476
|
3429, 3826
|
17292, 17639
|
2912, 3030
|
13386, 15940
|
9454, 9542
|
16033, 16449
|
12968, 13363
|
16500, 17269
|
3045, 3410
|
3892, 9417
|
3859, 3859
|
281, 324
|
9571, 10653
|
571, 1244
|
1266, 2516
|
2532, 2896
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
999
| 173,415
|
3344
|
Discharge summary
|
report
|
Admission Date: [**2119-6-4**] Discharge Date: [**2119-6-15**]
Date of Birth: [**2049-7-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
redness and swelling around peripheral iv site from recent
admission
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
History of Present Illness:
69yo male with PMH DM, HTN, CRI, recently dx carcoinoid tumor of
the rectum, hypothyroid, recent admission for hypercalcemia
presents with cellulitis at prior IV site.
.
Pt was admitted from [**Date range (1) 15523**] with hypercalcemia presumed [**2-3**]
taking too much calcium supplementation and treated with
hydration.
.
Pt states that over the past 2 days he has had fevers, chills,
and myalgias. After d/c he noted redness, warmth, and itchiness
around right antecub at recent PIV site. Denies cough/SOB,
n/v/abd pain/diarrhea, dysuria/urinary frequency. Denies
CP/palp.
.
In the ED, initial vitals were T 101.8, p104, 118/80, rr20,
97%Ra. Noted to have redness and previous right antecub IV site.
Blood cultures sent. Pt was given ancef 1gm, vanco 1gm, tylenol
1gm, 1L NS
Past Medical History:
1. carconid tumor of colon - schedule for transanal excision of
this tumor in the near future by Dr. [**Last Name (STitle) 1120**]
2. Thyroid carcinoma, status post total thyroidectomy. He
states he had two surgeries, one in [**2086**] and one in [**2092**] on his
thyroid. He is functionally hypoparathyroid and hypothyroid as
a result of these surgeries.
3. Type 2 diabetes - retinopathy, very early diabetic
nephropathy
4. In his chart, it is stated that he had laryngeal carcinoma.
There is no pathology in our system and the note that refers to
this documents that this occurred circa [**2105**].
5. hypocalcemia - since hypoPTH diagnosed, followed by Dr.
[**Last Name (STitle) 574**], on calcium and calcitriol
PAST SURGICAL HISTORY:
1. Thyroid surgeries as above.
2. Two emergent laparotomies following stabbings [**2086**] and [**2087**].
Social History:
from [**Male First Name (un) 1056**]. has nine children,. previously smoked
approximately two packs per day but quit in [**2086**]. h/o of heavy
drinking, but not recently.
Family History:
He is one of eight children. Three of his
siblings are deceased and presumably died from cancer. One of
his brothers died at age 74 from liver dysfunction possibly from
cancer. Another brother died at age 80 from complications of
"bone cancer." One of his sisters died at age 80 from an
unknown
cancer. His father died at age 82 from complications of the
CVA.
His mother died at age 70 from complications of lung cancer. He
apparently has had four maternal aunts who died of complication
of lung cancer. All of his children are well.
Physical Exam:
VS: t99.8, p83, 122/78, rr18, 100%RA
Gen: well-appearing, NAD
HEENT: PERRL, clear OP, MMM
CVS: RRR, nl s1 s2, 2/6 systolic murmur best heart at RUSB
radiating throughout precordium without radiation to carotids
Lungs: CTAB, no c/w/r
Abd: soft, NT, ND, +BS
Ext: no LE edema
Right antecub: ~10 x 4cm area of erythema, warmth, swelling
(marked) without signif pain on palpation around prior scabbed
over PIV site
Pertinent Results:
[**2119-6-4**] 06:05PM WBC-8.0# RBC-3.77* HGB-12.3* HCT-33.1* MCV-88
MCH-32.5* MCHC-37.0* RDW-14.4
[**2119-6-4**] 06:05PM PLT COUNT-267
[**2119-6-4**] 06:05PM NEUTS-82.0* LYMPHS-9.5* MONOS-7.2 EOS-1.0
BASOS-0.3
[**2119-6-4**] 06:05PM PT-11.9 PTT-26.0 INR(PT)-1.0
.
[**6-7**]: TTE: Conclusions: The left atrium is mildly dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is
moderately dilated. There is a mild coarctation of the distal
aortic arch. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
[**6-9**]: CXR IMPRESSION: No acute cardiopulmonary process.
.
[**6-9**]: RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale, color,
and spectral Doppler analysis were performed. There is no
evidence of thrombus in the right internal jugular vein, right
subclavian vein, right axillary vein, and right brachial vein.
There is thrombus in the mid right cephalic vein extending
distally to the level of the antecubital fossa. More proximally,
the cephalic vein is patent. The basilic vein appears patent.
IMPRESSION: Cephalic vein thrombosis. No right upper extremity
deep venous thrombosis.
.
[**6-12**]: TEE: Conclusions: No atrial septal defect is seen by 2D or
color Doppler. Overall left ventricular systolic function is
normal (LVEF>55%). There are complex (>4mm non mobile) atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. There is no pericardial
effusion. No vegetation or abscess seen.
.
MICRO:
[**6-4**] (first and last set of positive blood cultures - 3 out of 4
bottles)
AEROBIC BOTTLE (Final [**2119-6-13**]):
REPORTED BY PHONE TO [**Doctor Last Name **], VELEZKA [**2119-6-5**], 11:10AM.
STAPH AUREUS COAG +. FINAL SENSITIVITIES. SENSITIVITY
FOR.
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---------- 0.25 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ 0.06 S
ANAEROBIC BOTTLE (Final [**2119-6-7**]):
STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.
Brief Hospital Course:
69 yo m with PMH DM, HTN, carcinoid tumor, hypothyroidism,
hypoparathyroidism on Ca supplements, recent adm for
hypercalcemia presents with fever and found to have cellulitis
at prior IV site.
.
1. Fever/cellulitis: The patient initially presented with what
seemed to be a local cellulitis in the right antecubital fossa,
but given that the patient was also febrile on admission, blood
cultures were obtained which ended up growing out MSSA. The
patient was initially covered with vancomycin and with the
speciation of MSSA, we wanted to desensitize the patient to
nafcillin (being the better antibiotic for MSSA bacteremia).
This was done successfully overnight in the MICU, and the
patient returned to the floor and was maintained on nafcillin
throughout the rest of the admission. Additionally, to evaluate
the patient for possible endocarditis, he received a TTE first
which suggested aortic valve vegetations, but a TEE only showed
evidence of aortic plaques, no vegetations and no evidence of
abscess. An ultrasound of the antecubital fossa showed a
superficial thrombophlebitis.
Infectious Disease consult was involved and recommended a
total of 4 weeks of nafcillin from the date of last positive
blood culture ([**6-4**]). A picc was placed on [**6-14**]. The first and
last set of positive blood cultures were on [**6-4**], and
surveillence cultures have all been no growth to date.
.
2. Mild Transaminitis: the patient had a mild bump in his liver
function tests soon after starting nafcillin. Likely, it was
medication induced and resolved by the time of discharge.
.
3. CRI: the patient had a small bump in his creatinine on
admission, likely secondary to relative volume depletion in
setting of insensible losses with fever.
With initiation of antibiotics and fluid repletion, it has been
within his normal baseline range.
.
4. DM: The patient's metformin was held in the setting of
bacteremia out of concern for acidemia. Glipizide was added
instead and glucose has been under better control. He was also
maintained on a diabetic diet and covered with a regular insulin
sliding scale.
.
5. HTN: continued lisinopril
.
6. Hypoparathyroidism: Calcium, despite PO supplementation ran
low on several days during admission requiring IV repletion.
Calcium levels should be monitored carefully during rehab stay.
.
7. Hypothyroidism: continued levoxyl
.
Medications on Admission:
Lisinopril 2.5 mg qd
Levothyroxine 175 mcg qd
Iron 325 (65) mg qd
Calcitriol 0.25 mcg qd
Titralac (calcium) 1 spoonful po bid
Metformin 500 mg qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
sliding scale Subcutaneous ASDIR (AS DIRECTED).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed.
12. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours) for 3 weeks.
15. Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN
For PASV Picc flush before and after each use Inspect site daily
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
Primary:
Cellulitis
Bacteremia (MSSA)
Status Post Nafcillin Desensitization
.
Secondary
Type 2 Diabetes
Hypoparathyroidism
Hypothyroidism
Rectal Carcinoid Tumor
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted because of a skin infection around the site of
a peripheral IV. The bacteria managed to enter your blood stream
and therefore we needed to rule out bacterial invasion of the
heart, which was ruled out by transesophageal echocardiography.
You will need to remain on intravenous antibiotics for 4 weeks,
however.
.
If you experience fevers, chills, shortness of breath or chest
pain, please seek medical attention.
Followup Instructions:
Please be sure to make all of your follow up appointments:
.
INFECTIOUS DISEASES: Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2119-6-27**] 9:00am
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2119-7-19**] 3:00am
|
[
"041.11",
"362.01",
"V10.87",
"682.3",
"E879.8",
"585.9",
"357.2",
"252.1",
"250.50",
"250.60",
"421.0",
"403.90",
"154.1",
"996.62",
"790.7",
"244.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10800, 10869
|
6802, 9169
|
339, 371
|
11074, 11093
|
3255, 6779
|
11572, 11607
|
2267, 2809
|
9366, 10777
|
10890, 11053
|
9195, 9343
|
11117, 11549
|
1948, 2058
|
2824, 3236
|
231, 301
|
11631, 11953
|
399, 1181
|
1203, 1925
|
2074, 2251
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,568
| 112,038
|
34849
|
Discharge summary
|
report
|
Admission Date: [**2178-7-24**] Discharge Date: [**2178-8-3**]
Date of Birth: [**2100-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Myocardial infarction
Major Surgical or Invasive Procedure:
CABG x3 (LIMA->LAD, SVG->OM/PDA)
History of Present Illness:
Mr. [**Known lastname 79800**] is a 78M smoker with a history of end-stage renal
disease (on hemodialysis), hypertension, hyperlipidemia, and
stroke who presented to [**Hospital3 4107**] on [**2178-7-19**] after
waking up in the middle of the night with SOB. He was found to
have pulmonay edema and a new left bundle branch block, and he
ruled in for myocardial infarction with positive cardiac enzymes
(troponin peak of 30). He received heparin, which was
discontinued after his dialysis A-V fistula began to bleed, but
he was continued on clopidogrel. He [**Year (4 digits) 1834**] a pharmacologic
MIBI which showed an infero-posterior MI and lateral ischemia.
He was transferred to the [**Hospital1 18**] for further evaluation.
At [**Hospital1 18**], he had a cath on [**2178-7-24**] that showed three-vessel
disease and severe left ventricular systolic dysfunction. No
stents were placed, as the patient's anatomy was more amenable
to CABG. Cardiothoracic surgery saw the patient and plan to take
him for CABG on Tuesday. He also received HD before arriving on
the cardiology floor.
.
Past Medical History:
s/p CABG x 3
NSTEMI
CAD
HTN
DM
ESRD (on HD)
CVA
Social History:
Has not smoked cigarettes in 15 years but previously had a >120
pack-year history. No alcohol.
Family History:
No family history of premature CAD.
Physical Exam:
Vitals: T 98.7 BP 156/58 HR 72 RR 20 97RA
General: AO3 NAD
HEENT: PERRL EOMI
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: markedly decreased BS at R lung base, decreased BS
b/l
Cardiac: RRR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: mild edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no echymoses
Labs: See below
Pertinent Results:
[**2178-7-24**] 10:00AM GLUCOSE-135* UREA N-69* CREAT-6.4* SODIUM-133
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-22 ANION GAP-20
[**2178-7-24**] 10:00AM estGFR-Using this
[**2178-7-24**] 10:00AM ALT(SGPT)-17 AST(SGOT)-30 CK(CPK)-74 ALK
PHOS-73 AMYLASE-36 TOT BILI-0.3
[**2178-7-24**] 10:00AM cTropnT-3.88*
[**2178-7-24**] 10:00AM ALBUMIN-3.6
[**2178-7-24**] 10:00AM %HbA1c-5.5
[**2178-7-24**] 10:00AM TYPE-ART PO2-107* PCO2-40 PH-7.36 TOTAL
CO2-24 BASE XS--2
[**2178-7-24**] 10:00AM GLUCOSE-129* NA+-133* K+-4.5
[**2178-7-24**] 10:00AM HGB-10.1* calcHCT-30 O2 SAT-97
[**2178-7-24**] 10:00AM WBC-5.5 RBC-3.17* HGB-9.7* HCT-27.6* MCV-87
MCH-30.5 MCHC-35.1* RDW-15.2
[**2178-7-24**] 10:00AM PT-13.8* PTT-24.3 INR(PT)-1.2*
Cardiac Cath [**2178-7-24**]:
1. Selective coronary angiography of this right dominant system
demonstrated 3 vessel coronary artery disease. The LMCA was
moderately
calcified with a distal 30% lesion. The LAD was moderately
calcified
with a proximal 50% lesion after the take-off of D1. There was
mild
diffuse disease in the mid-LAD. The LCx was moderately
calcified with
an ostial 60-70% lesion. There was a proximal hazy 80% lesion
and a
large OM/LPL. There were multiple collaterals to the distal
RCA. The
RCA had a proximal 50% lesion, a mid 60% lesion and a mid total
occlusion. There was faint filling of the mid-distal RCA.
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with LVEDP of 17mmHg. The right sided filling
pressure was relatively normal, with [**Name (NI) 79801**] of 10mmHg. The
pulmonary
artery pressure was mildly elevated, at 37/14 mmHg. The
systemic
arterial pressure was elevated at 171/46 mmHg. There was no
gradient
between the LVEDP and the PCW. There was no gradient on
pullback from
the left ventricle to the aorta.
3. Left ventriculography showed left ventricular systolic
dysfunction,
with calculated ejection fraction of 40%. There was moderate to
severe
global hypokinesis, worst in the infero-lateral and infero-basal
segments. There was no mitral regurgitation.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe left ventricular systolic dysfunction.
3. Mild left ventricular diastolic dysfunction.
4. Mild pulmonary artery hypertension.
[**2178-8-3**] 01:00PM BLOOD WBC-6.9 RBC-2.91*# Hgb-8.6* Hct-26.3*
MCV-90 MCH-29.6 MCHC-32.7 RDW-15.2 Plt Ct-276
[**2178-8-1**] 08:30AM BLOOD PT-15.1* PTT-30.2 INR(PT)-1.3*
[**2178-8-3**] 05:50AM BLOOD Glucose-120* UreaN-53* Creat-7.8*# Na-134
K-4.7 Cl-97 HCO3-24 AnGap-18
[**Known lastname **],[**Known firstname 79802**] [**Medical Record Number 79803**] M 78 [**2100-7-6**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2178-7-31**] 2:07
PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2178-7-31**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79804**]
Reason: s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with
REASON FOR THIS EXAMINATION:
s/p ct removal
Final Report
REASON FOR EXAMINATION: Followup of a patient after removal of
the chest
tube.
Portable AP chest radiograph was compared to prior study
obtained yesterday on
[**2178-7-30**].
The patient was extubated with removal of the NG tube, Swan-Ganz
catheter, as
well as mediastinal drain and left chest tube. The
cardiomediastinal
silhouette is stable. No appreciable change in bibasilar
opacities consistent
with atelectasis is demonstrated, left more than right, expected
at this
stage. No appreciable pneumothorax is seen. There is no evidence
of failure
or significant increase in pleural effusion.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2178-7-31**] 5:23 PM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 79802**] [**Hospital1 18**] [**Numeric Identifier 79805**]
(Complete) Done [**2178-7-30**] at 8:35:00 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-7-6**]
Age (years): 78 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: intraop management
ICD-9 Codes: 402.90, 440.0
Test Information
Date/Time: [**2178-7-30**] at 08:35 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW3-: Machine: 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.5 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Inferobasal LV
aneurysm. Mild regional LV systolic dysfunction.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic arch diameter. Complex (>4mm) atheroma in
the aortic arch. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened
aortic valve leaflets.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
Mildly thickened mitral valve leaflets. Physiologic MR (within
normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium and right atrium are normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
Left ventricular wall thicknesses are normal. There is an
inferobasal left ventricular aneurysm. There is mild regional
left ventricular systolic dysfunction with the mid and apical
inferior and inferoseptal walls. The remaining left ventricular
segments contract normally.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion.
The aortic valve leaflets are mildly thickened. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits). There is no
pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the
results on [**Known lastname 79800**] at 8AM.
Post_Bypass:
Intact thoracic aorta.
Normal RV systolic function.
LVEF 45%.
Valves similar to prebypass study
POST-BYPASS:
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2178-7-31**] 11:27
?????? [**2172**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2178-7-30**] Mr.[**Known lastname 79800**] [**Last Name (Titles) 1834**] CABG x3 (LIMA->LAD,
SVG->OM/PDA) with Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **]. Please refer to
Dr[**Doctor Last Name 14333**] operative note for further details.
XCT=54min, CPB=61minutes. He was intubated and sedated when
transferred to CVICU. The drips were weaned to off and he was
extubated that night. POD#1 he went into AFib and was started on
Amiodarone, beta-blockers were optimized as BP would tol. Renal
was following due to Mr.[**Known lastname 79806**] ESRD and dependence on
hemodialysis.All lines and tubes were discontinued in a timely
fashion and he was transferred to the SDU for further telemetry
monitoring and recovery. The remainder of his postoperative
course was essentially uneventful. During dialysis on POD#4 he
was transfused one unit of PRBCs for a hematocrit of 21.3.
Follow-up HCT =26, and he Dr.[**First Name (STitle) **] cleared him for discharge.
POD#4 he was doing well and was discharged to home with VNA. All
follow-up appointments were advised.
Medications on Admission:
Hydralazine 50(2)
Labetolol 400(2)
Colace 100(2)
Ferrous 325(1)
Lipitor 80(1)
Plavix 75(1)
Lopid 300(2)
Levoquin 250(1)
Nephrocaps(1)
Neurontin 300(1)
prevacid 30(1)
ASA 325(1)
Tiazac CD 360(1)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 7 days then decrease to 200(2)x 7 days, then decrease
to 200(1).
Disp:*120 Tablet(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**]
Discharge Diagnosis:
s/p CABG x3
Coronary artery disease
endstage renal failure
Diabetes mellitus
hypertension
COPD
GERD
h/o CVA
s/p NSTEMI
Discharge Condition:
good
Discharge Instructions:
take all medications as prescribed
Shower daily, no baths or swimming
No creams, lotions or powders to incisions
No lifting more than 10 pounds for 10 weeks
No driving for 4 weeks and off all narcotics
report any temperature of more than 101
report any drainage or redness of incisions
Followup Instructions:
Dr.[**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**Last Name (STitle) **] in [**11-19**] weeks([**Telephone/Fax (1) 4475**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2178-8-3**]
|
[
"997.1",
"250.00",
"427.31",
"410.71",
"272.0",
"585.6",
"403.91",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.95",
"39.61",
"36.15",
"88.56",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
13401, 13452
|
10814, 11895
|
297, 332
|
13615, 13622
|
2251, 4340
|
13956, 14228
|
1655, 1693
|
12140, 13378
|
5206, 5227
|
13473, 13594
|
11921, 12117
|
4357, 5166
|
13646, 13933
|
9086, 10791
|
1708, 2232
|
236, 259
|
5259, 9037
|
360, 1452
|
1474, 1524
|
1541, 1638
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,604
| 185,562
|
1904
|
Discharge summary
|
report
|
Admission Date: [**2161-7-16**] Discharge Date: [**2161-7-23**]
Date of Birth: [**2089-12-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Epigastric discomfort, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is 71 yo male admitted overnight with 2 day hx of epigastric
discomfort described as bloating, that occurs immediately after
meals. He also reports diarrhea 5-10 minutes after meals with
urgency and several episodes of incontinence. No change in diet.
Diarrhea not related to type or quantity of food consumed.
Denies change in color of stools, denies bright red blood per
rectum or melena. He denies nausea, vomiting although states he
has had a loss of appetite with decreased po intake. Denies
abdominal pain. Reports "brown" urine x 1 day which he
attributes to decreased po intake. He reports 5 lb weight loss
unintentionally in last 4-5 months.
He also reports a cough x several days, non-productive of
sputum. No fevers, chills, night sweats. No shortness of breath.
No hx of TB exposure, might have had a PPD placed 30 years ago
in [**Location (un) 6847**]. No recent travel. No sick contacts. [**Name (NI) **] also
reports some dizziness, worse with standing. No LOC.
He immigrated for [**Country 651**] approximately 18 years ago and has lived
in [**Location (un) 86**] for this time.
Past Medical History:
Hepatitis B - patient denies this. No primary evidence in OMR to
support or refute
Thalassemia - verbally confirmed with patient
Skin condition for which he was using a topical cream
Recent gum infection from his dentures
Social History:
The patient was born in [**Country 651**] and speaks
Chinese, is married and has children. Daugher translated. No
tobacco, alcohol, or illicit drugs. Helps out at a restaurant.
Family History:
Mother lived to 90 and died after a fall. Father died of an
accident. Two brothers both died in their 40s of unclear
reasons, although pt states they drank etoh and smoked tobacco.
[**Name (NI) 1094**] wife thinks the brothers may have had a liver disease. No
known family h/o cancer.
Physical Exam:
vs: T 96.6, BP 140/70, HR 70, RR 18, 98% ra.
gen: Well appearing male. Thin, but not cachectic appearing.
heent: PERRLA, EOMI. Non icteric sclerae, left ptosis. mucous
membranes moist
neck: no cervical LAD, free range of motion
heart: RRR, nl S1S2, no M/R/G
lungs: CTA b/l, no crackles or wheezes. no rhonchi.
abd: slightly distended. grimace to palpation of epigastric
region. No rebound, no guarding. Liver not palpated or percussed
below costal margin.
rectal: guiac negative per ED resident
ext: no edema LE b/l. 2+ pedal pulses b/l
Pertinent Results:
[**2161-7-15**] 05:15PM BLOOD WBC-5.3 RBC-4.00* Hgb-8.7* Hct-27.4*
MCV-68* MCH-21.8* MCHC-31.8 RDW-19.1* Plt Ct-179
[**2161-7-16**] 07:20AM BLOOD WBC-5.5 RBC-3.76* Hgb-8.4* Hct-26.2*
MCV-70* MCH-22.3* MCHC-31.9 RDW-19.5* Plt Ct-138*
[**2161-7-16**] 07:20AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-2+ Schisto-1+ Stipple-3+
Acantho-1+
[**2161-7-16**] 07:20AM BLOOD PT-15.3* PTT-33.0 INR(PT)-1.3*
[**2161-7-15**] 05:15PM BLOOD Glucose-128* UreaN-26* Creat-0.8 Na-135
K-4.3 Cl-103 HCO3-23 AnGap-13
[**2161-7-16**] 07:20AM BLOOD ALT-145* AST-129* LD(LDH)-305* AlkPhos-89
TotBili-1.7* DirBili-0.8* IndBili-0.9
[**2161-7-16**] 07:20AM BLOOD Albumin-3.2* Calcium-7.5* Phos-3.9 Mg-2.0
Iron-76
[**2161-7-16**] 07:20AM BLOOD calTIBC-205* Hapto-35 Ferritn-1104*
TRF-158*
[**2161-7-16**] 07:20AM BLOOD CRP-4.6 AFP-2178*
CT ABD/PELVIS: Triple phase to r/o Portal Vein Thrombosis
1. Large, heterogeneous mass involving the majority of the right
lobe of the liver. Tumor/thrombus with expansion within the
inferior vena cava extending to the right atrium.
2. Portal vein tumor/thrombus with lumen expansion and
occlusion. This constellation of findings is concerning for
large infiltrative hepatocellular carcinoma.
3. Left lower lobe pulmonary embolism, not completely evaluated
on this CT of the abdomen and pelvis.
4. Ascites.
5. Bilateral pleural effusion.
6. Diffuse colitis extending from the cecum to the splenic
flexure.
Differential diagnosis includes infectious, venous congestion
and intramural hemorrhage.
.
CTA Chest ([**7-17**]):
1. Left basal artery pulmonary emboli.
2. Large heterogeneous mass in right lobe of the liver with
associated tumor thrombus in right atrium.
Brief Hospital Course:
HCC: Pt presented with epigastric discomfort, fecal
incontinence, and anemia. To evaluate this a CT of the abdomen
was done on [**7-16**], which incidentally showed an infiltrating
large heterogeneous mass involving the majority of the right
lobe of the liver. There was a filling defect with expansion of
the portal vein and and of the hepatic vein extending to the
inferior vena cava, consistent with tumor thrombus. The
thrombus extends superiorly into the right atrium. This was
presumed to be advanced stage Hepatocellular carcionma with
intravascualar extension, along with Budd-Chiari syndrome due to
occlusion of the portal vein. Pt was also found to have a LLL PE
which was confirmed by a CT chest. Thirdly, pt was found to have
diffuse colitis extending from the cecum to the splenic flexure.
Pt was started on a heparin drip due to the extensive clots,
which had already been c/b PE. Pt subsequently had hematemesis
pt was given 2 units PRBC, and did not become hypotensive.
.
Pt was transfered to the MICU with hematemesis for an EGD since
actively bleeding, did not require pressors. On EGD he was found
to have esophagitis and two non-bleeding varices. The Pt was
briefly intubated to airway protection in the context of
hematemesis. Pt had one subseqeuent epsisode of hematemesis of
100-150 cc in the ICU. Patient had 2 episodes of hematemesis.
HCT 26.2 on admission then 23.4. Patient has been transfused
2uPRBC, and on protonix IV BID and octreotide gtt. Scope showed
Grade 2 non-bleeding gastric varices, esophageal varices likely
cause of bleed Once his hematemesis resolved he was restarted on
heparin for anticoagulation for his portal vein thrombosis and
PE. Pt left the ICU with hcts stable at around 30s. The cause of
the bleeding was attributed to the pt's esophageal varices
.
Pt was transferred to Liver service, and octreotide was stopped.
After discharge from the MICU until discharge pt did not have
any subsequent episodes of hematemesis at all. With pt's CT
findings and AFP 2178, Hepatocellular Carcioma was confirmed
without need of tissue diagnosis. Pt's HBV viral load was
negative (<60), and HBeAg (-), but HBeAb was (+). HCV was also
(-). Pt did however was HBsAg (+) confirming chronic hep B
status as the cause of pt's HCC. Hem/Onc followed for
consideration of treatment options. Since tumor had already
metastisized outside of liver pt's treatment options were
limited. Possible treatment with sorafenib (monoclonal ab as
chemotherapy that would extend survival for possibly weeks), but
at the time it was not safe to be started due to the increased
bleeding risk as an adverse effect of this medicaiton. The plan
was discussed in coordination with the Hem/Onc team. Two options
were presented. The first was to prolong survival as much as
possible - to do so pt would need multiple banding by EGD to
reduce risk of bleeding so that sorafinab could be given. The
family after discussion opted with the second option - to
preseve quality of life. The patient and family understood the
diagnosis and what would be involved. Thus pt's heparin was
discontinued, and heparin and lovenox were rejected as an idea.
Pt's protonix was converted to po, continued on sucrulfate, and
a bowel regimen. Pt also was started on simethcone for bloating.
Pt was also started on morphine for pain. Palliative care was
also consulted and further educated the family about about what
to expect.
LE edema: Pt also developed lower extremity edema and scrotal
swelling. This was thought secondary to the pt's IVC and portal
vein thrombosis along with ESRD. If the edema is primary due to
the thrombosis causing (vs. ESLD) diuretics may not
significantly help. Pt was began on lasix and aldactone. This
was titrated to lasix 40mg [**Hospital1 **] and aldactone to 100mg QD by time
of discharge. There was some improvement of there LE edema on
day of dishcarge and expect this to improve.
PE: Lovenox and warfarin were rejected as they want to avoid
needle sticks as much as possible, and although warfarin is
oral, labs would be needed to be drawn to check levels and his
moniter his diet. Family is aware of the risk of massive PE and
is opting for comfort care measures as discused above.
Colitis: Initially it was unclear if the diffuse colitis was due
to infectious causes. Diffuse colitis extending from the cecum
to the splenic flexure. The differential diagnosis includes
infectious vs. ischemic causing venous congestion and intramural
hemorrhage. Pt was empirically placed on ceftriaxone and flagyl.
Pt's stool cultures were negative. In the end it was concluded
that the colitis was [**1-3**] the portal vein thrombosis causing
venous congestion and intramural hemorrhage. Pt's antibiotics
were discontinued when heparin was discontinued. Pt did not
complain of any melana, hematochezia, or left sided abdominal
pain even on dishcarge.
Medications on Admission:
Unknown. Pt and family did not bring list. He apparently was
taking a topical antibiotic for his dental infection, as well as
one pill for his itchy skin, and topical cream for skin.
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Morphine Concentrate 20 mg/mL Solution Sig: One (1) 2-20mg
PO under tongue q1h prn as needed for pain.
Disp:*150 * Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for bloating.
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
primary diagnosis:
- hepatocellular carcinoma (liver cancer) - with tumor extension
into portal vein, inferior vena cava, and right atrium
secondary diagnosis:
- pulmonary embolus
- peripheral edema
- hematemesis
- ischemic colitis
- thalesemia
- glaucoma
Discharge Condition:
fair - pt is hemodynamically stable, stable vitals, no signs of
bleeding
Discharge Instructions:
You have liver cancer for which we will treat your symptoms to
make you comfortable.
Followup Instructions:
if there are any concerning symptoms call the hospice nurse.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2161-7-23**]
|
[
"452",
"070.32",
"198.89",
"789.59",
"456.20",
"155.0",
"530.19",
"415.19",
"282.49",
"511.9",
"787.6",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"96.71",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10551, 10602
|
4530, 9400
|
344, 350
|
10903, 10978
|
2802, 4507
|
11112, 11326
|
1939, 2229
|
9635, 10528
|
10623, 10623
|
9426, 9612
|
11002, 11089
|
2244, 2783
|
276, 306
|
378, 1480
|
10784, 10882
|
10642, 10763
|
1502, 1725
|
1741, 1923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,639
| 156,989
|
18164
|
Discharge summary
|
report
|
Admission Date: [**2162-10-4**] Discharge Date: [**2162-10-11**]
Date of Birth: [**2102-6-28**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 year old
gentleman with no previous cardiac history who was admitted
to an outside hospital on [**2162-9-30**] with a one week
history of increasing shortness of breath with chest pain.
On [**10-1**], he underwent an exercise tolerance test which
was positive. He ruled out for myocardial infarction by
enzymes. Cardiac catheterization performed on [**10-4**]
revealed a 70% left main occlusion with a 90% left anterior
descending and 70% ostial circumflex, 70% ramus, 50%
posterior descending artery and a left ventricular ejection
fraction of 57%. This is per his cardiologist, Dr. [**Last Name (STitle) 3503**].
He was transferred to the [**Hospital6 2018**] for surgical evaluation.
PAST MEDICAL HISTORY: Significant for a three year history
of asthma. The patient states he has had no wheezes or
coughs but has had intermittent episodes of shortness of
breath. The patient also comes with a history of psychosis,
unclear etiology and unclear symptoms although the patient
says he has been well controlled on his current medications.
Status post eye muscle surgery [**98**] years ago. Status post
nasal fracture from a motor vehicle accident.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] works parttime. He is a nonsmoker with very rare
alcohol intake.
MEDICATIONS: Trilafon 24 mg p.o. q.h.s.; Cogentin 1 mg p.o.
q.h.s., Advair 250/50 b.i.d., Albuterol metered dose inhaler
prn.
Medications from the outside hospital upon transfer also
included Protonix 40 mg p.o. q.d., Aspirin 325 mg p.o. q.d.,
Nitropaste, Lopressor 25 mg t.i.d., Plavix 75 mg q.d., Zocor
40 mg q.d.
ALLERGIES: The patient states no known drug allergies.
PHYSICAL EXAMINATION: Physical examination upon admission
was unremarkable.
LABORATORY DATA: Laboratory values upon admission to the
hospital were also unremarkable. He ruled out for a
myocardial infarction by CPKs and troponins and his
electrocardiogram upon admission showed no acute ischemic
changes.
HOSPITAL COURSE: The patient was subsequent taken to the
Operating Room on [**2162-10-5**], by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
where he underwent coronary artery bypass graft times two
with left internal mammary artery to the left anterior
descending and saphenous vein to the obtuse marginal.
Postoperatively he was transported to the Cardiac Surgery
Recovery Unit in good condition on Nitroglycerin,
Neo-Synephrine and Propofol intravenous drip. The patient
remained on Nitroglycerin drip despite some marginal
hypotension due to small target vessels and some coronary
arteries which were unable to be revascularized fully due to
his anatomy. The patient also required insulin for a short
term in the Intensive Care Unit. On the night of surgery hew
as weaned from mechanical ventilator and extubated
successfully. On postoperative day #1 he remained in the
Cardiac Surgery Recovery Unit on Neo-Synephrine,
Nitroglycerin and insulin drip. On postoperative day #2, the
patient remained hemodynamically stable. He was transitioned
from Nitroglycerin drip to p.o. Imdur and was ultimately
transferred out of the Intensive Care Unit to the Telemetry
Floor. On postoperative day #3, the patient was alert,
intact and ambulating. He did receive one unit of packed red
blood cells for a hematocrit of 23 on postoperative day #3.
He continued to progress with ambulation as well as cardiac
rehabilitation. Cardiac consultation was obtained due to
questionable Q waves in the inferior leads with some vague
shortness of breath symptoms on examination. Dr. [**First Name4 (NamePattern1) 47897**]
[**Last Name (NamePattern1) 911**] was consulted and he felt that there were no acute
issues that needed to be addressed at that time and
recommended follow up as an outpatient. The patient
continued to progress well and remained hemodynamically
stable, continued to increase ambulation and cardiac
rehabilitation, remained in normal sinus rhythm and today,
[**10-11**], postoperative day #6 he is stable to be
transferred home.
Physical examination today is as follows: The patient is
afebrile, he is in the normal sinus rhythm with a rate of
about 90. His blood pressure is 100/60. Room air saturation
is 95 to 97%. Neurologically he is alert and oriented with
no apparent deficits. On pulmonary examination, his lungs
are clear to auscultation bilaterally. His coronary
examination is regular rate and rhythm. His abdomen is
benign. His extremities are without edema. His sternal and
leg incisions are clean and dry with no drainage or erythema.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. b.i.d. times one week
2. Potassium chloride 20 mEq p.o. b.i.d. times one week
3. Colace 100 mg p.o. b.i.d.
4. Enteric coated Aspirin 325 mg p.o. q.d.
5. Plavix 75 mg p.o. q.d., this is for the poor quality of
his targets as well as small coronary arteries.
6. Imdur 60 mg p.o. q.d. as well for his coronary
vasculature.
7. Lopressor 37.5 mg p.o. b.i.d.
8. Zocor 40 mg p.o. q.d.
9. Perphenazine 24 mg p.o. q.h.s.
10. Cogentin 1 mg p.o. q.h.s.
11. Niferex 150 mg p.o. q.d.
12. Vitamin C 500 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft
DISCHARGE CONDITION: Good.
FOLLOW UP: He is to follow up with his primary care
physician in two to three weeks, he is also going to follow
up with Dr. [**First Name4 (NamePattern1) 47897**] [**Last Name (NamePattern1) 911**] in two to three weeks and he is to
follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2162-10-11**] 18:38
T: [**2162-10-11**] 18:45
JOB#: [**Job Number 50225**]
|
[
"298.9",
"424.0",
"747.0",
"414.01",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"88.72",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5465, 5472
|
4820, 5354
|
5376, 5443
|
2228, 4797
|
5484, 6046
|
1924, 2210
|
185, 910
|
933, 1375
|
1392, 1901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,195
| 153,711
|
19241
|
Discharge summary
|
report
|
Admission Date: [**2146-4-23**] Discharge Date: [**2146-4-26**]
Date of Birth: [**2095-12-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Endoscopy and colonoscopy
central line placement
History of Present Illness:
50M PMH HCV cirrhosis s/p TIPS [**1-31**], TIPS revision by IR in [**6-1**]
at OSH and again [**1-1**] at [**Hospital1 18**]. Recent admission for
hematemesis with TIPS revision again [**4-17**] and discharge [**4-23**]. He
represented the day of discharge with four episodes of BRBPR and
was admitted to the MICU for further management.
.
MICU course: EGD performed [**4-24**] showed non-bleeding gastric
varices in the cardia and fundus of the stomach. Transfused 2
units PRBC. Patient was prepped for colonoscopy but this was
deferred for transfer to the floor. Patient started on
octreotide gtt; switched to SC prior to transfer. Diuretics and
nadolol have been held. No episodes of melena or BRPPR during
admission.
.
On arrival to the floor, the patient is without complaints. He
denies fevers, chills, abdominal pain, nausea, vomiting, melena,
BRBPR. His most recent bowel movement was immediately prior to
transfer
Past Medical History:
- HepC w/ cirrhosis - complicated by variceal bleeds s/p
banding.
- TIPS placement [**1-31**] with redo [**6-1**], another balloon dilation
[**1-1**]
- hepatic encephalopathy
- carpel tunnel syndrome
- h/o recurrent cellulitis
- obesity
- mild COPD by PFTs
- diverticulosis
- chronic low back pain [**2-26**] disk protrusion
- depression
- h/o substance abuse
Social History:
Lives with his sister. Previously used to work in bakery but
quit in [**Month (only) **] as was too tired to work (was lifting 50lb
bags of flour, etc). Smokes [**1-26**] ppd of cigarettes, no EtOH,
prior heroin use but reports being sober since [**1-31**].
Attempting to quit tobacco and feels like this hospitalization
may prompt change.
Family History:
No history of liver problems. Otherwise noncontributory.
Physical Exam:
VS: T 98.3 BP 108/60 HR 85 RR 20 98% RA
Gen: Obese, NAD
Skin: Jaundiced
HEENT: Sclera icteric, EOMI, PERRL, MM dry, no LAD
Neck: Supple, no JVD
Heart: RRR, II/VI SEM, nl S1 S2
Lungs: CTAB
Abd: Soft, obese, NT/ND, NABS, + fluid wave
Extr: 2+ pitting edema b/l, small excoriated lesions on R
forearm
Neuro: AAOx3, no asterixis
Pertinent Results:
DOPPLER EXAMINATION: Color Doppler and pulse wave Doppler images
were obtained. Flow within the main portal vein is hepatopetal
and the velocity is 63 cm/sec. The TIPS is patent with
wall-to-wall flow and velocities of 154, 136, and 180 cm/sec in
the proximal, mid and distal portions respectively. Flow within
the right portal vein was demonstrated to be toward the TIP
shunt. No flow is detected in the left portal vein. Appropriate
flow is seen in the IVC and the hepatic veins.
IMPRESSION: Patent TIPS shunt with wall-to-wall flow and stable
velocities.
Brief Hospital Course:
A/P: 50M PMH HCV cirrhosis s/p [**Hospital 52414**] transferred from OSH with
BRBPR.
.
# GIB: Recent variceal bleed with TIPS revision [**4-17**] with good
flow on US. No source of bleed on EGD; consider diverticulosis,
AVM, hemorrhoids. Hemodynamically stable. Protonix IV changed to
PO at d/c. Continue ciprofloxacin for SBP ppx. Colonoscopy in AM
showed no signs active bleeding, stable for d/c home.
.
# Cirrhosis: HCV cirrhosis. Recent VL [**2146-3-24**] was 755,000 IU/mL;
patient s/p treatment with interferon and ribavirin in [**2139**] and
relapse. Not currently on the [**Year (4 digits) **] list given a positive
tox screen while on the list in [**2142**] and currently attempting to
be re-listed. Sober for last year, attempting to lose weight
given requirement of BMI < 40. Encephalopathy - currently
without encephalopathy. Ascites - TIPS s/p 3 revisions,
currently holding diuretics in setting of GIB but consider
restarting after colonoscopy if stable. Varices - s/p recurrent
variceal bleeding and TIPS with three revisions, currently
holding nadolol but consider restarting after colonoscopy.
.
# Depression: No acute issues.
- Continue outpatient wellbutrin and trazodone at home doses
Medications on Admission:
1. Bupropion 100 mg [**Hospital1 **]
2. Furosemide 20 mg daily
3. Lactulose 30ml tid
4. Spironolactone 100 mg daily
5. Prilosec 40 mg daily
6. Trazodone 50 mg qhs
7. Nadolol 20 mg daily
8. Ciprofloxacin 500 mg Q12H for 2 days
Discharge Medications:
1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Lower GI bleed
Secondary
hepatitis C
cirrhosis
Discharge Condition:
Hemodynamically stable, hematocrit stable.
Discharge Instructions:
You were admitted with blood in your stools. Your endoscopy was
negative. Your colonoscopy showed diverticulosis and hemorrhoids
which are likely the causes of your bleeding. Your blood counts
were stable and you had an [**Hospital1 950**] which showed that your
TIPS was working properly.
Please take all medications as directed.
Please follow-up with all outpatient appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-6-22**]
10:30
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-6-22**] 1:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-6-22**]
2:00
|
[
"070.54",
"455.5",
"562.12",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5235, 5241
|
3087, 4295
|
321, 372
|
5341, 5386
|
2503, 3064
|
5818, 6187
|
2083, 2142
|
4572, 5212
|
5262, 5320
|
4321, 4549
|
5410, 5795
|
2157, 2484
|
276, 283
|
400, 1325
|
1347, 1709
|
1725, 2067
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,108
| 158,993
|
42203
|
Discharge summary
|
report
|
Admission Date: [**2132-1-15**] Discharge Date: [**2132-1-23**]
Date of Birth: [**2052-11-1**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Sulfa (Sulfonamide Antibiotics) / Lipitor
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Symptomatic Hiatal Hernia
Major Surgical or Invasive Procedure:
[**2132-1-15**] Laproscopic hiatal hernia repair
Pacemaker placement
History of Present Illness:
Ms. [**Known lastname **] is a 78 yo F who was referred to [**Hospital1 1388**] Thoracic
Surgery clinic for a large hiatal hernia that was seen on
imaging during workup for a pancreatic cyst (concerning for
malignancy given positive uptake on PET/CT and elevated
CA19-9). CT scan performed on [**2131-8-9**] also demonstrated
bilateraly hilar and mediastinal lymphadenopathy that is most
likely related to sarcoidosis.
.
She underwent cervical mediastinoscopy on [**2131-10-26**] with
sampling of level 4 lymph nodes which were negative for
malignancy on pathology and instead demonstrated granulomatous
lymphadenitis.
.
In regards to her gastroesophageal symptoms: Ms. [**Known lastname **] has had
complaint of dysphagia with solid foods, early satiety, and
overall poor PO intake - resulting in an approx 35 pound weight
loss over the past 4-5 months which seems most likely
attributable to her hernia. She was therefore consented for an
elective repair of her symptomatic hiatal hernia.
.
Of note, the patient underwent a coronary angiogram and
placement of a bare metal stent prior to surgery and was
maintained on Aspirin. The patient was also on Coumadin for
atrial fibrillation, but this was held 6 days before her
operation.
Past Medical History:
Past medical history:
1. symptomatic gallstones
2. atrial fibrillation, on Coumadin
3. osteoarthritis
4. hiatal hernia
5. head of pancreas cyst
6. coronary artery disease status-post cardiac stent placement
[**12-9**]
.
Past Surgical History
1. appendectomy as a child [**2059**]'s
2. Open cholecystectomy [**2089**]'s
3. exploratory laparotomy for endometriosis [**2079**]'s
4. carpal tunnel repair ([**7-/2131**])
5. recent cardiac stent placement ([**12-9**]) on Aspirin/Plavix
Social History:
The patient is a non-smoker and denies any other toxic habits.
She lives with her son
Family History:
Father: [**Name (NI) **] cancer
Siblings: 2 sisters with breast cancer
Offspring: Son status-post kidney transplant
Physical Exam:
Admission Physical Exam:
GENERAL: No acute distress; alert and fully oriented; pleasant
HEENT: Mucous membranes moist and pink; no scleral icterus; no
ocular or nasal discharge; no skin lesions
CARDIAC: Regular rate and irregular rhythm; normal S1 and S2; no
appreciable murmurs
PULMONARY: Good breath sounds bilaterally; slight diminishing of
the breath sounds at the lung bases bilaterally
ABDOMEN: Soft, non-tender, non-distended; no palpable masses;
laproscopic/port incisions sealed with dermabond; clean, dry,
and intact; no erythema or induration, no drainage
EXTREMITIES: No swelling or edema in the lower extremities
bilaterally
.
Discharge Physical Exam:
VS: 98.2 114-121/64-78 53-87 20 95%RA
GENERAL: WDWN woman in NAD. Laying comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple without JVD.
CARDIAC: Pacemaker in right upper chest covered in dressing;
CDI, mild erythema; Normal S1, loud S2. [**2-4**] diastolic murmur. No
thrills, lifts. No S3 or S4.
LUNGS: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Right arm in sling. No c/c/e. No femoral bruits.
Pertinent Results:
Radiology:
Pre-operative Chest X-ray [**2132-1-15**]:
IMPRESSION:
1. Possible persistent hiatal hernia or postoperative loculated
air in the
paramedian lowerr chest.
2. Large amount of subcutaneous air.
3. Small postoperative pneumomediastinum.
4. No definite pneumothorax
.
Upper GI/Swallow Study [**2132-1-17**]:
IMPRESSION:
1. Mild transient holdup of contrast in distal esophagus
proximal to a narrow GE junction, compatible with esophageal
dysmotility and postoperative edema of the GEJ.
2. No contrast leak.
3. No residual paraesophageal hernia is seen.
.
CXR [**2132-1-23**]: Left transvenous pacemaker leads terminate in a
standard position in the right atrium and right ventricle. There
is no pneumothorax. Large bilateral pleural effusion greater on
the left side are associated with adjacent atelectasis,
unchanged from prior. There is mild vascular congestion.
Brief Hospital Course:
79 y/o woman with a history of hypertension, CAD s/p BMS in
[**12-9**], A. fib on warfarin and metoprolol admitted for
laparoscopic hiatal hernia repair on [**2132-1-15**]; found to have
tachy-brady syndrome.
.
#HIATAL HERNIA REPAIR: The patient underwent a laparoscopic
hiatal hernia repair on [**2132-1-15**] which was complicated by
intra-op oozing at the port-sites. The patient remained
intubated in the PACU overnight where she was noted to have a
Hct of 15 and INR of 2.2 for which she was transfused 2 units of
PRBC, 2 units of FFP, and 1 unit of platelets. She was then
transferred to the TSICU on the morning of post-op day 1, where
she was further transfused 2 more units of PRBCs for a Hct of
21. She was successfully extubated [**2132-1-16**]. NGT was removed
[**2132-1-16**] and an upper GI/swallow study was performed which did
not demonstrate any esophageal leak or residual hernia. Diet was
advanced to soft solids on post-operative day 3. The patient's
Coumadin was held until post-op day 4 with stabilization of her
hematocrit.
.
# Tachy/Brady syndrome/ RHYTHM: The patient has a history of
atrial fibrillation with intermittent rapid ventricular
response, on warfarin (held for surgery) and metoprolol.
Following hiatal hernia repair, the patient began to develop
pauses, up to 5.68 seconds, accompanied by weakness and
lightheadedness. Metoprolol was discontinued, and patient
continued to have occasional symptomatic pauses alternating with
atrial fibrillation with RVR; indicating underlying tachy-brady
syndrome. The patient was transferred to the cardiology service
on post-op day 4 for evaluation for a pacemaker. Per surgery
recommendations, home coumadin was resumed. The patient
underwent pacemaker placement without complication. She was
then started on infectious prophylaxis and resumed on home
metoprolol. She continued to experience episodes of atrial
fibrillation with RVR to the 120s, accompanied by palpitations.
She was started on amiodarone 200 mg [**Hospital1 **] x 1 week (start date
[**2132-1-23**]), then 200 mg daily, then 100 mg daily. She was
discharged to home. She will receive VNA services for blood
pressure monitoring, and will have an INR check on [**2132-1-25**]. She
will follow up with her cardiologist and in device clinic.
.
# CORONARIES: Patient has hx CAD s/p BMS to mid LAD in [**12-9**].
Clopidogrel course completed. She was continued on aspirin
throughout admission. Metoprolol was held prior to pacemaker
placement for symptomatic pauses, but was resumed after
pacemaker placement.
.
# HYPERTENSION: Chronic. Patient remained normotensive
throughout admission. Prior to discharge, the patient was
resumed on home metoprolol. She will receive VNA services for
blood pressure monitoring.
.
# DM II: Diet controlled. The patient was continued on a
diabetic diet throughout admission.
.
# Code: Full, confirmed with patient
Medications on Admission:
metoprolol 25 mg daily,
tramadol 50 mg p.r.n.
vitamin D 5000 units daily
levothyroxine 100 mcg daily
Coumadin 3 mg QHS. (INR followed by cardiologist)
ASA
*She has just stopped clopidogrel (S/P bare metal stent)
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
3 days.
Disp:*6 Capsule(s)* Refills:*0*
10. Outpatient Lab Work
Please draw INR on [**2132-1-25**].
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Disp:*5 Tablet(s)* Refills:*0*
12. amiodarone 200 mg Tablet Sig: as directed Tablet PO TAPER
(): start [**2132-1-23**]. Take 200 mg PO BID for 1 week, then take 200
mg PO daily for 1 month, then take 100 mg PO daily ongoing. Take
amiodarone with meals .
Disp:*88 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses: Symptomatic Hiatal Hernia; sick sinus
syndrome
Secondary diagnoses: Atrial fibrillation with rapid ventricular
response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
.
You were admitted to the hospital for a hiatal hernia repair.
Your hospitalization was complicated by post-operative bleeding,
and you required multiple blood transfusions. The bleeding
resolved. You began to experience slow heart rate, accompanied
by weakness and lightheadedness. You also experienced
palpitations from atrial fibrillation. You were transferred to
the cardiology service, and had a pacemaker placed without
complication.
.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-8**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
.
Please follow-up with your surgeon, cardiologist, and Primary
Care Provider (PCP) as advised. Follow up in device clinic
regarding your pacemaker as scheduled.
.
MEDICATIONS CHANGED THIS ADMISSION:
START amiodarone - 200 mg twice a day for one week, then 200 mg
once a day for one month, then 100 mg daily. please take this
medication with meals
START keflex - 1 tablet by mouth twice a day for 3 days
START senna 1 tablet by mouth as needed for constipation
START colace 1 tablet by mouth twice a day as needed for
constipation START oxycodone as needed for pain **do not drive
or operate heavy machinery on this medication
.
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.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2132-1-31**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) **],[**Name6 (MD) **] GARTNER MD
Location: [**Hospital3 **]CARDIOLOGY
Address: 27 [**Location (un) **], [**Location (un) **],[**Numeric Identifier 43858**]
Phone: [**Telephone/Fax (1) 56234**]
Appt: [**2-8**] at 4:30pm
.
Name: [**Last Name (LF) 91504**],[**First Name3 (LF) **] M.
Address: [**Location (un) 35619**], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**Telephone/Fax (1) 59029**]
The office is working on a follow up appt for you in the next
week and will call you at home with the appt. IF you dont hear
from them by Thursday afternoon, please call them directly to
book.
.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (3) **] for a follow-up appointment
and chest X-ray in 2 weeks in the [**Hospital Ward Name 23**] Clinical Building, [**Location (un) 8939**].
Please present to clinic 30 minutes prior to your appointment
for your chest X-ray
|
[
"V58.61",
"998.11",
"V45.82",
"403.90",
"783.21",
"272.4",
"427.31",
"553.3",
"250.00",
"723.0",
"458.29",
"244.9",
"289.1",
"585.9",
"E878.8",
"E849.7",
"286.9",
"725",
"285.1",
"577.9",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"53.71",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
8963, 9038
|
4537, 7447
|
339, 410
|
9223, 9223
|
3638, 4514
|
11073, 12240
|
2297, 2415
|
7709, 8940
|
9059, 9126
|
7473, 7686
|
9374, 10740
|
10755, 11050
|
2455, 3070
|
9148, 9202
|
274, 301
|
438, 1674
|
9238, 9350
|
1718, 2178
|
2194, 2281
|
3095, 3619
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,084
| 112,452
|
10740
|
Discharge summary
|
report
|
Admission Date: [**2133-9-22**] Discharge Date: [**2133-9-26**]
Date of Birth: [**2072-6-13**] Sex: F
Service: MEDICINE
Allergies:
Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
DKA, UTI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61F w/ PMH DM, CKD (Cr 1.5-1.8), HTN, with recent
hospitalization for DKA/UTI now presenting to ED from PCP with
persistent dysuria, nausea and chills. She was discharged on
cefuroxime based on prior history of pan-sensitive
proteus/ecoli. During that hospitalization, she was noted to
have elevated blood glucose, increased anion gap, and ketones in
urine reflective of DKA thought to be precipitated by the UTI.
She initially received IV insulin and was transitioned to a SC
regimen.
She was discharged on [**9-18**] and notes that that the nausea and
chills returned the following day despite taking cefuroxime [**Hospital1 **]
as directed. She experiences dysuria and myalgias. No hematuria.
No back pain. No recorded fevers. Poor po intake x3 days.
In the ED, initial VS were 96 91 146/100 20 97% ra. She
received 2L NS, 4mg IV zofran, and ciprofloxacin 400mg IV x1 for
UTI (59 wbc, lg leuks, 300 protein, 1000 glu on UA) . She was
noted to have AG of 17 and glucose in the 300s, so was given 10U
regular insulin and started on insulin ggt at 2u/hr. Lactate
was 2.8. K+ was elevated to 6.3 but hemolyzed, and was 4.5 on
green top. WBC was elevated to 12.6 from 7.7 on last d/c.
Pt admitted to MICU for insulin ggt requirement. Access is 2
PIVs. Of note, ED reports that she appears more
somnelent/lethargic on transfer.
Past Medical History:
1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction
Social History:
The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.
Family History:
Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.5, 188/95, 98, 14, 96% RA
General: obese female lying in bed, somnelent, but [**Last Name (un) **]/oriented
and answering questions
HEENT: dry MM, OP clear, EOM intact, rosy face
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds but regular, no murmurs
Lungs: distant breath sounds, but clear bilaterally
Abdomen: obese, NT/ND, BS+
GU: foley
Ext: warm, well perfused, 1+ pulses, chronic venous stasis
changes and bilateral erythema of the shins with open ulcers,
multiple toe-amputations
Neuro: moving all extremities, A/O x2 (didn't have date right),
but lethargic
DISCHARGE PHYSICAL EXAM
VS: T97.6 BP 156/60 HR 75 RR 18 O2 sat 98% (RA)
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear, poor dentition
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft obese NT ND normoactive bowel sounds, no r/g
EXT warm, well perfused, 1+ distal pulses, chronic venous stasis
changes and bilateral erythema of lower extremities, multiple
toe-amputations
NEURO CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
[**2133-9-22**] 07:00PM BLOOD WBC-12.6*# RBC-5.18 Hgb-16.1*# Hct-48.8*
MCV-94 MCH-31.0 MCHC-32.9 RDW-13.6 Plt Ct-289
[**2133-9-22**] 07:00PM BLOOD Neuts-89.7* Lymphs-6.5* Monos-2.8 Eos-0.3
Baso-0.6
[**2133-9-22**] 07:00PM BLOOD Glucose-354* UreaN-29* Creat-1.3* Na-133
K-5.9* Cl-97 HCO3-19* AnGap-23*
[**2133-9-22**] 07:00PM BLOOD ALT-18 AST-46* AlkPhos-113* TotBili-0.7
[**2133-9-22**] 07:00PM BLOOD Lipase-16
[**2133-9-22**] 07:00PM BLOOD Albumin-4.2 Calcium-9.8 Phos-5.0*# Mg-1.8
[**2133-9-22**] 08:05PM BLOOD Osmolal-313*
[**2133-9-23**] 01:37AM BLOOD Type-[**Last Name (un) **] pO2-93 pCO2-44 pH-7.36
calTCO2-26 Base XS-0 Comment-GREEN TOP
[**2133-9-22**] 07:11PM BLOOD Glucose-347* Na-133 K-9.9* Cl-101
calHCO3-22
[**2133-9-22**] 07:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2133-9-22**] 07:00PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2133-9-22**] 07:00PM URINE RBC-5* WBC-59* Bacteri-FEW Yeast-RARE
Epi-1 TransE-<1
[**2133-9-23**] 06:32PM URINE CastHy-15*
Discharge:
[**2133-9-26**] 08:33AM BLOOD WBC-8.9 RBC-3.88* Hgb-12.0 Hct-36.3
MCV-94 MCH-31.1 MCHC-33.2 RDW-14.0 Plt Ct-259
[**2133-9-26**] 08:33AM BLOOD Glucose-141* UreaN-31* Creat-1.5* Na-143
K-4.1 Cl-106 HCO3-26 AnGap-15
[**2133-9-25**] 07:35AM BLOOD ALT-13 AST-17 AlkPhos-89 TotBili-0.3
[**2133-9-25**] 07:35AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.7
[**2133-9-24**] 08:00AM BLOOD CK-MB-5 cTropnT-0.01
[**2133-9-23**] 04:00PM BLOOD CK-MB-4 cTropnT-0.02*
MICRO:
URINE CULTURE [**9-22**]
URINE CULTURE (Final [**2133-9-23**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
URINE CULTURE (Final [**2133-9-25**]):
YEAST. >100,000 ORGANISMS/ML..
IMAGING:
[**9-23**] FINDINGS: In comparison with the study of [**9-16**], there is
again enlargement of the cardiac silhouette. There is better
penetration of the image, so that there is no evidence of
pulmonary vascular congestion at this time. The lateral view is
limited due to extensive scattered radiation related to the size
of the patient. No acute focal pneumonia.
Brief Hospital Course:
Brief Course:
Ms. [**Known lastname 35127**] is a 61 year old female admitted with diabetic
ketoacidosis (DKA) likely exacerbated by gastroparesis and UTI.
Active Issues:
# DKA: Patient presented with blood sugars in the 300s along
with anion gap metabolic acidosis and ketones in the urine. She
was maintained on an insulin drip and transitioned to
subcutaneous insulin when her anion gap closed. She tolerated
this well and was able to eat. Her precipitant was initially
thought to be due to cellulitis of the left lower leg. Her
outpatient provider reported that her leg looked much more
infected than previously in clinic 1 week prior. We consulted
podiatry about her leg to try to debride the chronic ulcers and
get culture data, but they did not think that the ulcers
warranted debridement. We felt the her leg exam was more
consistent with venous stasis changes than cellulitis. She
endorsed dysuria, however repeated urinalyses and urine cultures
showed contaminated from normal flora and yeast. We treated the
patient with 4 days of 1V ceftriaxone, based on prior culture
date. Her CXR was negative and her EKG was at baseline. She
did have a severe candidiasis of the intertriginous region of
her groin which may have contributed to her DKA. We treated her
with miconazole and a dose of fluconazole. [**Last Name (un) **] was consulted
to help transition to outpatient insulin regimen.
# Nausea and vomiting: Has been chronic for several months and
has prompted several admissions to the hospital for symptomatic
management. Likely also contributes to her DKA. She was
started on metoclopromide empirically and phenergan prn. She
has never had a work-up for gastroparesis but her symptoms would
fit with this and would help explain her difficult to control
blood sugars. She was discharged on metoclopramide and should
follow up with her PCP about continuing this medication. A
gastric emptying study can be considered as an outpatient.
# HTN: Patient hypertensive to the 170s-180s even after
restarting her home losartan and hydrochlorothiazide. Thus, she
was started on labetalol 200 mg [**Hospital1 **]. She will follow up with her
PCP about further HTN management.
# Lower extremity ulcers: Chronic appearing, likely secondary
to peripheral vascular disease and diabetes. Has element of
chronic venous stasis which can be confused with cellulitis but
she did not have evidence on exam of real cellulitis.
# Flattened affect: Had a recent head CT which was negative,
her neurologic exam was non-focal. She is slow to answer
questions and has a flattened affect which is likely her
baseline. Her nortriptyline was held initially but restarted on
discharge.
# Yeast infection: Likely in setting of poor glycemic control.
Was given miconazole powder and treated with 1 dose of
fluconazole.
# Chronic kidney disease: Stable. On admission Cr 1.3, within
recent baseline. Medications were renally dosed.
Transitional Issues:
1. Codes Status: DNR/DNO
2. Communication: patient
3. Medication Changes:
-CHANGE your Humalog sliding scale according to the attached
sheet
-START Labetolol for your high blood pressure
-START Metoclopramide for your gastroparesis. But please follow
up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**] to see if you should continue this
medicine long term.
4. Pending studies: fungal urine culture
5. Follow up: PCP, [**Name10 (NameIs) **], Podiatry
Medications on Admission:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Nortriptyline 150 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 50,000 UNIT PO MONTHLY
7. cefUROXime 500 mg [**Hospital1 **]
8. Detemir 70 Units Bedtime
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Rosuvastatin Calcium 20 mg PO DAILY
4. Nortriptyline 150 mg PO HS
5. Pantoprazole 40 mg PO Q24H
6. Vitamin D 50,000 UNIT PO MONTHLY
7. Detemir 70 Units Bedtime
8. Labetalol 200 mg PO BID
hold for systolic blood pressure < 130
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
9. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary:
DKA
UTI
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. [**Known lastname 35127**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you weren't feeling well and your glucose level was
found to be very high, and you were in DKA. We were able to
control your blood sugar and we made some adjustments to your
insulin regimen. You also were found to have a UTI which may
have been the same infection as your last admission that never
fully resolved. You were treated with antibiotics through your
veins.
Please make the following changes to your medications:
-CHANGE your Humalog sliding scale according to the attached
sheet
-START Labetolol for your high blood pressure
-START Metoclopramide for your gastroparesis. But please follow
up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**] to see if you should continue this
medicine long term.
Please call [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3146**] [**Location (un) 4628**] Services at [**Telephone/Fax (1) 35130**] to
arrange a home health aid that can help with bathing and wound
care.
Followup Instructions:
Please follow up with the following appointment:
Department: PODIATRY
When: MONDAY [**2133-9-28**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) **], [**First Name3 (LF) **]. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appointment Monday [**2133-9-28**] 10:00am
Department: ADULT MEDICINE
When: THURSDAY [**2133-10-1**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**Telephone/Fax (1) 6662**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2133-9-27**]
|
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"403.90",
"362.02",
"V49.72",
"440.23",
"112.1",
"536.3",
"250.52",
"250.62",
"250.72",
"250.12",
"V58.67",
"599.0",
"713.5",
"707.15",
"585.3",
"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10185, 10260
|
5889, 6046
|
323, 329
|
10321, 10411
|
3699, 5866
|
11580, 12633
|
2360, 2513
|
9656, 10162
|
10281, 10300
|
9355, 9633
|
10472, 10991
|
2553, 3680
|
9290, 9329
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8849, 8903
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11020, 11557
|
8923, 9279
|
275, 285
|
6061, 8828
|
357, 1695
|
10426, 10448
|
1717, 2159
|
2175, 2344
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,356
| 155,316
|
51286
|
Discharge summary
|
report
|
Admission Date: [**2151-9-14**] Discharge Date: [**2151-9-19**]
Date of Birth: [**2096-2-29**] Sex: F
Service: [**Hospital1 **] Medicine
HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old female
with history of insulin dependent-diabetes mellitus with
history of diabetic ketoacidosis, hypertension, history of
hemorrhagic CVA, hypercholesterolemia, and asthma admitted
with decreased responsiveness over the past 3-4 days with
decreased p.o. intake and increased thirst. [**Name (NI) **] son
noted that she had not been taking her NPH due to her
lethargy and questioned her compliance with her regular
insulin.
REVIEW OF SYSTEMS: She reports decreased urine output and
some chills. She denies nausea, vomiting, or fevers. She
received 1.3 lites of IV fluids in the Emergency Room in
addition to 10 units of subQ insulin plus 10 units IV push
insulin, and then was started on a 5 unit/hour insulin drip.
She was admitted to the MICU for likely diabetic
ketoacidosis.
PAST MEDICAL HISTORY:
1. Type 2 diabetes on insulin with history of diabetic
ketoacidosis, last admission [**2151-3-30**] with decreased
mental status, question of temporary hemiparesis. CT was
negative. LP was negative. EEG revealed mild
encephalopathy. She is followed by Dr. [**Last Name (STitle) 106400**] of [**Last Name (un) **].
2. Hypertension. Transthoracic echocardiogram on [**8-30**]
showed an ejection fraction of 55%.
3. History of hemorrhagic cerebrovascular accident with
residual right visual defect in [**2147**].
4. Hypercholesterolemia.
5. Asthma.
6. Osteoporosis.
7. Diverticulosis. Colonoscopy on [**2149-7-16**] revealed a
sessile 5 mm polyp, diverticulosis of the transverse and
sigmoid colon. Pathology of the polyp revealed prominent
lymphoid nodule, otherwise negative. Recommendation for
repeat in one year.
8. Granulomatous endometritis, focally necrotizing. It was
diagnosed by pathology on [**1-30**].
MEDICATIONS:
1. Fosamax 10 p.o. q.d.
2. NPH 15 b.i.d.
3. Hydrochlorothiazide 25 mg p.o. q.d.
4. Norvasc 5 mg p.o. q.d.
5. Atenolol 10 mg p.o. q.d.
6. Trandolapril 4 mg p.o. q.d.
7. Flovent.
8. Albuterol.
9. Regular sliding scale insulin.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: An aunt with diabetes. Mother with "heart
condition". No family history of cancer.
SOCIAL HISTORY: No tobacco, remote alcohol use.
PHYSICAL EXAMINATION ON TRANSFER TO THE FLOOR: Temperature
98.4, blood pressure 140/76, heart rate 70, respiratory rate
15, and oxygen saturation 100% on room air. In general, she
is a pleasant, elderly appearing female. She speaks slowly,
but is alert and oriented x3. HEENT: Pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. Right inferior quadrant anopia. Neck:
No lymphadenopathy or thyromegaly. Cardiovascular: No
carotid bruits, regular, rate, and rhythm, no murmurs, rubs,
or gallops. Pulmonary: Decreased lung sounds at the right
base, otherwise clear to auscultation bilaterally. Abdomen:
Normoactive bowel sounds, soft, nontender, nondistended.
Extremities: Right lower extremity scaling, no clubbing,
cyanosis, or edema. Left peripheral IV. Neurologic:
Cranial nerves II through XII are grossly intact except for a
left facial droop noticed due to her decreased palpebral
fissure, tongue deviates to the right, 3+/5 strength in the
lower extremities, 4/5 strength in the upper extremities
bilaterally, no tremor and negative Romberg.
LABORATORIES AND DIAGNOSTICS: Admission white blood cell
count 9.1, hematocrit 35.2, platelets 228. Chem-7: Sodium
134, potassium 4.2, chloride 98, bicarb 6, BUN 22, creatinine
1.9, glucose of 479, anion gap of 30 down to 9 with insulin
and IV fluids. Calcium was 11.4 down to 8.2 with IV fluids.
Serial cardiac enzymes include troponin-T 0.02 x2, CK of 45,
49, 82. TSH of 0.99. Urinalysis: Specific gravity 1.020,
negative nitrite and leukocyte esterase, positive protein and
ketones, 0-2 white blood cells.
CT of the abdomen and pelvis on [**2151-9-16**], no retroperitoneal
hematoma. A tiny nonspiculated nodule at the left lung base,
small bilateral pleural effusions right greater than left.
Liver diffusely hyperdense, diffuse calcium throughout
pancreas consistent with chronic pancreatitis, small calcium
calcifications in kidneys, multiple uterine fibroids, no bone
lesions.
Blood culture from [**9-14**]: [**1-2**] gram-positive cocci in pairs
and clusters from the triple lumen catheter. [**2-2**] peripheral
blood cultures with gram-positive cocci in pairs and
clusters.
MRI of the brain [**2151-9-15**]: No acute infarcts, no midline
shift, no hemorrhage, old left hemi and left external
capsular infarct unchanged, possible small vessel ischemic
changes in the palms, chronic periventricular white matter,
microvascular ischemic changes.
MRA of the circle of [**Location (un) 431**]: Mild stenosis of the left M1
segment of the MCA.
Chest x-ray: Low lung volumes. Heart within normal limits,
no effusion or infiltrate.
EKG: Normal sinus rhythm at 96 beats per minute, left axis
deviation, no ST-T wave changes.
HOSPITAL COURSE: This is a 55-year-old female with history
of insulin dependent diabetes and history of diabetic
ketoacidosis, hypertension, and hemorrhagic CVA in [**2147**]
admitted with altered mental status with slurred speech with
negative head MRI for stroke instead thought to be due to
diabetic ketoacidosis. She was initially admitted to the
MICU for insulin drip until her gap closed. Her mental
status improved with a correction of her metabolic
disturbances and she was transferred to the floor for further
management prior to discharge.
1. Diabetic ketoacidosis: Patient admitted to the ICU for
insulin drip. Her gap subsequently closed from 30 to 9 with
insulin drip in addition to aggressive IV hydration with
normal saline. Further workup was done for precipitation of
this event including infectious workup described below. She
was continued on her regular insulin-sliding scale insulin
and her home NPH.
2. Mental status changes: Urinalysis and urine culture were
negative. CT of the head was negative for bleed and a MRI
was done to rule out new stroke. Patient's altered mental
status was thought to be due to multiple metabolic
disturbances upon correction of her diabetic ketoacidosis.
Her mental status improved to what her son felt was baseline.
Chest x-ray was also done and was negative for infiltrate.
3. Normocytic anemia: Patient with longstanding history of
anemia of chronic disease. Colonoscopy in [**2149-6-29**]
revealed one nonmalignant polyp. Recommendation for followup
colonoscopy in one year. Patient's hematocrit was followed
q.d. and she was transfused for a hematocrit less than 25.
She received 1 unit overnight following transfer to the
floor.
4. Gram-positive bacteremia: The patient found to have 1/4
bottles from triple lumen catheter growing micrococcus in [**2-2**]
bottles from the peripheral IV growing coag-negative Staph.
Patient exhibited no elevated white blood cell count and
remained afebrile. These were found to be contaminants. All
lines were either pulled or replaced, and a transthoracic
echocardiogram was done to rule out bacterial endocarditis.
No obvious vegetation was noted.
DISCHARGE STATUS: The patient is discharged home with
services.
DISCHARGE CONDITION: Good. Patient remained afebrile,
taking adequate p.o.
DISCHARGE DIAGNOSIS: Diabetic ketoacidosis.
DISCHARGE MEDICATIONS:
1. Fosamax 10 mg p.o. q.d.
2. Hydrochlorothiazide 25 mg p.o. q.d.
3. Amlodipine 5 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d.
5. Trandolapril 4 mg p.o. q.d.
6. Flovent two puffs b.i.d.
7. Albuterol 1-2 puffs q.6h. prn shortness of breath or
wheezing.
8. Insulin NPH 18 units q.a.m., 10 units q.p.m.
FOLLOWUP: Patient is to followup with Dr. [**Last Name (STitle) **] in one
week at which time she should have her potassium and
electrolytes rechecked.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 5614**]
Dictated By:[**Name8 (MD) 16191**]
MEDQUIST36
D: [**2151-12-5**] 18:26
T: [**2151-12-7**] 10:02
JOB#: [**Job Number 106401**]
|
[
"403.91",
"584.9",
"438.89",
"275.42",
"285.29",
"250.42",
"298.9",
"250.32",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7378, 7434
|
2230, 2316
|
7503, 8215
|
7456, 7480
|
5143, 7356
|
654, 993
|
183, 634
|
1015, 2213
|
2333, 5125
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,095
| 119,380
|
44312
|
Discharge summary
|
report
|
Admission Date: [**2175-3-24**] Discharge Date: [**2175-4-2**]
Date of Birth: [**2123-6-19**] Sex: F
Service: SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
woman who had a past medical history significant for
diabetes, panhypopituitarism secondary to pituitary adenoma
and [**Location (un) 3484**] disease with multiple abdominal wall hernias.
She arrived to the emergency room with abdominal tenderness
and there were complaints of constipation.
PAST MEDICAL HISTORY: As noted above, the past medical
history was significant for panhypopituitarism, insulin
dependent diabetes [**Location (un) **] and [**Location (un) 3484**] disease.
PAST SURGICAL HISTORY: The patient had a hernia repair.
ALLERGIES: The patient was allergic to penicillin.
MEDICATIONS ON ADMISSION:
Keflex, even with the penicillin allergy.
Vicodin for right arm burning.
NPH insulin 30 units q.a.m. and 46 units h.s.
Prednisone 3 mg p.o. q.d.
Levoxyl 0.2 mg p.o. q.d.
Provera 2.5 mg p.o. q.d.
PHYSICAL EXAMINATION: The patient was afebrile with a
temperature of 98.9??????F and had a heart rate of 74, a
respiratory rate of 14 and a blood pressure of 114/61. The
heart was a regular rate and rhythm. The lungs were clear to
auscultation. The abdomen was obese with multiple abdominal
wall hernias apparent and an incarcerated and tender
abdominal wall hernia which was unable to be reduced. She
had no peritoneal signs, but was locally tender. The rectal
examination revealed normal tone and was heme negative.
HOSPITAL COURSE: The patient was admitted for urgent
operation to reduce the incarcerated ventral hernia. She
tolerated the procedure well without any complications.
However, in the postoperative recovery room, the patient was
noted to have respiratory difficulty when she was extubated.
Thus, she was reintubated and transferred to the Surgical
Intensive Care Unit.
The patient's stay in the Intensive Care Unit was primarily
for respiratory issues. The chest x-rays were noted to have
evidence of aspiration with questionable pneumonia. The
patient remained intubated for airway protection. She was
also maintained on intravenous steroids. On postoperative
day #3, her ventilator began to wean to a CPAP mode. As for
her pulmonary sputum cultures, they were noted to be a
mixture of mostly oropharyngeal flora without any overgrowth
of one organism.
On postoperative day #4, the patient was extubated. Her
glucose remained well controlled on sliding scale regular
insulin. On postoperative day #5, the patient was breathing
comfortably on just nasal cannula support. She remained
afebrile with stable vital signs. Her glucose was well
controlled with sliding scale regular insulin. Her wound was
clean, dry and intact with moderate amounts of [**Location (un) 1661**]-[**Location (un) 1662**]
drain output. However, she was considered to be stable for
transfer to the floor.
On the floor, aggressive chest physiotherapy and incentive
spirometry were emphasized. The patient's nasogastric tube
was discontinued, as the patient had begun to show signs of
gastrointestinal peristalsis. She was passing flatus and
moving her bowels. Her Foley catheter was also discontinued.
She was slowly started on sips, which she tolerated well, and
her diet was advanced to clears and eventually a full diet,
which she tolerated well.
Once the patient was taking p.o., her Synthroid was changed
from intravenous back to a p.o. dose. Her hydrocortisone was
continuously tapered to her home dose of prednisone 3 mg p.o.
q.d. Her oxygen nasal cannula was also continuously weaned
until, by postoperative day #8, she was on room air and
breathing comfortably. The patient was also noted to be
ambulating well. Thus, on postoperative day #9, the patient
was considered stable to be discharged home.
DISCHARGE INSTRUCTIONS: The patient will follow up with Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **]. She will also receive [**Hospital6 3429**] services to monitor her [**Location (un) 1661**]-[**Location (un) 1662**] drain
output, as she would be going home with all three of them.
DISCHARGE MEDICATIONS:
Prednisone 3 mg p.o. q.d.
Levoxyl 0.2 mg p.o. q.d.
Albuterol inhaler two puffs q.i.d.
Insulin per her home regimen, to be followed by her
endocrinologist.
Keflex 500 mg p.o. q.i.d. times seven days for as long as the
[**Location (un) 1661**]-[**Location (un) 1662**] drains are in place.
Diflucan 150 mg p.o. times two after finishing her Keflex.
Silvadene cream to her right wrist, where she had suffered a
burn previously.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2175-4-2**] 09:59
T: [**2175-4-2**] 11:38
JOB#: [**Job Number 95022**]
|
[
"250.01",
"518.0",
"486",
"997.3",
"552.21",
"253.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"53.61"
] |
icd9pcs
|
[
[
[]
]
] |
4173, 4599
|
817, 1013
|
1556, 3843
|
3868, 4150
|
704, 791
|
1036, 1538
|
168, 489
|
512, 680
|
4624, 4891
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,545
| 168,785
|
8391
|
Discharge summary
|
report
|
Admission Date: [**2182-10-17**] Discharge Date: [**2182-10-23**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 656**] is a 88yo Russian-speaking man with history of
hypertension, afib, pacemaker, and diabetes presenting with
nausea, vomiting, and elevated blood pressure. Patient states he
felt fine when he went to bed the night PTA and then he woke up
at 4 AM [**10-17**] feeling nauseated and vomited several times. His
wife took his blood pressure and it was reported as 240/140 (in
the setting of vomiting). Patient did not eat all day but was
able to take his medications. Patient states he has been
compliant with his blood pressure medication and has not had any
new adjustments in his medications. He denies headache, chest
pain, shortness of breath, cough, palpitations, or abdominal
pain. He has never had a blood pressure this high before.
.
In the ED, VS 97.6 62 197/75 16 96%. EKG showed paced @64 with
a prolonged QTc. CXR showed mild pulm [**Month/Year (2) 1106**] congestion, no
focal consolidation. Cr 1.4 was at baseline. Reglan given.
Admited for symptom control and rule out
.
Upon transfer to the floor, SBP > 200 and patient complained of
chest pressure/discomfort and so trigger was called. EKG showed
no changes, and CE were negatve x2. Hydralazine 25mg pushed and
new BP was SBP 140s. Patient was asymptomatic s/p hydralazine.
Family by bedside. Interpreter present.
Past Medical History:
paroxsymal atrial fibrillation on coumadin
tachy-brady syndrome s/p pacemaker placement (DDI)
hypertension
hyperlipidemia
diabetes mellitus type II c/b neuropathy
coronary artery disease, status post CABG in [**2169**]
- CABG: LIMA to LAD, SVG to OM2, SVG to RPDA, SVG to RPL
peripheral [**Year (4 digits) 1106**] disease, status post left popliteal to
peroneal bypass surgery 9/05
L first toe amputation [**10-2**]
chronic renal insufficiency (baseline Cr 1.0-1.2)
cataracts
glaucoma
CHF- EF 40-45% in [**8-2**]
- status post combined phacoemulsification, PCIOL placement,
and pars plana vitrectomy with membrane peel in the left eye in
[**2177-5-29**] and status post a revision vitrectomy with endoscopic
retinal photocoagulation in the left eye in [**2178-6-28**] for
recurrent diabetic vitreous hemorrhage
- stable quiescent proliferative diabetic retinopathy
Social History:
Lives with wife at home. No EtOH, no smoking, no illicits
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp afebrile, 203/98 BP , 63 HR , 20 R , 98 O2-sat % RA
GENERAL - tired appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
CHEST - Lsided pacemaker; sternotomy scar
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-2**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
DISCHARGE PHYSICAL EXAM:
VS - Temp afebrile, SBPs 160s, HR 60s
GENERAL - Well appearing, well nourished male in NAD,
comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
CHEST - Lsided pacemaker; sternotomy scar
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, S1-S2 clear and of good
quality
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-2**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
ADMISSION LABS:
[**2182-10-17**] 10:00AM BLOOD WBC-10.3 RBC-4.87 Hgb-15.1 Hct-45.3
MCV-93 MCH-31.0 MCHC-33.3 RDW-13.1 Plt Ct-133*
[**2182-10-17**] 10:00AM BLOOD Neuts-86.3* Lymphs-9.0* Monos-3.4 Eos-1.1
Baso-0.1
[**2182-10-17**] 10:00AM BLOOD Glucose-218* UreaN-30* Creat-1.4* Na-142
K-4.1 Cl-106 HCO3-25 AnGap-15
[**2182-10-18**] 06:50AM BLOOD Glucose-387* UreaN-42* Creat-1.9* Na-139
K-4.8 Cl-101 HCO3-15* AnGap-28*
[**2182-10-18**] 04:13PM BLOOD Glucose-298* UreaN-47* Creat-1.8* Na-140
K-4.3 Cl-107 HCO3-20* AnGap-17
[**2182-10-17**] 10:00AM BLOOD ALT-20 AST-22 AlkPhos-102 TotBili-0.4
[**2182-10-17**] 10:00AM BLOOD cTropnT-<0.01
[**2182-10-17**] 05:42PM BLOOD CK-MB-4 cTropnT-<0.01
[**2182-10-18**] 06:50AM BLOOD CK-MB-14* MB Indx-7.3* cTropnT-0.27*
[**2182-10-18**] 12:27PM BLOOD CK-MB-18* MB Indx-7.2* cTropnT-0.40*
[**2182-10-18**] 04:13PM BLOOD CK-MB-23* MB Indx-8.0* cTropnT-0.78*
[**2182-10-19**] 04:42AM BLOOD CK-MB-19* MB Indx-6.7* cTropnT-1.04*
[**2182-10-19**] 11:07AM BLOOD CK-MB-15* MB Indx-4.1 cTropnT-1.00*
[**2182-10-17**] 05:42PM BLOOD CK(CPK)-98
[**2182-10-18**] 12:27PM BLOOD CK(CPK)-249
[**2182-10-19**] 04:42AM BLOOD CK(CPK)-283
[**2182-10-19**] 11:07AM BLOOD CK(CPK)-370*
[**2182-10-18**] 06:50AM BLOOD Calcium-8.2* Phos-5.4*# Mg-1.8
[**2182-10-18**] 10:13AM BLOOD Type-ART pO2-65* pCO2-31* pH-7.32*
calTCO2-17* Base XS--8
[**2182-10-18**] 12:37PM BLOOD Type-[**Last Name (un) **] pO2-124* pCO2-35 pH-7.30*
calTCO2-18* Base XS--7 Comment-GREEN TOP
.
DISCHARGE LABS:
***
.
MICROBIOLOGY:
-[**10-18**] Urine Cx:
.
-[**10-18**] Blood Cx:
.
-[**10-18**] MRSA screen:
.
IMAGING:
.
#[**2182-10-18**] CXR:
FINDINGS: In comparison with the study of [**10-17**], the patient has
taken a
substantially better inspiration. There is continued enlargement
of the
cardiac silhouette with diffuse pulmonary [**Date Range 1106**] congestion.
Dual-channel pacemaker device remains in place. No evidence of
acute focal pneumonia
.
#[**2182-10-17**] SUPINE AND LEFT LATERAL DECUBITUS VIEWS OF THE
ABDOMEN: A non-obstructive bowel gas pattern is demonstrated. No
free intraperitoneal air or dilated loops of small bowel are
seen. There is no pneumatosis. Small-to-moderate amount of fecal
material is seen throughout the colon. There are diffuse
[**Month/Day/Year 1106**] calcifications with phleboliths noted in the pelvis.
Multilevel degenerative changes are visualized within the imaged
thoracolumbar spine. Several clips are noted within the
epigastric region.
IMPRESSION: Non-obstructive bowel gas pattern without evidence
for free
intraperitoneal air.
.
#[**2182-10-17**] UPRIGHT AP VIEW OF THE CHEST: Patient is status post
median sternotomy and CABG. A left-sided pacemaker device is
noted with leads terminating in the right atrium and right
ventricle, unchanged. There are low lung volumes. This
accentuates the size of the cardiac silhouette which is likely
mild. The mediastinal contours are unremarkable. There is mild
pulmonary [**Month/Day/Year 1106**] congestion. No pleural effusion or
pneumothorax is present. No focal consolidation is visualized.
There are no acute osseous abnormalities.
IMPRESSION: Pulmonary [**Month/Day/Year 1106**] congestion and low lung volumes.
.
#[**2182-10-18**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed with probable inferior hypokinesis
(LVEF= 45-50%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The tricuspid valve leaflets are
mildly thickened. There is an anterior space which most likely
represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2179-12-28**],
left ventricular function is probably similar but views are
suboptimal for comparison.
Renal US: Normal waveforms of the renal arteries bilaterally
without
evidence of renal artery stenosis.
Normal-appearing kidneys except for a nonobstructive right renal
calculus.
Stable-appearing right adrenal adenoma.
Brief Hospital Course:
Mr. [**Known lastname 656**] is a 88yo Russian-speaking man with a h/o CAD s/p
quadruple bypass in [**2169**], IDDM, CRI, HTN, Afib A-paced,
initially admitted for hypertensive urgency with the subsequent
development of DKA, now with elevated troponin levels and
minimal EKG changes from baseline without any chest pain. This
is concerning for a myocardial infarction most likely NSTEMI due
to increased demand in setting of acute stress.
.
Upon initial arrival to the medicine floor, pt's SBP > 200 and
patient complained of chest pressure/discomfort and so trigger
was called. EKG showed no changes, and CE pnd. hydralazine 25mg
pushed and new BP was SBP 140s. Patient was asymptomatic s/p
hydralazine. Family by bedside. Interpreter present.
.
In the AM before transfer to the MICU, the patient was found to
have increased cardiac enzymes. Patient was asymptomatic and
EKG showed no acute changes. NSTEMI was treated w/ high dose
ASA, high dose atorvatatin, heparin drip, and O2. Pt had
already gotten metoprolol that AM. Patient was also found to be
in DKA w/ ketones in urine, blood glucose above 400, and anion
gap of 23. He had an increase in lactic acidosis to in the 2 -
3 range. ABG showed metabolic acidosis c/w DKA. Patient was
started on q1hr finger sticks with prn IV insulin, but with
little effect as gap only closed to 20 and so it was determined
that transfer to MICU for insulin drip management was prudent.
CXR showed increased pulmonary congetion but no source of
infection. Cardiology consulted and agreed with NSTEMI and
asked for Stat TTE which showed no gross abnormalities.
.
While in MICU, pt was observed and treated for DKA with insulin
gtt. When anion gap closed, patient was converted to
subcutaneous insulin. FS were controlled and patient's diet was
advanced. Cardiac enzymes were trended and peaked. Pt was then
transferred to Cardiology for further management of NSTEMI.
.
ACTIVE ISSUES:
.
# Elevated troponins: Likely type 2 MI (demand ischemia) vs
NSTEMI. Cardiology consult suspected that the likely course of
events was hypertensive urgency -> demand ischemia -> DKA. Given
that cardiac biomarkers still trending upward (Tn peaked 1.04,
CK-MB peaked at 23), we proceeded with medically managing for
NSTEMI vs Type 2 MI at this time: ASA 325mg daily, metoprolol 25
[**Hospital1 **], atorvastatin 80mg daily, heparin gtt (given for 48hrs) and
discharged on plavix 75 daily. His LVEF currently 45-50%
([**2182-10-19**]). We held ACEi in setting of [**Last Name (un) **]. Cardiac
catheterization was not performed as it was thought this was
more likely demand ischemic (type 2 MI) in setting of
hypertensive urgency. His anatomy (LIMA to LAD, SVG to OM2, SVG
to RPDA, SVG to RPL) was obtained from [**Hospital1 2177**] records.
# DKA/DM: Gap closed after fluid administration prior to
admission to MICU. He was continued on ISS (home dose is Lispro
Protam & Lispro [HUMALOG MIX 75-25] 28 units in AM, 9units in
PM).
.
# Hypertensive urgency/HTN: SBPs currently still elevated. His
blood pressures were better controlled with lisinopril 40 daily,
coreg 25 [**Hospital1 **], amlodipine 5 mg po qdaily and chlorthalidone 25
daily. Workup for right adrenal mass was deferred as
outpatient.
.
# [**Last Name (un) **]/CRI: Baseline Cr ~1.5 in early [**2181**]. Peaked at 1.9 in
MICU, trended down over the next few days. Was likely prerenal
in setting of vomiting and NSTEMI.
.
CHRONIC ISSUES:
.
# Diabetic retinopathy: continued xalatan (home [**Year (4 digits) **] not on
formulary) and cosopt eye drops.
.
TRANSITIONAL ISSUES with PCP follow up
# Afib: Currently in sinus, a-paced. Switched metoprolol to
carvedilol to control BP's. Continued amiodarone.
Anticoagulation was not started with concern for fall. He was
discharged to rehab. Please reassess anticoagulation as
outpatient.
.
# Right adrenal mass. Stable from CT abdomen in [**2176**]. Below
cutoff of 4 cm concerning for malignancy. Recommend 24 hr urine
metanephrines and serum renin and aldosterone as outpatient with
refractory hypertension.
Medications on Admission:
- Amiodarone 200 mg Tablet daily
- Bimatoprost [[**Year (4 digits) **]] 0.03 % Drops at bedtime
- Dorzolamide-Timolol [Cosopt] 0.5 %-2 % Drops twice daily
- Fluticasone 50 mcg Spray, Suspension - [**12-30**] sprays(s) in each
nostril twice a day
- Furosemide 20 mg Tablet 1 Tablet(s) PO once a day alternating
with 2 tablets on the other day
- Insulin Lispro Protam & Lispro [HUMALOG MIX 75-25] 100 unit/mL
(75-25) twice a day 28 units in am, 8-10 units in pm
- Lactulose 10 gram/15 mL Solution - 15 cc(s) by mouth at
bedtime
- Lidocaine [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply to site of pain 12 hours on and 12 hours off
- Lisinopril 2.5 mg Tablet - 1 Tablet(s) by mouth twice a day
- Metoprolol Succinate 50 mg Tablet Extended Release daily
- Simvastatin 20 mg Tablet - 1 Tablet(s) by mouth qpm
- Aspirin 81 mg Tablet, Delayed Release (E.C.) daily
- Cholecalciferol (Vitamin D3) 1,000 unit Tablet
- Docusate Sodium 100 mg Capsule by mouth [**Hospital1 **]
- Polysaccharide Iron Complex 150 mg Capsule once daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic qHS ().
3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**12-30**]
Sprays Nasal [**Hospital1 **] (2 times a day).
5. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO HS (at
bedtime).
6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
7. polysaccharide iron complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
14. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses:
-Non-ST-elevation myocardial infarction
-Hypertensive urgency
-Diabetic ketoacidosis
Secondary diagnoses:
- Insulin-dependent diabetes
- Renal insufficiency
- Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 656**],
It was a privilege to provide care for you here at the [**Hospital 61**] Hospital. You were admitted because you were having
nausea and vomiting. You were found to have high blood pressure
and high blood sugar from your diabetes, and you were treated in
the intensive care unit. You were also found to have a type of
heart attack (non-ST-elevation myocardial infarction) based on
your blood tests.
Your condition has improved and you can be discharged to home.
The following changes were made to your medications:
NEW:
1. Carvedilol 25mg PO BID
2. Atorvastatin 80mg daily
3. Ranitidine 150mg daily
4. Plavix 75 mg daily
CHANGED:
1. Lisinopril 40 mg by mouth daily
STOPPED:
1. Simvastatin
Other Discharge Instructions:
Please keep your follow-up appointments as scheduled below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2182-10-28**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2182-11-15**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2182-11-29**] at 11:00 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
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
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icd9cm
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,909
| 196,221
|
20243
|
Discharge summary
|
report
|
Admission Date: [**2148-2-6**] Discharge Date: [**2148-2-10**]
Date of Birth: [**2102-10-18**] Sex: M
Service: MEDICINE
Allergies:
Gabapentin / Lipitor / Zyprexa / Seroquel
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 45yo male with history of CHF, COPD on home O2,
OSA, ESRD on HD MWF, and recent cocaine use who presented to the
[**Hospital1 18**] ED with new onset dyspnea the night of [**2148-2-6**]. Per report
from the ED and [**Location (un) 86**] Police Department, patient used cocaine
earlier that day prior to attempting to break into a [**Doctor Last Name **] to
sleep. When the police arrived, patient reported SOB and was
brought to ED for further evaluation. Mr. [**Known lastname **] [**Last Name (Titles) 15797**] any CP
or recent illnesses.
.
In the ED, initial vs were: T 96.3, P 74, BP 151/64, R 24, O2
sat. 92% 4L. Exam notable for rales at right lung base. Labs
notable for normal WBC, anemia with HCT 30.9, hyperkalemia with
K 5.5, and elevated BUN/Cr of 71/11.4. EKG showed sinus rhythm
with Q wave in III and TWI in III. CXR demonstrated right-sided
effusion. Patient was given tylenol 650mg PO x1,
albuterol/ipratropium neb x1, kayexalate 30mg PO x1, and lasix
60mg PO x1. He was initially admitted to the medicine floor, but
on arrival to the floor noted to be increasingly lethargic. Sats
were dropping to mid 80s on 5L NC, and patient became responsive
only to sternal rub, prompting a trigger for hypoxia and AMS.
Sats improved to 96% on NRB, but given concern for hypoxic
respiratory distress, patient transferred to MICU for further
evaluation. Just prior to transfer, ABG showed 7.20/72/62/29.
.
On arrival to unit, patient was more awake and alert. He was
very upset, stating he is homeless and does not want to live.
The patient [**Last Name (Titles) 15797**] any dizziness, CP, palpitations, fever, or
chills. Had nausea earlier and reports cough productive of
mucous.
.
Review of systems:
As per HPI.
He [**Last Name (Titles) **] fever, chills, headache, sinus tenderness, rhinorrhea
or congestion. Denies chest pain, chest pressure, palpitations,
or weakness. Denies vomiting, diarrhea, constipation, abdominal
pain, or changes in bowel habits. Oliguric. Denies arthralgias
or myalgias.
Past Medical History:
CHF
COPD on home O2
ESRD on HD M/W/F
OSA
Social History:
Per report, crack cocaine use prior to admission. Patient
reports tobacco use, will not quantify amount. Occasional EtOH
use. Remote IVDU, none currently. States he is homeless, but
residing at Cape Cove group home. He has been trying to get
accepted into the [**Hospital1 **]. Provided names of friend [**Name (NI) 5627**]
[**Name (NI) **], as well as two social workers, who could be called for
information.
Family History:
Mother - cancer, type unknown. Father was on dialysis.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.3 BP: 129/78 P: 84 R: 24 18 O2: 96% NRB
General: awake, alert, oriented to person, hospital, month/year,
slightly uncomfortable appearing but NAD (on repeat exam more
lethargic but still arousable to voice, frequently falling back
to sleep)
HEENT: PERRL, EOMI, sclera anicteric, conjuntiva injected,
slightly dry MM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles with diminished BS at bases, R>L
CV: Regular rate and rhythm, normal S1 S2, slight systolic
murmur at LUSB, no rubs or gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ DP/PT/radial pulses, no clubbing,
cyanosis or edema, LUE with AV fisulta with + thrill/bruit
Skin: linear excoriations from scratching
Psych: agitated
Neuro: AAOx3 in unit (prior to transfer to unit was only
arousable to sternal rub), CN 2-12 grossly intact, moving all
four extremities
.
DISCHARGE EXAM:
vitals: T96.8 63 140/70 62 95% 3L NC
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, MMM
Neck: Could not examine
Lungs: Distant breath sounds, no adventitious sounds
CV: RRR, no m/r/g, nml s1s2
Abdomen: Appears distended; golf ball sized supraumbilical
ventral hernia
Ext: Appears some pedal edema, dry skin on lower legs, min edema
Neuro: Unclear
Psych: labile mood.
Pertinent Results:
ADMISSION LABS:
[**2148-2-6**] 08:49PM BLOOD WBC-4.8 RBC-3.16* Hgb-10.2* Hct-30.9*
MCV-98 MCH-32.4* MCHC-33.2 RDW-21.5* Plt Ct-151
[**2148-2-6**] 08:49PM BLOOD Neuts-80.9* Bands-0 Lymphs-13.3*
Monos-4.9 Eos-0.5 Baso-0.3
[**2148-2-6**] 08:49PM BLOOD Glucose-100 UreaN-71* Creat-11.4*# Na-142
K-5.5* Cl-101 HCO3-26 AnGap-21*
.
PERTINENT LABS:
[**2148-2-7**] 05:20AM BLOOD CK-MB-4 cTropnT-0.04*
[**2148-2-7**] 11:21AM BLOOD CK-MB-4 cTropnT-0.05*
[**2148-2-6**] 09:19PM BLOOD Lactate-1.7
[**2148-2-7**] 03:05AM BLOOD Lactate-0.6
.
DISCHARGE LABS:
[**2148-2-9**] 05:05AM BLOOD WBC-3.4* RBC-2.70* Hgb-8.8* Hct-26.9*
MCV-100* MCH-32.8* MCHC-32.9 RDW-21.1* Plt Ct-115*
[**2148-2-9**] 05:05AM BLOOD Glucose-69* UreaN-79* Creat-12.1*# Na-140
K-5.2* Cl-99 HCO3-28 AnGap-18
[**2148-2-9**] 05:05AM BLOOD Calcium-8.9 Phos-7.2* Mg-2.6
.
MICROBIOLOGY:
[**2148-2-6**] Blood Cx: pending
[**2148-2-8**] Sputum Cx x2: contaminated
[**2148-2-8**] Rapid Resp Viral Cx: pending
[**2148-2-8**] Pleural Fluid Cx: pending
.
IMAGING:
[**2148-2-6**] CXR: Moderate pulmonary edema with right-sided moderate
pleural effusion. Renal osteodystrophy. Patchy opacities at both
lung bases, likely atelectasis.
.
[**2148-2-7**] CT Chest w/o con:
1. Large partially loculated right pleural effusion, exudate
until proved otherwise. Multifocal pneumonia raises the distinct
possibility of empyema.
2. Moderately severe central adenopathy could be reactive.
3. Diffuse alveolitis could be due to chronic inhalational
exposures.
4. Renal osteodystrophy.
Brief Hospital Course:
This 45yo male with CHF, COPD, OSA, and ESRD on HD MWF, who
presented with shortness of breath and hypoxia in the setting of
recent cocaine use, with CXR demonstrating right sided effusion.
# Hypoxic respiratory distress: Patient's dyspnea was felt to be
multifactorial in nature, secondary to volume overload in
setting of CHF and missed HD sessions, right sided pleural
effusion, and bilateral pneumonia. ACS was felt to be unlikely
etiology of dyspnea and acute hypoxia, in absence of chest pain,
EKG w/o evidence of ischemia, and flat cardiac enzymes. He was
initially admitted to the floor, but subsequently transferred to
the ICU given increased lethargy and worsening respiratory
acidosis/hypercarbia. Patient's sats improved on non-rebreather,
and he became more awake and alert. The patient had HD the
following morning, with removal of ~3.6L and continued
improvement in dyspnea. CT chest demonstrated loculated right
pleural effusion, concerning for parapneumonic effusion and
possible empyema in setting of multifocal PNA. He was started on
broad spectrum antibiotics with vanc/levofloxacin given concern
for multifocal pneumonia. Thoracentesis on [**2148-2-8**] yielded ~1L of
serosanguionous fluid, which was sent for cell count, gram
stain, culture and cytology. The patient was continued on BiPAP
at night given history of OSA and chronic CO2 retention, and
also continued on albuterol/ipratropium nebs as needed for
dyspnea.
# CHF: Patient's baseline cardiac function unknown. As above,
possible that patient had CHF exacerbation from increased salt
intake and missed HD sessions with volume overload. Imaging on
admission was suggestive that pulmonary edema and bilateral
effusions could be contributing to acute presentation. Patient
was continued on ASA, ACE inhibitor. EKG did not demonstrate any
evidence of ischemia to suggest acute worsening of CHF secondary
to an ischemic event. CEs negative.
# Hyperkalemia: Patient hyperkalemic to 5.5 on presentation,
likely secondary to ESRD. Received kayexalate in ED, with
subsequent normalization of K. He was monitored on telemetry,
and continued on HD M/W/F.
# ESRD: BUN/Cr elevated at 71/11.4 on presentation. Patient had
HD on [**3-14**]. He was continued on calcium acetate with meals.
CT showed evidence of renal osteodystrophy.
# COPD: Per reports, patient on baseline O2 at home, though
patient would not confirm this. Unclear if patient has had
recent PFTs. Continued albuterol and ipratropium nebs as needed.
# OSA: Continued CPAP/BiPAP at night.
# Depression: Patient initially stating he does not want to live
upon admission to ICU, though denies any SI or HI. Social work
was consulted.
# Substance Abuse: Patient admitted to cocaine use on admission.
Social work consulted.
Medications on Admission:
1. Norvasc 10mg
2. ASA 81mg
3. Lisinopril 40mg
4. Toprol XL 100mg
5. Phoslo
6. Epo
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*1800 Capsule(s)* Refills:*2*
6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching .
Disp:*90 Tablet(s)* Refills:*0*
7. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
Disp:*3 Tablet(s)* Refills:*0*
10. Vancomycin 1000 mg IV HD PROTOCOL
day 1 = [**2-7**]
Discharge Disposition:
Home
Discharge Diagnosis:
Health Care Associated Pneumonia
loculated hemorrhagic pulmonary effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were a patient at the [**Hospital1 18**] from [**2148-2-7**] - [**2148-2-10**] where you
were treated for a serious pneumonia and pleural effusion. You
initially presented to the emergency room requiring more than 5
liters per minute of oxygen therapy and were transfered to the
medicine service. While on the medicine service you became less
responsive and incerasingly hypoxic and were transfered to the
medical intensive care unit (ICU). While in the ICU you were
found to have a loculated pulmonary effusion and had a
thoracentesis positive for blood and puss. During this time you
were started on vancomycin and levofloxacin antibiotic therapy.
On [**2148-2-8**] your condition improved and you were transfered from
the ICU to medicine. There your conditioned continued to
improve as you were able to ambulate without supplemental
oxygen, tolerate food, and remained afebrile. You were
discharged on [**2148-2-10**] to return to Cape Cove with instructions
to continue hemodialysis 3 times per week.
Due to your significant health care associated pneumonia you
will need to continue levofloxacin and vancomysin therapy. The
Vancomycin therepy will need to continue until [**2148-2-13**] and
administered at hemodialysis to provide appropriate coverage for
your health care asociated pneumonia.
Followup Instructions:
Please make an appointment to see your primary care physician in
approximately 10 days.
Please be sure to go to hemodialysis. This is necessary renal
replacement for you and this is where you will receive
vancomycin.
|
[
"428.0",
"496",
"V60.0",
"276.7",
"305.1",
"V15.81",
"276.2",
"518.81",
"403.91",
"511.89",
"327.23",
"305.61",
"486",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
10032, 10038
|
5949, 8712
|
309, 325
|
10156, 10156
|
4410, 4410
|
11667, 11886
|
2910, 2967
|
8846, 10009
|
10059, 10135
|
8738, 8823
|
10307, 11644
|
4953, 5926
|
2982, 3983
|
3999, 4391
|
2100, 2400
|
262, 271
|
353, 2081
|
4426, 4735
|
10171, 10283
|
4751, 4937
|
2422, 2465
|
2481, 2894
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,011
| 142,987
|
21439
|
Discharge summary
|
report
|
Admission Date: [**2116-1-1**] Discharge Date: [**2116-1-5**]
Date of Birth: [**2075-9-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Pericardiocentesis
Chemotherapy
History of Present Illness:
40 yo HIV+ male (diagnosed [**2114**], last CD4 366, VL 54,000, never
on antiretroviral therapy), ?HBV, who presented to the ED [**1-1**]
with a several day h/o abdominal pain worst in the RLQ, nausea,
vomiting, and SOB/DOE. Mr. [**Known lastname **] states that these symptoms
appeared to begin abruptly, and denies any associated fever,
chills, or night sweats prior to admission. An abdominal CT
scan performed in the ED incidentally noted a large pericardial
effusion. He was noted on exam to have elevated neck veins,
tachycardia, and significant pulsus paradoxus. Follow-up
echocardiogram demonstrated EF >55%, with 1.5-2.2cm
circumferential pericardial effusion with extesive stranding and
likely loculation, and RV diastolic collapse. He was taken to
the cath lab for emergent pericardiocentesis, with drainage of
600 cc of serosanginous fluid and placement of drainage
catheter. He stayed in the CCU until the drain was pulled, and
then was d/c'ed to the floor.
Past Medical History:
HIV diagnosed 1 year ago (patient requested blood test after
former partner found to have gonorrhea; STD screen negative at
the time, but found to have seroconverted). Unaware of having
an acute retroviral conversion syndrome. He reports negative
prior HIV tests, perhaps 2 years prior. HIV RF is MSM. No
opportunistic infections. Has never been on antiretroviral
therapy. CD4 counts reportedly between 300-400, and viral loads
reportedly between 50,000-100,000.
Hepatitis A
?HBV: reports getting at least two vaccines for hepB after
contracting [**Last Name (un) **], and believes that subsequent studies may have
suggested HepB infection.
Social History:
in monogamous homosexual relationship. No tobacco, rare EtOH.
No IVDU.
Family History:
DM, CAD
Physical Exam:
T: 98.1 BP: 116/66 P: 70 R: 18 98%RA pulsus 6
Gen: alert and oriented pleasant male, sitting up and eating, in
NAD
HEENT: sclerae anicteric, conjunctivae not injected, MMM
Lungs: decreased breath sounds at bilateral bases
CV: RRR, no m/r/g.
Abd: soft, nontender, nondistended. +bs.
Ext: no edema.
Pertinent Results:
PPD negative
[**2115-12-31**] 08:42PM BLOOD WBC-5.6 RBC-4.92 Hgb-14.4 Hct-43.7 MCV-89
MCH-29.3 MCHC-33.0 RDW-15.0 Plt Ct-148*
[**2116-1-2**] 05:09AM BLOOD WBC-2.6*# RBC-4.30* Hgb-12.7* Hct-38.7*
MCV-90 MCH-29.6 MCHC-32.8 RDW-15.2 Plt Ct-136*
[**2116-1-3**] 05:51AM BLOOD WBC-2.6* RBC-4.08* Hgb-12.3* Hct-35.9*
MCV-88 MCH-30.1 MCHC-34.2 RDW-15.2 Plt Ct-147*
[**2116-1-4**] 06:58AM BLOOD WBC-2.6* RBC-4.03* Hgb-12.2* Hct-35.3*
MCV-88 MCH-30.2 MCHC-34.4 RDW-15.0 Plt Ct-162
[**2116-1-5**] 06:50AM BLOOD WBC-3.3* RBC-4.40* Hgb-13.1* Hct-38.8*
MCV-88 MCH-29.9 MCHC-33.9 RDW-15.1 Plt Ct-172
[**2116-1-1**] 10:00AM BLOOD PT-14.3* PTT-26.8 INR(PT)-1.3
[**2116-1-1**] 06:44PM BLOOD ESR-28*
[**2116-1-3**] 05:30PM BLOOD WBC-2.6* Lymph-32 Abs [**Last Name (un) **]-832 CD3%-85
Abs CD3-704 CD4%-24 Abs CD4-200* CD8%-61 Abs CD8-504
CD4/CD8-0.4*
[**2115-12-31**] 08:42PM BLOOD Glucose-103 UreaN-19 Creat-1.2 Na-136
K-4.1 Cl-99 HCO3-27 AnGap-14
[**2116-1-2**] 05:09AM BLOOD Glucose-90 UreaN-11 Creat-0.9 Na-139
K-3.8 Cl-106 HCO3-29 AnGap-8
[**2116-1-3**] 05:51AM BLOOD Glucose-84 UreaN-8 Creat-0.9 Na-140 K-3.9
Cl-106 HCO3-29 AnGap-9
[**2116-1-4**] 06:58AM BLOOD Glucose-85 UreaN-8 Creat-1.0 Na-140 K-4.2
Cl-107 HCO3-29 AnGap-8
[**2116-1-5**] 06:50AM BLOOD Glucose-90 UreaN-10 Creat-1.0 Na-140
K-4.4 Cl-105 HCO3-31* AnGap-8
[**2116-1-4**] 06:58AM BLOOD ALT-35 AST-30 AlkPhos-94 TotBili-0.6
[**2116-1-1**] 10:00AM BLOOD CK(CPK)-44
[**2115-12-31**] 08:42PM BLOOD ALT-46* AST-26 CK(CPK)-39 AlkPhos-100
Amylase-29 TotBili-1.4
[**2115-12-31**] 08:42PM BLOOD Lipase-15
[**2116-1-1**] 10:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2115-12-31**] 08:42PM BLOOD CK-MB-2 cTropnT-<0.01
[**2116-1-2**] 05:09AM BLOOD TotProt-6.2* Albumin-3.1* Globuln-3.1
Calcium-7.9* Phos-2.8 Mg-1.7
[**2116-1-5**] 06:50AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9 UricAcd-3.3*
[**2116-1-1**] 06:44PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2116-1-2**] 05:09AM BLOOD PEP-NO SPECIFI
[**2115-12-31**] 11:30PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.025
[**2115-12-31**] 11:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-8* pH-6.5 Leuks-NEG
[**2115-12-31**] 11:30PM URINE RBC-0 WBC-0 Bacteri-RARE Yeast-NONE Epi-0
[**2116-1-2**] 10:15AM URINE U-PEP-NO PROTEIN
HIV-1 Viral Load/Ultrasensitive (Final [**2116-1-6**]):
46,400 copies/ml.
LYME SEROLOGY (Final [**2116-1-2**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA
Pericardial fluid:
GRAM STAIN (Final [**2116-1-1**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2116-1-4**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2116-1-7**]):
PRESUMPTIVE PROPIONIBACTERIUM ACNES. RARE GROWTH.
ACID FAST CULTURE (Pending):
ACID FAST SMEAR (Final [**2116-1-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Final [**2116-1-16**]): NO FUNGUS ISOLATED.
[**2116-1-1**] 03:03PM OTHER BODY FLUID WBC-[**Numeric Identifier 961**]* RBC-[**Numeric Identifier 56618**]*
Polys-1* Lymphs-1* Monos-0 Macro-2* Other-96*
[**2116-1-1**] 03:03PM OTHER BODY FLUID TotProt-5.3 Glucose-60
LD(LDH)-[**2089**] Amylase-18 Albumin-2.8
Cytology: Numerous atypical and degenerated lymphoid cells are
present
singly.
1. Pericardial fluid cytospins (A):
Primary Effusion Lymphoma (see note)
Immunoperoxidase studies performed are not
contributory due to a high background staining.
Note: Primary effusion lymphoma is a form of high grade B cell
lymphoma confined to serosal cavities. It typically occur in the
setting of HIV infection, but can also be seen in other
immunodeficiency states, and presents with pleural or
pericardial effusions containing large anaplastic plasmacytic
immunoblasts which are typically negative for CD20 and CD79a but
positive for CD138. Typically there is no associated mass
effect.
2. Cell block, pericardial fluid (B):
Atypical degenerate plasmacytoid cells consistent with
necrotic primary effusion lymphoma (see note).
CT abd ([**1-1**]): Appendix measuring at the upper limits of normal
with likely wall enhancement related to phase of contrast.
There is a low suspicion for appeniditis given other features
including air in the lumen and lack of associated findings.
Recommend clinical correlation. Large paracardial effusion
associated pleural effusion, hepatic and venous congestion.
Periportal adenopathy. Small amount of free fluid in pelvis.
CT chest ([**1-2**]): Interval decrease in size of pericardial
effusion following pericardial drain placement, with a
small-to-moderate amount of fluid persisting. Thickening of the
pericardium with evidence of enhancement, in keeping with
exudative effusion. Increase in number but not size of multiple
mediastinal lymph nodes, with adjacent stranding of mediastinal
fat. These are nonspecific but may be inflammatory. Interval
increase in size of right pleural effusion. Bibasilar
compressive atelectatic changes. Nonspecific stranding of the
mediastinal structures.
ECHO [**1-2**]: Small pericardial effusion. No echocardiographic
signs of tamponade.
CXR [**1-4**]: Bilateral effusions; the left slightly smaller than
yesterday.
Brief Hospital Course:
1)Pericardial effusion: Because of his tachycardia, elevated
JVD, and RV collapse seen on echo, his effusion was drained
emergently in the cath lab, and he was monitored in the CCU
until the drain was pulled. He never experienced any
hemodynamic compromise. The fluid cytology was consistent with
Primary Effusion Lymphoma. This lymphoma is associated with
HHV-8, but the sample that was sent to the micro lab to test for
this was lost. He was evaluated by the Oncology serivce, who
recommended chemo. He received one dose of chemo (liposomal
daunorubicin), which he tolerated well. Tumor lysis labs were
checked and were normal, and he was given allopurinol. His
pulsus paradoxus was monitored and was normal. He had no
evidence of reaccumulation of the pericardial fluid.
2)Pleural effusions: These were seen on initial CT, and were
monitored by CXR. They were decreasing on size prior to d/c.
He denied shortness of breath, and his oxygen saturation was
normal on room air.
3)ID: He was begun on HAART per ID recommendations
(emtricitabine, tenofovir, and kaletra). His PPD was negative.
His CD4 count was 200, and his viral load was 46,400.
Medications on Admission:
flonase prn
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lopinavir-Ritonavir 133.3-33.3 mg Capsule Sig: Three (3) Cap
PO BID (2 times a day).
Disp:*180 Cap(s)* Refills:*2*
3. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
Disp:*30 Capsule(s)* Refills:*2*
4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion
Discharge Condition:
Stable
Discharge Instructions:
Continue HAART medications.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 7991**] within 1-2 weeks.
Follow up with Hematology/[**Hospital **] Clinic.
|
[
"420.90",
"042",
"202.80",
"070.70",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
9490, 9496
|
7684, 8844
|
283, 316
|
9561, 9569
|
2446, 5195
|
9645, 9765
|
2099, 2108
|
8906, 9467
|
9517, 9540
|
8870, 8883
|
9593, 9622
|
2123, 2427
|
5227, 7661
|
229, 245
|
344, 1322
|
1344, 1994
|
2010, 2083
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,169
| 163,435
|
32869
|
Discharge summary
|
report
|
Admission Date: [**2129-4-3**] Discharge Date: [**2129-4-5**]
Date of Birth: [**2070-2-6**] Sex: M
Service: MEDICINE
Allergies:
Dextran
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 76529**] is a 59 year old male with CHF, CAD, s/p 3 stents,
most recent [**10-25**], ESRD on [**Hospital **] transferred from [**Hospital1 5109**] with chest pain. The patient was in his USOH when he
went to scheduled HD on Friday [**3-31**]. HD was stopped early (only
3L removed, usually gets 4 L off) b/c he started to have
N/V/diarrhea. He went home had persistent symptoms until Sat
night when he developed L arm heaviness and pain, then CP,
consistent with his previous NSTEMI. He also was unable to take
his medications because of N/V. He reported dyspnea,
orthostatis, mild orthopnea. Denies PND, denies palpitations. He
presented to [**Hospital3 **] where he was noted to have
elevated Trop I (0.84), HTN to 220/110 (baseline 120-140 sys).
CXR was significant for pulmonary edema. He was started on nitro
gtt and given Lasix 60mg IV x1, zofran, lovenox. He also had a
leukocytosis to 12.3. OSH EKG: sinus tach, first degree av
block, LAD, marked LVH, peaked T waves in V3. ST depression in
I, aVL, and V6.
.
He was transferred to [**Hospital1 18**] for care. His chest pain finally
resolved upon presentation to [**Hospital1 18**]. In our ED, the patient had
continued. Vital signs were afebrile, 162/78, 85, 18, 100% 2L.
His nitro glycerine drip was weaned given improving
hypertension. Labs were notable for elevated potassium 7.3,
repeat 6.8. He was given insulin, calcium, and glucose.
Kayexalate was initially refused and renal was going to dialyse
him, but he then accepted kayexalate. Heparin gtt was started.
.
On the floor, he denies chest pain. Of note, he has had similar
in the past and he has been found to have MI latest in [**1-25**], at
which time his stent was restenosed, he underwent PTCA.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, black stools or red stools. He reports chronic
symptoms of PVD. He reports orthostatic symptoms with presyncope
before reporting to OSH ED. He has had body aches for the past
few days, but no fevers/chills. All of the other review of
systems were negative.
Past Medical History:
CHF
CAD s/p 3 stents in [**8-25**] with PTCA for instent stenosis [**1-25**]
(hospital records pending from [**Hospital1 2177**])
ESRD
hyperparathyroidism (likely from renal)
.
Cardiac Risk Factors: ESRD, Hypertension, tobacco, FH
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:
VS: 97.8 188/101 92 18 97%RA
gen: well appearing, nad, pleasant
heent: ncat, mmm, eomi, nonicteric sclera
neck: supple, no elevated jvd, + carotid bruit on right
pulm: bibasilar crackles, poor air movement throughout, no
wheezes
cv: hrrr, 1/6 SEM > at RUSB, no r/g
abd: s/nt/nd/nabs, no hsm
extr: no c/c/e
neuro: aox4, cn 2-12 intact grossly, nonfocal
Pertinent Results:
[**2129-4-3**] 03:40AM WBC-12.1* RBC-4.46* HGB-13.0* HCT-41.0 MCV-92
MCH-29.1 MCHC-31.6 RDW-18.7*
[**2129-4-3**] 03:40AM NEUTS-90.0* LYMPHS-5.4* MONOS-3.0 EOS-1.2
BASOS-0.4
[**2129-4-3**] 03:40AM CALCIUM-10.4* PHOSPHATE-8.4* MAGNESIUM-2.3
[**2129-4-3**] 03:40AM CK-MB-NotDone proBNP-[**Numeric Identifier 76530**]*
[**2129-4-3**] 03:40AM cTropnT-0.15*
[**2129-4-3**] 03:40AM CK(CPK)-37*
[**2129-4-3**] 03:40AM GLUCOSE-114* UREA N-50* CREAT-9.0* SODIUM-138
POTASSIUM-7.3* CHLORIDE-93* TOTAL CO2-26 ANION GAP-26*
[**2129-4-3**] 05:39AM GLUCOSE-129* UREA N-52* CREAT-8.7* SODIUM-137
POTASSIUM-6.8* CHLORIDE-92* TOTAL CO2-28 ANION GAP-24*
[**2129-4-3**] 10:00AM CALCIUM-10.0 PHOSPHATE-8.9* MAGNESIUM-2.3
[**2129-4-3**] 06:02AM K+-6.4*
[**2129-4-3**] 10:00AM cTropnT-0.18*
[**2129-4-3**] 10:00AM CK(CPK)-25*
[**2129-4-3**] 10:00AM CK-MB-NotDone
[**2129-4-3**] 10:00AM GLUCOSE-76 UREA N-53* CREAT-9.3* SODIUM-137
POTASSIUM-6.6* CHLORIDE-94* TOTAL CO2-29 ANION GAP-21*
[**2129-4-3**] 07:42PM CK-MB-NotDone cTropnT-0.26*
[**2129-4-3**] 07:42PM CK(CPK)-35*
[**2129-4-3**] 07:42PM POTASSIUM-6.7*
[**2129-4-3**] 10:42PM LACTATE-0.9 K+-5.8*
[**2129-4-3**] 10:42PM TYPE-ART PO2-62* PCO2-50* PH-7.38 TOTAL
CO2-31* BASE XS-2
[**2129-4-5**] 03:25AM BLOOD WBC-7.9 RBC-4.29* Hgb-12.9* Hct-39.7*
MCV-93 MCH-30.0 MCHC-32.4 RDW-18.1* Plt Ct-219
[**2129-4-4**] 03:20AM BLOOD PT-11.6 PTT-26.6 INR(PT)-1.0
[**2129-4-5**] 06:20AM BLOOD Glucose-83 UreaN-54* Creat-9.0* Na-142
K-5.8* Cl-98 HCO3-26 AnGap-24*
[**2129-4-3**] 03:40AM BLOOD CK(CPK)-37*
[**2129-4-3**] 07:42PM BLOOD CK(CPK)-35*
[**2129-4-4**] 03:20AM BLOOD CK(CPK)-35*
[**2129-4-3**] 03:40AM BLOOD cTropnT-0.15*
[**2129-4-3**] 10:00AM BLOOD cTropnT-0.18*
[**2129-4-4**] 03:20AM BLOOD CK-MB-NotDone cTropnT-0.36*
[**2129-4-5**] 06:20AM BLOOD Calcium-10.0 Phos-9.3* Mg-2.2
[**2129-4-3**] 10:42PM BLOOD Type-ART pO2-62* pCO2-50* pH-7.38
calTCO2-31* Base XS-2
CXR:
In comparison to the previous radiograph, there is increased
perihilar haziness and newly occurred interstitial fluid
accumulation, manifesting by Kerley B lines and peribronchial
cuffing. Overall, these findings suggest increasing interstitial
lung edema of moderate severity. The size of the cardiac
silhouette is unchanged, pleural effusions are not seen. No
pulmonary opacities suggestive of pneumonia.
IMPRESSION: Increasing interstitial pulmonary edema of moderate
severity.
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
59 year old male with CAD s/p multiple stents, CHF, ESRD on HD
who is transferred from OSH with hyperkalemia, chest pain and
positive troponins.
.
# CAD/Ischemia: had chest pain associated with elevated blood
pressure. Has recent history of PCI and MI as above. His
troponins were elevated slightly but his CKs were flat, making
acute ACS, especially in the setting of ESRD, very unlikely. His
pain was likely from some minor sub-endocardial ischemia in the
setting of volume overload and ventricular stretch. There was no
indication for cardiac catheterization. The patient was dialyzed
as below with no recurrence of his chest pain. He as continued
on his aspirin, plavix, statin, beta-blocker, norvasc, ACE.
.
# Pump: No echo on system, has a history of CHF. ECHO from OSH
show inferolat hypokinesis, latest EF 50-55%. CXR shows mild
congestive failure. ProBNP [**Numeric Identifier 76530**]. The patient became acutely SOB
overnight on admission in association with systolic BP in the
190s, and an exam consistent with flash pulmonary edema. The
patient was emergently dialyzed in the ICU with good results. He
received two total dialysis treatments, each removing 4 liters
of fluid. He was weened to room air on discharge and feeling
very well. There was no indication for a repeat TTE.
.
# HTN: The patient was poorly controlled on his home regimen.
Given his renal disease he was begun on Lisinopril with
uptitration to 40mg PO daily. He was also starteded on Toprol XL
at an increased dose. His isordil was converted to Imdur for
easier dosing, and his hydralazine was discontinued. He had good
control with this regimen.
.
# ESRD: Needed HD x2 as noted above. Continued on calcium
acetate, sevalemer, and sensipar
.
# FEN: diabetic, heart healthy diet.
.
# Prophylaxis: Heparin sc, [**Last Name (un) 12376**] regimen
.
# Code: FULL - confirmed with patient
.
# Communication: with patient
.
# Dispo: pending above
Medications on Admission:
aspirin 325
plavix 75
lopressor 50
norvasc 10
hydralazine 25 tid
isordil 20 tid
prilosec 20 qday
lipitor 80
phoslo 1334 tid
renagel 800 tid
sl NTG 0.4 prn
vit B complex
sensipar 120 tid
.
ALLERGIES: dextran
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. 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:*0*
8. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
9. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Vitamin B Complex Tablet Sig: One (1) Tablet PO once a
day.
13. Sensipar 60 mg Tablet Sig: Two (2) Tablet PO three times a
day.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed: take one if having chest pain. Can take
1 every five minutes up to 3 times if continuing to have chest
pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Systolic Congestive Heart Failure
Hypertensive urgency
End Stage Renal Disease
Discharge Condition:
good, tolerating pos, satting well on room air, ambulating
without assistance
Discharge Instructions:
You have been diagnosed with congestive heart failure and
hypertensive urgency. You have received dialysis and blood
pressure management with resolution of your chest pain and
shortness of breath.
It is important as prescribed and follow up as outlined below.
We have discontinued your hydralazine and isordil, and started
you on lisinopril, imdur, as well as increasing your metoprolol.
Followup Instructions:
We have called Dr. [**Last Name (STitle) **], who should be getting back to you about
a follow-up appointment. If you do not hear from his office,
please call ([**Telephone/Fax (1) 76531**] if you need to schedule.
You should also follow up with your nephrologist Dr. [**Last Name (STitle) 76532**].
Please call to arrange f/u
|
[
"428.21",
"428.0",
"496",
"585.6",
"403.91",
"041.02",
"276.7",
"414.01",
"599.0",
"588.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9468, 9474
|
5763, 7767
|
276, 283
|
9603, 9683
|
3321, 5740
|
10121, 10453
|
2851, 2933
|
8025, 9445
|
9495, 9582
|
7793, 8002
|
9707, 10098
|
2948, 3302
|
226, 238
|
311, 2456
|
2478, 2711
|
2727, 2835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,750
| 177,711
|
19207
|
Discharge summary
|
report
|
Admission Date: [**2143-7-9**] Discharge Date: [**2143-7-18**]
Date of Birth: [**2078-2-13**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Tetracycline / Penicillins / Cephalosporins
/ Vinorelbine / Peanut / Oxycodone Hcl / Hydrocodone / Atrovent
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
- Two bronchoscopies (one with Y-tube removal)
- Mechanical Intubation/extubation
History of Present Illness:
65yo F PMHx NSCLC s/p RUL VATS lobectomy [**5-/2143**] c/b LUL
subsegmental PE now s/p bronchoscopy and Y stent placement with
short portion in trachea placed yesterday , p/w acute dyspnea x
2hrs hours. Pt reports that since bronching "has not felt
right". Overnight, patient resp status worsened, called EMS.
On EMS arrival, O2 sat 90%, respiratory rate 40. Denies fevers,
chills, nightsweats, chest pain. Notes that was not taking
Mucinex because pills were too large to swallow.
.
In ED, initially VS HR106 134/94 40 97%FM, patient w loud ronchi
bilaterally, reports some relief from mucomyst, but remaining
very uncomfortable. CXR w/o focal opacities. Admitted
emergently to ICU for further management.
Past Medical History:
Past Medical History:
- NSCLC s/p LLLobectomy '[**39**] c/b recurrences/p L lingulectomy '[**40**]
- Right upper lobe nodule s/p Right VATS lobectomy/superior
segmentectomy [**2143-5-1**], exploratory R VATS/RML detorsion [**2143-5-3**]
- OA
- Chronic Lower back pain
- hypothyroidism
- benign Right parotid mass
- HTN
- HLD
.
PAST SURGICAL HISTORY:
C-section, Hemorrhoidectomy, Tonsillectomy, RUL VATS
lobectomy/superior segmentectomy [**2143-5-1**], exploratory R VATS/RML
detorsion [**2143-5-3**]
Social History:
She lives with her husband. She does not have any pets. She is
a lifetime nonsmoker. Sales clerk. Occasional etoh.
Family History:
Her son has allergies. Her brother has thyroid disease,
otherwise no pulmonary history.
Physical Exam:
On admission:
VS: 96.9 104 154/91 32 99%on Bipap
GEN: tachypnic, mild distress
HEENT: PERRL, EOMI, MMM
NECK: no JVD, no LAD, supple
LUNGS: loud rhonchi throughout, very junky, moving air well
bilaterally
HEART: tachy, regular,
ABD: Soft, NT/ND, no rebound/guarding
EXT: warm, sweaty, 2+radial pulses, no cyanosis/edema
Pertinent Results:
ADMISSION LABS:
[**2143-7-9**] 04:30AM BLOOD WBC-9.8# RBC-3.93* Hgb-12.6 Hct-36.9
MCV-94 MCH-32.0 MCHC-34.1 RDW-12.9 Plt Ct-172
[**2143-7-9**] 04:30AM BLOOD Neuts-75.3* Lymphs-18.7 Monos-5.6 Eos-0.1
Baso-0.3
[**2143-7-9**] 04:30AM BLOOD PT-13.9* PTT-31.3 INR(PT)-1.2*
[**2143-7-9**] 04:30AM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-140
K-4.1 Cl-102 HCO3-22 AnGap-20
[**2143-7-10**] 04:01AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.7
[**2143-7-9**] 08:13AM BLOOD Type-ART pO2-154* pCO2-43 pH-7.37
calTCO2-26 Base XS-0
[**2143-7-9**] 08:13AM BLOOD Lactate-3.1*
OTHER LABS:
[**2143-7-10**] 04:01AM BLOOD WBC-13.1* RBC-3.26* Hgb-10.3* Hct-30.1*
MCV-92 MCH-31.7 MCHC-34.3 RDW-12.9 Plt Ct-111*
[**2143-7-10**] 04:01AM BLOOD Neuts-93.8* Lymphs-3.6* Monos-2.3 Eos-0.2
Baso-0.2
[**2143-7-18**] 05:15AM BLOOD WBC-7.8 RBC-3.63* Hgb-11.6* Hct-33.1*
MCV-91 MCH-31.9 MCHC-35.1* RDW-12.9 Plt Ct-189
[**2143-7-15**] 06:00AM BLOOD PT-13.1 PTT-30.9 INR(PT)-1.1
[**2143-7-18**] 05:15AM BLOOD PT-19.1* PTT-40.8* INR(PT)-1.7*
[**2143-7-18**] 05:15AM BLOOD Glucose-85 UreaN-20 Creat-0.8 Na-138
K-3.9 Cl-104 HCO3-28 AnGap-10
[**2143-7-18**] 05:15AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9
[**2143-7-15**] 06:05AM BLOOD Vanco-16.6
[**2143-7-9**] 08:13AM BLOOD Type-ART pO2-154* pCO2-43 pH-7.37
calTCO2-26 Base XS-0
[**2143-7-10**] 01:42AM BLOOD Type-ART pO2-152* pCO2-50* pH-7.28*
calTCO2-24 Base XS--3
[**2143-7-10**] 03:12AM BLOOD Type-ART pO2-100 pCO2-36 pH-7.41
calTCO2-24 Base XS-0
[**2143-7-11**] 11:38AM BLOOD Type-ART PEEP-5 pO2-199* pCO2-37 pH-7.43
calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2143-7-9**] 02:11PM BLOOD Lactate-4.2*
[**2143-7-10**] 03:12AM BLOOD Lactate-2.8*
[**2143-7-12**] 03:39AM BLOOD Lactate-1.0
MICROBIOLOGY
[**2143-7-9**] 9:24 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2143-7-12**]**
GRAM STAIN (Final [**2143-7-9**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
RESPIRATORY CULTURE (Final [**2143-7-12**]):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2143-7-9**] 9:30 am BLOOD CULTURE (x2)Final [**2143-7-15**]: NO GROWTH.
RADIOLOGY
CHEST (PORTABLE AP); [**2143-7-9**] 4:28 AM
Again seen are changes of right upper lobe wedge resection with
chain sutures, staples, and superior retraction of the inferior
pulmonary ligament. Discoid atelectasis in the left upper lobe
has improved. There is no focal consolidation. Heart size is
normal. There are no pleural effusions or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
CHEST (PORTABLE AP); [**2143-7-11**] 9:25 AM
IMPRESSION: Increasing left lower lung consolidation consistent
with edema
Study Date of
CHEST (PORTABLE AP); [**2143-7-11**] 10:49 AM
FINDINGS: Single portable view of the chest shows an ET tube to
be in proper position. There is an oropharyngeal tube whose port
is seen within the region of the stomach. The previously seen
consolidation of the left lower lung has resolved. Again,
consistent with resolving edema. Post-surgical changes as
described previously.
IMPRESSION: Appropriate ET tube placement
CT TRACHEA W/O C W/3D REND [**2143-7-15**] 9:12 AM
Reason: Evaluate for tracheobronchomalacia
IMPRESSION:
1. No dynamic changes of the tracheobronchial tree on dynamic
expiration
versus inspiratory series.
2. Interval development of multifocal ground-glass
opacification, compatible with multifocal pneumonia.
3. Interval improvement though with small residual fluid
collection in the
right lateral chest wall.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 52354**] is a 65 year old woman with recurrent lung CA s/p
multiple lobectomies (LLL, lingula, RUL, R superior seg)
admitted to the MICU with respiratory distress 5 days s/p
Y-stent placement.
# Y-stent occlusion/respiratory distress - The patient presented
with respiratory distress in the setting of recent bronchial
Y-stent placement. Bronchoscopy demonstrated partial occlusion
of branching bronchi and the stent was removed; however, the
patient remained tachypneic and continued to have non-productive
cough. At this point, the patient was afebrile and without
leukocytosis and had a CXR without clear focal opacities. For 24
hours following bronchoscopy, the patient had intermittent
episodes of acute dyspnea and tachypnea with loud expiratory
upper airway sounds requiring intubation. Given high suspicion
for upper airway process, bronchoscopy and direct vocal cord
visualization was performed, which demonstrated infraglottic
edema/ulceration. The patient was treated with IV dexamethasone
TID, nebulizers, racemic epinephrine, and heliox. She improved
and was extubated and then remained stable >24hrs in the MICU
prior to transfer to the medicine service. After 5 days of
dexamethasone 10mg TID, steroids were tapered over two days. The
patient sometimes required albuterol nebulizers and O2 by NC
while on the medicine service. With extensive walking including
stairs, the patient's oxygen saturation did not drop below 96%
and thus did not meet requirements for home oxygen. PT evaluated
and recommended outpatient pulmonary rehab, which was arranged
for after discharge. She was walking and sleeping comfortably
without supplemental oxygen on the day of discharge.
.
The patient had evidence of intermittent airway closure with
respiration seen during bronchoscopy and was started on bi-pap
at night. A dynamic airway CT to evaluate for
tracheobronchomalacia did not show dynamic changes of the
tracheobronchial tree on dynamic expiration versus inspiratory
series. Continuing bi-pap was recommended by interventional
pulmonology due to closure seen during bronchoscopy; however,
the patient would not tolerate bi-pap while sleeping and it was
discontinued. An outpatient evaluation for OSA was recommended
after discharge, as outpatient positive pressure ventilation
would not be covered by insurance without this study.
.
# MRSA positive sputum cultures
The patient developed a leukocytosis to 13.7 on the day after
admission and sputum cultures obtained during bronchoscopy grew
out MRSA. A course of 8 days Vancomycin IV was completed prior
to discharge and leukocytosis resolved. On discharge, the
patient was started on a 6 day course of bactrim to continue
treating positive MRSA cultures per thoracic surgery
recommendations.
.
# History of pulmonary embolism
The patient is on home warfarin for history of PE. She was
transitioned to lovenox prior to bronchoscopy. Lovenox was held
for the bronchoscopies and restarted following the procedures.
She was bridged to warfarin for DVT prophylaxis after transfer
to the medicine service. On discharge, PT was 1.7. She was
instructed to have her PT/INR checked the day after discharge
and to continue SQ lovenox until instructed that INR was
therapeutic by primary care clinic. The patient was discharged
on her normal home warfarin dosing with possible changes
implemented by her primary care clinic pending results of PT/INR
the day after discharge.
.
# Anemia/thrombocytopenia
The patient developed both anemia and thrombocytopenia after ICU
admission. HCT fell from 37 on admission to 28; Plts fell from
172 to 111. Thrombocytopenia resolved with plts of 189 on the
day of discharge. Anemia improved to HCT of 33 on the day of
discharge.
.
# Tongue swelling/throat itching
Patient reported symptoms possibly associated with restarted
warfarin dose, though she had taken warfarin chronically prior
to admission. The symptoms never caused respiratory distress or
changes appreciable on physical exam. Symptoms may have been due
to anxiety and improved on subsequent days prior to discharge.
.
# Bradycardia ?????? The patient had an episode of bradycardia in the
ICU in the setting of propofol. This did not reoccur in the ICU
or after transfer to the medicine service.
.
# GERD
The patient was treated with IV PPI for GERD and switched to PO
PPI prior to discharge. She sometimes required additional PRN
maalox for GERD.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 3 ml inhaled via nebulizaiton every six (6) hours
as needed for shortness of breath or wheezing
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs inhaled a4h prn for SOB or wheezing
LEVOTHYROXINE [SYNTHROID] - 75 mcg Tablet - 1 Tablet(s) by mouth
once a day
WARFARIN - 1 mg Tablet - 2 to 3 Tablet(s) by mouth daily or as
directed based on INR
Medications - OTC
SENNOSIDES-DOCUSATE SODIUM - 8.6 mg-50 mg Tablet - 1 (One)
Tablet(s) by mouth twice a day as needed for constipation
ACETAMINOPHEN PRN pain
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
Disp:*QS * Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO Twice
daily as needed as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. warfarin 1 mg Tablet Sig: 2-3 Tablets PO once a day: 2
tablets M,W,F; 3 tablets TU,TH,[**Last Name (LF) **],[**First Name3 (LF) **].
9. guaifenesin 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1)
Tablet, ER Multiphase 12 hr PO BID (twice a day) as needed as
needed for cough, sputum.
10. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
11. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous every twelve (12) hours: Take this medication until
your INR is [**1-3**]. .
12. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY DIAGNOSES
# Airway obstruction
# MRSA Pneumonia
SECONDARY DIAGNOSES
# Anemia
# Thrombocytopenia
# History of DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent; with pulmonary
limitations
Discharge Instructions:
Dear Ms. [**Known lastname 52354**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you had difficulty breathing which was likely due to
problems with the [**Name (NI) 7935**] that had recently been placed to keep
your airway open. The stent was removed and you were treated
with antibiotics for a pneumonia, steroids for airway
inflammation, and an acid blocking medication for ulcers in your
airway. You will be discharged home today with outpatient
pulmonary rehabilitation and follow-up with multiple providers.
MEDICATION CHANGES
START Bactrim DS 1 tab twice per day for 6 more days
START Pantoprazole 40mg twice per day for your airway
ulcerations
START Guaifenesin 1200mg twice per day as needed for cough or
sputum
START Enoxaparin 60mg subcutaneous injection every 12 hours
until your INR is therapeutic
CONTINUE Warfarin: You will need to get your INR checked
tomorrow. You should take your usual home schedule of 2mg on
M,W,F; 3mg on T,TH,[**Last Name (LF) **],[**First Name3 (LF) **] unless you get different directions
from your primary care clinic after your INR is checked.
Followup Instructions:
Please follow-up with all of your outpatient appointments
scheduled below:
1. Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2143-7-23**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
2. Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2143-7-23**] at 11:00 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
3. Provider: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS Phone:[**Telephone/Fax (1) 2484**]
WEDNESDAY [**7-24**] 2:45
4. Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED
When: MONDAY [**2143-7-29**] at 10:50 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, MPH [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
5. Department: OTOLARYNGOLOGY-AUDIOLOGY
When: MONDAY [**2143-7-29**] at 2:30 PM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
*There is a shuttle that goes to this location from the [**Location (un) **]
office. Check with your PCP if you are interested in using this.
6. Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2143-8-22**] at 10:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
7. Department: MEDICAL SPECIALTIES
When: THURSDAY [**2143-8-22**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"530.81",
"478.5",
"V12.51",
"162.9",
"482.42",
"518.81",
"427.89",
"285.9",
"272.4",
"401.9",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.23",
"96.71",
"33.78"
] |
icd9pcs
|
[
[
[]
]
] |
13322, 13380
|
6704, 11144
|
395, 479
|
13546, 13546
|
2343, 2343
|
14881, 17150
|
1897, 1988
|
11793, 13299
|
13401, 13525
|
11170, 11770
|
13724, 14858
|
1593, 1745
|
2003, 2003
|
348, 357
|
507, 1221
|
2359, 2895
|
2017, 2324
|
13561, 13700
|
1265, 1570
|
1761, 1881
|
2907, 6681
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,586
| 161,878
|
50139
|
Discharge summary
|
report
|
Admission Date: [**2103-9-16**] Discharge Date: [**2103-10-1**]
Date of Birth: [**2051-12-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin / Methotrexate / Ticlid / Bactrim Ds /
Allopurinol / Tetracycline
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
from ED for hypoxic resp distress
Major Surgical or Invasive Procedure:
1. Bronchoscopy
History of Present Illness:
This is a 51 y/o female with PMH significant for mixed
connective tissue disease on chronic prednisone, CAD, NIDDM, and
h/o aspiration PNA, who was recently admitted from
[**Date range (2) 104660**] for PNA, who now presents to the ED today in
acute respiratory distress with symptoms of increasing dyspnea
and cough.
.
In ED, her VS on arrival were 104, HR 110, BP 90/palp, RR 30,
SaO2 80%/NRB. She was intubated for hypoxic respiratory
distress. Cultures were drawn and CXR was signigicant for
widespread RML PNA. She received 2 gm Cefepime IV, 1 gm
Vancomycin IV, 500 mg flagyl IV, 1gm tylenol pr, digoxin 0.5 mg
IV for SVT/a fib, and dexamethasone 10 mg IV. Patient was given
5 L NS for hypotension, but required pressors and was started on
a neosynephrine gtt.
.
Her last admission was for similar symptoms between [**Date range (1) 61239**].
She had presented to the ED then with chills, cough, and a temp
of 104. She was found to be hypotensive at that time with SBP's
in the 60's, tachycardic, +leukocytosis with left shift and
increased lactate of 2.2. Her CXR was positive for a RML and RLL
PNA. She was on Levophed, Vanc/Ceftaz, hydrocort, and insulin
gtt while in the [**Hospital Unit Name 153**] for 2 days and eventually transferred to
the floor in stable condition on [**2103-9-7**]. She was discharged on
[**2103-9-21**] on a course of levaquin for presumed aspiration PNA. She
was seen by S+S during her course who recommended a regular diet
with thin liquids and if needed, further w/u by GI if continued
aspiration events. Her steroids were tapered down during her
hospital course and she was discharged on her home dose of 10 mg
qd.
Past Medical History:
1. CAD, status post AMI in [**2096**], s/p LCx stenting in [**2096**] c/b
instent restenosis --> restented with 2 Cypher stents on
[**2102-4-5**]. Also s/p 2 cypher stents in mid RCA [**2102-4-5**] and
stenting of proximal RCA. LAD diffusely diseased up to 40%, no
intervention. EF 48% on ventriculography.
2. Mixed connective tissue disease manifested by myositis, +
[**Doctor First Name **], GERD, Raynaud's, sclerodactyly, malar rash, telangiectasia.
3. Diabetes mellitus type 2
4. Hypertension
5. Gout
6. Status post CVA without residual deficit
7. GERD with Barrett's esophagus
8. Peripheral neuropathy
9. ? H/O GIB in [**11-14**]. C-scope unrevealing- Grade 1 internal
hemorrhoids. Diverticulum in the sigmoid colon. Bluish
discoloration in the lateral wall of the terminal ileum
compatible with unclear significance.
10. Rt Breast bx lobular carcinoma in situ
Social History:
She lives with her husband. They have no children. She is a
lifelong non-smoker. No EtOH. At baseline, she ambulates with a
walker.
Family History:
Notable for CAD including her mother who died at age 52 of an
MI. Father had CABG in his 50s and later died of an MI. Two
brothers with [**Name (NI) 5290**] in their 50's and one with a CVA.
Physical Exam:
VS: Tc 102, BP 95/57, HR 140-170's, RR 14, SaO2 97% on AC/450 x
14/FiO2 100%/PEEP 5, CVP 15
General: Intubated, responsive to voice stimuli.
HEENT: NC/AT, PERRL. Dried blood on upper lips. ETT secured in
place.
Neck: R IJ in place, difficult to assess for JVP
Chest: Coarse rhonchi and rales throughout the lung fields
CV: Irregularly irregular and tachycardic, s1 s2 normal
Abd: soft, obese, NT, NABS
Ext: mottled distal extremities with faint DP's b/l
Neuro: intubated, responsive to voice stimuli
Brief Hospital Course:
Patient was admitted in shock without any clear etiology.
Patient received Xigris, stress dose steroids, and
broad-spectrum antibiotics. Culutres never grew anything
Pt was admitted in shock, although unclear etiology with no
cultures positive for yeast only. Patient continued to require
pressors and blood transfusions and her blood pressure was
unable to be maintained. Patient was changed to comfort measures
only and died soon after.
Medications on Admission:
1. Gabapentin 300 mg [**Hospital1 **]
2. Aspirin 325 mg qd
3. Clopidogrel 75 mg qd
4. Probenecid 500 mg qAM
5. Probenecid 250 mg qHS
6. Metformin 500 mg [**Hospital1 **]
7. Levofloxacin 500 mg qd
8. Albuterol inh q4-6 prn
9. Lipitor 80 mg qd
10. Omeprazole 40 mg [**Hospital1 **]
11. Prednisone 10 mg qd
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Patient expired.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"710.9",
"427.31",
"584.9",
"995.92",
"518.81",
"250.02",
"038.9",
"507.0",
"785.52",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"38.93",
"33.24",
"38.91",
"96.04",
"96.6",
"96.72",
"00.11"
] |
icd9pcs
|
[
[
[]
]
] |
4718, 4727
|
3881, 4322
|
391, 408
|
4778, 4787
|
4843, 4998
|
3149, 3341
|
4677, 4695
|
4748, 4757
|
4348, 4654
|
4811, 4820
|
3356, 3858
|
318, 353
|
436, 2091
|
2113, 2983
|
2999, 3133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,022
| 150,341
|
40709+58394
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-6-3**] Discharge Date: [**2193-6-10**]
Date of Birth: [**2125-12-2**] Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Chief Complaint: Chest pain
Reason for ICU transfer: Coffee ground emesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy, [**2193-6-4**].
History of Present Illness:
Ms. [**Known lastname 497**] is a 67 year-old female with a history of HTN, GERD,
anxiety, ETOH abuse, who initially presented for a complaint of
"chest pain." She had increasing reflux for a couple months with
2 days of increased nausea and emesis (possibly with blood once)
and mid-epigastric heartburn that seemed to radiate to the back,
occurring especially at night and only partially responsive to
Prilosec. She was concerned this was an MI so saw her PCP who
referred her to the ED due to concern for unstable angina. She
was given ASA 325, SL NTG, and lorazepam 0.5mg prior to
transfer.
.
In the ED, initial vitals were T 97.2, HR 105, BP 108/71, RR 18,
O2 sat 99% 2L NC. Labs showed WBC 17, TnT <0.01, Na of 129
(~baseline) and mildly elevated LFTs. Tox screen pos for
barbituates (pt took a friend's Fioricet). CT abdomen was read
as "small bilateral PEs" on prelim read and interpreted as
pulmonary emboli, so pt was started on Heparin gtt. Blood cx
were sent. 2L NS given. Pt received Morphine, Donnatol,
Lorazepam, Zofran and GI cocktail for symptom control. Pt also
given SL NTG (with no improvement) in ED. Vitals prior to
transfer were 99.1, 116, 114/78, 26, 94%ra.
.
On the floor, she reported that her chest discomfort feels
unchanged, as if there were a mass underneath her sternum. She
states that she became more concerned when this sensation
started radiating to her back yesterday--this component has
resolved. There is no radiation to the jaw or arms. She has
never had a similar sensation when exerting herself--her
exercise tolerance exceeds 3 flights of stairs without stopping.
She appears somewhat groggy and states that this is likely due
to the medications she received in the ED. She estimates that
she drinks 2 glasses of wine per night. Per PCP notes and her
friend (present this evening) she likely drinks more.
.
ROS: Recent 2hr car ride from NH on friday. Denies recent LE
swelling. She is post-menopausal. She is UTD with screening
colonoscopy, but has not had a mammogram x 2yrs (her sister had
[**Name2 (NI) **] CA). No fevers, chills. No hematemesis or black or bloody
stools.
Past Medical History:
1.) HTN
2.) HLD
3.) GERD
4.) Anxiety
5.) Insomnia
6.) EtOH abuse (states 2 drinks/day)
Social History:
The patient is a former senior vice president of a marketing
company. She is currently unemployed, which is a significant
source of anxiety. She has lost her home and is currently living
at a friend's home. She is a widow with 2 children.
- ETOH: 2 glasses of wine or gin and tonic/day
- Denies current or past tobacco use.
- Denies IVDU
Family History:
Brother Alive CAD/PVD - Early; Hyperlipidemia; Hypertension
Father Deceased Diabetes - Type II; Hypertension; Stroke
Mother Deceased CAD/PVD - Early
Sister Alive [**Name (NI) 3730**] - Breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 100.2, 110/60s, 120, 94/RA, 22
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric
Neck: supple, no JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
As above, except:
VS: Afebrile, 118/70, 100, 96RA
Pertinent Results:
ADMISSION LABS:
[**2193-6-3**] 10:15AM GLUCOSE-197* UREA N-12 CREAT-0.7 SODIUM-129*
POTASSIUM-3.3 CHLORIDE-80* TOTAL CO2-25 ANION GAP-27*
[**2193-6-3**] 10:15AM CALCIUM-9.4 PHOSPHATE-2.8 MAGNESIUM-1.7
[**2193-6-3**] 10:15AM WBC-17.5* RBC-4.32 HGB-14.5 HCT-40.1 MCV-93
MCH-33.5* MCHC-36.1* RDW-13.0
[**2193-6-3**] 10:15AM NEUTS-94.3* LYMPHS-3.9* MONOS-1.7* EOS-0
BASOS-0.1
[**2193-6-3**] 10:15AM ALT(SGPT)-46* AST(SGOT)-49* ALK PHOS-139* TOT
BILI-1.4
[**2193-6-3**] 10:15AM LIPASE-24
[**2193-6-3**] 10:15AM cTropnT-<0.01
[**2193-6-3**] 10:15AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-POS
[**2193-6-3**] 01:55PM URINE HOURS-RANDOM
[**2193-6-3**] 01:55PM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2193-6-3**] 12:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2193-6-3**] 12:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG
[**2193-6-3**] 12:35PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2193-6-3**] 12:35PM URINE GRANULAR-1* HYALINE-1*
[**2193-6-3**] 12:35PM URINE MUCOUS-RARE
[**2193-6-3**] 10:15AM estGFR-Using this
[**2193-6-5**] 04:14AM BLOOD TSH-6.8*
[**2193-6-5**] 04:14AM BLOOD Free T4-1.0
[**2193-6-5**] 04:14AM BLOOD PTH-71*
[**2193-6-6**] 06:10AM BLOOD VITAMIN D, 25 OH, TOTAL 30
DISCHARGE LABS:
[**2193-6-10**] 07:10AM BLOOD WBC-6.2 RBC-3.35* Hgb-11.0* Hct-32.1*
MCV-96 MCH-32.9* MCHC-34.4 RDW-14.4 Plt Ct-505*
[**2193-6-9**] 06:50AM BLOOD PT-11.8 PTT-23.5 INR(PT)-1.0
[**2193-6-10**] 07:10AM BLOOD Glucose-101* UreaN-4* Creat-0.7 Na-134
K-4.2 Cl-98 HCO3-25 AnGap-15
PROCEDURES/IMAGING/RADIOLOGY:
[**2193-6-3**] CXR:
FINDINGS: AP and lateral views of the chest demonstrate normal
lung volumes. No large pleural effusion, pneumothorax or focal
consolidation. Heart size is normal. Hilar and mediastinal
silhouettes appear unremarkable. Pulmonary vasculature is
prominent. Bibasilar opacities are noted. Visualized osseous
structures are intact. Mild blunting of the left costrophrenic
angle is suggestive of small left pleural effusion.
IMPRESSION: Small left pleural effusion. O/w normal.
[**2193-6-3**] CT ABD/PELVIS:
CT OF THE ABDOMEN: Small bilateral pleural effusions are seen
with adjacent areas of compressive atelectasis. No discrete mass
or nodule is seen within the visualized lung bases. Heart is of
normal size without pericardial effusion. Small hiatal hernia is
noted. The liver is of homogeneous attenuation without distinct
lesion. There is no biliary ductal dilatation. Hepatic
vasculature is patent. The gallbladder, spleen, pancreas, and
adrenal glands are unremarkable. The kidneys enhance and excrete
contrast symmetrically without evidence of hydronephrosis or
renal
masses. Subcentimeter bilateral renal hypodensities are too
small to
characterize. Visualized small and large bowel loops are normal
in caliber without bowel wall thickening or obstruction. No free
air or free fluid within the abdomen. There is no mesenteric or
retroperitoneal lymphadenopathy. Intra-abdominal aorta and its
branches are notable for calcified atherosclerotic disease
without associated aneurysmal changes.
CT OF THE PELVIS: The bladder, distal ureters, and rectum appear
unremarkable. Sigmoid and ascending colon demonstrate extensive
divertiula
without associated inflammatory changes.
OSSEOUS STRUCTURES: Multiple remote left-sided rib fractures are
noted. No
suspicious lytic or sclerotic lesion is seen.
IMPRESSION:
1. No acute findings to account for patient's clinical
presentation.
2. Numerous diverticula involving the sigmoid and ascending
colon without
associated inflammatory changes.
3. Small bilateral pleural effusions with adjacent areas of
compressive
atelectasis.
4. Small hiatal hernia.
[**2193-6-3**] CT HEAD W/O CONTRAST
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass
effect or shift of normally midline structures. There is no
cerebral edema or loss of [**Doctor Last Name 352**]-white matter differentiation to
suggest an acute ischemic event. The sulci and ventricles are
prominent, likely age-related involutionary changes. A focal
hypodensity in the left basal ganglia may represent a lacune or
dilated perivascular space. Visualized soft tissues and osseous
structures are unremarkable. No acute fracture is seen. Mild
mucosal thickening of ethmoid air cells are noted. The remainder
of paranasal sinuses and mastoid air cells appear well aerated.
IMPRESSION:
1. No acute intracranial process.
2. Prominent sulci and ventricles, likely age-related
involutionary changes.
[**2193-6-4**] PORTABLE CXR:
A nasogastric tube courses below the diaphragm and terminates
within the stomach, likely at the level of the pylorus. There
is increased opacification of the left lung base with blunting
of the left
costophrenic angle, findings concerning for a new small left
pleural effusion and associated compressive atelectasis.
Aspiration or pneumonia could be considered within the
differential in the appropriate clinical circumstance. The
right lung remains clear. There is no pneumothorax, vascular
congestion, or overt pulmonary edema. Cardiomediastinal and
hilar contours are within normal limits and unchanged from
prior.
IMPRESSION:
1. Interval placement of a nasogastric tube, terminating at the
level of the pylorus.
2. New small left pleural effusion with probable associated
compressive
atelectasis. Left basilar aspiration or pneumonia could be
considered in the appropriate clinical circumstance.
[**2193-6-4**] CT CHEST WITH CONTRAST:
IMPRESSION:
1. Bilateral moderate-sized pleural effusions with associated
relaxation
atelectasis.
2. No central or segmental pulmonary embolus.
3. Right thyroid nodule of 1.2 cm, for which outpatient
ultrasound is
recommended.
[**2193-6-4**] EGD:
Impression: Acute esophageal necrosis (black esophagus) from the
proximal esophagus to the GE junction, with adherent clot and
small amount of contact bleeding during the endoscopy. Small
hiatal hernia. No fresh or old blood throughout. Otherwise
normal EGD to third part of the duodenum.
PENDING ON DISCHARGE:
[**2193-6-5**] DESMOGLEIN ANTIBODIES (1 AND 3): Results Pending
Brief Hospital Course:
67 year old female who presented to the ED with abdominal pain
and was found to have acute esophageal necrosis as source of
upper GI bleed.
#) Acute Esophageal Necrosis/Upper GI Bleed: The patient was
admitted for complaint of chest pain with preceding symptoms of
epigastric abdominal pain and upon admission to floor (HD#0),
had hematemesis x1 and melena x2. She was found to have a
10-point Hct drop and was transferred to the MICU, where she
received 2U PRBC; Hct was stabilized at 30 and increased
thereafter. Patient had EGD performed which demonstrated
circumferential acute esophageal necrosis. Etiology is unclear
but may have been exacerbated by alcohol use. She was started
on 72-hour course of IV proton pump inhibitor drip with addition
of PO sucralfate QID and maintenance of NPO status. Hct was
stabilized thereafter at 30, and she was transferred to the
floor on HD#2. Famotidine IV BID was started. On HD#4 she was
transitioned to clear fluids, and diet was advanced to soft diet
as tolerated. IV medications were switched to PO medications.
Serum H. pylori antibodies returned positive, and she was
started on PO liquid forms of clarithromycin and amoxicillin for
2-week course. She was also discharged on pantoprazole 40 mg
[**Hospital1 **], famotidine 20 mg [**Hospital1 **], sucralfate 1 gm qid until GI
follow-up on [**7-2**]. She will need a repeat EGD in 6 weeks. On
discharge, desmoglein Abs pending; this was sent as ddx for
acute esophageal necrosis includes pemphigoid.
.
#) Bilateral Pleural Effusions: Upon ED presentation, the
patient underwent abdominal CT, with ultimate read of a
left-sided pleural effusion. Further CXR HD#1 demonstrated as
moderate bilateral pleural effusions without known etiology, and
also [**Last Name (un) **]. Patient had no clinical signs, symptoms, or known
history of heart failure; TTE was obtained with normal EF (55%),
with impaired left ventricular relaxation pattern, indicative of
possible diastolic dysfunction. Patient was asymptomatic
throughout admission with O2 saturation of 96-98% on RA. This
should be followed up by her outpatient providers on discharge
to ensure resolution.
.
#) Chest Pain with Heparin Initiation: In the emergency
department, the patient's abdomen/pelvis CT with and without
contrast was preliminarily read as "small bilateral PE." She
was thought to have pulmonary embolism and was initiated on
heparin drip. Follow up with radiology confirmed lack of
pulmonary embolisms and intended read of bilateral pleural
effusion. Heparin drip was discontinued in the presence of a
GIB, and the patient was continued on Pneumoboots for DVT
prophylaxis. The patient was notified and an incident report was
filed; QI investigation is ongoing.
.
#) Incidental Thyroid Nodule: A 1.2 cm thyroid nodule with
heterogenous density was found incidentally on Chest CT [**2193-6-4**].
The patient has mild TSH elevation with normal free T4. She
will require outpatient ultrasound for follow-up of the thyroid
nodule.
.
#) Rib fractures: Chronic rib fractures of the left 9th-11th
posterior ribs were found incidentally on Chest CT. Patient
denies any trauma or associated event, but has risk factor of
alcohol abuse for trauma/falls. The patient's laboratory
evaluation included mildly elevated PTH (71), as well as mild
hypocalcemia (nadir of 7.1, up to 8.6 upon discharge),
indicating possible secondary hyperparathyroidism.
25OH Vit D level wnl at 30.
.
#) Alcohol Abuse: The patient endorses no greater than 2
drinks/day, but upon presentation her family friend expressed
concern about patient's drinking. She had minimal elevation in
LFTs upon presentation. She was initially maintained on a CIWA
scale, which was > 10 on HD#[**12-16**]. She demonstrated insight into
her alcohol use and expressed desire to drink less, and was seen
by social work to discuss resources for alcohol abuse.
.
#) Issues for Outpatient Follow-Up:
1.) Ultrasound evaluation of asymptomatic, incidentally
discovered 1.2 cm thyroid nodule; mildly elevated TSH and normal
free T4 during hositalization.
2.) Monitor for bone-mineral density, given incidental
left-sided 9th-11th rib fractures.
3.) Repeat chest imaging to ensure resolution of bilateral
pleural effusion.
4.) F/u pending desmoglein Ab
Medications on Admission:
1.) Prilosec OTC
2.) ASA 81 mg daily
3.) Lipitor 20mg daily
4.) Metoprolol 50mg daily
5.) Hydrochlorothiazide (though listed as allergy)
Discharge Medications:
1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day): Slurry.
Disp:*120 Tablet(s)* Refills:*0*
2. 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:*0*
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*0*
4. amoxicillin 250 mg/5 mL Suspension for Reconstitution Sig:
1000 (1000) mg PO Q12H (every 12 hours) for 13 days: Total
14-day course; last dose [**2193-6-22**].
Disp:*[**Numeric Identifier 7040**] mg* Refills:*0*
5. clarithromycin 250 mg/5 mL Suspension for Reconstitution Sig:
Five Hundred (500) mg PO Q12H (every 12 hours) for 13 days.
Disp:*[**Numeric Identifier 7923**] mg* Refills:*0*
6. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 13 days: If liquid formulation not available.
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute esophageal necrosis
H. pylori infection
Secondary diagnoses:
GERD
Anxiety
Alcohol abuse
Paraesophageal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
O2 saturation: 96-98% on RA at rest and with ambulation.
Discharge Instructions:
You were initially referred to [**Hospital1 18**] due to concern for chest
pain. In the emergency department, you had a chest x ray, ekg as
well as imaging of your abdomen (Abdomen/Pelvis CT). The
preliminary read was initially interpreted incorrectly as
showing blood clots within your lungs, and you were started on a
blood thinner, called Heparin. Afterwards, you unfortunately
developed bleeding from your GI tract, so you were given a blood
transfusion and had an imaging study of your upper GI tract
(Esophagogastroduodenoscopy, or EGD), which demonstrated dead
tissues (necrosis) in the inside layer of your esophagus. You
were placed on an IV medications (Pantoprazole and Famoditine)
to decrease your stomach acid, given Sucralfate as a protective
layer to coat your esophagus, and did not eat or drink anything
by mouth. Once you were able to eat soft solids, you were
transitioned to oral forms of your medications, and you also
started on oral antibiotics (clarithromycin and amoxacillin) due
to a type of stomach infection (H. Pylori) that can increase
stomach acid and cause ulcers which may lead to abdominal and
chest pain. You will need to follow up with GI in sevearl weeks
and repeat an Esophagogastroduodenoscopy (EGD) in 6 weeks.
We held your blood pressure medication while in the hospital.
Your blood pressure was well controlled. Please check your blood
pressure daily at home. If it rises above 140 or 150, please
contact your PCP about restarting your medications.
Please also speak with your doctor [**First Name (Titles) **] [**Last Name (Titles) **] of your
anxiety.
We made the following changes to your medications:
1.) We STARTED Pantoprazole
2.) We CHANGED Ranitidine to Famotidine.
3.) We STARTED Sucralfate SLURRY.
4.) We STARTED Clarithromycin for treatment of C. difficile
infection.
5.) We STARTED Amoxacillin for treatment fo C. difficile
infection.
6.) We HELD Metoprolol. Restart as your blood pressure tolerates
per your doctor.
7.) We HELD Hydrochlorothiazide. Restart as your blood pressure
tolerates per your doctor.
8.) We STOPPED Aspirin
Followup Instructions:
Please follow up with your PCP. [**Name10 (NameIs) **] should review all your
medications and your pending vitamin D level at this visit:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 89020**]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appt: [**6-13**] at 9:20am
You are also scheduled to follow-up with GI.
Department: GASTROENTEROLOGY
When: TUESDAY [**2193-7-2**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14122**]
Admission Date: [**2193-6-3**] Discharge Date: [**2193-6-10**]
Date of Birth: [**2125-12-2**] Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending:[**First Name3 (LF) 1880**]
Brief Hospital Course:
# Anxiety: Pt acknowledged anxiety especially in setting of job
loss. She had expressed reluctance to take medications for this
in the past, but we recommended following up with her PCP to
address this.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1881**] MD [**Last Name (un) 1882**]
Completed by:[**2193-6-11**]
|
[
"041.86",
"530.89",
"511.9",
"300.00",
"807.03",
"530.81",
"285.1",
"588.81",
"276.1",
"241.0",
"530.82",
"305.00",
"276.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
19384, 19549
|
19157, 19361
|
354, 400
|
15684, 15684
|
3838, 3838
|
18008, 19134
|
3029, 3230
|
14535, 15475
|
15525, 15525
|
14373, 14512
|
15892, 17516
|
5214, 9966
|
3270, 3742
|
15612, 15663
|
9980, 10046
|
17545, 17985
|
257, 316
|
428, 2547
|
3854, 5198
|
15544, 15591
|
15699, 15868
|
2569, 2658
|
2674, 3013
|
3767, 3818
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,718
| 195,149
|
17483
|
Discharge summary
|
report
|
Admission Date: [**2152-4-12**] Discharge Date: [**2152-5-1**]
Date of Birth: [**2078-5-1**] Sex: F
Service: HEPATOBILIARY SURGERY SERVICE
CHIEF COMPLAINT: ERCP pancreatitis.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female who had presented to an outside hospital with symptoms
consistent with upper respiratory infection. The patient was
started on Amoxicillin when follow-up labs indicated
increased LFTs. Further evaluation revealed thickened
gallbladder wall, 4.2 mm, with small 6.5 x 3.8 x 3.6 mm
shadow in the neck of the gallbladder with common bile duct
approximately 10.6 mm.
An ERCP was performed which revealed common bile duct with
definite impression of cut-off in biliary system and
underfilling of right branch. A stent was therefore placed.
Following this stent placement, the patient developed
increased nausea and abdominal discomfort localized in the
epigastric region with subsequent development of mild
jaundice.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Vitamin B, Folic Acid.
PHYSICAL EXAMINATION: General: The patient was a
well-developed, well-nourished female in no apparent
distress. HEENT: At the time of discharge there was no
evidence of scleral icterus. Moist mucous membranes. No
evidence of oral ulcers. No evidence of cervical
lymphadenopathy. Cranial nerves II-XII intact. Chest:
Clear to auscultation bilaterally. Heart: Regular, rate and
rhythm. No murmurs. Abdomen: Soft, nontender,
nondistended. Extremities: No evidence of edema or rash,
although there was flying resting tremor with mild cogwheel
rigidity.
LABORATORY DATA: On [**5-1**] white blood cell was 9.9,
hematocrit 29.4, platelet count 414; sodium 130, potassium
3.6, chloride 96, bicarb 25, BUN 21, creatinine 0.8, glucose
121; ALT 74, AST 69, amylase 168, lactate 172, total
bilirubin 0.7, albumin 3.0, calcium 9.7, phos 3.4, magnesium
1.8.
HOSPITAL COURSE: The patient was a 76-year-old female with
post ERCP pancreatitis admitted to the Surgical Intensive
Care Unit for close observation.
CT of the abdomen performed at the time of admission showed
positive stranding around the pancreas with stent in place.
At the time of admission, the patient was tachycardiac with
pulse of 110, with decreased urine output. After placing a
Swan, the patient was aggressively fluid resuscitated with
repletion of electrolytes. Two units of packed red blood
cells were administered, and Zosyn was empirically initiated.
With acute elevation of pancreatic enzymes resolving, the
patient was transferred to the floor on hospital day #3. A
repeat CT scan of the abdomen was performed which revealed
worsening pancreatic inflammation at the neck of pancreas.
During this period, the patient continued to spike fever, and
a protocol of panculturing was performed every 24 hours with
each fever spike. Cultures continued to be negative, and
PICC line was inserted to provide nutritional support.
By [**4-24**], the patient's clinical picture began to improve
with minimal abdominal discomfort and decreasing pancreatic
enzyme levels. Follow-up CT scan was obtained which revealed
decreased fat stranding, inflammation and decreased
mesenteric fluid. With this improvement, the patient was
initiated on p.o. fluids.
Neurology was consulted additionally to evaluate for
persistent Parkinsonism-like tremor. As a result, Metoprolol
was initiated with Mysoline. The decision was made on [**5-1**] to discharge the patient to home with resolution of
pancreatitis.
At the time of discharge, the patient was tolerating a
regular diet without any abdominal discomfort, and white
blood cell count was normalized with amylase and lipase
decreasing.
DISCHARGE STATUS: To home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS: Status post ERCP, acute pancreatitis.
DISCHARGE MEDICATIONS: Protonix 40 mg p.o. b.i.d., Haldol
0.5 mg p.o. t.i.d., Lopressor 37.5 mg p.o. b.i.d., Mysoline
75 mg q.5 days.
FOLLOW-UP: The patient was instructed to follow-up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week. The patient was also instructed
to follow-up with the neurologist by calling the [**Hospital 878**]
Clinic at the [**Hospital6 256**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 48829**]
MEDQUIST36
D: [**2152-5-1**] 16:24
T: [**2152-5-1**] 15:25
JOB#: [**Job Number 48830**]
|
[
"997.4",
"576.2",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3935, 4576
|
3872, 3911
|
1106, 1130
|
2011, 3818
|
1034, 1079
|
1153, 1993
|
178, 198
|
227, 980
|
1003, 1010
|
3843, 3850
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,049
| 103,514
|
24777
|
Discharge summary
|
report
|
Admission Date: [**2175-10-30**] Discharge Date: [**2175-11-8**]
Date of Birth: [**2115-8-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
Incision and drainage of right groin abscess
History of Present Illness:
60 YO M w CHF, distant MI, VT s/p pacer/ICD/VT ablation who
presented with cloudy thinking and dizziness for 1 week in the
setting of polydypsia and polyuria.
.
Symptoms started about 1 week prior to presentation the [**Hospital1 18**],
with anorexia and sleeping constantly, followed by incontinence,
weakness, and dizziness. 2 days prior to admission, his wife
noted that he became disoriented, which persisted until the day
of admission, which was Monday evening [**10-30**], when the patient
requested to be taken to the hospital. He was transported by
Ambulance because he felt unable to make it down the stairs with
assistance only from his wife. [**Name (NI) **] never lost consiousness. Of
note, he did not take any of his medications the weekend prior
to admission because he dropped his pill box and his wife did
not know his usual regimen.
.
In the ED, he was noted to have a BS of >800, creat 2.8 (from
1.5) with a gap but no ketones. He was given levaquin and
admitted to the ICU for insulin gtt which was stopped within
24h. [**Last Name (un) **] was consulted and recommended starting lantus and
humalog. His BS decreased to 100s-200s but then his BS increased
to 300s on MICU day 2, [**11-1**], so his glargine was increased and
his humalog sliding scale was titrated up. His mental status
improved back to his baseline with improvement in his BS.
.
The patient has a known sacral decubitus ulcer, which he has had
for 3 weeks. He had no signs or symptoms of infection per his
wife - no fever, chills, cough, abdominal pain, diarrhea,
dysuria.
.
Never diagnosed with diabetes. Does not take diabetes
medications at home.
Past Medical History:
CAD s/p inferoposterior MI with PTCA [**2159**], [**2173**]
Dyslipidemia
Hypertension
Chronic Systolic Heart Failure, EF 25-30%.
Nonsustained ventricular tachycardia with ICD [**8-/2170**]
S/p VT ablation [**4-/2174**]
Hypertension
Hyperlipidemia
Obstructive sleep apnea
H/o vitamin B12 deficiency
Nephrolithiasis
Peripheral neuropathy
Remote history of peptic ulcer disease
GERD
Status post tonsillectomy and adenoidectomy.
Social History:
lives with wife, works part time in computer, quit smoking
couple months ago and uses an electronic tobacco relacement,
denies ETOH/IVDU
Family History:
Father - atrial fibrillation
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Otherwise non-contributory
Physical Exam:
VSS 98 74 97/54 25 96% 2L
GEN: Alert, oriented to person, place, but not time. Poor
attention - able to count 10 to 1, but not months of year.
HEENT: PERRLA. MMM. no LAD. neck supple.
Cards: Quiet heart sounds. Limited auscultory exam. Pulse
regular.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: Protuberant obese abdomen. NT, +BS. no rebound/guarding.
neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
*Sacral Decubitus Ulcer: Erythematous gluteal cleft with
erosions to subcutaneous tissue
*Groin Rashes: Right > Left crural rashes, with R > L edema and
warmth
Brief Hospital Course:
60-year-old male with hx of CHF (EF 40%), MI [**2159**], paroxysmal
ventricular tachyarrhythmia s/p pacemaker/ICD placement and VT
ablation in [**4-/2174**] presenting with altered mental status in
setting of severe hyperglycemia.
.
#Hyperosmolar hyperglycemic non-ketotic coma (HHNK):
Pt did not have diagnosis of DM on admission. Pt presented with
altered mental status and labs concerning for HHNK - blood
glucose [**Telephone/Fax (1) 62434**] glucose in UA, anion gap of 18, with absence
of ketones in urine favoring HHS over DKA. A1c on [**1-/2175**] was
6.5; A1c on admission was 13.3. The patient was placed on an
insulin drip for approximately 90 minutes. [**Last Name (un) **] Diabetes
Center was consulted and he was transitioned to a Lantus +
Humalog insulin sliding scale regimen and aggressively volume
resuscitated with 4L NS. Hyperglycemia rapidly improved and gap
closed. His lantus was gradually titrated to 30 units [**Hospital1 **] with
appropriate sliding scale with good glycemic control. In the
setting of WBC of 20 on admission, the trigger of the HHNK was
thought to be infectious with the source ultimately found to be
a right groin cellulitis as detailed below. Other infectious
etiologies were considered, but the work-up was negative, with
CXR showing no consolidation, and UA/UC negative.
.
#Right groin ulcer:
Right groin ulcer identified upon physical exam following
transfer from ICU. Evaluated by surgery who ultimately
performed I&D, recovering necrotic tissue that ultimately
cultured Staph Aureus and coagulase negative Staph sensitive to
Bactrim. Treated with IV Vancomycin and Zosyn for a total
course of 14 days and transitioned to Bactrim prior to
discharge.
.
#Hyponatremia:
Na 119 on admission due hyperglycemia. Normalized with treatment
of HHNK.
.
#Altered mental status:
Altered mental status was most likely secondary to HHNK. With
resolution of HHNK, mental status cleared markedly and pt was
oriented x 3 and answered questions appropriately once
transferred to the floor.
.
#Acute renal failure:
Cr was 2.8 on admission, up from 1.5 one month prior. Initially
acute renal failure was believed to be prerenal as pt appeared
severely volume depleted. Cr continued to rise, peaking at 3.6,
despite IV hydration. In setting of elevated CKs, acute renal
failure was attributed to rhabdomyolysis for which he was given
additional IV hydration, although this rise in CK was ultimately
attributed to a significant right groin abscess. Nephrotoxic
meds, including his home lasix, allopurinol, diovan and
spironolactone, were held during the majority of his hospital
course. As the patient recovered from his HHNK, his renal
function improved markedly to a creatinine of 1.8. He was
eventually restarted on his lasix and discharged on his home
regimen of allopurinol, diovan, and spironolactone.
.
#Anemia, guiac positive stool (OUTPATIENT FOLLOW-UP REQUIRED)
The patient had an initial Hgb of 14 and Hct of 40.1 on the day
of admission [**10-30**]. Over the next three days he developed a
slight anemia that remained stable at approximately Hgb 10 Hct
29 for the remaining five days of his administration. This was
attributed to anemia of inflammation. He did have one episode
of blood stained stool, and was guiac positive. Upon interview
the patient attributed this to a known history of hemorrhoids.
Given his age, however, outpatient colonoscopy is still
appropriate to work up his anemia and bloody stool. The patient
has otherwise been asymptomatic with regard to this anemia.
.
#Depression:
The patient has a history of depression, and his daughter
expressed concern near the end of his hospitalization that he
may try to harm himself. The patient denied suicidal ideation
and made no concerning statements during his hospital course.
He was seen by psychaitry, who cleared him for discharge and
confirmed no suicidal ideation.
.
#Chronic Systolic CHF, LV aneurysm, INR:
Pt with hx of systolic CHF with EF 40% on TTE. He required IV
hydration for both HHS and initial concern for rhabdomyolysis
but this was given judiciously given his reduced EF. TTE was
obtained that showed unchanged EF of 40% and mid inferior and
inferolateral akinesis which had previously been hypokinetic on
TTE from [**3-/2175**]; there was also an inferobasal left ventricular
aneurysm. Lasix was held due to acute renal failure until late
in his hospitalization but restarted several days prior to
discharge in the setting of dependent pitting edema. On
discharge, lungs were clear to auscultation and the patient was
clinically mildly hyper- to eu-volemic. Per OMR records, pt had
been started on coumadin after ablation for LV aneurysm. INR was
supratherapeutic 2 days prior to discharge in the setting of
antibiotics; coumadin was held for 1 day then restarted; the
patient was discharged on a lower dose than his prescribed 5mg
daily. **His INR will need to be followed-up and coumadin
redosed 2-3 days after discharge.**
.
#CAD:
Pt with extensive cardiac comorbidities, including CAD, CHF (EF
40%), prior MI, and paroxysmal ventricular tachyarrhythmia. MI
was considered as a possible etiology for his acute
hyperglycemic presentation. EKG was grossly unchanged with new
T wave inversions in V2-3. Troponin was elevated to 0.03 on
admission but this was in setting of acute renal failure. CK
was elevated to 600s on admission and increased to [**2165**] for
reasons discussed above. As TTE was grossly unremarkable,
suspicion for MI was low. He was continued on his aspirin;
statin was held due to elevated CKs in the setting of initial
concern for rhabdomyolysis and restarted on discharge.
.
#Paroxysmal Ventricular tachyarrhythmia:
Patient was s/p ablation and s/p pacer/ICD. Monitored on tele
for the duration of the hospitalization with no episodes of VT
or defibrillation.
.
#Hypothyroidism:
Pt had history of hypothyroidism and had been started on
levothyroxine as outpatient. He was treated with levothyroxine
and his TSH remained normal. He reported noncompliance with
levothyroxine. **[**Last Name (un) **] diabetes consult recommended thyroid
function tests as outpatient.**
.
Remained full code for the duration of the hospitalization.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
AMIODARONE - 200 mg Tablet - 2 Tablet(s) by mouth daily
CALCITRIOL - 0.25 mcg Capsule - one Capsule(s) by mouth every
other day
CARVEDILOL - 12.5 mg Tablet - 1 Tablet(s) by mouth twice a day
VITAMIN D 400 UNITS - - take 1 tablet by mouth twice a day
DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
FUROSEMIDE - 40 mg Tablet - one and [**1-7**] Tablet(s) by mouth twice
a day
GABAPENTIN [NEURONTIN] - 300 mg Capsule - as directed Capsule(s)
by mouth 2 TID and 3 qhs
HYDROMORPHONE [DILAUDID] - 4 mg Tablet - 1 Tablet(s) by mouth
four times a day as needed for for pain
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [**1-7**] Tablet(s) by mouth at
bedtime
NIACIN [NIASPAN] - 500 mg Tablet Sustained Release - 1 Tablet(s)
by mouth once a day
NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q3 minutes as needed for chest pain
OXYCODONE - 5 mg Tablet - [**1-7**] Tablet(s) by mouth four times a
day
as needed for for nueropathy
PRAMIPEXOLE - 0.25 mg Tablet - 1 Tablet(s) by mouth once a day
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
SPIRONOLACTONE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth
once a day
VALSARTAN [DIOVAN] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
WARFARIN - 5 mg Tablet - [**1-7**] Tablet(s) by mouth once a day as
[**Name8 (MD) **]
MD [**First Name (Titles) **] [**Last Name (Titles) 62435**]IN [JANTOVEN] - 2 mg Tablet - [**2-8**] Tablet(s) by mouth once
a
day
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
B COMPLEX VITAMINS [B-50] - Tablet - 1 Tablet(s) by mouth once
a day
CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by
mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
ERGOCALCIFEROL (VITAMIN D2) - 400 unit Capsule - 1 Capsule(s) by
mouth once a day
MAGNESIUM - (Prescribed by Other Provider) - 250 mg Tablet - one
Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - (Prescribed
by Other Provider) - 1,000 mg-5 unit Capsule - 1
SENNA - 8.6 mg Capsule - 1 Capsule(s) by mouth twice a day as
needed for constipation
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times
a day.
9. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
10. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime.
12. niacin 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily ().
15. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
17. valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
21. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
23. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
24. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
25. magnesium 250 mg Tablet Sig: One (1) Tablet PO once a day.
26. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO once a day.
27. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
28. insulin lispro 100 unit/mL Insulin Pen Sig: Two (2) units
Subcutaneous four times a day: According to scale.
Disp:*440 units* Refills:*2*
29. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
(30) units Subcutaneous twice a day: Before breakfast and before
bedtime.
Disp:*1800 units* Refills:*2*
30. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
31. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Disp:*500 grams* Refills:*2*
32. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
33. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
Disp:*1 tube/unit* Refills:*0*
34. Kerlex Sig: One (1) Sterile dressing twice a day: Twice
daily dressing changes for right groin wound.
Disp:*60 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Diabetes Mellitus II
Hyperosmolar Hyperglycemic Non-Ketotic coma (HHNK)
Right groin abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
1. Be sure to attend your follow-up appointment with your
primary doctor Dr. [**Last Name (STitle) 4922**] on Tuesday [**2175-11-14**] at 10:45 AM.
You have some new medications and will need to make changes to
how you take care of yourself to prevent future episodes like
this, and your primary doctor will be the best person with which
to discuss these issues.
Location: [**State **] ([**Location (un) **], MA) [**Location (un) **]
2. Be sure to attend your appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] at
the [**Last Name (un) **] Diabetes Center on Thursday, [**2175-11-9**] at 9 AM for
your continued diabetes care.
Location: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
3. Be sure to attend your appoint with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] at
[**Hospital1 **] Surgical Specialties for continued care of your right groin
wound on Monday, [**11-13**] at 3:30 PM.
Location: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
|
[
"585.9",
"682.2",
"707.03",
"428.0",
"403.90",
"272.4",
"V45.82",
"348.30",
"707.25",
"250.22",
"707.8",
"327.23",
"412",
"428.22",
"414.01",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.39",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
15188, 15274
|
3608, 5415
|
336, 382
|
15410, 15410
|
15560, 16689
|
2669, 2813
|
12088, 15165
|
15295, 15389
|
9840, 12065
|
2828, 3585
|
276, 298
|
410, 2049
|
15425, 15537
|
2071, 2498
|
2514, 2653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,384
| 148,754
|
9772
|
Discharge summary
|
report
|
Admission Date: [**2134-2-28**] Discharge Date: [**2134-3-2**]
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) 783**]
Chief Complaint:
Oozing from catheter site
Major Surgical or Invasive Procedure:
Attempt at central access
History of Present Illness:
39 yo F with ESRD [**3-10**] IgA nephropathy, recently admissted
[**Date range (1) 32930**] for HD access (R fem tunneled cath placed [**2-9**] --> c/b
venous thrombosis; [**2-17**] temp 102.3 --> vanco (then
linezolid)/levo; [**2-24**] PD cath attempted but pt brady/hypotense
in OR --> SICU; [**2-26**] R fem HD cath replaced; [**2-26**] and [**2-27**] HD
(3-4 L removed); [**2-27**] rehab). Felt dizzy and small ooze from
catheter so went to ED where was was bradycardic and
hypotensive. She received 2 amps CaGluc and atropine and her HR
improved to 70s.
Past Medical History:
1. ESRD due to IgA nephropathy 5. GERD
2. Schizoaffective disorder 6. Cardiomyopathy
3. Depression 7. Hypothyroidism
4. Anemia 8. GI bleed
PSH:
s/p L upper & lower AV fistula - failed
s/p R AV fisula basilic v transposition - failed
s/p R forearm AV graft - failed
s/p PD catheter '[**27**] - failed
central venous stenosis - R brachiocephalic v.
occlusion of inominate v.
s/p R arm brachial->axilla AV graft ([**2133-10-9**])
s/p thrombectomy & angioplasty of outflow stenosis ([**2133-10-11**])
s/p thrombectomy ([**2133-10-23**])
s/p thrombectomy and revision of R arm AV graft ([**2133-11-12**])
s/p thrombectomy of R arm AV graft ([**2133-11-16**], [**2133-12-15**])
s/p excision of infected R arm AV graft ([**2133-12-25**])
Social History:
Lives at [**Location (un) **] Health and Rehab center, unemployed, no
tobacco, alcohol, or recreational drug use.
Family History:
Non-contributory.
Physical Exam:
ED: BP 70/45 HR62
On xfer from micu:
98.6 68 117/82 16 94%RA-->96%2L
Lying in bed not in distress
PERRLA, M&O clear and moist, neck supple
coarse BS throughout
Nl S1/S2
Soft, NT, ND, NABS
warm X 4, no edema
CNII-XII intact, moving all four extremities
Constricted affect but speaking in full, appropriate sentances
On DC:
98.9 120/72 83 22 98%2L
Lying in bed snoring loudly and difficult to arouse
PERRLA, M&O clear and moist, neck supple
loud upper airway sounds
Nl S1/S2
Soft, NT, ND, NABS
warm X 4, no edema
CNII-XII intact, moving all four extremities
Constricted affect, anxious to return to sleep
Pertinent Results:
INDICATIONS: Portable chest of [**2134-2-28**] with clinical
indication of hypoxia.
FINDINGS:
There has been interval removal of an endotracheal tube and
nasogastric tube.
A catheter is identified within the abdomen, projecting to the
right of the
lumbar spine and extending just above the thoracoabdominal
junction to overlie
the right atrium. This may represent a venous catheter within
the IVC
extending into the right atrium. Alternatively, it could be a
structure
external to the patient. There is stable cardiac enlargement,
but there is no
evidence of congestive heart failure, allowing for accentuation
of vessels by
low lung volumes. No confluent areas of consolidation are
observed. Note is
made of a vascular stent in the right subclavian,
brachiocephalic and superior
vena cava regions.
IMPRESSION:
No evidence of pulmonary edema or pneumonia.
Catheter tip projecting over lower right atrium. Please see
description
above.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
-
-
HISTORY: Endstage renal disease, hypotension, hemodialysis
catheter placement
in the right groin, and failed on the left attempted peritoneal
drain.
TECHNIQUE: Noncontrast axial images through the abdomen and
pelvis.
CT ABDOMEN W/O CONTRAST:
There is bibasilar atelectasis. There is a small left pleural
effusion and a
small pericardial effusion. The liver is normal. The spleen is
normal. The
gallbladder contains contrast, likely from vicarious excretion.
A catheter, a
right femoral line, is seen extending to the IVC. Residual
contrast is seen
within the colon, presumably from a recent oral contrast load.
There is
cardiomegaly. Both kidneys are atrophic and contain scattered
calcifications
and cysts. The pancreas is normal. Both adrenal glands are
normal. There is
no free air or free fluid in the abdomen. No pathologically
enlarged
mesenteric or retroperitoneal lymph nodes. There are several
dilated loops of
small bowel in the right upper quadrant, likely representing a
localized
ileus. Surgical staples are seen in the right anterior abdominal
wall, with
some adjacent stranding, likely related to a recent procedure.
There is no
evidence of a retroperitoneal hemorrhage.
CT PELVIS W/O CONTRAST :
The bladder contains contrast, likely from the recent procedure.
There is a
catheter in the right femoral vein with a surrounding sheath. In
the right
thigh, in the adductor musculature, is a higher attenuation
region, likely
representing a hematoma. This measures approximately 4 x 2.5 cm.
There is
diffuse anasarca. There is a fat-containing hernia in the
anterior lower
abdominal wall. There is no free fluid in the pelvis. Residual
contrast is
seen in the rectum and colon.
BONE WINDOWS: There are no suspicious osteolytic or sclerotic
lesions.
IMPRESSION
1. Small hematoma in the right adductor musculature of the
thigh. This is
incompletely imaged.
2. No evidence of retroperitoneal hematoma.
3. Localized small bowel ileus in the right upper quadrant.
These findings were discussed with Dr. [**Last Name (STitle) **] in the Emergency
Department.
-
-
Portable chest of [**2134-2-28**], compared to previous study
of earlier the
same date.
CLINICAL INDICATION: Hypoxia.
Vascular stents remain in place. A catheter located to the right
of the
lumbar spine is also again demonstrated with the tip projecting
in the region
of the inferior aspect of the right atrium, unchanged. There is
stable
widening of the cardiac and mediastinal contours. There has been
development
of hazy increased opacity in the right hemithorax with loss of
sharp
definition of the right hemidiaphragm. There is also new patchy
opacity in
the left retrocardiac region.
IMPRESSION:
1) New hazy opacity in right hemithorax, most likely due to a
layering
pleural effusion.
2) New patchy left retrocardiac opacity, which may relate to
atelectasis or
aspiration.
[**2134-3-2**] 05:22AM BLOOD WBC-8.7 RBC-3.05* Hgb-9.4* Hct-29.4*
MCV-96 MCH-31.0 MCHC-32.2 RDW-18.6* Plt Ct-213
[**2134-3-1**] 04:34AM BLOOD WBC-12.9* RBC-3.21* Hgb-9.8* Hct-29.6*
MCV-92 MCH-30.7 MCHC-33.3 RDW-18.7* Plt Ct-249
[**2134-2-27**] 11:30AM BLOOD WBC-14.0* RBC-2.68* Hgb-8.6* Hct-26.1*
MCV-97 MCH-32.2* MCHC-33.1 RDW-17.4* Plt Ct-219
[**2134-3-1**] 04:34AM BLOOD Neuts-85.2* Bands-0 Lymphs-8.8* Monos-4.7
Eos-0.8 Baso-0.4
[**2134-2-28**] 05:20AM BLOOD Neuts-73.0* Lymphs-15.0* Monos-8.2
Eos-3.4 Baso-0.5
[**2134-2-27**] 11:55PM BLOOD Neuts-78.0* Lymphs-11.6* Monos-7.7
Eos-2.2 Baso-0.5
[**2134-3-1**] 04:34AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**]
[**2134-3-2**] 05:22AM BLOOD Plt Ct-213
[**2134-3-2**] 05:22AM BLOOD PT-13.5 PTT-26.3 INR(PT)-1.2
[**2134-2-28**] 05:20AM BLOOD PT-13.7* PTT-24.7 INR(PT)-1.2
[**2134-2-27**] 11:30AM BLOOD Plt Ct-219
[**2134-3-2**] 05:22AM BLOOD Fibrino-432*
[**2134-3-2**] 05:22AM BLOOD Glucose-78 UreaN-17 Creat-5.4*# Na-144
K-3.4 Cl-104 HCO3-30* AnGap-13
[**2134-2-27**] 11:55PM BLOOD Glucose-109* UreaN-29* Creat-7.8*# Na-139
K-3.5 Cl-97 HCO3-25 AnGap-21*
[**2134-3-1**] 03:20AM BLOOD CK(CPK)-125
[**2134-2-28**] 07:29PM BLOOD CK(CPK)-146*
[**2134-2-28**] 04:31PM BLOOD CK(CPK)-146*
[**2134-3-1**] 03:20AM BLOOD CK-MB-3 cTropnT-0.19*
[**2134-3-2**] 05:22AM BLOOD Calcium-9.0 Phos-3.4# Mg-1.8
[**2134-3-1**] 03:20AM BLOOD Calcium-9.1 Phos-5.3*
[**2134-2-27**] 11:55PM BLOOD Calcium-9.0 Phos-3.9# Mg-1.7
[**2134-2-27**] 11:30AM BLOOD Calcium-9.9 Phos-6.9* Mg-2.0
[**2134-2-28**] 04:31PM BLOOD TSH-13*
[**2134-2-28**] 04:31PM BLOOD Free T4-1.2
[**2134-2-28**] 08:58PM BLOOD Cortsol-42.1*
[**2134-2-28**] 07:29PM BLOOD Cortsol-18.1
Brief Hospital Course:
[**2-27**] presented to ED [**3-10**] oozing at catheter site s/p
non-mechanical fall. Hypotense in ED (75/27) with sinus brady.
In ED given 2 Uprbcs, 2 L IVF--> no change in BP, linezolid,
levoflox, atropine-> appropriate HR response, ceftriaxone,
calcium gluconate. Unable to get central access.
-
Pt was originally admitted to Tx Surgery-->MICU. CCB and BB
held. Overnight, +850cc and decreased pressor requirements and
not brady so called out to the floor.
-
Floor course:
-
Hypotension - I agree with cardiology assesment that pt was
agressive dialyzed thus hypotensive and unable to mount
tachycardic response given multiple nodal blocking agents. Pt
now off pressors and pressure of 117/82 w/HR 68. Maintained off
nodal agents and discharged off nodal blocking agents.
-
Arrythmia - h/o accelerated idioventricular rhythm admitted with
1st degree heart block. Held nodal blocking agents. EP
followed. Discharged on [**Doctor Last Name **] of Hearts to correlate sx
w/rhythm.
-
ESRD - HD per renal (T/Th on DC). Con't nephrocaps and epogen.
-
Bacteremia - Hx coag neg staph resistent to oxacillin.
Abacteremic since [**2-22**]. Will complete linezolid course for
previously dx'd line infxn.
-
Venous thrombosis - We continued coumadin and monitored coags.
Will need OP INR check in several days. Tried to call PCP to
make appointment, but office not open today so patient/ECF will
call.
-
Psych (schizoaffective) - continued home meds
-
Hypothyroid - TSH high 13.4, free t 4 nl. continued synthroid
-
PPx - PPI, coumadin were continued
-
Code - Full throughout her stay
-
Comm: [**Name (NI) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 32931**]; cousin [**Name (NI) **] [**Name (NI) 32932**]
[**Telephone/Fax (1) 32933**]
-
Access: IR cannot do any line. Current line is re-placement at
site of previous bacteremia. Renal plan is to continue using
this line for now. Peritoneal dialysis may be needed in future.
-
[**Name (NI) 11053**] Pt was DCed [**3-2**] after HD on [**Doctor Last Name **] of Hearts to [**Location (un) 32934**] Health Rehab.
Medications on Admission:
Linezolid 600 [**Hospital1 **]
DiH 20 tid
Lopressor 25 [**Hospital1 **]
Synthroid 75 QD
Prolixin 20 [**Hospital1 **]
Thorazine 25 [**Hospital1 **]
Remeron 45 QD
Klonopin .75 [**Hospital1 **]
Protonix 40 QD
ASA 81 QD
Plavix 75 QD
Coumadin 1.5 QD
Albuterol
Atrovent
Epogen
Reglan 10 tid
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Fluphenazine HCl 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday): Per renal at hemodialysis.
12. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Health & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Hypotension, bradycardia
Discharge Condition:
Fair
Discharge Instructions:
Please take all medications as directed. Please use [**Doctor Last Name **] of
Hearts Monitor as directed when you have symptoms. Please
attend all followup appointments as directed. If you experience
shortness of breath, chest pain, palpitations, light-headedness,
dizziness, or any other symptoms of concern to you, please call
your doctor or return to the emergency room immediately.
Followup Instructions:
Hemodialysis T/Th as before.
I attempted to make an appointment for you with your PCP, [**Name10 (NameIs) **]
their office is closed today. You will need to call your PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) 10900**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 32935**] immediately for a followup
appointment within one week to adjust your coumadin dose and
check up on your blood pressure.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"530.81",
"E879.1",
"996.62",
"285.9",
"790.7",
"458.21",
"V58.61",
"996.73",
"295.70",
"583.89",
"276.5",
"426.11",
"244.9",
"425.4",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11910, 12011
|
8351, 10423
|
426, 454
|
12080, 12086
|
2643, 8328
|
12524, 13063
|
1976, 1995
|
10758, 11887
|
12032, 12059
|
10449, 10735
|
12110, 12501
|
2010, 2624
|
361, 388
|
482, 1044
|
1066, 1829
|
1845, 1960
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,244
| 165,022
|
49809
|
Discharge summary
|
report
|
Admission Date: [**2108-10-5**] Discharge Date: [**2108-10-18**]
Date of Birth: [**2058-8-12**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
Endotracheal Intubation
DC Cardioversion
Implantable Automatic Cardioverter Defibrillator placement
History of Present Illness:
50 yo M with h/o asthma, who was found unresponsive and shaking
by his son. [**Name (NI) **] reports he was unresponsive for about 5 minutes,
called 911 who was there withn several minutes. Per EMS note, pt
found pulseless, apneic. AED read no shock. Pt intubated. Pt
then went into Vfib at 15:34 and was shocked, converted to sinus
brady, given lidocaine bolus, converted to Vfib and shocked
again. He went into sinus and was bolused with lidocaine again,
then went into Vfib ->then PEA, given epi with CPR, ->VT
shocked, ->sinus ->VT and shocked ->sinus ->VT and shocked ->
sinus continued, started on lidocaine drip. This period of
shocks lasted from 15:34 to 15:41. He arrive to [**Location (un) **] at
15:50, while there he was coded from 15:50-16:02, shocked 4 more
times, given calcium, epi, amiodarone 150 mg load and drip,
dopamine. He was med flighted to [**Hospital1 18**], on arrival to ED, he
lost pulse, given epi 1mg x2, calcium, shocked x2 and pulse
returned. He was sent up to cath lab, cath showed clean
coronaries, apex not moving well ?takasubo.
Past Medical History:
Stress test [**7-/2108**]: ?reversible area near lat wall near apex.
?mild dimished contractility to lat wall.
Asthma on steroids prn
hepatitis C
Social History:
no tobacco, no ETOH, history of drug use.
Family History:
DM in mother
Physical Exam:
95.5, 111/77 (on dopa 10), 78, 100% on vent AC 550x12, 0.4, 5
GENL: not responsive to painful stimuli
HEENT: no elevated JVP
CV: RRR no MRG
Lungs: CTA anteriorly
Abd: soft, nt, nd,hypoactive bs
Ext: no edema, 1+ pedal pulses
Neur: Pupils equal and reactive 7mm->3mm, nl Doll's eye,
+posturing
Pertinent Results:
[**2108-10-5**] CXR: IMPRESSION: No evidence of pulmonary infiltrates.
Endotracheal tube in satisfactory position, as clinically
questioned.
.
[**2108-10-5**] Cardiac Cath: FINAL DIAGNOSIS:
1. No flow limiting epicardial coronary artery disease.
2. Severe left ventricular dysfunction with LVEF of 25% and
[**Last Name (un) **]-tsubo
like wall motion abnormalities.
3. Severely elevated left sided filling pressure with LVEDP of
30 mm Hg.
4. Preserved cardiac index.
.
[**2108-10-6**] CT head: IMPRESSION: No acute intracranial hemorrhage or
mass effect.
.
[**2108-10-6**] ECG: Ectopic atrial rhythm
Long QTc interval
Left axis deviation - anterior fascicular block
Probable old inferior infarct
Generalized low QRS voltages
Anterior ST segment elevation - consider anterior myocardial
infarction
.
[**2108-10-8**] Echo: Conclusions:
Technically suboptimal study.
The left atrium is normal in size. No definite passage of saline
microbubbles at rest. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is good. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded ?mid septal
hypokinesis. Right ventricular chamber size is normal. Right
ventricular systolic function is borderline normal. The aortic
valve leaflets appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Overall good biventricular systolic function. No
definite
right-to-left shunt identified.
.
[**2108-10-16**] KUB: IMPRESSION: Nonspecific bowel gas pattern with
mildly distended transverse colon, without evidence of
obstruction or free air.
.
FECAL CULTURE (Final [**2108-10-14**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2108-10-14**]): NO CAMPYLOBACTER FOUND.
OVA + PARASITES (Final [**2108-10-15**]): NO OVA AND PARASITES SEEN.
.
HEPARIN DEPENDENT ANTIBODIES: POSITIVE
COMMENT: POSITIVE PF4 ANTIBODY BY [**Doctor First Name **]
.
[**2108-10-5**] 11:22PM K+-2.7*
[**2108-10-5**] 11:22PM TYPE-ART PO2-110* PCO2-37 PH-7.38 TOTAL
CO2-23 BASE XS--2
[**2108-10-5**] 06:41PM HGB-13.4* calcHCT-40 O2 SAT-98
[**2108-10-5**] 06:30PM ALBUMIN-3.2* MAGNESIUM-1.5*
[**2108-10-5**] 06:30PM WBC-16.3* RBC-4.32* HGB-12.7* HCT-35.9*
MCV-83 MCH-29.5 MCHC-35.5* RDW-14.1
[**2108-10-5**] 06:30PM NEUTS-84.4* LYMPHS-12.2* MONOS-2.9 EOS-0.4
BASOS-0.1
[**2108-10-17**] 11:10AM BLOOD WBC-17.9* RBC-3.42* Hgb-10.1* Hct-27.8*
MCV-81* MCH-29.6 MCHC-36.4* RDW-15.4 Plt Ct-172
[**2108-10-6**] 01:38AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
Brief Hospital Course:
Mr. [**Known lastname **] is a 50 year old male who presented with ventricular
fibrillation cardiac arrest in the setting of QT interval
prolongation, and hypokalemia likely secondary to diarrheal
illness. The patient received multiple shocks to achieve a
stable rhythm and was intubated for respiratory failure. He was
given the arctic sun therapeutic cooling protocol. On day 2 of
hospitalization there was 24hour period of sepsis physiology
requiring a brief period on pressors and broad antibiotic
coverage. The patient was extubated on hospital day #4 and
demonstrated improving mental status. The patient was treated
empirically for C. difficile infection and received an
implantable cardioverter defibrillator on [**2108-10-17**].
.
CARDIAC
Long QT: During investigation of the etiology of the patient's
cardiac arrest, it was noted that he had a prolonged QT interval
on ECG. Additionally an old ECG shows a long QT interval.
Cardiac catheterization was done which revealed clean
coronaries. Old echo and new echocardiograms were normal. A
tox screen was positive for opiates and THC, however it is known
the patient takes methadone for low back pain. The patient
endorses using marijuana. As Mr. [**Known lastname **] presented with
hypokalemia and required regular supplementation, he was started
on standing potassium. In addition, an ICD was placed for
prevention of recurrence. The procedure went well and no
hematomas developed. He will need to follow up with device
clinic and will require monitoring of his potassium as he is
receiving supplemental K in addition to being on spironolactone.
.
Rhythm: The patient is discharged in sinus rhythm. His QT
remains in the upper 400s. During the hospitalization he
required olanzapine for agitation secondary to anoxic brain
injury. Olanzapine was used as there is less evidence to show
it prolongs QT.
.
Pump: Mr. [**Known lastname **] presented with cardiogenic shock. A v-gram
showed possible takatsubo on the night of admission however an
echocardiogram on [**10-8**] was essentially nl. His EF was shown to
be >50%. He was diuresed minimally and the goal was to keep
fluid balance even.
.
PULMONARY
Respiratory Failure: The reason for intubation was thought to
be due to acute asthma. ABG on admission showed respiratory
acidosis and elevated lactate. The diagnosis of PE was also
considered. A CXR was done which showed a possible developing
RLL infiltrate. On HD #4, the patient was extubated
successfully, satting 97-100% on RA. He was treated initially
with IV steroids, changed to oral, and is now being tapered. He
will be discharged on 10mg of prednisone which will be further
tapered at time of PCP visit or as deemed appropriate at rehab.
He was given nebulizer treatments for acute asthma and completed
a course of vanco/zosyn for concern of aspiration pneumonia.
.
GI: During his hospitalization, Mr. [**Known lastname **] developed frequent
diarrhea. He has a known history of rectal fistula. Cultures
for C. diff were sent which were negative, however based on the
frequency of diarrhea and his elevated white count, he was
started on flagyl for empiric treatment of C diff. He continued
to tolerate PO with adequate fluid intake. He will require 8
more days of flagyl to complete a 14 day course. Of note, per
pt, he is hepatitis C positive. A hepatitis C RNA by PCR test
was pending at discharge.
.
FEN: As the patient presented with hypokalemia and has been
having frequent loose stools, he will require close potassium
monitoring given long QT syndrome
.
NEURO
The patient suffered from a possible anoxic brain injury of
unclear extent. A head CT done on admission shows an old
infarct with no acute changes. Neurology was consulted and
continued to follow the patient while in the hospital.
Initially the patient was unable to follow commands and was
extremely agitated. He became increasingly oriented over the
course of his hospitalization. He continues to improve daily
and is currently alert and oriented x3. He is able to give an
accurate history and according to his family appears to be back
at baseline. The patient will follow up with behavioral
neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
.
Of note, the patient was taking xanax as an outpatient so at the
onset of the delirium the differential included ICU delirium vs.
steroid induced vs opiate/benzo withdrawal. Psychiatry was
consulted who recommended a benzodiazepine taper. He was
treated with Ativan 1mg TID and titrated to off.
.
ID
Leukocytosis: Mr. [**Known lastname **] had an elevated WBC count during the
admission which was felt to be due to c. diff vs. prednisone
(WBC demarginalization) vs. UTI. A UA was negative, CXR was
neg. The patient remained afebrile, blood cultures remained
negative. He finished a course of vanco/zosyn for aspiration
pneumonia and is currently being treated empirically for C.
diff. He was put on 48 hours (4 doses) of vancomycin after his
ICD was placed; the final 2 doses will be given at rehab after
which his peripheral IV may be removed.
.
Code: Full Code
Medications on Admission:
Xanax 2 mg three times a day
Prednisone PRN
Metoprolol 25 mg [**Hospital1 **] (recently started)
Advair 50/500
Albuterol PRN
Aciphex 20 mg QD
Methadone for back pain (40/30/30)
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Five (5) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous Q 12H (Every 12 Hours) for 2 doses: 12:01am and
12:00pm [**10-19**].
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-16**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every 4-6 hours as needed for SOB .
5. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for Low back pain.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
take until directed by your doctor.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily).
11. Sodium Chloride 0.9 % Piggyback Sig: Three (3) ML
Intravenous DAILY (Daily) as needed: flush daily, inspect IV
site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary: Ventricular Fibrillation Cardiac Arrest
Secondary:
Long QT syndrome
Hypokalemia
Discharge Condition:
Good, stable, ambulating independently.
Discharge Instructions:
You had a sudden cardiac arrest related to a rhythm disturbance
within your heart and possibly made worse by a diarrheal
illness. You should take all medications as prescribed by your
doctor. You should consult your doctor before taking any new
medications as some may worsen your heart condition.
Followup Instructions:
You have an appointment at the Device Clinic to check your ICD
on [**10-29**]. The clinic is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**]
Building. You may call the clinic at [**Telephone/Fax (1) 59**] with any
questions.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2108-10-29**]
11:30
You have an appointment with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] on
[**11-12**] at 10:35am. You may call his office at [**Telephone/Fax (1) 11650**]
with any questions or if you need to reschedule.
You have a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
Behavioral Neurology on [**12-13**] at 11:30am. You may call
his office at [**Telephone/Fax (1) 6404**] with any questions or to reschedule.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD Phone:[**Telephone/Fax (1) 6404**]
Date/Time:[**2108-12-13**] 11:30
You should follow up with your primary care provider (Dr. [**Last Name (STitle) **]
[**Name (STitle) 28583**], [**Telephone/Fax (1) 28582**]) 1-2 weeks after being discharged from
rehab.
|
[
"304.70",
"292.0",
"427.41",
"584.9",
"276.8",
"401.9",
"518.81",
"493.92",
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"425.4",
"427.5",
"276.2",
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"348.1",
"070.70",
"565.0",
"507.0",
"293.0",
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.17",
"96.72",
"96.6",
"37.23",
"88.53",
"99.81",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
11464, 11550
|
4914, 10037
|
295, 397
|
11684, 11726
|
2081, 2254
|
12072, 13279
|
1738, 1752
|
10265, 11441
|
11571, 11663
|
10063, 10242
|
2271, 2566
|
11750, 12049
|
1767, 2062
|
237, 257
|
425, 1493
|
2575, 4891
|
1515, 1663
|
1679, 1722
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,159
| 188,063
|
13925
|
Discharge summary
|
report
|
Admission Date: [**2193-3-21**] Discharge Date: [**2193-4-4**]
Service: CSU
CHIEF COMPLAINT: Chest pain on admission.
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
with extensive cardiac history including a prior myocardial
infarction and recent abnormal stress test who presented to
the hospital with chest pain. She denied any nausea,
vomiting, fever or chills. There were no other associated
symptoms. She had relief with sublingual nitroglycerine. The
pain had lasted two hours. This was similar to her episode of
angina in [**2189**] at which time she required a stent in her left
anterior descending coronary artery for ischemia. She was
admitted to the medical service and her work up revealed
significant two vessel coronary artery disease and the
cardiac surgery team was consulted.
PAST MEDICAL HISTORY:
1. Anterior myocardial infarction in [**2182**], status post left
anterior descending coronary artery stent.
2. Re-stenosis with recurrent angina in [**2190-2-26**] with
percutaneous transluminal coronary angioplasty and left
anterior descending coronary artery stent.
3. History of atrial fibrillation.
4. Status post pacer placement for atrial fibrillation.
5. Hypertension.
6. Duodenal ulcer.
PAST SURGICAL HISTORY: Status post right mastectomy in [**2188**].
Status post hysterectomy. Status post appendectomy. Status
post cataract surgery. Status post bilateral vein stripping.
MEDICATIONS ON ADMISSION: Include Lopressor 50 mg p.o.
b.i.d., Digoxin 0.25 mg daily, Lasix 20 mg daily, Plavix 75
mg daily, isosorbide 30 mg p.o. b.i.d., Avapro 300 mg daily,
Zantac 150 mg b.i.d., Coumadin 5 mg daily, Zetia 10 mg daily,
Ativan 0.5 mg p.r.n. h.s., Welchol 3 tablets t.i.d.
SOCIAL HISTORY: She lives at home with her sister, denies
any ETOH or alcohol use.
FAMILY HISTORY: Is noncontributory.
ALLERGIES: She has allergy to amoxicillin, sulfa, Norvasc
and statins.
PHYSICAL EXAMINATION: On admission her vital signs included
a temperature of 97.8, pulse of 66, blood pressure of 149/60,
98 percent on room air. She is comfortable in no acute
distress. Neck was supple with no jugular venous distension.
Lungs were clear to auscultation bilaterally. Heart was
regular with no murmurs, rubs or gallops. Abdomen was soft
and nontender with good bowel sounds. Her extremities had no
edema and palpable pulses bilaterally.
LABORATORY RESULTS: White count was 7.5, hematocrit 36.7,
platelets 268, INR was 2.9. Sodium 137, potassium 4.0,
chloride 104, bicarb 25, BUN 16, creatinine 0.8 and glucose
of 112, troponin was 0.16. Electrocardiogram showed atrial
pacing at 60 beats per minute, no change from a previous
electrocardiogram. Chest x-ray demonstrated no
cardiopulmonary process.
She did undergo cardiac catheterization on [**2193-3-22**]. This
showed hypokinetic anterolateral wall and akinetic apical
wall, normal valves, a 60 percent stenosis at the mid RCA,
30% left main stenosis, 60 % proximal circumflex, 90% OM1 and
100% proximal left anterior descending coronary artery. Left
ventricular ejection fraction was 55%. She underwent a
carotid series on [**2193-3-22**] which demonstrated left sided 60 to
69% stenosis and a right sided stenosis which was less than
40%.
HOSPITAL COURSE: The patient was admitted to the cardiac
medicine service initially prior to the catheterization where
she was medically managed with aspirin, beta blockers,
Plavix. She remained asymptomatic during this time and she
underwent a preoperative preparation and went for surgery. On
hospital day #5 she went to the operating room where she
underwent a coronary artery bypass graft x1 off pump left
internal mammary artery to left anterior descending coronary
artery. She tolerated the procedure well, was transferred
intubated to the Cardiac Intensive Care Unit. Over the first
postoperative night her drips were weaned. She was extubated
on postoperative day #1 and had stable hemodynamics. She was
transferred to the floor on postoperative day #1. She
developed atrial fibrillation with rapid ventricular response
in the 140s. Though she remained hemodynamically stable she
was controlled with beta blockade. Her electrolytes were
optimized and she was transfused for postoperative anemia.
During the remainder of her recovery she did have
intermittent episodes of atrial fibrillation though never
hemodynamically significant.
She was evaluated and passed to level 5 physical therapy
evaluation. Her chest x-rays demonstrated a persistent small
left apical pneumonitis which was followed with serial chest
x-rays. Her chest tubes were removed sequentially and this
never led to any respiratory compromise. She was restarted on
her medications and she is now stable and ready for discharge
to home.
DISCHARGE DIAGNOSES:
1. Acute coronary artery disease.
2. Atrial fibrillation.
3. Hypertension.
4. Duodenal ulcer.
5. Persistent left pneumothorax.
INTERVENTIONS: Off pump coronary artery bypass graft, left
internal mammary artery to left anterior descending coronary
artery.
MEDICATIONS ON DISCHARGE: Colace 100 mg p.o. b.i.d., Zantac
150 mg p.o., b.i.d., aspirin 81 mg daily, Percocet 5/325 one
to two tablets p.o. q 4 hours p.r.n., Plavix 75 mg p.o.
daily, ezetimibe10 mg daily, colesevelam 625 p.o. t.i.d.,
Digoxin 0.25 daily, Lasix 40 mg p.o. daily x7 days, Lopressor
50 mg p.o. b.i.d., diltiazem 240 sustained release p.o.
daily, Coumadin 5 mg p.o. daily.
LABORATORY DATA ON DISCHARGE: Last INR is 2.1.
DISPOSITION: Patient is stable for discharge to home. She
will be followed by [**Hospital6 407**] who will check
her wound, check her medications, check vital signs.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 8958**]
MEDQUIST36
D: [**2193-4-3**] 15:21:55
T: [**2193-4-3**] 16:50:32
Job#: [**Job Number 41675**]
|
[
"410.71",
"V45.82",
"272.0",
"412",
"401.9",
"414.01",
"V10.3",
"427.31",
"285.9",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.15",
"99.04",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
1832, 1926
|
4776, 5035
|
5062, 5439
|
1465, 1730
|
3258, 4755
|
1273, 1438
|
1949, 3240
|
5454, 5910
|
106, 132
|
161, 820
|
842, 1249
|
1747, 1815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,677
| 122,381
|
3549
|
Discharge summary
|
report
|
Admission Date: [**2108-3-15**] Discharge Date: [**2108-3-24**]
Date of Birth: [**2035-6-27**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Codeine / Percocet
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
pelvic mass
Major Surgical or Invasive Procedure:
1. Panniculectomy.
2. Placement of an incisional VAC.
3. Exploratory laparotomy
4. right salpingo oophorectomy
5. Myomectomy
4. Lysis of adhesions
History of Present Illness:
72-year-old morbidly obese woman with a history of thyroid
cancer and atrial fibrillation who recently underwent a
colonoscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] here at [**Hospital1 827**]. The patient notes that on [**5-9**] she had a
colonoscopy and a few days after that she developed severe
right-sided pelvic and abdominal pain. This basically passed
over the course of two days, but she saw Dr. [**Last Name (STitle) 1940**] in followup
for this. It was not associated with fever, vomiting, change in
bowel habits. A CT scan was obtained on [**5-23**]. This
revealed a 15 cm right adnexal lesion, which appeared to have
"increased in size in comparison to a [**Hospital1 18**] MRI dated [**2099-11-26**]
and findings most consistent with ? fibroid versus ovarian
fibroma. The mass is inseparable on imaging studies from the
sigmoid colon and cecum. Also noted was a calcified thrombosed
aneurysm of the GDA and likely second aneurysm within the left
upper abdomen. She is here for discussion of treatment options.
[**Known firstname **] has had additional imaging studies and brings with her
today a MRI from [**Location (un) 1121**] Imaging. She has been followed by
Dr. [**Last Name (STitle) **] for this problem in the past and has basically been
observed during this time period. [**Known firstname **] has been reluctant
to undergo surgery for this mass in the past.
The patient was seen for follow up visit on [**2107-6-15**]. She
returned after having had a MRI to evaluate her pelvic mass at
an outside institution. She had a repeat of her MRI performed
once again at [**Location (un) 1121**] Imaging and this revealed, as
expected, a slight enlargement of the large 15-17 cm right
adnexal mass. It is unclear once again whether this is a
fibroid or a tumor of the ovary. She also had noted on her CT
scan an abnormality to the blood supply within the celiac axis.
She has undergone an MRA and this reveals significant
stenosis of the proximal celiac artery. There are also dilated
anterior and posterior pancreaticoduodenal arteries with
aneurysmal dilations and collaterals in the root of the
mesentery adjacent the SMA. A renal lesion was also identified
and was advised for evaluation in six months for a pre and post
contrast renal MRI. Also noted was a 3-mm cystic lesion in the
pancreatic
body. This could also be followed in six months. The patient
was recommended to have a preoperative evaluation.
The patient had several follow up visits between [**5-/2108**] and
03/[**2107**]. She returned on [**2108-2-8**] for a followup evaluation.
In the interim time period, the patient had elected to proceed
with surgery but unfortunately fell and had a urinary tract
infection as well as pneumonia. She was admitted here to the
hospital. We had to delay her surgery. Post-hospitalization
followup chest x-rays have been done. Her most recent was on
[**2-6**] and this reveals little change from her prior chest x-ray,
which shows "improved but not complete resolution of a right
middle lobe pneumonia," followup is recommended.
Past Medical History:
The patient has a history of fib, morbid obesity, and thyroid
cancer, which appears to be under control and without evidence
of recurrence. She denies history of hypertension, mitral valve
prolapse, asthma, or thromboembolic disorder. She is up-to-date
with respect to mammography and colonoscopy.
PAST SURGICAL HISTORY: She had an appendectomy in [**2080**], ovarian
cystectomy and fibroidectomy also in [**2080**]. This was evidently a
partial thyroidectomy.
OB/GYN HISTORY: Her last menstrual cycle was 30 years ago. She
denies postmenopausal bleeding. She denies any history of
fibroids, cysts, pelvic infections or abnormal Pap smears. On
further review, we discussed the fact that the pelvic masses may
in fact be a fibroid. She has had this for "for a number of
years." She reports she has never been pregnant.
Social History:
She denies tobacco or drug use. She is an association
executive.
Family History:
She reports a cousin both had breast cancer. She denies any
family history of thromboembolic disorder.
REVIEW OF SYSTEMS: She denies fever, weight change, or
weakness. HEENT: Denies headache, visual or hearing changes,
epistaxis, dysphasia. Cardiovascular: Denies chest pain,
palpitations, or orthopnea. Respirations: Denies cough,
dyspnea, or hemoptysis. GI: Denies abdominal pain, anorexia,
nausea, vomiting. She denies constipation, diarrhea or melena.
GU: Denies dysuria or frequency. She denies hematuria or
abnormal vaginal bleeding.
Neuro: Denies syncope, paresthesia, or muscle weakness.
Hematologic: Denies fatigue, petechia, or spontaneous bleeding.
Physical Exam:
PHYSICAL EXAMINATION:
GENERAL: The patient appears in no apparent distress. She
appears her stated age.
HEENT: Normocephalic, atraumatic. Oral mucosa without evidence
of thrush or mucositis. Eyes, sclerae are anicteric.
NECK: Supple. No masses, no palpable thyromegaly identified:
Lymph node survey, negative cervical, supraclavicular, axillary,
or inguinal adenopathy, however, her exam is limited due to
adiposity.
CHEST: Lungs clear bilaterally.
HEART: Regular rate and rhythm. I do not appreciate a murmur
today.
BACK: No spinal or CVAT tenderness.
ABDOMEN: Soft, nontender, no apparent distention. A large
vertical midline incision is noted to extend from the umbilicus
down. The pannus is without any evidence of edema or
irregularity.
EXTREMITIES: There is no clubbing or cyanosis. There is edema
of bilaterally, 1+ to 2+ of the lower extremities. The inner
thigh show evidence of a previous operation, which the patient
relates was resection of fatty tissue.
PELVIC: Normal external genitalia. The inner labia minora is
normal. Urethral meatus is normal. The speculum is placed and
a normal cervix is identified. Bimanual exam reveals a fairly
mobile uterus. The pelvic mass on the right side is very
difficult to palpate due to the patient's morbid obesity. I do
not palpate any mass on the the left side. There is a fullness
appreciated on the right side only. A rectal exam reveals good
sphincter tone without mass or lesion.
Pertinent Results:
[**2108-3-16**] 04:43AM BLOOD WBC-10.2 RBC-3.48* Hgb-10.3* Hct-31.1*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.2 Plt Ct-254
[**2108-3-17**] 09:05AM BLOOD WBC-8.4 RBC-3.18* Hgb-9.6* Hct-28.6*
MCV-90 MCH-30.1 MCHC-33.5 RDW-14.8 Plt Ct-241
[**2108-3-20**] 09:07AM BLOOD WBC-5.6 RBC-3.46* Hgb-10.3* Hct-30.1*
MCV-87 MCH-29.8 MCHC-34.2 RDW-14.7 Plt Ct-260
[**2108-3-16**] 04:43AM BLOOD Glucose-119* UreaN-24* Creat-0.7 Na-144
K-4.3 Cl-108 HCO3-26 AnGap-14
[**2108-3-17**] 05:41AM BLOOD Glucose-129* UreaN-21* Creat-0.7 Na-137
K-4.1 Cl-104 HCO3-26 AnGap-11
[**2108-3-23**] 06:22AM BLOOD Glucose-138* UreaN-17 Creat-0.6 Na-141
K-3.7 Cl-104 HCO3-28 AnGap-13
[**2108-3-22**] 05:23AM BLOOD CK(CPK)-53
[**2108-3-22**] 05:23AM BLOOD CK-MB-3 cTropnT-<0.01
[**2108-3-16**] 04:43AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.0
[**2108-3-20**] 09:07AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9
[**2108-3-23**] 06:22AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9
[**2108-3-21**] 3:41 am URINE Source: Catheter.
URINE CULTURE (Final [**2108-3-22**]): NO GROWTH.
[**2108-3-16**] 12:29 am MRSA SCREEN NASAL SWAB.
MRSA SCREEN (Final [**2108-3-18**]): No MRSA isolated.
[**2108-3-17**] Bilateral Lower extremity dopplers
FINDINGS: Focused exam for evaluation for DVT was performed. The
study was
moderately limited by body habitus. The bilateral common
femoral, superficial femoral and popliteal veins demonstrate
normal compressibility. Proximal flow, waveforms and
augmentation were normal.
IMPRESSION: Moderately limited exam without evidence of lower
extremity DVT.
[**2108-3-20**] CXR
REASON FOR EXAM: 73-year-old woman with shortness of breath.
Rule out
pneumonia versus volume overload.
Since [**2108-3-16**], right internal jugular catheter still ends
in the upper to mid SVC. Mild cardiomegaly is unchanged. Mild
vascular congestion is new. Small left pleural effusion
slightly increased. Basilar opacities are unchanged, likely
atelectasis. Lingular opacities are new, could be
atelectasis, should be followed.
[**2108-3-22**] ECHO
The left atrium is moderately dilated. The right atrium is
moderately dilated. 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. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened (?#). There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Mild mitral
regurgitation. Dilated ascending aorta.
Brief Hospital Course:
Ms. [**Known lastname 16232**] is a 72 year old with multiple comorbidities who
underwent an exploratory laparotomy, right salpingo
oophorectomy, myomectomy, adhesiolysis for a large ovarian
fibroma. She also underwent a panniculectomy by plastics given
abdominal wall laxity. Please see the operative report for
further details.
Patient was admitted to the gyn-oncology service. Post operative
course is outlined below.
*) Neuro:
- Pain control was initially managed with an epidural, which was
removed on POD # 3.
- Patient experienced intermittent periods of confusion which
were attributed to narcotic use. The neurological exam was
unremarkable. CBC, electrolyte panel, UA and urine cultures were
done, which were normal. Patient's confusion was much improved
with decreased narcotics.
- Pain control was achieved with Tylenol and minimal doses of
Dilaudid
*) Pulmonary
- Patient was admitted to the [**Hospital Ward Name 332**] ICU on POD # 0 for
monitoring of ventilatory status. She was initially retaining
CO2 and was placed on BIPAP overnight but was weaned off to
nasal canula by POD # 1.
- The patient maintained an oxygen requirement overnight until
POD # 4
- The patient had several episodes of desaturation and tachypnea
with activity, which was felt to be partially secondary to
severe deconditioning and volume overload. Chest XRay on
[**2108-3-16**] suggested mild volume overload. The patient underwent
diuresis with Lasix. She ambulated with physical therapy and had
significant improvement in her respiratory status.
- Given concern for potential DVT, the patient underwent LENI's
on [**2108-3-17**], which were negative
- She is discharged with oxygen saturations in the 94-98% RA
*) Cardiovascular:
- Patient has a history of Atrtial fibrillation. She was
monitored on telemetry on POD # [**12-2**] without any events. She
continued her home doses of flecainaide and metoprolol
- Patient has a history of congestive heart failure and
continued her home dose of Lasix. Given the intermittent
desaturations as described above, a medicine consultation was
obtained. The patient under recommendation of the medicine team
underwent a transthoracic echocardiogram on [**2108-3-22**] which
revealed a mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Mild mitral
regurgitation. Dilated ascending aorta. Overall the findings
were similar to prior studies on 08/[**2106**].
- Patient's antihypertensive medications were titrated and
Lisinopril was restarted.
*) Gastrointestinal
- The patient's diet was slowly advanced to regular diet by POD
# 2.
*) Renal/GU:
- The patient had transient oliguria on POD # 2, which resolved
spontaneously.
- The patient's foley catheter was kept in place until the
patient was ambulatory.
- The foley catheter was removed on POD # 6.
*) Wound care:
- Patient had a prophylactic wound vac placed by plastics, which
was removed on POD # 3.
- The patient had JP drains x 3 and was receiving prophylactic
Kefzol IV while the drains were in place. One JP was removed
prior to discharge.
- The patient will follow up with plastics for JP drain removal.
She will continue PO Keflex for prophylaxis until then.
*) Endocrine:
- Patient has hypothyroidism. She continued her home dose of
Synthroid.
*) Prophylaxis
- The patient received Protonix and subcutaneous heparin as well
as pneumoboots as prophylactic measures during her
hospitalization
- The patient was also asked to have aggressive incentive
spirometry
The patient was discharged home with home PT on POD # 9 in
stable condition.
Medications on Admission:
Crestor, Cymbalta, vitamin D, flecainide, Lasix, Synthroid,
metoprolol, Ditropan, Ambien, aspirin, loratadine,
pseudoephedrine.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*20 Tablet(s)* Refills:*0*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*40 Tablet(s)* Refills:*0*
4. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-2**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
6. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
9. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): take if you are taking narcotics to precent
constipation.
Disp:*40 Capsule(s)* Refills:*0*
14. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*30 Capsule(s)* Refills:*0*
16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
18. Dilaudid 2 mg Tablet Sig: [**12-2**] pill Tablet PO every 6-8 hours
as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Commode
Bedside commode
Disp: ONE
Refills: NONE
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Right ovarian fibroma and uterine fibroid.
Excessive abdominal laxity, abdominal pannus.
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or return to the hospital if you have:
-Increased pain
-Redness or unusual discharge from your incision
-Inability to eat or drink because of nausea and/or vomiting
-Fevers/chills
-Chest pain or shortness of breath
-Any other questions or concerns
Other instructions:
-You should not drive for 2 weeks and while taking narcotic pain
medications
-No intercourse, tampons, or douching for 6 weeks
-No heavy lifting or vigorous activity for 6 weeks
-You can shower and clean your wound, but do not use perfumed
soaps or lotions. Be sure to pat completely dry after washing.
-You may resume your regular diet and home medications.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 5343**]
Date/Time:[**2108-3-23**] 2:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2108-4-19**] 11:10
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
|
[
"278.01",
"614.6",
"220",
"701.8",
"428.0",
"788.5",
"292.81",
"V10.87",
"E935.8",
"518.81",
"427.31",
"447.4",
"428.33",
"218.2",
"577.2",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"86.83",
"68.29",
"65.49",
"93.56"
] |
icd9pcs
|
[
[
[]
]
] |
15471, 15546
|
9694, 12536
|
304, 453
|
15679, 15686
|
6718, 9671
|
16387, 16815
|
4546, 4650
|
13464, 15448
|
15567, 15658
|
13311, 13441
|
15710, 16364
|
3940, 4446
|
5234, 5234
|
5256, 6699
|
4670, 5219
|
253, 266
|
12548, 13285
|
481, 3593
|
3615, 3916
|
4462, 4530
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,938
| 103,401
|
26987
|
Discharge summary
|
report
|
Admission Date: [**2113-11-7**] Discharge Date: [**2113-11-9**]
Date of Birth: [**2070-1-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Seizure
EtOH withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. [**Known lastname **] is a 43 yo M w/PMHx sx for alcohol abuse (>5
drinks/day) with withdrawal seizures who presented initially to
the ED on [**11-7**] with tonic-clonic seizures at home witnessed by
his girlfriend, who per the MICU note, "states that he was
watching TV and started to shake all over and foam at mouth".
The episode lasted 10 minutes, followed by a 10 minute postictal
state w/o bowel or bladder incontinence, then had a second
episode. Patient was unresponsive during his seizure. She denied
head trauma or LOC at the time. He does not remember seizing,
but does remmeber that after the episode he did not
incontinence.
.
Per girlfriend, patient had his last drink 3 days ago. The
patient states that he had his last drink 8 days PTA because he
decided to stop drinking.
.
In the ED, vitals were 97.1, HR 134, BP 143/63, R 18, 99% RA. He
was given a total of 50mg IV valium, 1L NS, and a banana bag,
and subsequently admitted to the MICU for closer monitoring due
to concern for sedation.
.
In the MICU, patient received standing valium for alcohol
withdrawal with no recurrence of his seizures. A CT head was
performed, and was negative for bleed. He was noted to have a
transaminitis, likely alcoholic hepatitis, and also had an
elevated amylase and lipase, without symptoms, for which he was
given IVF. He was also started on a low dose BB w/ BP 130s/80s.
.
Past Medical History:
PMH:
LE muscle pain/aches
Hepatitis C
ETOH abuse
Tobacco abuse
H/o alcohol withdrawal seizures
Psoriasis
? seizures
Social History:
SH: Lives with GF. Smokes [**11-22**] ppd x > 20 yrs. Drinks vodka, [**11-22**]
shots at a time, all day and night per girlfriend. Denies
illicit drug use. Unemployed
Family History:
FH: non-contributory
Physical Exam:
PE
VS: 96.2 BP 143/106 HR 80 RR 18 O2sat 98% RA
Gen: Sleepy, well appearing. NAD
HEENT: MMM. No scleral icterus. Neck supple.
Hrt: RRR. No MRG
Lungs: Expiratory wheezing.
Abd: S/NT/ND. No hepatomegaly. No massess.
Ext: WWP. Psoriasis plaques noted bilaterlly.
Neuro: CN intact. 5/5 strength. Sensation to LT intact. No
asterixis.
Pertinent Results:
[**2113-11-7**] 06:15PM URINE HOURS-RANDOM
[**2113-11-7**] 06:15PM URINE HOURS-RANDOM
[**2113-11-7**] 06:15PM URINE GR HOLD-HOLD
[**2113-11-7**] 06:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2113-11-7**] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2113-11-7**] 06:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2113-11-7**] 06:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2113-11-7**] 03:40PM GLUCOSE-123* UREA N-7 CREAT-0.7 SODIUM-133
POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-22 ANION GAP-23*
[**2113-11-7**] 03:40PM estGFR-Using this
[**2113-11-7**] 03:40PM ALT(SGPT)-45* AST(SGOT)-64* ALK PHOS-103 TOT
BILI-1.0
[**2113-11-7**] 03:40PM LIPASE-129*
[**2113-11-7**] 03:40PM CALCIUM-10.0 PHOSPHATE-2.8 MAGNESIUM-1.7
[**2113-11-7**] 03:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2113-11-7**] 03:40PM WBC-5.8 RBC-4.25* HGB-14.9 HCT-42.8 MCV-101*
MCH-35.0* MCHC-34.8 RDW-14.7
[**2113-11-7**] 03:40PM NEUTS-76.0* LYMPHS-17.4* MONOS-5.5 EOS-0.6
BASOS-0.5
[**2113-11-7**] 03:40PM PLT SMR-VERY LOW PLT COUNT-73*#
.
Studies:
CT head negative for bleed or fracture
CXR: negative
Brief Hospital Course:
A/P: 43 y.o. man with ETOH abuse who presented with witnessed
tonic-clonic seizures in the setting of alcohol withdrawal
.
# Seizures: Likely alcohol related given tachycardia,
hypertension, agitation, and given history of heavy alcohol use
with history of alcohol withdrawal seizures. pt currently
asymptomatic, had been getting valium standing and per ciwa,
though no longer requiring valium. no seizures while in
hospital. Pt is s/p an uneventful micu course [**12-23**] concern for
respiratory depression [**12-23**] high dose benzos
.
# ETOH abuse/withdrawal:
-standing valium d/ced today, ciwa continued pt pt not
requiring: stable for d/c, will taper as valium clears
-Appreciate SW consult
-MVI/thiamine/folate
.
#. Wheezing. Likely has COPD given extensive tobacco hx.
-Continue albuterol/ipratropium nebs for now.
.
# Transaminitis: Most likely [**12-23**] hepatitis C and alcoholic
hepatitis
-Viral serologies pending
-Monitor LFTs for now
.
# Thrombocytopenia - likely [**12-23**] chronic liver dz. No evidence of
active bleeding. Avoid heparin SC
.
# LE cramps: continue amitriptyline and gabapentin
.
#.Psoriasis: triamcinolone cream.
Medications on Admission:
Amitriptyline 50mg QHS
Gabapentin 600ng QHS
Triamcinolone cream
Discharge Medications:
Amytriptylline 50 mg qhs
Gabapentin 600 mg qhs
cont Triamciniolone cream as well
Discharge Disposition:
Home
Discharge Diagnosis:
EtOh Withdrawal
Discharge Condition:
Good
Discharge Instructions:
You came into the hospital after having a seizure most likely
related to alcohol withdrawal. You had a short stay in the ICU
in order to have close monitoring surrounding the seizure. You
have gotten medication to prevent further problems during your
withdrawal from alcohol. At this point it is safe for you to go
home.
Please follow up as directed.
Please call your physician or return to the hospital for further
seizures or other medical concerns/problems.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 29932**]/Dr. [**Last Name (STitle) **] on
Friday [**12-15**] at 330. The office is located on the [**Location (un) **] of
[**Hospital Ward Name 23**]. If you need to change the appointment please call [**Telephone/Fax (1) 14384**].
In order to change your primary care provider as above you must
call your insurance company, mass health and notify them of the
change. Please give them Dr. [**Last Name (STitle) **] name.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"496",
"571.1",
"287.4",
"696.1",
"291.81",
"303.01",
"780.39",
"070.70",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5182, 5188
|
3806, 4960
|
339, 346
|
5248, 5255
|
2492, 3783
|
5769, 6337
|
2104, 2126
|
5075, 5159
|
5209, 5227
|
4986, 5052
|
5279, 5746
|
2141, 2473
|
276, 301
|
374, 1765
|
1787, 1904
|
1920, 2088
|
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